.;X'J£" 'J"^J2C T 'nr-^"O-Q'J-^'QCYQ.Cy&z ^t/^/A/-^'//'1 'twf/v?/p XSHT' 1 •;(. THE CHIRURGICAL WORKS OF PERCIVALL POTT, F.R.S. SURGEON TO ST. BARTHOLOMEW'S HOSPITAL. WITH HIS LAST CORRECTIONS. TO WHICH ABE ADDED, A SHORT ACCOUNT OF THE LIFE OF THE AUTHOR, A METHOD OP CURING THE HYDROCELE BY INJECTION, AND OCCASIONAL NOTES AND OBSERVATIONS. BY SIR JAMES EARLE, F. R. S. SUBGEON EXTRAORDINARY TO THE KING, &C A certis potius et exploratis petendum esse presidium; id eat, his que Experientia in ipsis curationibus docuent; sicut in ceteris omnibus artibus: nam ne agricolam quidem aut euberna- torem disputatione, sed usu fieri. A. CORN. CELSV& FIRST AMERICAN, FROM THE LAST LONDON EDITION, • IN TWO VOLUMES. VOL. II. PHILADELPHIA: PUBLISHED BY JAMES WEBSTER, NO. 24, SOUTH EIGHTH STREET. William Brown, Printer 1819. CONTENTS OF VOL. II. Page. A TREATISE on the Hydrocele, or Watery Rupture, and other Diseases of the Testicle, its Coats and Vessels ------ l Distinction between true and false Hernia.....5 Of the Hydrocele in general........7 Anatomical Structure of the Parts concerned.....11 Anasarcous Tumor of the Scrotum.......23 Distinction of the Three Sorts of Hydrocele of the Cells of the Tunica Communis...........31 The Encysted Hydrocele of the Tunica Communis - ... 42 Hydrocele of the Tunica Vaginalis Testis......51 Method of Palliative Cure of the Hydrocele of the Tunica Vaginalis Testis............69 Means for a radical Cure of the Hydrocele of the Tunica Vaginalis - 77 The Hematocele, or Tumor from Blood......94 Hydrocele in the Sac of a Hernia.......110 The Pueumatocele, Varicocele, Circocele, Sarcocele, and Hydrosar- cocele............114 The Sarcocele, or Diseased Testicle.......117 An Account of the Method of obtaining a Perfect or Radical Cure of the Hydrocele, by Means of a Seton -......171 Radical Cure of the Hydrocele, by Means of an Injection, by the Editor 189 Of the Fistula in Ano..........197 The Forms under which it makes its Appearance, &c. - 205 Habits most liable to the Disorder.......208 Manner of Treating it in its Different States and Circumstances - - 214 Remarks on the Cataract.........265 Remarks qn the Polypus of the Nose.......283 Cancer Scroti...........291 Observations on the Mortification of the Toes and Feet ... 297 Remarks on the Necessity and Propriety of Amputation in Certain Cases 305 Remarks on the Palsy of the Lower Limbs......325 Further Remarks on the Useless State of the Lower Limbs, in Conse- quence of a Curvature of the Spine......345 Account of Tumors which rendered the Bones soft .... 387 Account of a Hernia of the Urinary Bladder, including a Stone - - 395 Observations on Ilxmorrhoidal Excrescences, by the Editor - - 401 General Index . - . . ......413 A TREATISE ON OR WATERY RUPTURE, AND OTHER DISEASES OF THE TESTICLE, ITS COATS, AND VESSELS. ILLUSTRATED WITH CASES. voL. n, A PREFACE TO THE • SECOND EDITION The following tract, as the title expresses, is designed as a supplement to one published a few years ago; one of the objections to which was, that it was defective in matter, and ought to have comprehended the false her- niae; they being as real diseases, and requiring chirurgi- cal assistance as much as the true. This deficiency I have now endeavoured to supply in the best manner I am able. When I began#to put these papers in order, I did not think they would have run to such a length; and, when they were finished, I did not know how to shorten them without rendering them less explicit I am perfectly sensible that some parts of them will appear prolix and diffuse, and that such manner of writ- ing is in general very justly objected to; but yet cannot help thinking that sometimes it may be excusable, or even necessary. When application is made to the judgment merely, and information is intended to be conveyed to many people of different capacities, it may become necessary to set the same object in several different lights; and to repeat the same thoughts many times in different words: 4 PREFACE. to those who have not been much conversant with the thing treated of, a studied brevity would become a per- plexing obscurity. However satisfied such readers might be with the style of the writer, they would not be made sufficiently acquainted with the subject: they might be pleased, but they would not be informed. I should indeed be very sorry to have conveyed my meaning in such manner as to disgust the judicious; but, as my principal intention was to instruct the un- knowing, my chief aim has been perspicuity. If the learned and critical are not displeased, I shall be glad; if the ignorant gain any knowledge, I shall be much more so. The character of an elegant writer I make no pretension to; that of a skilful surgeon, and of a man who has done some good in the way of his profes- sion, I should be extremely glad to deserve. With regard to this second edition, all I have to say is, that it has cost me some time and trouble; that it con- tains many additions to the former; and, that I hope the reader will find it, not only a more correct, but a more instructive book. TREATISE OS THE II YD HOC ELK, $e. SECT. I. The various diseases comprehended under the general term hernia, have, by surgeons, been divided into two classes; one of which they have distinguished by the epithet true, the other they have called false, or spurious. Under the first, they have ranged all those tumors which arc produced, either by the descent, or protrusion, of some of those parts which should naturally be contained within the cavity of the abdomen; but which, by being displaced from their proper situation, form swellings in the navel, groin, belly, scrotum, and thigh. By the second, they mean all such diseases of the testicles, their coats, and vessels, as proceed from, or are accompanied by, the induration, enlargement, or other morbid affection of such parts; or occasion the lodgement, or accumulation, of extravasated fluid within them. So that what are generally called true hernia are tumors, occa- sioned by the removal of certain parts from their proper and natural situation, such parts still remaining, in general, sound, and free from disease; while those termed fake are original disorders of 6 A TREATISE ON THE HYDROCELE. the parts themselves in which they arc seated: a distinction which k invariably true, and very necessary to be attended to, by all who would understand the real nature of each. A part of the intestinal canal, or of the omentum, the stomach, uterus, or blad- der, arc what most frequently make the contents of the former; a varicous distention of the spermatic vessels, extravasated blood or water within the membranes either of the testicle or of the spermatic vessels, an inflammatory enlargement, and a scirrhous or cancerous state of the testis itself, constitutes the latter. The true hernial receive their distinguishing appellations, either from the particular part of the body in which the swelling makes its appearance, or from what is contained within such tumor; and are therefore called inguinal, scrotal, umbilical, and ventral; or intestinal and omental ruptures. The spurious derive their names either from their supposed contents, as the pneumatocele, hcemato- cele, and hydrocele; or from the alteration made by the disease in the natural structure of the parts concerned, as the varicocele, cirsocele, and sarcocele: to which some have added that inflamma tory defluxion on the testicle, commonly called hernia humoralis. The pneumatocele is a mistake; there is no tumor of this kind, and in this situation, in a living animal. It is indeed particularly described by many writers, both ancient and modern, and said to be a disorder to which infants are particularly liable: but the complaint so described, and which nurses and ignorant people do still call a icind-rupture, is not what they take it for; neither is it produced by wind: it is either a true intestinal hernia, or a species of hydrocele; which will be taken notice of hereafter. The varicocele (which is an enlargement and distention of the blood- vessels of the scrotum) is very seldom ah original'disease, inde- pendent of any other; and when it is, is hardly an object of sur- gery. The circocele, or varicous state of the spermatic vein though it be really a disease, and sometimes very troublesome to those who are afflicted with it, yet is seldom capable of much relief beyond that of a suspensory bandage. \ TREATISE ON THE HYDROCELE. SECT. 11. OF THE HYDROCELE IN GENERAL. The term hydrocele, if used in a literal sense, means any tumor produced by water; but surgeons have always confined it to those which possess either the membranes of the scrotum, or the coats of the testicle, and its vessels. The first of these, viz. that which has its seat in the mem- branes of the scrotum, is common to the whole bag, and to all the cellular substance which loosely envelopes both the testes. It is, strictly speaking, only a symptom of a disease, in which the whole habit is most frequently more or less concerned, and very seldom affects this part only.8 The latter, or those which occupy the coats immediately investing the testicle and its vessels, are abso- lutely local, very seldom affect the common membrane of the scrotum, generally attack one side only, and are frequently found in persons who are perfectly free from ail other complaints. Notwithstanding the obvious and material difference between the two kinds of disease, they have by the majority of writers been confounded together; have been considered as springing from the same immediate source; and as requiring the same kind of treatment; although the one is plainly and evidently a mere symp- tom or attendant on a general disorder; and the others are strict- ly and absolutely local complaints. This one fundamental error lias been the occasion of many others. The supposition that all collections found in the membranes and coats of the scrotum and testicles are of the same general kind, has produced an infinite variety of wild conjectures concerning the particular and imme- diate nature and origin of them. By some they have been attri- buted to a particular indisposition of the liver, kidneys, or spleen; by others, to a natural and necessary connexion between the sper- ." I-have seen a true anasarcous watery distention of the ce!!-: ofthe darlor confined to one sick? of the scrotum only 8 V TREATISE ON THE HYDROCELE. matic vessels and those of the kidney; by many, the fluid has been thought to be of the urinary kind, or at least that it ought to have passed through the kidney, but that mistaking its right way, it gets into the membranes of the scrotum and testicles;b while others have affirmed, that all complaints of this kind are really symptoms of a dropsical habit; that the fluid comes from the cavity of the belly, and either passes through the peritoneum, or extends that membrane down into the scrotum.0 Many cautions have been laid down against attempting the cure of one species of this disease hastily, or without a previous course of medicine, upon a supposition that the defluxion is of a noxious nature; and that, by falling on this part, it frees the constitution from several b "Supervenit quandoque ex causa aliqua externa et manifesta, ut ictu, "casu, &c. Crebro vero, ex latente, et non manifesta. Qux ab externa " causa accessit, aut dextrum, aut sinistrum renem indifferenter affligit; ala- " lente vero, et non manifesta causa originem duceujs, nunquam ahum quam " sinistrum." Schenkhs, Obs. " Rene, hec malo affecto, nee officio suo probe fungente, urinx pars quam " emulgens haec ad se pertraxit, cum ad vesicam per male affectum renem " non potest descendere, per seminalum in erythroideam delabitur; hoc mo- "do hydrocelem ingenerens. " Hinc apparet et abunde manifestum est, quamobrem hydrocele haud ab >{ externa, sed a latente originem ducens, non nisi in sinistrani membranam •' incidat; et hujus testem affligat" Scuenkius. " Hernia aquosa, si a causa interna et latente originem ducit, ut plurimum "sinistram partem scroti occupat j serosusque ille humer, in membrana tes- " tern involvente, erythroiden dicta, colligitur : idque fit praecipue, rene si- " nis'tro male affecto ; quapropter serosus humores non attrahens, et ad vesi- " cam non mittens, per venam seminariam, quae in isto latere, ex emulgente " procedit, in membranam erythroiden delabitur." Gut. Fab. Hildanus. " Xe serosus humor qui a rene attrahi non potest in abdomine retiffeatur." Hildancs. " Si hernia fiat ex humoribus venientibus a renibus ad testiculum, cognos- " citur tactu." Lanfrakc e " Colligitur liquor in hypochondriis, qui facile descendit." Fab. ab AauAPENB. " Aliquando descendit aqua illuc sicut descendit in hydropicis." Lanfranc A TREATISE ON THE HYDROCKLE. 9 other distempers."1 It has been described, as frequently pro- ducing a corrupted or otherwise diseased testicle ;e as being nearly allied in nature to those tumors which are called encysted, whose tunics are formed out of the common membrane by mere pressure, and as being generally accompanied with a true hernia, or de- scent of the intestine or omentum; which last (supposed) circum- stance has been gravely urged as a reason for not attempting a radical cure/ The same wanton liberty has been taken, in assign- * " Sarpe ego vidi multos per hernias liberatos esse a gravibus affectibus ; "ab empyemate, hydrope pulmonis, &c. unde si penitus sanetur, poterit " multos morbos postea inferre." Fallopius. • " Testis autem substantia, ab acrimonia humoris, successa tempoi is cor- " rumpitur." Sciienkics. " Sciendum est, quod in hernia ilia, in qua continetur aqua in vagina testiSj " et quae aliquantisper sit diuturna, corriSptus est testis." Fallopius. " Ubi paulo diutius humor iste intus relinquitur, metuendum est ne testi- " cuius sensim, cum eolem corrumpatur, vel occalescat, atque ita scirrhum, "vel farcocelen, vel cancrum tandem sentiat." Heister. " Ne scilicet collectum in scroto serum per acredinem paulatim contractam "partes, internas, et cum primis testiculum, corrumpat; et noxam magis " periculosam efficiet." Heister. "Notandum vero aquam in scroto non esse diu relinquendam ne a mora " testis corrumpatur; vel una cum aqua adveniat hernia camoso et caro con- " crescat." Fab. ab Aq.cafexdexti:. f The opinion of the late Mr. Cheselden on this subject is so singular, and so little consonant to truth or nature, that I shall take the liberty to repeat his words, lest his great character should mislead the unwary. In the last edition of his Anatomy, p. 264, he says, " The true hernia aquosa is from the " abdomen, which either extends the peritoneum into the scrotum, or breaks " it; and then forms a new membrane, which thickens as it extends, as in "aneurisms and the atheromatous tumors': the dropsy in the cyst (for such 'it properly is) rarely admits of more than a palliative cure by puncture, or " tapping, like the dropsy of the abdomen ; and this with some difficulty, be- " cause the omentum generally, and sometimes the gut, descends with it." Which is so far from being the ca»e, that unless in the particular and very singular instance of a combination of an hydrocele with a congenial hernia it never can happen; the bags or sacs of an hydrocele, and of a hernia, being in all other instances totally different; and the former never having: any com- munication with the belly. VOL. 11^ * 10^ A TREATISE ON THE HYDROCELE. ing different seats to these disorders, as in accounting for their origin: every part which invests, or accompanies, the spermatic vessels, or the testicles, not only the tunica communis of the pro- cess, and the cavity of the tunica vaginalis, (the true and real seats of one or other of these disorders,) have been enumerated, but several imaginary ones have been added; firm, compact mem- branes have been split into lamellae; and o^sts and coats have been devised, which never had a real existence. If all this was matter of mere speculation, and produced no mischief in practice, it would be of no importance; but, in mat- ters of physic and surgery, this seldom or never happens: errone- ous ideas of the nature, origin, and seats of diseases, most com- monly are followed by improper methods of treating them. In the present case, the absurdity of the conjectures concerning these circumstances in the disorder, is fully equalled by the methods of cure which have been proposed and practised. Upon a supposition that the extravasation of fluid was the con- sequence of a dropsical habit, strong purges and powerfully diu- retic medicines have been prescribed; actual cauteries have been used; and ligatures and incisions made, both on the spermatic vessels and in the groin, to hinder the descent of the water from the cavity of the belly;* astringent liquors and Qrdent spirits have e " Et cum totam evacuaveris aquam, cauteriza locum quem aperuisti; et "fac duo cauteria punctualia in inguina, ex utraque parte unum, supra didy- "mum; quod si non cauterizes, aqua iterum redit. Sed cauteria redire " materiam iterum non permittunt." LANFRAJiC " Et iterum redit nisi cauterizetur post perforationem." Bruxus. "In apertione duplex est intentio, scilicet aperire et prohibere ne rursus ''aquadescendat." Fab. ab Aqxtapend " Avicennas utitur ferratnentis candentibss in regione inguinis ut cor- " rugatur pars, ne aqua posset descendere." Fab. ab Aq.capend. " Sin autem in rene vitium non fuerit, et defluxum plane impedire volueris 14 incisionem, superiore parte scroti prope inguina, fieri expedit- m A ' " quidem duplex chirurgo est scopus ; prior evacuare serosum hu morem " terior prohibere ne de novo aqua in scrotum defluat." " ' "Et quia tota aqua in tunica ilia (nempe vaginali) continebattir it t A TREATISE ON THE HYDROCELE. 1 \ been injected, with a view to closing or soldering broken lym- phatics; tedious and painful operations have been practised, for the eradication of imaginary cysts; directions have been given to evacuate the water at different times, lest the patient's strength should fail, or his health suffer, by its being done too suddenly; and the testicles being supposed to be frequently spoiled, by long laying in the water, castration has often been performed in the simple hydrocele. Dr. Monro (the father) who is professor of anatomy at Edin- burgh, and Mr. Samuel Sharp, late surgeon to Guy's hospital, arc almost the only writers who have sensibly and rationally explained the true nature dhd theory of these diseases: to them the profession is greatly obliged for having thrown much light on the subject, and for having furnished their readers with more just ideas than any others. SECT. III. The spermatic vessels, like most of the contents of the abdo- men, lie behind the peritoneum, enveloped in the common tela cellulosa, or what used to be called the cellular appendix of the peritoneum. The arteries, which are two, arise from the trunk of the aorta, in the midway between the emulgent and lower mesenteric. At their origin they are very small, and, contrary to all the other arteries of the body, they seem rather to increase in diameter as they descend. In their passage downward, they im- part several branches to the cellular membrane which invests them; and before they arrive at the testicles, they are divided into four or five principal ones; one of these goes to the epididymis, the others to the testis; the latter having passed the tunica albuginea, "testiculus ei innataret, ne in posterum denuo descenderet aqua acu incur- " vato ac filo reduplicato universam hanc tunicam (prater vasa seminalia) ap- ■' prehendi et mediocriter constrinxi, atque ligavi." Fab. Hudacttk 12 A TREATISE ON THE HYDROCELE. and being convoluted in a most wonderful manner, composes the greatest part of the body of that gland: from these convolutions of the spermatic artery, the semen is secreted: which fluid is, after such secretion, immediately received by those particular vessels, which late anatomists have agreed to call the vasa efferentia. These vary in their number, in different subjects, being from ten to fifteen, moYe or less: when collected together they form the globus major, or larger extremity of that body, which, from its situation, is called epididymis: after this, they unite into one single tube, which being convoluted and contorted, in the most miraculous manner, constitutes the rest of that same body: so that the whole of ihe epididymis, except that immediate point which is formed by the concurrence of the vasa efferentia, does really consist of one single tube, whose diameter is said, in no part, to exceed the eightieth of an inch, but which is contorted some thousands of times; and if unravelled, and drawn out, is some yards in length. From the lesser extremity of the epididymis proceeds the vas deferens, or that tube through which the semen is conveyed from the testis toward the penis; or, in other words, when this wonderful tube ceases to be convoluted, and puts on the appearance of one single, smooth vessel, it is then called vas de- ferens. This arises from the lesser end of the epididymis, en- veloped in the same common tela eellulosa, in which the spermatic artery and vein are invested; and when it has got just above the edge of the os pubis, it separates from the said vessels, and pass- ing down behind the peritoneum, proceeds to the inferior part of the neck of the bladder, where it deposits the semen, in the receptacles appointed for that purpose, called the vesicular se- minales. The blood, after the seitiinal secretion is performed, returns back into the general mass, by the spermatic vein: which on the right side empties itself into the vena cava, and on the left into the emulgent. While the spermatic vessels are within the cavity of the belly the cellular membrane, in which they are enveloped, is much more lax and tender, and is endued with larger cells, than it is on the outside of the same cavity. As they go under the transversalis and obliquus internus muscle, and through the obliquus externus A TREATISE ON THE HYDROCELE. 13 they receive a considerable addition of cellular membrane from the adjacent parts; and, when they have passed through the ten- dinous aperture of the last named muscle, they, together with their cellular tunic,h are covered by, and enveloped in, that expansion of muscular fibres, called the cremaster. The membrane surrounding all that part of the spermatic ves- sels, which is on the outside of the abdomen, is called the tunica communis, or tunica vaginalis of the chord; and is (as has already been said) merely cellular; totally void of all other cavity than its cells; firmly adherent to the surface of the said vessels, in every part; and plentifully furnished with lymphatics. It is of very great importance to have a just idea of the struc- ture of this part of the funiculus spermaticus. The old term, tu- nica vaginalis, conveyed a very false one: it implied, that the ves- sels were contained within it, as in a sheath, and that, if the said vessels were not there, this coat would form an empty bag, con- sisting of one cavity only; than which nothing can be more un- true.' h The passage of the spermatic vessels tinder two of the muscles, and through the third, is a circumstance of much importance, and what every prac- titioner ought to be well acquainted with. The common doctrine is, that in each of the oblique muscles and in the transversalis is a tendinous aperture, for the transit of the sperniatic chord , and these supposed openings are called the rings. This is a mistake, which even some very modern writers in anatomy have fallen into : and lest their words should not convey an idea sufficiently erroneous, some of them have given us drawings of all these openings in regular gradations, above and be- hind each other. Nothing can be more false than such representation : the spermatic vessels do never pass through, but always under the transversalis and obliquus internus, at such distance as never to be affected by their action, or to suffer any stricture or strangulation from them. On the contrary, the spermatic chord always passes through an opening made for thai purpose in the tendon of the obliquus externus; the action of which it is liable to be af- fected by: and when it is accompanied by a portion of intestine, (as in the case of an hernia,) it is this tendinous aperture which produces the stricture, the symptoms, and the hazard—a circumstance of great consequence for every man to know, who may ever be called upon to operate on a strangu- lated hernia. 1 Even M. de la Faye, whose notes on Dionis have rendered the works of the latter more useful, has fallen into the common mistake with regard to this tunic, by supposing both it and the vaginalis to be formed out of the same membrane, and allotting a cavity or bag to the former. " II faut remarquer, 14 A TREATISE ON THE HYDROCELE. This is one great source, from whence many of the errors, which have been committed in the description of such diseases, as have (or are supposed to have) their seat in this part, have sprung; and therefore I take the liberty of repeating, that this tu- nic has no one particular cavity, but is a mere cellular membrane throughout its whole extent; and that it terminates, in a great measure, just above the epididymis, though a continuation of it may be traced on the surface of the tunica vaginalis testis. The coats of Jhe testicle are two only; viz. the tunica vaginalis, or that bag which loosely invests it, without any adhesion to it, except in one particular part; and the tunica albuginea, or that membrane, which is the immediate and proper covering of its vas- cular structure. A true and clear idea of these is absolutely ne- cessary to the right understanding the diseases to which this gland is subject. In order to obtain such idea, the testicles must be examined, not only in an adult state, but in the infantine, and in that before birth also; each of these states having its peculiarities, and all tending to explain the true nature of such maladies, as it is frequently subject to. The testicles of the human species are always formed within the cavity of the belly, and remain there until or very near unto the time of birth. While they are within the abdomen, they are covered by one coat only; which coat firmly adheres to the vascu- lar structure of them, and is evidently derived from the perito- neum, in the same manner as the outer coat of each of the viscera of the said cavity is. Their situation, during the first months, is higher than in the latter; and as the foetus increases in size, they slip gradually lower. Within the cavity of the abdomen, on each side, a little below the testes, is a small opening, or orifice which leads immediately into a small but firm membranous ba°- or cyst whose upper part, or neck, passes through the opening in the ten- dons in the obliqui externi muscles; while its lower part or sac- " que la tunique vaginale et la game du cordon spermalique sont une con- ■' tinuation du tissue celluleux du peritoine, qui s'allonge pour enveloper le " testicule ; a I'endroit, ou cette continuation s'elargit, la nature a fo ' " cloison qui empeche la communication qui se trouveroit entro l»:~» • ,., , , .. , . , , . cmre»mteneur de " la game du cordon spermatique, et celui de la tunique vaginale " D* ia Tayt A TREATISE ON THE HYDROCELE. 15 cuius, lies on the outside of said muscles in the groin, enveloped in the common tela cellulosa. These orifices are always open until birth; and, most frequently, for some while after; during all which space of time, the said sacculi have free and open com- munication with the cavity of the belly. By means of these orifices the testicles pass from the cavity of the abdomen, through the tendinous apertures, into the sacculi in the groins; but, the time in which they make this transit is by no means certain: sometimes it is just before birth, sometimes just after; sometimes they drop immediately into the scrotum, and sometimes they remain a considerable time in the groins; and, it now and then happens, that they never pass through the muscle at all, but remain for ever within the belly. These are a kind of lusus naturae; but, in the ordinary course, they soon pass from the groins into the scrotal bags, the communication between the said bags and the belly continuing open some little time longer. When the testicles are got fairly down into the sacculi, if the said sacculi be laid open, it will appear that the testicles are Joosely enveloped by them, in such a manner as to be perfectly free from all cohesion, except in one part, where this bag and the proper coat of the testicle (the albuginea) are so firmly united, as to be plainly and demonstrably a continuation of one and the same mem- brane. And, while the communication with the belly continues free and open, if the sacculi be divided from the bottom upward, it will as evidently appear that the membrane of which they are composed is a continuation, or process of that part of the perito- neum which lines the muscles of the abdomen. Some time after birth, the necks of these sacculi become close and impervious; and, from that time, all communication between their cavities and that of the befly ceases. The lime when this happens is various and uncertain; I have seen them perfectly closed within a week, and open at the end of two months; nor do they both necessarily become close at the same time, in the same sub- ject. It sometimes happens, that while these passages are open, a piece of intestine insinuates itself into one of them, and, prevent- ing its closing, produces what Haller calls a congenial hernia; a disease which, though a modern discovery* has always been very 16 A TREATISE ON THE HYDROCELE. frequent. It also sometimes happens, that the spermatic vessels not being sufficiently closed, one of the testicles rests in the groin, just without the opening in the abdominal muscle, and, by not be- coming pendulous in the scrotum, the orifice of the neck of the sacculus is not closed at all; even though no portion of gut or caul has got into it. When these orifices have been once perfectly closed, there never is any future communication between the cavities of the sacculi and that of the belly; nor can any thing solid or fluid (however small in size or quantity) ever, after this period, pass from the one to the other. The upper part, or neck, now loses all appearance of a distinct canal; and the lower part, or sac, loosely invests the testicle, and its epididymis, without any adhe- sion, except in the hinder part. The inside or cavity of this sac is constantly kept moist by the exudation of a fine fluid; which fluid is as constantly absorbed: so that, while these parts enjoy a sound healthy state, the fluid is no more in quantity, than what just serves to lubricate and keep moist the surfaces of both mem- branes, and thereby prevent any unnatural cohesion of them with each other. From these premises, the following inferences, serving to point out and explain the true nature and seat of some of the diseases in question, may, I think, be deduced. 1. That the sacculi, or bags, found in the groins, are originally formed parts. 2. That they are placed there for the future reception of the testicles; and that when the upper part, or neck, of one of them becomes close and impervious, the lower part, or sacculus con- stitutes and forms what is properly called the tunica vaginalis testis; which is therefore a true and original process of the peri- toneum. 3. That of all the parts contained within the scrotum these sacculi are the only ones which ever naturally communicate with the cavity of the belly. 4. That, after a certain space of time, that communication ceases. A TREATISE ON THE HYDROCELE. 17. 3. That whatever fluid may be shed from the spermatic ves- sels, or collected, or extravasaled, in the cells of the tunica com- munis, or in those of the dartos; yet no part of such fluid can be derived from, or received into, the cavity of the tunica vaginalis testis. 6. That a total failure of the secretion of that fine fluid, which should moisten the inside of the vaginal tunic, and the outside of the albuginea, must be followed by an unnatural cohesion of these membranes with each other; and either a partial or total abolition of the cavity of the former. 7. That if more of this fluid be deposited than the absorbent vessels can take up, or if the absorbent vessels do not execute their office, such fluid must be accumulated within the cavity of the said tunic; from which, there being no natural outlet, the conse- quence must be a gradual distention and enlargement of it. 8. That the natural communication between the cavity of the tunica vaginalis and the belly, not being shut until some space of time after birth, it may become close at its upper part, while there is a quantity of fluid in the lower, too large for the absorbent ves- sels to take up immediately; and, consequently, that such infant will, until that office be executed, labour under a true hydrocele of the tunica vaginalis testis; a case which is very frequent, though generally mistaken for a wind rupture. And, 9. That the fluid of that kind of hydrocele, which is form- ed by the sac of a congenial hernia, must be lodged within the cavity of the vaginal coat; while all collections of serum, in the sacs of all other kiijds of hernia), most necessarily be perfectly distinct from the sai<$ tunic. I should now proceed to the examination of each distinct spe- cies of hydrocele, but will intrude upon my reader's patience while I mention a circumstance or two, relative to the passage of the testicle from the belly into the scrotum; and which, as a prac- titioner, he may possibly think worth his attention. I have said, that the time in or at which the testicles pass from the belly, through the groin, into the scrotum, is by no means cer- tain; that it varies in different people; that even iii the sam;; per- son, the two testes do not always pass down at the same time; '/or., it. r IS A TREATISE ON THE HYDROCELE that sometimes both of them, sometimes one, remains within the bciv, or in the groin, for a considerable space of time afterbirth; and'that it now and then happens, that one or both of them never get into the scrotum at all. I do not know any particular inconvenience arising from the detention of a trslic le within the cavity of the belly; but the lodge- ment of it in the groin not only renders it liable to be hurt by ac- cidental pressure, &c. hut when it is so hurt, may be the cause of its being mistaken for a different disease, and thereby occasion its being very improperly treated. To which considerations, this may be added, that there is no kind of disease, to which the tes- ticle is liable in its natural situation, but what may also affect it.v in any or all its unnatural ones. CASE I. r I was sent to, in a great hurry, from the neighbourhood of Lime- house, and desired to bring with me whatever I might want for the operation of a bubonocele. I found a young, healthy, sea- faring man, lying across his bed, and complaining of most acute pain in his groin and back. He told me, that, " In the forenoon of the day before, being at work on board his own vessel, he fell.. and struck his groin against a piece of timber with great violence; that it gave him such exquisite pain, that he fainted away; that his groin became immediately swollen to a very considerable de- gree; that as soon as he could get home, he applied to his apothe- cary, who bled him, put him to bed, and poulticed the tumor; that he passed the night without sleep, and in great agony; that when his apothecary came to him the next morning, he (the patient) in- formed him of a circumstance, which, in his confusion he had forgot the night before, viz. that he had long had a rupture on that side, which hud never been perfectly returned- that upon receipt of this information, the apothecary had bled him awain and had taken some pains to return the rupture: but finding that he made no progress, and that his attempts produced great in- crease of pain, he had desisted, and had given him two clysters and a purge; neither of which occasioning such discharge as he A TREATISE ON THE HYDROCELE. 19 expected, and a kind of blackness now beginning to appear on the part, he desired immediate assistance." By the time this ac^ count was finished, the apothecary came in, and confirmed it. The pain was exquisite; and while I was asking the patient a few questions, he became very sick, and vomited. The groin and scrotum were much swelled, and very hard; but the general figure and appearance of the tumor did not appear to me like that of a bubonocele: instead of pointing obliquely from the ileum to- ward the pubes, it lay, as it were, across the groin: the scrotum was full and large; but I thought it felt much harder than I had ever found a piece of intestine do; and with regard to the altera- tion of colour, I cannot say it gave me much uneasiness; for it was not at all like the effect of mortification, but had all the ap- pearance of an extravasation, or ecchymosis. On the other hand, the man had not had a fair stool for three days; he had been very sick, and had vomited; his belly was tight, hard, and painful; and his pulse much too quick. From examination of the tumor, I could get very little information; for the pain was so exquisite, that he could not bear the slightest touch: however, from what Examination I could make, it appeared to me, that if this was an intestinal hernia, it was such an one as I had never yet met with; and nothing but the circumstance of his having worn a truss for- merly, by the direction of a surgeon of character, could have in- duced me to have entertained such suspicion. I inquired again concerning this rupture, and was told, that he had worn a truss for it the first four years of his infancy, but that it never kept the gut totally or perfectly up; and that, as he grew bigger, and ran about, he was obliged to leave it off, on account of the pain it gave him: that since he had left it off, he had not observed any, or very little alteration in the tumor; (none in its situation, though a little in its size;) and that it had never given him any trouble or uneasiness, if he did not handle it, or kept the waistband of his breeches and his watch from pressing it. All this was far from being satisfactory: and as the present state of the parts was such, as was by no means favourable fbr an operation, I determined, previous to any other attempt, to try what a brisk cathartic would produce. A stimulating clyster was immediately thrown up, and a solution of an ounce and a half of Glauber's salts in two ounces 20 A TREATISE ON THE HYDROCELE. of inf. sense swallowed, which, in little more than an hour, pro- duced so plentiful a discharge, that the belly became soft and easy, and we were perfectly free from all apprehensions of a stric- ture. Fomentation, poultice, &c. were frequently applied to the tumor, which in three or four days began to subside; and in about seven or eight the scrotum was so unloaded as to permit easy and accurate examination; by which means we were satisfied, that it contained no testicle. Upon mentioning this circumstance to the patient, he said that he never had one on that side. This declara- tion was a solution of all difficulties, and of all the appearances. Wrhen all the effects of the blow were removed, there appeared in the groin, just on this side of the opening in the abdominal ten- don, a testicle of natural size and figure; which testicle, by being much bruised, had caused all the mischief. CASE II A poor man came to St. Bartholomew's hospital, and desired assistance for a swelling in his groin; for which he had, for a month before, been taking Jesuits' drops and other quack medi- cines, till he had not a farthing left. Upon removing an adhesive plaster, I found a tumor which was large and painful; but at the same time so moveable, as to be very unlike any affection of the inguinal glands. The account which the man gave was, that ' He had always had a lump in that groin, and never any testicle on that side; that when young, he had worn a truss for it, upon a supposition of its being a rupture; that when he came to work for his living, he could no longer bear the uneasiness which the truss gave him, and therefore had left it off for years: that since that time he had never perceived any material alteration in the tumor, nor had it ever given him any trouble, till he had got a clap about two months before; upon the sudden disappearance of which the lump in his groin became large and painful." In short, the man had got a hernia humoralis of the testicle in his groin; which, by means of proper treatment, bleeding, cata- plasm, and rest, be soon got well of. A TREATISE ON THE HYDROCELE. 01 *j 1 CASE'III. A middle-aged man came to St. Bartholomew's, for advice for a tumor in his groin. He was apparently in good health; the tumor was of an oval or egg-like form, indolent when not pressed, perfectly moveable, lay just in the groin, and had by more than one person been mistaken both for bubo and bubonocele. When handled or pressed rudely in consequence of the latter opinion, it was painful for some hours after; and the pains (to use his own words) always shot up into his back. It was on the left side; on which side there was no testicle in the scrotum, nor had there ever been one; but on the right side every thing was as it should be. He said that within two years it had been considerably enlarged; and that it now was become very troublesome to him. It appeared very plainly to me that the tumor was caused by the left testicle; which testicle was in a diseased state, but very fit for and very capable of extirpation. I advised the man to submit to the operation, and he had complied; but the late Mr. Griffiths (one of our then assistants) coming into the ward, I desired him to look at the case. Whether he did not attend to all the cir- cumstances, or for what other reason, I know not; but he took it into his head, that it was a tumor of another kind, that might be removed by internal medicine; and dissuaded the man from un- dergoing what I had proposed: upon which I did not take him into the hospital. Some months after, the swelling becoming larger and more troublesome, he applied to St. George's hospital. The gentlemen there gave him the same opinion, and the same advice which I had given him; he submitted, and got a cure, by the removal of a testicle which had never been lower than his groin, and which was now become scirrhous. 11 A TREATISE ON THE HYDROCELE- CASE IV. The late Mr. Hollingworth desired me to go with him to see a patient in the neighbourhood of Clerkenwell. It was a man about fifty-five years old, who had a large ulcerated cancerous tumor in his right groin, with high callous edges: it always discharged a large quantity of a most offensive gleet; at times it bled profusely, and was always extremely painful. The patient said, that when first it became troublesome, he had showed it to two eminent rupture-curers; one of whom said, that it was a piece of caul, and offered, for twenty guineas, to cure him by cutting it out: the other (more modest, or less hardy,) only sold him two bandages for it; neither of which he could ever wear. When Mr. Hollingworth carried me to see it, it had just beep left by atancer-curer, who had applied to it an escharotic; and which, by the patient's account, as well as by the appearance of the sore, had made terrible havoc. During all this time, no one who had seen him (and what is still more remarkable, not even the patient himself) had remarked, that in that side of the scrotum he had no testicle. The state, both of the man and of the sore, forbad any chirur- gical process; and my advice to him was to dress the sore lightly, and have recourse to tinct. thebaic, for ease: which advice he fol- lowed, during the short remainder of his life. When dead we examined him, and found that the disease con- sisted in a cancerous testicle lying in the groin; the spermatic vessels of which were varicose, and knotty all the way up to the kidney, having here and there a bladder of yellow serum in the cellular membrane: the lymphatic glands about the vertebrae of the loins were diseased, as was the liver; and on the surface of the right kidney was a collection of offensive sanies. A TREATISE ON THE HYDROCELE. SECT IV. THE ANASARCOUS TUMOR OF THE SCROTUM. The scrotum is the common receptacle of both the testicles, and consists of the cuticula, cutis, and what all the anatomists have now agreed to call the dartos; which is a loose cellular membrane, perfectly void of fat, and whose cells or cavities communicate with each other, with the utmost freedom, through every part. As this membrane has no immediate communication ttilh the cavity of the abdomen within the peritoneum, it is plain, that whatever kind or quantity of fluid may be deposited in it, it cannot be derived from the said cavity, even though the patient should labour under a true ascites; but as its cells have a free intercourse with those of the general cellular membrane all over the body, they will be liable to be affected by all those disorders which have their seat in that membrane; that is, by all disorders pro- ceeding from a low impoverished state of blood, from a deficiency of the urinary secretion, or from non-execution of the office of the absorbent vessels; and consequently, in anasarcous and leuco- phlegmatic habits, will become the seat of a watery extravasation. This watery swelling of the scrotum, although it be most fre- quently a symptom of a dropsical habit, and very often accompa- nies both the general anasarca, and the particular collection with- in the abdomen, called the ascites, yet, even in the latter case, neither is, nor can be, derived from the cavity of the belly, but is confined to the tela cellulosa, which lies on the outside of the peri- toneum: the water derived from hence distends the scrotum, in the same manner, and for the same reasons, that it often docs the legs and feet. The cells of the dartos being larger and absolutely void of fat, and the skin which covers them being extremely dilatable, and giving way for a larger infltix into this part than into most others, has indeed occasioned its being taken notice of as a particular disease, though it is most properly a symptom only. This being the case, and the true method of cure consisting in 24 A TREATISE ON THE HYDROCLLL. an internal medical process, it has been, I think, improperly rank- ed among the species of hydrocele; though the nature of the con- tents will certainly admit the use of the word. It is indeed a disease, which properly belongs to the physicians; but as it is of some consequence to be able to distinguish it from other disorders affecting the same, or the neighbouring parts, and as surgeons are often called upon to assist in alleviating some of the inconveniences which this defluxion produces, it cannot be amiss in this place to give a short account of it, and of the most proper chirurgical method of attempting its relief. It is an equal, soft tumor, possessing every part of the cellular membrane, in which both the testicles are enveloped, and con- sequently is generally as large on one side as on the other; it leaves the skin of its natural colour; or, to speak more properly, it does not redden or inflame it. If the quantity of water be not large, nor the distention great, the skin preserves some degree of rugosity; the tumor has a doughy kind of feel; easily receives, and for a while retains, the impression of the fingers; the raphe or seam of the scrotum divides the swelling nearly equally; the sper- matic process is perfectly free, and of its natural size; and the testicles seem to be in the middle of the loaded membrane. This is the appearance when the disease is in a moderate degree. But if the quantity of extravasated serum be large, or the disease far- ther advanced, the skin, instead of being wrinkled, is smooth, tense, and plainly shows the limpid state of the fluid underneath: it is cold to the touch, does not so long retain the impression of the finger, and is always accompanied with a similar distention of the skin of the penis; the preputium of which is sometimes so enlarged, and so twisted, and distorted, as to make a very disa- greeable appearance. These are the local symptoms: to which it may be added, that a yellow countenance, a loss of appetite a deficiency of urinary secretion, swelled legs, a hard belly, and mucous stoob, are its very frequent companions. The cure of the original disease comes, as I have already said, within the province of the physician, and requires a course of inter- nal medicine: but sometimes the loaded scrotum and npnic *™ »« • I . |-*wiia d.rc SO troublesome to the patient, and in such dinger of mortifi t" that a reduction of their size becomes absolutely nectary- -> j t A TREATISE ON THE HYDROCELE. 2o other times a derivation, or discharge, of the redundant extravasat- ed serum from this part is ordered as an assistant to the internal regimen. The chirurgical means in use for this end is called in general scarification; a term, whose precise sense has by no means been settled; by which it has now and then happened, that a general order being given, and the particular method of executing it being left to the choice of those who have not been sufficiently acquaint- ed with this kind of business, much hazard has been incurred, and considerable mischief done, which might have been avoided. The means of making this discharge are two, viz. puncture and incision: the former is made with the point of a lancet; the latter with the same instrument, or with a knife. The generality of writers on this subject have spoken on the two methods in such a manner, that a practitioner, who had seen but little of either, would be inclined to think that it was a matter of great indifference which we should make use of, and that the safety and utility of each were equal, which is by no means the case. The intention of the use of either is, by a discharge of extrava- sated serum, to alleviate the present uneasiness; and, by reducing the size of the scrotum, to render it less troublesome, and less likely to mortify. In some few instances it has indeed happened, that this drain has proved a radical cure of the original disease; but that has been accidental, and is not in general to be expected. The intention is generally palliative; and, if the patient lives, is most likely to require repetition: therefore, if there be any differ- ence between the two methods, with regard either to ease or safety, there can be no doubt which ought to be preferred. All wounds of membranous parts, in anasarcous or dropsical habits, are necessarily both painful and hazardous: they are apt to inflame, are very difficultly brought to suppuration, and will often prove gangrenous in spite of all endeavours to the contrary. But, the larger and deeper the wouuds are, the more probable are these bad consequences. Simple punctures with the point of a lancet are much less liable to be attended by them, than any other kind of wound; they generally leave the skin easy, soft, cool, unin- vol. n. n 26 A TREATISE ON THE HYDROCELE. flamed, and in a state to admit a repetition of the same operation, if necessary. Incisions create a painful, crude, hazardous sore, requiring constant care. Punctures seldom produce any uneasi- ness at all; and stand in need of only a superficial pledget, for dressing. Now, although there is so very material a difference in the symptoms and trouble attending the two methods, yet there is none in their effect: the communication of the cells of the dartos with each other is so free, through every part of it, that punctures made with the fine point of a bleeding lancet, into the most superficial of them, will, as certainly and as freely, drain off all the water, as a large incision, without any of its inconveniences or its hazard. Neilher the one nor the other will cure the original disease, unless by mere accident: they are both made with a design to cure only the local one. The same habit and constitution remaining, the same effect will in general follow, and the same relief be again necessary. The ease, the freedom from bad symptoms, or from danger, and the state in which the parts are left, render one method practicable at all times, and capable of being repeated as often as may be thought necessary: the fatigue, pain, confinement, and ha- zard, which most frequently attend the other, make one experiment in general as much as most people choose to submit to, or indeed an opportunity of complying with. CASE V. A man, about fifty-five years old, who had lived freely, wa.< afflicted wtth an anasarcous tumor of the belly, legs, thighs scro- tum, and penis, accompanied with the general symptoms which most frequently attend such complaints, viz. prostration of appe- tite; little urine, and that high coloured; a hard belly; and a bloated face. He had taken many medicines bythe direction of a physician in the country, and more than one quack remedy since he had been in London, but to no purpose: the watery load increased daily, and the swelling of the penis and scrotum became so trou- blesome, as to prevent his wearing breeches A TREATISE ON THE HYDROCELE. 27 In these circumstances, a person who attended him in the ca- pacities of apothecary and surgeon, proposed to draw off the water by an incision on each side of the scrotum; to which the patient consented. The incisions were made, and in a few hours the scrotum was empty and flaccid. At the distance of five days from this operation, his surgeou died, and I was desired to visit him. I found him in bed, with a painful, foul, undigested sore, on each side of the scrotum; which, though it had at first been emptied by the incision, was now again considerably loaded with serum, but at the same time hard and inflamed: the edges of the wounds were livid, the discharge from them was a discoloured gleet; and the pain was so great, that the man could get no rest; his pulse was frequent, hard, and small; his breathing not perfectly free; his urine little, and high coloured; his thirst very troublesome; hi3 belly hard and tight; and, having taken an opiate every night from the time of the operation, he had not had a stool for three days past. 1 dressed the incisions with a soft digestive; and, covering the whole scrotum with a warm poultice, tied it up in a bag truss; di- rected a clyster to be thrown up immediately, and a purge to be taken the next morning: from which in the following day he had four or five stools, and by which his respiration was relieved, and his belly rendered softer. Next day the inflammatory hardness of the scrotum seemed to be going off, but to be succeeded by an emphysematous kind of tumefaction; and, in four days from that of my first visit to him, the whole bag was in a state of mortification, notwithstanding the constant use of fomentation, cataplasm, &c. Having already taken a large quantity of medicine of different kinds, it was with much difficulty that I could prevail on him to hear of any more: but, upon making a true representation to him of the state of his case, and of his imminent hazard, he consented to take the bark, with some confect. cardiac, and tinct rad. ser- pent, every three or four hours. By putting a tea-spoonful of brandy into each dose, it kept upon his stomach. At the end of three days, the pain and soreness w«rc considerably lessened; and on the sixth he got a little quiet 23 A TREATISE ON THE HYDROCELE. sleep without any opiate: on the ninth, the mortified parts seemed inclined to suppurate, and the gleet was small, in comparison of what it had been; on the twelfth, there was an appearance of tole- rable good matter from the edges; on the fifteenth, a laudable sup- puration was established, and the mortified parts were every where , loose and falling off. Instead of a small quantity of high coloured urine, he now made what was nearly equal to his drink, and that very well conditioned; and the watery extravasation in his legs and thighs was considerably diminished. He now began to nauseate the bark, in the form in which he had hitherto taken it; it was therefore changed for another, which he took at larger intervals; and, to assist his urinary discharge, his apothecary gave him an infusion of the cineres genistas and horse- radish, which answered the purpose very well. The whole scrotum and dartos cast off in a large slough, and left the tunica vaginalis of both testicles as bare and clean as if they had been dissected: these were soon covered by an incarna- tion, which supplied the place of the scrotum tolerably well; and, by persisting in the use of the same remedies for a few weeks longer, he was restored to perfect health. CASE VI. A man, not exceeding forty, who had drunk freely of spirituous liquors, was thereby brought into the same circumstances as the patient in the preceding case; that is, his countenance was yellow and bloated; his legs, thighs, scrotum, and penis, loaded with a watery tumor; he had little or no appetite; and made a very small quantity of high coloured urine. Internal remedies having been ineffectually tried for some time he was advised to have an incision made on each side of the scrotum; by means of which, all the swelling, both of it and of the penis, was immediately removed, and the patient much pleased. On the fourth day from the operation all discharge of serum ceased, and the wounded part swelled, inflamed, and became very v.laful. Fomentation, cataplasm, and proper digestive dressings A TREATISE ON THE HYDROCELE. 29 were used, but without any relief from the pain, or any beneficial alteration in the appearance of the sores. On the sixth day from that of the incision, I was desired to meet the gentleman that had the care of him. I found that the hard inflammatory swelling, which a day or two before had occupied the whole scrotum, was now gone off, and that it was become flabby and livid, especially about the incisions. I proposed his taking the cortex, but it was not complied with; nor do I know what the medicines were which he did take, neither myself nor his attendant surgeon being consulted on that head. Warm spirituous fomentations, with proper poultice and dressings, were continued, but to no purpose. I saw the patient each morning for four days; dusing which, he got little or no rest, and complained of great pain and burning heat within his belly; the watery extravasation in his thighs and legs increased daily; the whole scrotum and skin of the penis became black, and mor- tified, as did also the part of the pubes; and on the eleventh day from that on which the .incision was made, he died. CASE VII. A man, about forty-five years old, by name Corby, who was a patient in St. Bartholomew's hospital on another account, showed me a swelling on the left side of his scrotum. It was large, full, tight, and had all the symptoms and appearances of an hydrocele of the tunica vaginalis; viz. the fluctuation of the fluid, the freedom of the upper part of the process, and the concealment of the testicle. I thought myself so clear in the true nature of the disease, that, without any scruple, I pierced it with a small trocar in the lower and an- terior part, and thereby let out about two ounces of limpid water; but could by no means draw off any more, though I pressed a probe up through the cannula, and used every other means proper to obtain it. I withdrew the cannula, and examined the swelling again, which was but little diminished by what had been done: but, I hough it was not much decreased in size, it was considerably altered in appearance. I could now very plainly distinguish the 30 A TREATISE ON THE HYDROCELE. testicle, and was convinced, that the whole disease was confined to the cells of the dartos. In short, it was (what I had never seen before) an anasarca of that membrane, on one side only; having a certain quantity of the water in one cyst or bag, and the rest diffused through the cells in the usual manner: the latter made all the tumefaction which remained after tapping; and the former had concealed the testicle. Being now truly satisfied of the nature of the case, I made an incision, about an inch long, through the scrotum into the loaded dartos; intending thereby to drain off the water, and, by pro- curing a suppuration, to cure the disease. Into the incision I put a little dry lint, and tied the scrotum up in a bag-truss. To my great astonishment, the. next day my dresser told me, that Corby's scrotum was swelled to a great size, and that the in- cision was already livid. I went to the hospital and found it so: I ordered the |>art to be fomented, and wrapped up in a warm poul- tice; and that the man should take the cortex freely, till the phy- sician should see him. In three days time, the whole scrotum and the skin of the penis were completely mortified; and a considerable part of the pubes altered and vesicated: his pulse was quick and small; he com- plained of a burning heat in his belly and bladder; his thirst was intense; and his extremities cold. For several days I was convinced that each would be his last: his fomentation, cataplasm, and dressings, were continued. The doctor ordered him a dram of the bark, as often as his stomach would bear or keep it, in a julep, well impregnated with volatile salt; and the poor man earnestly begged to be allowed a pint of porter a day; which he had. At last, in about three weeks time, the whole scrotum, the integuments of the penis, and some part of the pubes cast off, leaving the corpora cavernosa and the tunica va- ginalis as clean as if they had been dissected. The man got well. More of the same kind of cases might be produced, in which the trouble and hazard attending large incisions of the scrotum in dropsical cases, have been great; but the similarity of them ren- ders it unnecessary. I shall therefore only add, that from the simple puncture I have seldom met with either: and that I have A TREATISE ON THE HYDROCELE. 31 as seldom known them fail to answer the purpose for which they were intended, viz. a temporary discharge of serum from the cel- lular membrane. SECT. V. If we consider the preceding complaint as merely symptomatic, and do not rank it among the different kinds of hydrocele, there will then remain only three; viz. 1. That which consists of a collection of water in the cells of the tunica communis, or cellular emembrane, enveloping and con- necting the spermatic vessels. 2. That which is formed by the extravasation of a fluid, in the same coat as the former, but which, instead of being diffused through the general cellular structure of it, is confined to one cavity or cyst, in which all the water constituting this species of disease is contained; the rest of the membrane being in its natural state. 3. That which is produced by the accumulation of a quantity of water, in the cavity of the tunica vaginalis testis. These three are distinct, local, and truly within the province of surgery. They may accidentally be combined or connected with other disorders, but not necessarily; and are frequently found in persons whose general habit is good, and who are perfectly free from all other complaints. THE HYDROCELE OP THE CELLS OF THE TUNICA COMMUNIS. In the anatomical account of the parts, which make the seats of the different kinds of hydrocele, it has been observed that the spermatic vessels, from their origin quite down to the insertion into the testicle, are enveloped in, and connected together by, a membrane, called formerly tunica vaginalis vasorum spermatico- rum, hut now (more properly) tunica communis. That this mem- 32 A TREATISE ON THE HYDROCELE. brane so enveloping the spermatic vessels has no one particular cavity (as its old name would seem to imply); but is merely cellular, as either the inflation of air, or the extravasation of a fluid, will always prove. That while it is within the cavity of the bellv, its cells are lax and large; and when it has passed out from thence, and has formed a part of the spermatic process, by enveloping its vessels, its cells are rather smaller, and the mem- brane composing them firmer. That it is included within that thin expansion of muscular fibres, called the cremaster. And that a great number of lymphatics, passing from the testicle to the receptaculum chyli, are always to be found in it. An attentive consideration of these circumstances in the struc- ture of this part will show us, why either obstruction or breach in the lymphatic vessels, considerable pressure by means of diseased indurations within the abdomen, or a morbid state of the parts which should receive the lymph from the vessels of the spermatic chord, may induce the disease in question; and also, when it is pro- duced, that its appearance, and nature of the extravasation, must make the term cellular a very proper one, as expressive of its true state.k When the disease is simple, it is perfectly local; that is, it is confined entirely to the membrane forming the tunica communis; and does not at all affect, either the dartos, the tunica vaginalis testis, or any other part. It is a complaint which does not give a great deal of trouble unless it arrives to a considerable size; and being by no means so frequent as either of the other two kinds of hydrocele, it is in gene- ral but little known or attended to. With some, it passes for a varix of the spermatic chord; with others, for the descent of a k "J'ai souvent vu des tumeurs aqueuses, grosses comme des grains de " rasin, placdes d'espace en espace le long du cordon spermatique accompa- "gner une veritable hydrocele placee surle corps du testicle." Le Dran. The first part of this paragraph is a just and true description of the hydro- cele of the cells of the tunica communis, w lien not much distended: but if by "une veritable hydrocele," Mr. Le Dran means that of the tunica vaginalis, his description of it, as " une tumeur aqueuse, placee surle corps du testi- cule," is very inexpressive, inadequate, and likely to convey an erroneous idea. A TREATISE ON THE HYDROCELE. 33 portion of omentum, which having contracted an adhesion cannot be returned. Thus its true nature not being in general rightly understood, and it giving but little trouble or uneasiness while it is within moderate bounds, and neither hindering any necessary action or faculty, they who have it are most frequently advised to be contented with a suspensory bandage, and find very little incon- venience from it. Sometimes it arises to so large a size, and gets into such a state, as to become an object of surgery, and to require our very serious attention. In general, while it is of moderate size, the state of it is as fol- lows. The scrotal bag is free from all appearance of disease; except that, when the skin is not corrugated, it seems rather fuller, and hangs rather lower on that side than on the other, and if sus- pended lightly on the palm of the hand, feels heavier: the testicle. with its epididymis, is to be felt perfectly distinct below this ful- ness, neither enlarged nor in any manner altered from its natural state: the spermatic process is considerably larger than it ought to be, and feels like a varix, or like an omental hernia, according to the different size of the tumor: it has a pyramidal kind of form, broader at the bottom than at the top: by gentle and continued pressure it seems gradually to recede or go up, but drops down again immediately upon removing the pressure; and that as freely in a supine as in an erect posture: it is attended with a very small degree of pain or uneasiness; which uneasiness is not felt in the scrotum, where the tumefaction is, but in the loins. If the extravasation be confined to what is called the spermatic process, the opening in the tendon of the abdominal muscle is not at all dilated, and the process passing through it may be very distinctly felt; but if the cellular membrane which invests the spermatic vessels within the abdomen be affected, the tendinous aperture is enlarged; and the increased size of the distended mem- brane passing through it, produces to the touch a sensation not very unlike that of an omental rupture. While it is small it is hardly an object of surgery; the pain or inconvenience which it produces being so little, that few people would choose to submit to an operation to get rid of it; and it is very seldom radically curable without one: but when it is large, vol. n. r •»4 A TREATISE ON 'I HE HYDROCIfli. or affects the membrane within the cavity as well as without, it becomes an apparent deformity, is very inconvenient both from its size and weight, and the only method of cure which it admits is far from being void of hazard; as must appear to every one who will consider, or who is at all acquainted either with the nature of lymphatic extravasation or absorption, or with the frequent consequences of wounds inflicted on parts merely mem- branous. CASE \III. A man about fifty-five desired me to look at a rupture, under which he said he had laboured for several years. For the greatest part of that time he had worn a steel truss, which had given him little or no uneasiness, but had never kept his rupture up. Dur- ing all this time he never had any symptoms of obstruction in the intestinal canal; nor had the tumor ever increased in size, or alter- ed its appearance, until within the last three or four months, when he had been persuaded to change his truss for a bandage without iron, and to make use of an external application, which was said to be infallible. What the application was I know not; but its effect was an excoriation of the groin and parts about: the bandage was made of dimity, had a large hard bolster, with three or four buckles, and was buckled on very tight. He said, that the pain it had caused had been great; but that he had cheerfully submitted to it, having been assured that the medicines, assisted by the pressure, would soon shrink up a piece of caul which was in the scrotum, and thereby free him from all possibility of a return of his disease; and that after that was done, he might leave off all kind of bandage, and do as he pleased. He had now made the experiment, till the pain was so great and the parts so swelled, that he could endure it no longer. The scrotum was much inflamed, and swelled; the groin excoriated- the testicle enlarged, but not hard; the spermatic process quite up to the belly, full, tight, and so exquisitely painful that he A TREATISE ON THE HYDROCELE. 35 could not bear the most gentle handling; he had no obstruction on his going to stool; nor any symptom of the confinement of anv part of the intestinal canal. The principal information which I could get was from his own account; for he could not bear the slightest touch. From this it appeared to me, that whatever might be the true state of the case, it was very clear, that the first thing to be done was to obtain ease. I therefore put him to bed, bled him freely, ordered him to have a clyster thrown up immediately, and to take two spoonfuls of a purging mixture every two or three hours, until he should have a free discharge per anum; and then to take a grain of extract, thebaic. I wrapped up the scrotum, and covered the groin and pubes with a warm soft poultice, and put on a bag truss. He passed the day in a very uneasy restless state; and in the evening, finding his pulse not at all lower, nor his pain less, (his purging mixture having done its duty,) I took away fourteen ounces more of blood, and ordered his opiate to be taken again, and repeated at the distance of every six hours. Forty-eight hours passed over, during which time he took seven grains of opium, before he could get sleep or ease; and when he obtained the former, it did not last more than three or four hours (an effect I have several times seen, in the exhibition of large and fre- quently repeated doses of opium, given either to appease pain, or to quiet a phrenzy). When he awoke, he was easier, and seemed to be much re- freshed; his pulse was softer, his perspiration free, and the parts less inflamed, and less painful; his poultice was renewed after fomentation; and he was directed to take a draught of the com- mon emulsion every six hours, with some manna and nitre in it; by which means he had, in the course of the next day, two plenti- ful discharges by stool. By these means, within the space of six or seven days, all his inflammatory symptoms were removed; and the parts reduced to nearly the same state in which they were when he put on his dimity bandage: that is, the testicle was of its natural size, but the spermatic process large and full, though soft and indolent, and feeling very like to a small omental rupture. 3d A TREATISE ON THE HYDROCELE For greater certainty, I kept him in bed a day or two more; and confined him to lire same low regimen, with an open body. The spermatic process continued in the same state. I at- tempted to reduce the apparent rupture, but without success; though there was no reason to think that there was the least stricture made on it by the tendon of the abdominal muscle. I could indeed make a small part of it recede, but even that did not pass the opening at all like a piece of omentum; it did not give any of that sensation to my lingers, nor produce that kind of noise, which the return of a rupture into the abdomen generally does; and the moment I removed my fingers, it fell down again, although the patient was in a supine posture. In short, I made attempts for reduction so long, and so often, that I was perfectly satisfied that the prolapsed part was not reducible (at least by me). It now gave him no pain, nor uneasiness of any kind: but he had suffered so much from the pressure of his bandage, and was so satisfied (from the successless attempts which I had made) that his rupture was not capable of being reduced, that he contented himself with a common suspensory bag, and found not the least alteration in it for the space of three years. At the end of this time he was attacked with a peripneumony, and died. I obtained leave to examine his body, and found, that what 1 had taken for a portion of omentum was a collection of water in the cells of the tunica communis of the spermatic Vessels, on the outside of the cavity of the abdomen; that nothing else had passed through the tendon of the oblique muscle; and that the tes- ticle and tunica vaginalis were perfectly unaffected. Notwithstanding the account which this patient had given of himself, and of his having frequently reduced his rupture, I am sa- tisfied he never had one; and that his disease had, from the first been what it at last appeared to be. There was no sign of a her- nial sac; and though the return of such sac back again into the belly, after it had been in the groin or scrotum, is a thing much talked of by late writers, I do not believe that it ever happened. The steel truss did not press hard enough to produce any mis- chief, and was thought not to have kept his rupture up; and the symptoms, under which I found him labouring, were occasioned merely by the dimity bandage, substituted in the place of ^ A TREATISE ON THE HYDROCELE. 37 truss; which having large hard bolsters, and being buckled on very tight, pressed violently on the spermatic vessels and loaded membrane. CASE IX. A healthy middle aged man, applied to me one day, while 1 was dressing the hospital, and showed me a considerable swelling in his scrotum. I examined it, and told him I believed it to con- sist of water. He replied, he knew it: for that Mr. Baker, then one of the surgeons of the Westminster infirmary, had a few days before drawn some from it by puncture with a lancet Upon hear- ing this, I examined it again; imagining that I might possibly find it to be blood (a circumstance which now and then happens, after tapping a common hydrocele): but still it appeared to me to have all the marks of a tumor from water, and to be principally in the spermatic chord. The dartos was indeed a little thickened by the insinuation of a small quantity of a fluid into some of its cells, but the testicle was much too plainly distinguishable for the case to be taken for a hydrocele of the tunica vaginalis; nor was the uppei part of the process in that free state in which it is most frequently found in that disease. I took him into the hospital, and ordered him to keep his bed, till I saw him the next day; at which time I passed a small trocar into the anterior part of the tumor a little higher than usual. At first a limpid serum flowed freely; but that soon stopped, and I was necessitated to pass a probe frequently up the cannula, to get away the remainder; neither could I, either by that means, or by pressure, reduce the scrotum to a proper size, or remove the fulness of the process above. I ordered the part to be fomented night and morning, and the whole scrotum and groin to be covered with a soft poultice; and that the man should take a solution of manna and Glauber's salt the next morning. The applications were continued, and the purge repeated every second or third day, for a fortnight; at the end of which time, the swelling was as large as when I first saw it. During this interval of time, I frequently examined the parts; and always found the testicle.much more free, and independent, 38 A TREATISE ON THE HYDROCELL. than I had ever felt it in a hydrocele of the tunica vaginalis. It ap- peared to me, from the kind of fluid which had already been twice let out, and from the present appearance of the part, that no cure would be obtained without laying the whole open; but as I was by no means certain, what was the precise nature of the disease, or in what state the parts might be found, I informed the man that it might possibly become necessary to remove that testicle. To this he consented; and I made an incision, through the skin, from the groin down as low as the testicle; intending, if I had found the process diseased, to have castrated. The incision was followed by a large discharge of water, not only from the lower pari, where there seemed to have been a con- siderable collection in one cavity, but from the surface of the whole cellular membrane enclosing the spermatic vessels. Finding this membrane no other way diseased than by the watery disten- tion of its cells, I went no farther with my operation, but filled the incision lightly with soft lint For three or four days the dis- charge of serum was large; but, that ceasing, a plentiful suppu- ration succeeded; which was followed by a perfect subsidence of the whole tumor; and in due time the wound healed, and the man obtained a cure. CASE X. A gentleman, about thirty-five years of age, came out of the North, to London, for the assistance of Mr. William Sharpe, in the case of a large tumor of the scrotum; which, he said, had been coming five or six years. The account which he gave of it was, that at first it was small easily (as he thought) put up, but came down again immediately;' which he attributed to his not having been accommodated with a proper bandage; that, at the end of about nine months, or rather more he found that he could not reduce it at all, whatever pains he took, or whatever posture he put himself into; and that from this time its increase had been daily more apparent. The Z was singular, and Mr. Sharpe desired me to see it with him A TREATISE ON THE HYDROCELE. 39 The scrotum was of a most prodigious size; it hung more than half way down to the patient's knee; it was very ill supported, by an awkward bag of his own making; and, toward the lower part, was much ulcerated, by neglected excoriations. Different parts of the tumor felt very differently; in some places, it was hard; in some, soft; and, in others, a thin fluid was palpably discoverable. The s-permatic process was large and full, quite up to the groin; the aperture in the abdominal muscle was considerably dilated by it; and, when the patient coughed, the whole tumor was mani- festly distended: his stools were regular, his appetite good, his urine proper in quality, but very deficient in quantity; his sole complaints were, a pain in his back, (proceeding, as we supposed, from the weight of the scrotum,) and a languor and dispiritedness, which he had not not been accustomed to, and could not account for. The feel of some part of the tumor was like that of an intestinal hernia, in which there is no stricture, and the gut does its office in scroto; but, other parts of it were so unlike to this, and the upper part of it toward the groin was so large, and so hard, that we re- mained in great doubt concerning the true nature of the con- tents. When we had sufficiently examined the tumor in an erect pos- ture, we put the patient into a supine one, which produced a consi- derable alteration in the appearances; the tumor became mani- festly less, and softer; and seemed, by retiring, to occasion a large swelling on that side of the belly, just above the os ilipn, tending backward toward the region of the kidney. Upon continued pres- sure, the contents of the scrotum seemed to recede still more; and still as they receded, the swelling on the side of the belly increased. When we had got up to a certain point, we could get up no more; but, during our endeavours to return as much as we could, we clearly discovered that the tumor in the scrotum, and that within the belly, were produced by the same body; that there was a palpable and free fluctuation, from the one to the other; and that the harder parts were mere indurations, and thickenings of the integuments and common membrane. The burden was so great, that the patient was desirous of being- eased, at any rate. We communicated to him our opinions, our 40 A TREATISE ON THE HYDROCELE. suspicions, fears, and uncertainty; and told him what hazard might possibly be incurred by acting according to the former, il we should be mistaken; but, he being determined to endeavour to obtain relief, at all events, and we being prepared, as well as we could, for whatever might happen, made a small incision into the lower and anterior part of the tumid scrotum. As soon as we had divided the skin, a quantity of clear limpid water burst forth, of which we caught above a quart; and then the opening was stopped, by something which thrust itself out, and looked like a piece of cellular membrane loaded with water. We cut a part of it off, and gently pushed back the rest with a probe; while, by moderate and continued pressure, we drained off eleven Winchester pints of water. When we could get no more away, we would have enlarged the opening; but, our patient found himself so lightened, and so easy,- that he would not permit it. The scrotum, it is true, was considerably lessened; but in no proportion to the quantity of water which had been drawn off: the whole spermatic process, from the testicle quite up to the belly, was still large and full; and the abdominal opening still dilated by a large body passing through it; but, as the swelling in the belly could not now be felt in any posture, and as the.scrotum was re- duced to such a size as to be easily supportable by a bag truss, he determined to wait the effect of what had already been done. In little more than a month we saw him again. The tumor in the side of the, belly was as apparent, the fluctuation as palpable, and the burden as great, as when we first saw him. His health was still good in general; but his face appeared to me to be more pale and wan, and he complained still more of thirst and lan- guor. As we were now sure of the nature of the contents, we divided the whole scrotum from the bottom upward. The lower part was formed into a cyst, or bag, made by the pressure of the water, which was discharged upon the first introduction of the knife- but all the rest of the tumor was formed by the diffusion of serum through all the structure of the tunica communis, the cells of which were all much enlarged with it, quite up to the groin- the testicle being very distinct, and free from disease. The serum A TREATISE ON THE HYDROCELE. 41 wcz.d freely from all parts of this membrane by gentle pressure; and as it seemed to subside considerably thereby, we meddled no farther, but contented ourselves with filling the incision lightly with dry lint, and suspending the scrotum in a bag truss. During the first two or three days, the discharge of water was constant and plentiful; and the sore was (as might be expected) crude and undigested; but without any of that inflammatory hard- ness and swelling, which wounds made in such parts, in healthy sanguine people, generally have; on the contrary, the lips were flaccid, and soft: is is true, he was perfectly free from fever or pain, and, except the circumstances just mentioned of thirst and languor, he had no apparent disorder; but they were great and troublesome. The discharge of water continued large, and his wound neither digested nor inflamed; nor did it wear any the least appearance of gangrene or mortification: his languor and anxiety increased daily; and on the fourteenth day from that of the operation, he died; the sore still wearing the same face. Upon opening his body, w*e found all the cellular membrane which invested the spermatic vessels within the abdomen loaded with water, and distended in a very irregular manner, from the origin of the said vessels quite down to the opening of the oblique muscle. At this place it was contracted into a round, or rather a flattish body, of less size, but still so large, as to dilate the open- ing in the tendon considerably. Below this it was again expanded and distended with water, through all its cells; but the testicle, and its tunica vaginalis, were in a sound state, and perfectly un- affected by the disease. Was it the large discharge of serum, or the free division of membranous parts which occasioned this gentleman's death? For my own part, I am inclined to attribute it to the former; for though aji incision, made in parts of such structure, and so diseased, does sometimes prove fatal, yet the parts themselves in such case gene- rally show, by a gangrenous or mortified appearance, what share such operation has in the patient's destruction. In this case, there was indeed no digestion, nor any of tha* in- flammation, which always precedes suppuration; nor, on the other vol. ir- v i> A TREATISE ON THE HYDROCELE. hand, was there any appearance like gangrene or sphacelus; but his manner of dying was very much like that of those who are de- stroyed by large haemorrhages. SECT. VI. THE ENCYSTED HYDROCELE OF THE TUNICA COMMUNIS. This species of hydrocele has its seat in the same part as the preceding; viz. the tunica communis, or cellular membrane, which invests the spermatic vessels; with this difference, that, in the former, the water is diffused in general through all the cells of the membrane; whereas in this, it is contained in one cavity only. If any of the three kinds of hydrocele deserves the name of en- cysted, it is this. The water which constitutes it being all con^ tained in a bag, formed in the same manner as all the coats of all encysted tumors are; viz. by mere pressure, and condensation of the common membrane. It is a complaint by no means infrequent, especially in children. It was very well known to many of the ancients, and has been very accurately described by some of them;' but later writers have ' By Albucasis, by Celsus, Paulus JEgineta, and others. The last lias par- ticularly distinguished this kind of hydrocele from that of the tunica vaginalis, liy a very just description of both: •< Si humor in membrana supernata coierit, ••tumor aller.us testiculi imaginem exhibet. Q«ibus in Erythroide tunica humor comprehensus est tumor rotundus paululum, et ovi modo longius- ••ptUitus»SteStl inconsPe<*umnonvenit, ut qui undiquaque sit im- The former of these descriptions, our countryman Pm« r u probably copied, when he says, «• It is sometinTTnJoZ ia" T "and appeareth like a third testicle." '" * membrane- Heister speaks of this species of hydrocele as very rare n«i authority of others to prove its existence, and seemsTnTomo „* ^^ found it with a collection of fluid in a congenial hernial sac " l° C°n' Page 842, he says, « Quandoque tamen etiam, ut nonnuiU "m pentonxi processu, supra testiculum, liquor prater natural .™ ' A TREATISE ON THE HYDROCELE. 43 often mistaken it for, and represented it as, a species of wind- rupture, or pneumatocele; a disease existing in their imaginations only. It most frequently possesses the middle part of the process, between the testicle and groin, and is generally of an oblong figure; whence it has by some people been compared to an egg, by others to a fish's bladder. Whether it be large or small, it is generally pretty tense, and consequentlv the fluctuation of the water within it not always immediately or easily perceptible; for which reason it has been supposed to contain air only. It gives no pain, nor (unless it be very large indeed) does it hinder any necessary siction. It is perfectly circumscribed; and has no communica- tion, either with the cavity of the belly above, or that of the vaginal coat of the testicle below it. The testis and its epididy- mis, are perfectly and distinctly to be felt below the tumor, and are absolutely independent of it. The upper part of the spermatic process in the groin is most frequently very distinguishable. The swelling does not retain the impression of the fingers; and when lightly struck upon, sounds as if it contained wind only. It undergoes no alteration from change of the patient's posture; nor is affected by his coughing, sneezing, &c; and has no effect on the discharge per anum. These marks (while the disease is simple and uncombined with any other) are sufficient to distinguish it by, from all others which may affect the same part: but it sometimes happens, that the present, complaint is found connected either with a true hernia, or with a hydrocele of the tunica vaginalis; by which the case is rendered complex, and less easy to be understood. "imo etiam in productione peritonaei, ab intestinorum hernia orta, copiosum "liquorem in cadavere, sectione aliquando deprehendi." And in a note on this passage he adds, " Wiedemannus, nee non Boerhavius, itemque Garen- "geotuset Dranius memorant istiusmodi hydroceles casus quandoque ob- " servari; ubi digito contingi testiculus queat; atque tunc supra testiculum in "peritonaei processu tumorem ethumorem consistere. In enterocele autem " contrarium quandoque usu venire, propterea quod intestina interdum, ut "supra monui, usque in tuntcam vaginalem, per septum illud naturale, quod " testiculum a parte superior! processus peritonaei distinguit penetraverunt." " Sed rari admodum sint necesse est, ad quos modo laudati autores pro- "vocant casus. Ego sane quanquam plurimos homines enterocele, non "minus quam hydrocele laborantes sanaverim, nunquam tamen adhuc ita "rem inveni," &c 44 A TREATISE ON THE HYDROCELE. In this, as in every other case where, from a complication of symptoms and appearances, a combination of diseases may be suspected, there is but one method of investigating the truth; which is, to consider carefully what disorders the part aggrieved is naturally liable to; what the distinct symptoms and appearances of each of those are; and what are the effects of the present com- plaint. The two diseases with which this kind of hydrocele is most likely to he combined, are, as I said before, an hydrocele of the tunica vaginalis testis, and a true hernia; the parts within the groin, the spermatic process, and the scrotum, being the seat of all three. One mark, or characteristic of an hydrocele of the tunica va- ginalis testis is, that it possesses and distends the inferior part of the scrotum; and that the testicle being nearly (though not abso- lutely) surrounded by the water, it very seldom happens that the former ean be clearly and plainly distinguished by the fingers of an examiner; whereas, in the encysted collection, in the mem- branes of the chord, the tumor is always above the testicle, which is obvious and plain to be felt below it. Another circumstance worth attending to is, that although the fluid in a hydrocele of the vaginal coat does so nearly surround the testis as to render it often not very easy to be distinguished, yet the different parts of the tumor have always a very different feel: for instance, in all those points where the vaginal tunic is loose, and unconnected wiih the tunica albuginea, the tumor is soft and compressible, and gives a clear idea of the contained fluid; but when these two coats are continuous, or make one and the same membrane, and have Fallopius, although he was unacquainted with the real and true origin and nature of this disease, and supposed its manner of production to be very 52 A TREATISE ON THE HYDROCELE. It is a disease from which no time of life is exempt; not only adults are subject to it, but young children are frequently afflicted wi'h it; and infants sometimes born with it. What is the'imme- diately producing cause, I will not take upon me to affirm. Ruysch is of opinion, that it proceeds from a varicose state of the sperma- tic vessels. What real foundation there may be for such conjec- ture, I cannot say; certain it is, that the spermatic vessels are very frequently found varicose, in persons afflicted with this kind of hydrocele; but whether such state of these parts ought to be re- garded as a cause, or as an effect of the disease, is a matter worth inquiring into. In Morgagni are some observations on the state of the parts concerned, particularly the inside of the tunica vaginalis, and out- side of the albuginea; which, if repeated and confirmed, may pos- sibly lead us on to furdier information. In the mean time, from all the circumstances attending the complaint, it is pretty clear, that whatever tends to increase the seerction of the fluid into the sacculus, beyond the due and neces- sary quantity, or to prevent its boing taken up, and carried off, by the proper absorbent vessels, must contribute to its production; which is so slow and gradual, and at the same time so void of pain, that the patient seldom attends to it, until it has arrived to some size. Not but that it sometimes is produced very-suddenly, and in a very short space of time attains considerable magnitude. The size and figure of the tumor are various in different peo- ple, and under different circumstances. In general, at its first be- ginning, it is rather round; but as it increases, it frequently as- sumes a pyriform kind of figure, with its larger extremity down- unlike what it really is, has yet given a very just account of ll«e appearance, both of this and of the former : " Alia vero est hernia aquosa, in qua aqua dis- "tillat per vasa et venas, occulto modo, ac sensim ad scrotum. Hxc autem "est duplex ; alia in qua continctur aqua in membrana adnata, et in proprio "folliculo; alia in qua continetsr in inguinali tunica qnx lestem vestit. Cog- "noscitur aquam esse in tunica adnata quia separatur testis a parte aquosa "manilms; praeterea, ista hernia habebit proprium circumscriptionem, ali- "quando rotundam, aliquando ovalem. Si autem fit in vaginali, non possum us " amplius arripere et distinguere testem ab hernia ; quoniam in eodctn loco et "aqua, et testis sunt constituti." Gati. Fitionu* A TREATISE ON THE HYDROCELE. 53 ward: sometimes it is hard, and almost incompressible; so much so, that, in some few instances, it has been mistaken for an in- duration of. the testicle: at other times it is so soft and lax, that both the testicle and the fluid surrounding it are easily discover- able. It is perfectly indolent in itself; though its weight does sometimes produce some small degree of uneasiness in the back. The great characteristic (as it is called) of this disease, and on which almost all writers have agreed to lay the greatest stress, and to rest their proof of the nature of the disorder, I mean the transparency of the tumor, is the most fallible and uncertain sign belonging to it: it is a circumstance which does not depend upon the quantity, colour, or consistence of the fluid constituting the disease, so much as on the uncertain thickness or thinness of the containing bag, and of the common membranes of the scrotum. If they are thin, the fluid limpid, and the accumulation made so quick as not to give the tunica vaginalis time to thicken much, the rays of light may sometimes be seen to pass through the tu- mor: but this is accidental, and by no means to be depended upon. Whoever wou'd be acquainted with this disorder, must learn to distinguish it by other, and those more certain marks; or he will be apt to fall into very disgraceful, as well as pernicious blunders. The colour of the fluid is very different and uncertain; sometimes it is of a pale yellow, or straw colour; sometimes it is inclined to a greenish cast; sometimes it is dark, turbid, and bloody; and sometimes it is perfectly thin and limpid. In the beginning of the disease, if the water be accumulated slowly, and the tunica vaginalis thin and lax, the testicle may easily be perceived; but if the said tunic be firm, or the water ac- cumulated in any considerable quantity, the testis cannot be felt at all; and other symptoms, or marks, must be attended to. In most cases, the spermatic vessels may be distinctly felt at their exit from the abdominal muscle, or in the groin; which will al- ways distinguish this complaint from an intestinal hernia, the dis- ease which it is most likely to be confounded with. It does in- deed now and then happen, that the vaginal coat is distended so high, and is so full, that it is extremely difficult, nay, almost im- possible, to feel the spermatic, process; and it also sometimes hap- pens, that the same kind of obscurity is occasioned by the addi- 54 A TREATISE ON THE HYDROCELE tion of an encysted collection of water in the membrane of the chord; or by the case being combined with a true enterocele. These circumstances are not very frequent, but yet do occur often enough to render it well worth while to mention them; and to signify that, when they are met with, recourse must be had to other marks. The general notion formed of this disease is, that it consists of a bag, filled with a fluid, in the middle of which the testicle hangs suspended, and by which it is completely surrounded. This idea is not only erroneous, and contrary to fact, but may- be productive of very mischievous consequences in practice. For from such conception (or rather misconception) of the state and disposition of the parts, it may be inferred, thai all points of the tumor are equally fit for such operation as may become necessary for the discharge of the fluid; which is so far from being the case, that, in some parts of it, such operation is perfectly safe, easy, and harmless; in others, it is hazardous, painful, and may be pro- ductive of the most dreadful consequences. Whoever will take the pains to examine the structure and disposition of the two coats of the testicle, the albuginea and vaginalis, will find, that in one part they are so inseparably united, (being indeed one and the same membrane.) that is impossible for any thing to insinuate it- self between them: while in every other part they are so abso- lutely unconnected, that from the great dilatability of the latter, a large quantity of fluid may be accumulated.0 In a hydrocele which is tolerably full, the place of this union is the posterior and superior, or rather the posterior and middle part of the tumor. A puncture or incision made here will do no ser- 0 " Humor magna ex parte, in tunica Erythroide appellata, testiculum am- " biente, in partem anteriorem colligitur; qua potissimum membrana ilia a testi- " culo separatw." Padlcs JEgini:ta. Mr. Le Bran, whose character in practical surgery stands deservedly high, seems to be less clear in his idea, and less perspicuous in his account of this disease, than of most others: his account is, " Une vessie auqeuse placee sur " l'un de testicules, auquel elle est adherente; et comme elle devient quel- " quefois tres grosse, elle remplit presque tout le scrotum." This does not at least to me) convey an idea that the seat of this disease is within the tu ilea vaginalis testis. A TREATISE ON THE HYDROCELE. 5 J vice, as it cannot reach the water, and therefore cannot answer the intention for which it ought to be made; but it will injure the testicle, or its epididymis, and thereby do great mischief; whereas an opening made in every other part, will not only give discharge to the water, but can do no harm, and is free from all kind of danger. This natural connexion between the two tunics, at the upper and hinder part, is the reason why, in a simple hydrocele, that part of the tumor feels so very unlike to every other. In that, the tunica albuginea, and vaginalis, being immediately continuous, no water can get between them; and therefore, the fingers of an in- telligent examiner must immediately discover the firmness and hardness arising from the union of these parts: in all others, the two membranes being unconnected, and affording a void space for the collection of water, the fluctuation of it will always be distin- guishable. This is a circumstance which must for ever discriminate the simple hydrocele of the tunica vaginalis, from the anasarcous swelling of the scrotum; from the encysted hydrocele of the chord; and from the intestinal hernia. The first is every way equal, tumid, and soft; and every where equally receives and retains the impression of the fingers: the second, though circumscribed, not very compressible, and affording the sensation of fluctuation, yet does not pit, and is alike to the touch in all parts of it: and, in the third, if the testicle be distinguishable at all, it is found at the inferior part of the whole tumor. An indurated or scirrhous testicle has indeed, very frequently, a quantity of fluid lodged in its vaginal coat; which is a circum- stance not to be wondered at; the diseased state of the gland being sufficient to account for the non-execution of the absorbent faculty, and, consequently, for the collection of the water. But although part of this mixed tumor is undoubtedly owing to a fluid, and such fluid as is lodged within the vaginal coat, yet it is a very different disease from the true simple hydrocele, and ought not to be con- founded with it; one of these marks of the latter being the natural, soft, healthy state of the testicle: and the characteristic of the former being its diseased and indurated enlargement.p ■"■ When I.w natural, soft, and hc:«Hiy state of the tes!lcle, I d » not mean, 56 A TREATISE ON THE HYDROCELE. This is a point of more consequence than it may, perhaps, upon a cursory view, seem to be. It not only regards the definitions, but the treatment of the diseases: and, being rightly understood, and attended to, or not, may be productive of much good or ill. We are, by most of the writers on this subject, advised in ope- rating for the radical cure of an hydrocele, to regard carefully the state and condition of the testicle; and, if we find it enlarged, har- dened, putrid, fungous, or any other way really diseased, to remove it immediately: which advice, within proper limitations, is cer- tainly good. A testicle, in almost any of the just mentioned cir- cumstances, ought undoubtedly to be removed: but these cautions have nothing to do with the true, simple hydrocele; and can relate only to the diseased, the scirrhous, or the cancerous testicle. When these disorders are the subject of consideration, then such hints and cautions make a very necessary part of it; but they can have no concern with the present*1 that the testicle, in a true, simple hydrocele, is never altered from its natural state, when unaffected by any disease : 1 know the contrary ; 1 know that the testicle, in a hydrocele, is very frequently enlarged in size, and relaxed in structure, as well as that its spermatic vessels are often varicose; I use the words in opposition to the diseased indurated state of the scirrhous testis. i " Xamque ubi forte vel putredo, vel scirrhus, vel alia quaedam corruptio " vehemens testiculum invasit, salutarius exscindere." He ist en. This is also the doctrine of most of the writers (a large number in sugery) who have copied each other, both in their ideas of diseases, and in their pro- posed method of treating them. Not writing from practice, or from what they have seen, they have related urcumstances, under the article of the simple hydrocele, which never occur and have directed a method of conduct, which, if followed, must mislead the surgeon, and subject the patient to pain, fatigue, and even loss of parts, with- out any the least necessity. Under the head of radical cure of the simple hydrocele by incision, Heister has mentioned several circumstances as neces- sary to be attended to for the regulation of the operator's conduct, which circumstances do not occur in that disease : " Deligari autem vasa sperma- " tica filo, rescindique testiculus omnino debet sicuti in cap. de sarcocele do- " cuimus, quoties vasa seminalia, non insigniter tantum induruerunt, sed mag- " nis quoque cruciatibus hominem aegrum affliguent. Despiciendum quoque porro est num testiculus tumefactus forte materiam aliquam " fluidam, sicut quandoque contingit, intus contineat. Si quid enim fluidi " intus haerere tactu percipimus, aut lympham, aut pus inibi consistere rec- " tissime colligimus. Interim neque tunc rescinderecontinuo (ut nonnullent,) ' " sed incidere potius, atque expurgare testiculum istum conveniet, &c. Sed A TREATISE ON THE HYDROCELE. 57 The truth is, that the majority both of the ancient writers and practitioners, misled by the sound of the term hydrocele, have mistaken a mere accidental effect for a cause; and "have supposed that the fluid contained in the tunica vaginalis testis may not only constitute a disease by the mere distention of it; but may be pro- ductive of other diseases of the testicle itself. They have fancied the water to have in itself a noxious quality, or disposition; and that the testicle, by merely swimming in it, might become dis- eased, and unfit for use; whereas in cases wherein a disordered state of the testis accompanies a collection of water in its vaginal coat, the truth is just the reverse of this supposition: the testis is first diseased, and the faculty of equal, regular absorption thereby interrupted; by which means a quantity of fluid is accumulated, and that mixed appearance produced, which is not improperly called hydro-sarcocele. But in this case, the extravasation of wa- ter is really the consequence of the morbid state of the gland; and (being still mere simple lymph) neither is, nor can be the cause of it. They who choose it may call this a species of hydrocele; -and the literal sense of the word will certainly vindicate them; but they will by that means run the risk of confounding together two things extremely unlike to each other, and which require very different treatment: I mean the true siinjple hydrocele, in which " si forte simul nimis jam tunc induratus, vel corruptus idem inveniatur, pre- "dicta ratione, ligmdus et resecandus, ne in carcinoma forte abeat." That such state of the spermatic vessels and testicle does occur is beyond all doubt; but not in the simple hydrocele; not in the hydrocele that any ra- tional practitioner can possibly deem fit for the attempt for the radical cure by incision. Neither is it possible for a man, who understands the disease at all, not to be acquainted with these circumstances before he attempts such operation ; and if he is previously acquainted with them, he must be a very extraordinary man indeed to set about relieving them in such a manner. If the state of the testicle and its vessels be such as to require castration, (a thing always capable of being known before hand,) let that operation at once be performed, in a proper and expeditious manner, and not by piece-meal, as it is here described. If castration be not requisite, neither can any other part of the operation (with regard to the testicle) be so; for, notwithstanding these descriptions of incisions into, and expurgations of, diseased testicles may make a figure in hooks, they are very unfit to be introduced into prac- tice. They never can do good: they roust do unwarrantable, and generally irremediable, mischief. VOL. II. II 58 A TREATISE ON THE HYDROCELE. the testicle is soft and sound, (only perhaps a little more lax, and larger than ordinary,) and the hydro-sarcocele, in which the tes- tis is not only enlarged, but hardened, and not in a sound or healthy slate: the former of these will permit such treatment with perfect safety; but in the other, may bring the patient into a state both of pain and hazard.' It may indeed, and does sometimes, become necessary to let out the water from the vaginal coat of a testicle, in some degree iliseased: but this should always he done with caution, and under a guarded prognostic; lest the patient be not only disappointed, by not having that permanent relief, which for want of better inform- ation he may be induced to expect; but be also (possibly) sub- jected to other unexpected inconveniences from the attempt. Upon the whole, as just definitions, and accurate distinctions of diseases from each other, are absolutely necessary towards under- standing them rightly, it seems to me much more proper to con- fine the term-hydrocele to the mere simple accumulation of a fluid within the coats of the sound testicle, and to refer all those which either are combined with, or proceed from, diseases of that gland, to another class. When the disease is a perfect, true, simple hydrocele, the tes- ticle, though frequently somewhat enlarged, and perhaps loosened in its vascular texture, is nevertheless (as I have already observed) sound, healthy, and capable of executing its proper office: neither is the spermatic chord any way altered from a natural state, ex- cept that its vessels are generally somewhat dilated; neither of which circumstances are objections either to the palliative or ra- dical cure of the disease. But in those disorders, which in some degree resemble this, the case is different; either the testicle, or spermatic chord, or both, bearing evident marks of a diseased state. In the true, simple hydrocele, the water is accumulated r Some instances of this are related in this tract. Hildanus has given a particular account of a mistake of this kind: " Inciso scroto plurimum affluxit " aqua:, hinc primo subsedit scrotum ; post paucos tamen dies secutus est " dolor, vehemens inflammatio et cancrosum ulcus, maximeque malignum; " quod adeo impetuose adjacentes partes occupavit, ut iupsius malignitas nui- " lo modo arceri possit; sed intra paucos dies maximo cum cruciatu e \ ita " decessit." A TREATISE ON THE HYDROCELE. 59 merely from the non-execution of the office of the absorbent ves- sels; which (whatever ultimate cause it may have) leaves no ap- pearance of real disease on the parts: in all the other collections of fluid in this part, there are such appearances and marks of dis- temper, as may clearly convince us, that the extravasation is only a consequence of such state. The two principal complaints, liable to be mistaken for an hy- drocele, are, that kind of scirrhous testicle in which an extravasa- tion of fluid is made in the tunica vaginalis; and the venereal in- duration of the testicle, attended with the same circumstance. One of these is always a disease of the general habit; the other too often so. One requires, and generally submits to, a proper course of spe- cific remedies; for the other (notwithstanding all that has been said on the subject) we as yet know of none; and therefore it is seldom cured but by total removal. In neither of these, can the mere discharge of the fluid contribute any thing material toward a cure; and in both of them, such attempt, injudiciously made, has often proved both painful and hazardous. In the true venereal sarcocele, or indurated testis, the disease ought always to be eradicated from the habit before any attempt be made locally: the mere discharge of the water can never remove the obstruction in the gland; but when such obstruction has been by proper remedies removed, it is no uncommon thing to have the extravasated fluid again absorbed; or if it be not, and any operation becomes necessary, a soft, easy, healthy state of the testi- cle is* certainly preferable to an indurated diseased one. These two cases, or, to speak more properly, these two states of the testicle, although they agree in this one circumstance of not being essentially relieved by the mere evacuation of the water, do yet differ so widely in almost every other, that it behoves prac- titioners to be very careful in distinguishing between them. That method of treating the venereal induration, which is most fre- quently successful, will prove highly prejudicial in the scirrhous hardness. By mercury, in judicious hands, the pocky patient's disease may be removed, and his health restored: but I have hardly ever seen a scirrhus or cancer that was not exasperated, and made worse by it. Or, if that does not happen, yet, a mercurial course, ig 60 A TREATISE ON THE HYDROCELE. such case, will always occasion a loss of time, which is not always retrievable. In short, he who treats a scirrhous testicle as he ought to do a venereal one, will not cure the disease, but waste his patient's time, and hurt his general health: and he who treats a venereal one as he most frequently ought, to do a scirrhus, will, without any necessity, submit his patient to a painful Operation, and thereby deprive him of a part very essential to him as a man. CASE XV. A gentleman, about thirty years old, showed me his testicle, which was both enlarged and hardened, and had very palpably a quantity of fluid in the vaginal coat. He had been told, that it was a water rupture, and that it might be immediately cured by meansof a small incision. The whole testicle and epididymis were" (as I have already said) large and hard; and so were the vas deferens, and part of the spermatic process; but there was no kind of inequality on the surface; neither did it give the patient any pain, except what pro- ceeded from its mere weight. He had some brown spots on his breast; a hardness below the fraenum penis; a raggedness and indu- ration of the edges of the sinis of the left tonsil; a pale plumbean countenance; and complained much of frequent pain in his knees and elbows. I made no scruple to inform him that he appeared to me to be] poxed; and that I did verily believe, that the disorder in his testi- cle arose from the same cause. I took pains to dissuade him from submitting to any attempt toward curing his local complaint in the testis, until he should have got rid of the disease which had infected his whole habit, by assuring him, that if what had been proposed to him was intended merely to let out the water, it could not even contribute to his being made well; and that if more than that was desired, he might probably experience more harm than good from the attempt. Not satisfied with my opinion, he went to Mr. Sainthill, who gave him the same kind of advice. In a little time he applied to a gentleman well known for pro- mising impossibilities; who told him, that this was a disease with which the faculty were perfectly unacquainted; and if he would a treatise on the hydrocele. 61 give him ten guineas, and take a lodging near him, he would un- dertake to cure him in a week. He made an incision of about half an inch in length, in the very inferior part of the tumor, and let out a small quantity of bloody water; and then applied a pledget of lint, and a piece of sticking-plaster. The patient passed the night in a good deal of pain, and in the morning found his testicle much swelled, and very uneasy. He sent for his operator, who said, that this was of no consequence, and that if he would keep quiet that day, he would be very well the next. On the third day his testicle was so large, so inflamed, and so painful, that he became exceedingly alarmed, and sent for me. I found the scrotum highly inflamed; the testicle and spermatic process large and hard; his pain exceedingly great; his pulse hard, full, and frequent; and his skin hot and dry. I bled him freely, and ordered him a clyster and a lenient purge, and wrapped the testicle up in a soft poultice. Next day, both the patient and the parts were in the same state. I bled him again; and his clyster and purge having thoroughly emptied him, I gave him two grains extract, thebaic, and directed that he should take one grain every six hours, until some ease or rest was procured. Two days were spent before any remission of symptoms was obtained: and it was near a fortnight, before the constant use and application of fomen- tation, cataplasm, &.c. together with a general antiphlogistic regi- men, and confinement to bed the whole time, had reduced the testicle to such state as to bear examination. When it became capable of this, it was found large and hard, but without any water in the tunica vaginalis. His general habit being recruited by a proper regimen, country air, and the bark, he was then put into a mercurial course, by inunction; under which all his other symptoms gradually disappeared, so likewise did his indu- ration of the testicle. CASE XVI. A poor labouring man in Essex got a venereal hernia humo- ralis. As his daily work would not permit him to take proper 62 A TREATISE on the hydrocele. care of Jiimself, it was a considerable while before he had got rid of his inflammatory symptoms; and when he had so done, a part of the testicle, and the whole epididymis were left hard, and rather too large. In getting over a high stile he missed his footstep, and struck his scrotum with violence against the upper rail: the blow gave him excessive pain for some minutes; but that soon ceased, and he went on with his day's work. Next day his testicle ap- peared swelled, and was painful to the touch; but as the man had no subsistence but from his labour, he was obliged to follow it. At the end of a week, he was so much worse that he could go out no longer; and making his case known to some gentlemen, who used to employ him, a neighbouring practitioner was desired to visit him. A fluctuation being felt, it was supposed to be matter; and a warm adhesive plaster was applied to forward it. In a few days an opening was made for discharge of the supposed pus, but nothing followed except a very small quantity of bloody serum. The smallness of the quantity, and the nature of the fluid, joined to the very small subsidence of the tumor, induced the surgeon to think he had not gone deep enough; and to thrust a lancet further in: this was attended with acute pain, and followed by a copious haemorrhage, which was not easily restrained; or, to speak more properly, did not soon cease. Inflammation, pain, tumefaction, &c. followed this method of proceeding; and at the end of a week the man was brought to St. Bartholomew's hospital. Upon mere sight of the part, I should have supposed the case to have been a scirrhus of the malignant kind: the testicle or scro- tum was large, hard, unequal, of a deep red dusky colour, with distended veins, and so painful tiiat it could not bear the slightest touch; and the spermatic process was far from being in a natural or a healthy state. The man complained of constant pain in his back; the wound discharged a bloody offensive gleet; and long pain, and want of rest, had given him a very diseased aspect Nothing but the clear and circumstantial account, which both the man and the surgeon who had attended him (and who came with him to the hospital) gave, could have induced me to have thought the case to be any other than what I have just mentioned: but they were so positive, and so consistent, that I thought myself obliged to regard what they said, and to act accordingly. A TREATISE ON THE HYDROCELE. b;j By phlebotomy, evacuations, anodynes, rest, alow regimen, and the general antiphlogistic method, pursued vigorously and long, he got a cure. CASE XVII. A gentleman, about thirty-seven years old, apparently in good health, asked my advice concerning a diseased appearance in his scrotum, for the relief of which he had come from a considerable distance to this town. The testicle was not much increased in size, but had lost its equality of surface, and was craggy, and very hard; and the vas deferens and epididymis were in the same indurated state; the spermatic chord was somewhat varicose, but not hard; and in the cavity of the tunica vaginalis was palpably a small quantity of fluid. It was somewhat tender to the touch; but the pain upon being handled was very slight, in comparison of what was felt an hour or two after such examination: at which time, although the pains were not constant, but rather attacked the part by intervals, yet they were extremely acute. He said, that he had been told that his complaint was venereal, (to which opinion his method of life much inclined him to ad- here,) and that he had also a beginning hydrocele. I replied, that I wished, for his sake, that I could think so too; but that I had no. doubt of its being a scirrhus, which would not long remain quiet He seemed dissatisfied; and said, that, considering the persen who had pronounced his case to be venereal was a man of character in his profession, and whose judgment he believed was good, he ihought I was rather too peremptory. I desired him to take the opinion of some people of eminence in London, and named some to him: whether he did or not, 1 know not; but in about a fortnight or three weeks, I received a letter from him out of the country, signifying, that his friend was so clear in his first opinion, that the case was venereal, that he had prevailed on him to submit to a salivation for il; and that he only now desired my opinion concerning the best method of procuring G4 A TREATISE on the hydrocele. it; that is, whether he should attempt it by internals, or by mercu- rial inunction. I wrote back, that I was sorry to differ from hi^ friend, or to seem loo tenacious of, or partial to, my own opinion, and sincerely wished I might be mistaken; that I looked upon the method of salivating by inunction to be in general the least fa- tiguing or prejudicial to the constitution; and that in the case ol particular, local induration, it certainly had the advantage of being applied immediately to the part affected; and therefore, if I could think that his complaint was venereal, I should undoubtedly pre- fer the use of the ointment to every internal means; but that I was so thoroughly satisfied that it was not, and so averse to the use of mercury for him, that I desired him to keep that letter as my protest against the process he was going into. The ointment was freely used for above a month, but no alter- ation appeared in the testicle, except that it became rather larger, and more tender to the touch. As the mercurial ointment happened not to affect his mouth, or make him spit any considerable quantity, the inefficacy of it with regard to the testicle was imputed to that; and a course of the mercurius calcinatus, with the kermes mineral, undertaken and followed for another month. During this, the testicle manifestly increased in size, became more unequal, and more frequently painful. He now came to London again; and calling on me, told me all that had passed; but being still possessed with the venereal idea, said that he was come hither in order to try the Lisbon diet drink, or something of that kind. At my request he showed his disease to Mr. Nourse and Mr. Sainlhill, who were clear that it was not venereal, and advised the operation. This he would not hear of at present, having got it into his head that when every thing else had been tried, it would always be time enough for that During three weeks that he staid here, he drank, by the direction of some friend, every day a quart of strong decoction of sarsaparilla, with some of the sublimate solution in it. The testicle continued to increase, and the sperma- tic vein became somewhat varicose: but still there was a fair op- portunity for extirpation. He did now indeed begin to incline to it; but being considerably reduced in strength and flesh by what he had taken, he would not comply with it until he haa" been in A TREATISE ON THE HYDROCELE. 65 the country, and was somewhat recruited: to which I could not ob- ject, as he then did not appear to be a fit subject for such an operation; I mean, on account of his great reduction of strength. At the end of two months, he came to me again. I was much concerned to see him so much altered for the worse; he was ema- ciated to the greatest degree; and had such a leaden paleness in his countenance, that, had I known nothing of him, I should have concluded that such a man had a cancer about him. He had totally lost his appetite, and was never free from pain: his testicle was at least twice the size as when I last had seen it, and the whole process, quite up to the belly, large, hard, and knotty. I would now by no means propose the operation: a consultation of physicians was therefore had, in which the solanum was pre- scribed. This was immediately tried, and proved here, as it has wherever I have seen it used; that is, the patient was much dis- ordered by it in general, and received no benefit with regard to his disease: but as this affair happened not long after this poison had been in a kind of vogue, it was repeated until the patient could hardly see or hold his hand still. When this was laid aside, recourse was had to the cicula, which, as usual, was perfectly in- efficacious: to it, however, a fair trial was given. And when the poor man had thus made experiment of our most boasted specifics, and was satisfied that no honest or judicious man would attempt the operation, we had recourse to opium, during a few weeks that he existed. When dead, 1 examined him. The spermatic process was thoroughly diseased, about half-way up from the groin to the kidney; that is, it was enlarged, hard, and very full of knots; but I did not find any apparent disease in any other part within the abdomen. CASE XVIII. I received a letter from Lincolnshire, in the month of Novem- ber, desiring to know whether that season of the year was an im- proper one for the operation of castration, in the case of a scirr- hous testicle; for that, if! did not, a patient labouring under such vol. n. I tib" A TREATISE ON THE HYDROCELE. complaint would set out immediately upon the receipt of my an- swer. I wrote back, that the state and nature of the disease were of much more consequence toward determining the propriety or im- propriety of an operation, than the time of the year could be: and therefore I desired either that I might have a circumstantial ac- count of the case from some medical man, or that the patient would come to London. In about a week I received another let- ter, containing the following account That the patient was thirty-five years old; that previous to the appearance of the disease in the testicle, he had for some weeks been troubled with frequent and acute pains in his back and loins; that the testicle was considerably enlarged, indurated, and (in ite posterior part) unequal in its surface; that part of the spermatic process, nearest to the testis, was too hard also; that the whole of it was now perfectly free from pain; that the patient was a mar- ried man, much subject to scorbutic eruptions and flying pains, from the same cause; that his appetite was fallen off, and his as- pect become pale and wan; that he had taken a considerable quantity of the cicuta, and as much of the infusion of the solanum as his weak state would bear; that from the former he had neither experienced good nor harm, but that the latter had disagreed with him extremely; that he was now determined for the operation; and that he would be in London in a few days. In less than a fortnight he came to me. He was extremely thin; and had a countenance so pale, and eyes so languid, that I made no doubt that his nights were sleepless. His testicle was large and hard, but perfectly equal, and perfectly indolent; the tunica vaginalis contained a small quantity of limpid fluid; and the vas deferens and epididymis had that kind of enlargement and induration which frequently accompanies a hernia humoralis: but the spermatic vessels were in a natural state, of proper size and free from all kind of induration. He was so hoarse, that I could hardly hear him speak; and so deaf, that it was as difficult to make him hear. He complained much of frequent pains in his shoulders and elbows, one of the latter of which was consider- ably stiffened. The biceps muscle of the left arm was bard and gummy; on one of his eye-brows was a large spot, with a thir A TREATISE ON THE HYDROCELE. 61 scab on it; and, between the scapulae, were four or five of the same. I told him, that I had no doubt that his deafness, hoarseness, pains, spots, swellings, &c. were all venereal; and that I was much inclined to believe that the complaint in his testicle pro- ceeded from the same cause. He did as venereal patients are frequently too apt to do; that is, he endeavoured to render my opinion improbable, by attesting, that there had been an interval ©f some years since he had held any illicit commerce with any woman whom he could suppose capable of injuring him; that he had been two or three years married; had only had a slight chancre, of which he was sure he had been well cured, &c. I answered, that I was clear in my opinion; and would under- take to serve him on no other principle; but desired him to take the judgment of some other gentlemen of the profession; which he did, and returned to me again, with an account that tbey thought of his case as I had done. The weakened reduced state in which he was, and a natural disposition which he had to a haemoptysis, obliged me to proceed very cautiously: his stomach would bear no medicine of the mer- curial kind; and a very little acceleration of pulse made him hawk up a bloody phlegm. I therefore determined upon the ointment in small quantities, and to do in this case what I have done in simi- lar cases several times; that is, as soon as ever the mercury raised the pulse, or began to affect the mouth, I ordered him to take a decoct, corticis twice or thrice a day, through the whole of the salivation. By these means he got rid of all his complaints, both general and particular, and came out of his mercurial course with a more healthy aspect, and more flesh on his bones, than he went into it. Before I proceed to give an account of the means used for the relief, or cure, of the hydrocele of the tunica vaginalis testis, it may not be improper to inform the reader, that I have twice in my life seen this disease, though in a confirmed state, and in adult patients, disperse. 68 A TREATISE ON THE HYDROCELE. CASE XIX. A gentleman, about forty-five years old, consulted me on ac- count of a swelling in his scrotum, which was not very large, but palpably contained a fluid, and was so circumstanced in every respect, as to prove it to be a true hydrocele of the vaginal tunic; from which I advised him to have the water immediately drawn off. As it was not very troublesome to him, he did not choose to have it done then; but went away, telling me that I should soon see him again. He took the opinions of two others, both of whom told him the same thing, and gave him the same advice. At the end of half a year he came to me again, with the scro- tum full, and of a pyriform figure, and so large as to be very evi- dent through his breeches. I would have tapped him immediately; but as he had never seen any thing of the kind, I could not convince him that it would not confine him the next day; and as he had some particular business to transact in the country, he chose to go thither first, and to sub- mit to the operation when he should return from thence. I saw no more of him for near two months; at the end of which time he called upon me, and showed me a scrotum perfectly empty, and free from disease. Taking it for granted that he had been tapped, I asked him who had done it for him: he told me, that before he could finish the business for which he went into the country, he was seized (for the first time in his life) with a severe fit of the gout, which had confined him to his bed for six weeks; during which confinement, his swelling had gradually and totally dissipated. I have often seen him since; and he still remains perfectly free from all appearance of disease. CASE XX. A middle-aged man showed me a hydrocele of the vaginal tunic, which had been near two years collecting, but from which A TREATISE ON THE HYDROCELE. 69 the water had never been drawn: I advised him to have it done soon, and he fixed on the next morning. In his way home he got fuddled; fell down into the area Of an empty hmise; and in his fall struck his scrotum against a piece of scaffolding. In the morning early he sent for me. I found him in bed, with »a great ecchymosis under the skin of the scrotum, which was much swollen, and very.painful. I would have persuaded him to have permitted me to let the water out, (thinking thereby to to have taken off part of the tension,) but he would not consent; and I was obliged to have recourse to fomentation, cataplasm, &c. In about a fortnight, all the ecchymosis was dissipated, and all the swelling from the sound side of the scrotum; and both the pa- tient and myself thought, that the tumor from the hydrocele was considerably less than it was before the accident. By per- sisting in the same method for about three weeks more, the whole of it disappeared, nor has returned since. Nor have I, ever since, seen the same attempt succeed. SECT. VIII. METHODS OF CURING THE HYDROCELE OF THE VAGINAL COAT. The methods of cure (as they are called) in this species of hy- drocele, though various, are reducible to two; viz. the palliative, or that which pretends only to relieve the disease in present, by discharging the fluid; and the radical, or that which aims at a perfect cure, without leaving a possibility of relapse. The end of the former is accomplished by merely opening the containing bag in such manner as to let out the water: that of the latter can- not be obtained unless the cavity of that bag be abolished; and no receptacle for a future accumulation left One may be prac- tised at all times of the patient's life, and in almost any state of health and habit: the other lies under some restraints and prohi- lU A TREATISE ON THE HYDROCELE. bitions; arising from the circumstances of age, constitution, state of the parts, &c. &c. &c. The palliative cure (as I have just observed) consists in merely giving discharge to the fluid which is contained in, and distends, the tunica vaginalis. The operation by which this may be accomplished is a very simple one. The only circumstances requiring our attention in it are, the instrument wherewith we would perform it; and the place or part of the tumor, into which such instrument should be passed. The two instruments in use are the common bleeding lancet, and the trocar. The former, having the finer point, may possibly pass in rather (he easier, (though the difference is hardly perceptible,) but is, in my opinion, liable to inconveniences, to which the latter is not. The trocar, by means of its cannula, secures the exit of the whole fluid without a possibility of prevention; the lancet cannot. And therefore it frequently happens, when this instrument is used, cither that some of the water is left behind, or that some degree of handling and squeezing is required for its expulsion; or, that the introduction of a probe, or a director, or some such instrument, becomes necessary for the same purpose. The former of these may in some habits be productive of inflammation:' the latter pro- longs what would otherwise be a short operation, and multiplies the necessary instruments; which, in every operation in surgery, is wrong. To which it may be added, that if any of the fluid be left in the vaginal coat, or insinuates itself into the cells of the dartos, the patient will have reason to think the operation imperfect, and to fear that he shall not reap even the temporary advantage which he expected. The place where this puncture ought to be made is a circumstance of much more real consequence; the success of ihe attempt, the ease, and ever, sometimes the safety of the patient. depending upon it. Whoever conceives, as many have done, and some still do, that the testicle hangs loose in the middle of the water within the * A consequence which I have seen to proceed from it, attended with a slough of the whole dartos, and which I am much inclined to believe would ;,othave happened in the same person, had the water been drawn off by a ;roeap. A TIUIATISE ON THE HYDROCELE. ii vaginal coat, (like a clapper within a bell,) must also suppose that every part of the general tumor is equally fit and proper for this operation. The idea is erroneous, and the experiment may prove highly mischievous. All the anterior and lateral parts of the vaginal coat are loose and detached from the albuginea: in its posterior and superior part these two tunics make one; consequently, the testicle is, as it were, affixed to the posterior and superior part of the cavity of the sac of an hydrocele; and consequently, the water or fluid can never get quite round it. This being the state of the case, the operation ought always to be performed on that part of the tumor, where the two coats are at the greatest distance from each other, and where the fluid must therefore be accumulated in the largest quantity; and never on that part of it where the fluid cannot possibly be. The consequence of acting otherwise must not only produce a disappointment, by not reaching the said fluid; but may prove, and has proved, highly and even fatally mischievous to the patient. It was a custom formerly, after performing this operation, to make use of fomentations and discutient applications, upon a sup- position that by such means a return of the disease might be pre- vented. Among the old writers are to be found the forms of medicines to be applied to the groin and scrotum, to prevent a future descent of the fluid; but anatomy and experience have proved the falsehood of such supposition, and the absurdity of such applications: the present practitioners content themselves with a bit of lint and a plaster; and, if the scrotum has been considerably distended, they suspend it in a bag truss, and give the patient no further trouble. In most people, the orifice thus made heals in a few hours (like that made for blood-letting); but in some habits and circum- stances, it inflames and festers. This festering is generally su- perficial only, and is soon quieted by any simple dressing; but it sometimes is so considerable, and extends so deep, as to affect the vaginal coat, and by accident produce a radical cure. I have also seen it prove still more troublesome, and even fatal: but then the circumstances, both of the patient and of the case, have been particular, and such as required attention. ''See Case XXI. and XXII) 72 A TREATISE ON THE HYDROCELE. Whether it arose from a fear of wounding the testicle in the operation, or from a supposition that while the quantity was small it was more likely to disperse, or that while there was but little fluid, they did not think the disease sufficiently characterised, or from some other reason which they have not thought fit to give us; but many writers of good authority (and among them Mr. Ser- jeant Wiseman) have forbid the puncture in an adult, while the quantity may be supposed to be under a pint: which restriction is still scrupulously attended to by many practitioners, to the no small trouble and inconvenience of their patients. When there is a sufficient quantity of fluid to keep the testicle from the instrument, there can be no reason for deferring the dis- charge; and the single point on which this argument ought to rest is this: " Whether the absorbent vessels, by which the extravasa- " tion should be prevented, are more likely to reassume their " office, while the vaginal coat is thin, and has suffered but little " violence from distention; or after it has been stretched and dis- " tended to ten or perhaps twenty times its natural capacity, and "by such distention is {like all other membranes) become thick, u hard, and tough." For my own part, I think the probability so much more on the side of the former, that I should never hesi- tate a moment about letting out the water, as soon as I found that the puncture could be made securely. And from what has hap- pened within the small circle of my own experience, I am inclined to believe, that if it was performed more early than it generally is, it might sometimes prevent the return of the disease. CASE XXI. A gentleman, turned of sixty, came to me with an hydrocele of the tunica vaginalis. He was corpulent, full habited, inclined to be asthmatic, and subject to an irregular kind of gouty inflammation, which attack- ed different parts of him, at different times. The disease was on the right side, the scrotum much distended, and on the skin of it was an inflammatory kind of blush. His pulse was hard, and as I A TREATISE ON THE HYDROCELE. to thought too frequent; and he seemed to me to have a degree of heat and thirst not consistent with health. His age, his habit, his general state, and what I apprehend to be the state of the sac, all forbade any attempt but the puncture; and I took some pains to dissuade him from that, until he should have removed both his general complaints, and the local inflammation on the scrotum. He said that he felt himself perfectly well; tjiat he was sure he had no gout about him then; that what I took for an inflammation on the scrotum was only a scorbutic eruption, to which he was frequently subject; and concluded with a hint, that he thought whatever should be done previous to letting out the water, could be designed only for my own benefit, by lengthening the time of my attendance. I pierced the middle and anterior part of the scrotum with a small trocar, and drew off near a quart of a greenish fluid; I put a bit of lint and plaster on the orifice; and as the empty scrotum hung very loose and flabby, I persuaded him to let it be suspend- ed in a bag-truss. In the afternoon he went out; and at night, finding that the plaster was rubbed off, and thinking that the suspensory was put on for no other reason bat merely to keep the dressing on, he took off his bandage. Next day he went out again, walked a good deal, drank freely after dinner, and when he came to his lodging in the evening, he went to bed much out of order. In the night he had a severe rigor, for which he took a large spoonful of a tincture of snake-root and saffron, which he always kept by him. On the third day, finding his scrotum much swollen, and very uneasy, he sent for me. I found him in bed, complaining of great pain in the lower part of his belly and groin; his pulse was quick, hard, and irregular; his skin hot; his tongue dry, and black; his countenance flushed; and his intellects not quite steady. His scrotum was swelled and in- flamed all over; and in a part,considerably distant from the punc- ture, was a mortified spot as big as a shilling. After I had dressed him, I desired, as he was quite a stranger to me, as well as to the people of the house where he lodged, that he might have more assistance: accordingly a physician was sent for, vol. ir. K T4 A TREATISE ON THE HYDROCELE. who prescribed for him. At the end of three days one half of the scrotum was completely mortified; and in about seven more it cast off, with so large a portion of the tunica vaginalis, that I had no doubt that none of it was left. The gout now made an attack on his feet, and the inflammation left all other parts: the sore put on a good aspect, and in a short time he got well. But notwithstanding the very large portion of the vaginal coat which came away in a slough, I have twice since drawn off'a full pint of water from the same side. CASE XXII. A man, about forty, afflicted with a large hydrocele of the tunica vaginalis, and which, from a misapprehension of the true nature of the disease, he had never consulted any body about, having been robbed by a servant of a considerable sum of money, was obliged to travel very hard, on horseback, from the neighbourhood of Exeter, to London. When he set out, his scrotum was free from all disease, except its distention by the water; but when he came to this town, it was covered all over with an inflammation of the erysipelatous kind; was much increased in size, and very painful to the touch. He was much fatigued with his journey; and just before he went to bed in the evening, had a shivering, which was followed by a very rest- less night, and a considerable degree of fever. In the morning his scrotum was so much inflamed, that he was alarmed at the ap- pearance, and sent for assistance. The person who came to him immediately made an opening, by means of a pointed knife, into the tunica vaginalis, and gave discharge to a considerable quan- tity of water; but by night the whole scrotum was mortified. That evening I saw him, but without any hopes of being able to serve him. His pulse, which had been full, hard, and' rapid, was now small and faltering; his head was very unsteady, and his extremities cold; all the tumefaction of the scrotum was gone, and it seemed one large eschar. On the next morning he died. Now, though it be very possible, that the same appearance and event might have ensued, if no puncture had been made; yet I A TREATISE ON THE HYDROCELE. 75 think it is very clear, that it would have been more prudent to have tried first what a soft cataplasm and an antiphlogistic method could have done. For, by making the opening hastily, and without a pro- per prognostic, the operator (whether deservedly or not) incurred all the blame. CASE XXIII. A poor man was brought from the neighbourhood of Rosemary- lane to St. Bartholomew's hospital. His scrotum was of prodigious size; very hard, excessively in- flamed quite up to his groin; it was of a dusky red colour; ex- tremely painful to the touch; and in one part seemed inclined to sphacelate: the spermatic process also was considerably thick- ened. He had a hard, full, rapid pulse; a hot skin, a flushed countenance, great thirst; and complained of most excruciating pain in his back. The account he gave was, that he had, for some years, been troubled with a swelling on the right side of his scrotum, which some of the surgeons of St Thomas's hospital had told him was a water-rupture, and would have tapped; that he had also applied to several rupture-doctors, each of whom had sold him a bandage, and some of them had pretended to cure him by medicines and appli- cations; that, finding no relief from any of these, he had a few days before given an itinerant stage-quack three guineas to cure him. That this operator laid hknon his back, on a couch, and lifting up the tumor, thrust an instrument into it. That no discharge followed but blood. That it bled for near a quarter of an hour, and then stopped upon his fainting away. That from the time of this operation (which was two days) he had been in extreme pain; and, that his operator not coming to take any care of him, his friends had brought him to the hospital. He was immediately bled, had a clyster injected, and the scrotum was enveloped in a soft, warm poultice, and tied up in a bag-truss. When he had passed a stool, I ordered him a grain of extract, thebaic, to be ta- ken immediately, and repeated again at the distance of six or eight hours. Next day he was much the same in every respect; 76 A TREATISE ON TIlE HYDROCELE his pain was excessive, particularly in his back, and he had not closed his eyes. I bled him again freely, (he had two stools in the night,) and gave him two grains of opium, mid direction to repeat one grain every six hours until he got ease and sleep. His scrotum was well fomented, and the cataplasm continued. Two days more were spent in this manner before we obtained any re- mission of the symptoms: when that was done, I pierced the an- terior part of the tumor, and drew off more than a pint of bloody serum. The testicle now appeared very much enlarged, and hardened; but, by persisting in the antiphlogistic method, he at length got well. I suppose the reade r will have as little doubt as I have, that all this mischief was produced by wounding the testicle, or epidi- dymis. CASE XXIV. A young fellow, who was waiter at a tavern in the city, and who had for some months past laboured under a succession of pocky symptoms, had at last a true venereal sarcocele, with a small quantity of fluid in the vaginal coat. As he had several other venereal symptoms then upon him, and his way of life subjected him to great irregularity, 1 advised him to obtain leave to quit his place, and attend to his cure. This he did not choose to comply with; and I heard no more of him till about a month afterwards, when his master desired me to call at his house. I found the lad in bed, with a high fever, and with his scrotum swelled and inflamed to a very great degree. He said that two days before, he had met with an acquaintance, (a surgeon's mate of a man of war,) who told him, that his whole complaint was a water-rupture, and that for a bottle of claret he would cure him immediately. That he had thrust a lancet deep into the lower part of the swelling; that nothing followed but blood; that he had spent some minutes in poking into it with a probe, in hopes of getting the water out, but ineffectually; but that he had been in racSirig pain ever since. Phlebotomy, clysters, opiates, febri- A TREATISE ON THE HYDROCELE. 77 fuge medicines, &c. were all employed, by which means his pain, fever, &c. were at length got the better of; but almost the whole testicle cast off in one large slough. MEANS FOR A RADICAL CURE. Every other method of treating this kind of hydrocele, except the puncture, was either originally intended to obtain a radical cure; or, having been found to have been often productive of such, has been, by different people, ranked sometimes among the pallia- tive, sometimes among.the radical means. In many of the old writers are found directions for obtaining the cure of this disease by the use of a seton, a cannula, a tent, a caustic, a ligature, an injection, or an incision. Some of these are adopted or preferred by one and some by ano- ther, according to the theory which they entertained of the disor- der, or to the benefits which they had seen to have accidentally arisen from the use of the said means. To reduce these under some kind of method, (which the man- ner of their being delivered to us does in general not very easily admit,) we may say, that the seton, the tent, and the cannula, were either originally meant to palliate a disease, of which the old practitioners had very disagreeable apprehensions; or that they were made use of upon a supposition that the fluid contained in the cyst was in itself noxious; or that the general habit of the pa- tient was relieved, and many other disorders prevented by the said humour falling, or being deposited in that part; or from an opinion that the cure of it ought not, by any means, to be hastily or rashly attempted; that the caustic, cautery, and ligature, were designed to prevent the supposed descent of the water from the ab- domen into the scrotum; and, that the injection was calculated for the constriction of a supposed breach in lymphatic vessels. Some of these (happily for mankind) are now quite laid aside, the reasons for their use being found to be false and groundless: of this kind are the cautery, the ligature, and the injection. The wa- ter is now, by every body who has made any inquiry into the mat- ter, known to be formed and collected in the part where it is found; and not to have fallen into it from the belly: and, though an 78 A TREATISE ON THE HYDROCELE. obstruction in the lymphatic vessels of the.spermatic chord, may in some degree prevent the regular and due absorption of the fluid from the vaginal tunic, yet no breach or rupture of such vessels can ever produce the disease in question: the extravasation, in such case, must be in another port; and may possibly cause a hydrocele of the cellular kind, hi the common membrane of the spermatic vessels, but which can never be-found within the tunica vaginalis. The reasons original! v given for the use of the the tent and the can- nula, viz. the noxious quality of the fluid, and the necessity of a gradual cure, are now also known and acknowledged to be without foundation; and therefore though these methods,or methods like these, do still continue to be used, yet it is with another view, and upon other principles: not with intention to lengthen the time of a cure, by making a gradual drain for the prevention of other disorders; but merely to abolish the cavity of the tunica vaginalis, by having excited and maintained such a degree of inflammation and suppu- ration, as shall produce an union between that coat and the albu- ginea testis. This is indeed the only rational end which can, by any of these means, be pursued: for the disorder being absolutely local, and the tunica vaginalis (the seat of it) most commonly somewhat altered from its natural state, by having been distended, unless the ab- sorbent vessels can again be restored to a capacity of doing their duty, (a circumstance which does not very often happen,) the arte- ries will continue to exhale new serum into the cavity, and the hy- drocele will still remain, or be renewed in a short time after each discharge. To obtain this end, two kinds of means are proposed: in the use of one, it is intended, by means of a small wound, to excite such a degree of inflammation as shall occasion, or be followed by a to- tal and absolute cohesion of the tunica vaginalis with the tunica albugiuea. In the other, a larger and more free incision is made; whereby the cavity of the former of these coats is'convertedintoa hollow or open sore, or ulcer, to be filled up by a new incarnation; or else, a part of the said tunic being cut away, its power of again holding the extravasated fluid is equally prevented. The first, or union of the two coats, in consequence, of inflamma- tion, has sometimes been found to follow the use of such means as A TREAT!PE ON THE HYDROCELE. 79 were intended to procure only a temporary relief: it sometimes follows the simple puncture with the trocar, or lancet. The an- cient method of letting out the water, by a small incision, frequent- ly produced it;1 and the seton, the tent, and the cannula, though used for another purpose, or at least for other reasons, were found to be followed by it so often, that they soon were ranked among the means for obtaining a radical cure. 1 This was by making, first, an incision of so me length through the scrotum and dartos, so as to lay the tunica vaginalis bare, and then by making a punc- ture in the latter. The acounts given by Brunus and Theodoric are the same as that of all the writers before them, and have been copied by many since : " Curatio ejus est, ut incidatur cutis testiculorum sectione ampla secundum " longitudinem ejus ; dein perfora, et aquam extrahe." a Many of the old writers have left us directions *or passing the seton, and for introducing the tent, either of lint or sponge ; and the cannula, either of alder, or of silver. Gulielmus e Saliceto, having first proposed the use of external applica- tions, says, " Si hac via non consumitur aqift, tunc perfora bursam, cum " phlebotomo tuo acuto, et extraho aquam, non subito totam, sed partem ; et " pone in foramine illo tentam lineam, vel stupjieam, aut spongiam; ut posses " de die in diem aquam extrahere : et nota, quo*d hujusmodi a:gritudo mul- " toties recidivat; et si sic, semper redeas ad perforationem antedictam : et " via ista, et modo, perfecte curabitur." Fabritius ab Aquapendente speaks of the tent as frequently used by him in the mixed case of hydrocele and sarcocele, or diseased testicle ; thoifgh, by the account he gives of his success, it is pretty clear that he used it in the hydrocele only, or when the testicle was not really diseased. His words are, " Si carnosa simul et aquosa sit hernia, ego talem adhibeo curam. Scco cutem. " et incisionem facio exiguam, et in loco potius altiori, quam in fundo ; inde, ' turunda imposita cum digestivo, et pus movente medicamento procedo, " neque, unquam totum pus extraho, sed perpetuo bonam partem intus rc- " linquo, quod sensim carnem corrodat, et ita sanat." An adhesion of the vaginal coat with the albuginea may be the consequence of such treatment of an hydrocele, and consequently such patient may obtain a radical cure; but whoever has seen any thing of the disease properly called a sarcocele, will know, that it will very seldom bear such rough treatment. This method of procuring a firm cure (by the tent) is mentioned by Ruysch: " Sanari quidem valet id mali pertuso scroto, ope instrumenti touchart dicto, " vel lanceola phlebotomica, ut aqua vulncre exeat, sed sito plerumque re- " crudescit malum. Si autem curationem aggrederis aperiendo scrotum a '« parte superiori ad latus, tumque vulnus turunda oblongaunguento rosaceo, " mercurio precipitato rubro inuncto oppleveris, donee lenis inflammatio, " eique succedens suppuratio parva, mcmbranulas stillantes putrefecerit, rt tuncquc eastenaculo eduxeris," &c. 80 A TKEATISE ON THE HYDROCELE. They were indeed (as I have already observed) originally de- signed to discharge the water gradually; and to continue such a drain from the parts where it had been collected, as might prevent any of the ill consequences apprehended from the removal of the local disorder: but the inflammation which supervened sometimes, producing a cohesion of the sacculus to the surface of the testicle, Professor Monro, of Edinburgh, has proposed a method of cure upon the same principle ; but much better, and more likely to procure the one thing aimed at, (the lenis inflammatio,) as he employs no catheretic medicines. His words are, " Considering how readily contiguous inflamed parts grow toge- " ther ; and how many instances there are, of people having a radical cure " made of this hydrocele, by inflammations coming on the part; it would " seem no unreasonable practice, to endeavour a concretion of the two coats " of the testicle, when they are brought contiguous, after letting out the wa- " ter through the cannula of a trocar, by artfully raising a sufficient degree of " inflammation. " This to be sure must be done cautiously, and so that the surgeon can " rrasonably expect to be master of the inflammation ; and therefore the ap- plication of all irritating medicines, the operation of which he could not " immediately stop, or any single mechanical effort, the effect of which he " could not be sure of, are not to be employed. " Suppose the cannula of the trocar was to be left in ; by the extremity of " it rubbing against the testicle, an inflammation might be artfully raised ; " the cause of which might be taken away as soon as the surgeon thought " fit," &c. Mkdicai Essays. This method, with some small alteration, I have once or twice used with success. Being afraid of the pain which might be caused by the extremity of the cannula rubbing against the tunica albuginea, and the irritation in con- sequence thereof, I have left it in, but with a piece of bougie (whose length exceeded that of the cannula about a quarter or an eighth of an inch) within it. Of all the methods of using a tent, I think this is the best, as the cannula secures its passage into the cavity of the vaginal coat; which the collapsing of that tunic, and the loose texture of the dartos, would other- wise render somewhat difficult. But although I have once or twice suc- ceeded in this manner, I have much oftener been frustrated : sometimes it has proved absolutely ineffectual; and at others, 1 have seen it raise such a disturbance, as to render it necessary to lay the whole cavity open before a cure could be obtained. Of all the methods of obtaining a radical cure of an hydrocele, by exciting inflammation within the tunica vaginalis, and thereby obtaining an adhesion between it and the albuginea, that by the seton is by much the best: it is the least painful, the most easily managed, excites the least troublesome symp- toms, and is the most frequently successful; but, as I shall have occasion to speak of this hereafter, I shall defer saying any more concerning it in this place. A TREATISE ON THE HYDROCELE. 81 what was originally calculated for a palliative remedy only, was by many adopted for a radical one. If the event, and consequence flowing from these means, were as much in our power as they have been said to be; that is, if we could with any tolerable precision or certainty determine the de- gree of inflammation to be excited, and the effect of such inflam- mation on the vaginal coat, there would be no doubt of the utility of them: but this is far from being the case: for although it some- times is sufficient for the purpose wished for, and rises no higher than just to a degree equal to that purpose, yet it also frequently happens, that either such degree and extent of it is not excited, or it rises much higher, and proves much more painful and fatiguing, than was promised or intended; or (as I have several limes seen,) after a great deal of pain and confinement, a partial cohesion only has been the consequence, and the disease has still remained, not- withstanding all the patient's and our trouble. Sometimes the pain, inflammation, and symptomatic fever are but little; but on the other hand, they are all three sometimes so great as to become alarming, at least to a patient who has been taught to expect a cure upon much more easy terms. The whole scrotum some- times becomes excessively inflamed; and after a good deal of * pain and trouble, large deep sloughs are produced, and the pro- cess becomes as irksome as any of those, whose event (with re- gard to a cure) is much more certain. If the inflammation be but slight, the pain and tumefaction moderate, the symptomatic fever light, the suppuration small, and an universal cohesion of the two membranes is produced, the event is very fortunate, and a troublesome complaint is thereby got rid of, upon easy terms. If the event prove what I have mentioned in the second place; that is, if either the inflammation be confined to the dartos, where it sometimes produces several superficial ab- besses (of no consequence toward the cure of the disease); or if it has been so partial, as only to have occasioned the cohesion between the tunics of small compass, the cavity will not by this means be abolished, nor any thing like a radical cure be obtain- ed; consequently the patient will have undergone all the fatigue, confinement, or pain (be it more or less) for nothing, But yf the inflammation rises high, if the scrotum swells considerably, and VOL. II. l 82 A TREATISE ON THE HYDROCELE. large deep sloughs are formed, (as sometimes happens) the symp- toms and the hazard are then fully equal to what attend those more certain methods. Which of the three will be the event, no man can say. Under the same external appearances, different people are more or less liable to inflammation and fever. The confinement of matter, in consequence of too small an opening, will in some habits make strange havoc, in a very short time; and if a large opening and a plentiful suppuration must at last be sub- mitted to, the method by a large incision at first is preferable, as the cure is more certain, and the loss of time less. Different cir- cumstances in the patient will render one method preferable to, and more likely to succeed than another; but whenever a cure is attempted by any of the before mentioned means, the uncertainty of the event should be made known, and the patient be apprised of what may happen, either with regard to trouble or disappoint- ment All the methods hitherto taken notice of, are calculated to pro- duce a perfect or radical cure, without making a large wound, or bearing the appearance of a chirurgical operation: those of which I am now to speak, are intended for the same purpose; but by making a large and free opening into the bag containing the fluid, to render the accomplishment of such purpose more certain. These are called the cure by caustic, and the cure by incision. The cure by caustic is calculated to spare the terror which a cut- ting instrument always conveys; and (as the patrons of it say) to avoid the painful symptoms, and hazard, which frequently attend a large incision in these parts. The method is this: a piece of the common paste caustic, rather less than a finger's breadth, pro- perly secured by plaster, is applied the whole length of the ante- rior part of the tumor, which will necessarily make an eschar of proportional size. When this eschar either casts off, or is divided, an opening of nearly the same length and breadth is thereby in- tended to be made into the cavity of the tunica vaginalis testis: by which means an opportunity is given to the surgeon to apply such dressings to the inside of the said tunic, as shall, by the ge- neration of new flesh, fill up, and abolish its cavity. The prefer- ence which some practitioners have given to this method before that by incision, has been upon a supposition that a circumstance which A TREATISE ON THE HYDROCELE. 83 very seldom happens, will most frequently occur; I mean, the penetration of the caustic through the vaginal tunic, containing the fluid. By this they hope to avoid the symptoms which are supposed to be generally excited by the division of the said bag by a cutting instrument. 1 will not say, that the caustic never does this; but I must say, that I have very seldom seen it do so. If the tumor be very large and full, the containing parts be very much on the stress, and the skin and dartos very thin, the caustic may now and then penetrate through, to the vaginal coat: but this, whatever may be thought or pretended, very seldom happens; and when it does not, the tunica vaginalis must be divided in the same state, and manner, as if no caustic had been applied. All the differ- ence between the two methods (caustic and incision) will then amount to this: that in the former, the skin being mortified, the patient is freed from a part of his apprehension at its being cut; and the surgeon fancying that his escharotic has gone through the vaginal coat, will divide it, as a part of the eschar: but a more careful examination of what he is about, at the time of such opera- tion, would generally convince the latter, that he divides the bag unahered by the caustic; and the symptoms which often attend this process, confirm it. It has indeed been proposed to divide the eschar made in the skin, down to the surface of the tunica va- ginalis, and then, by the application of a fresh caustic, to make an eschar in that coat also. But whoever makes, or submits to this experiment, will find that of two evils he chooses the greater; and to avoid the pain of incision, incurs a much greater degree of it by the repetition of the escharotic. The pain attending the first application of the caustic is indeed to some persons but little; but in many it is fully equal to that of the knife, and must always be of much longer duration. If it does not penetrate the tunica vaginalis, that bag must be divided by a cutting instrument (as I have already said) in the same state as if no caustic had been ap- plied; which incision is and must be accompanied with the same symptoms (in the same person) as in the operation by the knife only. Nor can we at all times confine the caustic, so as that it shall not cause a much larger sore than is intended, or can be necessary. $4 A TREATISE ON THE HYDROCELE. Upon the whole, the cure by caustic, as it spares the tenor and apprehension of a bloody operation by the knife, and as it requires no dexterity in the operator, may on those two accounts become preferable both to many patients and surgeons; yet who- ever promises to perform, or expects to receive, a radical cure by caustic, upon much easier terms thai) by incision, will most fre- quently be disappointed; that is, they will frequently find the fever and inflammatory symptoms full as high, and the sore full as pain- ful in the one as in the other; and consequently all their care and attention to obviate mischief, full as necessary. Neither is the accessary confinement, in general, at all less in the one than in the other. One of the methods made use of by the ancients, to let out the fluid from an hydrocele of the vaginal coat was (as I have already observed), by making a pretty large division of the scrotum and dartos; and having by that means laid the tunic bare, to make an opening into that also, and thereby discharge the contents. This method sometimes produced a perfect cure in the first instance, but much more frequently produced only a temporary relief. If the opening made in the tunica vaginalis was small, and united again immediately, the bag filled again with wafer, and the dis- ease recurred; but if the orifice, instead of immediately uniting, became inflamed, or sloughy, such an adhesion of that coat to the- albuginea testis sometimes followed, as caused an abolition of the cavity of the former, and consequently a radical cure. Though this happened now and then, and the cure was really accidental, yet it furnished a hint for attempting to attain the same end, with a much greater degree of certainty. This was, by dividing or lay- ing open the whole cavity or bag containing the water: and that, sometimes; by a mere simple division of it; sometimes, by the total removal of some part of it. Paulus iEgineta, Albucasis, Severinus, and many others of the best of the ancient writers, have given a particular account of this operation; and it has at all times been practised by some, though it has generally been decried, and dreaded. In what manner, and with what caution it may have been executed, by those who have given so bad an account of it, I know not; but by what I have ▲ TREATISE ON THE HYDROCELE. 85 seen of it, I am very confident that the ills attending it have been mu; h exaggerated; that, under proper cautions and restrictions, it wiU be found to be practicable with perfect safety; and that it ought by no means to be laid aside. Some writers of very good character have appeared very averse to it, and have ascribed to it such symptoms in general, as are indeed very alarming; but which do not occur, unless the operation be performed improperly, or on subjects unfit for it. I have practised it very often, and do not remember to have seen any ill effects from it, more than two or three times. I would be very cautious how I advanced any thing in a matter of this kind, which experience would not vindi- cate, or by which others might be misled; but I have so often made the experiment, and with such success, that I cannot hesitate to assert, that under the necessary restraints, regarding age, habit, state of the disease, &c. it is a very useful operation, and may be praetised with great propriety. I may, perhaps, be thought to speak better of it than it deserves: I am not conscious that I do; but I am much inclined to believe, that they, who appear so averse to it, have either practised it on improper subjects, and impro- per circumstances, or, having imbibed a prejudice against it, have been unnecessarily alarmed at what would not in other cases have alarmed them; or, that not being sufficiently apprehensive and attentive, they have suffered their patients to get into circum- stances of hazard, which are not justly chargeable on the opera- lion merely, and would not happen under more careful manage- ment. Advanced age, an apparently bad or cachectic habit, a disposi- tion to anasarcous or leucophlegmatic swellings, an intemperate life, the custom of drinking spirituous liquors, and any such gene- ral disorder in the constitution as is likely to increase the symp- tomatic fever, which such an operation must necessarily produce, are just objections to it: any disease of the glandular part of the testicle, its coats or vessels, an old irreducible hernia, a diseased state of the urethra, prostate gland, or neck of the bladder, are (while they continue) good reasons for not performing it: but consideratis considerandis, in young and healthy people, and in a recent state of the disease, this method of obtaining a radical cure is a very good and a very practicable one. 86 A TREATISE ON THE HYDROCELE. The method* of performing the operation is as follows: Having appointed an assistant to grasp the upper part of the tumor, in order to render it tense below, a puncture should be made in" the lower and anterior part, through the skin and vaginal coat. If the operator intends to finish the incision with a knife, he should make this puncture large enough to admit the end of his fore-finger; which he should introduce immediately, before the water is all discharged, and the vaginal coat collapsed; and upon that finger so introduced, he should continue his division of the whole length ef the bag, and of the scrotum which covers it. If he intends to use the probe-scissors (a more tedious and a more painful method), he may make his first puncture with a lancet, and then introduce his scissors. Upon the first division, the water rushes out, and the tumor subsides: if the puncture be made small, a part of the fluid will insinuate itself into the cells of the dartos, and by the immediate collapsion of the vaginal coat, the operator will find some difficulty in introducing either his finger or his instrument into the orifice made in it; if he does not do this, he will divide only the skin and the dartos, and the patient must undergo a second incision, for the division of the cyst: all which inconvenience may be avoided, by making the first opening large enough for the introduction of the finger; and when that is in, all the rest is, upon that, very easily executed.* When the vaginal tunic is divided, and the fluid thereby dis- charged, the testicle, covered only by its tunica albuginea, comes into view; and if the incision was either begun, or continued very low, it generally thrusts itself out from the wound. This should be gently replaced; and if the vaginal coat is not much thickened by having been long distended, nothing more need be done, than * Some practitioners, terrified at the accounts which they have received ef the operation, and yet being desirous of producing a radical cure in this manner, have thought that they might lessen the hazard, by reducing the size of the incision; and therefore make a very small one : but whoever depends upon this, will find himself mistaken. An incision made one-fourth of the length of the sac will be attended with all the trouble and hazard, which follow one of two-thirds; with this additional inconvenience, that the former wjll very often prove ineffectual at last. A TREATISE ON THE HYDROCELE. 81 to lay a small quantity of fine lint? into its cavity; and then covering the wound with a large pledget and a soft bolster, tie the scrotum up in a suspensory bag. This operation, if properly per- formed, may be executed in a very few seconds: it requires no other violence, than the mere division of the parts; and if this divison be made with a knife, rather than scissors, it will require much less time, and cause much less pain. The membranous structure of the parts on which this wound is inflicted; their continuation from the peritoneum; and the great ir- ritability of some of those which are necessarily laid bare, and put under a necessity of receiving dressings, must occasion pain and symptomatic fever. This it is the business of art to moderate and relieve: phlebotomy, lenient aperitives, febrifuges, and opiates, will therefore become necessary. But in this case, as in many others, it will generally be found much more easy to prevent bad symptoms than to remove them, when they have been permitted to attain a considerable height. The operation is, or ought to be, con- fined to the young and the healthy, in whom inflammatory symp- toms are most likely to occur; but (I believe I may venture to say) to whom we have more efficacious remedies to apply in such dis- orders, than can be used to people of a different habit, and in dif- ferent circumstances. The general induration of all the parts about, the thick tumid lips of the incision, and the general inflammatory enlargement of the scrotum, have for the first four or five days a disagreeable ap- pearance; and may, if neglected or mistreated; prove very trou- blesome or even hazardous; and the kind of discharge, which during that time is made, (a thin discoloured gleet,) seems very unequal to the reduction of so much tumefaction; but when the febrile symptoms are appeased, and a kindly suppuration begun, let the surgeon have patience, and not by an over-officiousness, or by improper dressings, interrupt nature in what she is about: let him, by warm fomentations, keep the parts clean and perspirable; let him dress the wound with a small quantity of soft, easy, di- y By no means to fill, or distend it, or to make any pressure on the testi- cle ; whose tunica albuginea is very irritable, as well as acutely sensible 88 A TREATISE ON THE HYDROCELE. gestive applications; and covering the whole scrotum2 with a soft, warm poullice, suspend it in a proper bag; and he will in general, soon see a favourable change in all the appearances; he will see the inflammation disappear, the tumor resolve, and all the tume- faction in due time subside. But if he neglects these general cautions, and under a notion of assisting digestion, goes to work with precipitate and other irritating dressings, the face of things will not be so agreeable; the tumor will not subside; and he will continue, or rather create, a painful, undigested sore, with all its consequences; but, for which, he only is accountable, a z The impalpable farina seminis lini, put into boiling water, with a proper quantity of ung. sambuc, fresh butter, or lard, is the easiest made, and is the neatest, softest, smoothest, and most relaxing application of the kind ; hat. nothing offensive in its flavour; nor is it, like most other cataplasms, likely to excite a herpes. a The great hardness which almost always attends inflammations of these parts, has (I suppose) been the reason, why so many writers have advised, and so practitioners still use such applications,-as (though i-eally cscharoticsj are called dissolvers of induration, and removers of obstruction. I would be very cautious how 1 made objection to what so many have re- commended; and, in a matter of mere speculation, would rather doubt my own judgment, than that of some others : but this is a fact, of which I have too often been convinced to be mistaken ; and, therefore, I cannot help say- ing, that it appears to me, that all applications of this kind, even in the mild- est of them (the red precipitate) are generally very improperly used; that they give unnecessary pain; and retard, what they are used with design to expedite. Inflammatory hardness and tumefaction is not peculiar to the scrotum, upon its being wounded: it is common to all parts of similar structure; that is, the adipose and cellular membrane all over the body. When such parts are irritated by a large wound, they cannot resist a sud- den influx; the consequence of which must, for a time, be obstruction, in- duration, and swelling: but one moment's reflexion on the natural structure and state of these parts, before such wound was inflicted, or such irritation excited, will prove that ease, relaxation, and free suppuration, must be the intentions proper to be pursued; and that every application, which either stimulates, gives pain, or corrodes, must pervert and counteract such inten- tions. a The breasts of women, the axillae of both sexes, the parts surrounding the intestinum rectum, the cellular membrane in the perinsum, under the in- teguments of the penis, and in several other parts of the body, are liable to this kind of alteration, when injured ; but this induration is very unlike to a glandular one, and requires very different treatment. In the latter, a A TREATISE ON THE HYDROCELE. 89 In about six weeks, the scrotum is generally reduced to nearly sis natural size; and when the wound is quite healed, the cicatrix is a mere line, corresponding to the original incision; which is a destruction of parts is sometimes necessary, and escharotic medicines may therefore be required. But in the former, mere relaxation is all that is wanted: whatever gives ease, and appeases the inflammatory tension, will best produce matter, and answer the purpose which ought to be aimed at. The most convincing proof of the truth of this doctrine may be drawn from that case, which, of all those which affect this kind of membrane, is generally the most troublesome ; I mean the fistulse in perinaeo. In these the induration and enlargement of the parts are sometimes so great, as to be very alarming; hard callous excrescences; deep and long sinuses, with small orifices; constant pain and irritation, from the lodgement of matter and urine ; a symptomatic fever of the hectic kind; and a difficulty either of re- taining the urine within, or expelling it from the bladder, make a part of the most frequent characteristics of this disease: and yet, even these cases, terrible as diey are, do frequently admit relief, and are sonietifties even cured, without any destruction of parts, or the use of any one escharotic ap- plication : a free division of all the hollow and hard parts; the application of soft, easy digestives, and of a warm, relaxing poultice j a total abstinence from all such external remedies as corrode or irritate ; and all such internal ones as, under the title of deobstrucnts, increase the velocity of the circu- lation, and waste the patient's strength, by watching, purging, and sweat- ing; and an easy and gradual distention of the urethra, by a simple unmedi- tated bougie ; will, in some instances (indeed, in all, where any good can be done at all) remove most of these disagreeable circumstances and appear- ances : in which cases, a kindly suppuration will be afforded by all the di- vided parts ; a florid, well conditioned incarnation will be the consequence; the cicatrix will be small, soft, and moveable, and very unlike to what must follow from the use of catheretic applications. This is really a matter of much greater general importance, than it is sup- posed to be : the symptomatic fevers, which are either produced or main- tained by the injudicious application of painful dressing, are much more fre- quent than they are thought to be : not to mention the loss of time which they must always cause, and the very disagreeable deformities they often occasion. The surgery of most of our forefathers was coarse and rough ; and many of the practitioners affected a kind of brutal, unfeeling rusticity. The old maxim," Dolor medicinadoloris," was so generally received, that the surgeon almost forgot his patient's sensation; and the common people thought they were neglected, if they were not tortured, hord Bacon's most excellent advice, " Inveniend uinquid natura ferat aut faciat," was but half remem- bered- they tried very sufficiently what nature would boar, but very seldom had patience to know what she could do. Under a mistaken notion of going VOL. \y M 90 A TREATISE ON THE Hi'DROCELE. circumstance of more consequence to the patient than is ima- gined, especially if he be obliged to get his bread by labour. If the tunica vaginalis, containing the water, by long or frequent distention; or from any other cause is become thick and hard, and cannot therefore contract itself, or be contracted, upon the evacua- tion of the fluid; it will contribute considerably to the thickness of the I;ps of the w.;u:;d, as well as to their hardness, pain, and diffi- culty of digestion. In this case, the best way is to remove a part Of it, on each side, at the time of the operation. The cellular structure of the dartos easily admits this to be done; and when these sides are thus taken away, the lips of the wound consist on- ly of the common integuments. A knife will do this with much more ease and expedition than any other instrument whatever. The method proposed by the late Mr. Douglas, of doing it by re- peated snips of the probe-scissors,'is operose, unhandy, and unne- to the bottom of wounds and abscesses, and of dissolving indurations, they crammed and distended the cavities, and corroded and irritated their sides, till a train of bad symptoms were often excited, which the original disease had no share in the production of. That this is no exaggeration, let their works testify ; and that something of this kind is still too much in use is too well known. All dressings are in fact extraneous bodies; and when they either consist of such materials as give pain, and excite irritation, or are crammed in with injudicious violence, they are foreign bodies, vvith other mischievous qualities annexed- Where destruction of parts is necessary, the sooner it is executed the better, and the necessary pain must be complied with ; but in the application of dress- ings to the inside of abscesses, to hollows made by the removal of diseased parts, to large sores attended with hardness and inflammation of the com- mon membrane: in short, wherever mere suppuration is required, they cannot be too light, soft, and easy; all that we have to do is, not to obstruct nature in the execution of those offices, to which she is generally fully equal; in which we can lend her no assistance beyond removing impedi- ments out of her way. In the particular case of the divided tunica vaginalis, that degree of thickness and hardness, which it sometimes acquires by long distention, is urged as a reason for the use of caustic applications: but this is a method of reasoning to which I cannot agree, having often expe- rienced the contrary. That membrane, like all others of the exanguious kind, is difficult and slow of digestion, especially if altered by disease; but that it will in time become sloughy, digest, and yield a kindly suppuration and incarnation, by the mere use of simple, easy applications, and without that of any escharotic, (not even the red precipitate,) I have often and often 'txperienced- A TREATISE ON THE HYDROCELE. 91 cessarily painful and tedious: nor is the cutting away an oval piece of the scrotum, as advised by that gentleman and some others, at all necessary: on the contrary, the more loose that part of the < scrotum is, which is to cover the testicle, (now deprived of its vagi- nal coat,) the better; as it will be more capable of corrugation. With these cautions, and under the proper restrictions already mentioned, this method of obtaining a radical cure is very practi- cable. That it is sometimes accompanied by troublesome symp- toms is beyond all doubt; and so is the method by caustic. I cannot say, that I have never seen it prove fatal; nor can that be said of any operation of consequence. Much depends on the choice of a proper subject, and the observance of the necessary means and cautions; without which, both this, and the use of the caustic, will always be troublesome, and sometimes hazardous. Before I finish the account of this method of cure, I would take the liberty of mentioning one circumstance more, which appears to me to be of consequence. When the quantity of fluid is large, and the scrotum and tunic much on the stretch, I think it is better to discharge the water by mere puncture; and not to perform the operation for the radical cure, until a fresh accumulation has again moderately distended it The inflammation necessarily conse- quent upon the division of these parts, just after they have been so much on the stretch, and so suddenly let loose, may be (and I think I might say, that I have seen it prove) productive of worse symptoms, and a higher degree of fever and tumefaction, than usually occurs when the same parts are divided in a less distended state. This method of obtaining a radical cure by incision, of which I- have given the fairest and most impartial account in my power, must always be considered as a matter of choice, and never can be an operation of necessity; that is, they who are afflicted with the disease, for whose cure it is calculated, will always have it in their power to be temporarily relieved by the palliative means, or may make trial of any of the above mentioned less certain at- tempts, without incurring any, or a very small degree of hazard. Now as this method can never be said to be totally and absolutely void of some danger; as it bears the appearance of an operation of some severity; and as it must always be voluntarily and deliber* 92 A TREATISE ON THE HYDROCELE. ately submitted to, without any real necessity from the circum- stances of the disease; in other words, as it must be chosen by the patient, merely to avoid the trouble and inconveniences Vat- tending the disorder, and not necessarily applied to, as some other operations are, to save or preserve life, it does not often happen that we are railed upon to practise itb The number of people labouring under this disease, and who come within the above mentioned necessary restraints, from age, habit, manner of living, date of the complaint, thickness of sac, &c. &c. &c. is great And that of those, who either have an in- superable dread of an operation, or are so circumstanced or con- nected in life, as to make any such degree of danger highly impro- per to be voluntarily incurred, is still greater: so that by far the majority of those who are afflicted with the disorder, are obliged (however irksome it may be, or however disagreeable it may prove to them) to carry it through their life, seeking relief now and then from the palliative remedy of tapping. This renders it, to the active and to the laborious, a complaint of more conse- quence than is generally imagined. From these considerations, I have often been induced to think seriously on the subject, and to make many experiments; the re- sult of which, when likely to prove at all useful to mankind, or creditable to the art of surgery, I shall always think myself oblig- ed to communicate. Every practicable method proposed by the ancients I have tried: b The method of cure of the hydrocele by incision, which Mr. Pott has here so fully described, he did not perform during the last twenty years of his life; on the contrary, in every conversation, public and private, repre- sented it as a severe and unnecessary operation; during which time it has not been performed at St. Bartholomew's hospital. Before that period it was the usual practice. As this disease has of late been the subject of so much disquisition, and so many improvements have taken place in the treatment of it, I had entertain- ed hopes that the operations by incision and excision would have been wholly laid aside, as I must confess they always appeared to me painful in the execution, and productive of great and dangerous inflammation, often caus- ing a fever which put the life of the patient in considerable hazard. Mr. Cheselden, who was by no means a timid operator, speaking of the cure of the hydrocele by incision, says, " This I have done, and seen done several • times ; but never thought the cure worth the trouble and pain tb« patient •'•' underwent."—E- A TREATISE ON THE HYDROCELE. 93 and have found them in general painful, fatiguing, hazardous, or inefficacious. The tent, whether of lint or sponge, is subject to great objec- tions, both in its first application, and its future necessary con- tinuance. The cellular structure of the dartos, and the loose con- nexion between the skin and tunica vaginalis, render its intro- duction (unless a cannula be used) sometimes difficult When in, great care must be taken to keep it there for some time, or the effect intended (an inflammation of the vaginal coat and al- buginea) cannot be obtained; and the means made use of for its distention, as well as the nature of the tent itself, (especially if made of sponge,) prove frequently very fatiguing, not to say mis- chievous, by the irritation and the necessary confinement of the matter. And, after all, I have several times seen it produce on- ly a partial cohesion; and that so small an one, as to prove no cure at all, nor at all prevent the future accumulation of water, or the necessity of frequent tapping. The cannula, when used for the same purpose instead of a tent, is indeed easily introduced; and when in does not confine the matter: but then its hardness, inflexibility, and thin edge, and the absolute impossibility of directing or managiug it in the fre- quent and necessary motions of the patient, though confined to hi* bed, render it a*very unpleasant and troublesome guest within the tunica vaginalis; and if, to avoid this inconvenience, a piece of bougie be kept within it, this, while it is there, confines, what ought to be discharged. The point to be aimed at is, to excite such a degree'of inflam- mation, both in the tunica vaginalis and tunica albuginea, as shall occasion a general and perfect cohesion between them: and this, if possible, without the production of slough or abscess; without the hazard of gangrene; and without that degree of symptomatic fever which now and then attends both the caustic and the inci- sion; and which, when it does happen, is so alarming both to patient and surgeon. These ends I have frequently obtained, by the use of a seton. It is a method of cure mentioned by Aquapendens, as used by Guido, and others before him (though their process was somewhat different from mine). I hove several times tried it on subjects of 94 A TREATISE ON THE HYDROCELE. very different ages, some of them more than fifty years old. It requires confinement to bed only for a few days; after which, the patient may lay on a couch to the end of the attendance; which is generally finished in about three weeks, or a month at the far- thest: and, during all that time, no* other process or regimen is necessary; than what an inflammation of the same part from any other cause (for example, a hernia humoralis) would require. But for a more particular account of this I must refer the reader to the tract on this subject, which he will find at the end of the present. SECT. IX. THE HEMATOCELE, OR TUMOR FROM BLOOD. Tins is a swelling of the scrotum, or of the spermatic process, proceeding from, or caused by blood; and though spoken of by writers as one simple disease, is liable to so considerable variety, both vvith regard to nature and situation, as to admit, or even require, being divided into several kinds. Such distinction of the different kinds of hematocele, though not usually made, is absolutely necessary toward rightly under- standing the disease; the general idea or conception of which appears to me to be somewhat erroneous, and to have produced a prognostic which is ill founded, and hasty. According to my conception and experience in this matter, the disease, properly called hematocele, is of four kinds; two of which have their seat within the tunica vaginalis testis; one within the albuginea; and the fourth in the tunica communis, or common cellular membrane, investing the spermatic vessels. In passing an instrument, in order to let out the water from an hydrocele of the vaginal coat, a vessel is sometimes wounded; which is of such size as to tinge the fluid pretty deeply at the time of its running out. The orifice becoming close, when the water is all discharged, and a plaster being applied, the blood A TREATISE ON THE HYDROCELE. 95 ceases to flow from thence, but insinuates itself partly into the cavity of the vaginal coat, and partly into the ceils of the dartos; making, sometimes, in the space of a few hours, a tumor nearly equal in size to the original hydrocele.—This is one species. It sometimes happens, in tapping an hydrocele, that although the fluid discharged by that operation be perfectly clear and limpid, yet, in a very short space of time (sometimes in a few hours) the scrotum becomes as large as it was before, and palpa- bly as full of a fluid. If a new puncture be now made, the dis- charge instead of being limpid (as before) is now either pure blood, or very bloody.—This is another species; but, like the preceding, confined to the tunica vaginalis. The whole vascular compages of the testicle is sometimes very much enlarged, and at the same time rendered so lax and loose, that the tumor produced thereby has, to the fingers of an examiner, very much the appearance of a swelling composed of a mere fluid, supposed to be somewhat thick or viscid. This is in some mea- sure a deception; but not totally so: the greater part of the tume- faction is caused by the loosened texture of the testis; but there is very frequently a quantity of extravasated blood also. If this be supposed to be an hydrocele, and pierced, the discharge will be mere blood.—This is a third kind of hematocele; and very different, in all its circumstances, from the two preceding: the fluid is shed from the vessels of the glandular part of the testi- cle, and contained within the tunica albuginea. The fourth consists in a rupture of, and an effusion of blood from, a branch of the spermatic vein, in its passage from the groin to the testicle. In which case, the extravasation is made into the tunica communis, or cellular membrane investing the spermatic vessels. Each of these four I have seen so distinctly and perfectly, that I have not the smallest doubt concerning their existence and of their difference from each other. The tunica vaginalis testis, in a natural and healthy state, is a membrane, which, although firm, is of no great thickness; it is white, or rather of a reddish white colour; and its blood-vessels arc (in a healthy state) no more apparent to the eye, than are those of the tunica albuginea-* but when it has been long or much distended, 96 A TREATISE ON THE HYDROCELE. it thereby becomes thick, and tough; and the vessels (especially those of its inner surface) are sometimes so large as to be very visible, and even varicous. If one of these lies in the way of the instrument, wherewith the palliative cure is performed, it is some- limes wounded: in which case, as I have already observed, the first part of the serum which is discharged is pretty deeply tinged vvith blood. Upon the collapsion of the membranes, and of the empty bag, this kind of haemorrhage generally ceases, and nothing more comes of it But it sometimes happens, either from the toughness of the tunic, or from the varicous state of the vessel, that the wound (es- pecially if made by a lancet) does not immediately unite; but con- tinues to discharge blood into the cavity of the said tunic, thereby producing a new tumor, and a fresh necessity of operation. This is what I have taken the liberty to call the first species of hematocele, and plainly and evidently consists in a wound of a vessel of the vaginal tunic. Upon the sudden discharge of the fluid, from the bag of an over- stretched hydrocele, and thereby removing all counter-pressure against the sides of the vessels, some of which are become vari- cous, one of them will, sometimes, without having been wounded, burst If the quantity of blood shed from the vessel so burst be small, it is soon absorbed again, and, creating no trouble, the thing is not known.' But if the quantity be considerable, it, like the pre- ceding, occasions a new tumor, and calls for a repetition of the operation. This I call the second species: which, like the first, belongs entirely to the vaginal coat, and has no concern either with the testicle, or with the spermatic vessels. In both, the bag which was full of water, becomes in a short space of time distended with blood; which blood, if not carried off by absorption must be discharged c From this cause it very often happens, that the last running (if I may use the phrase) of the water from an hydrocele, is bloody (all the former part having been perfectly clear) ; and from hence it is, that a bloody discharge may almost always be produced upon the same occasion, by pressing and handling the scrotum. They who would see a very ingenious account of this kind of hematocele, and a very probable application of the same principle, for the solution of some other appearances in diseases, may find it in the Edinburgh Essays from Professor Monro, the father. A TREATISE ON THE HYDROCELE. 91 by opening the containing cyst; but in neither of these can cas- tration (though said to be the only remedy) be ever necessary: the mere division of the sacculus,d and the application of dry lint to its inside, will in general, if not always, restrain the hemorrhage, and answer every purpose, for which so severe a remedy has been pre- scribed. The other two are indeed of more consequence: they interest either the testicle itself, or the vessels by which it is sup- plied with blood, and rendered capable of executing its office; and are sometimes not curable, but by removal of the part One of these is seated within the tunica albuginea of the testicle; the other in the tunica communis of its vessels: they are neither of them very frequent; but when they do happen, they call for all our attention. If blood be extravasated within the tunica albuginea, or proper coat of the testicle, in consequence of a great relaxation, and (as it were) dissolution of part of the vascular compages of that gland, and the quantity be considerable, it will afford or produce a fluctuation, to the hand of an examiner, very like to that of an hydrocele of the tunica vaginalis; allowing soineihing for the diffe- rent density of the different fluids, and the greater depth of the for- mer from the surface. d It may indeed happen, that the blood of the patient may be in stub state. as to be incapable of coagulation: in which case, the hemorrhage will con- tinue from the inside of the sac, although it be laid open; and also from all the divided parts. This circumstance, though a very hazardous one, cannot be foreseen; nor do I know, in this state of the juices, what benefit can arise from the removal of the testicle; for the haemorrhage will certainly be con- tinued, from all parts of the wound necessary in such operation, upon the same principle, and for the same reason that it could not be restrained from the inside of the sac. Such an indisposition of blood is often, in cachectic habits, the cause of very troublesome and fatal haemorrhages, at some distance of time from amputation, as well as immediately. If this want of an agglu- tinant quality in the blood is not corrected, or is not capable of correction, it generally goes hard with the patient, let the operation be what or where it may: for it is not merely the suppression of the bleeding that is required the same ill quality of blood will prevent suppuration, produce bloody, sanious gleeting, gangrene, and mortification. This is an evil, of which every practitioner must have seen so many instance, that it is needless to produce particular ones. VOL. II x ■Jb A TREATISE ON THE HYDROCELE. If this be mistaken for a simple hydrocele, and an opening be made, the discharge will be blood; not fluid, or very thin; not like to blood circulating through its proper vessels; but dark, and dusky in colour, and nearly of the consistence of thin chocolate (like to what is most frequently found in the imperforate vagina). The quantity discharged will be much smaller than was expected from the size of the tumour; which size will not be considerably diminished. When this small quantity of blood has been so drawn off, the testicle will, upon examination, be found to be much larger than it ought to be; as well as much more loose and flabby; instead of that roundness and resistance arising from a healthy state of the gland, within its firm strong coat: it is soft, and capable of being compressed almost flat, and that generally without any of that pain and uneasiness which always attend the compression of a sound testicle. If the bleeding ceases upon the withdrawing tin cannula, (supposing a trocar to have been used,) and the puncture closes, a fresh accumulation of the same kind of fluid is soon made, and the same degree of tumefaction is produced, as before the ope- ration: if the orifiee does not close, the hemorrhage continues, and very soon becomes alarming. In the two preceding species, the blood comes from the tunica vaginalis, the testis itself being safe and unconcerned; and the re- medy is found, by opening the cavity of the said tunic: but in this, the hemorrhage comes from the substance of the testicle; from the convolutions of the spermatic artery, within the tunica albuginea. The division of the vaginal coat can here do no good;, and an in- cision made into the albuginea can only increase the mischief: the testicle is spoiled, or rendered useless, by that kino1 of alteration made in it, previous to the extravasation; and castration is the only cure, which a patient in such circumstances can depend upon. The last species of this disease arises from a bursting of a branch of the spermatic vein, between the groin and scrotum, in what is generally known by the name of the spermatic process This, which is generally produced by great or sudden exertions of strength, feats of agility, &c. may happen to persons in the best health, whose blood and juices are in the best order, and whose genital parts are free from blemish or disease A TREATISE ON THE HYDROCELE. 99 The effusion, or extravasation is made into the cellular mem- nrnne, which invests and envelopes the spermatic vessels, and has something the appearance of a true hernia. When the case is clear, and the extravasated blood does not give way to discu- tient applications, the only remedy is to lay the tumor fairly open, through its whole length. If the vessel or breach be small, the hemorrhage may be restrained by mere compression with dry lint, or by the use of styptics; but if it be large, and these means do not succeed, the ligature must be made use of. If the bleeding branch can be tied singly, the testicle may be preserved; if it can- not, and the whole spermatic process must be included, it is un- necessary to add, that the testicle must be removed. CASE XXV. A healthy man, about thirty years old, desired me to let out riie water from an hydrocele; which operation he said, had, for some time past, been performed upon him, twice a year, by the late Mr. Bell, of Red-lion-square; and he desired also that I would do it with a lancet. I let out near a pint, the first part of which was deeply tinged with blood; but as it ran, it became clearer and clearer, and at last was perfectly limpid; and when I put on the plaster, he did not bleed a drop. The next morning he came to me again; told me that he had bled a good deal in the night; and showed me his linen, which was very bloody. As there was no discharge at this time, I only renewed his plaster, put him a bag- truss on, and desired that he would go home and keep quiet He remained free from hemorrhage for some hours, and there- fore neglecting my last caution, he walked about a good deal, and heated himself, and the next day sent for me to look at his scro- tum, which was large and full. Making no doubt, from all the circumstances, that the tumefaction was from blood, I told him my opinion; and at the same time advised, if it did not dissipate by proper attempts for that purpose, to submit to have the vaginal coat laid open, and thereby obtain a radical cure. Some time was spent in attempting discussion; during which 100 A TREATISE ON THE HYDROCELE. the tumor increased, and he now and then bled pretty freely from the orifice, which became spongy, and would not heal. Finding all endeavours ineffectual, he submitted: the tunica vaginalis was laid open; a considerable quantity of blood was dis- charged (some in a fluid state, but principally grumous;) he had no disagreeable symptoms, and, in about six weeks, was perfectly well. CASE XXVI. An elderly man, who had often had a large hydrocele tapped at the hospital, came one day, as usual: I made a puncture with a lancet, and let out the water; but was near half an hour before I could stop an hemorrhage fronuthe wound. The next day he came again, and complained to one of my dressers, that he had bled, more or less, all the night. He was properly dresssed; the bleeding restrained; and he was advised to go home, and keep quiet upon the bed. The third day, when I was again at the hospital, he came and showed me his scrotum; which was as full, and as large, as when I first tapped it: the orifice was not healed; and, upon pressure, blood was discharged from it. He said, that he could not afford to rest from his labour; and my week for accidents being expired, Mr. Crane took him under his care. He (finding the bloody discharge still continued, notwithstand- ing the man kept in bed, and was properly taken care of) made a free incision into the tumor; turned out a good deal of coagulated blood with his finger; and then, lightly filling the cavity with lint, obtiined a suppression of the hemorrhage, and produced a radical cure. CASE XXVII A gentleman who used to come to London about every five or six months, to have a large hydrocele emptied, came to me under a great alarm. A TREATISE ON THE HYDROCELE. 101 Having often had the water drawn off by puncture in London, he determined to let the apothecary of the village where he lived do it for him, and thereby save him the trouble of a journey. The operation was very properly performed, and the bag perfectly emptied: but the next morning, to his great astonishment, he-found it as full as before. His apothecary was as much surprised as himself; and the patient got into a post-chaise, and came imme- diately to London. Upon hearing this account, and seeing and feeling the tumor, I made no scruple of declaring it to be bloody; and that if it did not soon dissipate by rest, and proper applications, it must certain- ly be let out. All attempts for dispersion proved fruitless, the tumor increased, and as his health and habit were good, and his age by no means advanced, I advised him to submit to an incision; by which I hoped that he would not only get rid of the present evil, but would most probably obtain a radical cure. He complied, upon condition, that I would first by puncture satisfy him, that I was right in my conjecture with regard to the contents. I passed a lancet into the fore-part, and gave discharge to a clear blood: while that was running out, I made, by means of a probe-pointed knife, an incision of sufficient size to admit a dos- sil or two of fine lint. For a day or two, the symptoms were un- towardly, and the discharge was large, and bloody; but by pro- per care, keeping very quiet, and taking freely of the bark with elixir vitrioli, every thing ended well. CASE XXVIII A lusty, healthy man, about forty, who had the care of a ma- nufacturer's warehouse in my neighbourhood, consulted me on account of a large hydrocele of the tunica vaginalis. The tumor was very large, the parts considerably on the stretch, and I advis- ed him to have it tapped directly. About twenty ounces of clear water were drawn off by means of a trocar, without the appearance of a drop of blood. As he had carried his burthen long, and had never been relieved from it be- 102 A TREATISE ON THE HYDROCELE. fore, he was much surprised at this immediate ease, and went to work as soon as he got home. The next morning he came to me much alarmed, and showed me his scrotum; which was full half as big as before the punc- ture had been made. 1 had no doubt that its present contents was blood; and was very apprehensive that it might require the same treatment as the preceding case: which, in his constitution, and manner of living, must have been attended vvith hazard. I ordered him home to bed immediately, took some blood from his arm, and directed a cooling purge to be taken the next morn- ing; the scrotum was suspended, and wrapped in a rag folded seven or eight times, and wetted in a solution of sal. amnion, crud. in vinegar and water, and he had direction to keep it constantly wet. On the third day I bled him again, and ordered him another purge for the fourth, and continued the same application. Finding the swelling quite at a stand, and imagining that by mending his state of blood, a further effusion might possibly be prevented, and an opportunity given for the absorption of what was already shed, I advised him to take a dram of the cortex every six hours: this he did for as many days; during which, the tumor visibly lessened: and, by persisting in the same method, he got well: that is, all that degree of tumefaction, which I suppose to have been caused by blood, disappeared. After some months the scrotum became large again; and he followed the advice which I had given him: viz. to have the fluid drawn off; before it attained too- large a size. I have several times since tapped it, and have always drawn off a clear fluid. CASE XXIX. A man, about forty-seven, of a sallow complexion, and subject to colicky complaints, had the water drawn off from an hydrocele of the vaginal coat, by means of a small trocar. The quantity was near a pint; and the bag was perfectly emptied. The next morning it seemed to contain a fluid, although in no great quan- tity: he showed it to the person who tapped him the day before, and who advised him to put on a bag-truss, and to take a smart A TREATISE ON THE HYDROCELE. 103 purge. In three days it was so manifestly increased, as to alarm the patient, ai:.l make him desirous of further advice.» On the sixth day from the first operation, I saw him, and found the scrotum so much enlarged, that I made no doubt the vaginal tunic contained at least seven ounces, which I suspected to be blood. I advised a discutient application, and the free use of the cor- tex; but this did not suit the humor, either of the patient or of his surgeon. He took three or four purges of rati, jalap, and made use of a warm fomentation. At the end of about a month, I was desired to see him again. The tumor was larger, and his strength impaired by his purging. It appeared to me to be now of such a size, and in such state, that nothing but the operation could serve him; and for which I prepared him, if the puncture should pro- duce a discharge of blood only. An opening was made with a lancet, and the discharge was clear fluid blood: I would have pro- ceeded, but the patient would not permit me: and he was dressed with a superficial pledget, and a plaster. Blood oozed from the orifice all that night, and part of the next day; and when I saw him again, he could not have lost less than a pint. I was well aware, what might be the consequence of a division of the tunica vaginalis, in such a habit; but, at the same time, it seemed to be the unicum remedium, for he would take no medi- cine. The hemorrhage continuing another day, he submitted. The operation discovered no one bleeding vessel; nor did I ima- gine that it would, being convinced that it came from the inside of the tunic. He was dressed with dry lint, and put to bed vvith an opiate. All that night, and the succeeding day, the discharge was large and bloody: and the lips of the incision, on the second, were flabby, and free from inflammatory tumefaction. 1 told him my opinion freely, and pressed him to take the bark, or have more assistance; both which, at that time, he refused lo do. On the close of the third day, the hemorrhage still continuing, he becoming sick and faint, and his pulse failing a little, he was alarmed, and permitted us to direct for him. A draught, consist- ing of a dram of bark, half a dram of confect cardiac, and three or four drops of tinct thebaic, was ordered lo be taken every four hours 104 A TREATISE ON THE HYDROCELE. Not to make the account tedious, by a relation of every minute circumstance, he persisted in this method, and it was four days be- fore the bleeding ceased, or the edges of the incision became in- flamed, or showed any tendency toward the suppuration. But at last, with some difficulty, he got well. CASE XXX. A labouring man, who had fallen down in the street with a load on his back, was brought into St. Bartholomew's hospital, on a suspicion of his having got a rupture, in consequence of his fall; he having immediately perceived a swelling in his groin and scrotum, which he had not before. The tumor seemed to occupy the whole spermatic process; which was so enlarged by it, that it was impossible to feel the passage of it from the abdomen, through the muscle: but the tes- ticle below it was perfectly distinct. The appearance of a tumor, the suddenness of its formation, the distinct situation of the testicle below, and an accidental cir- cumstance of the man's not having had a stool for two days past, inclined Mr. Freke (whose week it was) to believe it to be, and to treat it as, a rupture. He made some attempts for reduction; and, finding them fruitless, determined upon the operation imme- diately. He divided the skin and membrana adiposa, down to what he took to be the hernial sac; and when he had so done, had a mind to endeavour at the return of the intestine, without opening the sac. Mr. Freke was a man not easily to be dissuaded from what he had a mind to do; and having got the whim into his head, was determined to make the experiment on this, which he thought a fair case for the purpose. Accordingly (with his probe-scissors) he divided the tendinous opening in the abdominal muscle; and then again tried to reduce the gut, but to no purpose; for no- thing would go up. At last, though with much reluctance, he was obliged to lay open the containing membrane. He had no sooner done this, than a large quantity of blood, partly fluid, and partly grumous, burst forth, and the whole tumor subsided; leaving A TREATISE ON THE HYDROCELE. 105 the process perfectly free; and containing neither intestine nor omentum. The parts were now washed clean, and diligent search made for the breach whence this blood issued; but none could be found: the man was dressed with lint and pulv. boli armen. (a method of dressing, which Mr. Freke was fond of) and, in a proper space of time, the man got well without any new hemorrhage. In this case, some of the circumstances might be said to render an intestinal hernia not improbable; and the want of stools might have increased such probability: but then it should have been con- sidered, that although this be one symptom of the strangulated intestine, yet it is not by any means, an univocal, or infallible one. A vyant of stools may happen from other causes, even in a person who has a rupture, but cannot singly be a reason for the operation immediately; which ought to be indicated and authorised by other concomitant symptoms and appearances. A costive ha- bit may attend a person who has an intestinal hernia, when the gut labours under no stricture, and does its office perfectly well in the scrotum;.but such patient vull not have the symptoms of an incarcerated intestine; nor indeed had this man. His not hav- ing been at stool two days before, was an accidental circumstance; which might or might not have been occasioned by the descent of a piece of the intestinal caned: the truth of which should have been proved by the use of a clyster and a purge, before an opera- tion had been performed. CASE XXXI. A young fellow, straining to get rid of a hard stool, felt a sud- den pain in his left groin; and, upon examination, found a swell- ing, extending from thence into the scrotum. He took it for a rupture, and immediately applied to an advertising operator; who, after several unsuccessful attempts to reduce it, put a truss on him; and told him that the tumor would gradually shrink to nothing. The truss he wore for some days, when, finding both his pain and swelling increase, he applied to a surgeon in his own neighbour* hood; with whom I saw him. vol. u. o A TREATISE ON THE HYDROCELE*. The tumor was large, and had somewhat the feel of an omen- tal hernia; the abdominal aperture seemed to be dilated by it; the testicle was tolerably distinct below; his pain in an erect posture was considerable, but in a supine one, very little: he had neither heat, nor quickness of pulse, nor hiccough, nor vomiting; and had been thrice at stool that day. As there was no reason for supposing any degree of stricture on the intestinal canal, I advised the keeping him in bed, bleed- ing him freely, and trying what a proper poultice would do. This method was tried for several days, but without any bene- fit: on the contrary, the pain increased, as well as the tumor; and a fluctuation within became palpable. This fluid I thought possibly might be collected in the sac of an omental hernia (a case which I had more than once seen); and as there was plainly enough in quantity to render a puncture per- fectly safe, we made one with a lancet, and let out some ounces of clear blood. When the swelling was thereby lessened, we felt the spermatic vessels, but could discern them very indistinctly; and the process seemed much loaded and enlarged. Next day the man was perfectly well in health; but the scro- tum looked swelled, and black, as if it had been much bruised: he had also bled from the puncture, which was not closed, and discharged blood freely, upon any pressure being made above. Though we were in some doubt concerning the true nature of the case; yet it was clear, thaf if the hemorrhage continued, the part must be laid open. For three or four days it continued, notwithstanding all our endeavours; and at last it was so considerable, as to indicate the operation immediately. A knife was introduced into the orifice made by the lancet, and an incision of some length made; but no sacculus, no particular cavity found; nothing like a hernial sac, or tunica vaginalis testis; in short, nothing but cellular membrane; which satisfied us that the blood must come from the spermatic chord. As the bleeding still continued, and was derived from a part above our incision, we continued it quite up to the groin, and found that all the cellular membrane of the process was loaded fharUjDafc JO?. Kit.: StuobJJ&xSur Sr 109951 A TREATISE ON THE HYDROCELE. 10*< with extravasated blood; and that it came from a considerable breach now in view. We dressed it with lint, pressed out from a styptic, and intended to have permitted that dressing to have re- mained on for a day or two: but we were soon sent for on account of an alarming return of the hemorrhage; which had been so considerable as to produce a swoon. Castration appeared to us to be the only remedy; and it was immediately performed. CASE XXXII A middle-aged man came to St. Bartholomew's hospital, and desired me to look at a swelling in his groin and upper part of the scrotum on the right side; which, he said, came suddenly, by lifting a heavyweight. From the groin quite down to the testicle the spermatic process was enlarged; he had no symptoms of a hernia; and the testis was much too distinct and free for a hydro- cele. While I was examining it, I perceived some blood to drop from the lower part of the swelling; and, upon inquiring the reason, he told me that a puncture had been made in it a day or two'before, upon a supposition that the swelling was from water; that it had at intervals bled ever since; but that since it had last stopped, the tumor was increased. From these circumstances, I concluded the swelling to be caused by blood, shed into the tunica communis, from a branch of a varicose spermatic vein. He submitted to have it laid open? no particular breach was discovered, though the whole membrane was much loaded: the wound was dressed with lint pressed out from spirit, vin. These dressings were suffered to remain on, until they were separated by a beginning suppuration: and by keeping quiet, and being properly taken care of, the man got well, without any return of hemor- rhage. 106 A TREATISE ON THE HYDROCELE. CASE XXXIII. A poor man was brought to my house, by a gentleman of the profession, for my own opinion concerning a tumor of the scro- tum. The swelling was large; of a globular kind of form; painful, not only in general from its weight, but often even when suspended, or when the patient was in bed. It palpably contained a fluid; but the fluctuation of that fluid was not (to my fingers) like the fluctuation of water. In all the posterior part of the tumor, an enlarged, and somewhat hardened testicle might plainly be dis- tinguished; and the general weight of the whole far exceeded that of any hydrocele I had ever met with of equal size. That it was not a mere simple hydrocele I was very clear: but, whether it was a collection of fluid in the tunica vaginalis of a diseased testicle, (what is in general called a hydro-sarcocele,) or what other morbid or altered state of parts it might be owing to, I would not pretend to say. A puncture was made in it vvith a small trocar; and about four ounces of dark-coloured blood, not so fluid as blood generally is while circulating in its proper vessels, was drawn off; a bit of plaster and lint was applied to the orifice, and the man went about his business. In two days the same surgeon brought the man to me again. The puncture was healed; but the tumor was as large as when I had seen it two days before, and palpably contained the same kind of fluid. What that was we" knew: and the consideration was, what was the prop^rest method of giving the man relief. Had he been in good health, I believe I should have advised lay- ing the tumor open; at least so far as to have obtained a more precise knowledge of its nature; but the patient's age and general health were such as would by no means make an operation of that sort an eligible thing. He was near to sixty; asthmatic; had drank freely, and had a yellow countenance, and swelled legs in conse- quence of it. I advised him to come into the hospital, and try whether, by proper care, his habit might not be mended. Soon after his admission, I had a mind to see whether the contents of A TREATISE ON THE HYDROCELE. 109 the tumor were really the same as before, and made a puncture in it again with the trocar; the discharge was again blood; and it was two days from this operation, before a bloody discharge from the orifice ceased. A continuance of dram-drinking brought on a general anasarca, and an extravasation of water in the abdomen; and when he had been in the hospital about two months, he died. I would not omit the opportunity of examining his scrotal dis- order; and found, that the trocar had, at each operation, pierced the tunica albuginea, that the bloody extravasation was within that coat; that the tunica vaginalis was almost universally, though slightly, adherent to the surface of the albuginea; that the vascu- lar compages of the whole testicle was much enlarged, and at the same time so loosened, that a part seemed to have been dis« solved into the fluid which produced the fluctuation, which fluid was mere blood; and that the epididymus was hardened, and very considerably enlarged. I have since had an opportunity of seeing a patient labouring under the same complaint; whose testicle was rather hastily, and inadvertently, laid open; that is, divided. The immediate conse- quence was a large and obstinate hemorrhage. Whether it was produced by the division of the substance of the testicle, or by the irritation of such applications as were made use of for slopping the bleeding, I will not pretend to say: but when I saw him, he had a rigid neck; and was what is commonly called jaw-locked. Castration, from the state in which his testicle was when I saw it, must have been the only remedy for his local complaint; but his spasmodic attack rendered that improper, and every thing else fruitless. I have also (from a very ingenious practitioner of my acquaint- ance) received an account of a similar case, in which the testicle was divided, and the hemorrhage (from the patient's obstinate refusal to submit to the operation of castration) proved at last fatal 110 A TREATISE ON THE HYDROCELE SECT. X. To the different kinds of hydrocele, which have already been mentioned, some of the modern French writers have added another, viz. that which is formed by a collection of fluid in the sac of a true hernia. The title of this clearly describes its true nature; and therefore I shall only inform the reader .of what has fallen within my own knowledge relative to this disease. CASE XXXIV. A young fellow, about twenty-five years old, applied to me on account of a swelling in his scrotum. It was large, of an irregular figure, not very tense, perfectly indolent, and accompanied with a remarkable fulness of the spermatic process. ' The account which he gave of himself was, that he had had a rupture as long as he could remember; that he had, on that ac- count, worn a steel truss for many years; that, upon taking his truss off, his rupture always came down immediately, and was very easily returned up again; that it had never occasioned any obstruction in his stools, nor given him any pain; that, about a year ago, he had been persuaded to leave his truss off, and to sub- stitute in its place., a bandage made of dimity, without any iron in it, but which had been buckled on very tight; that, when he had worn this bandage about six months, he found that his rupture was down, and that he could not get it up again; that, upon this, he had applied to the person of whom he bought the bandage; who, after he had ineffectually tried to reduce the rupture, sold him another bandage, and buckling it on still tighter than the first, assured him, that it would never do him any harm; that, from the time of putting on this second, his scrotum had gradually become larger, with considerable pain and uneasiness. From the feel of all the lower part, I made no doubt that the tumor contained a considerable quantity of fluid; and had there A TREATISE OiS THE HYDROCELE'. HI been no other circumstance to influence my judgment, I should have supposed the disease to have been a hydrocele of the tunica vaginalis testis; but the very distinct and particular account which the man gave of himself, and the feel and the appearance of the spermatic process, made me hesitate. Whatever might be the true nature of the case, a fluid there certainly was; and that in quantity sufficient to render the dis- charge of it both safe and warrantable. I made a puncture in the middle and anterior part, and let out above a pint of brown se- rum. This discharge removed all the swelling from below; but made little or no alteration, either in the look or the feel of the upper part of the process. I endeavoured to reduce it; but found it impracticable, and desisted; advising the man to let it alone, to wear no bandage of any kind; and if at any future time it be- came troublesome to him, I desired that I might see it In about a year's time, he came lo me again, with his scrotum as big as before, and palpably containing a fluid. As I had felt the testicle very plainly after the first operation, and as I did not believe the tumor in the process to be formed by the intestine, I advised him to have the whole laid open. He sub- mitted, and I took him into the hospital for that purpose. I made an incision, from the middle and anterior part of the scrotum, quite up to the groin, and found in the lower part of the bag, which contained the fluid, the testicle covered only by its proper coat, or tunica albuginea; and in the upper part, or neck of the same bag, a considerable portion of omentum. The upper part of this por- tion of caul was hardened in its texture, and so perfectly adherent to every point of the neck of the sac, as to prohibit the return of even a fluid from thence into the belly: but the lower part was in its natural state, loose, soft, and capable of being expanded. All the lower or loose part 1 cut off, without making a ligature, or being troubled with any hemorrhage; the upper part I left as I found it; filled the wound lightly with dry lint, and treated the case as I should have done'..hat of the .radical cure for an hydro- cele. In about seven weeks the man got well, and has ever since remained so. This man's rupture was of the congenial kind; and therefore the sac of the hernia, and that of the hydrocele, were the same, viz. the tunica vaginalis testis. \VZ A TREATISE ON THE HYDROCELE. CASE XXXV. While the first edition of this book was in the press, Mr. Spray desired me to visit a patient with him, who had some pressing symptoms of a strangulated rupture. The patient was a healthy young man, about twenty-two years old, and he gave the following account of himself. That, as long as he could remember, he had been subject to a rupture, which never came lower than his groin, was always easily put up, and had never given him any trouble; that he had, when a child, worn a truss, but, either from its being ill-made, or from his not knowing how to put it on, it had never answered the pur- pose, and that he had for some years disused it; that, for a month or two past, his rupture had been constantly down; and that, within that space of time, he had never been able to return it, though he had often tried; that still, as it gave him no pain, nor produced any other inconvenience than the mere swelling of the scrotum, he had taken no notice of it, nor applied to any body for assistance until within the last three days; since which, he had been affected with great pain in his belly, a stoppage of stools, and a vomiting. The lower part of the scrotum was much enlarged, contained a considerable quantity of fluid, and bore very much the appearance of a hydrocele; but the upper part, or spermatic process, was hard and painful, and seemed to be girt tight by the tendon of the abdominal muscle. This, added to an extreme tightness of his belly, want of stool for three days past, anxiety, restlessness, vomiting, and beginning hiccough, determined me to propose the operation immediately. The lad consented, and I made an incision from the upper part of the tumor, just above the abdominal opening, quite down to the bottom of the scrotum. Having carefully divided the cutis and common membrane, I came to what appeared to be a hernial sac: this I opened, and thereby let out about half a pint of clear limpid water; upon the discharge of which the whole tumor of the scrotum subsided; and my assistants were convinced, that I had mistaken a hydrocele for A TREATISE ON THE HYDROCELE. 113 a hernia. But, although the whole of the swelling of the scrotum was entirely dissipated by the discharge, yet the tumor and hard- ness about the abdominal opening was unaltered, and the patient's pain the same. With a probe-pointed knife I laid open the whole sac, whence the water had proceeded, quite down4:o its bottom; and found the naked testicle within it: this gave the disease still more the appearance of a hydrocele, and I began to think that it was so; but, upon passing my finger up to examine the state of the abdo- minal tendon, I found a small portion of intestine engaged in it, and bound extremely tight. I lengthened the incision, so as to have a fair view of it, and thereby we all became thoroughly satisfied of the true nature of the case. The piece of intestine was small, a good deal darkened in colour, and bound so tightly by the tendon, that it was with great difficulty that I could introduce my finger for the conveyance of the knife. When I had made a sufficient dilatation, I endeavoured to return the gut; but could not execute it, although there was no obstruction from the tendon. I drew out some inches of it, thinking that I might thereby be ena- bled to make the return more easily: that which I drew out, I replaced with the utmost ease; but could not disengage the small portion which made the original disease. At last, passing my finger round in the dilated opening, I found that the intestine adhered to the lower border of it, by a small membranous filament; upon the division of which the gut slipped in immediately. The young man had stools very soon; and, by proper care, very soon got well. This also was a congenial hernia; the sac which contained the intestine, «he fluid, and the testicle, being the tunica vaginalis: but had I been contented with merely dividing the tunic, and had not proceeded in the examination and division of the abdominal tendon, the lad would have been destroyed by the stricture. VOL. it. v 114 A TREATISE ON THE HYDROCELE- SECT. XI. The rest of the false hernie (as they are railed) are the pneu- matocele, the varicocele, the cirsocele, and the sarcocele; to which,. some have added the hydro-sarcocele. The first of these is (as I have already said) a mistake: there is no hernia produced by mere wind. The two diseases, which, in new-born children and infants, are taken for, and called wind- ruptures, are, a tumor produced by a small quantity of fluid remaining in the lower part of the tunica vaginalis, after its com- munication above with the cavity of the belly is closed; and a true (but small) intestinal hernia. The varicocele is a dilatation of the blood-vessels of the scrotum. These are of different size, in different people; and, like the vessels in other parts of the body, are liable to become varicose; but are seldom so much enlarged as to be troublesome, unless such enlarge- ment is the consequence of a disease, either of the testicle, or of the spermatic chord. When this is the case, the original disease is what engages our attention, and not this simple effect of it; and therefore, considered abstractedly, the varicocele is a disease of no importance. The cirsocele is a varicose distention and enlargement of the spermatic vein; and, whether considered on account of the pain which it sometimes occasions, or on account of a wasting of the testicle, which now and then follows if, may truly be called a dis- ease. It is frequently mistaken for a descent of a small portion of omentum. The uneasiness which it occasions is a dull kind of pain in the back, generally relieved by suspension of the scrotum. It has been supposed to resemble a collection of earth-worms; but whoever has an idea of a varicose vessel, will not stand in need of an illustration by comparison. It is most frequently confined to that part of the spermatic process which is below the opening in the abdominal tendon; and the vessels generally become rather larger, as they approach nearer to the testis. In books are to be found prescriptions for lessening the distended veins; but I cannot A TREATISE ON THE HYDROCELE. US say that I ever saw any good effect from external applications of any kind. In general, the testicle is perfectly unconcerned in and effected by this disease; but sometimes it happens, that it makes its appear- ance very suddenly, and with acute pain, requiring rest and ease; and sometimes, after such symptoms have been removed, I have seen the testicle so wasted, as hardly to be discernible. CASE XXXVI. A young fellow, on a journey, found himself one evening more than ordinarily tired; and, as soon as he got to bed, was seized with a violent pain in his back, which (to use his own words) shot down into his stone. The pain was so great, as to oblige him to send for somebody immediately, who bled him freely: this produced no relief, nor was the pain yet attended with any tumor of the scrotum, or tes- ticle; or by any appearance whatever of the parts affected. The pain continued, without remission, all the next day: he was again let blood, had a clyster, and a gentle purge. On the third day, toward evening, the pain totally left him, and a fulness appeared in the groin, tending down toward the testicle: this made him so uneasy, that, finding the apothecary, who had the care of him, did not seem clearly to know what it was, he got into a post-chaise, and came home to London. His journey brought on a return of pain: but by losing some more blood, keeping in bed, applying an emollient poultice to the groin, and suspending the parts in a bag-truss, he became easy, and all the tumefaction dispersed; except a small fulness of the spermatic chord, occasioned by the varicose state of its vessels. But the testicle was so diminished, as to be hardly perceptible; and remains so, to the time of my writing this. CASE XXXVII. An ostler, at an inn in Smithfield, was, by the fall of a horse, thrown over his head, and his groin struck against the pummel of 116 A TREATISE ON THE HYDROCELE. the saddle. It gave him exquisite pain; and he was brought im- mediately lo the hospital, upon a supposition that he had burst himself. Upon examination, no swelling appeared, either of the testicle or of the spermatic chord; but the pain (which he said was ex- quisite) was confined to that part of the latter, which is between the testicle and the groin. He was largely blooded, had a clyster, and a purge: his pain continued two days; and, when it left him, the spermatic vessels became greatly varicose. No application, which was made use of on this account, proved at all beneficial; that is, rendered the distended vessels at all less; and, when he left the hospital, he was perfectly free from pain: but his testicle, on that side, was scarce discernible. I once saw the same effect, from the injudicious application of a truss, on a true circocele: the vessels, by means of the pressure, became enlarged to a prodigious size, but the testicle shrunk to almost nothing. CASE XXXVIII. A young gentleman about twenty-five years old, after having heated himself much vvith exercise, went too soon into a river to bathe. In the middle of the ensuing night, he was seized with a coldness and shivering; which were followed with great heat and thirst, and a slight sweat. He sent for a surgeon, who bled him and gave him a clyster, bid him keep in bed, and drink plentiful- ly. Next day, he gave him a laxative medicine, and some febri- fuge draughts. For three days, his fever was unremitting; but on the fourth he became cooler, and was seized with a most acute pain in his loins; for which he was again bled and purged. On the fifth day, h^s back became easy; but both testicles, though very little swollen, were so tender, as hardly to admit the touch; and, in a very few hours, the spermatic vessels were so distended, as to make an ap- parent tumor. By means of fomentation, poultice, and rest, all tineasiness was removed in about a fortnight; but, at the end of A TREATISE ON THE HYDROCELE. 1 17 that time, both patient and surgeon were excessively astonished, at not being able to find the testicles. The latter came to London immediately, and desired me to examine him, after having given me the preceding account. The spermatic vessels were full, and varicose; the vasa differen- tia too large, and rather too hard; as were also the epididymes: but there was not, on either side, the least appearance of a natural testicle. A flattened, compressed kind of membranous substance (which, I suppose, was the tunica albuginea) seemed to hang from each epididymis; but there was not any trace or vestige of the glan- dular or vascular parts of either testis. This is the only time I ever saw this complaint on both sides in the same subject. SECT. XII. THE SARCOCELE, OR DISEASED TESTICLE. This is a disease of the body of tne testicle; and, as the term implies, consists, in general, in such an alteration, made in the structure of it, as produces a resemblance to a hard, fleshy sub- stance, instead of that fine, soft, vascular texture, of which it is ii\ a natural and healthy state composed. The ancient writers have made a great number of distinctions of the different kinds of this disease according to its different ap- pearances, and according to the mildness or malignity of the symptoms, with which it may chance to be attended. Thus, the sarcocele, the hydro-sarcocele, the scirrhus, the cancer, the caro adnata ad testem, and the caro adnata ad vasa, which are really little more than descriptions of different states and circumstances of the same disease, are reckoned as so many different complaints, requiring a variety of treatment, and deriving their origin from a variety of different humours.' e " Humores crassi sunt duo, pituita et melancholia, e quibus turn scirrhi " in aliis partibus, turn indurationes earns in testiculis oriunttu*. Tumor hie 118 A TREATISE ON THE HYDROCELE. Every species of sarcocele consists primarily in an enlargement, induration, and obstruction of the vascular .part of the testicle; but this alteration is, in different people, attended with such a va- riety of circumstances, as to produce several different appearances, and to occasion the many distinctions which have been made. If the body of the testicle, though enlarged and indurated to some degree, be perfectly equal in its surface, void of pain, has no appearance of fluid in its tunica vaginalis, and produces very little uneasiness, except what is occasioned by its mere weight, it is usually called a simple sarcocele, or an indolent scirrhus. If, at the same time that the testis is enlarged and hardened, there be a palpable accumulation of fluid in the vaginal coat, the disease has by many been named a hydro-sarcocele. If the lower part of the spermatic vessels and the epididymis were enlarged, hard, and knotty, they supposed it to be a fungous or morbid acretion, and called it the caro adnata ad vasa. If the testicle itself was unequal in its surface, but at the same time not painful, they distinguished it by the title of caro adnata ad testem. If it was tolerably equal, not very painful, nor frequently so, but at the same time hard and large, they gave it the appellation of an occult or benign cancer. If it was ulcerated, subject to frequent acute pain, to hemorrhage, &c. it was known by that of a malignant or confirmed cancer. These different appearances, though distinguished by different ti- tles, are really no more than so many stages (as it were) of the same kind of disease, and depend a great deal on several acci- dental circumstances; such as age, habit, manner of living, &c It is true, that many people pass several years with this disease, under its most favourable appearances, and without encountering any of its worst; but, on the other hand, there are many, who, in a very short space of time, run through all its stages. They who are most conversant with it, know how very convertible its mild- est symptoms are into its most dreadful ones; and how very short a space of time often intervenes between the one and the other. " est durus, tactui renitens, indolens, et si exquisitus sit scirrhus, sensu " caret. Si a melancholia oriatur, color sublividus; si a pituita, colorem " cutis non mutat; si a melancholia superassata, dolor punctorius, et inequa- •' lis tumor; hie durus, ibi mollis." FAB. AB AftTJAPEXDESTE. A TREATISE ON THE HYDROCELE. 119 There is hardly any disease, affecting the human body, which is subject to more variety than this is, both with regard to its first manner of appearance, and the changes which it may undergo. Sometimes the first appearance is a mere simple enlargement and induration of the body of the testicle; void of pain, without inequality of surface, and producing no uneasiness nor inconveni- ence, except what is occasioned by its mere weight. And some few people are so fortunate to have it remain in this state for a very considerable length of time, without visible or material al- teration. On the other hand, it sometimes happens, that very soon after its appearance in this mild manner, it suddenly be- comes unequal and knotty, and is attended with very acute pains, darting up to the loins and back; but still remaining entire, that is, not bursting through the integuments. Sometimes the fury of the disease brooks no restraint; but making its way through all the membranes which envelope the testicle, it either produces a large, foul stinking, phagedenic ulcer with hard edges; or it thrusts forth a painful gleeting fungus, subject to frequent hemorrhage. Sometimes (as I have already observed) an accumulation of water is made in the tunica vaginalis, producing that mixed ap- pearance, called the hydro-sarcocele. Sometimes there is no fluid at all in the cavity of the tunica va- ginalis; but the body of the testicle itself is formed into cells, con- taining either a turbid kind of water, a bloody sanies, or a puru- lent, fetid matter. Sometimes the disorder seems to be merely local, that is, confin- ed to the testicle, not proceeding from a tainted habit; nor accom- panied with diseased viscera; the patient having all the general appearances and circumstances of health, and deriving his local mischief from an external injury. At other times, a pallid, leaden countenance, indigestion, frequent nausea, colic pains, sudden purgings, &c sufficiently indicate a vitiated habit, and diseased viscera; which diseased viscera may also sometimes be discovered and felt. The progress also which it makes from the testis upward, toward the process, is very uncertain; the disease occupying the testicle only, without affecting the spermatic process, in some 120 A TREATISE ON THE HYDROCELE. subjects, for a great length of time; while in others, it totally spoils the testicle very soon, and almost as soon seizes on the spermatic chord.* These, and some other circumstances to be mentioned hereafter,' are materially necessary to be observed; as they characterise the disease, point out its particular nature and disposition, and serve as marks whereon to found our judgment and prognostic of the most probable event, as well as the most proper method of treat- ment. Various have been the causes to which theoretic and whimsical people have assigned this disease; but as a recital of conjectures can convey no instruction or useful information, I shall pass them over; and only take notice, that among the great num- ber which have been mentioned, there are two, which, though equally groundless with the rest, have yet obtained a degree of credit that may mislead: these two are the hernia humoralis, and the hydrocele of the vaginal tunic. The hernia humoralis is a defluction of the inflammatory kind, proceeding most frequently from an irritation in that part of the urethra, where the vasa deferentia, or vesicule, seminales termi- nate. It is attended with pain and heat, and most frequently fever. During the first, or inflamed state of the disease, the whole compages of the testicle is enlarged; but when by rest, evacuation, and proper applications, that inflammation is calmed, there seldom or never remains, either fulness, hardness, or any other mark of disease in the glandular part of the testis. The epididymis indeed seldom escapes so well: that often continues enlarged and indurated for a considerable space of time, but without producing either pain or inconvenience; and without occasioning any altera- tion in the figure or structure of what is called the body of the testicle: whereas the true sarcocele, or hernia carnosa, most com- { This is the common language, and therefore I use it; but I would not be understood to mean that the progress of the disease is always and invariably upward, from the testis into the process. I have seen the spermatic process truly cancerous, when the testicle has been free from disease; and am well satisfied, from experience, that a diseased state of the vessels within the ab- domen, or of the parts in connexion with those vessels, may produce a mor- bid state of the process, proceeding downwards from thence; but the other is by much the most frequent. .. A TREATISE ON THE HYDROCELE. 121 monlyc begins by an indolent induration of that part of the testis, and affects the epididymis secondarily; or after it has already spoiled the vascular part of the gland. I would not be understood to mean, that a sarcocele never fol- lows a hernia humoralis; there is no reason in nature why it should not: a hernia humoralis does not, nor can prevent the testicle, in any future time, from becoming scirrhous; I only say, that it does not, at any time, necessarily cause or produce it. So also with regard to the epididymis; I do not mean to say, that it never is the primary and original seat of a scirrhus; I know that it is, and and shall produce some instances of it. Neither do I intend to say. that a scirrhus never attacks an epididymis, which has been pre- viously hardened by a hernia humoralis: there can be no reason why it should not; I only mean to signify, that it is my opinion, that the induration caused by a venereal hernia humoralis does not, at any time, necessarily produce a scirrhus. A scirrhus indeed may fall on that part, after it has been so diseased, but it would as certainly have attacked it, if there had been no preceding affec- tion of it. There is also a venereal affection of the testicle, independent ef a gonorrhoea, or of any disease of the urethra. This is seldom an early symptom; and I do not remember ever to have seen an instance in which it was not either immediately preceded, or accompanied, by some other appearance plainly venereal. It has neither the inequality, nor darting pains of the scirrhus, and always gives way to a mercurial process, properly con- ducted. A quantity of water is frequently collected in the vaginal coat of a truly scirrhus testis. This has given rise to the supposition, that the testicle often becomes diseased, from its being surrounded by, or swimming in, the same fluid—a supposition entirely ground- less. That scirrhous and cancerous testes very frequently are found to have a quantity of fluid accumulated in the tunica vaginalis of them, is beyond all doubt; but that such testicles become diseased. ' 1 say most commonly, because it is neither necessarily, nor always VOL. II. Q 122 A TREATISE ON THE HYDROCELE. f in consequence of being surrounded by such fluid, or, in other words, that a simple hydrocele may produce a scirrhous testicle, is by no means due. The simple hydrocele is (as I have already at large observed) a collection of water in the tunica vaginalis: this lluin, in a natural and healthy slate of the parts, is small in quantity, and, by being constantly absorbed, does not distend the ca- vity of the tunic, but only serves to keep that membrane from contracting any unnatural cohe&ion with the tunica albuginea. The regular absorption of this fluid being by some means prevent- ed, the quantity soon becomes considerable, and, distending its containing bag, constitutes the disease called a hydrocele; but makes no morbid alteration in the structure of the testicle.*1 When the testicle becomes enlarged in size, hardened in texture, craggy and unequal in its surface, painful upon or after being handled, attended with irregular pains shooting up the groin towards the back, and this without any previous inflammation, disease, or injury from external violence, it is said to be affected with a scirrhus. This, as I have already remarked, is of different kinds and degrees, and appears under different forms; but, although the appearances which the disease makes are various, according to the alteration produced by it in the testicle, yet every such morbid alteration may obstruct or prevent the regular absorption of the fluid deposited in the vaginal tunic, and occasion a species of hydrocele; that is, a tumour from water. This is that kind of disease, which, by Fabritius ab Aqua- pendeute, is called hydro-sarcocele; but which was so very unlike to a simple hydrocele, that, whoever mistakes the one for the other, will commit an error, which may prove very mischievous to his patient, and very detrimental to himself. In the true simple hydrocele, the testis, though somewhat loos- ened in its texture, and a little enlarged, yet preserves very nearly its natural form; the collection is made without pain or uneasiness, and very soon becomes sufficient to hide or conceal the testicle; nor is the examination of such tumour attended vvith any pain; but •» That is, no such alteration as renders it painful, or incapable of executing its office ; and, consequently, no such alteration as can ever require extir pation, or any other chirargical operation on the testicle itse'♦' A TREATISE ON THE ilYDROCELE. 123 the increased size, and hardened state of the scirrhous testis, renders it discoverable, through a much larger quantity of fluid than will totally conceal the former. When felt, it will be found to be hard, and generally somewhat unequal, and not unfrequently attended with irregular shooting pains, especially after having been examined. In the simple hydrocele, the fluid distends the tunica vaginalis so equally, that, although it does not surround the testicle, (nor indeed can,) yet it seems so to do: whereas in the hydro-sarcocele, though the anterior part of the tumor may, in some measure, bear the appearance of a simple hydrocele, yet an examination of its posterior part will always discover the true nature of the case:' to which may be added, that, under the same apparent magnitude, the latter will always be found to be considerably heavier than the former. In short, the name of this species of disease (hydro-sarcocele) is undoubtedly a very proper one, and capable of conveying a very just idea of its true nature, viz. an accumulation or collection of water in the vaginal coat of a scirrhous or diseased testicle: but the majority of writers have, by supposing the water to be the cause, instead of the consequence of the diseased state of the testis, committed a very material blunder, and endeavoured to establish and authorise a very prejudicial and destructive method of practice. For, by conceiving that the noxious quality of the fluid produces a fungus or fleshy excrescence on the surface of the testicle, they have supposed, that after having discharged the said fluid from its containing bag, they could, either by establishing a suppuration, or by using escharotic medicines, waste or destroy ■ This has been very judiciously remarked bv Mr Le Dran. Schenkius gives an account of a beginning sarcocele, which was mistaken for an hydrocele; upon which a radical cure was performed by castration. Upon dividing the body of the testis, a quantity of thick fluid was discharged; a thing by no means uncommon, but which was here mistaken for sen en. The patient died not long after the wound was healed; and the kidney on that side, and the parts about it, made a very morbid appearance. This appearance was by Schenkius supposed to be owing to the hasty cure of the hydrocele; bu' was indeed the efleet of the same virus which had first spoiled the tf-v icle. Neither was the fluid in the body of it semen, bu sanies or matter; a cir- cumstance most frequently met with in scirrhous testes. 124 A TREATISE ON THE HYDROCELE. the said excrescence, and cblain a radical cure of the whole dis- ease. Now the scirrhosity of the testicle being the original disease, £and the extrav saiion a mere accident, such treatment can never do any material good, and may often be the cause of very essential evil. Fabrkius ab Aquapendente has given a particular description of this method, which he recommends, from having practised it with success: his words are, " Modus singularis est quando hernia " aquosa cum caruosa mista est; tunc enim primum incide, etfac " foramen in parte scroti que non sit declivis, ncque in fundo u scroti, sed circa medium; nee fac admoduin latum: et extracta " aqua, turundam impone quam longissimam, medicamento, pus " moventi infectam, ut resina terebinthine, cum thure, ovi vitello, " et butyro; emplastrum emolliens, et pus movens applica, ut •' diachylon cum gummis, et axungia porci; genitum autem pus, :'non evacueter per forament, sed data opera intus servetur, ut " contactu suo, carnem sensbn putrefaciat. Neque inovenda medi- " camenta, nisi tota caro fuerit in pus conversa; id quod longo sit u tempore.Vk Now, to pass over the absurdity of the doctrine of removing or dissolving a fungous excrescence, by means of the putrefying quality of matter, as well as the great disturbance which must be the consequence of confining it within the tunica vaginalis, it is very clear from these, and from every other circumstance attending the disease in question, that the cases which Fabritius had success- fully made his experiment upen, must have been mere simple hydroceles, attended with a small degree of enlargement; but without any diseased state of the testicle. This is one method of procuring a radical cure of the said disease—a method in use before Fabritius practised it, and still in some measure employed—a method which, in some instances, has always been successful; and which may, in general, be tried on any simple hydrocele, in a young and healthy subject. The k " Si carnosa, et aquosa sit hernia, ego talem adhibeo curam ; seco cutem, " et incisionem facio exiguam, et in loco potius altiore, quam in fundo: inde " turunda imposita cum digestivo et pus movente medicamento diutius " procedo, neque unquam pus extraho, sed perpetuo bonam partem intu? " relinquo; quod sensim carnem corrodit, et ita sanat." V TREATISE ON THE HYDROCELE. 125 cure (when it effects one) is not brought about by the destruction of an excrescence from the testicle, or the dissolution of its sup- posed induration; but merely by exciting such an inflammation, as hhall occasion an adhesion of the tunica vaginalis to the tunica albuginea; by which means, the cavity of the former is oblite- rated; the testicle remaining, as to size and consistence, just as it was before such operation was performed.1 But this, though practicable, and sometimes successful in the hydrocele, is not to be thought of in the diseased or scirrhous testicle. The operation, as described by Aquapendente, consists of two points; first to let out the water, and then to cause a plentiful suppuration. When the testicle is really and primarily diseased, and the extravasation is a consequence of such disease, the discharge of the water from the cavity of the tunica Vaginalis, whether by puncture, or by incision, can contribute nothing material toward a cure of the principal com- plaint, and is therefore useless; but it may, in r.iany cases, do harm, by creating a disturbance in parts whose state requires the most perfect quietude; and is therefore wrong. When the disease is a mere simple hydrocele, the palliative cure, as it is called, by t Another method of treating this disease, in use before Fabritius ab Aqua- pendente, (as may be seen in Guido and others,) and much preferable, if used in proper cases, is the method by seton. This, as 1 have already observed, I have several times practised vvith success, in those who would not submit to incision, or in whom it was by no means proper. Fabritius ab Aquapendente had a different, and that an erroneous, idea of this disease : he conceived that there was a fungous kind of excrescence on the testicle, arid that this excrescence required erosion and destruction ; this he aimed at accomplishing, by means of the matter collected within; and therefore his principle aim was to confine and increase it, by making his puncture, for the introduction of his tent, in the upper part of the tumor ; and by imbuing it, from time to time, medicamentis pus moventibus. Had he been right in his idea, his practice would have been just; but his conception of the disease was erroneous, and his practice absurd. The rational intention should be, to excite such a degree of in£ammation as may produce an union between the tunica vaginalis and the albuginea. The forma- tion of matter is a mere accidental consequence of this inflammation; uk' the means used to procure the end (provided it be procured) cannot be too gentle. The matter is of no real use, and therefore it is so far from being necessary to confine it, that if the conjunction of the coats can be obtained, without the formation of any, it is so much the better 126 A TREATISE ON THE HYDROCELE. puncture, is right and necessary: it renders the life of the patient easy; rids him, every now and,then, of a very troublesome burden; is perfectly safe; may be performed and repeated occasionally, at any time of the patient's life, or in almost any state of the disease; bin the introduction of tents or setons, or the endeavour by any means to excite inflammation, or to establish suppuration within the tunica vaginalis, requires (even in the simple hydrocele, where the testicle is unaffected) some little consideration, and ought not to be hastily or unadvisedly put in practice. In some ages, habits, &c. the symptoms will rise very high, and occasion both trouble and hazard; and if this be the the case, when the testis is not at all diseased, and when there is no malignity, either in the local complaint, or in the habit of the patient, what have we not to fear where there is both? where the parts are al- ready spoiled by disease, and where irritation and inflammation may (and do) excite the most fatiguing symptoms, and the most direful consequences? Besides the hydro-sarcocele, or lympid extravasation of fluid, in the cavity t>f the vaginal coat, (and which must therefore always be external to the testicle,) scirrhous and cancerous testes are lia- ble to collections of fluid, within the substance of them, under the tunica albuginea."1 These are sometimes large, and in one cavi- ty; sometimes small, and in several distinct ones. They are also very different in nature, in different cases; sometimes serous, sometimes sanious; sometimes purulent; sometimes bloody. These are very apt to impose on the inadvertent and injudicious (espe- cially if they be attended with some degree of inflammation in the skin); and to induce an opinion of an abscess, or imposthuma- "» Job a Meekren has made a very just and judicious remark on this sub- ject. Fabritius ab Aquapendente had reckoned a collection of fluid, within the tunica albuginea testis, among the kinds of hydrocele. This Meekren does not allow ; but, having described the true hydrocele of the vaginal coat, speaks of this collection within the albuginea, as it really is; that is, as a con- sequence of the diseased state of the gland. His words are, " Hieronjmus " Fabritius ab Aquapendente, Part I. de Operat. Chirurg. cap. 75. aquam in " testibus congregari docet earn quae ex imo ventre eo defluit: at error est " (mco judicio) magni anatomici. Spatio enim eo, quod est inter testiculum " et tunicam, imo in scroto ipso, aqua sspius colligitur : nungitam in testibus a ipsis, nisi putrescant." A TREATISE ON THE HYDROCELE. 127 tion, which may be relieved or cured by an opening; but caveat operator. These collections will be found to bear a much snjaller proportion to the general size of the tumor, than they who are not conversant vvith them are inclined to apprehend; the subsidence, after the opening has been made, will also be much'smaller than was expected; and instead of relief and ease, all the symptoms of pain, swelling, inflammation, &c will be increased and aggravat- ed; and if the opening be considerable, it not infrequently happens that an ill-natured fungus is thrust forth, which, by bleeding. gleeting, and being horridly painful, disappoints the surgeon, and renders the state of the patient much, more deplorable than it was before. Neither is this sensation, which is thought like the fluc- tuation of a fluid within the testicle, to be at all times depended upon as implying that there is any fluid at all there. The touch. in thiscase, is subject to great deception; and I have seen a loosen- ed texture of the whole vascular structure, or body of the testicle. produce a sensation so like to the fluctuation of a fluid lying deep, as has imposed on persons of good judgment and great caution. Many of the most esteemed writers on this part of surgery, either not being practitioners, or being afraid to differ from those who have written before them, have lazily and servilely copied each other, and have thereby fallen into an obscure jargon concerning this disease, wThich neither themselves nor their readers have un- derstood. They have talked of the scirrhous testicle, flie cart adnata ad testem, and the caro adnata ad spermatica vasa, as so many different diseases, requiring different methods of treatment The melancholia, the atra bilis, and a certain inexplicable adust state of humours, are said to be the causes of these different appear- ances,- and the fleshy substance arising from, or adhering to, the spermatic vessels, is said to be more benign, than either the fun- gus arising from the testicle, or the true scirrhus. For the first. they have described an operation, which is coarse, cruel, painful, and (notwithstanding all that they have said about it) unsuccessful; all which they must have known, if they had practised it. I therefore am much inclined to believe, that this is one of the many parts of ancient surgery, which, having been devised by some one bold, hardy operator, and by him described as practicable, has been re- lated by many of his successors as practised. The second, the 126 A TREATISE ON THE HYDROCELE. caro adnata ad testem, they allow to be attended with more diffi • culty, as well as hazard, and seldom to be attempted with suc- cess." n " Ramex hsec inter excrescentias annumcrari potest, cum sit additamen " turn ex toto prxter naturale; nee illi insunt signa apostematis, sed tantum " ut caro qua; circa scrotum aut cpididymem generari solet." Andreas a Cruce. " Curatio ejus est, ut incidatur cutis testiculorum, et excorietur usque ad " superiora ; deinde extrahe didymum et testiculum, et libera eos ab omni " parte ex illo carnositate." Brtjncs. " Fit etiam hernia quandoque ex carnositate quadam praeter naturam nas- '• cente juxta testiculum ; et tunc pellicula incisa undique debet excoriari ; " et discooperta carnositate ilia a corio exteriori usque, superius cauterio " abscindatur." Kolandus. " Cura ejus non potest fieri nisi cum manu pellem exteriorum scihdendo, " et carnem a testiculis scarnando, et incarna-auferendo." Lasfranc. " Scinde pellum tcsticuli cum rasorio usque ad testiculum, ettunc carno- " sitatcm, quam invenis, removeas et excarnes totalitur a testiculo." Gul. e Saliceto. " Notandum est in hac operatione num caro concreverit circa tunicas, an "circa ipsos testis ; numque firmiter an minus firme adhereat partis sub- " stantix. Incidendum esttotum scrotum usque ad carnem concretam, quse " si quidem valentcr haud sit alfixa, vel summis digitis, vel manubriolo scal- " pente, £f teste vel tunicis, sensim sit auferenda." Fab. ab AauAFEjjDENTE. " Caro item sxpissime testiculis, aut eorum tunicis adnascitur, serosus " enim humor iste nonnunquam acris factus venas capillares, membranasque " leviter erodit. Mine pars ilia sanguinis que paulatim exudat, quaeque op- '* tima et laudibilis est, beneficio caloris innati, in carneam substantiam con- " crescit, &c. reliquum vero sanguinis quod serosum est, paulatim mem- " branas totumque scrotum adeo extendit, ut caro ista quae testiculo adherit, " digitis palpari non possit." Fabritius Hildanus. " Se.candum est scrotum, et detegenda caro, et a teste deradenda vel a '' vasis, &c." Gab. Fallopics. The false reasoning, the want of anatomical knowledge, the cruelty and inutility of the proposed operations, and the terrible consequences which must follow from their being put in practice, are too glaring to need any com- ment; and such as must incline every reasonable man to hope, that these authors (and a great multitude of others, who might be named) did in this A TREATISE ON THE HYDROCELE* 129 They who are under a necessity of forming their opinions principally from books, and who have not frequent opportunities of knowing from experience, how very little they are (in many cases) to be depended upon, may be inclined to think that all these distinctions really.exist; and that these operations by fire and sword, by knives and cauteries, so exactly described, must be sometimes necessary; but having never seen the particular cases requiring such treatment, have a very imperfect idea, either of them, or of the operations; and are, to the last degree, alarmed and intimidated, when any thing, which they think is like to it, oc- curs to them in practice. To such, it may not be amiss to ex- plain this matter, in as few words as I can; begging pardon of the more intelligent reader for the digression. In the short anatomical account which I have given of these parts, 1 have taken no notice, that the spermatic vessels terminate in the testicle; and that, after the semen has been secreted from part of surgery as they have done in many others; that is, copy each other in the precepts relative to the cause and treatment of this disease, but did not put their directions often into practice. The imperfect state of anatomy, in the time of the above cited writers, may be admitted as an excuse for them ; but even very late ones have fallen into the same error. " In the fungous excrescence upon the testis, when the same is not over- grown, you are to make way thereto; which is then to be consumed by escharotics, or by the actual cautery." Turxeh. " Si quid vero carnis enatum a testiculo deprehenditur, quod graviter " homincm affligat, nee discuti tamen per adhibita medicamenta convenien- " tia queat, turn si testiculus integer adhuc est, atque illibatus, feliciter ut " plurimum sanari noxa poterit, ipscque testiculus servari -, dummodo quic- '• quid prxter naturam super increvit, deoperto scrotu,quam exactissime ab eo " solvatvr, atque rcscindatur." " Quod si autem ipsum testiculum invaserit: vel exindi etiam propter " nimios ciMciatas, vel similes alias causas, indecore prominentes partes " nequeant, necessarium utique erit, vel universum testiculum, vel quondam " saltern ejus partem, modo jam proposito exscindere." Hkister. Te set aside the strange distinction between the "caro enata a testiculo," and that " quar ipsum testiculum invaserit," (a distinction taken from books only,) I believe I may venture to say, that the professor never found, that the operations which he describes and advises, were attended with success; and I hope that he has not often seen them performed. vol. ir r I .SO A TREATISE ON THE HYDROCELE. the blood, it passes from that gland into a body which seems su- peradded to, although it be really continuous with, it. This body- is therefore called the epididymis, and is so placed, with regard lo the testis, that a heedless or uninformed observer may suppose, that the spermatic vessels terminate in it; especially if it be en- larged by disease. It lakes its rise from the testiole, by a num- ber-of vessels, called from their office, vasa efferentia: these soon become one tube, which, being convoluted and contorted in a most'wonderful manner, forms the greater part of the said body; and at last ceasing to be so convoluted, it ends in one firm canal, called the vas deferens; by which the secreted semen is conveyed from the testicle to the vesicule seminales. Whoever will attentively consider the epididymis in its natural position, vvith regard to the testicle and the spermatic vessels, will see, that if it be enlarged beyond its proper size, it will ex- tend itself upward, in such a manner as to seem to be closely con- nected with them, and to bear the resemblance of a diseased body, springing from them. This is the case called the caro adnata ad vasa spermatica; and is really and truly nothing more, than an enlargement of the epididymis;*a circumstance which occurs not infrequently, but does not imply any malignity, either in the part or in the pa- tient's habit; and can never require such a horrid operation as our forefathers have directed us to perform upon it; nor indeed any at all. The epididymis is frequently enlarged, in venereal cases, either separately, as in the remains of a hernia humoralis, or together with the testicle, in that affection of it, which I have called the ve- nereal sarcocele; and sometimes from mere relaxation of its na- tural texture, without any disease at all. But in none of these can it require, or even admit, any manual operation of any kind. Indeed, whoever will consider the epididymis, as it really is, as the medium by and through which the semen is conveyed from the testicle to the vas deferens, must immediately be sensible of She glaring absurdity of removing any part of it. The scirrhus and cancer do not very often begin in this part: they most frequently make the first attack on the body of the testis; and, though the epididymis is often cancerous, yet it most frequently A TREATISE ON THE HYDROCELE. 131 becomes so secondarily, or after the testicle is spoiled; so that the removal of it, if practicable, could serve no good purpose. It would not remove the disease; for that has, before-hand, most commonly taken possession of the testicle; and the cutting off anv part of a scirrhous or cancerous tumor of any kind, is what no man, who has the least knowledge of what he is about, will ever think of. In short, these two cases, which, by the inattention and misre- presentation of our ancestors, have created such perplexity in the minds of their readers, are either a simple enlargement of the epi- didymis, without any morbid alteration in its structure; or a dis- eased (that is, a scirrhous) state of the same part; or else, a scir- rhous or cancerous testicle, vvith inequality of surface. The first of these requires no manual operation of any kind; and the two last will admit of none: the first is no disease at all; and the two last are such diseases, that every attempt made on them, by knife or caustic, (unless for total expiration,) must render them worse, and more intractable. The manner of treating a sarcocele, or hernia carnosa, depends entirely on the particular nature and state of each individual case. In some, it will admit of palliation only; in others, the disease may be eradicated by the extirpation of the part; so that, under the article of method of cure, we have only to consider, and point out, as clearly as the nature of the disease will permit, what states and circumstances, both of it, and of the patient labouring under it, forbid the operation, and what render it advisable. On this head, great variety of opinions will be found among writers; so great, that a man, who is under a necessity of forming his judgment from them, will find himself under some difficulty how to act; and so great, that I cannot help thinking it to be clear, that the majority have not written from practice, but from mere conjecture, or from the works of those who who have gone before them. Some have given it as their opinon, that while the testicle is perfectly indolent, (let the alteration in its structure, form, or con- sistence, be what it may,) it is better to suffer it to remain, than to remove it. In support of this opinion, they say, that although the disease has plainly taken possession of the part, yet, while it 132 A TREATISE ON THE HYDROCELE. causes no pain, the constitution receives no damage from it; nor is the health of the patient impaired by it; whereas, by removing the testicle, the same virus may seize on some part of more con- sequence to life. This* method of reasoning takes for granted two things, which do not appear to be strictly or constantly true, viz. that this disease is never perfectly local; and that a scirrhous testicle, though free from pain, will not in time produce any evil to the general habit of the patient Others advise us to stay until the tumor becomes painful, and manifestly increases in size, or ac- quires a sensible inequality of service: that is, (in other words,) until it begins to alter from a quiet state to a malign one: which advice, as well as the preceding, supposes that the hazard of the mere operation of castration is too great to render it an advisable thing, until the patient is pressed by bad symptoms; and that a scirrhous testicle, which has been quiet and free from pain for some time, may be as successfully extirpated after it has become painful, and has acquired a malignant and threatening state, as at any time before such alteration. The latter of these will hardly be admitted (I believe) by those, who form their opinions from experience; and with regard to the former, I can, with great truth, affirm, that I never saw the mere operation of castration, when performed in time, and on a proper subject, prove fatal. Many people have I known, who have lived several years, their whole lives, perfectly free from disease, after the removal of quiet, indolent, scirrhous testicles; and several have I known, wjio, hav- ing deferred the operation until they were urged by pain, increase of size, and inequality of the tumor, have, from the sore becoming cancerous, not been able to obtain a cure. That I have seen the same thing happen, after the removal of a testicle, circumstanced in the best manner, is beyond all doubt; but not near so frequent- ly as in those cases in which the operation has been deferred un- til the symptoms became alarming, and the disease had changed its appearance, from a benign quiet one, to one that was malign and painful. Indeed, were we capable of knowing with certain- ty which those scirrhi were, that would remain quiet and inoffen- sive through life, or for a great length of lime, and which would not, we should then be enabled to advise or dissuade the operation upon much better (that is, much surer) grounds, than at present A TREATISE ON THE HYDROCELE. 13J we are able to do. We have no such degree of knowledge; all our judgment is formed upon the mere recollection of what has happened to others in nearly similar circumstances; and experi- ence, though the best general guide, is, in these cases, more falla- cious than in many others. A few people there certainly have been, who have been so fortunate as to carry a scirrhous testicle through many years, with little or no pain or trouble: but the number of those, in whom time (and that frequently a short space), change of con- stitution, external accidental injury, &c. do not make such an alteration in this disease, as lo render the operation less likely to be successful than it would have been at first, and under more favourable circumstances, is so small, that I think early castration (that is, as soon as the disease is fairly formed and characterised) may be recommended and practised by every honest and judicious surgeon. 0 Scirrhous and cancerous tumors are found in many parts of the body, as well as in the testicle; and in all others, as well as in that, bear different characters; that is, show a greater or less disposition to malignity ; remain- ingsometimes of small size, and easy for many years ; at others, increasing- fast, and so producing great pain, and all its bad consequences. Of all the kinds of this disease, those which follow upon some external violence (such as blow, bruise, &c.) are thought and said to be the least ; therefore, great regard has always been paid to this distinction by writers, and great hopes conceived from this circumstance by patients. I wish I could pay that such hopes were always as well founded as they are thought to be. I mean, that experience most frequently verified them. When a scirrhus seizes a part that has previously sustained an injury from without, such probable cause is undoubtedly a favourable circumstance; but it does not, by any means, necessarily follow from thence, that the constitu- tion of such person is free from taint. It is a presumption, but not a proof; and this presumption becomes more reasonable, if the diseased state of the part follows such accidental injury soon, than if it appears at a great distance of time. No man will pretend to say, that such mischief has not been done by out- ward violence, that cancerous disorders have not followed, in the parts so injured, in persons, who, before such accident, never had any appearance of such disorder; and who possibly might have lived many years, nay, their whole life, without its appearing in such form and manner: but that, pre- vious to such accident, there was no cancerous disposition or malignity in the babit, is an inference which cannot be admitted. What disorders of the joints do we see produced by very slight injuries 134 A TREATISE ON THE HYDROCELE. Indeed, the circumstances of frequent pain, and the manifest tendency to an increase of size, are by some people looked on as done to them ? disorders which are clearly and plainly scorphulous, and which would not have appeared at that time, or in that part, had it not been for such accident; but surely no man will from thence conclude, that such people have no scrophulous taint in their blood, or glands, previous to such strain or bruise. How many internal part* are there for this disease, as well as some others, to make its attack upon ; but which, by being out of sight, and not deemed objects of surgery, are not known; and pass either for other diseases, or for the symptoms of other diseases ? What tumors of the lum- bal glands and mesentery; what obstructions, in all parts of the contents both of the abdomen and thorax, do we not find, upon examining the dead, whose disorders were very little known or understood while they were living; but whose prevailing indisposition, whose natural dyscrasia, would most probably have shewn itself in some more visible part, if such part had accidentally suffered from external violence ? All that we from experience know, and therefore all that we ought honest- ly to say on this occasion, is, that it hus very often happened, that where that kind of disorder, which produces scirrhous or. cancerous tumors, has been brought into action by external injury (whether it be in the breast, testicle, or any other part, it matters nut); or when such kind of disease h;is seized such part, no preceding violence having been offered to it, and has therein occa- sioned a fixed but indolent kind of swelling, which has either remained a long time of one size and stale ; or, if it has altered, has altered very slowly, and given the patient but little uneasiness; if such tumor has been so situated and circumstanced, that it could safely be extirpated or removed, that such removal or extirpation has often cured the present evil; and that the patient has remained free from any thing of like sort, during his or her life. This is true, and therefore is and ever will be a sufficient reason for press- ing such operation, when all other circumstances are favourable. That the patient may keep well after it, is by no means improbable; that the scirrhus would remain, through life, indolent and inoffensive, is very improbable. But whoever boldly asserts, that such extirpation will always and certainly cure the disease, is very inexperienced, or is wilfully guilty of a deception, the two distinguishing marks of a quack, who always promises, what he either does not know, or does not believe. When a scirrhus or cancer is favourably circumstanced, and so situated as that it may be extirpated, such extirpation is indeed the only remedy: and that method by which such extirpation can be most certainly and expedi- tiously executed, is, beyond all doubt, the best. The two in use are, the knife and the caustic. The former, in the hand of a surgeon who is an anatomist, has every advantage which can be desired or supposed : it gives less pain, is more secure and more expeditious; but it im- presses on the patient the apprehension of an operation, and the fear of an haemorrhage. The use of caustic is infinitely more painful, not only in imme- diate sensation, but in duration; it often requires repetition ; it is less man- A TREATISE ON THE HYDROCELE. 13u such marks of a malignant disposition, that they have been by them reckoned as dissuasives from the operation. ageable, less secure ; and the great length of time which sometimes the sepa- ration of the mortified parts takes up, renders it very tedious. But it is at- tended with two circumstances, which have greatly contributed to the support of cancer quackery : one is, that it spares the patient the horror of an opera- tion, whirh, though infinitely less painful than the effect of the caustic, is not believed to be so ; the other is, that the ragged appearance, which the bottom and sides of the parts make after having been removed by such application, is so unlike to the smoothness of that which has been removed by incision, that ignorant people are easily induced to believe, what the designing always tell them, viz. that the medicine has taken their disease out by the roots; and that the ragged parts which they see, are such roots. It is amazing what weight this single circumstance has with many, and even with some sensible people ; few of whom are persuaded to believe what is as true as any proposition in Euclid, viz. that the caustic of equal strength, applied on any glandular part of any person, will always produce exactly the same effect and appearance, as, in this case, passes with them for the roots or branches of the disease. When nurses and quacks talk of the fibrous roots of a cancer, and of can- cerous fermentations, they are excusable ; the one from their ignorance," the other from the nature of their trade ; but when they who pretend to some kind of medical knowledge use this kind of language, it is shameful. If either the fears of the patient, or the particular circumstances of the part to be removed, render the use of caustic preferable, or necessary, every prac- titioner is well acquainted with those which are perfectly efficacious; but every practitioner also knows, that good reasons for preferring the use of them to the knife very seldom occur : it is in this as in the attempts toward a radical cure for ruptures, and some other parts of surgery, we are censured where we ought to be applauded, and blamed for those very things from whence we ought to derive praise. W'e have laid aside certain methods and processes, because we found them (upon experience) to be painful, hazard- ous, and ineffectual; and these very methods, destructive and infallible as they arc, have given credit and honour to those who have had ignorance and in- humanity enough to revive them. We are not yet so happy as to be possessed of any medicine which will mre a cancerous habit. When the constitution is thoroughly infected, nei- ther our knives nor caustics will avail: they can only remove the local mis- chief, but can have no effect on the general one in the constitution. Who- ever says otherwise, says what is not true; and whoever believes otherwise, is imposed upon. When the habit is concerned, as it too frequently is, it must be an internal remedy that proves a specific, whenever we are so hap- py as to be blessed with the discovery. The supposition, that an escharotic can, by destroying a particular part, eradicate the disease from the habit, is ■ one would be inclined to suppose) too gross an absurdity fu- the most cre- dulous believer to swallow ; and yet it is believed, and trusted to every day. 136 A TREATISE ON THE HYDROCELE. But these gentlemen carry their fears and apprehensions much too far the other way. Pain and a quick increase of size are certainly no favourable symptoms; they show a disposition to mis- chief, but they are not such positive proofs of a cancerous habit, as to render all hope of a cure, from the removal of the diseased part, vain: there are many instances to the contrary; and though no honest or judicious man will venture to promise success, even in the most favourable of these cases, yet it is well known, that those which have had very unpromising appearances, not only from the state of the testicle, but from that of the spermatic chord, have succeeded often enough, to make the chance of a cure, by the operation, by no means a desperate one. The state of a man left to his fate in these circumstances, that is, to the fury and progress of the disease, is so truly miserable, that nothing should be left unattempted, which carries with it any probability of being serviceable; and a practitioner is vindicable, in pressing what he has known to be successful; though, at the same time, he ought to make a guarded kind of prognostic. Upon the whole, I think it may justly be said, that the man who has the misfortune to be afflicted with a truly scirrhous tes- ticle, has very little chance (notwithstanding all that has been said and written about specifics) to get rid of it by any means, but by extirpation; and all the time the operation is deferred, he carries about him a part not only useless and burthensome, but which is every day liable, from many circumstances (both exter- nal and internal) to become worse, and more unfit for such ope- ration. While the testicle is small, and free from acute or frequent pain, the vessels from which it is dependent are most frequently Indecd, it sometimes happens, in the treatment of these cases, that either the~ arrival of puberty, a favourable turn in a constitution, or the renewal of long- obstructed evacuations, (especially the uterine ones,) shall restore the patient to a better state of health, and prevent either the further progress of the dis- order, or any new appearance of it in any other place. In this case, if the extirpation was made by an external application, and not by an instrument, 6uch application is thought to have wrought the cure, and has all the credit of doing what it really had no share in then, what it never can do, nor have the appearance of doing again, but in the like accidental circumstances. A TREATISE ON THE HYDROCELE. 131 soft, and free from disease; whereas, when the testis has been suf- fered to attain a considerable size, the case is frequently otherwise; the spermatic vessels are often large and varicose; and the cellular membrane investing them sometimes becomes thick, and contracts such connexions and adhesions, which, though they may not amount to an absolute prohibition of the operation, do yet render it tedious, troublesome, and more hazardous, than it would be in other circumstances. Every addition to the original complaint in the body of the gland is against the patient; and if any of these are the consequence of not having removed it in time, it will fol- low, that the sooner it is removed, the better. If we wait for what some call indications of the necessity of operating, we shall often stay until it will do no good. Many a one have I seen lose a very probable chance of a cure by delay: but I do not remember ever to have seen a testicle removed, by a man of judgment, which tes- ticle did not, upon ' examination, fully vindicate the extirpation. If we were possessed of any medicine, either external or internal, which had been known now and then to have dissolved scirrhi, it would always be right to recommend the trial of them previous to an operation; and it would always be right to defer operating until such trial had been made. But the truth is, we know no such medicine. The credulous on the one hand, and the designing on the other, have told us many strange stories of cures effected by such applications and remedies; and I do most sincerely wish, that what each of them have said was true; but repeated, faith- ful experience has proved that it is not; and that they who have placed their confidence in them, or laid out their money on them, have been disappointed and cheated. Some circumstances there are now and then attending this dis- ease, which are out of our sight, and out of our knowledge, and which will render all our pains abortive: such are tubercles, indu- rations, and other diseased appearances in the cellular membrane enveloping the spermatic vessels within the abdomen; scirrhus, vis- cera, &c. If any of these can be known, they constitute a good rea- son for not attempting the cure by the operation; but the mere possi- bility that such may exist, is certainly no reason for abstaining from it. The apparent evil, that is, the diseased testis, is certain; the other vol. u. s 133 A TREATISE ON THE HYDROCELE. may or may not be the case. The one, if left to itself, is most likely to destroy the patient in a most miserable and tedious man- ner; and the other (the suspected mischief) may possibly not exist. But though the timely and proper removal of a scirrhous or cancerous testicle does frequently secure to the patient life, health, and ease, which, in such circumstances, are not attainable by any other means; yet it must be remarked, that the improper and un- timely performance of the operation is not only not attended with such happy and salutary event, but generally bringson high symp- toms, and quick destruction. It therefore behoves every practi- tioner to be perfectly well acquainted, not only with such circum- stances as render castration practicable and advisable, but with those which prohibit such attempt. These are of two kinds, and relate either to the general habit of the patient, and the disorders and indispositions of some of the viscera, or to the state of the testicle and spermatic chord. A pale, sallow complexion, in those who used to look otherwise; a wan countenance, and loss of appetite and flesh, without any acute disorder; a fever of the hectic kind; and frequent pain in the back and bowels, are, in those who are afflicted with a scir- rhous testicle, such circumstances as would induce a suspicion of some latent mischief, and incline one to suppose that the same kind of virus, which had apparently spoiled the testis, may also have exerted its malign influence on some of the viscera: in which case, success from the mere removal of the testicle is not to be expected. They, whose constitutions are spoiled by debauchery and intemperance, previous to their being attacked with this dis- ease, who have hard livers, and anasarcous limbs, are not proper subjects for such an operation. Hard tumors within the abdomen. in the regions of the liver, spleen, kidneys, or mesentery, imply- ing a diseased state of the said viscera, are very material objec- tions to the removal of the local evil in the scrotum. In short, > whenever there are manifest appearances or symptoms of a truly diseased state of any of the principal viscera, the success of the operation becomes very doubtful; more especially, if such symp- toms and appearances, upon being properly treated, resist in such manner as to make it most probable, that a cancerous virus is the A TREATISE ON THE HYDROCELE. 139 real cause of them. When none of these require our attention, the object of consideration is the testicle and its spermatic vessels. The state of the mere testis can hardly ever be any objection to the operation; the sole consideration is the spermatic chord. If this be in a natural state, and free from disease, the operation not only may, but ought to be performed, let the condition of the tes- ticle be what it may. If the spermatic chord be really diseased, the operation ought not to be attempted. For although, on the one hand, a probability of success will vindicate an attempt, even though it should fail; yet, on the other, where there is no such probability, an operation, though performed in the most dexter- ous manner, will prove only a more ingenious method of tor- menting. This therefore (the state of the spermatic chord) is a matter which may require our most serious consideration; since, on this it is (when the disease appears to be local) that we must found our judgment; and by this must form our resolution, either to leave a man to the truly miserable fate of being slowly, though certainly, destroyed, by a cruelly painful, and frequently very offensive dis- ease; or endeavour to save, and preserve him in health and ease, by means which have so often proved successful, as truly to de- serve the appellation of probable. All writers on this subject agree in saying, that if the spermatic process has partaken of the diseased state of the testicle, that is, has become enlarged and hardened, and such enlargement and induration extends itself quite up to the abdominal muscle, that the operation of castration ought not to be performed, because it not only will prove successless, but will hasten the death of the patient. And this is, in some degree, most certainly true; but not without some limitation. A truly and absolutely diseased state of the spermatic chord, in any part of it, is certainly a very material objection to the operation, as it most commonly proves a bar to the success of it; and a morbid state of the same chord quite as high as the abdominal muscle, that is, of all that part of it which is exter- nal to the cavity of (he belly, is a just and full prohibition against such attempt. But on the other hand it must be observed, that every apparently morbid alteration of the spermatic chord is not really such; and therefore, that every enlargement, induration, 140 A TREATISE ON THE HYDROCELE fulness, &c. which seems to alter the spermatic vessels from that state which is called a healthy and natural one, is not to be re- garded as a disease; at least, not as such a disease as is sufficient to prohibit the attempt to obtain a cure by extirpation. The difference between these, it is the duty of every practition- er to become perfectly acquainted with, as it is from a considera- tion'of these, that he ought to determine, whether he may, with that firmness and assurance which the probable expectation of success will give him, propose and advise castration, or find himself obliged in conscience to dissuade, or refuse, the perform- ance of it. When the spermatic vessels are not only turgid and full, but firm and hard; when the membrane, which invests and connects them, has lost its natural softness and cellular texture, and has contracted such a state, and such adhesions, as not only greatly to exceed its natural size, but to become unequal, knotty, and pain- ful, upon being handled; and this state has possessed all that part of the chord, which is between the opening in the oblique mus- cle and the testicle, no prudent, judicious, or humane man will attempt the operation; because he will most certainly not only do no good to his patient, but will bring on such symptoms as will most rapidly as well as painfully destroy him. Of this there are so many proofs, that the truth of it is inconlestible. In some modern French books, we have indeed miraculous ac- counts of operations of this k ind, performed by dividing the tendon of the oblique muscle, by tracing the diseased spermatic vessels with- in the cavity of the belly, and there making the ligature and ex- cision: but these are operations which make a figure in books only, and are performed only by visionary writers; or, if ever they have been practised, serve to show the rashness and insensibility of the operators, much more than their judgment or humanity. Whoever (notwithstanding these tales) performs the operation in the circumstances above mentioned, will prove himself much more hardy than judicious; and will destroy his patient, without hav- ing the satisfaction of thinking that his attempt, though success- less, was yet vindicable; the only circumstance which can, in such events, give comfort to a man who thinks rightly. On the other hand, as I have already said, every enlargement A TREATISE ON THE HYDROCELE. Ml of the spermatic chord is not of this kind, nor by any means suf- ficient to prohibit or prevent the operation. These alterations, or enlargements, arise from two causes, viz. a varicose dilatation of the spermatic vein, and a collection, or collections of fluid in the membrane investing and enveloping the said vessels. In the first place, as there is no reason in nature why a testicle, whose vessels have previously (for some time per- haps) been in a varicose state, should not become scirrhous; so it is also clear, that the scirrhosity seizing such testicle, will by no means remove, or even lessen, such varicose dilatation of the ves- sels from which it is dependent; on the contrary, will most proba- bly, and indeed does most frequently, increase such distention: but such mere varicose enlargement of the vessels, whether it be pre- vious or consequential to the morbid state of the testis, does not, nor ought to prevent the removal it, if otherwise fit and right. It is indeed an objection to the doctrine of Mr. Le Dran, and a few other writers, who make no ligature on the chord, and trust to a slight contusion of it between the finger and thumb for a suppres- sion of haemorrhage; but is none to the rest of the operation, as I can from experience testify. In the next place, the diseased state of a truly scirrhous testicle, its weight, and the alteration that must be made in the due and proper circulation of the blood, through both it and the vessels from which it is dependent, may and do concur in inducing a va- ricose dilatation of the spermatic vein, without producing that knotty, morbid alteration and hardness, which forbid our attempts. Between these, a judicious and experienced examiner will gene- rally be able to distinguish. In the former (the truly diseased state) the chord is not only- enlarged, but feels unequally hard and knotty; the parts of which it is composed are undistinguishably blended together; it is either immediately painful to the touch, or becomes so soon after being examined; the patient complains of frequent pains shooting up through his groin into his back; and from the diseased state of the membrane composing the tunica communis, such adhesions and connexions are sometimes contracted, as either fix the process in the groin, or render it difficult lo get the finger and thumb quite round it. 14J A TREATISE ON THE HYDROCELE. In the other, (the mere varicose distention,) the vessels, though considerably enlarged and dilated, are nevertheless smooth, soft, and compressible; the whole process is loose and free, and will easily permit the fingers of an examiner to go all round it, and to distinguish the parts of which it is composed. It is not painful to the touch; nor does the examination of it produce, or occasion, those darting pains which almost always attend handling a process malignantly indurated. I do not say, that the distinction between these two states is al- ways and invariably to be made; but that it often may, I know from repeated experience; and that the operation may safely be attempted, and successfully be performed, I know from the same experience. The state of a man, left to the mercy of a malignant scirrhus, is so truly deplorable, that we cannot be too attentive in examining the precise nature of each individual case, and in em- bracing every opportunity of giving him that relief, which it may at one time be in our power to give, and which, the favourable opportunity missed, it may never be in his power again to re- ceive. The other circumstance which I have mentioned as capable of deceiving an operator, and inducing him to believe that the sper- matic chord is much more diseased than it really is, and thereby deterring him from the performance of an operation which might prove successful, is the extravasation, or collection of fluid in the cellular membrane enveloping the spermatic vessels, between the abdominal opening and the testis. In the cellular membrane leading to a diseased testicle, it is no very uncommon thing to find collections of extravasated fluid. These, as they add considerably to the bulk, and apparent size, of the process, make the complaint appear more terrible; and, as I have just said, less likely to admit relief. When this extravasation is general through all the cells of the investing membrane, and the spermatic vessels themselves are hardened, knotty and diseased, the case is without remedy; for although a puncture, or an incision, will undoubtedly give dis- charge to some, or even the greatest part of the fluid; yet this ex- travasation is so small, and so insignificant a circumstance of the disease, and the parts in this state are so little capable of bearing A TREATISE ON THE HYDROCELE. 143 irritation, that an attempt of this kind must be ineffectual, and may prove mischievous. But on the other hand, collections of water are sometimes made in the same membrane, from an obstruction to the proper circula- tion through the numerous lymphatics in the spermatic process, while the vessels themselves are really not diseased, and therefore very capable of permitting the operation. In this case, the fluid is generally in one cyst, or bag, like to an encysted hydrocele, and the spermatic chord, cyst and all, are easily moveable from side to side; contrary to the preceding state, in which the general load in the membrane fixes the whole process, and renders it almost immoveable. A discharge of the fluid will, in this case, enable the operator to examine the true state of the process, and, as I have twice or thrice seen, put it into his power to free his patient from one of the most terrible calamities, which can befal a man. There is one more circumstance relative to the scirrhus testicle, which appears to me to be worth attending to, as I cannot help thinking, that it has misled many, who have not had sufficient opportunity of comparing theory with practice. It has been confidently asserted, and is generally believed, that a scirrhus testicle never begins in the epididymis of the said tes- ticle. The consequence of this doctrine is, that when a disease, which affects a testicle, by enlarging and hardening it, makes its fust attack on the epididymis only, such disease is not allowed lo be a scirrhus, nor permitted to be treated as such. That inflammatory kind of tumor, which, in the virulent go- norrhoea, seizes the testicle, and is called the hernia humoralis, affects the epididymis; and, even under the best care, sometimes leaves it too large, and too hard. This is said never to end in, or produce a scirrhus; and I do not recollect that I have ever known it to do so. The disease, which consists in an induration and en- largement of the whole testicle, in the more confirmed lues, affects the epididymus also, as well as the glandular part of the testicle; and I do not remember to have seen it either become cancerous, or not yield to mercury, properly administered. But that a true scirrhus, or cancer, sometimes makes its first attack on the epidi- dymis, which it alters or spoils, before it at all affects the testicle, 144 A TREATISE ON THE HYDROCELE. is a truth, of which I have not the least doubt. Among others, I formerly believed the contrary doctrine; and, in the first edition of this book, have given it as my opinion; but I am, from experience, so perfectly convinced of the truth of what I have now asserted, that I think myself obliged to declare it. The mistake I suppose to have been made by the first propagators of this opinion, thus: The hernia humoralis, and the venereal sarcocele, always enlarge the epididymis, and generally leave it somewhat too hard: both these have, by adventurous and unknowing people, been mis- taken for scirrhi: but it being found, by experience, that these alterations in the epididymis, were either totally removed by me- dicine, or, if any part remained, it continued harmless through life, an inference was drawn, that, as true scirrhi are not often either removed by medicine, or continue harmless, therefore an original affection of the epididymis could never be a true scirrhus— a deduction, which the premises do not by any means authorise; and which I am satisfied is not true. The operation of castration is performed as follows:— The patient being laid on a table of convenient height, the in- teguments covering the spermatic vessels in the groin are to be divided. This incision should be begun, as nearly as can be, opposite to the opening in the abdominal muscle, and should be continued a good way down the scrotum. The manner of beginning this incision is differently described by writers; some of them advising that the skin be held up by an assistant; others that the knife be used perpendicularly, in this as in other parts. It is indeed a matter of no importance at all, either to patient or surgeon, and therefore may very safely be left to the choice of the latter; hut the length of the division is of con- sequence to both. A small wound will indeed serve to lay bare the spermatic chord, but it will not permit the operator to do what is necessary afterward, with dexterity or facility: a small wound gives as much pain in the infliction as a large one; and, as the scrotum must, first or last, be divided nearly to the bottom, it had better be done at first, on every account. The spermatic chord, thus laid bare, is to be freed from its surrounding membranous connexions; and then the operator, with his finger and thumb separating the blood-vessels from the vas deferens, must pass a A TREATISE ON THE HYDROCELE. 145 needle, armed with a ligature, between them; and having tied the former only, must cut through or divide the whole chord at a quar- ter or half an inch distance from the said ligature, according as the state of the process and testicle will admit. This done—he is then (with the same knife, vvith which he has performed the former part of the operation,) to dissect the testicle out from its connexion with the scrotum: the loose texture of the dartos, the previous separation of the testicle from the spermatic vessels, and the help of an assistant to hold up the lips of the wound, will ena- ble him to do this with very little pain to the patient, and great facility to himself.1' If any considerable artery bleeds, either in the scrotum or in the dartos, it must be restrained by ligature; and when that is done, the void space in which the testicle was, is to be very lightly filled with soft dry lint;q Which lint should be suffered to remain until it P This circumstance of cutting off the testicle, before it be dissected out from the scrotum, immediately after the ligature has been made, is of more consequence to the patient's ease, as well as to the facility and expedition of the operation, than they who have not tried it are aware of. 1 Lint, however soft and lightly applied, acts as a foreign body, and pre- vents the immediate union of the wound. Our present method, and which Mr. Pott practised since his publication of this work, appears to be a consi- derable improvement on this part of the operation:—When the testis is re- moved, and the bleeding vessels of the scrotum, if there are any of conse- quence, are secured, no lint, nor dressing of any kind, is introduced ; but the parietes of the wound are brought together and retained by ligatures, more or fewer, according to the extent of the wound, as, from the moisture of the parts, sticking-plaster cannot be depended on : these ligatures should be tied with slip-knots, that they may be loosened, without a necessity being induced of removing them, in case of any fresh haemorrhage, which some- times happens after the patient is warm in bed. Dry lint is then applied, and kept on by a simple dressing, avoiding every thing greasy on the edges of the wound : by these means the parts unite and heal in great measure by the first intention; or, if any collection of matter is formed in the cavity which the testis occupied, it will be in small quantity, and easily discharged by the lower part of the wound, which must form a depending and an advantageous opening; after which the granulations will gradually fill the space, and the cure will be but little retarded. This excellent plan of preserving as much sound and undiseased skin as possible, and putting no obstructions in the way of Nature's healing powers, has of late years been applied to almost every species of tumor which it may be necessary to remove, and may be esteemed one of the greatest improvements of modern surgery. E. VOL. IT. T 14G A TREATISE ON THE HYDROCELE. be perfectly loosened by the suppuration from every part of the sore. If it be removed sooner, it must be done by force: in which case, it will give unnecessary pain, and leave a crude, un- digested sore; if it be not removed until quite loose, it will give no pain, and the sore will be found clean, and well digested, and requiring no other dressing afterward than mere dry lint; which, from this time, should be applied in such quantity and manner, as to give Nature an opportunity of contracting and healing the wound as fast as she can; in both which, she may be considerably assist- ed by the judicious exhibition of the bark. I am very sensible, that in the above direction for the perform- ance of the operation ef castration, I have differed from the doc- trine of some very eminent modern practitioners; and particularly from Mr. Le Drain. No man thinks more highly of Mr. Le Dran's abilities than I do; but, in these matters, every one must take the liberty of judg- ing for himself; and I cannot help thinking, that I have good rea- son for my opinion. Mr. Le Dran, having divided the integuments in the groin and scrotum, separates the testicle from the surrounding membrane with his fingers, and with scissors. This method is rather coarse, is unnecessarily painful, and does what must for ever be wrong— multiplies the instruments to be used, without any necessity. The knife, in the hands of any man, at all accustomed to the use of one, will execute the whole with more apparent dexterity, with less pain, and much greater expedition." I have, without hesitation, directed the spermatic chord to be r " Je fens le scrotum jusqu'au des'sous du testicule malade, et avec mes " doigts je detache le testicule d'avec le tissu cellulaire, qui le tient attache "dansle scrotum. Si quelque portion membraneuse a de la peine a. se de- "tacher, je la coupe avec des ciseaux." Mr. De Garengeot divides the whole scrotum with scissors ; and I cannot say that I have not seen it done in Lon- don : but it is a tedious, coarse, cruel, and very unhandy method of doing it. "Cette premiere incision faite, l'operateur poussera de force le doigt indice, "ou le grand doigt, sous la peau, dans les cellules graisseuses, afin d'entrer '* dans le scrotum, et il aggrandira son incision, en coupant sur son doigt avec "des ciseaux mousses la peau, qu'il aura separ£e des graisses, et il ouvrira '*ainsitoutle scrotum." Gakekgeot, Opbbat. C'm-n A TREATISE ON THE HYDROCELE. 147 tied. Mr. Le Dran's advice is different. He advises, that a liga- ture be passed underneath it, and left there to be tied; or not, as occasion may require. He then takes the extremity of the latter between his finger and thumb; and, by rubbing, pinching, or bruising, produces a degree of contusion sufficient (as he thinks) to prevent, in general, any haemorrhage; and, having so done, he cuts off the testicle from the said chord, immediately below the bruised part, leaving (as I said before) the ligature ready to be tied, if necessary." This method of first bruising, and then cutting off, the spermatic chord, without making a ligature on it, is also prescribed and practised by some gentlemen of eminence here; and I make not the least doubt, that, both with these gentlemen, and with Mr. Le Dran, it may have been successful; but, as I have seen three people lose a very alarming quantity of blood, and one very nearly his life under it; and as in the many times which I have performed this operation, I never saw the least inconvenience arise from the ligature, I cannot approve the omission of it.1 Mr. Le Dran himself not only seems to be apprehensive of what may be the consequence, by his passing a ligature, and leaving it ready to be tied, and by the very good reason which he gives 6 " ll n'y a que l'artere qui m'interesse, parce qu'il n'y a qu'elle qui puisse " donner du sang apres que j'anrai coupe le cordon. Je la prends entre " deux doigts, a 1' endroit ou elle passe surTos pubis, et avec elle les veines '* qui l'entourent; puis je passe entre ces vaisseaux et le canal deferent, que " l'on distingue sous le doigt, a sa duret£, une aiguille, enfilee de deux brins " de fil cire. • J'dte l'aiguille, et je laisse les fils, pour faire la ligature,au cas " qu'elle devienne necessaire. Je prends aussitot les vaisseaux plus bas que " l'os pubis, etje le froisse entre mes doigts, pour y faire une espece de " contusion; puis je coupe le cordon un peu au dessous de cette endroit " froisse." M. Le Dkak. « That it would be in the highest degree dangerous lo omit securing the spermatic artery, is now universally acknowledged; but as tying the chord (notwithstanding the vas deferens is left out) is by far the most painful part of the operation, it has been the practice of many good operators to'dissect down to the vessel, and to put a ligature round it, by a needle ; or, if the vessel be divided by means of the forceps, without including any surrounding parts; then to divide the remainder of the chord, and finish the operation in the usual manner. E. 148 A TREATISE ON THE HYDROCELE. for not cutting off the spermatic chord (as most of his countrymen advise) close to the opening in the tendon of the oblique muscle; but also in the same paragraph acknowledges, that a fatal haemorr- hage has been the consequence of the ligature having slipped off, after it has been made." la the case of a perfectly sound and unaltered spermatic chord, in which the vessels are not become varicose, and the operator can make his division of them as low as he pleases, this froissement, this contusion may be sufficient to prevent an haemorrhage; but in cases where the spermatic chord is enlarged, Mr. Le Dran himself does not think it safe to trust to it. And that the vessels from which a scirrhous testicle is dependent, may be considerably enlarged and distended, and that pretty high, and yet not so diseased as to render the operation unadviseable or unsuccessful, I bave more than once or twice seen. The compression which may be made of the extremity of the divided chord against the os pubis, on which some stress seems to be laid, will, whether it be made by the finger, or by compress and bandage, prove more troublesome to the patient than the very momentary pain of the ligature. u " On demandera, pourquoi je ne fais pas la ligature du cordon immedi- " atement au dessous de 1'anneau, comme les auteurs le prescrivent. Je " reponds, que, si la ligature s'echappe, on ne peut plus lier 1'artere, qui se " retire au dessus de 1'anneau, ou elle peut donner du sang dans le tissu " cellulaire du peritoine, et faire perir le malade, comme I'on a vu arriver." Le Dhax. " Si le cordon spermatique est gonfle jusque' aupres de 1'anneau, on ne " peut suivre cette methode; et il faut absolument faire la ligature du cordon, " immediatement au dessous de 1'anneau" The remainder of this paragraph does indeed seem a kind of contradiction of the preceding. " S'il est tres " gonfle meme un plus haut que 1'anneau, et qu'on ne puisse se dispenser de " faire l'operation, il n'y a point de ligature a faire ; il faut fendre un peu "1'anneau, puis couperle cordon, et 1'artere ne donnera pas de sang." Set aside all considerations of the propriety or impropriety of performing the operation, when the spermatic chord is diseased above the ring, (as it is called,) what can be the reason why the artery should not be expected to bleed, after being divided within the abdomen ? when the same gentleman allows it to have produced a fatal hemorrhage, upon retiring into that cavity, or into the cellular membrane of the peritioneum, after having been cut off without the said ring. A TREATISE ON THE HYDROCELE. 149 The last circumstance in which I have ventured to differ from the commonly prescribed rules, is, that I have not advised the removal of any part of the scrotum.3 ; My reason is, that I never found it necessary, in any case, when the scrotum was not adherent to the testicle. Let the size of the scirrhus be what it may, the scrotum will corrugate to its natural form, when the wound is healed; and if in the operation it fairly be divided to the bottom, will neither lodge matter during the cure, nor produce any inconvenience afterward. When it is adherent to the testicle, and the cellular structure of the dartos is thereby destroyed, all such adherent part should cer- tainly be removed; not only because it is diseased, but because it will give the patient a great deal of unnecessary pain to dissect it: but then it should always be removed along with the testicle, in the manner directed by Mr. Samuel Sharpe, and not be dissected off first, and removed afterwards. By the latter method, the patient's pain is increased, prolonged; and even renewed, without the least necessity. In every operation in which a considerable portion of skin is to be divided, and particularly in this, and the amputation of womens' breasts, it should always be remembered, that, as the division of the skin (the general organ of sensation) is the most acute and painful part of what is done by the knife, it cannot be done too quick, and should always be done at once: the scrotum should always be divided to the bottom, and the circular incision in the skin of a breast always made quite round, before any thing else be thought of.y If this be not executed properly and perfectly, * " Si quelque portion membraneuse a de la peine a se detacher, je la " coupe avec des ciseaux; et quand le testicule est ote, j'enleve une partie de " la peau du scrotum, si cette peau s'est trop £tendue par le volume de la " tumeur." Le Drax. The same direction is given by Laur. lleister. " Cutis scroti qua; exempts " testiculo supervacanea ut resecari forfice debet." By which means (that is, by not removing the skin along with the testicle, but afterward) the patient suffers almost as much pain as the whole operation, properly performed, would occasion; and that without any necessity. y This passage has been quoted as a proof that Mr. Pott's usual practice was to remove the whole skin covering a cancerous breast; but it could only 150 A TREATISE ON THE HYDROCELE. the operation will be attended with a great deal of pain which might be avoided, and the operator will be justly blameable. * Before I take my leave of this operation, I think it right to give the young practitioner a caution, viz. that if the tumor be of a pyri- form figure, perfectly smooth, and equal in its surface, and free from pain, notwithstanding the degree of hardness may be great, and he may, in his own opinion, be clear that the tumor is not produced by water, but is a true scirrhus, I would advise him, immediately previous to the operation, to pierce the anterior part with a trocar, in order to be certain. My reason for giving this advice is, that I was once so deceived by every apparent circum- stance of a true, equal, indolent scirrhus, that I removed a testicle, which proved, upon examination, to be so little diseased, that, had I pierced it with a trocar previous to the operation, I could, and cer- tainly should have preserved it. Having, in the immediately preceding pages, given my opinion very explicitly concerning the expediency and propriety of re- moving, by the operation of castration, a scirrhous testicle, when fairly characterised, and properly circumstanced, it cannot be necessary to relate any such cases. Every man, who is at all con- versant with this kind of business, knows, that the operation on proper subjects, and in proper instances, is very frequently suc- cessful; and that many people have been by it rescued from imme- diately impending misery, and have passed many years in health and ease, and in a state to propagate their species. Particular accounts of such, would appear like mere boastings of success. Those, therefore, which follow, are selected, either because the fortunate event was not very probable; and they may therefore serve to prove, that we should not too hastily or inadvertently despair: Or, because their true nature was mistaken; and, therefore, they were improperly treated: relate to those cases in which the skin was fixed to the gland, and partook of the disease. When it was sound and unaffected, Mr. P. by his doctrine and practice inculcated the preservation of it; and I have many times seen him remove large tumors by means of a simple line, so as to preserve the skin entire. E. A TREATISE ON THE HYDROCELE. 151 Or, that they were attended with circumstances not to be fore- seen or prevented: Or, that the case was too long neglected, and the operation too long deferred; or performed when success from it was not at all likely: Or, that they were combined with other complaints, either general or local, by which the best calculated attempts must be frustrated: Or, that they contain something in their nature which appears to be singular. From each, or all of which, I apprehend the practitioner may reap full as much, if not more, beneficial instruc- tion, than from the most pompous histories of success. CASE XXXIX. A man about forty-seven years old, who had been, for the space of three or four years, afflicted with a truly scirrhous testicle, applied to me. He had been more than once, during that lime, advised to part with it, but was afraid of the operation. He was now alarmed by an alteration which it had lately undergone, and from some circumstances in his general health which were new. The tumor, from its first appearance, had been indolent and equal, the spermatic chord in a natural state, and he had no other com- plaints of any kind. The testicle was now very unequal in its surface; it had increased considerably within the last three months; and the spermatic chord was enlarged; that is, become varicose, more than halfway from the testicle to the groin. He had also a colicky disorder, which recurred frequently, without any purg- ing. The case was unfavourable, and there appeared to me to be no chance, but from castration. The state of the spermatic vessels rendered that dubious; but the improbability of the disease remain- ing in its present state, made it still worth embracing. The gene- ral state of the patient's health was also an alarming circum- stance; but neither could that be amended, while the local disease remained. 152 A TREATISE ON THE HYDROCELE. Having apprised him of all these circumstances, he willingly submitted to the operation; which was performed the next day. The slate of the process just admitted of making the ligature between the enlarged part and the abdominal muscles. Nothing particular attended the cure: the sore healed very kindly, and the man has enjoyed a good state of health ever since; which is now between four and five years. CASE XL. A gentleman from America applied to me, on account of a complaint in one of his testicles. It had, while he was abroad, been supposed to be, and had been treated as, venereal; by which means, what was, at first, a simple, equal, indolent scirrhous, with a spermatic chord unaltered from a natural state, was, when I saw it, unequal, at times painful, and dependent from spermatic vessels, considerably enlarged and swollen, though still soft, and free from knot or induration. He was otherwise in perfect health, his age thirty-three, and his constitution unhurt by debauchery or intemperance. With regard to the testicle, there could be no doubt, either of the nature of the disease, or the propriety of its being removed; but the state of the spermatic vessels was such, as made the pros- pect of success from castration very uncertain. Two or three consultations were had, the result of all which were nearly the same; that is, the surgeons were very apprehensive of the opera- ration, from the state of the chord, and therefore would not press it; and the physicians prescribed internal remedies; and among these the cicuta, which luckily happened to disagree so much with the patient, that he would not go on with it:—I say luckily, because it thereby prevented the loss of more time in the use of it. The patient was single, a sensible man, and had a great deal of courage and resolution in his natural constitution. Having maturely weighed all that had been said to him, and finding that no relief was likely to accrue from medicine, and that his disease was as little likely to stand still, he determined rather A TREATISE ON THE HYDROCELE. 153 to take the chance which the operation would give him, either of sudden destruction, or a cure, than live in that state of anxiety, which must arise from a constant meditation on the nature of his disease. The operation was performed; and in the execution of it, I was particularly attentive to the state of the vessels. The whole pro- cess was, I may venture to say, full double the size it ought to be, and the veins very tortuous, by their being distended; but there was no induration, nor any inequality, save that proceeding from the varicose state of them. When the testicle was removed, I examined that also verycare- ful'y. The cavity of the tunica vaginalis was, in a great measure, abolished by an almost general adhesion of that membrane vvith the albuginea; the epididymis was tolerably sound; but the whole compages of the testis hard and diseased; and in the very centre of it was a putrid slough, and a very small quantity of ill-colour- ed sanies. It is now above five years since the operation. The patient has enjoyed perfect health ever since, and finds no one inconve- nience from the loss of the part. In these two cases, the event was fortunate beyond expectation. In such circumstances, every thing is to be feared: the operation is seldom advisable, because seldom successful. However, they may stand as instances to prove that where there is even a small foun- dation for hope, it is better to embrace such opportunity, than to leave the patient to his fate. Neither himself nor his friends should, in such case, be flattered or deceived; but the uncertainty should be laid before them, and the operation should be their own choice. CASE XLI. A young man, about twenty-four years old, desired my opi- nion concerning a testicle, which was beginning to enlarge, and was already become very hard. The account he gave was as follows:— That, about seven or eight mouths before, fie had a common vol. n.. u 154 A TREATISE ON THE Hi'UROCELE. h< rnia humoralis, in consequence of the suppression of a gonor- rhoea by hard riding. That the inflammatory symptoms were soon removed by rest, evacuation, and proper application; but that neither the testicle, nor the epididymis, had ever returned to theit natural size. That the surgeon, whose care he had been under, had, since the inflammation was gone off, given him a consider- able quantity of mercuiial medicine internally, and had rubbed on a good deal of the ointment externally; by which his mouth had been made sore; and that he had also taken two or three mercurial vomits. The tumor was perfectly indolent, even upon being handled; it had a stony, incompressible kind of hardness; and the sperma- tic vessels were in a sound natural state. I told him, that whatever might have given rise to his disease, il was my opinion that it was a true scirrhus; that it would never be cured by medicine; that, although it was quiet, and free from pain now, no man would pretend to say how long it might con- tinue so; and that I should, by all means, advise him to part with it in its present state, rather than stay till such alteration should be made in it, as, though it might induce him to- comply, might render the operation unsuccessful. He disapproved my advice, and I saw no more of him for near four months; at the end of which time he called upon me again. His testicle was a good deal increased in size, but the sperma- tic chord still unaffected. I repeated my former advice, and he again refused to comply. At the distance of two months from this time, I saw him again. His testicle was still more enlarged, and the cavity of the tunica vaginalis palpably contained a fluid. He said, he had showed it to two other surgeons; both of whom had promised him much relief, if not a cure, by letting out that water, which they told him made the principal part of his disease. I answered, that I had no manner of doubt that there was a fluid; but I apprehended it to be much less, in quantity than either he, or they who had pro- mised a cure by letting it out, took it to be; that it appeared to me to make so small a part of the swelling, that I was sure that the decrease of size, upon its discharge, wouid bear no proportion to A TREATISE ON THE HYDROCELE. 155 to his expectation; that this fluid made no part of the original dis- ease, but was an accidental consequence; that an opening made into a testicle so circumstanced might excite very disagreeable symptoms, from which he was at present free; and that my opi- nion was still, that it ought to be totally removed, or not meddled with. He left me with much dissatisfaction. He said, that I was too tenacious of my own opinion, and too regardless of that of others. But I had seen too many of these cases, to be in any doubt concerning its nature; and I knew the people, under whose direction he then was, too well to suppose, either that they knew any thing of the matter, or that they would leave any thing unattempted, while he had either credulity or money. Soon after this I heard that he had submitted to have a punc- ture made, by which a very small quantity of bloody serum was discharged; but the size of the tumor so little lessened, that his operator would fain have thrust a lancet in again, and deeper; but this the patient would not permit. Being vexed at what had happened, he came not again to me, till at the distance of near two months more. He was now in a very different state. His complexion was wan and pale, his flesh and appetite gone, his testicle very large, unequal and painful; and the spermatic chord diseased quite up to his groin. I was very sory to be obliged to tell him, that I could do him no good; and that the operation was by no means advisable. He now, of course, fell into the hands of those who only want- ed a little ready money; and having tried two or three of these, he was advised to take the cicuta; which he did for some time, and in large doses, but (as usual) without any real or permanent good effect. His state, soon after this, became truly deplorable; his testicle was of an amazing size; the spermatic chord, quite up to his belly, so large as hardly to be capable of being grasped by the hand; a very large, hard tumor within that side of the belly; his pain acute and constant; and his flesh, strength, and appetite, totally gone. In these circumstances, a believer in the omnipotence of the sublimate solution, prescribed it for him; from which he receiv- ed the advantage of having his death hastened. 156 A TREATISE ON THE HYDROCELE. CASE XL1I. A man about thirty, of a full plethoric habit, showed me a tu- mor in the spermatic process, about the midway between the groin and testicle: it was hard, circumscribed, indolent when not meddled with, but painful for a long time after having been han- dled, and the pain of such kind, as to indicate the disease not to have a very benign character; the testicle was perfectly free. I advised the loosing some blood, gentle evacuation by stool, the use of a suspensory to take off the weight, and desired the pa- tient to let me see him again in about ten days. At the distance of somewhat more than a month, he came to me again; and told me, that from me he had gone to a rupture-doctor, who put a truss on him, and giving him an external application, bade hina come to him again in a week; that the pressure of the truss, joined to the irritating quality of the ointment, greatly increased the pain and the swelling; that his doctor then applied an adhesive plaster, and when he had worn that a few days, he thrust a lancet into the body of the tumor; that nothing followed the lancet but blood; that he enlarged the opening, and filled it with lint; and that for several days after, he had dressed the sore with red pow- der (precipitate). He had now as truly malignant a cancerous sore as I ever saw; and all the spermatic process above it was so diseased, as to prohibit all thought of an operation. Nothing palliated the fury with which it proceeded; he lived several months in great and constant pain, having a large hard, body within the belly (on that side,) extending from the groin quite up to the re- gion of the kidney; and which I make no doubt, consisted of the diseased spermatic vessels. CASE XLIII. A man, about forty-eight years old, who lived at some consider- able distance from London, perceived one of his testicles becoming A TREATISE ON THE HYDROCELE. 157 hard; larger in size than it used to be; and when he was on horse- back, somewhat painful. Having several times had a gonorrhoea, and twice been confined with a hernia humoralis, he thought that this swelling was of the same kind, and applied to the apothecary of the town where he lived; who, not being much accustomed to surgery, and being misled by the patient's opinion and account, looked on it in the same light, and gave him several doses of calomel: tiiese not succeeding to his wish, he confined the patient to his bed, applied a poultice to the scrotum, and vomited him twice or thrice, with the mercurius emet. flavus. By this process the man became fe- verish; lost his appetite, sleep, and flesh; and the testicle increas- ed, both in size and hardness. I was now consulted by letter, and gave my opinion, that the case was not venereal; that mercurial medicines, or whatever was likely to increase the circulation, were wrong, and would be found prejudicial; that whatever might become necessary hereafter, the present intentions ought to be, to procure ease, to remove the fe- ver, to keep the body (which had always been costive) gently open, and to acquire strength by the administration of soft, light nourishment; and I recommended the decoct, sarsaparilla', with milk, for his common drink. In another letter, which I received at about three weeks' dis- tance from the first, my opinion was asked concerning the cicuta: to which 1 replied, that in scirrhous and cancerous cases (one of which I took this to be) I had never yet s^en it do any good, though taken for a considerable time, and in large doses; but, on the other hand, as I had never seen it do any harm, I could have no objection to its being tried. In about two months, or a little more, I had another letter, giv- ing me an account that the cicuta had been taken freely, and had also been constantly applied as a cataplasm; that, in about a month after its first application, the pains, both in the part and in the patient's back, were remarkably increased; that he now and then complained of being chilly; and that there had been, from about that time, a palpable fluctuation of a fluid, near to the surface of the tumor; that this fluid had been let out by the point of a lancet, and proved to be only a small quantity of a 158 A TREATISE ON THE HYDROCELE. bloody serum; that, from the time this opening had been made, the pain as well as the side of the tumor had increased; that, by continuing the cicuta poultice, vvith the addition of some Burgun- dy pitch, a collection of matter, or imposthumation, was now pro- duced, plainly to be felt, though deep in the body of the testicle; and I was desired to say what I thought would be the properest manner of giving discharge to it. I returned answer, that it was a very disagreeable thing to be obliged to give a positive opinion on a case by relation only; and that from those who I was.sure thought not of it as I did. That as it was by no means unlikely that I might be mistaken, I desired, that what I should now say might not be understood or applied to any other case, than what / took this to be; that I took it to be a scirrhus, which was becoming cancerous apace, and would very soon show more of its malignant disposition; especially if irritated. That the fluid, which had been let out, was nothing more than the water of the tunica vaginalis, whose absorption was prevent- ed; and whose colour was produced by the diseased state of the testicle. That I should not have advised the letting it out at all; much less in that small quantity. That it was my opinion, that the fluid, which was now supposed to be felt to fluctuate deep in the body of the testicle, was by no means matter, or the effect of a kindly suppuration; but a malignant sanies, the consequence of the very diseased state of the testis. That I did verily believe they would find, that the quantity of it bore small proportion to the size of the general tumor That the letting it out would more probably occasion an aggravation than an alleviation of symptoms, and render the disease still more painful and more hazardous than it was already. And that I should not be surprised to hear, that there was no fluid at all. To this I received a short reply, signifying that it was appre- hended I had mistaken the case. That another gentleman in London had been consulted, who (from the account given of the state of tiie spermatic chord, of the preceding hernias humorales, and, most probably, from a misrepresentation of the case) had ad- vised the making an opening by knife; which had been done; but the writer of the letter did not say a word about what was let out. A TREATISE ON THE HYDROCELE. 159 1 heard no more of the case, or patient, for near another month; and then was sent for, one evening, to an inn in this town, where I found him in a situation truly deplorable. The testicle was amazingly large, and one half of it covered by a prodigious fungus, whicji was intolerably painful, glected largely, and at times bled profusely; the spermatic process was also very large, and a tumor plainly to be felt within the belly, caused by the diseased state of the seminal vessels. The man's strength and flesh were exhaust- ed; in short he was dying, and did not live above a week or ten days from this time. I believe it must be unnecessary for me to observe, that the misconception of the nature, and the method of treating the three preceding cases, had no small share in contributing to the suffer- ings of the patients, and to the fatality of their events. I believe also, that most practitioners who have been conversant with this kind of business, will be of opinion that the operation, performed in due time, would certainly have contributed to the ease, and perhaps to the preservation of them. A cancerous disposition in the habit will certainly render a patient liable to be destroyed, by the diseased state of parts out of our reach; and thereby render the operation, although performed in due time, in the best manner, and under the most favourable apparent circumstances, unsuccessful; but as this very often can- not be foreseen, or foreknown, surely it must be very wrong to omit doing what may preserve health and life, only because it may also happen, that it may do neither. In all these cases, a guarded prognostic should be made; and it should be considered, that though we are sometimes deceived and frustrated by sinister events, yet, on the other hand, it happens, and that not infre- quently, that cases which have even an unfavourable and threaten- ing aspect at first, come to a very happy issue. CASE XLIV. A man, about fifty years old, desired my advice concerning a diseased testicle. It was about the size of a small pomegranate, very hard, perfectly free from pain, and the spermatic process 160 A TREATISE ON THE HYDROCELE. free from all appearance of disease. Castration, he said, he was determined not to submit lo; and only wanted to know, whether rcould put him into any other method of getting rid of his dis- ease. I gave him my opinion very freely, on the great improba- bility of his being served by any other means; and though I did, in some degree, artvise him to submit to the operation, yet there were some circumstances in his general health, which induced me not to press it; and made me rather pleased, that he was pre- viously determined against it. He had a very sallow diseased complexion, a general want of muscular flesh and firmness; a very frequent colic, sometimes attended with a threatening diarrhoea, and sometimes with an obstinate constipation. In the space of two or three years, he took a great variety of medicines, and saw a great number of practitioners, both regular and irregular, but found no benefit; neither did the testicle in all that space of time suffer any material alteration, or the process become at all affect- ed. He died of an obstinate and painful dysentery; and when he was opened, his mesentery was found full of large, hard, scir- rhous knots; all the lymphatic glands about the receptaculum chyli, and beginning of the thoracic duct, remarkably diseased; and the liver much enlarged and hardened. The want of an healthy appearance, the pains, and other com- plaints which attended the man, might have been owing to causes independent of his scirrhus testicle; and upon such supposition, the removal of the said testicle by the operation might have been vindicable; but if it had been done, it should have been under a very guarded and doubtful prognostic. CASE XLV. A man about fifty, showed me a large, diseased testicle, which he said had been gradually, for near four years, getting to that size and state; and was produced, as he thought, by the kick of a child. The surgeon who attended his family had often seen it, while it was small, equal, and free from pain; and had as often pressed A TREATISE ON THE HYDROCELE. 161 him to part with it; but while it was easy, he would never think of it. It was now large, and unequally hard; it had, in some parts of it, a quantity of fluid, in others none; it was very painful to the touch; it gave him great uneasiness in his back, from its weight; and even while it was suspended, or he was in bed, he had such and so frequent darting pains in it, as to render him very unhappy, and to deprive him very much of his natural rest. The spermatic chord was perfectly free; but the frequency of his pain, and the disturbance of his sleep, gave him a very unhealthy appearance. I told him, that I thought he had missed the most favourable oppor- tunity, by not submitting to the operation while the testicle was small, smooth, and indolent; that some circumstances in his gene- ral state and habit were unfavourable; but still, as the spermatic process was free, and as there was no great probability that the testicle would ever again be easy, or cease to increase in size un- til the spermatics should become diseased also, I thought it was better to take the chance of the operation, than submit to that certain misery which must attend the further progress of the dis- ease. The patient consented; the operation was.performed; and every thing went on in the most favourable manner, till the sore was re- duced to the size of a sixpence; he was then seized with a pain in his belly, the sore changed its aspect, and from appearing to be almost healed, it fretted, became foul, spongy, and spread so con- siderably, that in a fortnight's time it was as broad as a hand; it bled frequently, gleeted largely, was extremely painful, and very offensive; nothing that was done had any good effect on it; and, having languished some months, he died. Some of the circumstances in this case were undoubtedly un- favourable; but I have seen people do very well under similar ones; and I still think, that the patient chose the lesser of the two evils, and embraced the more probable chance. VOL. II. \ 162 A TREATISE ON THE HYDROCELE. CASE XLVI. A poor man, who was in St. Bartholomew's hospital for a hurt in one of his legs, desired me to look at his scrotum, which was of a very large size. The tumor was principally formed by water in the tunica vagi- nalis testis; but, through the fluid, it was easy to distinguish a dis- eased testicle. He complained of uneasiness from the weight, and had, he said, now and then a pain shot up from the tes- ticle into his back; he had also, now and then, a colic, with nausea and inclination to vomit; and was very subject to a sort of strangury. I drew off near a wine quart of a yellow thin fluid, by means of a trocar; and when that was done, was so satis- fied that the testis was diseased, that I would have immediately removed it; but the man would not consent. He soon got well of his leg, and was discharged from the hospital. ' He was a bricklayer's labourer; and in about a fortnight or three weeks' time from his discharge, fell from a high scaffold, and was so much hurt that he died, after he had been again in the hospital two days; and I gladly embraced the opportunity of ex- amining his dead body. The tunica vaginalis was not only much distended, but considerably thickened. The testicle was a great deal too large and too hard; but, upon division, did not show any considerable mark of disease, except in its very centre, where there was a small quantity of discoloured sanies, and a putrid slough. The spermatic vessels were not at all altered from a na- tural state, except that the vein was varicose. Immediately below the emulgent vessels, on the right side, was an irregular tumor, near as big as the kidney itself, perfectly scirrhous, and firmly attached both to the renal blood-vessels, and to the aorta. The external part of this tumor was rough and unequal, and of a whit- ish colour; and in the centre of it were exactly the same appear- ances as within the testicle, viz. a small quantity of matter, and a slough. Where the ureter was crossed by this tumor, it was much com- pressed and straitened in its diameter; but below this stricture it A TREATISE ON THE HYDROCELE. 163 was considerably dilated. The kidney was not quite healthy in its appearance. Had this man been castrated, I make no doubt that his inter- nal scirrhus would have destroyed him; but that was a circum- stance not to be collected from his general slate, or from his com- plaints; and therefore not to be foreknown. The operation would therefore have been vindicable, though unsuccessful. CASE XLVII. A middle-aged man, was brought into St. Bartholomew's hos- pital for au accidental hurt of which he soon got well; and when he was going to be discharged, he desired Mr. Freke, whose pa- tient he had been, to look at one of his testicles. It was large, and unequally hard; gave him a great deal of pain at short inter- vals; and seemed to contain a quantity of fluid in its middle part: the spermatic chord was pretty free, just at its exit from the abdomen; but all between that point and the testicle was much diseased. Sgme of the gentlemen present expressed their apprehensions, that the state of the process was such, that the operation would most probably be unsuccessful, and therefore they were rather inclined that the man should be discharged without any attempt of that kind; but Mr. Freke thought otherwise, and performed it immediately. The vessels of the diseased process were varicous to a great degree, and very knotty and hard; the connecting mem- brane was much thickened; the epididymis and testicle quite confounded together; and in the body of the latter was a quantity of bloody sanies, contained in two or three large cells. The man got no rest after the operation, the vessels of the dartos bled through all the dressings more than once, and in a few hours he became very hot and restless, with a pulse quick and hard. The next day he bled again, not from the chord, but from the whole dartos; his scrotum became much swelled, and loaded with a lymphatic kind of tumefaction, but was very little inflamed; his pulse was inconceivably rapid, but small; he complained of acute pains in his back, a burning heat within it, an intolerable thirst, 164 A TREATISE ON THE HYDROCELE. and an anxiety that was more terrible to bear than all the rest; towards night (of the second day) his pulse faultered, he became easy, and his extremities cold; and early on the third morning he died. CASE XLVIII. A healthy man, under forty, came to me with a complaint in one of his testicles, the epididymis of which was much enlarged and hardened, while the body of the testis seemed to be in a natural state. His age, his general appearance, and the particular state of the part, induced me to believe it to be venereal; but, upon asking him a few questions, he asserted, that he had never received any taint of that kind in his life. He said, that the first time he had ever taken notice of this complaint, was about six weeks before, after riding hard in the day, and dancing all night; that it was very small at first, had increased gradually, and now began to be very troublesome to him, either in riding or walking; and that not only from its mere weight, but from frequent pain in it. I am obliged to acknowledge, that I was at this time so preju- diced by the general prevailing doctrine, that a true scirrhus or cancer never began in the epididymis, that I tHought, either that my patient was deceived himself, or had a mind to deceive me. I therefore gave him a mercurial pill to take every night, con- sisting of a small dose of calomel, with some kermes mineral, and directed a small portion of ung. mercur. to be rubbed every evening into the spermatic process. By pursuing this method for about ten days, his mouth became sore, and he was much displeased thereby. I gave him some gentle cathartics, but his spitting kept at above a pint a day, for more than a fortnight; at the end of which time, the hardness, as well as size and inequality of the epididymis and vas deferens were manifestly increased; and his uneasiness in these parts was greater. The death of a near relation now called him into the country, where he staid about a month. At his return he sent for me. The A TREATISE ON THf. HYDROCELE. 165 disease was increased, but still confined to the epididymis; which was now in that state, which f suppose constituted the caro adnata of the ancients: it was hard, craggy, painful, and in size nearly equal to the testicle itself; the darting pains were frequent; and the uneasiness from its weight was constant and tiresome. I was now satisfied of the true nature of the case, and let drop a hint of the propriety of removing the part; but having a very delicate and timorous man to deal with, I desired him to take the opinions of some other gentlemen. He saw Mr. Middlelon and Mr. Nourse as surgeons, and a third gentleman as a physician. The two former advised immediate castration; the last seemed to wish him to take the cicuta, or the solanum, medicines then in fashion. The thought of castration shocked him so much, that he willingly embraced any hints concerning specifics. He took the cicuta for more than two months, beginning vvith a small dose, and increasing it gradually to very large ones. It now and then made him a little sick and giddy; but the disease increased under it so manifestly, that 1 was .apprehensive that we were doing much worse than merely losing lime. I signified my suspicion, and pressed the operation; but he would not hear of it. The solanum was now tried under the direction of the doctor; but it disagreed so much, .even in the smallest quantity, that there was no possibility "of persisting in it. Upon this, as upon most occasions of this kind, every acquaint- ance recommended either a specific or a quack; most of which were tried, and I saw no more of my patient for above four months. He then sent for me again. The whole testicle and spermatic process, quite within the belly, were thoroughly diseased, hard, and knotty; his pain was acute, and almost constant; and his whole appearance truly pitiable. He was much displeased that I, who had often pressed him to submit to the operation, would not now perform it; but it was too late. In a few days after this visit, he applied to an operator, who required a very considerable fee before-hand, and laid the whole spermatic process open. A very terrible haemorrhage ensued, and he died the next day in inexpressible agony. 166 A TREATISE ON THE HYDROCELE. I visited a patient with Mr. Markland, whose first local com- plaint was a hardened, enlarged, epididymis, and vas deferens; and upon whom the whole power of mercury, and other supposed deobslruent medicines, together with cataplasm, fomentation, &c. were tried, during a long space of time, in absolute confinement, but to no good purpose; the part became so large, so diseased, and so painful, and the habit of the patient so much affected by it, that extirpation was absolutely necessary. When the part was removed, I examined it very carefully; and never saw a more true and perfect scirrhus in my life. The epididymis was thrice the size it ought to have been; its external surface was very unequal, and very hard; and in the centre of it was a putrid slough, with a small quantity of matter, jus; as it is found very often in the middle of a scirrhous and cancerous testicle. The testicle was hardly, if at all, altered from a natural state, except that the tuni- ca vaginalis was generally adherent to the albuginea. Its internal texture was soft, and bore very little mark of distemper. I have, at this instant, a lad in St. Bartholomew's hospital, both whose testicles are so truly diseased, that they must of necessity be removed. I have seen him from the first of the attack. The disease for several months occupied only the epididymis; and had no connexion with, or dependence on, any venereal mischief. Every thing that the art of surgery could do (or at least every thing that I am acquainted with in it) has been tried, but without any effect; and nothing but the operation can save him. CASE XLIX. Mu. William Sharp desired me to visit a patient with him. The case was a scirrhous testicle. It was large, and verv hard; but smoo h, equal, and no other vv-iy painful, than from its weight. There was nothing in the testicle which forbade the operation; on the contrary, it was in such state, as to promise very fair for suc- cess; but the spermatic process, from the testis quite up to, and apparently within, the opening in the abdominal tendon, was so large and full, that it was impossible to feel the vessels. This ful- ness, and increase of size, if it could be supposed to proceed from A TREATISE ON THE HYDROCELE. 1G"7 a diseased state of these vessels and their membranes, was such a bar to castration, that nobody could possibly think of it in such circumstances; but, on-the other hand, if it could be supposed to be owing lo an extravasated fluid, the withdrawing such fluid might make a very material alteration in the state of all the parts. Mr. Sharp said, that he had seen this patient some months before, and had let out (as he thought from the tunica vaginalis) a quan- tity of water; and that he then found the testicle a great deal too large; and was very sure that he then distinctly felt the spermatic vessels. Tlje tumid process, though large, full, and tight, yet was smooth and equal throughout; and I thought, that I could very plainly feel a fluctuation through the whole of it; that is, from the opening in the oblique muscle, tq the upper part of the testicle. The patient was young and healthy, the weight and size of the tes- ticle very troubelesome; and nothing but this state of the process in the case, to make it necessary to defer the operation a moment. A puncture was made vvith a large lancet into the tumor just above the testicle; near a pint of clear yellow serum was discharged; the swelling subsided; the spermatic vessels, which were in a sound, natural state, became easily distinguishable; the operation was immediately performed, and proved successful. CASE L. A i'Oor sailor, who had been discharged from one of the navy hospitals, applied to St. Bartholomew's. He had a scirrhous testicle, which was not large but was as hard as marble; very craggy and unequal, and attended vvith frequent acutepain; the process alsowasso large, that, upon such examination as I had then time to make, I told the man, that I did not conceive that he could receive any benefit, even from the operation; but one of the governors, prevailed on by the man's solicitation, desir- ed that he might be admitted. The first time we were all met together, I produced this man for the general opinion; which was, that if the increased size of the spermatic process was the effect of a diseased state of the parts composing it, the operation was improper, as it would only hasten 168 A TREATISE ON THE HYDROCELE. the man's death, and that in a very painful manner: but if it could be thought to be owing (as in the preceding case) to an extravasa- tion of fluid in the common membrane, it was certainly worth while to try what the discharge of that fluid might produce. The whole was related to the man; he was informed of our doubts, of what we intended to do, and of the probability that it might be of no service to him; a puncture was made in that part of the process where the fluid was most palpable; a large quantity of lymph was. discharged, the tumor subsided, the spermatic ves- sels became very distinguishable; the operation of castration was immediately performed, and the man went out from the hospital well. CASE LI. A poor man was taken into St. Bartholomew's hospital, for a complication of complaints; but particularly for a frequent and acute pain in his back and belly. When he had been there a day or two, he told the nurse that he had a complaint in his scrotum; and the next day I was desired to look at him. He had a diseased testicle of the scirrhous kind, which was not very large, but was hard and unequal; the spermatic process was not in a natural state, nor very much diseased; and he had a large and very troublesome omental hernia. The man had also a very morbid aspect; had his rest frequently disturbed by pain, and was near to fifty years old. He was very solicitous to have something done for him, and willing to submit to any thing for that purpose; but his case was such, as to render it not an easy matter to determine what to do. Flis rupture was large, and very troublesome; it was merely omental, and could not be kept up a moment, while he was in an erect posture, without a truss; a truss he could not wear to any good purpose, without the pad of it pressing on the spermatic chord, and aggravating a greater evil than his rupture; viz. his scirrhous testicle. The weight of his rupture, added to that of A TREATISE ON THE HYDROCELE. 169 his scirrhous, rendered it impossible for him to get his bread by labour. The only method whereby.he could be made capable of wear- ing a proper bandage for keeping up his rupture, or even of sus- pending it with ease, was, by submitting to have the scirrhous testicle removed by castration; and then, his rupture being return- ed, he might be enabled to wear a truss. But lo this there were some objections. In the first place, the hernial sac came so low, that the process could not be tied, or cut off, without the sac hav- ing been first either laid open, or dissected off from it. In the next place, I did not like the state of the spermatic process, which was both too large and too hard; and in the third place, I thought the general circumstances of .his morbid appearance, and bad state of health, were great objections to operations of such conse- quence, as either the laying open, or dissecting of the hernial sac from the spermatic process, or castration. All this was related to the man in the fairest manner possible; and he desired to have such, or any operation performed, which I should think right. Having been confined to his bed for more than a week previous to the operation, the omentum had hardly ever been down during that time, and was now perfectly up. This, though it might prove a circumstance in the man's favour, was none in mine as an operator; for the hernial sac being empty and flaccid, gave me thereby more trouble. The hernia was of the congenial'kind; ;uid, consequently, when I had divided the sac to the bottom, the state of the spermatic chord and testicle was manifest; and I had -nly to pass my needle and ligature round the upper part of the former, without paying any more or particular regard to the her- nial sac. Upon a nearer view of the state of the process, I liked it still less than I had done before; but there was nothing now could be done, but to go through with the operation, and to take the chance of it. I did so; the man bore it well, and was better for the first two or three days, than I could have expected. After the (\t:A week was past, I was daily surprised at the good state of my patient. He was easy, free from pain or fever, slept well, took nourishment; and it was impossible for any sore to be or to look better. vol. n t 170 A TREATISE ON THE HYDROCELE. At the end of three weeks, when he was to all appearance well. and his sore almost healed, he was suddenly seized with pain all over him, and died on the second or third day from this attack. I had him opened. The portion of omenium, which had form- ed the hernia, had an attachment to the peritoneum, just within the mouth of the hernial sac; which, I suppose, was the reason why it could not be kept up while he was erect. The lymphatic glands about the lumbral vertebrae were all diseased; the liver was scirrhous throughout, and had a large collection of matter in its lower part. AN ACCOUNT OF THE METHOD OF OBTAINING A PERFECT OR RADICAL CURE OF ^mis n¥®iB®©isiyss> BY MEANS OF A SETON. CURE OF HYDROCELE BY A SETON. An hydrocele is so irksome a disease to the indigent and la- borious, furnishes even the easy and opulent with such disagree- able ideas and apprehensions, and is to all who are afflicted vvith it so troublesome and inconvenient, that every rational attempt toward relieving mankind from such an evil, will, I make no doubt, be favourably received. It is now some years since I first began to make particular in- quiry into the nature of this and some other diseases of the testi- cle, and the usual methods of treating them: an inquiry, which they appeared to me for many reasons, both to deserve and require. The result I communicated to the public, under the tide of a A " Treatise on the Hydrocele, or Watery Rupture, and other Dis- " eases of the Testicle, its Coats, and Vessels;" in which I en- deavoured to be as precise and as explicit as I could. One part of this tract contains an examination of the various means, which, at different times, have either accidentally produc- ed a radical cure, or have been professedly proposed and practised for such purpose. Among other means used to obtain this end, I mentioned the seton; and spake of it as that which for many reasons, appeared to me to be preferable to all others; as a method which I had for some time practised vvith great success; and as that which, if no- thing should occur to induce me to change my opinion, I should continue to m.ake use of. Since that time I have had frequent opportunities of repeating the experiment; and it has so constantly and uniformly answered my expectation, that my opinion concerning it is determined; and I am convinced, that it is the most successfully efficacious of any. This might be urged, and would perhaps be admitted, as a good 174 RADICAL CURE OF THE HYDROCELE reason for laying my though is on the subject again before the p'lblu ; but I have others also to plead in vindication of the few following pages. In the first place, I think that I have considerably and materially improved the operation and process; and have rendered it less painful and more certain. In the second, I find, that what I said of it in the general trea- tise, has not been so clearly and perfectly understood as I could have wished, and in consequence either of brevity and obscurity on my part, or misunderstanding on the part of some of my readers, my true meaning has not been received; and I have been subjected to the frequent interruption of troublesome corre- spondences on the subject. And, in the third place, I might add, that some few gentlemen of consequence, who have by this means been cured, have re- quested this publication. A minute account of the nature and circumstances of the dis- ease, would be a mere repetition of what I have already said at large in the book referred to; would be therefore unnecessary, and beside my present purpose: a short and cursory one may perhaps throw just as much light on the subject, as may serve to render the description of the operation, and the treatment after it, more easily intelligible. The common bag in which both the testicles are included, is called the scrotum, and consists of epidermis, skin, and that loose cellular membrane, which is here called the dartos; to which might perhaps be added the expanded fibres of the cremaster muscle on each side. The proper coats of the testicle are, the tu- nica albuginea, and the tunica vaginalis. The former of these immediately invests the vascular compages of the testis, and is that coat vvith which it is covered while within the cavity of the abdomen, before birth. The latter is formed on the outside of the said cavity, is a process of the peritoneum, and is placed ready for the reception of the testicle when it shall be thrust forth through the groin into the scrotum. Between the vascular struc- ture of the testicle, and the tunica albuginea, there is no vacuity; but the external surface of the gland is in every part firmly adherent to, and connected vvith, the internal one of the investing coat: the tu- EV MEANS OF A SETON. 175' nica vaginalis forms a hollow cavity, or bag, which loosely and unconnectedly envelops the testicle, covered by its albuginea. When I say loosely and unconnectedly, I would wish to be un- derstood aright. I do not mean that the testicle hangs in the middle of the tunica vaginalis (like a clapper within a bell,) and has no connexion vvith it—I mean that all the superior, anterior, and lateral parts of the tunica vaginalis are loose from, and un- connected with, the testicle, which is at the same timo firmly united to its posterior part, in such manner, that if the cavity of the tunica vaginalis was to be distended vvith wind, such wind would occupy or fill all the loose and unconnected part, and pro- duce a tumefaction not unlike to a hydrocele, while the testicle would be found firmly and immoveably attached to the hinder part of the said cavity so distended. To prevent the accretion of these coats in those parts where they ought to be unconnected, and perhaps for some other pur- poses, the cavity of the tunica vaginalis is furnished with a fine lymph constantly exsuding into it; which lymph is as constantly absorbed by proper vessels; so that, in a healthy and natural state there never is any more of this fluid within the bag at a time, than may just serve (beside what other purpose it may be intended for) to keep the two membranes from coining into imme- diate dry contact and cohesion with each other. This small quantity is sufficient to preserve the proper and natural cavity of the tunic; but never occasions any degree of intumescence, or any unnatural or diseased appearance of the part. A deficiency, or total failure of the secretion of this fluid, will be followed by a partial or total coalescence of the two coats vvith each other; and consequently a total or partial abolition of the cavity. A superabundance^ or a secretion of more than the ab- sorbent vessels can take up, must, on the other hand, enlarge and distend the said cavity, by carrying all the loose unconnected part of the bag further and further from the testicle, in proportion to the quantity accumulated. The former, I do know to be some- times, and I verily believe most frequently is, the consequence of a severe hernia humoralis, as well as of other inflammations of the testicle. The latter, among other diseases, produces the hydro- drocele or watery rupture. 176 RADICAL CURE OF THE HYDROCELE. This being the case, that is, the intumescence of the scrotal bag being caused by the gradual accumulation of a fluid, which ought to have been absorbed, it is almost always produced gradually; and therefore has, in most instances, made some progress before it is taken notice of; especially by careless and inattentive people. For the same reason it will be found, that as it depends upon the cir- cumstances of secretion and absorption, it will, in different people, make quicker or slower progress, according as the deposition shall happen to be quicker or slower, and the absorbent faculty only more or less impaired, or totally obstructed. As this disease is confined to the cavity of the tunica vaginalis testis, and as this bag has no communication with the cavity of the belly, the tume- faction can never be lessened by any attempt toward reducing or returning it into the abdomen. For the same reason, it never is, nor can be liable to any alteration of size, or temporary distention, from the efforts or actions of coughing, sneezing, expulsion of fecces, &c. F^r !he same reason, (I mean the confinement of the fluid will.in the cavity of the tunica vaginalis,) the intumescence, when early attended to, will always be found in the lower part, and does not rise above the upper part of the testicle, until the disease has"made some progress, and the quantity is become con- siderable; therefore the spermatic process will always, in the early stage of this distemper, be capable of being felt perfectly and dis- tinctly; although when the tumor has arrived to any considerable degree of size, the fluid does so conceal the testicle, as to render it not a very easy matter to find it The three last circumstances, well attended to, will always serve to distinguish the hydrocele from the intestinal hernia or common rupture, at least in the be- ginning. To these might be added, several other characteristical marks of this distemper, such as: Th».t being neither accompanied by, nor occasioning any inflammation or irritation, it never gives pain, unless it be very rudely handled, or be permitted to attain such size as to he troublesome from its weight, or to be subject to cxcoiiation from its magnitude; which may serve to distinguish it from the hernia humoralis, an inflammatory and often a very pain- ful disorder. That if the fluid be thin and limpid, and the va- ginal coat and munbrancs of the scrotum not thick, the tumor is often in some degree transparent; that is, the light of a candle or BY MEANS OF A SETON. 177 lamp may be seen through it. That constipation of the belly does not render it at all more tense, or produce any uneasiness in it while it lasts; neither does the removal of such obstruction or con- stipation at all lessen its volume, or make any alteration in it, either to the eye or to the finger. To all which ought always to be added, the fluctuation of the fluid. The size and figure of the tumor, caused by this disease, are liable to considerable variety, dependent upon the quantity and consistence of the fluid accumulated; the time such accumulation may have taken up; the thickness or thinness of the vaginal bag and membranes of the scrotum; and the equal or unequal manner in which these parts may have given way to the distention. Hence the tumor will be larger or smaller, round, flattish, pyriform, or globular; will be firm, tense, and resistent, or lax, soft, and easily compressible; smooth and regular in its surface, making one uni- form figure, or divided by a kind of depression or stricture, which will make it appear as if the water was in two distinct sacculi or bags; it will also be more or less tense, as well as regular in its surface, as the contractile power of the scrotum, by means of the cremaster muscles, shall be more or less. The qualities of consistence and colour in the contained fluid is also various: it is thin, aqueous, ropy, viscid, limpid, citrine, greeuish, brown, bloody, clear, or turbid; from each of which some small differences in the aspect, feel, weight, transparency, or obscurity of the tumor will arise; but are of no consequence with regard to any method of treatment, palliative or radical. The methods of cure of a hydrocele are said to be two, one called the palliative, the other the radical; the latter of which alone deserves the name of cure. The former consists merely in letting out the water occasionally, and is so simple and so trifling an operation, that I shall say no- thing more of it, than that I think a small trocar a much prefer- able instrument for this purpose, on all accounts, to the lancet, or any other. The radical cures, as they are called, may be collected from the writings of several of our predecessors. The general means they made use of were cautery, caustic, ligature, and tent. For the particulars relative to each of these, I must beg leave to refer vol. n. z 178 RADICAL CURE OF THE HYDROCELE my reader to the writers themselves, a minute detail of them not being consistent vvith the plan of these few sheets. But without entering into such disquisition, I believe I may venture to say, that whoever will give himself this trouble, will find, that ail the means which were either professedly used to obtain a radical cure, or which ultimately and accidentally produced such event, were put in practice for three general reasons, or under the influence of three general opinions; the first of which was, that the fluid found in the sac of a hydrocele was always originally formed in the cavity of the belly, and descended from thence into the scrotum; the second, that it was a disease of the habit, as well as of the partieular.part, that is, that it was general, as well as local; the third, that the collection of liquor found in it was either the neces- sary cause, or the consequence of a diseased state of the testis. From these flow the applications of cautery and caustics to the groin, and of ligatures on the spermatic process. From these are derived all the cautions to undertake the cure guardedly, to con- duct it slowly, and to attend rigidly to the patient's general state by cathartics, alteratives, specifics, issues, &c. &c. &c; and to these we owe the experiments made to induce suppuration from the parts affected. Not being acquainted with the anatomical structure and dispo- sition of the parts concerned in the disease, they had very terrible as well as very erroneous notions concerning it. They supposed that the fluid contained in the cyst was thrown off from the habit as a kind of crisis; that the general constitution of the patient was, by such deposition, much relieved; that it prevented many other and those worse disorders; and, either that a morbid state of the testicle and epididymis concurred in producing the fluid, or that the same parts necessarily became diseased from lying in it. They therefore concluded, that although a radical or perfect cure might be obtained by certain means, or that certain means having been found now and then to have produced such event, they might with probability be expected to answer such purpose, yet the attempt ought never to be made without a strict attention to the general evils which might ensue, as well as to the particular ones proceeding from the supposed morbid state of the parts. BY MEANS OF A SETON. 179 Inquiry and experiment have taught us better; have given us truer notions of the nature of the complaint; have induced us to- tally to lay aside many of the means used by our forefathers; and although we do still in some sort continue some of them, yet it is upon different principles, and with very different views. The noxious quality of the fluid; the diseased state of the parts whence it proceeds, or wherein it is deposited; the critical, or depuratory nature of the deposition; the necessity of drawing off the water partially, and at short intervals; and the fear of curing it locally, lest the general habit should suffer, are all now known to be groundless apprehensions: and it being also known, that the collection of fluid is originally made in the tunica vaginalis only, and that it does not descend from the belly, all attempts towards preventing such descent are become equally absurd. The testicle, although frequently somewhat enlarged in its di- mensions, and relaxed in its texture, is known to be sound, to be otherwise unaffected and unaltered, and to be fit for, and capable of performing the functions it was designed to execute; the fluid is acknowledged to be innoxious in its nature, neither proceeding from parts in a diseased state, nor causing any disease in the parts in which it is deposited, and vvith which it is in contact; but being accumulated in consequence of constant secretion, and deficient or non-executed absorption, the intention of every rational prac- titioner, when he aims at a radical cure, is, to abolish the cavity of the tunica vaginalis, and thereby to prevent any future collec- tion. Whatever means can accomplish this end with the least fatigue, pain, or hazard, are certainly the best. Of the incision, I shall in this place say nothing, except that it lies under so many restraints from a variety of circumstances, is so improper for the majority of persons afflicted with the disease, and requires such nice attention, and such judicious management, that it never can be recommended as fit for general practice. The caustic, upon the rational principle of which I am now speaking, viz. that of abolishing the cavity of the tunica vaginalis, has been practised by many, and that with such success, as to induce some to think it the best and most eligible method. Among ISO RADICAL CURE OF THE HYDROCELE these is Mr. Else, who has lately published his opinion on the subject. The introduction of suppurative medicines, by means of a tent, was practised by some of even our remote predecessors; and, as they tell us, with success, even in complicated cases; that is, in cases where a diseased state of the testicle has been added to the hydrocele. But whoever will attentively consider their accounts of this matter, will see, that this method, whatever might be its accidental consequence, was not intended for the purpose which I am now speaking of. Perhaps there is no part of surgery which was less understood by our ancestors, or concerning which they expressed themselves with so little precision, as the subject of diseases of the testicle: they have multiplied and confounded them in such manner, and speak of them in such a jargon of unintelligible terms, that it is next to impossible to understand often what they really mean. For a particular elucidation of this subject, the cbirurgic world are much obliged to the late professor Munro of Edinburgh, and Mr. Samuel Sharp, late of Guy's Hospital, now of Bath. The accounts which many of the best among the writers in surgery, even quite into our own time, have given of the diseases of these parts under the terms sarcocele, fungus attached to the spermatic vessels, fungus arising from the testis, hydrocele, and hydro-sarcocele, are error itself; and the operations which they describe and recommend are many of them coarse, and either impracticable or very unfit for practice. Btit, however, from these accounts, strange and irrational as they are, we may collect that they conceived the diseases which they call the hydro-sarcocele, and the caro adnata ad vasa spermatica, to be (in contra-distinc- tion from the sarcocele, and the fungus springing from the testicle) curable diseases, the one by extirpation of the fungus, the other by suppuration. No precise definition of what they have thought proper to call the hydro-sarcocele has been given by them, and therefore we have no better method of forming a judgment concerning it, than by considering the event and success of their method of treating what they have so called, with what we know concerning the structure of the testicle, its disorders, the means which we now find to be BY MEANS OF A SETON. 181 successful in them, and the disappointments and disagreeable cir- cumstances which sometimes occur in them. Fabritius ab Aquapendente has been particular on what he calls the hydro-sarcocele, and has given an account of his method of curing it; but whoever is acquainted with diseases of the testicle, and will compare with such knowledge what Fabritius has said concerning his method and its success,* will, I am inclined to believe, think on this subject as I do; that the disease which he gave this hard complex name to, is nothing more than true, simple hydrocele, in which the testis is somewhat enlarged beyond its natural size, and perhaps somewhat relaxed in its texture, in con- sequence of such enlargement; but still sound, and free from disease; still fit for, and capable of, executing its office. That by his method he obtained a radical cure I make no doubt: his ' turunda digestivo et pus movente medicamento imbuta,1 would most probably occasion a sloughing of the tunica vaginalis, and consequently an abolition of the bag or cavity. But whoever knows any thing of these matters, must know, that a testicle really and.truly diseased would not bear such treatment; and therefore, that his success was owing to the state of the testicle not being what he supposed it to be, and what the term he makes use of implies. The method of Fabritius was within a few years past adopted and practised by Ruysch.b The means and conduct were nearly the same, and I have no doubt that the success was equal. But the same objection still " " Si carnosa simul et aquosa sit hernia, ego talem adhibeo curam. Seco " cutem et incisionem facio et exiguam, et in loco potius ultiori quam in " fundo, inde turunda imposita, cum digestivo et pus movente medicamento " procedo, neque unquam totum pus extraho, sed perpetuo bonam partem " intu9 relinquo, quod sensim carnem corrodat et ita sanat." FAB. IB Aq.UAPEWDEHTE. b " Sanara quidem valet id mali pertuso scroto ope instrumenti trochert " dicti, vel lanceola phlebotomies, ut aqua vulnere exeat, sed cito plerumquc " recrudescit malum. " Si autem curationem aggrederis aperiendo scrotum a parte superiori, ad " latus, tumque vulnus turunda oblonga, unguento rosaceo mercurio praeci- " pitato rubro inuncto oppleveris, donee lenis inflammatio, eique succedena " suppuratio parva, membranules stillantes putrescent, tuncque eas tenaculo, " eduxeris," &c. Fcysch 182 RADICAL CURE OF THE HYDROCELE remained; which was, that not only a suppuration was brought on, but the whole tunica vaginalis was so irritated and inflamed, that it necessarily became sloughy, and was entirely destroyed; an objection which had been made to the method by caustic; and which, I must acknowledge, is, in my opinion, an objection to it still. The late professor Monro, whose observations on the diseases of the testicle are very pertinent and very ingenious, seemed to think that it was by no means impracticable, by means of a slight degree of irritation, to excite such an inflammation both in the tunica vaginalis and albuginea, as might occasion a coalescence of them with each other, and thereby answer the end of abolish- ing the cavity, without destroying any part of either tunic. I made the experiment proposed by him, and found it some- times successful; never hazardous or prejudicial, but by no means certainly efficacious, or to be depended upon. The cannula, by its hardness and resistance, was a very unpleasant guest within the vaginal coat; and from its inflexibility, upon any unguarded motion of the patient, injured the testicle, and gave very acuto pain; and the tent and bougie, which I occasionally substituted in its place, although they did not give so much pain, were liable to a considerable degree of uncertainty. Uncertainty and hazard are certainly very different things, and the latter much preferable to the former: not to have injured a man by an experiment, affords some degree of consolation under a disappointment; but yet, when it is considered, that an opera- tion and process of this kind are submitted to from choice, and not from necessity, if it fails of success, although no real harm be done either to the part, or to the constitution of the patient, both the loss of time and the confinement will become doubly irksome, as they will be found not only not to have answered the end proposed, but not to have brought the patient at all nearer to a cure than he was before the attempts. The reflection is unpleasant to both parties. Being, from the effects both of the cannula and tent, satisfied that there was no kind of hazard in the introduction of a foreign body into the cavity of the tunica vaginalis, nor from its remain- BY MEANS OF A SETON. 13J ing there; and having many opportunities of meeting with this disease in St. Bartholomew's, 1 determined to try what a seton would do toward raising such a degree of inflammation as might occasion a coalition of the two membranes, and effect the purpose proposed by professor Monro.0 The success fully answered my expectation. # In my general treatise on the diseases of the testicle, I mention- ed and recommended it; but as I could not be certain what a greater length of time might produce to make me change my opi- nion, I mentioned it with some degree of caution. Since that time I have embraced every opportunity, both in the hospital and out, of practising it, and that under some improve- ments; and as I can now speak positively to its success, I thoight" it right to give it to the public, who are always intituled to every benefit arising from the labours of every man whom they have ho- noured with any degree of confidence; and this as well on a prin- ciple of humanity as of gratitude. What I have said of it in the general treatise is in the follow- ing words, " The point to be aimed at is, to excite such a "• degree of inflammation, both in the tunica vaginalis and tunica " albuginea, as shall occasion a general and perfect cohesion "between them; and this, if possible, without the production of " slough or abscess; without the hazard of gangrene; and without " that degree of symptomatic fever which how and then attend c His words are, " Considering how readily contiguous inflamed parts " grow together, and how many instances there are of people having a radi- " cal cure made of this hydrocele by inflammations coming on the part, it " would seem no unreasonable practice to endeavour a concretion of the two " coats of the testicle when they are brought contiguous, after letting out '• the water through the cannula of a trocar, by artfully raising a sufficient " degree of inflammation. " This to be sure must be done cautiously, and so that the surgeon can " reasonably expect to be master of the inflammation; and therefore the ap- " plication of all irritating medicines, the operation of which he could not " immediately stop, or any single mechanical effort, the effect of which he " could not be sure of, are not to be employed. " Suppose the cannula of the trocar was to be lefi, by the extremitv of it " rubbing against the testicle, an inflammation might be artfully raised, the .'' cause of which might be taken away as soon as the surgeon thought tit." Medical Essay-.. 184 RADICAL CURE OF THE HYDROCELE " both the caustic and the incision; and which, when they do hap- " pen, are so alarming both to patient and surgeon. " These ends I have frequently obtained by the use of a seton. " It is a method of cure mentioned by Aquapendens from Guido, " and others before him, though their process was somewhat dif- " ferent fr*m mine. I have several times tried it on subjects of very " different ages, some of them more than fifty years old. It re- " quires confinement to bed only for a few days, after which the " patient may lie upon a couch to the end of the attendance, " which is generally finished in about three weeks or a month at " furthest, and during all that time no other process or regi- " men is necessary, than what an inflammation of the same part " from any other cause, (for example a hernia humoralis) would " require. "The manner of performing it is as follows: Choose a time " when the vaginal coat is moderately distended, and having " pierced it with a trocar of tolerable size, draw off the water; " when that is done, introduce into the cannula a probe armed " with a seton consisting of ten or twelve strings of candle-wick " cotton; pass the probe as high to the upper part of the vaginal " coat as you can, and on the end of that probe make an incision " of such size as to enable you to pull it out easily, together with " a part of its annexed seton; then cut off the probe, and tie the " cotton very loosely, covering the orifices with pledgets. By the " next day the seton will be found to have contracted such an " adhesion to the tunica albuginea as would cause a great deal of " pain to detach; but this it is perfectly unnecessary to do, and it " should be suffered to remain without molestation. In about " forty-eight hours the scrotum and testicle begin to swell and " inflame; the patient should then lose some blood, and have a "'■ stool or two, and the whole tumefied part should be wrapped " in" a soft poultice, and suspended in a bag-truss. The disease " from this time bears the appearance of a large hernia humora- " lis, and must be treated in the same manner, by fomentation, " cataplasm, &c. " The adhesion of the seton to the albuginea generally continues " firm, and I never meddle with, or move it, till it becomes perfectly BY MEANS OF A SETON. 185 " loose, which it seldom does for the first fortnight, or until the " inflammation is going, and the tumor subsiding. By the time " the seton becomes loose, the coalition of parts is universally " and firmly accomplished: I then withdraw it, and heal the ori- u fices with a superficial pledget, &c." This method was, as I said, in general very successful; but re- peated trials furnished me with objections to some parts of it, and induced me to think that such parts might be amended. I found that cutting upon the end of the probe was troublesome, both from its smallness and from its flexibility, and also that it was sometimes difficult to keep it steady for the same reasons, and that it always required the assistance of another person's hand besides that of the operator—a circumstance one would al- ways wish to avoid, when possible. I found also, sometimes, that the seton of a candle-wick cotton did not pass so easily as I could wish, and by rubbing the tunica albuginea too rudely, gave more pain than I liked. The seton, as made of cotton, adhered, in some instances, too long and too firmly. From the intimate con- nexion of the parts of the wet cotton with each other, it could never be brought away but entire; which in some cases occasion- ed an unnecessary waste of time^ and, what was still worse, in two instances it adhered so firmly, that I was obliged to make a small incision to get it away at all. All these inconveniences and objections I have now obviated and removed. The instruments I now make use of are in the annexed plate, and are— A trocar, the diameter of whose cannula is very nearly, but not quite, one fourth of an inch; another cannula, which I call the seton- cannula, which is made of silver, and is of such diameter as just easily to pass through the cannula of the trocar, its length five inches; and a probe of six inches one half long, having at one ex- tremity a fine steel trocar-point, and at the other an eye which carries the seton; which seton consists of just so much strong, coarse, white sewing-silk as will without difficulty pass through the latter cannula, but at the same time will fill it. With the trocar, the inferior and anterior part of the tumor is f to be pierced, as in common palliative tapping. As soon as the vol. n. a a 186 RADICAL CURE OF THE HYDROCELE water is discharged, and the perforator withdrawn, the seton-can- nula is to be passed through that of the trocar, until it reaches the upper part of the tunica vaginalis, and is to be felt in the very up- per partof the scrotum. This done, the probe, armed with its seton, is to be conveyed through the latter cannula, the vaginal coat and integuments to be pierced by its point, and the seton to be drawn through the cannula, until a sufficient quantity is brought out by the upper orifice. The two cannulae are then to be withdrawn, and the operation is finished. It is executed in two or three seconds of time, and with little more pain than is fell in common tapping. By this method, every advantage which attended the former operation is obtained, and every inconvenience which it was li- able to is obviated and provided against. The seton-cannula, by its firmness, bears tight against the place where the seton should be brought out; the trocar-point of the probe is kept from deviating by its confinement, and its point pierces through the skin immediately and exactly in the place in- tended; while the seton, by passing through the cannula, is pre- vented from rubbing rudely over the testicle. As soon as the operation is finished, I put the patient into bed, and immediately give him twenty or twenty-five drops of tinctura thebaica, which 1 repeat or not, pro re nata. About the third day the testicle and scrotum begin to inflame and swell, and to put on the appearance of a hernia humoralis, or the swelled testicle which now and then attends a gonorrhoea, and re- quires the same, and no other kind of treatment; that is, fomen- tation, poultice, a suspensory bag, a cool, temperate regimen, and ah open belly. By these means the inflammation is soon and easily appeased. As soon as this end is accomplished, I permit the patient to get ou of bed, and lie on a couch, or sit in a great chair, with his legs up; and I generally give the cortex, in some form or other, twice or thrice a day. The soreness and tumefaction now diminish apace; and as soon as the pai\s are quilc easy, which is generally about the tenth or twelfth, day, I begin to withdraw the seton, taking out four, five, six, or seven threads of it at each dressing; which dressing con- BY MEANS OF A SETON. 187 sists of nothing more than a superficial pledget upon each of the orifices while they continue open, and a discutient cerate (such as the ceratum saturnin.) to cover the scrotum. The discharge of matter from the orifices is small and trifling, no more than might be expected; the tunica vaginalis does not be- come sloughy, but is preserved entire; and the cure is ac- complished merely by the coalescence or cohesion of the tunica va- ginalis with the tunica albuginea—an event, which, from what has fallen within my observation, I am inclined to believe is most frequently the consequence of a severe hernia humoralis. In this circumstance, viz. the accomplishment of the cure, by ad- hesion of the two coats together, without any destruction of parts, consists the material difference between the method of cure by seton, and that by caustic. All the practitioners who make use of the latter allow, that it produces a slough of the whole tunica vaginalis; that it destroys the whole bag or cyst; and that it is used with intention so to do. In the cure by seton no slough is produced, (at least I have ne- ver seen one,) nor is the vaginal coat destroyed in any part of it; a firm cohesion is made between the two membranes, occasioned by the inflammation; and the cure is effected solely thereby. I shall always most gladly embrace any opportunity to improve so noble and so really useful an art as surgery; but, at the same time, should be very sorry to have it supposed, that any partiality to my own opinion would make me misrepresent, or deviate from truth. Since this pamphlet first appeared, Mr. Else has published a second edition of his account of the cure by caustic. In this he has recited two attempts by the seton, which were under the conduct of Mr. Martin, in St. Thomas's hospital. I make no doubt that the circumstances were as Mr. Else has related them; but I must take the liberty of saying, that although I have practised the method of cure by seton on a very consider- able number of people, both in the hospital of St. Be riholomew, and out of it, of all ages and in all circumstances, I have never yet met with that trouble, or those disagreeable symptoms, which Mr. Else has related as happening to Mr. Martin's two patients: 188 RADICAL CURE OF THE HYDROCELE, &C on the contrary, I am, from very frequently repeated experience, convinced, that the cure by the seton is by much the least ha- zardous, painful, or fatiguing, as well as the most expeditious and certain of any yet proposed.*1 d Although I am as much a friend to simplicity in chirurgic operations as any man can be, and think that whatever can be well done by means of one instrument, is most frequently better done than by means of several, yet, in this instance, I cannot help thinking otherwise. The intent of the seton-cannula is to defend the tunica albuginea testis from the rude passage of the silk over it. From the pain and other disagree- able circumstances which I have seen attend the omission of it, I must again recommend its use, though'it does add to the instrumental apparatus. From frequent and repeated experience, I must also advise the using a skein of white silk instead of ribband or tape. Whatever is used will necessarily contract some degree of adhesion to the testicle during its inflamed state ; and this adhesion will unavoidably create some little trouble and uneasiness whenever the seton is withdrawn j but this pain and trouble will necessarily be least when the seton is composed of such materials as are capable of being taken away at different times, instead of all at once. When a seton of any kind is used for the purpose of making, or of continu- ing, a drain of matter, it is right to move it daily, and frequently to shift it; but in this case, as the intention is different, so should our conduct be. The intention is merely, by the residence of the seton, to excite such a slight de- gree of inflammation as shall occasion an adhesion of the tunica albuginea tes- tis to the tunica vaginalis, and not a suppuration : the moving it daily, or even at all, until the proper time of taking it quite away, can do no good, and must, by exciting unnecessary pain, do harm. 1 therefore must repeat my advice, to let it remain unmoved for a week or ten days, at the end of which time it will have accomplished its end, and then had better be removed than not. Suppuration is not only not intended, but should, as much as it may be in our power, be guarded against. RADICAL CURE OF "siem MswmmwLMz BY MEANS OF AN INJECTION. BY THE EDITOR. CUIIE OF HYDROCELE BY INJECTION. The inconveniences attending the usual methods of treating the hydrocele are well known to those who are engaged in the practice of surgery. The disease itself is attended with little pain and no danger: many of the remedies now in use for it are pro- ductive of considerable pain, and are not totally destitute of hazard. The proper object of all operations for the radical cure of the hydrocele, is to produce such an adhesion of the distended vaginal coat qf the testis vvith the gland, or such a consolidation of the conti- guous parts, as shall annihilate the cavity in which the water con- stituting this disease is contained. We know that this effect may be produced by a certain degree of inflammation, and are unac- quainted with any other process, either natural or artificial, by which it can be brought about. Before the method by the seton was recommended by our author, the necessary inflammation was excited by dividing the scrotum and the vaginal coat, or by de- stroying a part of them by the knife or caustic. Mr. Pott took no small pains to mitigate the severity of this operation, and to raise inflammation in a more simple manner, by the introduction of a foreign body, without destruction of parts. With this view he preferred the seton. This he soon discovered to be productive of more inflammation than was necessary; and, after a series of trials, he suggested many very ingenious directions for performing and conducting this operation, in such a manner as to produce the least possible irritation. We must allow that he carried the process he recommends to a great degree of perfection; and if the operation be performed without deviating from the direc- tions he has laid down, I am convinced it will be found preferable 192 RADICAL CURE OF THE HYDROCELE to any of the methods which have been usually practised in this country; yet it must be observed, that even this remedy goes beyond the proper intention, as the seton not only excites adhesive inflammation, but is necessarily attended with some degree of sup- puration, at least in the track of it, before it can be removed: add to this, an objection of much more practical consequence, that even in its present state the inflammation produced by the seton some- times runs much higher than is intended, and demands the atten- tive administration of antiphlogistic remedies. The late Mr Else's method, by the application of a small caus- tic, has the same inconveniences, and is liable to a much greater objection; as it is not only attended vvith more inflammation than is necessary, but also unnecessarily causes a painful, offensive sore, producing a slough of part, if not the -whole, of the tunica vagi- nalis testis. The human frame is liable to few diseases which have more frequently exercised the ingenuity of practitioners, to find an easy and effectual cure for them, than this. Among the various me- thods which have be^n proposed, an external discuticnt has of late been strongly recommended. It would certainly be a most de- sirable plan, to get rid of the disease without any operation; but we know too well how confined our powers are in dispersing col- lections of fluids within sacculi mucosi, and some kinds of en- cysted tumors, whose integuments are comparatively thin, and, therefore, must conceive that much greater power would be re- quisite to act through the scrotum and thickened tunica vaginalis, so as to produce absorption of the fluid and cohesion of the tunics. Hydroceles have been accidentally dispersed by various means, particularly by a blow, by a fever, and by sickness at sea. I do not entertain the smallest doubt, that the above remedy, which has been proposed by an ingenious and able practitioner, has pro- duced the same effect; but I cannot help doubting its capability of frequently producing it, having myself tried it, and known it tried by others, several times, without success. The proportional merit, However, of different remedies, can never be exactly determined: few men have opportunities of see- ing a variety of remedies repeatedly tried, and perhaps still fewer possess a sufficient share of candour, to weigh the merits and defects BY MEANS OF AN INJECTION. 193 of each in an equal balance; consequently medical practice is never settled in any case till it be nearly perfect, or at least till some one proposed remedy bears no comparison, in point of ex- cellence, with the rest. Thus, in regard to the treatment of the hydrocele, though the methods of Mr. Pott and Mr. Else are cer- tainly great improvements; yet, as some objections may be made to them, there are at this time surgeons, who have returned to the old painful practice of incision, and cutting away a part of the scrotum and vaginal coat. In this unsettled state of practice it will not, I hope, be thought improper to subjoin some observations of my own, on this subject, to those of Mr. Pott; which, however, I should not take the liberty of intruding into this work, had not Mr. Pott himself so far ap- proved of the method which I am going to recommend, as to de- clare to me, not long before his death, his intention of giving it a fair trial. It is well known that our forefathers made use of injections for the cure of hydroceles, and this method is now not out of practice on the continent; but it is wonderful that a remedy, which may be made to answer the intention of exciting inflammation to any de- gree, and is attended with no inconvenience, present or future, should have fallen almost into total disuse in this country: some of the later English writers on the hydrocele do not mention it; and if it be noticed by others, it is only to show their disappro- bation of it. Injections introduced within the tunica vaginalis testis, into the urethra, or into any cavity of the body, natural or formed by dis- ease, are certainly capable of doing mischief; but the mischief must arise from the nature of the injection: if it be violent and ir- ritating, it may produce too great inflammation. It is very probable that the caustic, and highly stimulating ingredients, which have been sometimes most injudiciously injected, and confined an un- reasonable and an unnecessary length of time, have done harm, and have been the cause of bringing injections in general, and for the cure of the hydrocle in particular, into discredit; but it is ex- tremely absurd to infer, from such instances, that all kinds of in- jection must hi- pernicious; in the use of them wc are not limited VOL. II. b b 194 RADICAL CURE OF THE HYDROCELE to any degree of stimulus. Injections may be found so bland, as not to offend the most sensible membrane or surface in the human body; on the other hand, they may be prepared so corrosive as to inflame, and even to dissolve the most indolent parts; and they be made to produce any intermediate effect. There is no kind of stimulus which admits of such various modifications. Another great advantage of injections is, that they apply them- selves equally and universally over the whole cavity into which they are thrown, which no solid body can do. As 1 had frequently succeeded in procuring an adhesion and consolidation of parts in sinuses and other large cavities, by injec- tions of variotre kinds, without causing great inflammation, and had by those means avoided the necessity of extensive divisions of the skin and integuments, which should be avoided as much as possible in every part, I conceived that the cure of hydroceles might be effected by the same gentle means, wilhout deranging, more than is necessary, the economy of those tender and sensible organs which are the seat of the disease, and I determined to make the experiment. The injection I employed for this purpose is wine, which I made choice of for several reasons: it had been used with success in France; the strength of it is never so great as to render it an un- safe remedy, and it may be readily lowered, according to the different sensibility of the parts. Thus a vinous injection ap- peared capable of producing all the good effects which could be desired, with scarce a possibility of doing harm. The success which has attended it has more than answered my expectation; and, from every trial I have made, I have no reason to wish for a different one: the pain which is produced by it is incomparably less than by any other operation: it does nothing more than is in- tended, and the curative effect is equally certain. In my last edition of these works I inserted a circumstantial account of my method of using the injection, which was then in its infancy, and of which I then had doubts; but I have since experienced such success, that I thought proper to publish a se- UJY MEANS OF AN INJECTION. 19i» parate account of it, which has been repeated in several editions, and is now so well known and so universally practised in all parts of the world, that I think it unnecessary to swell this work with a repetition of it—I must therefore beg leave to refer whoever wishes to be further informed of the cure of the hydrocele by in jection, to my treatise on that subject. A TREATISE ON THE FISTULA IN ANO. PREFACE It has been said, that when a man thinks that he can, by pub- lishing his opinion, derive any benefit to his fellow-creatures, he has no reason to be anxious about making an apology for such publication. This, within a certain limitation, is true; but, taken in its full extent, may be urged as an excuse for obtruding that on the world which may not be worth its acceptance. Possibly the following sheets may be thought to come within that predicament. The only defence I have to make for them is, that from the most diligent and most frequent inquiry into the general method of treating the disease in question, I am convinced, that such me- thod may be considerably improved; that is, may be rendered less painful, more expeditious, and more successful. I should be very sorry to have it thought, that I meant, by this, to signify, that my opinion on this subject is different from that of all my brethren: I know it is not; I know that there are some gentlemen of the profession who think of it as I do; but I also know, that a very different doctrine is inculcated, and a very dif- ferent method followed, by the majority of writers, practitioners, and teachers. The number of those who have had frequent opportunities of seeing this kind of disease, is not large, compared to that of those who are dailv liable to be called to the care of it: the number of 200 PREFACE. those who reflect on what they see or read, and who take the li- berty of thinking for themselves, is still smaller; so that the pre- cepts delivered by such as have obtained any degree of reputa- tion, do almost necessarily become rules of practice to the mul- titude. I have, on this occasion, carefully perused almost every writer of character on the subject; and think, that I may venture to say, that they are all either defective or erroneous: they either pass the disease over slightly, and without that regard which it cer- tainly requires and deserves, or subject it to a method of cure, which is operose, painful, tedious, and unnecessarily productive of future evil. The term Cutting for a Fistula, conveys to a patient a terrible idea; and this terror is not a little increased by his incapacity of seeing the part diseased. The majority of writers have greatly increased, rather than lessened this dread; and as the operation is (under their directions) sometimes performed, it is, indeed, a very severe one. A great part of this severity appears to me to be unnecessary; and I cannot help thinking, that a more serious reflexion on the parts concerned in the disease, and on its differ- ent nature, in different states and circumstances, would lead us lo a more rational method of treating it, and to a more easy and ex- peditious cure. To point such method out is the intention of the following Tract. In the execution of it, I have sometimes found myself under a necessity of controverting the opinion of some gentlemen of de- served eminence: if I have done this with decency and good man- ners, no apology is necessary. The honour of our art, and the moral characters of its professors suffer, whenever we pay so blind deference to any one, as prevents us from using our own judg- ments, and from declaring freely the results of our inquiries or PREFACE 2U1 experiments. Truth, as Lord Bacon has said, is not the child of authority, but of time. And were we to allow ourselves to sup- pose (let the subject be what it may, provided it be liable to ex- periment) that nothing more or new could be taught, it is pretty clear, that nothing more or new would be learned. I therefore hope, that the freedom which I have used, either in relating the opinions, or in objecting to the practice of others, will not be attributed to an invidious disposition to find fault; but merely to a desire of being serviceable to mankind in that way, in which, I flatter myself, that I may be in some degree ca- pable; and of improving, as much as in me lies, the very neces- sary and universally useful Science of Surgery. vol. II. r. r / FISTULA IN ANO. SECT. I. Clear and precise definitions of diseases, and the application of such names to them as are expressive of their true and real na- ture, are of more consequence than they are generally imagined to be: untrue or imperfect ones occasion false ideas; and false ideas are generally followed by erroneous practice. It would be no difficult matter to produce instances of disorders, whose treatment has, for a great length of time, been accommo- dated more to the titles imposed upon them, than to their true and real character: among these my present subject is a most glar- ing proof. The custom of giving the appellation of Fistula to every impos thumation, and to every collection of matter formed near to the anus, has, by conveying a false notion of them, been productive of such methods of treating them, as (though, perhaps, suited to such idea) are diametrically opposite to those which ought to be pursued: such as have often rendered those cases tedious and pain- ful, which might have been cured easily and expeditiously; and consequently such as have brought disgrace on our art, and unne- cessary trouble on mankind. A small orifice or outlet from a large or deep cavity, discharg- ing a thin gleet or sanies, made a considerable part of the idea, which our ancestors had of a fistulous sore, wherever seated. With the term fistulous, they always connected a notion of callosity; ;ind therefore, whenever they found such a kind of opening yield- ing such sort of discharge, and attended with any degree of indu- ration, they called the complaint a Fistula. Imagining this calosi- fy to be a diseased alteration made in the very structure of the 204 A treatise on the parts, they had no conception that it could be cured by any means, but by removal with a cutting instrument, or by destruction with escharotics; and therefore they immediately attacked it vvith knife or caustic, in order to accomplish one of these ends; and very terrible work, by their own accounts, they often made before they did accomplish it. Several of the above mentioned circumstances do frequently attend collections of matter near to the rectum; and therefore, for want of proper attention to the true nature of the case, the custom of calling them all Fistulae has generally prevailed, though without any foundation in truth or nature. That abscesses, formed near the fundament, do sometimes, from bad habits, from extreme neglect, or from gross mistreatment, become fistulous, is certain; but the majority of them have not, at first, any one character or mark of a true fistula; nor can, with- out the most supine neglect on the side of the patient, or the most ignorant mismanagement on the part of the surgeon, degenerate, or be converted into one. Collections of matter from inflammation (wherever formed), if they be not opened in time, and in a proper manner, do often burst. The hole, through which the matter finds vent, is gene- rally small, and not often situated in the most convenient, or most dependent part of the tumon; it therefore is unfit for the discharge of all the contents of the abscess; and, instead of closing, contracts itself to a smaller size; and, becoming hard at its edges, conti- nues to drain off what is furnished by the undigested sides of the cavity. This is often the case in the most muscular or fleshy parts of the body, where the cellular and adipose membrane does not abound; but is more particularly so in the neighbourhood of the anus, where that membrane is large in quantity, well stocked with fat, and not compressed by the action of any large or strong muscles. Why critical defluxions and abscesses are frequently formed ii. this part, is so obvious to every one who considers its natural structure, that it must be quite unnecessary to enter into an expla- nation of it: I shall therefore only observe, that when it becomes the seat of such kind of defluxion. it can make little or no resist- fistula in ano. Wb ance, but immediately swells, and becomes hard to a considerable extent; and although imposthumation is very frequently the con- sequence, yet the induration extending itself a good way beyond the bounds of the abscess, the first suppuration is by no means equal to the dissolution of such hardness; especially, if, instead of being opened properly, the skin has been suffered to burst. The smallness of this accidental orifice, the hardness of its edges, its being found to be the outlet from a deep cavity, the daily dis- charge of a thin, gleety, discoloured kind of matter, and the indu- ration of thf Parts round about, have all contributed to raise and confirm the idea of a true fistula. To this idea, the general treatment of these cases has therefore been made to accord: upon this has been built the prevailing doc- trine of free excision, or as free destruction, without any regard to the original production of the complaint, its particular seat, its date, or any other attendant circumstances; and without examin- ing, whether it would not admit a more easy and a more expe- ditious method of cure. In short, this notion, that all sinuses near the rectum are necessarily fistulous, has occasioned the pre- scription of such a manner of treating them, from their very first appearance, as they can hardly ever stand in need of at any time; and a mere ill founded supposition, that the induration of the parts about may be owing to a diseased callosity, is urged as a reason for using them with more severity than even such state would require. SECT. II. Whoever would obtain a true notion of the disease in question, must eonsider it under all the forms in which it makes its appear- ance. These, which are many and various, (both with regard to aspect, situation, and symptoms,) are what show the different na- ture of the complaint in different states, and are the circumstances which ought to regulate a surgeon's conduct in the care of it. 206 A TREATISE ON THE Sometimes the attack is made with symptoms of high inflam- mation; with pain, fever, rigor, &c. and the abscess proves truly critical; that is, it becomes a solution of the fever. In this case, a part of the buttock near to the anus is consider- ably swollen, and has a large circumscribed hardness. In a short time, the middle of this hardness becomes red and inflamed; and in the centre of it matter is formed. This (in the language of our ancestors) is called in general a Phlegmon; but when it appears in this particular part, a Phyma. The pain is sometimes great, the fever high, the tumor large, and exquisitely tender; but however disagreeable the appearances may have been, or however high the symptoms may have risen, before suppuration, yet when that end is fairly and fully accom- plished, the patient generally becomes easy and cool; and the matter formed under such circumstances, though it may be plenti- ful, yet is good. On the other hand, the external parts, after much pain, attend- ed with fever, sickness, &c. are sometimes attacked with Consid- erable inflammation, but without any of that circumscribed hard- ness, which characterised the preceding tumor; instead of which the inflammation is extended largely, and the skin wears an ery- sipelatous kind of an appearance. In this the disease is more superficial, the quantity of matter small, and the cellular mem- brane sloughy to a considerable extent. Sometimes, instead of either of the preceding appearances, there is formed in this part what the French call une suppuration gangreneuse; in which the cellular and adipose membrane is af- fected in the same manner, as it is in the disease called a Car- buncle. In this case the skin is of a dusky red or purple kind of colour; and although harder than when in a natural state, yet it has by no means that degree of tension or resistance, which it has either in the phlegmon, or in the erysipelas. The patient has generally, at first, a hard, full, jarring pulse, with great thus', and very fatiguing restlessness. If the progress of the disease be not stopped, or the patient relieved by medicine, the pulse soon changes into an unequal, low, faltering one; and the strength and the spirits sink in such manner, as to imply FISTULA IN ANO. 207 great and immediately impending mischief. The matter formed under the skin, so altered, is small in quantity, and bad in quali- ty; and the adipose membrane is gangrenous and sloughy through- out the extent of the discoloration. This generally happens to persons, whose habit is either naturally bad, or rendered so by- intemperance. In each of these different affections, the whole malady is often confined to the skin and cellular membrane underneath it; and no other symptoms attend than the usual general ones, or such as arise from the formation of matter or sloughs in the part imme- diately affected. But it also often happens, that, added to these, the patient is made unhappy by complaints arising from an influ- ence, which such mischief has on parts in the neighbourhood of the disease; such as the urinary bladder, the vagina, the urethra, the haemorrhoidal vessels, and the rectum; producing retention of urine, strangury, dysury, bearing down, tenesmus, piles, diarrhoea, or obstinate costiveness; which complaints are sometimes so press- ing, as to claim all our attention. On the other hand, large quan- tities of matter and deep sloughs are sometimes formed, and great devastation committed on the parts about the rectum, with little or no previous pain, tumor, or inflammation. Sometimes the disease makes its first appearance in an indura- tion of the skin, near to the verge of the anus, but without pain or alteration of colour; which hardness gradually softens and sup- purates. The .matter, when let out, in this case, is small in quantity, good in quality; and the sore is superficial, clean, and well conditioned. On the contrary, it now and then happens, that although the pain is but little, and the inflammation apparent- ly slight, yet the matter is large in quantity, bad in quality, ex- tremely offensive, and proceeds from a deep crude hollow, which bears an ill-natured aspect. The place also where the abscess points, and where the matter, if let alone, would burst its way out, is various and uncertain. Sometimes it is in the buttock, at a distance from the anus; at other times near its verge, or in the perineum; and this discharge is made sometimes from one orifice only, sometimes from several In some cases, there is not only an opening through the skin ex 208 A TREATISE ON THE ternally, but another through the intestine into its cavity; in others, there is only one orifice, and that either external or internal. Sometimes the matter is formed at a considerable distance from the rectum, which is not even laid bare by it; at others, it is laid bare only, and not perforated. It is also sometimes not only de- nuded, but pierced; and that in more places than one. The ori- ginal seat of the mischief is, in some cases, high up in the pelvis, near the lower vertebrae of the loins, and the os sacrum; and the matter comes from parts so diseased, and so out of reach, that the case is hopeless from the first. These discharges are to some per- sons salutary, and prove solutions of general diseases, which have long infested the habit; to others, they often prove fatal, by ex- hausting the small remains of strength. If the disease has its foundation in the lues venerea, (which is not a very uncommon case,) it freque-ntly communicates with the urethra and neck of the bladder, producing great disturbance and misery to the patient. And sometimes it happens, that fistulous openings, near the anus, give discharge to a sanies, proceeding from a cancerous state of some of the parts within the pelvis. Whoever attends to this variety of states and circumstances, must be convinced, that no one particular method can suit them all; but that in this, as in many other cases, the surgeon's con- duct must be varied occasionally, and adapted to the exigencies of each individual. SECT. III. It very seldom happens, when inflammatory defluxions are made on the cellular membrane surrounding the intestine rectum, that it is in our power to prevent the formation of matter; nor, if it was, would it often be right so to do; as these abscesses seldom happen to any body, to whom they are not, at least, a temporary relief. AH consideration, therefore, of that kind is generally out of the FISTULA IN ANO. 509 question; and our business, if called to it at the beginning, must be to moderate the symptoms; to forward the suppuration; when the matter is formed, lo let it out; and to treat the sore in such a manner, as shall be most likely to produce a speedy and lasting cure. When there are no symptoms which require particular atten- tion, and all that we have to do is to assist the maturation of the tumor, a soft poultice is the best application. When the disease is fairly of the phlegmonoid kind, the thinner the skin is suffered to become, before the abscess be opened, the better; as the indu- ration of the parts about will thereby be the more dissolved, and, consequently, there will be the less to do after such opening ha? been made. This kind of tumor is generally found in people of full, sanguine habits; and who, therefore, if the pain be great, and the fever high, will bear evacuation, both by phlebotomy and gentle cathartics; which is not often the case of those who are said to be of bilious constitutions; in whom the inflammation is of larger extent, and in which the skin wears the yellowish tint of the erysipelas; persons of such kind of habit, and in such cir- cumstances, being in general seldom capable of bearing large evacuation. The observation is general with regard to erysipelatous inflam- mations in any part of the body, and is by no means confined to this. I may possibly be censured, for stepping out of my way to men- tion it; but it is a truth of so much importance to many, and I have seen such melancholy instances from its being not known, or not attended to, that my intention must plead my excuse. This kind of inflammation (I mean the erysipelatous) generally makes its attack with nausea, vomiting, slight rigor, heat, thirst, and restlessness. The quickness of pulse, and heat of skin, are indications for some degree of evacuation, and indeed sometimes render it requi- site; but it is a very prevailing opinion with many practitioners, that these evacuations should be freely made, and frequently re- peated: in short, that the cure of this kind of inflammation is safe- ly to be affected by them; which is so far from being true, that vol. it. d d 210 A TREATISE ON THE the practice has proved fatal to many. If, for instance, blood be drawn off in such quantity as the patient's pulse sinks suddenly, or if his strength be considerably reduced by purging, it is no very uncommon thing for the inflammation to leave the part first affect- ed, and for such complaints to come on immediately, as soon prove destructive, and afford no opportunity to repair the mischief which the evacuation has produced. When the inflammation is of this kind the quantity of matter formed is small, compared to the size and extent of the tumor; the- disease is rather a sloughy, putrid state of the cellular membrane, than an imposthumalion; and, therefore, the sooner it is opened, the better. If we wait for the matter to make a point, we shall wait for what will not happen; at least not till after a consider- able length of time; during which, the disease in the membrane will extend itself, and, consequently, the cavity of the sinus, or abscess, be thereby greatly increased. When, instead of either of the preceding appearances, the skin wears a dusky, purplish-red colour; has a doughy, unresisting kind of feel, and is very little sensible; when these circumstances are joined with an unequal, faltering kind of pulse, irregular shiverings, a great failure of strength and spirits, and inclination to dose, the case is formidable, and the event generally fatal. The habit, in these circumstances, is always bad; sometimes from nature, but much more frequently from gluttony and intem- perance. What assistance art can lend, must be administered speedily; every minute is of consequence; and if the disease be not stopped, the patient will sink. Here is no need for evacua- tion of any kind; recourse must be immediately had to medical assistance; the part affected should be frequently fomented with hot spirituous fomentations; a large and deep incision should be made into the diseased part; and the applications made to it should be of the warmest, most antiseptic kind. This also is a general kind of observation, and equally applica- ble to the same sort of disease in any part of the body. Our an- cestors have thought fit to call it in some a carbuncle, and in others by other names; but it is (wherever seated) really and tru- ly a gangrene of the cellular and adipose membrane: it always implies great degeneracy of habit, and, most commonly, ends ill. FISTULA IN ANO. 211 Strangury, dysury, and even total retention of urine, are no very uncommon attendants upon abscesses forming in the neigh- bourhood of the rectum and bladder; more especially, if the seat of them be near the neck of the latter. They sometimes continue from the first attack of the inflam- mation, until the matter is formed, and has made its way out- ward; and sometimes last a few hours only. The two former most commonly are easily relieved by the loss of blood, and the use of gum arabic, with nitre, &c. But the last, the total retention, is, while it continues, both fatiguing and alarming. They who have not often seen this case, generally have immediate recourse to the catheter; and for this they plead the authority of precept: but the practice is so essentially wrong, and I have seen such terrible consequences from it, that I cannot help entering my protest against it. The neck of the bladder, from its vicinity to the parts where the inflammation is seated, and from its being involved in the same common membrane, does certainly participate, in some de- gree, of the said inflammation. This will, in some measure, ac- count for the complaint: but whoever considers the extremely irritable state of the parts composing that part of the urethra, (if I may be allowed so to call it,) and will, at the same time, re- flect on the amazing and well known effects of irritation, will be convinced that the principal part of this complaint arises from that cause; and that the disease is, strictly speaking, spasmodic. The manner in which an attack of this kind is generally made, the very little distention which the bladder often suffers, the small quantity of urine sometimes contained in it even when the symp- toms are most pressing, and the most certain as well as safe me- thod of relieving it, all tend to strengthen such opinion.* But whether we attribute the evil to inflammation, or to spas- a Great and acute as the pain is in the neck of the bladder, and about the pubes, in a retention of urine, it is not greater, nor more acute than is sometimes felt in the same parts by those in whose bladder no urine is to be found, and in whom the catheter may be passed with very little trouble or resistance. This complaint, which I have more than two or three times seen, is truly spasmodic; and, accordingly, always gives way to opium, more especially if used in the form of a clyster. 212 A TREATISE ON THE modic irritation, whatever can, in any degree, contribute to the exasperation of either, must be palpably and manifestly wrong. The violent passage of the catheter through the neck of the blad- der (for violent in such circumstances it must be) can never be right. I will not say that it never succeeds; but I will say, that it can hardly ever be proper to make the attempt. If the instrument be successfully introduced, it must either be withdrawn as soon as the bladder is emptied, or it must be left in it: if the former be done, the same cause of retention remaining, the same effect returns; the same pain and violence must again be submitted to, under (most likely) increased difficulties. On the other hand, if the catheter be left in the bladder, it will often, while its neck is in this state, occasion such disturbance, that the remedy (as it is called) will prove an exasperation of the disease, ami add to the evil it is designed to alleviate. Nor is this all; for the resistance which the parts, while in this state, make, is sometimes so great, that if any violence be used, the instrument will make for itself a new route in the neighbouring parts, and lay the foundation of such mischief as frequently baffles all our art— an accident, which I have known happen to those whose judg- ment and dexterity have never been doubted. The true, safe, and rational method of relieving this complaint is by evacuation and anodyne relaxation: this not only procures immediate ease, but does, at the same time, serve another very material purpose; which is that of maturating the abscess. Loss of blood is necessary; the quantity to be determined by the strength and state of the patient. The intestines should also be emptied, if there be time for so doing, by a gentle cathartic: but the most effectual relief will be from the warm bath, or scmicupium, the application of bladders with hot water to the pubes and perineum, and, above all other remedies, the injection of clysters, consisting of warm water, oil, and opium. There may have been cases which have resisted and baffled this method of treatment; but I have never met with them. On the other hand, I have seen so great and permanent mis- chief from the premature use of the catheter, that it would have been better for the patient to have sunk under the first evil, than to have lived to experience that variety of misery, to which all FISTULA IN ANO. 213 they are subject wfco are afflicted with a diseased or injured neck of the bladder. A painful tenesmus is no uncommon attendant upon an inflam- matory defluxion on the parts about the rectum. The frequent use of the muscles, whose office it is to expel from the gut whatever is troublesome to it, and by whose action the paris, which make the seat of the disease, must be continually compressed, make this, while it lasts, a very disagreeable complaint. If a dose of rhubarb, joined with a warm anodyne, such as the conf. mithrid. or such like, does not remove it, the injection of thin starch and opium, or tinctura thebaic, is almost infallible. The bearing down, as it is called, in females, as it proceeds, in this case, from the same kind of cause, (viz. irritation,) admits re- lief from the same means as the tenesmus. In some habits, an obstinate cosliveness attends this kind of in- flammation, accompanied, not unfrequently, with a painful disten- tion and enlargement of the haemorrhoidal vessels, both internally and externally. While a quantity of hard faeces are detained within the large intestines, the whole habit must be disordered; and the symptomatic fever, which necessarily accompanies the formation of matter, must be considerably heightened. And while the vessels surrounding the rectum (which are large and numerous) are distended, all the ills proceeding from pressure, inflammation, and irritation, must be increased. This is too obvious to need any explanation; and it must be as obvious, that phlebotomy, laxative clysters, and a low, cool regimen, must be the remedies; while a soft cataplasm, applied externally, serves to relax and mollify the swollen, indurated piles, at the same time that it hastens the sup- puration. These arc, I think, the most material of the complaints which attend inflammatory deductions and formations of matter about the anus and rectum. They are indeed most of them symptomatic or accessory to the original disease: but they are frequently of such immediate consequence to the ease, and sometimes even to the safety of the person afflicted, that they require all our attention. Whoever neglects or mis-treats them, will cause his patient to suffer a great deal of unnecessary pain, Cuigue, and even hazard: 214 A TREATISE ON THE whoever attends to, and treats them properly, will find that, by relieving and appeasing these accidental ids, he will assist the cure of the principal complaint, and gain time, instead of losing it. SECT. IV. Let us now consider this disease, when the first symptoms attending the inflammation are gone off, and matter is either formed and collected, in such manner as to be fit for a surgeon to give dis- charge to it: or (that opportunity having been avoided or neglected) it has burst through the parts containing it, and has made its own way out. The different states and circumstances produced, either by the collection of this matter, or by the manner in which it has made its escape, will necessarily occasion a difference in the manner of treating the case; and may, for method sake, as well as for the more perfectly understanding the true nature of the disease, be reduced to two general heads; viz. 1. Those in which the intestine is not at all interested; and, 2. Those in which it is either laid bare, or perforated. Let us first suppose the matter to be fairly formed; to have made its point, as it is called; and to be fit to be let out. Where such point is, that is, where the skin is most thin, and the fluctuation most palpable, there the opening most certainly ought to be made. Some of our predecessors, either from a fear which almost neces- sarily accompanies the want of anatomical knowledge, or from an awkwardness attending the disuse of a cutting instrument, adopted the method of opening these (as well as most other abscesses) by caustic. With all due deference to authority, I will venture to say, that it is in general wrong; and particularly so in the present case. It often gives unnecessary pain; and it produces a loss of sub- stance, and a kind of cicatrix, which is not only unseemly, but frequently proves a lasting inconvenience. FISTULA IN ANO. 215 Some of the patrons of potential fire do, indeed, give a specious kind of reason for its use; viz. that it makes a more large and free opening for the discharge; and that, by the time the eschar is separated, the hollow underneath is generally more than half filled up. In a few (very few) particular cases, where the destruction of glandular parts may become necessary, after the eschar is thrown off, (as in the case of venereal buboes,) there may be some force in this argument, and caustics may be found useful; but in the present case, and in most others, in which they are freely and fre- quently applied, they appear to me to be highly improper; as they necessarily occasion a loss of parts, and a kind of eschar, which is, in general, an indelible blemish, to say no worse. And vvith regard to the particular circumstance of the hollow being filled almost up, by the time the eschar is separated, if the surgeon will dress an abscess, opened by incision, in the same easy, superficial manner he does one opened by caustic, he will find the consequence to be the same. But (I know not why) a notion has long prevailed, that an abscess opened by a knife must be immediately crammed and stuffed with dressings, while that on which a caustic has been applied must be let alone until the eschar casts off. Let the one be treated as the other is, (and as they both ought to be,) and the event will be found to be alike in each; excepting this material difference in favour of the knife, that it will not necessarily occasion any destruction of parts, loss of substance, nor any deformity which is at all comparable with what must follow the use of the caustic. In making the opening; the knife or lancet should be passed in deep enough to reach the fluid, and, when it is in, the incision should be continued upward and downward,b in such a manner as to divide all the skin covering the matter. By these means, the contents of the abscess will be discharged at once; future lodge- ment of matter will be prevented; convenient room will be made for the application of proper dressings; and there will be no b When I say upward and downward, I suppose the patient to stand on his feet, with his legs and thighs straight, and his body leaning forward over a table, or a bed; which posture gives the fairest view of the parts ; and puts them into the best position for the operation, as well as for the operator. 216 X TREATISE ON THE necessity for making the incision in different directions, or for removing any part-of the skin composing the verge of the anus. Notwithstanding that all these collections of matter are generally called by the name of Fistulae, and are all supposed to affect the' intestinum rectum, yet it is very certain that the seat of the abscess (the place where the matter is formed) is sometimes at such dis- tance from the gut, that it is not at all interested by it; and that none of these cases either are, or can be, originally fistulae. In this state of the disease, we have no more necessarily to do with the intestine, than if it was not there; the case is to be con- sidered merely as an abscess in the cellular membrane, which will require (in the usual phrase) to be digested, incarned, and (if practicable) healed without meddling with the rectum in any manner. As this is a matter of some importance to the patient, it is worth a little consideration. Suppose an abscess formed in the neighbourhood of the rectum, which, after a certain degree of swelling and inflammation, ripens, or comes to a point, somewhere near to the verge of the anus. Suppose also a large and convenient opening to have been made by a simple incision; the contents of the abscess to have been thereby discharged; and a sore or eavity produced, which is, per- haps, considerable in size; this cavity is to be filled up in such manner, as to produce a firm and lasting cure. The frequent use of the term filling up, and the generally re- ceived opinion, that the induration of the parts about is a diseased callosity, appear to me to have been the two principal sources of error and misconduct in these cases. Wherever matter is formed in consequence of inflammation, it always leaves, upon being let out, a proportional hollow, and some degree of induration. The former of these is of different size, according to the quantity of matter; and the latter depends both on the degree of previous inflammation and the more or less perfect suppuration of the abscess. The generally received opinion, vvith regard to these two cir- cumstances, (hollow and hardness,) is, that the former is caused entirely by loss of substance; and the latter (as I have already ob- served) by diseased alteration in the structure of the parts. FISTULA IN ANO. 211 The consequence of which opinion is, that as soon as the mat- ter is discharged, the cavity is filled and distended, in order to pro- cure a gradual regeneration of flesh, and the dressings, with which it is so filled, are most commonly of the escharotic kind, intended for the dissolution of hardness. The practice is a necessary consequence of the theory. Who- ever supposes diseased callosity, and great loss of substance, will necessarily think himself obliged to destroy the former, and lo prevent the cavity, formed by the latter, from filling up too hasti- ly. On the other hand, he who considers this matter as it really is; that is, he who regards the cavity of the abscess as being prin- cipally the effect of the gradual distraction and separation of its sides, vvith very little loss of substance, compared with the size of the said cavity; and who looks upon the induration round about. as nothing more than a circumstance which necessarily accom- panies every inflammation in membranous parts, more especially in those which tend to suppuration; will, upon the smallest re- flexion, perceive, that the dressings applied to such cavity ought to be so small in quantity, as to permit nature to accomplish that end which she always aims at as soon as the matter is let out (I mean, the approach of the sides of the cavity toward each other); and that such small quantity of dressings ought to consist of materials proper only to encourage easy and gradual suppura- tion. This is a fact so obvious to common sense, that it must appear lo every one who will coolly and impartially consider it. What is the part in which the disease is seated? and what are the alterations which such disease produces? The part is mere cellular membrane; and the alteration is obstruction and in- flammation, ending in the formation of matter. But do these cre- ate any new body? do not the sides of the abscess still remain cellu- lar and adipose membrane, only inflamed, thickened, hardened, and rendered purulent? can such alteration require any thing more toward restoring the parts to a natural state, than a free suppura-. lion from the parts so altered? or can it make extirpation or de- struction necessary? Most certainly it cannot. How then is sup- puration to be produced and maintained? Not by thrusting in such applications, as by their quantity distend, and by their quality vol. n. e e 218 A TREATISE ON THE irritate and destroy; but by dressing lightly and easily with such as appease, relax, and soften. The fact is capable of experiment; and every man who will make it, that is, who will try the different methods, and attend to the consequences, must be able to determine it; unless blinded by prejudice, or influenced by a worse motive. A moment's attention to the conduct of nature, when left t© herself, and not interrupted by art, will, perhaps, set this matter in a clearer light. When an abscess of this kind is opened by a surgeon, the ca- vity is found proportioned to the contents; and, consequently, if the quantity of matter be large, ihe hollow is considerable. If this hollow be immediately filled with dressings (of any kind,) the sides of it- will be kept from approaching toward each other, or may even be further separated. But if this cavity be not filled, or have little or no dressings of any kind introduced into it, the sides immediately collapse; and coming nearer and nearer, do, iu a very short space of time, convert a large hollow into a small si- nus. And this is also constantly the case, when the matter, instead of being let out by an artificial opening, escapes through one made by the bursting of the containing parts. It is indeed true, that this sinus will not always (and particular- ly 4n the disease I am now speaking of) become perfectly close, and heal; but.the aim and conduct of nature is not, therefore, the less evident; nor the hint, which art ought to borrow from her, the less palpable. In this, as in most other cases where there are large sores, or considerable cavities, a great deal will depend on the patient's habit, and the care that is taken of it; if that be good, or if it be properly corrected, the surgeon will have very little trouble in his choice of dressings; all that he will have to do will be, to take care that they do not offend either in quantity or quality; but if the habit be bad, or injudiciously treated, he may use the whole v farrago of externals, and only waste his own and his patient's time. In short, all these cases are, at first, mere abscesses; the conse- quences of inflammation, and require no other treatment than what would be proper in the same kind of case in all other parts. FISTULA IN ANO. 219 Some few of them are so circumstanced, with regard to the intes- tine, that it is quite unnecessary to meddle with it at all; but whe- ther that be the case or not; whether the division of the rectum become a necessary part in the cure, or not; they, most cert;iinly, do not deserve the name of fistulae, nor require that sort of treat- ment which fistulae are said and thought to stand in need of; though by being, from their very first appearance, supposed to be such, they are frequently, by mismanagement, rendered truly fis- tulous. By this (that is, by light, easy treatment,) large abscesses form- ed in the neighbourhood of the rectum will sometimes be cured without any necessity occurring of meddling vvith the said gut. But it much more frequently happens, that the intestine, although it may not have been pierced or eroded by the matter, has yet been so stript or denuded, that no consolidation of the sinus can be obtained, but by a division; that is, by laying the two cavities, viz. that of the abscess and that of the intestine, into one. The necessity of doing this, may, in many cases, be known by the surgeon at first; that is, when he opens the abscess he may find the intestine so bare, and in such state, as plainly to prove that he will not be able to effect a cure without the operation; in other instances, he may have reason at first to flatter hiihself with success, and be disappointed. When the former is the case; when the gut is found to be in such state, that there is no reason to expect a cure, without its being divided; that operation had better (on many accounts) be performed at the time the abscess is first opened, than be deferred to a future one. For if it be done in the manner in which I will venture to say that it always may, it will add so little to the pain which the patient must feel by opening the abscess, that he will seldom be able to distinguish the one from the other, either with regard to time or sensation; whereas, if it be deferred, he must either be in continual expectation of a second cutting, or feel one at a time when he does not expect it. The intention in this operation is to divide the intestine rectum from the verge of the anus, up as high as the top of the hollow in which the matter was formed; thereby to lay the two cavities of the gut and abscess into one; and by means of an open, instead of a hollow or uinuous sore, to obtain a firm and lasting cure. 220 A TREATISE ON THE Ingenious, mechanical, and whimsical people,0 have often bu- sied themselves in inventing instruments for this purpose: the syringotomy, the cultellus falcatus, the probe-razor, &c. have all at times been in use; scissors also of various kinds, both straight and crooked, have been employed in this operation; the three first may be made to serve the purpose very vvell; but'for the last (the scissors,) there is in this, as vvell as in almost every operation in which they are frequently used, a palpable objection; viz. that by pinching at the same time that they cut, they occasion a great deal of unnecessary pain. They are, I know, in great use with many, who, if they were deprived of their probe-scissors, would think themselves incapacitated from doing business; but they are, upon all occasions, where mere division is required, a very bad in- strument; they may assist an aukward or an unsteady hand, but are more fit for a farrier than for a surgeon. In all chirurgic operations, the instrument made use of cannot be too simple, nor too keen; and, if possible, should never be out of the sight or the direction of the finger of the operator; and, whenever it is (as must sometimes necessarily be the case), it is liable to some degree of uncertainty. Scissors introduced into the rectum are always in this predicament; and are, therefore, (as well as on account of their pinching quality,) bad. The curved, probe-pointed knife, with a narrow blade, I have always found to be the most useful and handy instrument of any. This, introduced into the sinus, while the surgeon's fore finger is in the intestine, will enable him to divide all that can ever require division; and that with less pain to the patient, with more facility to the operator, as well as with more certainty and expedition, than any other instrument whatever. If there be no opening in the intestine, the smallest degree of force will thrust the point of the knife through, and thereby make one; if there be one already, the same point will find and pass through it. In either case, it will be received by the finger in ano; will thereby be prevented from deviating; and, being brought out by the same finger, must necessarily divide all that is between the edge of the knife and c The late Mr. Freke invented an instrument for this purpose ; but it was. ^tpon trial, found to cut the operator's finger with so much more certainty than the patient's intestine, that it has long been laid aside. FISTULA IN ANO. 2£l the verge of the anus; that is, must, by one simple incision (which is made in the smallest space of time imaginable) lay the two cavities of the sinus and of the intestine into one. Authorfe make a very formal distinction between those cases in which the intestine is pierced by the matter, and those in which it is not; but although this distinction may be useful when the different states of the disease are to be described, yet in prac- tice, when the operation of dividing the gut becomes necessary, such distinction is of no consequence at all; it makes no altera- tion in the degree, kind, or quantity of pain which the patient is to feel; the force required to push the knife through the tender gut is next to none; and when its point is in the cavity, the cases are exactly similar. This is the only operation which (in the circumstances under our present consideration) ever can be necessary; and this appears to me to be the safest, easiest, and most expeditious method of performing it. I know that it is contrary to the opinion and practice of many . who think that the removal of some part, both of the intestine and of the verge of the anus, is necessary in these eases; but long and repeated experience has convinced me of the contrary; and I shall, in the next section, have occasion to speak more particu- larly to that point. Immediately after the operation, a soft dossil of fine lint should be introduced (from the rectum) between the divided lips of the incision, as well to repress any slight haemorrhage, as to prevent the immediate re-union of the said lips; and the rest of the sore should be lightly dressed vvith the same. This first dressing should be permitted to continue, until a beginning suppuration renders it loose enough to come away easily; and all the future ones should be as light, soft, and easy as possible; consisting only of such ma- terials as are likely to promote kindly and gradual suppuration. The sides of the abscess are large; the incision must necessarily, for a few days, be inflamed; and the discharge will, for some lime, be discoloured and gleety. This induration, and this sort of dis- charge; are often mistaken for signs of diseased callosity, and un- discovered sinuses; upon which presumptions, escharotics are freely applied, and diligent search is made for new hollows: the 222 A TREATISE ON THE former of these most commonly increase both the hardness and the gleet; and by the latter new sinuses are sometimes really pro- duced. These occasion a repetition of escharotics, and, perhaps, of incisions; by which means, cases which at first, an'd in their own nature, were simple and easy of cure, are rendered complex and tedious. That this is the truth, without exaggeration is well known to many; and whoever will look over the writings of some of our immediate predecessors, or even of some of our contem- poraries, will find that immediately after pinching and snip- ping the gut vvith scissors, we are directed to fill the incisions with lint; and, after having distended the cavity by such means, to dress in future with such medicines as, though used under the specious names of digestives, detergents, &c. do really inflame and irritate the parts to which they are applied, and retard, in- stead of encouraging, a kindly suppuration. Among these, the mercurius piaecipitatus ruber stands princi- pal: this seems to have been the great external specific of most of our immediate predecessors, and to have been used by them for the very different purposes of destruction and restoration. With this, either in dry powder, or mixed with unguent, the tents, pledgets, &.c. with which they dressed these sores were spread or embued; with this they dressed the recently divided lips of the wound in the intestine, and with this they filled the whole cavity of the abscess. That the same practice still too much prevails, they who please may be convinced/1 I would beg leave to ask any patron of this method of dressing, what he would say to a man, who shall order a large tent, well charged with precipitate, to be thrust up the undivided, un- wounded rectum of a person, who, from any cause whatever, had an inflammatory defluxion on the haemorrhoidal vessels and inside of the said gut? Would he not say that such tent would prove a d Mr. De la Faye says : " Si les chairs s'elevent trop, on les consumera avec la pierre infernale ;" and in many books of reputation, the butyrum antimonii, the trochisci e minio, the pulvis angelicus, &c. are prescribed IV frequent use. FISTULA IN AN0. 228 fatiguing, inflammatory suppository? and would he not be right in saying so? Is then the rectum rendered less sensible, and less ir- ritable, by being wounded? Or can that very application, which proves a painful stimulus to a gut not divided, become an easy digestive to one that is? If any man thinks that it will, I would advise him to make the experiment on himself; and I would then appeal to the testimony of his own unprejudiced sensations. In short, lo quit reasoning, and speak to fact only: In the great number of these cases, which must have been in St. Bartholo- mew's hospital, within these ten or twelve years, I do aver, that I have not met with one in the circumstances before described, that has not been cured by mere simple division, together with light, easy dressings; and that I have not, in all that time, used, for this purpose, a single grain of precipitate, or of any other escharotic. Why is it that we hear so much of miracles performed by the paste of one quack? and by the injections, oils, and balsams of others? when we all know, that there is nothing specific for the cure of this disease in their compositions; and when we also know that the venders of these remedies are people whose ignorance in matters of physic and surgery is below all notice. That these cures are much more frequently talked of than made, I well know; but that some few people, who have been long and unsuccessfully treated by surgeons, have got either vvell, or better, under the very negligent management of some of these quacks, is an incontesiible truth; and very strange it is, that we do not see why. Fas est et ab hoste doceri. The truth is, that, while we are looking for what these people do, we (if I may be allowed the phrase) overlook what they do not do. It is true, we cannot find any specific quality in the strange jumble of ingredients which they put into their internal remedies; nor any particularly sanative Qne in their injections, balsams, &c. and therefore are surprized at even the few instances of their suc- cess; but still overlook the one single circumstance by which the good is produced. It is, and ever must be, a first principle in quackery, to disap- 224 A TREATISE ON Ttik prove and condemn whatever has been done before, be it right or be it wrong; and it is also necessary for quacks, to avoid all con- nexion with those who are called Regular Practitioners; as vvell in order to have the sole management of the patient, as to avoid in- spection. For these reasons, they always order all former dressings to be immediately thrown aside and disused; and not having in general ingenuity enough, even to seem to apply others with any degree of judgment or dexterity, they make use of a mere superficial plaster, ointment, or injection; that is, without intending any such thing, upon an honest or a rational principle; they, for want of knowing what to do properly, leave the conduct of the sore to nature; who, when the impediment of dressings (which often offend either in quantity or quality) are removed, will do much more than her too officious assistants believe. That the very few cures, which we have heard so much of, are produced in this manner, I am convinced; and so I am, that many of those which are thought by several practitioners to have been brought about by a multiplicity of dressings crammed in tight, and endeavoured to be kept so, by- all the caution of compress and bandage, are very frequently effected by the constant and gene- rally successful endeavours of nature to thrust them forth again; or, at least, so to displace them, that she gradually gets opportunities of doing her own business, in spite of the impediments of art. The business of good surgery is to assist nature; but she will, some- times, get the better even of the worst. Usque recurrel, Fd mala perrumpet, furtim fastidia victrk. SECT. V. In the preceding section, I have supposed the matter of the abscess to have been formed and collected; but still to have been FISTULA IN ANO. 225 contained within the cavity, until let out from thence by an inci- sion. I am now to consider it, as having made its own way out, without the help of art. This state of the disease is also subject to some variety of appear- ance; and these different appearances have produced, not only a multiplicity of appellations, but a groundless supposition also of a variety of essentially different circumstances. When a discharge of the matter by incision is too long delayed or neglected, it makes its own way out, by bursting the external parts somewhere near to the fundament, or by eroding and making a hole through the intestine into its cavity, or sometimes by both. In either case, the discharge is made sometimes by one orifice only, and sometimes by more, Those, in which the matter has made its escape by one or more openings, through the skin only, are called blind, external fistulae; those in which the discharge has been made into the cavity of the intestine, without any orifice in the skin, are named blind, internal; and those which have an opening both through the skin and into the gut, are called complete fistulae. This is the language of all writers, as I have already observed; and thus, all these cases are deemed fistulous, when hardly any of them ever are so; and none of them necessarily. They are still mere abscesses, which are burst without the help of art; and, if taken proper and timely care of, will require no such treatment as a true fistula may possibly stand in need of. The most frequent of all are what are called the blind external, and the complete. The method whereby each of these states may be known, is, by introducing a probe into the sinus by the orifice in the skin, while the fore-finger is within the rectum: this will give the examiner an opportunity of knowing exactly the true state of the case, with all its circumstances. Whether the case be, what is called a complete fistula, or not; that is, whether there be an opening in the skin only, or one there, and another in the intestine, the appearance to the eye is much the same. Upon discharge of the matter, the external swelling subsides, and the inflamed colour of the skin disappears; the ori- fice, which at first was sloughy and foul, after a day or two are vol. n. f f 226 A TREATISE ON THE past, becomes clean, and contracts in size; but the discharge, by fretting the parts about, renders the patient still uneasy. As this kind of opening seldom proves sufficient for a cure,' (though it sometimes does,) the induration, in some degree, remains; and if the orifice happens not to be a depending one, some part of the matter lodges, and is discharged by intervals, or may be pressed out by the fingers of an examiner. The disease, in this state, is not very painful; but it is troublesome, nasty, and offensive: the continual discharge of a thin kind of fluid from it, creates heat, and causes excoriation in the parts about; it daubs the linen of the patient; and is, at times, very fetid: the orifice also sometimes contracts, so as not to be sufficient for the discharge; and the lodgement of the matter then occasions fresh disturbance. The means of cure proposed and practised by our ancestors were three; viz. caustic, ligature, and incision. The intention in each of these is the same; viz. to form one ca- vity of the sinus and intestine, by laying the former into the latter. Fear of haemorrhage, in making a large division of parts, and a design to destroy callosity, gave rise to the use of caustics for this purpose. By the introduction of them in different forms and man- ners into the sinus, that part of the intestine which divides its cavity from that of the abcess is intended to be destroyed; and thereby the proposed end of making one cavity of two is to be accomplished; while at the same time the supposed callosity is to be wasted. For this purpose, some of the most fatiguing and painful escharotics have been prescribed and used; the pulvis an- gelicus, the lapis infernalis, and troches and pastes made with sublimate, arsenic, &c. But the method is so cruel, so tedious, and so inexpert, that I hope it is by this time totally out of use: it was founded* in error, tends only to mischief, and I will not waste the reader's time in saying any thing more about it.f TDr Daniel Turner, who practised surgery within these few years, used this method in its full extent. In his works may he found an account of his forming tents of the trochisci e minio, and thrusting them into the sinus, there to remain till they had produced a sufficient eschar. In the same writer are accounts of strong probe-scissors, made to cut through parts of a considera- ble thickness, and where the external orifice was at a great distance from the anus; and of an iron scoop, made (to use the doctor's own words) like a FISTULA IN ANO. 227 The terror which a cutting instrument necessarily carries with it, the fear of a flux of blood from some considerable vessels, toge- ther with a strange, nonsensical opinion, that a gradual division of the parts was followed by a more sound cure, than an immediate one by cutting, produced the coarse, unhandy method by ligature. The manner of using it was this: A probe, or needle, (according to the complete or incomplete state of the supposed fistula,) armed with a strong ligature, was introduced, either naked or in a can- nula, .by the orifice in the buttock, and brought out at the anus, by the operator's finger: when that was done, the two ends of the said ligature were tied together, in such manner, and at such re- peated times, as by degrees to cut through all that was between its loop and its knot; that is, all that part of the intestine which was next to the sinus. Among writers on this subject will be found very formal direc- tions about the proper time of the year for performing this oper- ation, as well as concerning the proper materials where- with to make the ligature. But as the whole operation is, on every principle of ease, expedition, safety, or certainty, unfit for practice, it would be an abuse of the reader's patience to dwell any longer upon it.g The third method is that by incision. cheese-monger's taster, to be thrust up the rectum, and assist in the division of it. What ideas this gentleman had of the disease, or of human sensation, I cannot imagine. The same gentleman, speaking of the use of this iron scoop, tells us, that when he used it on one particular patient, the man thought that the Doctor was only thrusting up the dressings. It is no diffi- cult matter to conceive what kind of dressings this man must have been ac- customed to, who could not distinguish between the application of them and the thrusting up an iron scoop. e See Celsus, whose account of the method by ligature has been followed by most of the writers since. " In has demisso specillo, ad ultimum ejus ca- " put incidi cutis debet; dein novo foramine specillum educi lino sequente ; " quod in aliam ejus partem, ob id ipsum perforatum, conjectum sit: ibi " linum apprehendendum, ligandumque cum altero capite est; ut laxecutem, " quae super fistulam est, teneat: idque linum debet esse crudum, et du- " plex, triplexve, sic tortum ut unitas in eo facta sit. Interim autem licet " negotia agere, ambulare, lavare, cibum capere, perinde atque sanissi- " mo," &c. 228 A TREATISE ON THE I have already given my opinion on what appears to me to be the best and most proper method of dividing the intestine, in the case of a collection of matter formed juxta anum. The intention to be aimed at by incision in the present case is exactly the same, and (I think) ought to be executed in the same manner. I never saw that another kind of operation was neces- sary; I have not for many years performed any other; and I do not recollect a single instance in which it has failed to produce a cure, in such cases as were curable by any means. If, therefore, I intended to give my own opinion merely on this subject, I should say, the same division of the intestine, and with the same instrument, is all that is required; and, referring my reader back to the preceding section, should give him no further trouble on this head. But as I find my sentiments in this matter are somewhat different from those of many, I must beg leave to be indulged in the use of a few words. I have said, that in whatever manner, or with whatever instru- ment, the intestine be divided, the intention is the same; viz. to lay the cavity of the abscess into that of the gut, and thereby to convert a hollow sinus sore into an open one; preventing, by the same means, the future lodgement of matter, and giving rqpm for the application of proper dressings. The two cases (a collection of matter and a sinus,) seem to me to require exactly the same treatment; and I have never found it fail of being equally successful in both; that is, I never found that the matter, having found its own way out, made any other opera- tion on the gut, except the mere simple division, at all necessary. But it is said, and that by authors to whom great regard is due, that this is not all that is requisite, especially in the present cir- cumstances; that this will not produce a cure, or assure success; that mere division of the intestine is not sufficient; and that, un- less we cut out, remove, and extirpate a portion both of the said intestine, and the skin constituting what is called the verge of the anus, a firm and lasting cure will not follow. This is the doctrine of writers of eminence, and the practice of a iarge body of surgeons. When I have mentioned the names of Cheselden, De la Faye, FISTULA IN AN0. 229 and Le Dran, I need not cite any others of less note. The first of these was a gentleman whose reputation in his profession was great; the two latter are in as high character now in France. The influence of these upon their readers must be considerable; and therefore it becomes a matter of the more importance that their doctrine be just and defensible. The meihods which these gentlemen have proposed, and which have been by many adopted, are somewhat different from each other, but do all tend to the same purpose, are all calculated to prevent imaginary evils, and are all productive of real ones. Mr. Cheselden, in the last edition of his Anatomy, says— " The true fistula runs between the muscular and inner coat of " the rectum: it is cured by opening it the whole length into the " cavity of the gut; but it is yet better, if it can be done, to extir- " pate all that is fistulous and scirrhous; for that is a sure way to " make one operation perfect the cure." In his observations, published at the end of Mr. Gataker's translation of Le Dran's Surgery, Mr. Cheselden describes a me- thod of his own inventing, by the introduction of one blade of a pair of polypus-forceps into the sinus, and of the other into the rectum; by which means a certain portion of the intestine is held fast between the chops of the instrument, in order to be cut out with the scissors. After having given an explanation of a plate, designed to repre- sent the forceps introduced in such a manner as to hold the piece of intestine fast, he adds—" I formerly cut out a pyramidal piece " in the manner here described; but I find this way with the " forceps much more convenient, and more easy to be executed." How much this method, may be preferable to that which Mr. Cheselden used to practise, I know not; but I will venture to say, that this more easy method is horridly painful, is operose, and absolutely unnecessary towards obtaining a cure. The wound, that is, the orifice of the sinus in the buttock, is, by Mr. Cheselden's direction, to be first dilated with a sponge tent; then one of the blades of a pair of large polypus forceps is to be thrust up the sinus, while the other within the intestine pinches it between them; and then this piece, so pinched, is to be snipped out by the repeated attacks of a pair of scissors. A very 230 A TREATISE ON THE tedious and very painful operation this must necessarily be; and, by- Mr. Cheselden's own account, not always successful: for although he does say—" The operation being thus performed, I have never " found wanting a second cutting;" yet he immediately adds— " If, after this operation, there is still an internal discharge into " the gut, it may be an useful issue; and continue the benefit which " nature designed by the disease.11 We should also be very care- " ful not to perform it when the patient is troubled with the piles; " for I have known one in that case bleed to death." It would be no difficult matter to make great objections to this method of operating, even if the one thing intended by it was ne- cessary; I mean the extirpation of a portion of the rectum. This end might certainly be obtained by easier means; but as that is not the case, as such extirpation appears to me to be totally unne- cessary, I shall not enter into it. Mr. De la Faye, a practitioner and writer of eminence in France, and a gentleman to whom the chirurgic world is much indebted, is a warm patron of the practice of cutting away both a part of the intestine and of the skin composing the verge of the anus. After the external incision, necessary for letting out the matter, has been macje, he says—" Si les pus a fait " un progres considerable du cote de la fesse, on y fera une autre " incision, qui tombera, perpendiculairement sur l'incision longitu- It has been supposed, by very good anatomists, that the human crystal- line has sometimes, between its surface and its capsula, a small quantity of fine pellucid lymph ; and consequently that there is no immediate connexion between that body and its investing membrane. In many beasts, as well as fishes, this is known to be the case ; but whether it be so in the human eye, is not very easy to be known during life ; but that this is the case, sometimes from distemper, 1 have no doubt. I mean, that the whole crystalline is dis- solved into a fluid, still preserving its transparency. This kind of alteration, as I take it, forms what is by some called one species of the gutta serena ; by others, the ':hck cataract. 26S REMARKS ON THE CATARACT. though very rarely, becomes opake through its whole substance, and yet preserves its natural degree of firmness.6 Whenever the crystalline becomes softer than it should be, or tends towards such state, it is certainly distempered, and unfit for perfect vision, whether it be opake or not, or whatever its de- gree of opacity may be; but whoever supposes that such softened and opake crystalline will necessarily, or even frequently, ac- quire firmness, or become hard by time, is exceedingly mistaken. Opacity, though now and then accompanied by what is called in- duration, is no proof of it, nor of any tendency towards it; so far from it, that some of the most dissolved or fluid cataracts, and which have been so for the greatest length of time, are found full as opake as the most firm ones. Whoever has an opportunity of observing this distemper, and will embrace it, will find that cataracts which have in a length of time gone through all those alterations of colour, which are said to indicate unripeness and ripeness, are often as perfectly soft as they ever could have been; and, on the other hand, will some- times find them what is called firm or hard very soon after the first appearance of obscurity. That is, to speak more truly, as well as more properly, the former having been at first dissolved, have remained in the same state of dissolution; and the latter, having been at first only partially softened, have been found in the Same unequal state, with a firm nucleus.d When, therefore, I make use of the term induration, I do it in compliance with the common method of speaking; and not be- cause I think it conveys, by any means, an adequate idea of the real alteration made in the state of the crystalline: far from it; it e From this variety of alteration, which the crystalline is- capable of under- going, proceeds that variety of appearance which our ancestors have called so many different kinds of cataracts. d For there is no possibility of accounting rationally, but by having recourse to the natural state of the crystalline, vvith regard to the different consist- ence of its different parts. This will account for the alterations to which it is liable from time, accident or distemper: this will show why there is no uni- formly and universally hard cataract; why, in all of them, the softest part is al- ways on the surface; why, even in the hardest, the central part is always the most firm ; and why the external and internal parts of the same, cataract, are so often so different from each other in colour. REMARKS ON THE CATARACT. 269 neither conveys an idea of the nature, nor of the extent of such al- teration. With regard to the former, the term induration can with propriety be used only in opposition to a perfect or general distem- pered dissolution; by much the majority of what are called firm cataracts, being much less firm than the same crystalline was be- fore such alteration; and with regard to the latter circumstance, the extent of the mischief, it is subject to the greatest degree of uncertainty; being seldom or never an induration of the whole body, but most frequently a firmish kind of nucleus, of greater or less size, contained within more or less of a gelatinous, or softer kind of substance: so that the nucleus is called firm only in oppo- sition to what envelopes it. In short, if we would think and speak of this matter as it really is, (or as it appears to me to be,) instead of using the terms soft and hard in opposition to each other, and as implying different effects, either of time or of distemper, on the crystalline, we should say, that dissolution or softening, in some degree, is by much the most common effect; that, except in some few instances, where that body retains its natural firmness, while it loses its transpa- rency, the most frequent consequence is a softening of its texture, either partial or total; and that seven times in nine, when the crystalline becomes opake, and tends towards forming a cataract, it is more or less softened; sometimes equally through its whole substance, sometimes partially, having a greater or less portion left undissolved. This undissolved part, which always makes what is called a hard cataract, may indeed be called firm in opposition to the softer, by which it is surrounded; but even this very part is hard- ly, if ever, so firm as the centre of the natural and sound crys- talline. I beg the reader's pardon for having been somewhat prolix, but the subject did not appear to me to have been properly at- tended to. It would be exceedingly pleasant, as well as advantageous, if we could, previous to an operation, know the true state of an opake crystalline: it would enable a surgeon to determine his mode of operating with more precision, and to explain what his intention by such method was: it would give satisfaction to him- 270 REMARKS ON THE CATARACT. self as well as to standers by; and make that appear to be judi- cious and rational, which, under our present uncertainty, has often the appearance of being accidental, and done at random. It is agreed by all, who have carefully considered this subject, and who are ingenuous enough to speak the truth, that the mere colour of a cataract furnishes no proof, to be by any means de- pended upon, relative to its consistence; and that they which ap- pear greyish, or bluish, or like whey, are sometimes found to be firm and resistent, while the more equally white ones are per- fectly soft. I do not mean to assert, but merely to propose to-the consider- ation of such as may have leisure and opportunity, whether, when the opake crystalline is quite dissolved, so as to form a soft ca- taract, it is not, at the same time, somewhat enlarged; and whether, when such dissolution does not take place, and what is called a hard cataract is formed, the crystalline is not, in some degree, lessened or shrunk? Among the circumstances which have concurred to incline me to be of this opinion, is this; that when the pupil has been ob- served to be always in a state of dilatation, even when exposed to a strong light, and, although capable of motion, yet never to contract in the usual manner, 1 have most commonly found the cataract to have been soft; and, on the contrary, when the pupil has been capable of full and perfect contraction over the cataract, I think that it has most commonly proved firm; and this differ- ence I have more than once observed in the different eyes oi the same person. The greater degree of facility with which the firm cataract quits its place, and passes through the pupil upon the di- vision of the cornea, does not lessen the probability of this opinion. I could also wish that they who have an opportunity would in- quire, whether the cataracts which have been found perfectly soft, have not, in general, become gradually more and more opake by very slow degrees, and, in a length of time, the patient feeling lit- tle or no pain; and whether the firm ones do not, in general, be- come hastily opake; and are not preceded, or accompanied, by severe and deeply seated pain in the head, particular!v in the hinder part of it? REMARKS ON THE CATARACT. 271 What has hitherto been said, as it principally regards the theory •f the distemper, may perhaps be thought to be of little import- ance; but when the influence which these opinions may produce, and indeed have produced on practice, is considered, it will be found to be matter of some consequence: while they are confined to a surgeon's imagination only, they are not of much considera- tion; but when they are to regulate his judgment, and direct his hand, they become rather serious. Since the operation of extracting the cataract, instead of de- pressing it, has been introduced into practice, and made a kind of fashion, it has been the humour to exaggerate all the objections to which the latter has been said to be liable; and that in such a manner, that they who have not had frequent opportunities of see- ing business of this kind fall, without reflection, into the prevail- ing opinion, seem to wonder, that the operation of couching should ever have had any success at all; and at the same time are, from the accounts given, inclined to believe, that the extraction is al- ways safe, easy, and successful. The objections which are made against the operation of couch- ing, at least those which have any semblance of truth or force, are reducible to four. The first is, that if the cataract be perfectly soft, the operation will not be successful, from the impossibility of accomplishing the proposed end of it. The second is, that if it be of the mixed kind, partly soft and partly hard, it will most probably fail of success, not only from the impracticability of depressing the softer parts, but also because the more firm ones will either elude the point of the needle, and, remain- ing in the posterior chamber, still form a cataract; or getting through the pupil into the anterior chamber, will there bring on pain and inflammation, and induce a necessity of dividing the cornea for their discharge. The third is, that if the cataract be of the firm, solid kind, and therefore capable of being depressed, yet, in whatever part of the eye it shall happen to be placed, it will there remain undissolved, solid, opake; and although removed from the pupil, yet prove some hinderance to perfect vision. 272 REMARKS ON THE CATARACT. The fourth objection is, that however successfully the depression may have been accomplished, yet that the operation will necessa- rily occasion such violation and derangement of the internal parts of the eye, as must cause very considerable mischief. These objections, if they have any real weight, are of equal force in every species of cataract—and therefore are the more worthy our attention; since, if they be founded on truth, they render the operation unfit for practice; but if they be not, misrepresentation and fashion should never induce us to lay aside any means which have been, and still may be, beneficial to mankind. The first and second I can, from frequently repeated experience, affirm not to be true. I mean that the operation of couching will not necessarily, or even generally, be unsuccessful, merely because the cataract shall happen to be either totally or partially soft; on the contrary, although these states will prevent perfect depression, yet, by the judicious use of the needle, a recovery of sight (the true end and aim of the operation) will be as certainly and as per- fectly obtained, as it would have been, either by depression or by extraction, in the same subject; and that, generally, without any of the many and great inconveniences which most frequently attend the latter operation. The third objection is specious, and therefore very generally credited. That it never happens I will not take upon me to say, because so many have asserted it; some of whom, one would hope, had some kind of authority for what they have so positively affirmed. But, on the other hand, when we consider how few there are who have written from their own examination and experience, and how many who have taken for granted, and copied, what others have said before them, our faith will not-be quite implicit. Certain I am, from repeated experience and examination, that this opinion has not that foundation in truth which it is generally supposed to have; and that it has been embraced and propagated hastily, and without sufficient inquiry and experiment. As this supposed indissolubility of the opake crystalline is not only so principal an objection to the operation of couching, even when it is capable of being perfectly depressed, as to be said to overbalance all the evils, many and great as they are, which fre- quently attend the extraction; but is also supposed to be the cause REMARKS ON THE CATARACT. 273 of the failure of success, when the depression of the softer kinds of cataracts is attempted; it may be worth a little serious examina- tion. I should be sorry to have it thought, that I had any predilection or partiality to one method of operating more than to another; or that I would wish to give to either any preference, but what its superior excellence or utility might justly demand. But, on the other hand, I cannot possibly pay regard to any authority, however otherwise respectable, when it contradicts what I know to be fact. Both operations are equally practicable by any man who has a hand and an eye, and is capable of performing either; but it has of late years been so much the humour to depreciate the one, and to extol the other, that it becomes necessary to examine the sup- posed merits of one, and demerits of the other, and to see whether they be drawn from premises which are true: if one is to be deemed universally preferable to the other, let the circumstances, on which preference is be founded, be drawn from fact, and not from fiction; let them be fairly and faithfully inquired into, and let such inquiry determine. In order to assist in one part of this inquiry, I beg leave to lay before the reader a few experiments and observations which I have made; or, I believe I shall more properly say, have repeated; they having been often made and observed, but not properly enforced or applied.*5 When the opake crystalline is in a state of dissolution, or the cataract is what is called perfectly soft, if the capsula of it be freely wounded by the couching-needle, the contents will immediately issue forth, and, mixing vvith the aqueous humour, will render it more or less turbid; sometimes so much as to conceal the point of the needle and the iris of the eye from the operator. This is a circumstance which has been observed by most ope- rators, and has been mentioned by many writers; but it has always been regarded and mentioned as an unlucky one, and as being in some degree preventative of success; which is so far from being the fact, that as far as relates to this circumstance merely, all the » When I say experimentsand observations which I have made andrepeated, I would wish the reader to understand, that I have made them carefully, for the purpose ; and so repeatedly, as to be satisfied of their p-nerol truth. VOL. II. M m 274 REMARKS ON THE CATARACT. benefit which can be derived from the most successful depression, or extraction, most frequently attends it; as I have often and often seen. The aqueous humour, however turbid it may become, will, in a very short space of time, be again perfectly clear; and if no dis- order of the capsula of the crystalline, previous or consequential, prevents, the rays of lightf will pass without obstruction through the pupil, and the patient will be restored to as perfect vision as f The capsula, or investing membrane of the crystalline, has very often an unsuspected share m the apparent opacity of that body ; and is thereby the cause of disappointments and inconveniences during some operations, and after others. This is a circumstance which, undoubtedly, has been men- tioned ; but has not been by any means sufficiently attended to. The capsu- la is capable of becoming white and opake, while its contents shall be clear and transparent: it becomes so sometimes by being wounded by the couch- ing-needle, used either for the depression of a firm cataract, or for the letting out a soft one ; and it will not infrequently be found so, after the operation of extraction, when no instrument has touched it. Whenever this happens, it is an unpleasant circumstance ; but still more so if it continues for any length of time : I have seen it disappear in a week; I have seen it continue two, three, or four, and at last totally disappear; and I have seen it continue so long as to require the re-application of the in- strument. When it appears after the depression of a firm crystalline, or after an unsuccessful attempt to depress one which has proved not firm enough, it may easily be, and generally is, mistaken for a portion of the cataract risen again; but from which an attentive observer will always be able to distinguish it. But when such opacity follows what is called a successful extraction, in which the cornea only was divided, the capsula not touched by the instrument, and the cataract came away intire through the pupil, the case is self-evident. This may truly and properly be called, as it has been by Monsieur Houin, Haller, and others, a membranous cataract, as it consists merely of the mem- branous capsula of the crystalline. Writers of credit have mentioned, that a cataract may be formed almost instantaneously, by external violence. There is no doubt of the fact; I have seen it four different times. Whether this be not an affection of the capsula merelv, I much doubt; or rather am much inclined to suspect that it most frequently is. In three of the four, w'i ch have fallen under my observation, the opacity has gradually disappeare ! after the inflammation, in consequence of the blow, had gone off; and the eyes were left as clear as ever—a consequence which, I think, may be accounted for, by supposing the opacity in the capsula only ; but cannot, if we suppose it to be in the corpus crystallinum itself. REMARKS ON THE CATARACT. 275 could have followed the most successful operation of either, or of any kind in the same subject, and under the same circumstances. When the cataract is of the mixed kind, partly soft, and partly hard, the immediate effects of the needle are somewhat different; the soft part of the cataract being less in quantity, as vvell as gene- rally less soft, the aqueous humour is less turbid, and the firm part or parts of the crystalline will be very visible. In this state, these firmer parts will very frequently elude the attempts made by the needle to depress them; and will therefore remain in the posterior chamber. This is also reckoned among the unfortunate circumstances; but although to an operator not aware of, nor ac- quainted vvith the consequence, it mav •have all the appearance of being so, yet it really is not; the true end and aim of the opera- tion not being thereby necessarily frustrated. In this case, if the needle has been so used as to have wounded the capsula very slightly, it will sometimes happen, that the firm part of the crys- talline will remain in its nidus, and still form a cataract, which may possibly require a future or re-application of the instrument. This is the worst that can happen, and happens indeed very seldom; for if the capsula be properly wounded, so that the aqueous hu- mour be freely let in, the firm part or parts, though very visible at first, and preventing the passage of light through the pupil, will, in due time, in some longer, in others shorter, gradually dissolve, and at last totally disappear; leaving the eye as fair, as clear, and as fit for vision, as any the most successful operation could have rendered it, of which I have seen and exhibited many proofs.g t The space of time which the accomplishment of such dissolution will re- quire, is very uncertain; I have seen 'he eye perfectly fair and clear within a week after the operation ; and 1 have seen it require two months for the dissolution of all the opake parts. This has been observed by man)-, even before the nature and sea of a ca- taract were truly known; among the rest, by Read, who, speaking of one of his own operations, says, " At the end of nine days, I visited my patient, and found both her and " her friends highly discontented; so that 1 met with nothing but invec- " tives, &.c. " Within a fortnight after, when art and nature having performed theii " mutual operations, and all the cloudy vapours and rags of the c ttu>act « er<- " consumed and dispersed, her eyes grew clear, and her sight became per- " feet, &c. 276 REMARKS ON THE CATARACT. In order to render the fact still more clear, I have sometimes. when I have found the cataract to be of the mixed kind, not at- tempted depression; but have contented myself with a free lacer- ation of the capsula; and having turned the needle round and round, between my finger and thumb, within the body of the crystal- line, have left all the parts in their natural situation; in which cases I have hardly ever known them fail of dissolving so entirely as not to leave the smallest vestige of a cataract.fc In a few instances, where I have had fair opportunity, I have pushed the firm part through the pupil into the anterior chamber, where it has always gradually and perfectly dissolved and disappeared, not producing pain or trouble, while such dissolution was accomplishing.' " I would have every patient, though after a cataract be couched, and nine " or ten days expired, he see little or nothing at all, or that he cannot endure " the light for a month or two, or even for a qurater of a year, as I have " known many, not to be discouraged; for their sight may, notwithstanding, " become well and perfect, and continue so ever after. On the other hand, " some come to good and perfect sight within a fortnight or three weeks." Sir W. Read, p. 7. b The operation of extraction, though said in general to remove the crystalline intire, and calculated for such purpose, does not always do so : but when the cataract is of the mixed kind, does not infrequently leave some of the firmer part behind; which one of the warmest patrons of the operation allows does dissolve and disappear. " Extrahendum statim post operationem est quic- " quid remanet opaci ope Cochlearis Davielis. Hoc quidem facile sit ali- " quando, aliquando vero et imprimis ubi membrana crystallina non satis la- " cerata cochlear in ipsam capsulam lentis, ubi hseret illud opacum corpus- " culum non admittit, tantis difficultatibus circumfusum est, ut quicquid "etiam moliaris extrahere illud non possis, et ne oculum nimis irrites, desis- "tere ab opere, et relinquere illud in oculo cogaris. "Neque tamen tunc etiam spe optimi successus destituimur. Sxpe enim " observavi, opacum illud remanens, sive sit mucus, sive frpstulum lentis crys- " tallinae, sensim, et sponlc, citiusvel tardius, penitus disparuisse. An resor- " betur mucus lacteus, an frustula lentis crystallinae liquescant sensim, etre- " sorbentur, an in fundum oculi sensim, sc precipitant, dubium est. Utrum- " que tamen fieri credo. Quoties lactea materia post depressam cataractam " totum humorem aqueum opacitate sua et albedine inficiens sensim peni-. " tus evanuit ? Quoties pus in oculo haerens vel sanguis insigni quantitate "in ilium effVus, sensim resorptus evanuit ? Quoties frustula lentis crys- " tallina:, post depressionem cataractae, in pupilla relicta ? &.c. immo liques- " cere aliquando et resorberi haec frustula me ipsum experientia docuit." &c. Ricuter de Cataractae Extract. ' I should be sorry to have it inferred from hence, that 1 would recommend the passing the opaque crystalline through the pupil: far from it; I think it REMARKS ON THE CATARACT. 277 What I have advanced not being matter of opinion, but matter of fact, capable of being inquired into, and proved by any who will lake the trouble of so doing, I do not desire any man to give credit lo it upon my mere assertion. But if, upon repeated trial and inquiry, it should be found to be as generally and as frequently true by others, as it has been by me, may it not fairly be inferred, that whatever other reasons there may be for preferring the ope- ration of extraction to that of depression, or the use of the knife to that of the needle, yet those drawn from the supposed indissolubi- lity of the crystalline are by no means conclusive; on the contrary, are very inconclusive. But this is by no means all; for if what I alleged be true, some other consequences, not a little interesting to the afflicted, will necessarily follow. First, if the soft cataract will, when its capsula is properly wounded, mix with the aqueous humour, and undergo such a per- fect dissolution and absorption, as to leave the eye fair, clear, and fit for vision, and which I have so often proved, that I have not the smallest doubt about it; it will then follow that the softness of a cataract is so far from being an unlucky circumstance, that it is rather a fortunate one; as it enables the patient to receive more early assistance; and that from an operation attended with less pain, and a less violation of parts, than a firmer one would ne- cessarily require. Secondly—When the cataract is of the mixed kind, and which therefore frequently foils all the attempts toward depression, the firmer parts may very safely be left for dissolution; and vision be thereby restored- And, Thirdly—When the cataract shall happen to be of the firmer kind, and during an unsuccessful attempt to depress, get through the pupil behind the cornea, disappointment will be so far from being the consequence, that if no other injury has been done to the parts within, than what such attempt necessarily required, the displaced crystalline will gradually dissolve and disappear; wrong, as it is apt to produce one of the most frequent inconveniences at- tendingthe operation of ext taction—an irregularity of the pupil. I only meant to prove the fact of dissolution of the cataract in such situation; and that it will not caus^ thaf pain and trouble which it is so positively said to do. 278 REMARKS ON THE CATARACT. and the patient will see as well as any operation could have ena- bled him to have done. I may perhaps be told, that what I have hitherto alledged only tends to prove, that both the soft and mixed cataract, when mixed with the aqueous humour by the laceration of the capsula, will dissolve; but that the firm one will not, and therefore must remain, wherever placed, a solid opake body. To which I answer, in the first place, that if what has been said relative to the soft, and to the mixed cataract be true, I cannot help thinking it to be very advantageous. In the second place, that the opinion concerning the indissolubility of the displaced crystalline has, I think, been taken up, and propagated, without proper authority from inquiry and experiment, fairly and deliber- ately made, and stands merely on a few accidental observations, which are by no means satisfactory. And, in the third place, that, as far as my own inquiry and observation go, I am satisfied that it does dissolve wherever placed, provided it be perfectly freed from its attachment in its natural nidus.k Both men and books talk of firm, hard, intire, uniform cataracts, as if they were as much so as what are found in the eye of a boil- ed fish. Whence they borrow this idea, I know not, unless it be from boiled fish; certain I am that it is not from nature. Let any man examine the most firm, opake crystalline, taken from the eye of a living person, and which, from its firmness, pass- ed out through the* pupil and the divided cornea with the greatest facility; he will generally find it to be in figure, size, and consist- ence, exceedingly unlike either to the natural and sound crystalline, or to one rendered opake by heat; and he will also find, that such alteration of shape and size is owing to a partial dissolution of its k While I was preparing these sheets for the press, an old man was taken into St. Bartholomew's, who had a cataract in one eye, and had, by some ac- cident, lost the sight of the other. I couched him; the cataract was as firm as I had ever felt any, and went down as easily, as immediately, and as intire - ly as possible. Three days after the operation, he was seized with so bad a small-pox, that he died on the eleventh, and the next day I took his eye home and examined it. The cataract lay just below and behind the uvea, towards the external canthus. It was become small, irregular, and manifest- ly in a state of dissolution. REMARKS ON THE CATARACT. 279 surface, particularly its anterior one; in short, if he will examine it carefully, and without prejudice, he will see, that what he calls an intire, firm cataract, is most frequently little more than the nucleus of an opake crystalline. If a man might be allowed to argue in a case of this kind, a pri- ori, he might very reasonably ask, why should the corpus crystal- linum, which although opake, is, while in its natural situation, and enveloped in its proper capsula, so prone to dissolve, as we must know that it is, be supposed to be as prone to induration, immedi- ately upon being removed from its place. The most strenuous advocates for extraction cannot help al- lowing, that a portion or portions of a firm cataract, which they have been obliged to leave behind in the operation, dissolve and disappear in due time: it is, indeed, a fact not to be contradicted; but the same people say, that the intire cataract will not. What idea they, who argue thus, have of an intire cataract, I know not: they may possibly conceive it to be depressed, still remaining en- veloped in a firm capsula, and therefore to remain indissoluble; but if they would reflect on the extreme fineness of the capsular membrane; on the necessary action of the couching-needle, when applied to it; and on the different consistence of the different parts of every, even the most opake and firm cataract, they must see that it is a portion only of any cataract, however firm, which can in general be depressed. One of the arguments, made use of by some of the late writers, in favour of extraction, is, that as the crystalline must be destroyed, it had better be removed. Now how can it be said to be destroy- ed, if it be only displaced, and remain indissoluble? Let them take which side of this argument they please, they must be wrong; for if the diseased crystalline remain, though depressed, a solid body within the eye, how can it be said to be destroyed? and on the other hand, if it be destroyed in the operation of couching, it must be by dissolution; and therefore cannot remain. The last objection to the operation of couching is, that it must necessarily derange and violate the internal parts of the eye, par- ticularly the vitreous humour. • If what I have said on the subject of the perfectly soft cataract, as well as on that which is partially so, be true, the greatest part, 280 REMARKS ON THE CATARACT. if not the whole of this objection, will cease, with regard to these two; and it will be principally, if not totally, confined to that which is called firm and hard, and which, by its resistance to the instrument, will admit of being placed in the inferior part of the eye. In the performance of this operation, the needle may certainly be so used, as to do considerable mischief; but then it must be from the unskilfulness or awkwardness of the operator; and which may be the case of every operation in surgery. But is an opera- tion, justly chargeable vvith ills, deducible merely from its having been ill executed?—I hope not. I am very sensible that much mischief has been done by at- tempts to couch; but, in the first place, they have almost always been the consequence of want of judgment, or want of dexterity in the operator; and, in the next place, even under the most ex- aggerated representations, they are by no means equal to what has frequently been the consequence of attempts to extract. It may possibly be supposed, that I have conceived a prejudice against the operation of extraction. Of this I am not conscious. I have sought and embraced every opportunity which a public hospital, and many years practice, have afforded me of operating in both ways, and of comparing the consequences. I have seen many of the patients of others, not only of thie gentlemen of the profession, but of most of the itinerant operators; and am thereby convinced, that the greatest part of the objections to the operation of couching are invalid; have not been the result of unprejudiced experience, or a candid regard for truth; that only the fair and prosperous side of the question, regarding the operation of extrac- tion, has been industriously exhibited, while its manifold failures and ill consequences have been as industriously concealed, and that, upon a fair detail and comparison of all the advantages and dis- advantages, conveniences and inconveniences, attending each, the preference will be found justly due to the needle. Inconveniences and disappointments they are both too liable to: I heartily wish they were not. But, from the most cool and candid attention to fact, I am convinced, that the former are much greater, and the latter much more frequent, in the operation of extraction, than in that of depression, executed with the same de- gree of judgment. The couching-needle which is commonly in use, has on the face which is applied to the cataract, a flat, highly polished surface, which makes it, as I have experienced, liable to slip, if it meets with any little resistance when in contact with the surface of the cataract; or if the crystalline breaks, it does not readily attach the small portions of it. As the other side, near the point, is necessarily convex, to give a proper degree of strength to the in- strument, I conceived that an advantage might be drawn from its form to obviate the inconvenience. I therefore got some needles made with a small cavity on the flat side, the opposite convexity allowing sufficient depth for it, and the surface of this cavity was left rough and unpolished. I have used them many times during several years, and I am of opinion that this altera- tion gives a considerable advantage in laying hold of that small slippery body, the lens, or any fragment of it, and in conducting it to whatever part of the eye we think proper : by a turn of the instrument it is immediately disengaged, and neither the entrance nor passage of the needle is in any degree impeded by it. The annexed figures show the difference between the two needles. E. VOL. II. N n SOME FEW REMARKS OS THE POLYPUS OF THE NOSE. In these, as in the preceding remarks on the cataract, I do not mean to enter into a circumstantial history of the disease, but merely to offer a few practical observations on such parts of the doctrine concerning it, as appear to me to have been either inad- vertently or erroneously delivered. The polypus is a complaint which is always troublesome, fre- quently painful, and sometimes hazardous: the first of these is the necessary consequence of the situation of the distemper; the se- cond arises from its peculiar nature in the individual; and the last, sometimes from its particular nature, and sometimes from the man- ner in which it -may have been treated. Writers tell us, and very truly, that it is a disease of the mem- brana pituitaria narium; that it has different seats, origins, and attachments; that it springs from the ethmoid bone, from the ossa spongiosa, from the septum narium, and even from the antra maxil- laria; that it is hard or soft, pale or deep red, or sometimes pur- ple; that it is equal in its surface, or unequal; large or small, moveable or fixed, single or multiform, painful or indolent; that it makes its appearance forward in the nostrils, or backward in the fauces behind the uvula; and that it may be strumous, vene- real, or cancerous. When they have given us these general and merely definitive descriptions, they immediately proceed to the chirurgic treatment, or method of cure; which, they tell us, is either by extraction, or the use of escharotics; to which some have added ligature: they then give a general description of the man- 284 ON THE POLYPUS ner of using the forceps, of applying escharotics, or of passing the string round it; and having provided styptics for the suppression of haemorrhage, they leave every thing else to the reader's ima- gination, and to the practitioner's choice and judgment. From these accounts, those who have not had much opportunity of seeing for themselves, and who are thereby under a sort of ne- cessity of forming their opinions, and regulating their practice, by books, are induced to believe that, except in some few particular instances, where the distemper is palpably cancerous, all others are equally objects of chirurgic treatment; and therefore, that if, in the first instance, they can lay hqld of the polypus with the forceps, and, in the second, can provide against the haemorrhage, which they have heard so much of, they shall have nothing else to do or to fear. To me I must acknowledge the matter appears very differently. I cannot help thinking, that there are many polypi, which, al- though they are neither scirrhous nor cancerous, are very unfit for any chirurgic treatment whatever, and that from several circum- stances; which circumstances may act in different manners, though equally prohibitory: they may forbid an attempt, merely from the impossibility of its being successful; or they may forbid it, because it is more likely to do harm than good, more likely to exasperate the disease than cure it, to increase the misfortune than to lessen it. The distinctive marks of the distemper, as laid down by wri- ters, are, in general, just and true; but they only teach a young practitioner to know the disease when he may see it: they give him no warning of the mischief he may incur by attacking it un- guardedly, nor inform him of a very serious truth, viz. that this is a sort of case, in which, when real mischief has been done, it is sometimes without remedy. As far as my experience and observation go, the polypi which begin with, or are preceded by, considerable or frequent pain in the forehead and upper part of the nose, and which, as soon as they can be seen, are either highly red, or of a dark purple co- lour; they, which from the time of their being first noticed, have never been observed to be sometimes bigger, sometimes less, but have constantly rather increased; they in which the common ac- OF THE NOSE. 285 lion s of coughing, sneezing, and blowing the nose, giVe pain, or produce a very disagreeable sensation in the nostril and forehead; they which, when within reach, are painful to the touch, or which, upon being slightly touched, are apt to bleed; they which seem to be fixed, and not moveable by the action of blowing the nose, or of deriving the air through the affected nostril only (where the polypus is only on one side); they which are incompressibly hard, and which, when pressed, occasion pain in the corner of the eye, and in the forehead, and which, if they shed any thing, shed blood; they which, by adhesion, occupy a very considerable space, and seem to consist of a thickening, or of an enlargement of all the membrane covering the septum narium; they which sometimes shed an ichorous, offensive, discoloured discharge; and they, round whose lower part, within the nose, a probe cannot easily and freely be passed, and that to some height—ought not to be attempt- ed, at least by the forceps, nor indeed by any other means with which I have the good fortune to be acquainted; and this for rea- sons obviously deducible from the nature and circumstances of the polypus. On the one hand, the very large extent and quantity of adhesion will render extirpation impracticable, even if the dis- ease could be comprehended within the forceps, which it very frequently cannot; and, on the other, the malign nature of the dis- temper may render all partial removal, all unsuccessful attacks on it, and indeed any degree of irritation, productive of the most dis- agreeable consequences. But the polypi which are of a palish or greyish light brown colour, or look like a membrane just going to be sloughy; they which are seldom or never painful, nor become so upon being pressed; they which have appeared to be at one time larger, at another less, as the air has happened to be moist or dry; they which ascend and descend freely by the action of respiration through flie nose; they which the patient can make to descend by stopping the nostril which is free, or even most free, and then de- riving the air through that which the polypus possesses; they which when pressed give no pain, easily yield to such pressure, become flat thereby, and distil a clear lymph; and they, round whose lower and visible part a probe can easily, and that to some height, be passed—are fair and fit for extraction; the polypus, in 286 ON THE POLYPUS these circumstances, frequently coming away intire; or if it does not, yet it is removeable without pain, haemorrhage, or hazard of any kind; the second of which circumstances, I can with strict truth affirm I never yet met with, when the disease was at all fit for the operation.111 Of the benign kind of polypus, fit for extraction, there are two sorts, whose principal difference from each other consists in their different origin or attachment: that which is most freely moveable vyiihin the nostril, upon forcible respiration; which has been found to be most liable to change of size, at different times and seasons; that which has increased the most in the same space of time; that which seems most limpid, and most freely yields lymph upon pressure, has its origin most commonly by a stalk or kind of pe- duncle, which is very small, compared to the size of the polypus; while that which, although plainly moveable, is still considerably less so than the other; which has been less liable to alteration from air and seasons; and has been rather slow in arriving at a very troublesome size, is most frequently an elongation of the membrane covering one of the ossa spongiosa: they are both ca- pable of being extracted, and that with no kind of hazard, with very little pain, and hardly any haemorrhage at all: but the for- mer requires the least force, and most frequently comes away in- tire; while the latter often breaks, comes away piecemeal, and stands in need of the repeated use of the forceps. From the preceding observations a few practical inferences may be drawn, such as the following:— m They, who are affected with this sort of polypus, generally complain, and that for a considerable time before the polypus becomes visible, that they are perpetually catching cold, more especially in moist or wet weather; though they seldom have any other symptoms of such colds than the stop- page in and discharge from the nose. They also always complain, that these colds always deprive them of the sense of smelling. In moist weather, or in a sudden change from dry to wet, they are also subject to frequent fits of sneezing; and when the relaxed membrane is most affected to very considera- ble discharge of thin mucus, from the affected nostril. Nor do I remember ever to have seen a polypus of this kind, which was not immediately subject to a change, upon the sudden alteration of the atmosphere, from dry to moist; that is, they always become longer, fall down lower, and look fuller and paler, and generally deprive the patient of all power of smelling. OP THE NOSE. 287 First, That the polypi, under the first description, very rarely, if ever, admit at attempt toward extraction, and that not merely from the improbability of its being attended with success, but be- cause such attempt may be the cause of very disagreeable conse- quences. Second, That in those which do admit an operation, or the use of the forceps, the degree of success will depend principally upon two circumstances; viz. the benignity of the disease, and the de- gree and quantity of attachment; for although the nature of the complaint may be perfectly benign, yet it may happen, that a cure may not be attainable, and that merely from the degree and kind of attachment. And, Third, That the haemorrhage so much talked of, so solicitously guarded against by writers, and so much dreaded by young prac- titioners, will not often, if ever, be met with, in such cases as fairly and properly admit the operation. The polypus is a disease, which, of all others, is said to be most difficult totally and perfectly to eradicate, and most liable to re- production. This is, in some degree, true. It is difficult, in many instances, to extirpate it totally, and it often does grow again, more especially that sort which springs from the ossa spon- giosa; but yet, that it is not so often the case as it is supposed to be. It not infrequently happens, that there are, at the same time, two, three, or more different polypi, each of which is perfectly distinct from the others, and has a separable distinct attachment. When this is the case, the lowest or most anterior, having the open nos- tril before it, easily makes its way down, uncompressed; while the other, or others, are not only kept up, and out of sight, but are also considerably compressed. When the one, which was within sight and reach, has been re- moved, the next falls downward, and soon becomes visible; if it was large and lax, and merely kept up by what lay before it, it is often to be seen immediately; but if it was small, il may be out of sight, and can only be suspected by the passage of air through the nostril not being free, although the polypus which was re- moved came away perfect and intire; and when it does appear, it passes for a reproduction from the old stem, though it is really an- other and perfectly distinct polypus, of which the intire state of the 288 ON THE POLYPUS investing membrane, and the separation of the polypus from its single point of attachment, will upon careful examination appear irrefragable proofs.11 It may, perhaps, be remarked, that, in what I have offered concerning this distemper, I have confined myself merely to the operation of extraction only; and have said nothing concerning the various methods and means which have been proposed for its de- struction. I am very sensible that many of our books are furnished with relations of attempts made by escharotics, and by a kind of medi- cated setons; some of which have been said to be successful. If I had ever found them so, I should have been glad to have related it; but I cannot say that I have: on the contrary, all that I have done of this kind, or have seen done by others, have served more and more to deter me from practising it again. When the polypus is loose, and fairly circumstanced for extraction, it is not only the best method of cure, but is always advisable, and very frequently successful; but when from immobility, largeness of attachmen', malignity of nature, or from any other cause, il becomes Unfit for the use of the forceps, it is always, as far as I have been able to observe, still more unfit for caustic; nor indeed do I remem- ber a single case, which has been so circumstanced as to render the use of the forceps absolutely unadvisible, where the applica- tion of escharotics would not have been much more so, as experi- n Mr. Pott was particularly competent to describe this disease, having been troubled with polypi in his nose during many years: at one time they increased to such a degree as to dis-end the nostrils, and almost totally to prevent the passage of air. When they were fallen sufficiently low, Mr. Pott took an opportunity, in moist weather, and when they were in a state of relaxation, to extract the most prominent ones for himself, by means of a -pair of window forceps, before a mirror. In no great length of time others came in sight and supplied their place, which also Mr. Pott extracted in the same manner, till he had a collection of five or six large polypi: one of thein had a single basis, but was branched out into two large lobes; to some of them there adhered a small portion of bone, to which they had been fix- ed—a sufficient proof that it required no small degree of fortitude and per- severance to perform ihe operation on his own person. Of late years he had intirely got rid of them; but there remained such a thickness of the whole membrane, that he continued totally deprived of the sense of smelling— a circumstance which he never much regretted. E. OF THE NOSE. 289 menl, in some of them, has fatally proved. The structure and irritability of parts within the nose, and the impossibility of con- lining the application or limiting the effects of caustic medicines in such a part, in whatever manner or furm applied, tire pahuihle objections a priori; and the very disagreeable consequences which have been often found lo follow from the inflammation and irrita- tion of what ii was impossible totally to destroy, have been loo serious to be slighted.0 The polypus sometimes, instead of falling down the nostril, makes its appearance backward in the fauces behind the uvula; in which case the general method is, to extract it by introducing the instrument into the mouth instead of by the nose. This, though sometimes practicable, is much more easily de- scribed than executed; and in some people will be found absolutely impracticable. The objection arises from the great difficulty of keeping the tongue down in some, and in others, from their inca- pability of permitting any tiling to touch the root of that part, or any part of the fauces, without immediately producing a spasm: to which might be added, that, in some cases, the polypus is so ex- panded, as almost to conceal the uvula, which is therefore liable to be laid hold of by the instrument, to the no small detriment of the patient. However large, pendulous, or expanded such polypus may be, its attachment always is, and must be within the cavity of the nose, and therefore always within the reach of a pair of forceps intro- duced that way, especially if the forceps be somewhat curved; and which, when the excrescence appears behind the uvula, will have one advantage superior to what it has when the polypus appears in the nose; which is, that it will be applied much nearer to the point of attachment, and therefore most likely to extirpate it perfectly. » The method by ligature, whether of silk or wire, is not attended with the inconveniences of the caustic, and is certainly practicable in some instances; but, as far as 1 have seen of it, is by no means equal to that by the forceps, either for its general utility, or its capacity of perfectly eradicating the excrescence. I know some ingenious practitioners, who approve of it; but I cannot say, from what has come within my knowledge, that it appears to me in so recommendable a light. VOL. II- 00 290 ON THE POLYPUS OF THE NOSE. I cannot leave this subject without cautioning the young prac- titioner to be exceedingly careful in examining and inquiring into all the circumstances previous to his undertaking a cure, lest he should find, too late, that he has gone too far to recede. For want of such caution, I have seen haemorrhages which have been frightful, and inflammations which have proved fatal. I have seen a case wherein an untoward looking polypus, and which ought not to have been meddled with, has been so attached to a distempered septum nasi, that it has come away with it: I have seen the same thing happen with regard to almost the whole of the ossa palati; and I have more than once known a polypose thickening of the membrane covering the ossa spongiosa, and septum nasi, which, in all probability, would have remained quiet a great length of time, so irritated by rough treatment and successless attempts, as to render the remainder of the patient's life truly miserable to himself, and offensive to others. \ CANCER SCROTI Ramazini has written a book De Morbis Artificium.—The colic of Poictou is a vvell known distemper; and every body is acquainted with the disorders to which painters, plumbers, gla- ziers, and the workers in white lead, are liable: but there is a dis- ease as peculiar to a certain set of people, which has not, at least to my knowledge, been publicly noticed; I mean the chimney- sweepers' cancer. It is a disease which always makes its first attack on, and its first appearance in, the inferior part of the scrotum; where it pro- duces a superficial, painful, ragged, ill-looking sore, vvith hard and rising edges: the trade call it the soot-wart. I never saw it under the age of puberty, which is, I suppose, one reason why it is generally taken, both by patient and surgeon, for venereal; and being treated with mercurials, is thereby soon and much exaspe- rated. In no great length of time, it pervades the skin, dartos, and membranes of the scrotum, and seizes the testicle, which it enlarges, hardens, and renders truly and thoroughly distempered; from whence it makes its way up the spermatic process into the abdomen, most frequently indurating and spoiling the inguinal glands: when arrived within the abdomen, it affects some of the viscera, and then very soon becomes painfully destructive.* 1 From the soot being collected and remaining in the moist rugx of the scro- tum, it is not difficult to conceive why the disease should generally begin in that part; but I have seen the true soot-wart in the face of a chimney- sweeper, just under the left eye, who had never suffered from the disease in ».tv other part, though !iesai! tl.e patiuits have gone from the hospital seemingly well, yet, in the space of a few months, it has generally happened, that they have returned, either vvith the same disease in the other testicle, or in the glands of the groin. or with such wan complexions, 6uch pale leaden countenances, such a total loss of strength, and such frequent and acute inter- nal pains, as have suflv imtly proved a diseased stale of some of the viscera, and which have soon been followed by a painful death. If extirpation ever bids fair for the cure of a cancer, il seems • scrotum, which, when they grew troublesome, he picked off; but he had never perceived any sore, ulceration, or considerable hardness in that part. Mr. Pott has observed that he never saw the disease under the age of pu- berty ; but since the publication of his treatise I saw it in an infant under eight years of age, who was brought into St. Bartholomew's hospital, and was un apprentice to a chimney-sweeper. I showed it to Mr. Pott, who acknow- ledged it to be the true disease, and that he had not before seen it in so young a subject. It had infected all the lower part of the scrotum ; but as the testis had not imbibed the poison, the diseased part being removed, the wound healed, and the boy was discharged perfectly vvell. E. CANCER SCROTI. 293 to be in this case; but then the operation should be immediate, and before the habit is tainted. The disease, in these people, seems to derive its origin from a lodgement of soot in the ruga? of the scrotum, and at first not to be a disease of the habit. In other cases of a cancerous nature, in which the habit is too frequently concerned, we have not often so fair a prospect of success by the temoval of the distempered part; and are obliged to be content with means, which I wish I could say were truly palliative. But here the subjects are young, in general in good health, (at least at first,) the disease brought on them by their occupation, and in all probability local; which last circumstance may, I think, be fairly presumed from its always seizing the same part: all this makes it (at first) a very different case from a cancer which appears in an elderly man, whose fluids are become acrimonious from time, as well as other causes; or from the same kind of complaint in wo- men who have ceased to menstruate. But be all this as it may, the scrotum is no vital organ, nor can the loss of a part of it ever be attended with any the smallest degree of inconvenience; and if a life can be preserved1 by the removal of all that portion that is distempered, it will be a very good and easy composition; for when the disease has got head, it is rapid in its progress, painful in all its attacks, and most certainly destructive in its event.b b This species of cancer, which Mr. Pott has so accurately described, ap- pears to be produced by some peculiar acrimonious quality in soot, when in- corporated and fermenting with the secretions on the skin of some persons, whose constitutions are disposed to undergo a certain change, or receive a new modification of their inherent properties. As chimney-sweepers are in the constant habit of beingin contact with soot, it follows that they must be most liable to a disease which is evidently caused by it; but, as was before observed, those only whose constitutions are disposed to receive the poison are infected ; not one in many hundreds being injured by it. Mr. Pott seem- ed to suppose that this species of cancer was peculiar to chimney-sweepers; but I have strong grounds for thinking that he was mistaken in that idea. There are instances, though I believe them to be very rare, (as I know no one, either author or practitioner, who.has noticed them); yet there are instances of other persons being infected by the contact or effluvia of soot; ami as a caution for every one to be c.ireful of handling it, or in any way being expo- sed to its action, I will relate the case of a man who was attacked with this dreadful disease to a most lamentable degree, and was brought into the hos- '".<:•!. The ecr^i'm nnd lesti,;, wi'h the spermatic ''"ids. ♦otjethf,r -villi the 294 CANCER SCROTI. glands in the groin, were included in a large phagedenic ulcer. The nature of the disease was so marked and evident, that I took for granted that he was a chimney-sweeper, and was much surprised to find that his business was quite of another kind. I could not, however, avoid repeatedly asking him if he had ever had any thing to do with sweeping chimneys : he assured me not. Some time after he told me, that on considering the questions which I hud so often ur^td, he recollected, that not many years before he had lodg- ed at the house of a chimney-sweeper, in the apartments of which soot-bags and soot were deposited. He did not appear very accurate in his account, but thought on recollection that the complaint began in the scrotum soon af ter he left the chimney-sweeper's house. This goes nearly to prove that soot in substance, or perhaps the volatile parts of it, have the power of pro- ducing the disease ; and not any thing peculiar to the occupation or manner of life to which chimney-sweepers are subject. Probably the man's body, or his linen, were liable to be daubed with soot, or the dust arising from it; and the scrotum was first affected, as it is among chimney-sweepers, for the reason before given ; that of the moist rugae retaining the poison more readi- ly than other parts. As a further caution to "-persons who may be employed in making use of .soot, to be careful in washing and cleansing themselves, I will mention an- other case which I met with, and which in my mind goes pretty clearly to ascertain the fact, that soot is of a dangerous nature, and capable of produ- cing this disease in other people, as well as chimney sweepers. Allan Spragg, aged 49, came into St. Bartholomew's hospital, on account of a large cancerous sore, which reached from the bend of the wrist to the knuckles, occupying almost the whole of the back of the left hand. He had been under the care of many persons, and various applications and internal medicines had been given. The circumference of the sore rose in large ul- cerated tumors, and seemed inclined to spread. In some parts of the middle it appeared in a healing state—in other parts ulcerated ; but he said differ- ent parts of it had often healed and broke out again, as we afterward found it inclined to do. There was an indescribable something in the appearance of the complaint, which put me in mind of the sooty-wart, or chimney-sweep- ers' cancer ; for there is a peculiar appearance in that disease, to the eye of any one who has paid attention to it, very different from any other cancer- ous sore. This led me to make a particular inquiry into this person's life and occupation. He said he was a gardener ; that about five years before (in 1800) he was employed in a garden at Lowlayton, in Essex; that iu the spring of that year h•• was engaged about two hours every morning to strew soot on the ground, round the young and tender plants, to preserve them from the slugs ; that he carried the soot in an old garden-pot, which hung on his left hand by a handle over the top, while he strewed it with the * right. About \his time he conceived the wart commenced near the knuc- kles and continued not very troublesome all that year ; the next spring he was again employed to distribute soot; the wart was then increased and ideerated, and continued growing worse all that year. The spring follow- CANCER SCROTI. 29o mg he again used soot in the same manner : the sore then spread, and grew larger, which made work of any kind very difficult to him. It is to be remarked that the right hand which strewed the soot was unaf- fected. Probably from that action it got rid of the effect of the effluvia; but the left, being two hours exposed to the vapours or dust arising from the soot, as it was continually stirred up, a lodgement of it was probably made on the thin skin at the back of the hand. The man said he always washed his hands before he came in to breakfast, but such persons are not always very accurate in their ablutions. For the last two years he had not used soot, but the sore continued to spread rapidly; however he kept on working till October, 1*04, when he was incapable of using the hand. December 27th, he came into the l.ospital. The various means which were used, both internally and externally, to en- deavour to stop the progress of, and cure the disease, it is unnecessary to de- tail in this place, as unfortunately none of them proved of any very materia service; for though sometimes one part appeared healing, another continued to open and spread. In rerum naturd there may probably exist a cure for this dreadful malady, but it has hitherto escaped our researches. Poor Allan left the hospital several times, and put himself under the care of some soi-disans doctors, both male and female, who promised to cure him, but always returned with the disease worse and worse, till at last he submit- ted to amputation, after which the excruciating pains which he had suffered soon left him, and as a pretty clear proof of the locality of the disease, and that it was not constitutional, the wound from the operation healed kindly, and he got perfectly well. E. OBSERVATIONS OX THE MORTIFICATION OF THE TOES AND FEET. The powers and virtues of the Peruvian bark are known to almost every practitioner in physic and surgery. Among the many cases in which its merit is particularly and justly celebrated, are the distempers called gangrene and mortification; its general power of stopping the one, and resisting the other, have made no inconsiderable addition to the success of the chirurgic art: but still there is a particular species even of these, in which this noble medicine most frequently fails; I mean that particular kind, which, beginning at the extremity of one or more of the small toes, does, in more or less time, pass on to the foot and ankle, and sometimes to a part of the leg, and, in spite of all the aid of physic and surgery, most commonly destroys the patient. It is very unlike to the mortification from inflammation, to that from external cold, from ligature, or bandage, or to that which proceeds from any known and visible cause, and this as vvell in its attack as in its process. In some few instances it makes its appearance with little or no pain; but in by much the majority of these cases, the patients feel great uneasiness through the whole foot and joint of the ankle, particularly in the night, even before these parts show any mark of distemper, or before there is any other than a small discoloured spot on the end of one of the little toes. vol. n pp 298 ON THE MORTIFICATION It generally makes its first appearance on the inside, or at the extremity of one of the smaller toes, by a small, black, or bluish spot: from this spot the cuticle is always found to be detached, and the skin under it to be of a dark red colour. If the patient has very lately cut his nails, or corn, it is most frequently, though very unjustly, set to the account of such opera- tion. Its progress in different subjects, and under different circum- stances, is different; in some it is slow, and long in passing from toe to toe, and from thence to the foot and ankle; in others its progress is rapid, and horridly painful. It generally begins on the inside of each small toe, before it is visible either on its under or upper part; and when it makes its attack on the foot, the upper part of it first shows its distempered state, by tumefaction, change of colour, and sometimes by vesication; but wherever it is, one of the first marks of it is a separation or detachment of the cuticle. Each sex is liable (o it; but for one female in whom I have met with it, I think 1 may say, that I have seen it in at least twenty males. I think also that I have much more often found it in the rich and voluptuous, than in the labouring poor; more often in great eaters, than free drinkers. It frequently happens to persons advanced in life, but is by no means peculiar to old age. It is not, in general, preceded or accompanied by apparent distempera- ture either of the part, or of the habit. I do not know any par- ticular kind of constitution which is more liable to it than an- other; but, as far as my observation goes, I think that I have most frequently observed it to attack those who have been subject to flying, uncertain pains in their feet, which they have called gouty, and but seldom in (hose who have been accustomed to have the gout regularly and fairly. It has, by some, been supposed to arise from au ossification of vessels; but for this opinion I never could find any foundation but mere conjecture. The common method of treating this distemper is, by spirituous fomentations, cataplasms actually and potentially warm, by dress- ings of the digestive kind, as they are called, animated with warm, pungent oils and balsams, &c; and, internally, by the Peruvian bark. OP THE TOES AND FEET. 299 I wish I could say that this, which, with little alteration, has been the general practice, had been most frequently, or even often successful; but I am, from long and repeated experience, obliged to say, that it has not. I am sensible that many of my readers will be surprised at my affirming, that the Peruvian bark will not stop a mortification, a distemper in which, for some years, it has been regarded as spe- cific; but I must beg not to be misunderstood; I mean to confine my observation and my objection to this particular species of mor- tification, which I regard as being sui generis; and under this re- striction I must repeat, that I have seldom, if ever, seen the bark successful: in all other cases, wherein it is used or recommended, no man has a*higher opinion of it; but in this I cannot give it a praise which it does not deserve. I believe I may venture to say, that I have tried it as fairly, as fully, and as variously, as any man has or can: I have given it in the largest quantity, at the shortest intervals, and for the longest possible space; that is, as long as the patient's life would permit. I have given it by itself, in decoction, extract, and substance. I have combined all these together. I have joined it vvith nitre, sal. absynth., with snake-root, with confect. cardiac, with vola- tile salts, and with musk, as different circumstances seemed to re- quire or admit I have used it as fomentation, as poultice, as dressing. I have assisted it with every thing which has been usually thought capable of procuring, or assisting digestion: still the distemper has continued its course, perhaps a little more slowly, but still it has ended in death. # I am sorry to rob one of our great medicines of any part of its supposed merit; but as, on the one hand, its claim, in fhis in- stance, is unjust, and as, on the other, I hope to add as much to the character of another, the res medica will be no sufferer. Some time ago, I had a patient labouring under this complaint, who, from antipathy, obstinacy, or some other cause, could not be prevailed on to take bark in any form whatever. I made use of every argument, but to no purpose. Fomentation, poultice, and the usual dressings were applied in the usual manner; the disease advanced, some days more, some days less, and, at the end of a fortnight, the small toes were all completely mortified, the great 300 ON THE MORTIFICATION one become blackish, the foot much swollen, altered in colour, and the disease seeming to advance with such hasty strides, that I sup- posed a very few days would determine the event. The pain in the foot and ankle was so great, and so continual, as totally to deprive the patient of sleep. On this account, and merely to pro- cure some remission, I gave two grains of opium at night, which not having the desired effect, I repeated it in the morning. Finding, during the following day, some advantage, I repeated the same dose night and morning, for three days; at the end of which time the patient became quite easy, and the appearances on the foot and ankle were visibly more favourable. Encouraged by this, I increased the quantity of the medicine, giving one grain every three or four hours, taking care to wateh its narcotic effect, and to keep the belly empty by clysters. In nine days from the first administration of the opium, till the tumefaction of the foot and ankle totally subsided, the skin recovered its natural colour, and all the mortified parts plainly began to separate; in another week they were all loose, and casting off, the matter was good, and the incarnation florid. During the whole of this time, I continued the use of the opium, varying its quantity as circumstances required, but never gave less than three or four grains in twenty-four hours. When the sloughs were all cast off, the bones separated, and I had only a clean sore to dress and heal, I gradually left off the medicine. I am very willing to acknowledge, that however well pleased I might be with the event of this case, yet I really regarded it as accidental; so much so, that having very soon after another oppor- tunity, I did not care to trust to opium alone, but joined the bark with it.» The event was equally fortunate. But although I had joined the cortex with the extractum thebaicum, and did therefore attribute the success to their united powers, yet the effect was so very unlike to what I had ever seen from the bark without opium, that I could not avoid seriously, and often, reflecting on it, and determining to use it by itself, whenever another opportunity should offer. I did so, and succeeded in the same happy manner, though under the very disagreeable circumstances of seventy years of age, a broken, distempered constitution, and the disease making a hasty progr* ss. OF THE TOES AND FEET. 301 To relate cases which are nearly, or at least materially similar, is of no use: I shall therefore only say, that every opportunity, which I have had since of making the experiment, has still more and more conv inced me of the great value and utility of this medi- cine, and of its power of rescuing from destruction persons under this affliction. I cannot say that it has never failed me: it certainly has; but then it has been under such circumstances, as I think would fairly account for the failure. I should be exceedingly sorry to be misunderstood; I should be still more so to mislead any body; and therefore I beg it may be noticed, that I do not propose the extractum thebaicum, in this case, as an universal, infallible specific. I know, from experience, that it is not: but as I also know, from repeated experience, that it will, under proper management and direction, do more than any, or than all other medicines; and that I have, by means of it, saved some lives, which, I am very sure, would, under the common and most approved method of treatment, without it, have been lost— I could not answer to myself the not communicating what I had observed. If this was an experiment, in which the life, or limb, or health of the patient was in any degree endangered, or by which the per- son, on whom it may be tried, could in any degree be injured, I should have withheld what I now publish, until a greater length of time, and more experience, had rendered it still more, absolutely certain; and I should have thought myself strictly vindicable in so doing: but as this is a medicine, whose general effects are well known, and which is at the same time so capable of direction and management, that it is almost impossible for any person, who deserves to be trusted with medicine at all, to do any material harm with it, I thought it would be wrong and unjust to conceal what had occurred to me, lest I might thereby deprive the afflicted of an assistance, which, I verily believe, is not to be obtained from any other quarter. In short, from what I have seen and done, I am perfectly con- vinced, that, by its means, and by its means solely, I have saved lives which, without it, must have been lost. If it preserves a few of those, who are so unfortunate as to labour 302 ON THE MORTIFICATION under this nasty, painful, lingering, and destructive disorder, to which we are all liable, and which has hitherto, most frequently, foiled all attempts of art, I shall be sincerely glad to have con- tributed to so good an end: if it should prove in other hands as successful as it has with me, I shall be still more so: but on the other hand, if after several times giving me reason to believe and hope that it would prove an instrument for the preservation of many, it should, upon more repeated trial, be found to fail, I shall be sorry for the event, but shall still think, that I did right in com- municating what I had seen, and thereby endeavouring to be useful to mankind. Hoc opus, hoc sludium, parvi properemus et ampli, Si patriae volumus, si nobis vivere cari. If I am right in my conjecture concerning this hazardous and destructive malady; and if the method which I have proposed and practised, should prove as successful in the hands of others, as it has in mine, I cannot help thinking, that the external or chirurgic treatment of the disorder might be amended; that is, might be made to coincide more than it does at present with such sooth- ing kind of plan. Since I have had reason to embrace this opinion, and to act in conformity to it, I have found more advantage from frequently soaking the foot and ankle in warm milk, than from any spiritu- ous or aromatic fomentations whatever; that is, I have found the one more capable of alleviating the pain, which such patients al- most always feel, than the other; which circumstance I regard as a very material one. Pain is always an evil; but in this par- ticular case I look upon it as being singularly so. Whatever heats, irritates, stimulates, or gives uneasiness, appears to me al- ways to increase the disorder, and to add to the rapidity of its progress; and, on the contrary, I have always found that what- ever tended merely "to calm, to appease, and to relax, at least re- tarded the mischief, if it did no more. The whole plan of the chirurgic treatment of this disease is founded on a general idea of warming, invigorating, stimulating, 3nd resisting putrefaction; and the means generally made use of OF THE TOES AND FEET. 303 are very proper for such purpose; but I must own that I think the purpose, or intention, to be improper. Upon this principle, the old theriaca Londinensis, and the pre- sent cataplasma e C)mino, have been, and still are so freely used on this occasion. A composition of this kind, if it does any thing, must heat and stimulate, and it is by heating and stimulating the skin, to which it is applied, that it so frequently does that mis- chief which I am confident it often does, though such mischief is set to the account of the nature of the disorder. Cases exactly similar, in all circumstances, are not to be met vvith every day; but I am from experience convinced, that of two, as nearly simi- lar as may be, in point of pain, if the one be treated in the usual manner, vvith a warm, stimulating cataplasm, and the other only wilh a poultice made of the fine farina seminis lini, in boiling milk or water, mixed with ung. sambuc. or fresh butter, that the pain, and the progress of the distemper, will be much greater and quicker in the former than in the latter. When the black or mortified spot has fairly made its appear- ance on one or more of the toes, it is the general practice to scarify or cut into such altered part with the point of a knife or lancet. If this incision be made merely to learn whether the part be mor- tified or not, it is altogether unnecessary: the detachment of the cuticle, and the colour of the skin, render that a decided point. If it be not made quite through the eschar, it can serve no pur- pose at all; if it be made quite through, as there is no confined fluid to give discharge to, it can only serve to convey such medi- cines as may be applied for the purpose of procuring digestion lo parts capable of feeling their influence, and on this account they are supposed to be beneficial, and therefore right. When the upper part of the foot begins to part vvith its cuticle. and to change colour, it is a practice with many to scarify imme- diately; here, as in the preceding instance, if the scarifications be too superficial, they must be useless; if they be so deep, as to cause a slight haemorrhage, and to reach the parts which have not yet lost their sensibility, they must do what indeed they are generally intended to do, that is, give the medicines which shall be applied, an opportunity of acting on such parts. The medicines most frequently made use of for this purpose 304 [ ON THE MORTIFICATION are, like the theriaca, chosen for this supposed activity; and con- sist of the warm, pungent oils and balsams, whose action must necessarily be to stimulate and irritate. From these qualities they most frequently excite pain, which, according to my idea of the disease, is diametrically opposite to the proper curative inten- tion; and this I am convinced of from repeated experience. The dressings cannot consist of materials which are too soft and lenient; nor are any scarifications necessary for their applica- tion. But I would go further and say, that scarifications are not only useless, but, in my opinion, prejudicial, by exciting pain, the great, and chiefly to be dreaded, evil in this complaint. The poultice should be also soft, smooth, and unirritating; its intention should be merely to soften and relax; it should comprehend the whole foot, ankle, and part of the leg; and should always be so moist or greasy, as not to be likely to become at all dry or hard between one dressing and another. I will trouble the reader with only one remark more. When the toes are, to all appearance, perfectly mortified, and seem so loose as to be capable of being easily taken away, it is, in general, thought right to remove them. However rotten and loose they may seem to be, or really are, yet while they hold on, they hold by something which is still endued with sensation, as may always be known, if they be bent back or twisted with any de- gree of violence. I will not enter into a dispute about the sensibility or insensibi- lity of ligaments, nor undertake to determine whether thay be liga- ments, or any other kind of parts which still maintain the connex- ion of the toes with their own respective joints, or with the me- tatarsal bones; it is sufficient for me to know, and to inform the young practitioner, that however loose they may seem, yet if they be violently twisted off, or the parts by which they hang be divid- ed, a very considerable degree of pain will most commonly attend such operation, which therefore had much better be avoided; and that I seen this very pain, thus produced, bring on fresh mischief, and that of the gangrenous kind. If the patient does vvell, these parts will certainly drop off: if he does not, no good can arise from removing them. REMARKS ON THE NECESSITY AND PROPRIETY OF THE OPERATION OF AMPUTATION, IN CERTAIN CASES, AXJl LNDER CERTAIN CIRCUMSTANCES VOL. II w q REMARKS OPERATION OF AMPUTATION. No man, however slightly acquainted with the history of Sur- gery can have the smallest doubt of the superiority which its pre- sent state justly claims over that of our predecessors, especially over that of our more remote ones. The surgery of the last century, and even of some part of this, was coarse and cruel in its operative part, painful and tedious in what is generally called the curative. A multiplicity of heavy unmanageable instruments characterised the former, and a variety of irritating applications the latter. By means of the one, many operations were rendered much more terrible to bear, as well as more hazardous in the event, than they ought to have been; while long suffering and tedious confinement became the necessary con- sequences of the use of the other. To simplify the art has been the aim of all the best practition- ers of later times, and to this they owe both their success and their reputation; by this they have reduced our instruments to a small number, and have rendered those which are now used much more manageable; upon the same plan, they have discharged a farrago of external applications, the majority of which were either useless or mischievous. A prosecution of the same method will. 308 REMARKS ON AMNJTATION. I make no doubt, produce greater improvements, but still opera- tions will for ever remain unavoidable in particular circum- stances, and some diseases will still sometimes require applica- tions which must produce uneasiness: to render these as seldom necessary, and as little painful as possible, should be the business of every practitioner, and this is all that art can do, or that should be expected from it. The boast of universal specifics, of reme- dies infallibly preventive of diseases, and of means whereby chirurgical operations may be rendered totally unnecessary, is the language of quackery, and not of science. The amputation of a limb is an operation terrible to bear, hor- rid to see, and must leave the person on whom it has been per- formed in a mutilated, imperfect state; but still it is one of those which becomes, in certain circumstances, absolutely and indis- pensably necessary. To those who are well acquainted with surgery, it must ap- pear needless to have said this; they well know the truth of it: but as they who have not had sufficient opportunity of obtaining practical information, may be misled by a contrary doctrine, when boldly advanced; and as they who are reallv well informed, may, under certain circumstances, be deterred from acting up to their knowledge, I have thought that I should not absolutely mis- spend my time, nor do mankind a disservice, if I took (Iks oppor- tunity of giving the subject a little consideration. I am the more inclined to do this for three reasons: 1st. Because I am satisfied that the propriety of amputations in certain cases, stands upon as fixed and as rational principles as any part of surgery. 2d. Because a contrary doctrine has within a few years been boldly and industriously propagated, not without some very in- decent, as well as untrue reflections, on the profession in general, and on those who have the care of hospitals in particular: and, 3dly. Because I am convinced that such doctrine has been em- ployed to the prejudice of mankind, by covering ignorance and timidity, and also for serving the base purpose of malevolence. "Neoccidisse nisi servasset,'''' is, under certain limitations, a very just and prudent maxim, but taken at large may be produc- REMARKS ON AMPUTATION. 309 live of much mischief. Mankind are rather too apt to form their opinion from events only; success with many constitutes propriety, and the failure of il is often very unjustly set to the account of mis- conduct, or of want of knowledge. A young practitioner at a distance from assistance, and thereby deprived of that support, may be afraid to put his character to hazard, by. acting in such manner, as although it might justly entitle him to success, yet cannot command it. He may understand his art, but art is not infallible. He may be a very excellent surgeon, and yet be afraid to encounter the prejudices of some, or the malevolence of others. A few years ago a book was published professedly to oppose and condemn the practice of amputation, in all cases whatever, and almost without exception. The book was written by a Mr. Bil- guer, a surgeon in the Prussian service. Mr. Tissot wrote some Annotations on it, and a Preface, announcing its great and won- derful merit and utility; and the whole was translated into Eng- lish, and dedicated to Sir John Pringle. Both the book and the Annotations contain some very extraordinary doctrines and asser- tions, neither of which it is my intention to criticise in this place. They who read the work, and understand the subject, will, I verily believe, have but one opinion. The writer, as well as the annotator, may have meant well; but certain I am, if their^pinions were generally followed, mankind would be great sufferers. The particular cases in which the operation of amputation is totally and absolutely unnecessary, and therefore wrong, are in his own words, or at least in those of his translator, as follow:— " 1st. A mortification which spreads until it reaches the bone. « 2dly. Any limb so greatly hurt, whether by fracture or dilace- " ration, that there is room to dread the most fatal conse- " quences. " 3dly. A violent contusion of the soft parts, which has at the u same time shattered the bones. " 4thly. Wounds of the larger vessels, which ctrvey blood into « the limb, either as the only way of stopping-the haemorrhage, or « through apprehension it should perish for want of nourishment. u Sthlv. Au incurable caries of the bone.v 310 REMARKS ON AMPUTATION. In the first of these the art of surgery has very little to do, ex- cept the mere sawing the bones through: nature, if the patient lives, will in general do all the rest, and will remove the limb, whether the surgeon may choose it or not. In the 2d, 3d, and 4th, what the writer has asserted is so repugnant to the universal opinion of all the ablest and best practitioners, to common sense, and to constant experience; and his doctrine would, if followed, be productive of so much mischief to mankind, that I cannot help bearing my testimony against it. But as flat contradictions have no more authority than positive assertions, I take this opportunity of giving my reasons for a different opinion at large. The cases in which, under certain circumstances, amputation may become necessary for the preservation of the patient's lifet are several; but I will confine myself to four. These are: 1. A compound fracture. 2. Some kind of scrofulous joints. 3. Some kind of aneurisms. 4. A caries of the whole substance of the bone or bones com- posing a limb. In all, and each of which, it may, and does sometimes so hap- pen, that the patient's life can be only preserved by the loss of his limb. This doctrine is very opposite to that of the book just cited; but if it be consonant to truth and experience, it matters not from whom it may differ. In compound fractures, there are three points of time in which the operation of amputation may become necessary. The first of these is immediately, or as soon as may be, after the receipt of the injury. The second is, when the bones continue for a great length of time without any disposition to unite; and the discharge from the wound has been so long and is so large, that the patient's strength fails, and general symptoms foreboding dissolution come on. And the third is, when a mortification shall have taken such complete possession of the soft parts of the inferior part of the limb, quite down to the bone, that, upon separation of such parts, the bone or bones shall be left bare in the inter-space. The first and second of these are matters of very serious consi- deration. The third hardly requires any. When a compound fracture is caused by the passage of a very REMARKS ON AMPUTATION. 311 heavy body over a limb, such, for instance, as the broad wheel of a wagon, or a loaded cart, or by the fall of a very ponderous body on it, or by a cannon shot, or by any other means so violent as to break the bones into many fragments, and so to tear, bruise, and wound the soft parts, that there shall be good reason to fear that there will not be vessels sufficient to carry on the circulation with the parts below the fracture, it becomes a matter of the most seri- ous consideration, whether an attempt to save such person's limb will not be the occasion of the loss of his life: this consideration must be before any degree of inflammation has seized the part, and therefore must be immediately after the accident. When inflammation, irritation, and tension have taken place, and when the air admitted freely into the tela cellulosa has begun to exert its pernicious influence, it is too late: an operation then, instead of being beneficial, would prove destructive. The necessity of immediate, or very early decision in this case, arising from the circumstances already mentioned, make this a very delicate part of practice: for however pressing the case may seem to the surgeon to be, it will not in general appear in the same light to the patient, to the relations, or to by-standers; they will be inclined to regard the proposition as arising from ignorance how to treat the case properly, or from an inclination to save trou- ble; or perhaps from a still worse motive, a desire to operate; and it will often require more firmness on the part of the practitioner, and more resignation and confidence on the part of the patient, than is generally met with, to submit to such a severe operation, in such a seeming hurry, and upon so little apparent deliberation: and yet it often happens, that the suffering this point of time to pass, decides the patient's fate. I must repeat, that this necessity of early decision, arises from the very just dread of the ill effects of a greatly obstructed circulation, owing to a large destruction of ves- sels: these, added to those arising from pain, irritation, and the admission of air, often produce a high fever, and intense inflam- mation, ending, and that very shortly, in gangrene, mortification. and death. That this is no exaggeration, melancholy and fre- quent experience evinces, even in these whose constitutions pre- vious to the accident were in good order; but much more in those who had been heated bv violent exercise, or labour, or liquor, 312 REMARKS ON AMPUTATION. who have led very debauched and intemperate lives, or who have habits naturally inflammable and irritable. This may be, and often is the case, when the fracture happens to the middle part of the bones, at the greatest possible distance from the extremities; but is much more likely to happen, and in- deed much more frequently is the case, when any of the large joints are concerned: the circumstances of broken bones in these parts, and of torn, bruised, and wounded ligaments, to say nothing of the admission of air into joints, are dreadful additions to the hazard, and demand a speedy decision, as they are productive of the worst consequences in the shortest space of time; and there- fore, that, in many of these cases, a determination for or against amputation is really a determination for or against the patient's existence, is a truth of which I am as well satisfied, as I am, or can be, of any truth whatever. That it would have been impossible to have saved some limbs which have been cut off, no man will pretend to say; no man that knows anything of the matter can say it:, but this does not at all alter the consideration, or render the practice injudicious or blama- ble, the question really standing thus:—Do not the majority of those whose misfortune it is to get into the just mentioned hazard- ous circumstances, and on whom the operation of amputation is not performed, perish, and that by means of their wounds? Or, to put the same question into other words, have not many lives been preserved by means of amputation, which, from the same circumstances, would otherwise most probably have been lost?j It is not for me, especially after what I have said, to determine it: it is not indeed for any one man to do it. I therefore appeal to all the best practitioners, to thoso who have seen the most of these accidents, for the truth of the assertion. When a judicious man says that a limb ought to be removed, it is not to be supposed that he means to say, that it is absolutely impossible, at all ever.ts, that such limb can be saved, nor that such patient must infallibly die if the operation be not performed; no, he only means, that from repeated experience of himself and others, in all times, it has been found, that the circumstances above mentioned put the patient's life much more to hazard in an attempt <<) save the \ini\>. than the operation does in removing it; and thcr••-- REMARKS ON AMPUTATION. 313 fore that humanity as well as judgment determine for the latter. On the other hand, it must be allowed, that, from some of the worst of these cases, some have had the good fortune to escape; but escapes they so truly are, that I make no scruple to affirm, that in certain cases and circumstances, a determination not to amputate, is a determination much more unfavourable and hazardous to the patient, than that for amputation can be. It is, I think, impossible for any person, who has either sense or candour, so to misconstrue what I have said, as to imagine that I would recommend the amputation of the majority of limbs which have suffered a compound fracture: such conduct would be as inju- dicious as it would be cruel. My meaning is, that the operation should be limited and confined to certain cases and circumstances already mentioned, and that under them it is not only proper, but necessary. Pressing and urgent as the state of a compound fracture may be at this first point of time, still it will be a matter of choice whether the limb shall be removed or not. Very serious deliberation may be required, added to all the judgment and experience of the most able practitioner, to determine what may be most for the patient's safety; but at the second period which I have mentioned, the opera- tion ceases to be a matter of choice, it must be submitted to, or the patient must die. The most unpromising appearances at first do not necessarily or constantly end unfortunately. Every body conversant with busi- ness of this kind, knowTs, that sometimes, after the most threatening first symptoms, after considerable length of time, great discharges of matter, and large exfoliation of bone, it happens, that notwith- standing all these difficulties and discouragements, success shall ultimately be obtained, and the patient shall recover his health and the use of his limb. But it is also as well known, that after the most judicious treat- ment through every stage of the disease; after the united efforts of physic and surgery, it sometimes happens that the sore, instead of granulating kindly, and contracting daily to a smaller size, shall remain as large as at first, with a tawny, spongy surface, dis- charging a large quantity of thin sanies, instead of a small one vol. ir. r r 314 REMARKS ON AMPUTATION. of good matter; that the fractured ends of the bones, instead of tending to exfoliate, or to unite, will remain as perfectly loose and disunited as at first, while the patient shall lose his sleep, his appe- tite, and his strength, a symptomatic fever of the hectical kind, vvith a quick, small, hard pulse, profuse sweats, and collfquative purgings, contributing at the same time to bring him to the brink of the grave, notwithstanding every kind of assistance. In these circumstances, which are by no means uncommon, if amputation be not performed, I should be glad to be informed what else can rescue the patient from destruction. Let it not, by way of answer, be said, that a more generous plan of diet should be prescribed; that bark, cordials, anodynes, astrin- gents, &c. should be taken, because I should be very sorry to have it supposed that I was either so unknowing or so brutal as to think of amputation, before every thing of this kind had been fairly and fully tried, and found ineffectual. I confess that I know of nothing but the operation which can be attempted; and when, instead of this, I hear people talk of specific balsams, particular fomenta- tions, &c. I can only be sorry to find that they are so weak or so wicked. I might in this place mention a case which I have twice seen, which is, that in a compound fracture, which has got well through the first or inflammatory state, the bones, instead on the one hand of exfoliating or uniting, or on the other of remaining entirely dis- united, shall (in particular constitutions) become thoroughly dis- tempered and enlarged through their whole substance, forming such a kind of caries as nothing but amputation can cure. The third and last period which I mentioned regarding compound fractures, and requiring amputation, is indeed a matter which does not require much consideration. Every practitioner knows that sometimes, too often indeed, it happens that the inflammation consequent upon the injury, instead of producing abscess and suppuration, tends to gangrene and mor- tification; the progress of which is often so rapid, as to destroy the patient in a very short space of time, constituting that very sort of case in which amputation should have been immediately performed. But it also sometimes happens, that even this dreadful and very threatening malady is, by the help of art, put a stop to, REMARKS ON AMPUTATION. SI5 but not until it has totally destroyed all the surrounding muscles, tendons, and membranes, quite down to the bone, which, upon the separation of the mortified parts, is left quite bare, and all circulation between the parts above and those below, is, by this totally cut off. If it should be said, that merely sawing the bare bones cannot be called amputating, I will not dispute about the propriety of the phrase; but only beg leave to observe, that call the operation by what name you please, the patient loses his limb. The case is exactly the same, when a mortification, from what- ever cause, has seized the lower part of a limb, and produced the same effect. This is the very case which M. Bilguer has mentioned, of mortification seizing all the parts down to the bone. Let the cause of the mortification be what it may, if the effect be the destruction of all the soft parts down to the bone or bones, either the surgeon must saw them, or they must be left to separate: in cither case the patient loses his limb. Scrophulous joints, with enlarged carious bones, and distemper- ed ligaments, make a second kind cf case, in which I have said that amputation may become absolutely necessary. There is one circumstance attending this kind of complaint, which often renders it particularly unpleasant, which is, that the subjects are most frequently young children, or at least are at so early an age, as to be incapable of determining for themselves, which inflicts a very distressing task on their nearest relations. The common people call these, white swellings; a term not very inapt, because it conveys an idea of one mark of the distem- per, which is, that notwithstanding the increase of size in the joint, the skin is not inflamed, but retains its natural colour. A history of this kind of disease is a thing very much wanted;" and I much wish that some man, who has leisure and capacity, and who has seen business, would undertake it. If I was possess- ed of the requisite knowledge, it would carry me too far from my present purpose, which is only to prove that, when it affects the joints in a certain manner, and to a certain degree, that then the mischief which it causes is such, that nothing but the removal of the joint can remedy. Whoever has had opportunity of seeing much of this disease. 316 REMARKS ON AMPUTATION. must know, that all the efforts of physic and surgery, by internal as well as external means, do often prove absolutely ineffectual, not only to cure, but even to retard the progress of this most ter- rible malady. I should be sorry to be misunderstood: I do not mean to say, that this is always, or even most commonly the case, nor that scrophulous joints are not sometimes relieved, and even cured, by means of art. I sincerely wish that they were more frequently, and that we were possessed of more effectual remedies for this purpose than we are, or at least than I am acquainted with; but to the great misfortune of scrophulous people, every man conver- sant with business knows, that the disease often begins in the very inmost recesses of the cellular texture of the heads of the bones forming the larger articulations, such as the hip, knee, ankle, and elbow; that the bones so affected spread gradually, and becdme enlarged to a very considerable degree, and carious throughout, sometimes with great pain and symptomatic fever, sometimes with very little of either, at least in the beginning; that the cartilage's covering the ends of these bones, and designed for the mobility of the joints, are totally destroyed; that the epiphyses in many young subjects are either partially or totally separated from the said bones; that the ligaments of the joints are so thickened and spoiled by the distemper, as to loose all natural appearance, and become quite unfit for all the purposes for which they were intended; that the parts appointed for the secretion of the synovia become distem- pered in like manner; that all these together furnish a large quan- tity of stinking sanious matter, which is discharged either through artificial openings made for the purpose, or by small ones made by erosions, and that these openings commonly lead to bones which are rotten through their whole texture; that, bad as this is, it is not all, nor the worst; for when the disease is got into this state, the constant pain, the irritation, and the absorption of poison from all these distempered parts, bring on a fever of the truly hectical kind, attended with the most destructive general symptoms, such as total loss of appetite, rest, and strength, profuse night sweats, and as profuse purgings, which foil all the efforts of medicine, and bring the patient to the brink of destruction. REMARKS ON AMPUTATION. 317 That this is no exaggeration is known to every body. Now, supposing that the art of surgery, or, what is by many supposed to be more capable, the art of quackery, could exfoliate all the bones of a large joint, and restore the internal and medul- lary parts of it to a sound state; supposing either of them capable of giving the ligamentous parts a new and healthy structure, and of re-uniting the loosened epiphyses; I say, supposing, against all sense, and experience, all this to be practicable, yet it must require a length of time to accomplish, which such patient's state will not admit. The state which I have described is no uncommon one, neither are the circumstances at all exaggerated; but it is the state of a person hastening rapidly to destruction, who has no time to lose, and whose life can be preserved by the removal of the limb only. That unless the operation be performed, such patient will perish, is an incontestible truth; and it is as incontestibly true, that num- bers in the same circumstances have, by submitting to the opera- tion, recovered firm and vigorous health, which they have enjoyed for many years, or even during a long life; and therefore, bad as this state of things is, and terrible as it must be to loose a limb, yet if it be thought preferable to parting with life, it is a consola- tion to have the malady fall on a part where amputation can be performed, such as the knee, ankle, or wrist, rather than on the hip, where it cannot, or on the parts about the lumbal vertebras, there causing those most dreadful and most destructive distempers, known*5 by the names of the Lumbal and Psoas Abscess. eM. Bilguer and M. Tissot are the only people whom I have^met with, or heard of, in the profession, who speak of an amputation in the joint of the hip, as an advisable thing, or as being preferable to the same operation in the thigh: the doctrine is so new, and so uncommon, that I must beg leave to cite the whole passage in their own words, lest my reader should not give me credit. " The difficulty attending amputation in the upper pails of the thigh is so " considerable that surgeons rather choose to abandon to their fate those " wounded men, where it appears necessary, than to undertake it; and I own "I am of the same opinion with them. If, nevertheless, a case occurred, " wherein the death of the patient was cevtain, if amputation wis not per- $15 REMARKS ON AMPUTATION. The third kind of disorder which I mentioned as sometimes producing the necessity of amputation, was the aneurism. That kind of dilatation of the arterial tube, which is called a true aneurism, is sometimes found in the middle, sometimes in the upper part of the thigh, and sometimes in the ham. The general characteristic marks of this distemper are, a cir- cumscribed tumor, small at its first appearance, but gradually in- creasing, and for some length of time having a pulsatory motion and feel, exactly correspondent with the patients pulse at the wrist. This pulsation arising from the motion of the blood from the heart through the artery, is very easily seen and felt for some "formed, I would even prefer taking off the limb at the articulation, rather " than at any other place." The reason which M. Bilguer gives for this is as extraordinary : " for al- " though it be extremely difficult, yet it prevents the inconveniences and " accidents which a stump might occasion." M. Bilguer's annotator seems determined not to be behind hand with his author, part of his note on the preceding passage being as follows :—" I am "of opinion that if any one had the misfortune of being reduced to the ne- cessity of choosing between amputation at the upper part of the thigh, or uat the articulation itself, one reason for preferring the latter would be, the "greater ease there is in stopping the haemorrhage of the crural artery."— Very extraordinary doctrine this! That amputation in the joint of the hip is not an impracticable operation (although it be.a dreadful one), I very well Know: I cannot say that T have ever done it, but I have seen it done, and am now very sure I shall never do it unless it be on a dead body. The parallel which is drawn between this operation, and that in the joint of the shoulder, will not hold. In the latter it sometimes happens, that the caries is confined to the head of the os hume- ri, and that the scapula is perfectly sound and unaffected. In the case of a catious hip joint, this never is the fact: the acetabulum ischii, and parts about, are always more or less in the same state, or at least in a distemper- ed one, and so indeed most frequently are the parts v/ithin the pelvis—a circumstance this of the greatest consequence ; for the power of perform- ing the operation beyond the seat of the disease, and consequently of to- tally removing all the distempered parts, is the very decisive circumstance in favour of amputation every where but in the hips, where (to say nothing of the horridness of the operation itself) the hemorrhage from a multiplicity of vessels, some of which are of considerable size, and the immense discharge which a sore of such dimensions must furnish, the distempered state of the parts, which cannot by the operation be removed, will render it ineffec- tual, bold and bloody as it must be. REMARKS ON AMPUTATION. 319 length of lime; but as the tumor becomes gradually larger, the pulsation in it becomes more and more obscure to the touch; and in length of time, when either the artery is dilated to a very con- siderable size, or has burst, and has shed part of its contents, the motion becomes, in some cases, so obscure as hardly to be felt at all, or at least not without very diligent attention. When it has got into this state, whether it be femoral or poplitean, the lower part of the limb becomes, by the pressure of the extravasated blood, and by the obstruction to the circulation through the dilated artery, considerably loaded and swollen, unfit for use or motion, and generally very painful. This is the state, or very nearly the state, in which we most frequently see it, especially among the labouring poor, who gene- rally neglect it until it renders them lame and incapable of fol- lowing their employment; and when it is got into this state it re- quires immediate attention. In what manner is this disease, when got to this point, to be treated? or how is the curie of it to be attempted? for, if some- thing be not done, the limb will become mortifie.d, and the patient will perish. If a man was to answer from theory, he would say, that the skin is to be divided, the extravasated blood to be cleared away, and the artery to be tied above and below the dilatation—in short, that what is called the operation for the aneurism, is to be per- formed. Sorry I am to find myself obliged to say, that, as far as my observation and experience go, such operation, however judi- ciously performed, will not be successful; that is, will not save the patient's life. In both these aneurisms, the femoral and the poplitean, it most frequently happens that the artery is not only dila'ted and burst, but it is also distempered some way above the dilatation, particu- larly in the poplitean. This may very probably be one reason why the ligature is in general so unsuccessful. The want of col- lateral branches of sufficient size to carry on the circulation, is another very powerful impediment. Whether these may be allow- ed sufficient to frustrate the attempt by the operation, I will not take upon me to say; but certain I am, that it does not succeed: I have tried it myself more than once or twice; I have seen it tried 3,40 REMARKS ON AMPUTATION. by others; but the event has always been fatal. Excessive pain, a high degree of symptomatic fever, great tension of the whole limb, rapidly tending to gangrene, and ending in mortification both up- wards and downwards, have destroyed all those whom I have seen, on whom the operation of tying the artery has been prac- tised. Nor have I ever seen any other operation than that of amputa- tion, which has preserved the life of the patient/ To this, an objection has been made by some, which, if it was founded in fact, would be a very valid one. It has been said, that the aneurism in the thigh, or ham, is very seldom the only one which the patient labours under, and that he most frequently has the same kind of dilatation either of the aorta, or of some of the larger vessels within the body. This is urged as a reason against amputation in this disease; they who maintain this opinion, very justly observing, that it cannot be of any use to cut off a patient's leg for a femoral or a poplitean aneurism, who will, in all proba- bility, be destroyed very soon by the same kind of disease in another part of him. If the datum were true, the inference would be just; but it is not. When I say that it is not true, I mean that it is not con- stantly or necessarily, or even generally so, as I can from repeated experience affirm, having several times performed the operation of amputation for both these, on people who have lived several years after, without any symptoms of the same kind of disease in f Since Mr. Pott's time, very considerable improvements have taken place in the treatment of aneurisms, by which the arguments against the operation are completely obviated. The late Mr. Hunter suggested the idea of tying the artery above, .and at a distance from the disease itself, by which the bad and often fatal consequences, which attended the laying open the aneu- rismal sac, are avoided; and the anastomozing vessels being found sufficient to cany on the circulation, completely removes the other objection which Mr. Pott had conceived. In cases of popliteal aneurisms, it is well known that the artery has frequently been tied in the thigh with complete success. And in a case where it was dilated so high up, and so near the groin, that it v/as impossible to get above it by any ordinary operation, Mr. Abernethy was compelled to put a ligature on the external iliac within the pelvis, and the branches of the internal iliac were found sufficient for the nourishment of the parts below. He has since twice repeated the operation with suceess. E REMARKS ON AMPUTATION. 321 any other part of them. Indeed, the determination for an opera- tion when a poplitean aneurism is arrived to the state which I have just described, is hardly to be called a matter of choice; it is indeed a matter of absolute necessity. When the swelling from the extravasated blood is become so large, that the pulsatory feel of the artery is rendered very obscure, the whole limb below is exceedingly loaded and swollen, the return of the fluids, both by the veins and by the lymphatics, so very difficultly executed, that the patient gets little or no rest from the constant pain; and if some relief be not obtained, and that speedily, from the art of surgery, gangrene and mortification are the inevitable conse- quences. The means of relief are two—and two only; the operation of amputation, and that of tying the artery above and below the dis- eased part. The operator undoubtedly may make his choice between them, and follow the dictates of his own judgment and his own expe- rience; but it must be worth his while to observe, that for the success of the latter, a free circulation through all the inferior part of the limb seems to be a very necessary circumstance, and that when the load, and pressure, and obstruction, are become so great as even to threaten gangrene and mortification, which is fre- quently the case, such free circulation is not much to be expect- ed; but, on the contrary, all the evils arising from a very obstruct- ed one, and that through distempered parts. There is another kind of complaint affecting the leg, remove* able (as far as my experience goes) by amputation only, which is one reason why I mention it in this place, and to which I might add another reason, which is, that it either derives its origin from a burstern artery, or at least is accompanied by it. I know no name to give it, or under what class to range it, but will describe it in the best manner I can. It has its seat in the middle of the calf of the leg, or rather more toward its upper part, under the gastrocnemius and soleus muscles: it begins by a small, hard, deep seated swelling, some- times very painful, sometimes but little so, and only hindering the patient's exercises; it does not alter the natural colour of the skin, at least until it has attained a considembk si&e: it n*Wgp* vol. r> s s 322 REMARKS ON AMPUTATION. gradually, does not soften as it enlarges, but continues through the greatest part of it incompressibly hard; and when it is got to a large size, it seems to contain a fluid which may be felt toward the bottom, or resting, as it were, on the back part of the bones. If an opening be made for the discharge of this fluid, it must be made very deep, and through a strangely distempered mass. Thit- fluid is generally small in quantity, and consists of a sanies mixed with grumous blood: the discharge of it produces very little dimi- nution of the tumor; and in a few cases which I have seen, very high symptoms of irritation and inflammation come on, and, ad- vancing with great rapidity and most exquisite pain, very soon destroy the patient, either by the fever, which is high and unre milting, or by a mortification of the whole leg. If amputation has not been performed, and the patient dies, after the tumor has been freely opened, the mortified and putrid state of the parts prevents all satisfactory examination: but if the limb be removed without any previous operation, (and which, as far as my experience goes, is the only way of preserving the pa- tient's life,) the arteria tibialis postica will be found to be en- larged, distempered, and burst; the muscles of the calf of the leg to have been converted into a strangely morbid mass; and the posterior part of both the tibia and the fibula more or less carious. The fourth kind of distemper, which I mentioned, as being sometimes productive of the necessity of amputation, is a caries of the whole bone or bones forming a limb. By this I would be un- derstood lo mean a caries possessing not only the surface of such bones, but the whole internal substance, and that from end to end. This I take to be the very individual case, in which both M. Bil- guer and M. Tissot have reprobated amputation, and which the former has mentioned in his fifth article, under the .title of Incu- rable Caries. The terms in which M. Bilguer has chosen to express himself, are rather unfortunate. After having mentioned three or four different distempers, in which, in certain cases, and under certain circumstances, ampu- tation has in general been thought necessary and right, and in which he is of a totally different opinion, he adds—An incurable. REMARKS ON AMPUTATION. 323 caries of the bones; which incurable caries he says, ought not to be amputated, because there is a method of curing it. If this was merely a blunder in language, and went no farther, it would be a matter of little importance; but it is a serious piece of advice, delivered authoritatively, and by a writer who professes to correct the errors both of his predecessors and contemporaries, therefore it should not be merely laughed at; and as it is an ad- vice which is not built on fact, and which is fraught with mischief to mankind, it ought to be contradicted. That bones become carious from a variety of causes, such as the struma, the lues venerea, deep-seated imposthumation, pres- sure, &c. is well known to every body; and that such carious bones, properly treated, will exfoliate, and cast off their rotten parts. is as well known; but when, in some particular habits, whether scrophulous, scorbutic, or cancerous, the whole substance of Un- bone becomes diseased, not only on its surface, but through its whole internal medullary texture, and that from end to end, the same means, be they what they may, will not avail. The use of the scalper, the raspatory, and the rugine, for the removal of the diseased surface of bones; of the trephine, for perforating into the internal texture of carious ones, and of what are called exfoliating applications, are as well known, I presume, to every practitioner, as to M. Bilguer; but giving to these all their real or their sup- posed merit, still I affirm, and that from repeated experience, that there are cases of caries, in which none of these will succeed, though ever so judiciously used; that neither by these, nor by any other means, can an exfoliation be obtained; and that, unless the whole bone be removed by amputation, the patient will perish. The metaphor, or simile, by which M. Bilguer endeavours to illustrate his meaning, is somewhat singular: he says, u The real " method of doing service to bones consumed by caries, is like " what happens to boards joined together by nails: if you make " them excessively dry, the nails fall out of themselves," &c. Now admitting what I think will not be admitted, that this si- mile conveys a just and true idea of the manner in which the rotten parts of bones are separated from the sound, yet it neces- sarily implies, that in these very bones there are some sound part or parts, from which the rotten are to be dried off, in order to 324 REMARKS ON AMPUTATION. loosen the nails, and that the existence of such sound parts is the sine qua non of the cure. It may, perhaps, in answer to this, be said, that proper treat- ment, external and internal, may so alter and correct even the carious part of a bone, as to render it capable of parting with the rest, and thereby of becoming sound. I say, admitting this, which is not in general admissible, yet it sometimes happens, that there is not time for such experiment, and that, even in very young sub- jects, the whole habit is, by the rotten bone, so poisoned and spoiled, that a hectic fever of the putrid kind, with all its train of horrid symptoms, will, in spite of the efforts of physic and surgery, in spite of bark and every other specific, in spite of drying, burn- ing, rasping, and boring, come on, and in a very short space of time destroy the patient, unless rescued by amputation, which alone can remove a whole bone. I have as high an opinion of, and as just a reverence for, both branches of the medical art, as any man; but I also know, that they are both in many instances exceedingly unequal to our expec- tations, and very much limited. This is a disagreeable and an unfortunate truth, but still it is a truth, and so much so, that whoever professes a contrary opinion, is either much deceived himself, or inclined to deceive others. REMARKS ON THAT KIND OF IPMiSl ©» '3HBIB M)WMB mus^ WHICH IS FREQUENTLY FOUND TO ACCOMPANY A CURVATURE OF THE SPINE, AND IS SUPPOSED TO BE CAUSED BY IT. TOGETHER WITH ITS METHOD OF CURE. TO DR. JOHN LEWIS PETIT, ONE OF THE Physicians to Sti Bartholomew's Hospitaf THE FOLLOWING TRACTS ARE INSCRIBED, AS V SMALL MARK OF THE GREAT ESTEEM AND REGARD OF THE AUTHOR ON IHE PALSY OF THE LOWER LIMBS, &c. Among the various objects of Physic and Surgery, there are unfortunately some, in which all the efforts of both have hitherto been found absolutely ineffectual, and which therefore have always made a very disagreeable and melancholy part of practice. To remove, or even to relieve any of the miseries to which mankind are liable, is a very satisfactory employment; but to at- tend on a distemper from its beginning, through a long and pain- ful course, to its last, fatal period, without even the hope of being able to do any thing which shall be really serviceable, is, of all tasks, the most unpleasant. In such cases, any attempts, however hazardous, provided they were rational, would be justifiable; certainly then, whatever is not in itself dangerous, and affords the smallest ray of hope, ought to be embraced. Some little time ago I gave to the public an account of the success which 1 had seen attend the free use of opium in morti- fications of the toes and feet; particularly in those which began, or were attended with, great pain. In that publication I merely related the fact, as it had happen- ed under my own eye. I entered into no reasoning about it; nor did I give to the medicine any greater degree of credit than it appeared to me lo deserve. I did not propose it as a certain specific, or as a remedy whose success was always and infallibly, VOL. it. t t 330 ON THE PALSY 01 or indeed even generally to be depended upon. I acknowledged, that I had several times seen it fail; but as I had also several times seen it succeed, as I was very sure that no hazard could possibly attend the experiment; and as the best and most experi- enced practitioners were obliged to allow, that they were not yet acquainted with any means whereby they were enabled to prevent the fatal effects of this most horrid distemper, or even to retard its daily and painful ravages, I thought it my duty to make known as early as I could what I had seen, that others might make the same trial, and thereby propagate the benefit. Had any other means of relief been known to the faculty, and this had therefore appeared to me only in the light of another, or a preferable one, I should certainly have withheld my observations, until more time had verified and confirmed -them, and thereby had proved the su- perior utility of what I had to propose: but as the fact was direct- ly the contrary, as opium was the only medicine which I had ever seen prove really and essentially serviceable; as it had succeeded so often, and to such a degree, as to satisfy me that much good might be expected from it; and as I was perfectly sure that not the feast degree of hazard could attend the trial, I thought that such publication, though early, could not be regarded in any other light than its true one; I mean that of a request to the profession in general to repeat the experiment; and that therefore it could not be justly deemed premature. If upon repeated trial the suc- cess should not be found equal to what I thought I had good rea- son to expect, no harm could accrue to the patient: if it should answer my expectation, it would serve the most valuable of all purposes. Since that time I have had the satisfaction of having my opi- nion confirmed, not only by my own experience, but by the con- current testimony of several practitioners of eminence in different parts of the kingdom, who have done me the favour to commu- nicate to me the result of their experiments: the success of these, as I expected, from what I had seen, has not been constant, but it has been so frequent, as to make me very vvell pleased at having furnished the hint. I sincerely wish that the good effect was more general and more certain; but the preservation of even a few, from a malady, found hitherto to have been inevitably destructive to all, THE LOWER LIMBS. 331 is a matter of some importance, and furnishes no unpleasing reflection. I now do the same thing, relative to another disorder, which I then did with regard to the mortification. I publish an account of the good success which has attended a particular method of treating a disease, which has hitherto foiled all the efforts of art; and as I do it now from the same principle which I did then, viz. that of inducing others, by making the same experiment, to propa- gate the benefit, I offer no apology for another early publication. The disease of which I mean to speak, is generally called a palsy, as it consists in a total or partial abolition of the power of using, and sometimes of even moving the lower limbs, in conse- quence, as is generally supposed, of a curvature of some part of the spine. To this distemper both sexes, and all ages, are equally liable. If the patient be an infant, it becomes an object of constant, though unavailing distress to its parents; if an adult, he is render- ed perfectly helpless to himself, and useless to others, which, of all possible states, is surely the very worst. When this disease attacks an infant of only a year or two old, or under, the true cause of it is seldom discovered until some time after the effect has taken place, at least not by parents and nurses, who know not where to look for it. The child is said to be un- commonly backward in the use of his legs, or it is thought to have received some hurt in its birth. When it affects a child who is old enough to have already walked, and who has been able to walk, the loss of the use of his legs is gradual, though in general not very slow. He at first com- plains of being very soon tired, is languid, listless, and unwilling to move much, or at all briskly: in no great length of time after this he may be observed frequently to trip, and stumble, although there be no impediment in his way; and whenever he attempts to move briskly, he finds that his legs involuntarily cross each other, by which he is frequently thrown down, and that without stum- bling; upon endeavouringto stand still and erect, without support, even for a few minutes, his knees give way and bend forward. When the distemper is a little further advanced, it will be found 332 ON THE I'ALSV OF that he cannot, without much difficulty and deliberation, direct either of his feet precisely to any exact point; and very soon after this, both thighs and legs lose a good deal of their natural sensi- bility, and become perfectly useless for all the purposes of loco- motion. When an adult is the patient, the progress of the dis- temper is much the same, but rather quicker. Until the curvature of the spine has been discovered, it gene- rally passes for a nervous complaint; but when the state of the back bone has been adverted to, recourse is almost always bad to some previous violence to account for it, some pulling, lifting, carrying, or drawing a heavy body, which is supposed to have hurt the back. In some few instances, this exertion may have been such, as might be allowed to have been equal to the effect; but, in by much the majority, this is so far from being the case, that, if it be admitted to have had any share at all in it, some predisposing cause, at least, must be looked for, in which, in my opinion, con- sists the very essence of the disease. I have, in compliance with custom, called the disease a palsy; but it should be observed, that notwithstanding the lower limbs be rendered almost or totally useless, yet there are some essential circumstances in which this affection differs from a common ner- vous palsy; the legs and thighs are, I have just said, rendered un- fit for all the purposes of locomotion, and do also lose much of their natural sensibility; but notwithstanding this, they have nei- ther the flabby feel, which a truly paralytic limb has, nor have they that seeming looseness at the joints, nor that total incapacity of resistance, which allows the latter to be twisted in almost all directions; on the contrary, the joints have frequently a consider- able degree of stiffness, particularly the ankles, by which stiffness, the feet of children are generally pointed downward, and they are prevented from setting them flat upon the ground. The curvature of the spine, which is supposed to be the cause of this complaint, varies in situation, extent, and degree, being either in the neck or back, and sometimes, though very seldom, in the, upper part of the loins; sometimes comprehending two ver- tebrae only, sometimes three, or more, by which the extent of the curve becomes necessarily more or less; but whatever may be the number of vertebrae concerned, or whatever may be the degree or THE LOWER LIMBS. 333 extent of the curvature, the lower limbs only feel the effect—at least I have never once seen the arms affected by it. This effect is also different in different subjects; some arc ren- dered totally and absolutely incapable of walking in any manner. or vvith any help, and that very early in the course of the distem- per; others can make a shift to move about wih the help of crutches, or by grasping their own thighs with their hands; some can sit in an erect posture, or in a chair, without much trouble or fatigue, which others are incapable of, at least for any length of time; some have such a degree of motion in their legs and thighs, as to enable them to turn and move for their own convenience in bed; others have not that benefit, and are obliged to lie till moved by another. When a naturally weak infant is the subject, and the curvature is in the vertebras of the back, it is not infrequently productive of additional deformity, by gradually rendering the whole back what is commonly called humped; and by alterations which all the bones of the thorax sometimes undergo, in consequence of the flexure and weakness of the spine, by which such persons are justly said to be shortened in their stature; but in all cases where this effect has been gradually produced, to whatever degree the deformity may extend, or however the alteration made in the dis- position of the ribs and sternum may contribute to such deformity, yet I think that it will always be found, that the curvature of the spine appeared first, and, if I may so say, singly, and that all the rest was consequential. While the curvature of the spine remains undiscovered or un- attended to, the case is generally supposed to be nervous, and me- dicines so called are most frequently prescribed, together with warm liniments, embrocations, and blisters, to the parts affected; and when the true cause is known, recourse is always had to steel stays, the swing, the screw chair, and other pieces of machinery, in order to restore the spine to its true and natural figure; but all, as far as I have observed, to no real or permanent good purpose; the patient becomes unhealthy, and, languishing for some time under a variety of complaints, dies in an exhausted, emaciated state; or, which is still worse, drags on a miserable existence. 334 ON THE PALSY OF confined to a great chair, or bed, totally deprived of the power of locomotion, and useless both to himself and others. This in an infant is most melancholy to see, in an adult most miserable to endure. The general health of the patient does not seem at first to be materially, if at all, affected; but when the disease has been some time, and the curvature thereby increased, many inconveniences and complaints come on, such as difficulty in respiration, in- digestion, pain, and what they all call tightness at the stomach, ob- stinate constipations, purgings, involuntary flux of urine and faeces, &c. with the addition of what are called nervous com- plaints; some of which are caused by the alterations made in the form of the cavity of the thorax; others seem to arise from im- pressions made on the abdominal viscera. These are different both in kind and in degree, in different subjects, but seem to de- pend very much on the consequences of the curvature—that is, in naturally infirm children, although the curvature of the dorsal vertebras is always the first mark of the distemper, by preceding every other, yet It is frequently soon followed by such a degree of deformity of the bones of the trunk, as to be, in conjunction with the necessary inactivity and confinement of the patient, produc- tive of all the ills above mentioned. An affecting instance of this distemper, in the person of a very promising youth of fourteen years old, with whose family I was nearly connected, induced me to think more of it than perhaps I otherwise should have done; and the restoration of the use of his limbs, immediately after a seemingly accidental abscess near the part, engaged my attention still more, and became a matter of frequent, though not very satisfactory contemplation; I say unsa- tisfactory because it served only to increase mv doubts, without leading me toward a solution of them. The more I thought upon the subject, the more I was inclined to suspect that we had been misled by appearances, and that a distempered state of the parts forming, or in the neighbourhood of curvature, preceded, or ac- companied it: in short, that there was something predisposing, and that we had most probably mistaken an effect for a cause. For these suspicions, I had the following reasons, which appear- ed to me to have some weight: THE LOWER LIMBS. 335 1. That I had never seen this paralytic effect on the legs from a malformation of the spine, however crooked such malformation might have rendered it, or whether such crookedness had been from time of birth, or had come on at any time afterwards, during infancy. 2. That none of those strange twists and deviations, which the majority of European women get in their shapes, from the very absurd custom of dressing them in stays during their infancy, and which put them into all directions but the right, ever caused any thing of this kind, however great the deformity might be. 3. That the curvature of the spine, which is accompanied by this affection of the limbs, whatever may be its degree or extent, is at first almost always the same, that is, it is always from within, outward, and seldom or never to either side. 4. That since I had been particularly attentive to the disorder, I had remarked, that neither the degree nor the extent of the curve made any alteration in the nature or degree of the symptoms at first, nor for some time after the appearance; or, in other words, that the smallest curvature, in which only two "or three of the vertebras were concerned, was always, at first, attended by the same symptoms as the largest. 5. That although it sometimes happened that a smart blow, or a violent strain, had immediately preceded the appearance of the curve, and might be supposed to have given rise to it, yet in many more adults it happened that no such cause was fairly assignable, and that they began to stoop, and to faulter in their walking, be- fore they thought at all of their back, or of any violence offer- ed to it. 6. That exactly the same symptoms are found in infants, and in young children, who have not exerted themselves, nor have been injured by others, as in the adult, who has strained himself, or re- ceived a blow; and that the case was still the same in those grown people, who have neither done nor suffered any act of violence. 7. That although it must be allowed, that a dislocation of any of the vertebrae, would most probably be attended vvith the same kind of symptoms, from the pressure it must make on the spinal marrow, yet it is also most probable that such symptoms would 336 ON THE PALSY OP be immediate, and attended with great pain in the part; neither of which is in general the case here. These considerations appear to me to have much force; but what confirmed me in my opinion was the state of the parts form- ing the curvature, and which I had several fair opportunities of examining after death. By these examinations I found, in infants, in young children, and in those who had been afflicted vvith the disorder but a small space of time, that the ligaments connecting the vertebrae, which formed the curve, were in some degree alter- ed from a natural state, by being somewhat thickened and relaxed, and that what are called the bodies of those bones, were palpably spread and enlarged in their texture, just as the bones forming the articulations are in children who are called rickety. That in those who had long laboured under the distemper, and in whom the symptoms were aggravated, whatever might be their age, the ligaments were still more thickened, relaxed, and altered, the bo- dies of the bones more spread, more enlarged, and more inclining to become carious, and the cartilages between the bodies of the vertebrae much compressed and lessened in size; and that in all those who had so long laboured under the disease, as to have been destroyed by it, or by its consequences, the corpora vertebra- rum were completely carious^ the intervening cartilages totally destroyed, and a quantity of sanies lodged between the rotten bones and the membrane investing the spinal marrow.0 All these circumstances put together, induced me, as I have al- ready said, to suspect, that when we attribute the whole of this mischief to the mere accidental curvature of the spine, in conse- quence of violence, we mistake an effect for a cause; and that pre- vious both to the paralytic state of the legs, and to the alteration of the figure of the back bone, there is a predisposing cause of both, consisting in a distempered state of the ligaments and bones, where the curve soon after makes its appearance. While the subject was fresh in my mind, I happened to be at Worcester, and in a conversation on it with the late Dr. Cameron »In the body of a man, who died not long since of this disorder, in its last and worst state, the bodies of three of the vertebrae were not only quite carious, but completely separated from all connexions with the 9ther parts of the same vertebra;. THE LOWER LIMBS. 337 of that place, I mentioned to him my opinion, and my doubts: the doctor concurred with me, and at the same time mentioned a cir- cumstance, which made a strong impression on me. He said, that he remembered, some years ago, to have noted a passage in Hippocrates, in which he speaks of a paralysis of the lower limbs being cured by an abscess in the back or loins; and that taking the hint from this, he, Dr. Cameron, had, in a case of a palsy of the legs and thighs, attended by a curvature of the back bone, en- deavoured to imitate this act of nature, by exciting a discharge near the part, and that it had proved very advantageous. He also referred me to Mr. Jcffrys, a surgeon of eminence at Worcester, for a further account of the same kind of attempt: this gentleman confirmed what Dr. Cameron had told me, and assured me that he had found the method equally successful. It may easily be supposed, that these accounts from gentlemen of veracity, and of reputation in their profession, still added to my desire of knowing more on this subject, and determined me to lose no opportunity of getting information. The first that offered was in an infant, whose curvature was in the middle of the neck, and who had lost the use of its legs for about two or three months. 1 made an issue by incision on one side of the projection, and gave strict charge to the mother to take care that the pea was kept in; the woman, who had no faith in the remedy, did not take the proper care, and consequently the discharge was not equal to what it should, and might have been; but notwithstanding this neglect, at the end of about three weeks or a month the child was manifestly better, and began to make use of its legs: it was then seized with the small pox, and died. The bodies of the vertebrae concerned in the curve were larger than they should be, and than those above and below were, and their texture much more open and spongy; which difference appear- ed immediately, before the parts covering them were dissected off. Some time passed before I had another opportunity. My next patient was a tall, thin man, about thirty-five years old, who thought that he had hurt himself by lifting a heavy weight: his legs and thighs were cold, and what he called numby, but not abso- lutely useless: he could with difficulty go about the room with the help of a pair of crutches, but he could neither rise from his vol. n. u u 338 ON THE TALSY OF chair, nor get on his crutches, without the assistance of another person, nor could he, without them,-walk at all. I made a seton on each side of the curve, which was in his back, about the middle; and having given his wife directions how to dress them, I called on him once in three or four days. At the end of six weeks he had recovered the due degree of sensation in his limbs, and found much less necessity for the use of his crutches; he could rise from his bed and from his chair without assistance; and by means of one crutch, and an underhand stick, could walk for an hour, or more, without resting, and without fa- tigue. The setons had now, from not having been properly ma- naged, worn their way out, and I would have converted each of them into an issue; but as neither the patient nor his wife had ever believed that the discharge had had any share in his amendment, but, on the contrary, that he would have been better without it, he would not submit to what I proposed, and I left him. At the distance of about three weeks from the time of my leaving him, I met him in the street, walking very stoutly, with a common cane, of which he made little or no use. I asked him what he had done: he told me that the sores had continued to discharge till within a few days; but that he had drunk a great deal of comfrey root tea, with isinglass, and he supposed that had cured him. I believe that the cure of this man will, by all who know any thing of medicine, be thought to be so unlikely to have been ef- fected by the comfrey and isinglass, that my inference in favour of the seton will not be thought unreasonable, and that my deter- mination to prosecute the method, from what I had heard and seen, was vvell founded. Within the course of the last ten or twelve months, I have had several fair opportunities of doing this, both in St. Bartholomew's hospital, and out of it; and am yery happy to be able to say, that it has not only always .-answered, but in some instances greatly exceeded my most sanguine expectations, by restoring several most miserable and totally helpless people to the use of their limbs, and to a capacity of enjoying life themselves, as well as of being useful to others. I have now in the hospital, a boy about twelve years old, whose case was so truly deplorable, that I made the experiment merely THE LOWER LIMBS. 339 to avoid the appearance of inhumanity, by discharging him as in- curable, without trying something. The curvature was in his back, and consisted of three or four vertebrae; but by means of the weakness thereby induced, the whole set of dorsal ones had so universally and gradually given way, that he was exceedingly deformed both behind and before: he was so absolutely incapable of motion, that he could neither turn himself, nor sit up in his bed: his feet were pointed downwards, and his ankles so stiff, that when he was held up under the arms, the extremities of his great toes touched the floor, nor could his feet be brought flat to the ground by any means or force whatever. In short, he was as perfectly and as totally helpless as can be supposed; and at the same time in an exceedingly general bad state of health, from dis- orders of the thoracic and abdominal viscera. In this state he had been more than a year: it is now about three months since the caustics were applied; he is become healthy, and free from most of his general complaints, has the most perfect use of his legs while he is in bed, can walk without the assistance of any body, or any thing to hold by; and from his manner of executing this, will, I make no doubt, in a very short space, recover perfectly the use of his legs. To this I ought to add, that notwithstanding a considerable degree of deformity does, and I suppose will, remain, yet the spine in general is so much strengthened, that he is some inches taller than he was four months ago. The remedy for this most dreadful disease consists merely in procuring a large discharge of matter, by suppuration, from un- derneath the membrana adiposa on each side of the curvature, and in maintaining such discharge until the patient shall have per- fectly recovered the use of his legs. To accomplish this purpose, I have made use of different means, such as setons, issues made by incision, and issues made by caustic: and although there be no very material difference, I do, upon the whole, prefer the last. A seton is a painful and a nasty thing; besides which, it fre- quently wears through the skin before the end for which it was made can be accomplished: issues made by incision, if they be large enough for the intended purpose, are apt to become inflam- ed, and to be very troublesome before they come to suppuration; but openings made by caustic are not in general liable to any of 310 ON THE PALSY OP these inconveniences, at least not so frequently, nor in the same de- gree: they are neither so troublesome to make or to maintain. I /^~~\ make the eschars about this size and shape, on / \ each side the curve, taking care to leave a ( ] sufficient portion of skin between them: in I ) a few days, when the eschar begins to loosen V J and separate, I cut out all the middle, and ^-^ put into each a large kidney-bean. When the bottoms of the sores are become clean by suppuration, I sprinkle, every third or fourth day, a small quantity of finely powdered cantharides on them, by which the sores are prevented from contracting, the discharge increased, and possibly other benefit obtained. The issues I keep open until the cure is complete: that is, until the patient recovers perfectly the use of his legs, or even for some time longer; and I should think that it would be more prudent to heal only one of them first, keeping the other open for some time; that is, not only until the patient can walk, but until he can walk firmly, briskly, and without the assistance of a stick; until he can stand quite up- right, and has recovered all the height, which the habit, or rather the necessity of stooping, occasioned by the distemper, had made him lose. I have said that the discharge by means of the issue, is all that is requisite for a cure; which is true, as I have experimentally proved by not using any other, in cases which have succeeded per- fectly; but this fact being established, there is no reason why every assistant means should not be applied at the same time, in order to expedite: such as bark, ecld-bathing, frictions, &c. That the patient becomes more upright as his legs become stronger, is certain, and therefore appears taller, as vvell as straight- er, in proportion as the whole spine strengthens; but whether the curvature will always and totally disappear, I am not yet able to say with certainty. In two late instances, both adults, it has; but the deformity which, in weak infants and children, is often the consequence of the curvature, and of the state of the spine at that place, must, in some degree, I fear, be expected to remain; but of this I am not yet able to speak with absolute certainty. There are a few other circumstances, of no great moment perhaps, THE LOWER LIMBS. 341 but which will require more lime to ascertain than I thought should be suffered to pass, before mankind were made acquainted vvith the great means of relief, in so distressing, so melancholy, and so dreadful a malady: for the reader will be pleased to re- member what I told him at the beginning of this tract, which was, that my motive for publishing this account sooner th.in might ap- pear in general to be right, or indeed than I otherwise should have done, was a desire that as little time as possible might be lost, in conveying to the profession in particular, and to mankind in gene- ral, the means of relief under an affliction, which, till these were known, has not admitted of any; and this I was still more incited to do, because the remedy is as harmless, and as void of hazard, as it is efficacious. In the preceding tract I have related the appearances which the parts constituting the seat of the distemper make upon exami- nation after death; or, to speak more properly, the different slates of these parts in different persons, and at different periods of this disease. These, though necessarily subject to considerable variety, may, I think, be reduced to three general ones. 1. A small degree of an increase of size in the bodies of the vertebrae, forming the curve, with an apparent laxity in their tex- ture, and a relaxed state of the connecting ligaments, by which they seem to have lost part of their power of holding the bones together. 2. "A more considerable and more apparent enlargement of the same parts of the vertebrae, whose spongy texture becomes more visibly spread through their whole substance, and tending towards a caries, with an apparently distempered state, both of the liga- ments and of the intervening cartilages. 3. A truly carious state of the bodies of the bones; a dissolu- tion or destruction of the cartilaginous substance between them; and a lodgement of sanies on the surface of the membrane envelop- ing the spinal marrow. These are I think the most particularly different states or stages of the disorder, and are such as, in my opinion, decisively mark the true nature of it. Between these, in different persons, and under different circum- 342 ON THE PALSY OF stances, there must be a considerable variety, but the material difference will be only in degree. From the whole, the few following practical inferences seem fairly deducible: 1. That the disease does not originally consist in a displacement of the vertebrae, made by violence, the bones and ligaments being previously in a sound and uninjured state; but in such a morbid alteration of the texture of both, as will, if not timely prevented, produce curvature and caries, with all their consequences. 2. That the proper remedies for this disease cannot be applied too soon. 3. That the restoration of the spine to its natural figure, depends .much on the early administration of the help proposed. 4. That although the distemper may be so far cured, that the patient may perfectly recover the use of his legs, yet such an alteration may have taken place in the bodies of the vertebrae, as to render it impossible for the spine to become straight again. 5. That when three or four, or more vertebrae, are concerned in the curve, the trunk of the body will have so little support from that part of the spine which is not distempered, that no degree of deformity can be wondered at; nor can it be expected that such deformity should be removed, whatever other benefit such patient may receive. 6. That if from inattention, from length of time, or from any other circumstances, it happens that the bodies of the vertebrae become completely carious, and the intervening cartilages are destroyed, no assistance is to be expected from the proposed remedy. To these I will take the liberty of adding, that it appears to me well worth while, to try what a large and free discharge, made for a length of time from the vicinity of the distempered part, might be capable of doing in the very beginning of what are commonly railed scrophulous joints; which, when arrived to a certain point, baffle all our art, and render a painful and hazardous operation absolutely necessary. Within these last six or eight months, several cases of curved spine have been received into St. Bartholomew's hospital, where they have been seen by great numbers of the profession. The THE LOWER LIMBS. 3 13 novelty of the treatment, and the success which has hitherto conr stantly attended it, has necessarily engaged the attention of many, and occasioned some conversations on the subject. In some of these it has been said, that as it appears to be undeniably a disease of the bony texture of the bodies of the vertebras, it may be appre- hended, that the relief expected from the caustics may in some cases fail, and in others may not prove permanent; and, that the same kind of constitution remaining, a return of the malady may not unreasonably be feared. To this I can only answer, that although I have called this an early publication, yet I have waited a sufficient length of time, and have treated a sufficient number of subjects, to be clear in the truth of what I have asserted, as far as such time, and such individuals go. That the patients whom I have attended in the early part of the distemper, of whatever age, have all got well; that is, have all not only regained the use of their legs, but have become healthy, and fit for any exercise or labour, as numbers can testify, who have seen them daily. Most of them have become much straighter, some quite straight, and all of them perfectly free from all kind of inconvenience arising from the curve. That in all the infants whom I have seen, the general health of the patient has always been restored, in proportion to the resto- ration of the use of the limbs. That I must suppose all this to have been done by the discharge from the caustics, because in many of them no other means of any kind have been made use of. That as far as my experience goes, I have not the least doubt, that if the means proposed be made use of before the bones are become really carious and rotten, they will always be successful. When indeed a truly rotten state of the bones takes place, no good is to be expected from this, or from any thing else: but it should be observed, at the same time, that this never happens but when the distemper is of very old date, and that, when this is the case, the whole machine is so disordered, and the patient so truly and so generally distempered, that there can be no reasonable expec- tation of success from any thing. To this I must take the liberty of adding, that what I have affirmed, is what I have seen and proved, and that the objections 344 ON THE PALSY OF THE LOWER LIMBS. are merely speculative and theoretical. However, supposing them to be not quite unreasonable, the most useful inference to be drawn from them is, that the same remedy by which so great and so evi- dent relief is obtained, ought to be continued, while there may be any fear of return of the mischief; and that every other means for the restoration of health and strength should at the same time be made use of; both which coincide absolutely vvith my own opinion and advice. FURTHER REMARKS OK THE USELESS STATE OF THE LOWER LIMBS, IN CONSEQUENCE OF A CURVATURE OF THE SPINE, WITH SOME OBSERVATIONS ON THE Al Xff LIARY ASSISTANCE OP MECHANISM, AND OTHER REMARKS. BY THE EDITOR VOL. II XX FURTHER REMARKS ON THE PALSY OF THE LOWER LIMBS, &c. It is now near three years since I first troubled the public with my observations on the disease which makes the subject of the following tract. The apology which I then made, for what I was perfectly aware might be thought a premature publication, was,"that the distemper to which it related was supposed to be incapable of receiving any relief from art; and that they who were afflicted with it, were therefore deserted, and left to linger out a most miserable exist- ence; but that, from the benefit which I had seen to be derived from a particular, and, at the same time, a perfectly safe method of treating it, I thought that it demanded the immediate and seri- ous regard of the profession. Previous to the publication, I had considered the disease with some attention, and had made some experiments on it, which, al- though not many, were sufficient in number, and had been at- tended with such a degree of success as to satisfy me, that it was a subject in which mankind was much interested; but as I did not think that any one man's experience, be it what it might, was sufficient to determine a matter of so much importance, I wished that the faculty at large might be made acquainted with what I had seen and done, that they might be induced to make the same experiment, and thereby either contradict or confirm what I had said. If the former should be the result, my proposition would soon meet with the neglect which it would deserve: I ronld only 346 ON THE PALSY OP console myself with the rectitude of my intention, and be sorry for my mistake: but if, on the contrary, the attempts of others should prove as successful as mine, it appeared to me, that the chirurgic art would make a great acquisition, as it would be thereby furnish- ed with the means of relieving one of the most distressing mala- dies to which human nature is liable; a malady which, when it befalls an adult, makes him completely miserable, by depriving him of all power of being useful to himself or others; a malady which, when an infant becomes its victim, renders all the care and tears, all the tenderness and anxiety of the fondest parent abso- lutely unavailing, and a malady for which it was supposed there was no remedy. These were my reasons for hazarding my opinion so hastily; the importance of the subject, and the perfect safety of the experi- ment, were, as I thought, a sufficient excuse for so doing. My wishes, and my expectations, have been most pleasingly fulfilled. I have received such manifold and repeated testimony of the success of the proposed method, from so large a number of the most eminent 'practitioners, not only in this town and king- dom, but in many other parts of Europe; that these, added to my ovvn experience, have completely satisfied me, and enabled me to say, that in proper cases, and under proper treatment, I have no doubt of its being universal. In all the time which has passed since the first publication, I have sought and embraced every opportunity of obtaining inform- ation, both from the living and from the dead; and I have re- quested and received the assistance of many friends, whose civili- ties, and whose information, I take this opportunity of acknow- ledging. By these means I have been enabled to correct several errors, and to make some additional observations, which I hope may not only elucidate the original subject, but may serve other equally valu- able purposes. Truths, built on observation and experience, seldom stand single; they generally lead to others, and become the means of more diffusive knowledge. The disease of which I am to speak, is a disease of the spine, producing an alteration in its natural figure, and not unfrequentlv THE LOWER LIMBS. 349 attended with a partial, or a total loss of the power of using, or even of moving, the lower limbs. From this last circumstance, (the loss of the use of the limbs,) it has in general been called a palsy, and treated as a paralytic af- fection; to which it is in almost every respect perfectly unlike. The occasion of the mistake is palpable; the patient is deprived of the use of his legs, and has a deformed incurvation of the spine; the incurvation is supposed to be caused by a dislocation of the vertebrae; the displaced bones are thought to make an unnatural pressure on the spinal marrow; and a pressure on that being very likely to pro- duce a paralysis of some kind, the loss of the use of the legs is in this case determined to be such. The truth is, that there is no dislocation, no unnatural pressure made on the spinal marrow; nor are the limbs by any means paralytic, as will appear to who- ever will examine the two complaints with any degree of atten- tion. In the true paralysis, from whatever cause, (lie muscles of the affected limb, are soft, flabby, unresisting,' and incapable of being- put into even a tonic state: the limb itself may be placed in al- mosfranv position or posture: if it be lifted up, and then let go, it falls down, and it is not in the power of the patient to prevent, or even to retard its fall: the joints are perfectly and easily moveable in any direction: if the affection be of the lower limbs, neither hips, knees, nor ankles, have any degree of rigidity or stiffness, but permit the limb to be turned or twisted in almost any manner. In the present case, the muscles are indeed extenuated, and lessened in size; but they are rigid, and always at least in atonic state, by which the knees and ankles acquire a stiffness not very easy to overcome. By means of this stiffness, mixed with a kind of spasm, the legs of the patient are either constantly kept stretched out straight, in which case considerable force is re- quired to bend the knees, or they are by the action of the stronger muscles drawn across each other in such manner as to require as much to separate them: when the leg is in a straight position, the extensor muscles act so powerfully as to require a consider- able degree of force to bend the joints of the knees; and when they have been bent, the legs are immediately aud strongly drawn tip, with the heels Inward the buttocks: by the rigidity of the 350 ON THE PALSY OF ankle joints, joined to the spasmodic action of the gastrocnemii muscles, the patient's toes are pointed downward in such manner as to render it impossible for bim to put his foot flat to the ground; which makes one of the decisive characteristics of the distemper. These are strong marks of the distinction which ought to be made between the two diseases; and fully sufficient to show the impropriety of confounding them with each other. The majority of those who labour under this disease are infants or young children: adults are by no means exempt from it; but I have never seen it at an age beyond forty. When it attacks a child who is old enough to have walked pro- perly, its awkward and imperfect manner of using its legs, is the circumstance which first excites attention; and the incapacity of using them at all, which very soon follows, fixes that attention, and alarms the friends. The account most frequently given is, that for some time pre- vious to the incapacity, the child had been observed to be languid, listless, and very soon tired; that he was unwilling to move much, or briskly; that he had been observed frequently to trip and stum- ble, although no impediment lay in his way; that when he moved hastily or unguardedly, his legs would cross each other involunta- rily, by which he was often and suddenly thrown down; that if he endeavoured to stand still and upright, unsupported by another person, his knees would totter and bend under him; that he could not with any degree of precision or certainty steadily direct either of his feet to any particular point, but that, in attempting so to do, they would be suddenly and involuntarily brought across each other; that soon after this, he complained of frequent pains and twitchings in his thighs, particularly when in bed, and of an un- easy sensation at the pit of his stomach; that when he sat on a chair, or a stool, his legs were almost always found across each other, and drawn up under the seat; and that in a little time after these particulars had been observed, he totally lost the power of walking. These are the general circumstances which are found, at least in some degree, and that pretty uniformly, in most infants and THE LOWER LIMBS. 351 children; but there are others which are different in different sub- jects. If the incurvation be of the neck, and to a considerable degree, by affecting several vertebrae, the child finds it inconvenient and painful to support its own head, and is always desirous of lav ing it on a table or pillow, or any thing.to take off the weight. If the affection be of the dorsal vertebrae, the general marks of a dis- tempered habit, such as loss of appetite, hard, dry cough, laborious respiration, quick pulse, and disposition to hectic, appear pretty early, and in such a manner as to demand attention; and as in this state of the case there is always, from the connection between the ribs, sternum, and spine, a great degree of crookedness of the trunk, these complaints are by every body set to the account of the deformity merely. In an adult, the attack and the progress of the disease are much the same, but there are some few circum- stances which may be learned from a patient of such age, which either do not make an impression on a child, or do not happen to it. An adult, in a case where no violence hath been commitled, or received, will tell you, that his first intimation was a sense of weakness in his back bone, accompanied with what he will call a heavy, dull kind of pain, attended with such a lassitude as render- ed a small degree of exercise fatiguing; that this was soon followed by an unusual sense of coldness in his thighs, not accountable for from the weather, and a palpable diminution of their sensibility: that, in a little time more, his limbs were frequently convulsed by involuntary twitchings, particularly troublesome in the night; that soon after this, he not only became incapable of walking, but that his power either of retaining or discharging his urine and faeces was considerably impaired, and his penis became incapable of erection. The adult also finds all the offices of his digestive and respiratory organs much affected, and complains constantly of pain and tight- ness at his stomach. In infants, the curve is seldom noticed till it has got to such size and state, as to demand attention from the deformity: previ- ous to this, all the marks of distemper which appear in the child. 352 ON THE PALSY OF pass for the effects of general weakness, and are treated as such; differently by different people, and under different circumstances, but never with any permanent good effect; some of the adventi- tious symptoms, if I may so call them, are, in some degree, reliev- ed; but the principal remain in full force, or, what is much more frequent, go on increasing. In an adult it passes for rheumatism, or gravel, or a strain; and the defect in the limbs' is the first thing that occasions an in- quiry into the state of the back bone. When a curvature is perceived in an infant, it is always sup- posed to have received a hurt by a blow or Tall, and an adult has always recourse to some exertion in pulling, drawing, lifting, or carrying, by which the spine is thought to have been deranged, or injured; but which supposition is seldom, if ever, true in either case. The true cause of the disease is a morbid state of the srine, and of some of the parts connected vvith it; which distempered state of parts will, upon careful inquiry, be always found to have preceded the deformity some length of time: in infants this is the sole cause, and external violence has nothing to do with it. In the adult, I will not assert that external mischief is always and totally out of the question, but I will venture to affirm what is equal, as far as regards the true nature of the case, which ft, that although acci- dent and violence may in some few instances be allowed to have contributed to its more immediate appearance, yet the part in which it shows itself, must have been previously in a morbid state, and thereby predisposed for the production of it. I do not by this mean to say that a violent exertion cannot injure the spine, nor produce a paralytic complaint; that would be to say more than I know: but I will venture to assert, that no degree of violence whatever is capable of producing such an appearance as I am now speaking of, unless the bodies of the vertebrae were by previous distemper disposed to give way; and that no supposable disloca- tion, caused by mere violence done to the bones of the back, which bones were before the receipt of the injury in a sound state, can possibly be attended with the peculiar symptoms of a curved spine. In which distinction, according to my judgment, consists the very essence of the disease. Violence may easily be supposed to bring THE LOWER LIMBS. 353 the two vertebrae nearer to each other than they ought to be, and by crushing an intermediate one to produce a curvature; but then the body of the vertebrae so crushed, must have been in a distem- pered state previous to such violence. Great violence may also suddenly and immediately displace a perfectly sound vertebra from its proper and natural situation, with regard lo those annex- ed to it; but the necessary consequences of these two kinds of in- jury must be so very different, that they never can be confounded together, or mistaken for each other, even by the most inattentive observer. The true curvature is invariably uniform in being from within outwards; but it varies in situation, in extent, and in degree; it affects the neck, the back, or the loins; it comprehends one verte- bra only, or two, or more; and as few or more are affected, or, as these are more or less morbid, and consequently give way more or less, the curve must be different: but whatever variety these circumstances may admit, the lower limbs alone,b in general, feel the effect. Some are, very soon after the curvature, rendered totally and absolutely incapable, not only of walking, but of using their legs in any manner; others can make shift to move about with the help of crutches, or by grasping their thighs, just above the knees, with both hands; some can sit in an armed chair without much trouble or fatigue, others cannot sit up with any help; some retain such a degree of power of using their legs, as to be able to shift their posture when in bed; others have no such power, and are obliged to be moved upon all occasions. Weak and delicate children are the most frequent subjects of this distemper; and when, in these, it seizes on the dorsal verte- brae, great defojmity of the trunk, both before and behind, is the almost inevitable and necessary consequence: this will be differ- b Since I began to put these papers together, I have seen two cases, in one of which the arms only were afT cted; in the other both legs and arms. Mr. E. Ford, of Golden square, has favoured me with the examination and case of a lad, who lost the use of both letfs, and both arms, from a curvature, which Mr. Ford cured by means of the caustics. Mr. Parke, of Liverpool, has also obliged me with an account of two persons, both under his care, both with useless arms and legs, and both cured by the same means. VOL. II. Y V 354 ON THE PALSY OP cnt in different persons; but let the difference in this be what it may, it is an adjunct circumstance; and upon due inquiry it will always be found, that the curvature from within outward preceded the other deformity, and was, at one time, the only one to be seen. Before the alteration of figure in the back bone has been dis- covered, all the attention is paid to the limbs, in which the whole disorder is supposed to reside, and all the applications for relief are made to them; frictions, liniments, embrocations, blisters, &c. to vvhrh is generally added cold bathing and electricity. When the curvature has been noticed, recourse is immediately had to back boards, collars, steel boddice, swings, screw chairs, and other pieces of machinery, but all to no purpose; the patient be- comes daily more and more helpless and unhealthy, languishes for more or less time, and at last dies either in an emaciated state from an hectic, or by a drain from an abscess formed within the body. That this is the case frequent and melancholy experience evinces; but why it is so, is perhaps not generally so well under- stood or attended to as it ought to be. The primary and sole cause of all the mischief, is a distemper- ed state ef the parts composing, or in immediate connexion with, the spine, tending to, and most frequently ending in, acariesof the body, or bodies, of one or more of the vertebrae: from this proceed all the ills, whether general or local, apparent or concealed; this causes the ill health of the patient, and, in time, the curvature. The helpless state of the limbs is only one consequence of several, pro- ceeding from the same cause; but though this effect is a very fre- quent one, and always affects the limbs in nearly the same man- ner, yet the disease not having its origin in them, no application made to them only can ever be of any possible use. The same failure of success attends the use of the different pieces of machinery, and for reasons which are equally ob- vious. They are all, from the most simple to the most complex, but particularly the swing and the screw, calculated to obviate and remove what does not exist. They are founded upon the supposi- THE LOWER LIMBS. 355 tion of an actual dislocation, which never is the case, and therefore they always have been, and ever must be, unsuccessful. To understand this in the clearest and most convincing man- ner, we need only reflect on the nature of the disease, its seat, and the state in which the parts concerned must necessarily be. The bones are either already carious, or tending to become so; the parts connected vvith them are diseased, and not infrequently ulcerated; there is no displacement of the vertebrae with regard to each other; and the spine bends forward only because the rotten bone or bones, intervening between the sound ones, give way7, being unable in such state to bear the weight of the parts above. The most superficial reflection on this must point out to every one, why attempts of this kind can do no good; and a little more at- tention to the subject will show why they may be productive of real and great mischief. The bones are supposed to be sound, but displaced: these machines are designed to bring them back to their former situation, and thereby to restore to the spine its pro- per rectitude. If therefore they have any power, that power must be exercised on the parts in connexion vvith the curve; which parts, when the disease is at all advanced, are incapable of bear- ing such a degree of violence without being much hurl thereby: this, if it were merely theoretical, being a conclusion drawn from the obvious and demonstrable state of the distempered parts, could not be deemed unreasonable; but, unfortunately for the afflicted, it is confirmed by practice. They who have had patience and fortitude to bear the use of them to such a degree as to affect the parts concerned, have always found increase of pain and fever, and an exasperation of all their bad symptoms; and I have known more than one instance in which the attempt has proved fatal. The use of some or other of these pieces of machinery is so ge- neral, and the vulgar prejudice in their favour so great, that not- withstanding I have been long convinced of their perfect inutility, yet if I had no other objection to them, I would not attempt to rob the afflicted of what they seem to derive such comfortable ex- pectation from; but as I am satisfied of their mischievous effects, not only in the case of the present subject, but in many others, I 356 ON THE PALSY OF cannot help bearing my testimony against the indiscriminate and very improper use which is daily made of them. They are used with design to prevent growing children from be- coming crooked or misshapen; and this they are supposed to do by supporting the back bone, and by forcing the shoulders unnatu- rally backward: the former they cannot do; and in all cases where the spine is weak, and thereby inclined to deviate from a right figure, the latter action of these instruments must contribute to, rather than prevent such deviation; as will appear to whoever will with any attention examine the matter: if, instead of adding to the embarrassments of children's dress by such iron restraints, parents would throw off all of every kind, and thereby give nature an op- portunity of exerting her own powers; and if, in all cases of mani- fest debility, recourse was had to friction, bark, and cold bathing, with a due attention to air, diet, exercise, and rest, the children of the opulent would, perhaps, stand a chance of being as stout, as straight, and as well shapen as those of the laborious poor. When a child appears to be what the common people call natu- rally weakly, whatever complaints it may have are supposed to be caused by its weak state, and it is generally believed that time and common care will remove them; but when a curvature has made its appearance, all these marks of ill health, such as laborious respi- ration, hard cough, quick pulse, hectical heat and flushing, pain and tightness of the stomach, &c. are more attentively regarded, and set to the account of the deformity consequent to the curve, more especially if the curvature be of the dorsal vertebrae; in which case the deformity is always greatest: but whoever will carefully attend to all the circumstances of this disorder, will be convinced, that most, if not all the complaints of children, labouring under this infirmity, precede the curvature, and that a morbid state of the spine, and of the parts connected with it, is the original and primary cause of both.0 0 When I published the first edition of this tract, I was not so aware of this truth, as a more enlarged experience in, and a more careful attention to, the disorder since has made me. I am very glad to embrace this opportunity of ackwowledging, and of cor- recting the mistake, and the more so, as I am convinced that an inference of the greatest importance may be drawn from it. I am satisfied that this malady THE LOWER LIMBS. 357 I have in the former edition informed the reader, that my par- ticular attention to this disease was first exeiied by an instance of its being cured by a seemingly accidental abscess; that this first gave me reason to suspect, that we had mistaken an effect for a cause; and that, upon mature delibera iun upon the matin, I was still more inclined to think so, for the following reason: 1. " That I did not remember ever to have seen this useless " state of the limbs from a mere malformation of the spine, how- " ever crooked such malformation might have made it. 2. " That none of those deviations from right shape, whhh " growing girls are so liable to, however great the deformity might " be, was ever attended with this effect. 3. " That the kind of deformity, which was attended with this " affection of the limbs, although it was different as to its degree " and its extent in different people, yet it was uniform in one cir- " cumstance, which was, that the curvature always was from " within outwards. 4. " That since I had been particularly attentive to the disorder, " I thought that I had observed, that neither the extent nor degree " of the curve, had in general produced any material difference in " the symptoms, but that the smallest was, when perfectly formed, 16 attended vvith the same consequences as the largest. 5. " That although it had sometimes happened, that a blow, or " a strain, had preceded the appearance of the curve, yet it much " more frequently happened, that no such cause was assignable. 6. " That I had observed exactly the same symptoms in infants, " and in young children, who had neither exerted themselves, nor " were supposed to have received any injury from others; and that " the case was still the same in those adults, who had no such " cause to look to. 7. " That although it might be expected that a dislocation of " any of the vertebrae would be attended with symptoms of the " paralytic kind, yet they would be very unlike to those which " affected the limbs in the present case." may, in many instances, by early and proper attention, be prevented from prodncing its otherwise inevitable consequences, temporary lameness, and permanent deformity. 358 ON THE PALSY OF The suspicions which these circumstances had excited in my mind, were confirmedd by what I had a few opportunities of observ- ing in the dead bodies of some, who had died afflicted with this dis- order, and altogether satisfied mc, that there raust be something pre- disposing in the parts concerned; and that when we attribute the useless state of the limbs merely to the curvature, we mistake, as I have just said, an effect for a cause. At the same time I gave an account of a conversation which passed between me and the late Dr. Cameron, of Worcester, who told me, that having remarked in Hippocrates an account of a paralysis of the lower limbs cured by an abscess in the back, he had, in a case of useless limbs, attended with a curvature of the spine, endeavoured to imitate this act of nature, by exciting a purulent discharge, and that it had proved very beneficial; which was confirmed to me by Mr. Jeffrys, of Worcester, who had made the same experiment with the same success.*5 From the time of my receiving this first information to the present, I have sought every opportunity of making the experiment. St. Bartholomew's hospital has seldom been without cases of this kind, and it is with infinite pleasure and satisfaction, that I find myself enabled to say, that in all cases where the complaint has been so circumstanced as to admit of even probable expectation, the attempt has been successful. If the cure of this most dreadful distemper had depended upon d In the first edition, I had described the bones on which the disease had seized, as being enlarged and spread: upon repeated inquiry and examination, I am convinced that they are not. The bodies of the vertebrae concerned are often affected, while the liga- ments bear but little mark of distemper; but whether the ligaments be affected or not, the bodies of the vertebrae are always diseased, which disease does not so properly enlarge as erode: the state also of the intervertebral cartilages, I find to be subject to great ^variety, they being sometimes to- tally destroyed, while the caries is small in degree, sometimes apparently but httle injured, where the caries has done considerable mischief, and sometimes totally destroyed and annihilated. e In this place-of the first edition, I have a short account of the first two or three cases which occured to me : in this I omit them as needless. The number of experiments which have been made by many of the most eminent practitioners, at home and abroad, have sufficiently established the fact, and render the relation of particular cases unnecessary. THE LOWER LIMBS. 359 an application to the" constitution in general, it might have re- quired a variety of medicines, the administration of which must have demanded judgment in adapting them to particular persons and constitutions; and it must also, in the nature of things, have happened that many individuals could not have been benefited at all. But fortunately for the afflicted, the means of relief are sim- ple, uniform, and safely applicable to every individual, under al- most every possible circumstance, not attended by the smallest degree of hazard, and capable of being executed by any body who has the least portion of chirurgic knowledge: it consists merely in procuring a large discharge of matter from underneath the mem- brana adiposa, on each side of the distempered bones forming the curvature, and in maintaining such discharge until the patient shall have recovered his health and limbs. They who are little con- versant with matters of this sort, will suppose the means very in- adequate to the proposed end; but they who have been experimen- tally acquainted vvith the very wonderful effects of purulent drains, made from the immediate neighbourhood of diseases, will not be so much surprised at this particular one; and will immediately see how such kind of discharge, made and continued from the dis- tempered part, checks the further progress of the caries, gives na- ture an opportunity of exerting her own powers, of throwing off the diseased parts, and of producing by incarnation an union of the bones, (now rendered sound,) and thereby establishing a cure. However, be all this as it may, the fact is undoubted, and the number of witnesses, as well as patients, producible in con- firmation of it, is so considerable, that it is needless to say any thing more on that head. It is a matter of little importance towards the cure, by what means the discharge be procured, provided it be large, that it come from a sufficient depth, and that it be continued for a sufficient length of time.1 I have tried the different means of setons, issues by incision, and issues by caustic, and have found the last in general prefer- r When I say this, I mean to signify that it is absolutely without limitation, and must depend on their beneficial effect. 360 ON THE PALSY OP able, being least painful, most cleanly, most easily manageable, and capable of being longest continued. The caustics should be applied on each side of the curvature, in such a manner as to leave the portion of skin covering the spi- nal processes of the protruding bones, intire and unhurt; and so large, that the sores, upon the separations of the eschars, may easily hold each three or four peas in the case of the smallest cur- vature; but in large curves, at least as many more. These issues should not only be kept open, but the discharge from them should be maintained by means of orange peas, can- tharides in fine powder, aerugo aeris, or any such application as may best serve the intended purpose, which should be that of a large and long continued drain. Whatever length of time it may take to obtain a complete cure, by restoring the health as well as the limbs, the issues must be continued at least as long; and, in my opinion, a considerable time longer, especially in the persons of infants and growing children; the necessity of which will appear more strongly, when it shall be considered that infants and young children of strumous habits, are the subjects who are most liable to this distemper, and that in all the time previous to menstruation in one sex, and pu- berty in the other, they are in general more served by artificial drains than any other persons whatever. This, and this only, does or can alleviate the misery attending this distemper, and in proper time effect a cure. By means of these discharges, the eroding caries is first check- ed, and then stopped; in consequence of which an incarnation takes place, and the cartilages between the bodies of the vertebras having been previously destroyed, the bones become united with each other, and form a kind of anchylosis. The time necessary for the accomplishment of this, must, in the nature of things, he considerable in all cases, but very different, according to different circumstances. No degree of benefit or relief, nor any the smallest tendency towards a cure, is to be expected until the caries be stopped, and the rotten bones have begun to incarn: the larger the quantity of bones concerned, and the greater degree of waste and havock committed by the caries, the greater must be the length of time THE LOWER LIMBS. 361 required for the correction of it, and for restoring to a sound state so large a quantity of distempered parts—and vice versa.g In the progress toward a cure, the same gradation or succes- sion of circumstances may be observed^ as was found to attend the formation of the disease; with this difference, that they which at- tend the latter, are much more rapid than those which accompany the former. After the discharge has been made some lime (very uncertain what), the patient is found to be better in all general respects; and if of age to distinguish, will acknowledge that he feels him- self to be in better health; he begins to recover his appetite, gets refreshing sleep, and has a more quiet and less hectical kind of pulse; but the relief which he feels above all others, is from hav- ing got rid of that distressing sensation of tightness about the sto- mach: in a little time more, a degree of warmth and a sensibility is felt in the thighs, which they had been strangers to for some time; and generally, much about the same time, the power of re- taining and discharging the urine and faeces begins to be in some degree exerted. The first return of the power of motion in the limbs is rather disagreeable, the motions being involuntary, and of the spasmodic kind, principally in the night; and generally attended vvith a sense of pain in all the muscles concerned. At this point of amendment, if it may be so called, it is no un- common thing, especially in bad cases, for the patient to stand some time without making any further progress: this in adults oc- casions impatience, and in parents despair: but in ihe milder kind of case, the power of voluntary motion generally soon follows the involuntary. The knees and ankles by degrees lose their stiffness, and the re- laxation of the latter enables the patient to set his feet flat upon the ground, the certain mark that the power of walking will soon fol- low: but those joints, having lost their rigidity, become exceed- e Nothing can be more uncertain than the time required for the cure of this distemper. I have seen it perfected in two or three months, and I have known it require two years; two-thirds of which time passed before there was any visible amendment. VOL. II. 7' Z S62 ON THE PALSY OF ingly weak, and are not for some time capable of serving the pur- pose of progression. The first voluntary motions are weak, not constantly perform- able, nor even every day,' and liable to great variation, from a number of accidental circumstances, both external and internal. The first altempts to walk are feeble, irregular, and unsteady, and bear every mark of nervous and muscular debility; the patient stands in need of much help; and his steps, with the best support, will be, as 1 have just said, irregular and unsteady: but when they have arrived at this, I have never seen an instance in which they did not soon attain the full power of walking. When the patient can just walk, either with crutches, or be- tween two supporters, he generally finds much trouble and incon- venience, in not being able to resist, or to regulate, the more power- ful action of the stronger muscles of the thigh over the weaker, by which his legs are frequently brought involuntarily across each other, and he is suddenly thrown down. Adults find assistance in crutches, by laying hold of chairs, tables, &c; but the best and safest assistance for a child, is what is called a go-cart, of such height as to reach under the arms, and so made as to enclose the whole body: this takes all inconvenient weight off from the legs, and at the same time enables the child to move them as much as it may please. Time and patience are very requisite: but they do in this case, as in many others, accomplish our wishes at last. The deformity, remaining after recovery, is subject to great un- certainty, and considerable variety, as it depends on the degree of caries, and the number of bones affected; in general, it may be said, that where one vertebra only is affected, and the patient young, the curve will in length of time almost totally disappear: but where two or three are affected, this cannot be expected. The thing aimed at is the consolidation and union of the bones, which had been carious, and are now become sound: this is the sine qua non of the cure, and this must in such cases render the curvature, and consequently the deformity, permanent: the issues will restore the use of the limbs, but not the lost figure of the spine. THE LOWER LIMBS. 363 Since this method of treating the distemper has been made known, the disease itself has been more adverted to, and applica- tions for relief have been more frequent than they were while it was regarded as incurable. The number received into St. Bar- tholomew's hospital has been considerable, and, as it may be supposed, some in a state to admit of cure, others not. While the thing was new, and before a number of cures sufficient to establish the fact had been wrought, it was doubted by most and positively denied by some: but since a variety of successes has put the matter beyond all doubt, with regard to the restoration of the use of the limbs, it has been said, that as the disease is mani- festly a disease of the bones, it is to be apprehended, that the ex- pectation of relief may in some cases fail, and that in others it may not prove permanent; that the same kind of constitution re- maining, a return of the malady may be feared; and, in short, that a much greater degree of uncertainty may occur, than might be expected from the account which I have given. To the first I answer, that in cases where the caries is very ex- tensive, and the constitution has been thereby so injured as to produce a degree of mischief tending to the destruction of the pa- tient, no good is to be expected; the disease has been too long ne- glected, and is become thereby an overmatch for the remedy. But how does this differ from what may be said, with the same truth, of every disease, and of every remedy? To the second, third, and fourth remark, all I can say is, that in the space of three years, during which I have had many opportunities of mak- ing the experiment, I have met with but one single instance in which it has failed, where, from the state of the disease, and of the patient, there was any reasonable foundation for hopes; that all those who have submitted to keep the issues open long enough, have been so restored to health, and to the free use of their limbs, as to be perfectly capable, not only of exercise, but of hard la- bour; and that I have never yet, among those so treated, met with one on whom the disease has returned. On the other hand, the nature of the original distemper in the habit, its effects, both local and general, the gradual, slow manner in which alone a cure is obtainable, and the particular circum- 364 ON THE PALSY OF stance on which such cure entirely depends, I mean the removal of the caries, and the union of the bones with each other, all very strongly point out the propriety of continuing that discharge for a sufficient length of time, from which, and from which only, such benefit has been derived. At the beginning of the preceding tract I have said, that when I first began to consider the distemper with that degree of at- tention which it seemed to deserve, I was inclined to suspect that we had hitherto regarded it too superficially; that we had been satisfied with observing its external appearance merely, without inquiring into its real nature; that we had thereby been led to mistake an effect for a cause; and that there must certainly be, either in Ihe constitution of the patient, or in the state of the parts concerned, something which tended to produce this very dreadful malady. I am satisfied I was right in my conjecture, and am convinced, from every circumstance, general and particular, in the living, and from every appearance in the dead, that the complaint arises from what is commonly called a strumous or scrophulous indisposition, affecting the parts composing the spine, or those in its immediate vicinity. This morbid affection shows itself in a variety of forms; but, al- though its appearances be various, yet they are always such as determine the true nature of the distemper. Sometimes it appears in a thickened state of the ligaments, con- necting the vertebrae together, without any apparent affection of the bones. Sometimes in the form of a distempered state of the interver- tebral substances, called cartilages. Sometimes in that of diseased glands, either in a merely indu- rated and enlarged state, or, what is more frequent, in that of a partial suppuration. Sometimes it is found in the form of bags or cysts, containing a quantity of stuff of a very unequal consistence, partly purulent, partly sanious, and partly a curd-like kind of substance; and not Unfrcquently entirely out of the last. THE LOWER LIMES. 865 Sometimes under these bags, or cysts, even while they remain whole, the subjacent bones are found to be distempered; that is, deprived of periosteum, and tending to become carious. Sometimes these collections erode the containing membranes, and make their way downward by the side of the psoas muscle, toward the groin, or by the side of the pelvis behind the great tro- chanter, or in some cases to the outside of the upper part of the thigh. Sometimes each of the distempered states of these parts is ac- companied by a greater or less degree of deformity and crooked- ness of the spine, without any apparent disease of the bones com- posing it: sometimes the deformity is attended with an erosion, or caries of the body or bones of some of the vertebrae; and some- times the same bones are found to be carious, without any crook- edness or alteration of figure. These different affections of the spine, and of the parts in its immediate neighbourhood, are productive of many disorders, ge- neral and local, affecting the whole frame and habit of the patient, as well as particular parts; and, among the rest, of that curvature which is the subject of this inquiry; and it may not be amiss to re- mark, that strumous tubercles in the lungs, and a distempered state of some of the abdominal viscera, often make a part of them. From an attentive examination of these morbid appearances, and of their effects in different subjects, and under different cir- cumstances, the following observations, tending not only to illus- trate and explain the true nature of the disease in question, but also to throw light on others of equal importance, may, I think,' be made. 1. That the disease which produces these effects on the spine, and the parts in its vicinity, is what is in general called the scro- phula; that is, that same kind of indisposition as occasions the thick upper lip, the tedious, obstinate ophthalmy, the indurated glands under the chin and in the neck, the obstructed mesentery, the hard, dry cough, the glairy swellings of the wrist and ankles, the thickened ligaments of the joints, the enlargement and caries of the bones, &c. &c. &c. 2. That this disease, by falling on the spine, and the parts con- 366 ON THE PALSY OF nected with it, is the cause of a great variety of complaints, both general and local. 3. That when these complaints are not attended with an altera- tion of the figure of the back bone, neither the real seat, nor true nature of such distemper are pointed out by the general symptoms; and consequently, that they frequently are unknown, at least while the patient lives. 4. That when by means of this distemper an alteration is pro- duced in the figure of the back bone, that alteration is different in different subjects, and according to different circumstances. 5. That when the ligaments and cartilages of the spine become the seat of the disorder, without any affection of the vertebrae, it sometimes happens that the whole spine, from the lowest verte- brae of the neck downwards, gives way laterally, forming some- times one great curve to one side, and sometimes a more irregular figure, producing general crookedness and deformity of the whole trunk of the body, attended with many marks of ill health. 6. That these complaints, which are by almost every body sup- posed to be the effect of the deformity merely, are really occasion- ed by that distempered state of the parts within the thorax, which is at the same time the cause both of the deformity and of the want of health. 7. That the attack is sometimes on the bodies of some of the ver- tebrae; and that when this is the case, ulceration or erosion of the bone is the consequence, and not enlargement. 8. That when this erosion or caries seizes the body or bodies of one or more of the vertebrae, it sometimes happens that the particular kind of curvature which makes the subject of these sheets is the consequence. 9. That this curvature, which is always from within outward, is caused by the erosion or destruction of part of the bodv or bo- dies of one or more of the vertebrae; by which means that imme- diately above the distemper, and that immediately below it, are brought nearer to each ether than they should be, the body of the patient bends forward, the spine is curved from within outward, and the tuberosity appears behind, occasioned by the protrusion of THE LOWER LIMBS. 367 the spinal processes of the distempered vertebras. See plate 1.2, and 3. 10. That according to the degree of carious erosion, and ac- cording to the number of vertebrae affected, the curve must be less or greater. 11. That when the attack is made upon the dorsal vertebra?, the sternum and ribs, for want of proper support, necessarily give Way, and other deformity, additional to the curve, is thereby pro- duced. 12. That this kind of caries is always confined to the bodies of the vertebrae, seldom or never affecting the articular processes.1" 13. That without this erosive destruction of the bodies of the vertebrae, there can be no curvature of the kind which I am speak- ing of; or, in other words, that erosion is the sine qua non of this disease; that although there can be no true curve without caries, yet there is, and that not infrequently, caries without curve. See plate 5. 14. That the caries with curvature and useless limbs, is most frequently of the cervical or dorsal vertebrae; the caries without curve, of the lumbal, though this is by no means constant or ne- cessary. 15. That in the case of carious spine, without curvature, it most frequently happens, that internal abscesses and collections of matter are formed, which matter makes its way outward, and ap- pears in the hip, groin, or thigh; or being detained within the body, destroys the patient; the real and immediate cause of whose death is seldom known, or even rightly guessed at, unless the dead body be examined. 16. That what are commonly .called lumbal and psoas ab- scesses, are not infrequently produced in this manner, and therefore when we use these terms, we should be understood to mean only a description of the course which such matter has pursued in its way outward, or the place where it makes its appearance exter- nally, the terms really meaning nothing more, nor conveying any '■ 1 have seen two cases in which the bodies of the vertebrae were totally separated from all connexion with the other parts, leaving the membrane, which included the spinal marrow, perfectly bare. See plate 4. 368 ON THE PALSY OF precise idea of the nature, scat, or origin of a distemper, subject to great variety, and from which variety its very different symptoms and events, in different subjects, can alone be accounted for. 17. That contrary to the general opinion, a caries of the spine is more frequently a cause than an effect of these abscesses. 18. That the true curvature of the spine, from within outward, of which the paralytic, or useless state of the lower limbs, is a too frequent consequence, is itself but one effect of a distempered spine; such case being always attended with a number of com- plaints which arise from the same cause; the generally received opinion, therefore, that all the attending symptoms are derived from the curvature, considered abstractedly, is by no means found- ed in truth, and may be productive of very erroneous conduct. 19. That in the case of true curvature, attended with useless limbs, there never is a dislocation, properly to be so called, but that the alteration in the figure of the back bone is caused solely by the erosion, and destruction of a part of one or more of the cor- pora vertebrarum; and, that as there can be no true curvature with- out caries, it must be demonstrably clear, that there must have been a distempered state of parts previous to such erosion; from all which it follows, that this distemper, call it by what name you please, ought to be regarded as the original cause of the whole; that is, of the caries, of the curvature, and all the attendant mis- chiefs, be they what they may, general or particular; a considera- tion, as it appears to me, of infinite importance to all such infants and young children, as show, either from their general complaints, or from their shape, a tendency to this kind of evil; and whose parents and friends generally content themselves with a swing, or piece of iron machinery, and look no further. 20. That whoever will consider the- real state of the parts when a caries has taken.place, and the parts surrounding it are in a state of ulceration, must see why none of the attempts, by means of swings, screws, &c. can possibly do any good, but on the contrary, if they act so as to produce any effect at all, it must be a bad one. 21. That the discharge, by means of the issues, produces in due time (more or less under different circumstances) a cessa- tion of the erosion of the bones, that this is followed by an incar- THE LOWER LIMBS. 369 nation, by means of which the bodies of the vertebrae which had been the seat of the disease, coalesce, and unite with each other, forming a kind of anchylosis. 22. That the different degrees and extent of the caries, in dif- ferent subjects, must render all attempts to cure uncertain, both as to the time required, and as to the ultimate event: the least and smallest degree will (every thing else being equal) be soonest relieved and cured: the larger and more extensive will require more time; and where the rottenness is to a great degree, and all the surrounding parts in a state of distempered ulceration, it must foil all attempts, and destroy the patient. 23. That when two or more vertebrae are affected, forming a large curve, however perfect the success may be with regard to the restoration of health and limbs, yet the curvature will and must remain, in consequence of the union of the bones with each other. 24. That the useless state of the limbs is by no means a conse- quence of the altered figure of the spine, or of the disposition of the bones with regard to each other, but merely of the caries: of this truth there needs no other proof, than what may be drawn ' from the cure of a large and extensive cur\ ature, in which three or more vertebrae were concerned: in this the deformity always re- mains unaltered and unalterable, notwithstanding the patient re- covers both health and limbs. Upon the whole, after due consideration of what has been said concerning the nature of the complaint, its producing cause, and the method by which it is capable of being cured, I would ask, whether the diseased state of the spine, and of the parts connected with it, (which, if not prevented, must produce some of its very dreadful effects,) may not, by a timely use of proper means, be prevented? A morbid state of parts previous to deformity, caries, or curve, must be allowed: every complaint of the living, and every appear- ance in the dead, prove it beyond contradiction or doubt. All the general complaints of persons afflicted with this disorder, will always, upon careful inquiry, be found to have preceded any degree of deformity, to have increased as the curve became apparent, and to have decreased as the means used for relief took place: the pain and tightness about the stomach, the indigestion, the want of appe- VOL. II. 3 A 370 ON THE PALSY OF lite, the disturbed sleep, &c. &c. gradually disappear, and the marks of returning health become observable, before the limbs re- cover the smallest degree of their power of moving. On the other band, it is as true, that when, from extent, or degree, or inveteracy of the caries, the issues are found to be unequal to the wished for effect, the general complaints receive no amend- mentj but increase until the patient sinks under them. If all this be true, which, that it is, the manifold and repeated experience of many, as well as myself, can amply testify; and if it be found that the issues are capable of effecting a perfect cure, even after a caries has taken place, and that to a considerable degree, which is also true to demonstration, is it not reasonable to conclude, that the same means, made use of in due time, might prove preventive? If this was a matter of mere speculation or opinion, I would be very cautious how I spake on the subject: but it is really a matter Of experiment; and as far as I have had it in my power to put it to that test, it has succeeded, by the restoration of lost health, and the prevention of a deformity which was advancing rapidly. It may, perhaps, be said, that if no such means had been used, the same space of time might have produced the same effect: to this it is impossible to make an answer: I shall, therefore, content myself with having given my opinion, vvith the circumstances and reasons on which it is founded. I should be sorry to be misunderstood on this point, or to have it thought that I meant to say, that every weak or rickety child was necessarily liable to a curved spine; or that issues were to be deemed an infallible remedy for the ills arising from a strumous habit: far be it from me to say either: what I would wish to be understood to mean is, that such kind of habit appears to me to be most apt to produce some of the mischiefs mentioned in this tract; that, as a purulent discharge, derived froq the neighbourhood of the spine, is found, from repeated experience, to be a successful remedy, even after the disease is confirmed by a caries, it seems to me to bid fairer than any thing else, if used in time, to become a preventive; and that, us some other kinds of deformity are found to follow attacks of the same kind of constitutional disorder seizing on these parts, and »vhich, though not causing precisely the same effect, areneverthe- THE LOWER LIMBS. 371 less attended with the same general symptoms, I cannot help think- ing, that it may be well worth while to try whether benefit be not attainable by the same means, in the one case as in the other; and if the old maxim," anceps remedium quam nullum," be admissi- ble, surely an experiment, which is in its nature perfectly inca- pable of harm, is worth making. 372 ON THE PALSY OF ' <;* Since Mr. Pott made his first observations on this disease, it has much engaged the attention of the profession, and from re- peated examinations it has been proved to be caused by the giving way of ihe bodies of some of the vertebrae, owing to a loss of sub- stance produced by caries: in many cases the remaining parts of the bone show that they were considerably enlarged before the carious disposition took place, which has led some to consider it as a species of spina ventosa of the back bone. Such a state of the bones often produces bad symptoms and much mischief; but the curvature cannot take place till the caries has caused a loss of substance in the bodies of the vertebrae. The first and great object, in our endeavours lo relieve this dis- ease, must be to prevent the increase or continuance of the caries, and to give nature an opportunity of restoring the weakened part by furnishing fresh growth of bony matter. That this effect has been produced by issues opened on each side of the curvature, has been proved beyond controversy, by symptoms in the living, and by examination of the parts after death. Many persons have, in a great variety of instances, had opportunities of observing the gradual progress from total imbecility to strength and vigour, with- out the intervention of any other means than issues; and I feel the highest satisfaction in having it in my power to assert, that by such simple means one of the most destructive disorders which attack the human frame may be prevented, and the blessings of health restored. To him who invented or proposed the plan, every praise is due; and I may presume that any attempt to im- prove on it cannot fail of being well received. On these grounds I shall take the liberty to remark, that highly as I think of the power and efficacy of issues in these cases, I must confess that in many which I have attended, I have been con- scious of the want of some power, or means, to raise and support the superior parts, and to take off the superincumbent pressure. And I have long been of opinion that, in this case, surgery will find great advantage in the aid of mechanism. THE LOWER LIMBS. SI3 The assistance derived from mechanical powers, in a variety of chirurgical cases, is too notorious to require to be mentioned: their effects on bent bones, clubbed feet, and other distortions of the limbs, must be manifest to any one who will candidly give his attention to the subject; yet?from unaccountable prejudices, I have known some eminent practitioners in surgery oppose, even in these cases, what they call the use of irons, and who would let Nature persist in her error, in hopes that she may rectify herself in the general growth of the body, rather than take proper means to lead her into the right path; while the real state of the fact is, that the distortion is much more likely to become consolidated with the growth of the child, and strengthen with its strength, until it is confirmed and unalterable. Mr. Pott had no objection to the use of instruments in cases of distorted limbs: 1 have many times known them applied under his direction with great advantage; but he certainly did not entertain a favourable idea of any assistance to be gained by mechanical powers in those distortions, or incurvations of the spine, which were the subject of his treatise; on the contrary, in several pass- ages of the work alluded to, he showed a marked disapprobation of them. He was of opinion that the discharge produced by the issues was all which is requisite for a cure, and so it has certainly often proved, no other means being employed in cases which have succeeded perfectly; yet he agreed that olher assistant means, such as bark, cold bathing, frictions, &c, might occasionally be added, in order to expedite the cure; but with regard to pieces of me- chanism, as was observed, he always objected to them, and would not allow them to be in any degree assistant to his plan. 1 should certainly be cautious in giving an opinion after such respectable authority; yet I must observe, that the more respectable an author is, the more weight his opinions carry; and consequently there is more reason why those opinions should be scrutinized, if they clash with subsequent observations apparently well founded. Thus, with all due deference to the judgment of a man, of whom no one can entertain a higher opinion, I must observe that I think some powers of mechanic ingenuity may, in many cases of distortions of the spine be made, not only to assist in accomplishing the end which Mr. Pott intended by the caustics, but to produce effects 374 ON THE PALSY OF more beneficial, and far beyond what he himself expected from their application. Mr. Pott observes that " these pieces of mechanism are calcu- " lated to obviate and remove what does not exist; that they are " formed on a supposition of actual dislocation, which never is " the case; and therefore they always have been and ever must be " useless." I readily allow that in those cases in which the issues have been so successful, there is no dislocation; but it must be ac- knowledged that the part occupied by the disease is in general extremely weak, and incapable of supporting the weight of the parts above the curvature. On this head Mr. Pott himself re- marks, that, u if the curvature be of the neck, the child finds it " inconvenient and painful to support its own head, and is always " desirous of laying it on a table, pillow, or any thing, to take off* " the weight." The same thing precisely happens when the dis- ease attacks the dorsal or lumbal vertebrae. Every one who. has attended to these cases, must have remarked the efforts which children make under such circumstances: I speak of children as being most frequently liable to the complaint; but adults, and every one subject to a weakness in the back, from whatever cause, endeavour to take off the load which oppresses them, by support- ing themselves on tables or chairs; and when they rise to walk, they press their hands on their knees in order to relieve the spine: all this points out the necessity of giving what assistance is in our power to the weak part. In another place Mr. Pott observes, that the bones are already carious, or tending to become so, the parts connected with them diseased, and not infrequently ulcerated; that " there is no dis- " placement of the vertebrae with regard to each other, and that " the spine bends forward only because the rotten bone or boneis " intervening between the sound ones give way, being unable in " such state to bear the weight of the parts above." Surely then it appears reasonable that those parts should be strengthened and supported, while nature, with the assistance of the issues, is doing the work of restoration, by putting a stop to the caries, after which bony matter is deposited to supply the deficiency which the dis- ease has produced. We apply splints to a broken leg while ossi- fication is forming; we do not allow any pressure to be made on THE LOWER LIMBS. 375 it while that natural process is going on; and the patient afterwards takes off the weight of the body from it by means of crutches, until it is perfectly strong and capable of its own duty. I am at a loss to find any good reason or sound argument why the same means of assistance, at least so far as lies in our power, should not be applied in cases of a weakened spine, in order to take off su- perincumbent pressure, and to endeavour to restore the actual form of the spine during the progress of the cure: if this be not attempt- ed, or cannot be brought about at this time, the consequence must be that the back will remain crooked during the cure. Nature is obliged to do her work while it is in the bent position; and though the strength of the pillar be subsequently increased, the cure itself becomes in some degree an evil, and a lasting one, as the growth of new bone in that situation must consolidate all the parts, and must confirm the curvature exactly, or nearly as it stood, before the cure was attempted; for whatever power the issues have in strengthening, it cannot be supposed that they can materially alter the curve which is already formed. The period when we are most likely to improve the form of the pillar must be during the progress of the cure, while the parts allow of some latitude of motion: when they are once become consolidated and fixed by the growth of bony matter, no alteration scarcely can take place but what is effected by the future general growth of the whole body. In very young subjects this is certainly very considerable; but is not this an argument why the assistance to be obtained by growth should as early as possible be determined in a proper direction? When that is accomplished, bark, cold bathing, and frictions may be useful; but till then, the aid which they may give only contri- butes to fix and confirm the parts in a wrong situation. From repeated observation I am so convinced, and conceive the benefit likely to result from mechanic assistance so self-evident, that had not the objections to it originated in an authority so gene- rally respected, I should think it unnecessary to advance any thing more on the subject. But this being the case, I take the liberty to add, that as a further proof how necessary it is that by some means or other the pressure of the parts above must be in many cases taken off while the cure is perfecting, and to show that Mr. Pott himself was convinced of the necessity of it. though perhaps 376 ON THE PALSY OF it did not appear to him exactly in the same point of view, 1 must remark, that in many cases of curved spines which Mr. Pott attended, he thought it necessary to confine his patients to bed, or to a horizontal, situation during the greatest part of the cure, as they could not bear to remain in an upright position. I need not observe how irksome this must be, how it must tend to relax and weaken the patient, and consequently to retard the cure: seeing it only in this light, it must be acknowledged that any means which would render unnecessary this severe and unhealthy process, must be desirable and advantageous. That many of the machines which have been invented to re- medy distorted spines, from having been imperfectly or improperly made, badly contrived, or injudiciously applied, are capable of doing much mischief, must certainly be allowed: the neck swing, and the screw chair, I should conceive, can do little good, for it is obvious that a posture produced by swinging a child by the neck, or stretching it in a chair, cannot long be borne: he may be amus- ed in it at first, but in a short time it will become irksome, if not painful, and he will be urgent to be released; and then what good can an extension of such duration have done? The weight of the superior parts, all the rest of the day, destroys the little effect produced. If it be often repeated, the alternative of exten- sion and relaxation must be injurious, as it interrupts the regene- ration of parts, and by moving the diseased bones on one another, is a constant source of irritation. In some cases, when the parts are already weakened by the disease, much mischief, even to fa- tality, may be the consequence of imprudently or violently stretch- ing them. The stays, which are intended to apply forcible pres- sure to the prominent part of the curve, are also in my opinion inefficacious, and sometimes detrimental: but if a machine be con- trived to elevate the head, and support the thorax, passing down the spine, and strengthening it, as a splint does a broken limb, resting on the pelvis, as its basis, with a contrivance to give such gradual and permanent extension as the weak parts vv ill bear without in- jury, and to be continued until, by a deposition of osseous matter, the yielding vertebrae become firm and compact bones, 1 am clearly of opinion that much good from it may be derived. THE LOWER LIMBS. 377 This instrument has received still further improvements, which in some cases have been found necessary and efficacious, particu- larly when there is also a diseased state of the bones of the pelvis. It has been contrived to pass under the arms, and to rest on the seat, so as to take off the whole weight of the body when sitting: it has also been connected, by means of joints, to perpendicular bars, passing down the outside of the thighs and legs, to support it when in a standing posture. The want of some assistance in aid of Mr. Pott's plan always appeared to me in a strong light, and I was induced to give my opinion on it more at large, in a pamphlet, published in 1799, of which this is an extract. Indeed, the good effects arising from a well adapted instrument in cases of curvature, from various causes unaccompanied with caries, is so generally known and acknowledged, that it is unne- cessary to say more on the subject in this place: what I principally wished, by the description of it in the pamphlet alluded to, was to show that it is safe and useful, and to endeavour to set aside the disinclination which I perceived in many practitioners, as well as in the writings of Mr. Pott, to admit of its use or assistance in cases of curvature, attended vvith caries; and further, I have en- deavoured to make it apparent, that such a contrivance is not only frequently useful, but often absolutely necessary. I need not ob- serve that undoubtedly greater care and judgment are required in the application of it, where some of the bones of the spine being carious, the parts connected with them may more easily be injured by improperly or suddenly stretching them, than when the curve has arisen from muscular action or other causes. But I hope not to be misunderstood: I do not mean to say, indeed am far from thinking, that instruments of any sort are wanting in every case of curvature of the spine. The issues are often sufficient to complete the cure without any other assistance, as has been proved in many instances. Mr. Pott has, in his usual perspicuous manner, given a circum- stantial account of the method of applying the caustics and con- ducting his mode of cure; but as some alterations have since been introduced which appear to be improvements on his plan, I think it vol. n. 3 B 378 ON THE PALSY OF right to notice them. Mr. Pott has directed the issues to be made of an oval shape, and has left a sketch of one, as a pattern, one inch long by three quarters of an inch wide. From repeated ex- perience I have found longitudinal eschars, according to the extent of the curve, answer better. They should be made so that the peas may lie imbeded on each side, and near to the spinal pro- cesses. Particular attention should be given that the caustics be applied so as to reach just above the curvature. I have many times seen a large and copious drain maintained without effect, because it was made below the beginning of the curve; but, on its being opened above, the good effect derived from it soon took place. If peas or small beans are used, they should be softened by soaking them in water: they should then be strung on a thread and suffered to dry, when they are to be cut into proper lengths according to the drain, which, as was observed, must vary with the circumstances of the case: thus they are easily applied and easily removed. It has always been no small difficulty to keep these issues open and in a good state, so as to furnish a proper discharge. The means which have been usually employed for this purpose are painful, and the effects produced by them of short duration; so that the issues were perpetually closing and filling up with fungous granulations, in consequence of which the unpleasant task of using escharotics became necessary, at least once a week, or oftener in some subjects. This in adults was often as much as they could bear; in children particularly distress- ing to every one concerned. At some intervals this was neces- sary to be done with fresh application of caustic, perhaps more painful than the original one. Very small solid glass beads, placed all round the edges of the wound, have of late years been found to obviate these difficulties, for wounds never heal from the centre; and if the beads are pro- perly applied, they will soon sink in beneath the granulations; and being foreign bodies, the sides of the wound will never heal over them. Another advantage which the beads have over peas, is, that when once they are fairly established, they may be left in, and the issues may be dressed like other superficial wounds; whereas peas or beans swell, and require to be daily renewed, as. being vegetable productions, they soon become putrid. THE LOWER LIMBS. 379 I have sometimes used setons, and in some cases am inclined to give them the preference for several reasons: they embrace a large extent, which is of material consequence when the diseased part cannot be very accurately determined, or where there is reason to suppose that several vertebrae may be affected: they become effi* cient in three or four days, when the sloughs from the caustics do not separate generally in less than a week or ten days: they are not offensive; and they never need the application of escharotics, except at the extreme points from which only fungous granula- tions can arise. The object is to procure a large discharge of matter by suppu- ration from underneath the membrana adiposa on each side of the curvature, and to maintain it until the cure be accomplished, or so long as may be thought necessary. Whether this be brought about by issues or setons is perhaps'not very material, but the easiest means will always be the best. Mr. Pott disliked setons: he observes, " A seton is a painful and nasty thing; besides which, " it frequently wears through the skin- before the end for which " it is made can be accomplished." In the common way of making and managing setons this was certainly the case; the usual mode was in general to make the track of the seton short, but, be the length what it might, the silk, or whatever it was thought proper to use, was passed through and cut off an inch or two above and below, and a knot was fastened at each end, to pre- vent it from slipping out. This was ordered to be moved every day backward and forward, and the wounds at each end to be made clean; but the seton was not changed, so that it constantly re- mained in the wound, immersed in, and confining a quantity of putrid matter, the acrimony of which certainly tended to inflame the skin, and made it wear its way out: but under different ma- nagement I conceive the effect produced will be very different. The method I would recommend is the following. A seton needle being passed in the usual manner through as great a space as may be deemed necessary, will conduct a skein of coarse silk, which, when brought out at the lower wound, should be cut off from the needle, leaving about an inch to be secured by a slip of sticking plaster, to prevent its being drawn back again. The remainder of the silk above should be neatly doubled 38Q ON THE PALSY OF up, and confined by a slip or two of sticking plaster. When the suppuration is established, and the seton become loose, it may be drawn down. The part which is soiled by the matter may be cut off, and a fresh portion of silk introduced. When one skein is used, another may be connected to it, and drawn through in the same manner. Thus it may be changed as often as necessary, and the wound be kept perfectly sweet and clean. By these means the skin will not become inflamed or irritated, and the drain may be continued almost for any length of time. I have frequently remarked that the first action or stimulus of the caustics produces an almost immediate effect; the patients, in a day or two after they are applied, find a considerable alteration for the better in the general state of their health, attended with a glowing warmth, and sometimes a degree of motion in the limbs. I have often pointed out this at the Hospital, at the same time ob- serving that this agreeable symptom would soon be less apparent; nor until the issues should arrive al a more advanced stage, would any permanent good effects be observed; and my conjecture has seldom proved unfounded. I mention this, that people may not be discouraged at experiencing this kind of check upon their hopes: let them wait with patience till the drain is fairly established, and they will rarely be disappointed in their expectations. Parents, nurses, and persons unaccustomed to these cases, dread the quantity of the discharge, and conceive it must tend to weaken the constitution; but it certainly has not such an effect. I have often remarked children improving in health and strength, and growing fat under a very considerable drain of this sort. I do not mean to say that this is the cause of the amendment; the return of health probably arises from the stop which is put to the ravages of the disease; and I only mean to infer that neither health nor strength appears to be diminished by the discharge, which it is necessary to keep up in order to effect a cure. Mr. Pott has remarked that " there can be no curvature from " within outward, without an erosive destruction of the bodies of " some of the vertebrae; but that there is not infrequently caries, " without any curvature being produced; that this happens more " frequently in the loins than in any other part of the spine; that THE LOWER LIMBS. 381 " what are called lumbar or psoas abscesses are not uncommonly " produced in this manner; and that a caries of the spine is more " usually a cause than an effect of these abscesses." That caries of the bodies of the vertebrae may produce bad symptoms, and may cause great mischief, before it has destroyed sufficient of the bony support to make the spine bend, is not only probable but a f.ict well known. Not only abscesses are produced by it, but it is fre- quently accompanied with grinding, deep seated pains in the pel- vis and thighs, sometimes to such a degree as to produce an ina- bility of motion in the limbs, bordering on paralysis, but not to such a degree as when the bones have given way, and caused a compression on the spinal marrow. It is reasonable to conclude that the same means which are known to cure a disease in its ad- vanced state, would be more likely to prove efficacious in stopping its progress in the beginning; but Mr. Pott has remarked, that " when " these complaints are not attended with an alteration of the " figure of the backbone, neither the real seat nor the true nature of " such distemper is pointed out by the general symptoms, and con- " sequently that they are frequently unknown, at least while the "patient lives.'''' This is an observation of material import, and should not be passed by without a comment, as it rather tends to damp our inquiry into this species of mischief, the progress of which might often be arrested, if found out in time. It may be ri°nt therefore to observe, what from repeated instances I have learned, that, in cases which have led to a suspicion of the pro- ducing cause being derived from the back, if we attend to the pa- tient's complaints, and observe the part to which he points, the seat of the mischief may often be discovered, by pressure with the fingers, or tapping with the knuckles gently on each vertebrae, singly, one after another. I need not repeat that this is a fact of great consequence to be known, as when discovered, the incipient disease may often be stopped; and probably many lumbar abscesses, with all the consequences of increase of mischief, may be pre- vented. The following case will serve to illustrate this point of practice: In ApriL 1795, Mrs. F-------•, a lady from Ireland, consulted Dr. Turton on account of pains, vvith which she was afflicted 382 ON THE PALSY OF about the lower part of the loins and hips, which were thought to be rheumatic. As she received no relief from medicine, and there was some inability to walk, Dr. Turton, with his usual acuteness of judgment, suspected that her complaints might arise from some disorder in the spine. I was accordingly desired to examine it; I found the spinal processes of all the vertebrae perfectly regular and even, and could discover no reason to suppose that the disease had its source from that origin. On its increasing, I was desired to meet the doctor again. She was now considerably worse, her pains in bed were tormenting and almost constant: with great dif- ficulty, and not without the assistance of a servant, she could drag one foot after the other across the room. I again examined the spine, and could discern not the smallest deviation from the right line; but, on pressing pretty firmly on every vertebrae singly, I ob- ' served, when I came to the two lowermost of the loins, she shrunk from the touch, and said, in that part I gave her a sensation she had not felt before, amounting to pain, though not acute. From these observations alone, it was determined to apply caustics on each side of those vertebrae, the sur- prising and happy consequence of which was, that in a few nights her pains grew better, and soon in a great degree left her. In a fortnight she was able to walk without assistance across the room: soon after she went into the neighbourhood of'Hampton- Court, where her health and strength improved rapidly, and in about two months she was able to walk a couple of miles. In the autumn I saw her at Brighthelmstone, where she bathed, walked, rode on horseback, and enjoyed good health and spirits; and I may add, that I afterwards met her frequently in London, where she spent the winter, without any return of the complaint. Many more instances might be adduced when the cause, though occult, has been discovered, and the mischief, which we may posi- tively conclude would have gone on from bad to worse, has by the assistance of caustics been restrained and prevented. If any doubt should arise about the precise spot where they should be applied, the caustics, if it be thought proper to use that method^ not being confined to small oval ones, but made longitudinal, so as to take in one or more of the vetebrae, according to circumstances, will be the means of findi ng out the disease and acting upon it; or if setons THE LOWER LIMBS. 383 are used, they may be made sufficiently long to include with cer- tainty the seat of the disease. In the latter part of Mr. Pott's life, he had applied the method of cure by issues to other diseases: particularly in strumous affec- tions of the joint of the hip, he had been several times successful in preventing an increase of caries, by means of an ulcer being es- tablished in the neighbourhood of it. In those deplorable cases, where one hip is let down below the other, where the parts are flab- by? tne glutaei muscles lose their firmness, the buttock its figure and convexity, and the leg is lengthened, probably by the increase in size of the head of the os femoris, he found that the progress of the disease may frequently be stopped, and the parts restored to their natural firmness and figure, by making an issue just behind the great trochanter. Mr. Pott remarked that the time when the change will take place, and the restoration be complete, is indefi- nite: it may take place in a few weeks or months: or, as was ob- served with regard to the effect of caustics in diseases of the spine, it may require a much longer lime. In short, every thing relative to the complaint is uncertain, except the ultimate cure, which will rarely fail to reward our perseverance; provided, that at the same time the constitution is attended to, and the diseased habit of body corrected by medicine, proper diet, and good air. When the thigh was retracted, and accompanied with a consi- derable swelling, Mr. Pott was not sanguine in his prognostics of recovery, but spoke of most applications as inefficacious. Yet, even in these cases, I have known the caustics applied vvith great apparent advantage. Some years ago I was desired by the late Mr. Berry to visit a girl about eighteen years of age. She complained of pain in her knee, leading up toward the hip; she could not straighten her thigh, which was drawn up toward the pelvis, and with great dif- ficulty she could walk across the room; she had been electrified, and had used variety of remedies, by the advice of some gentle- men of eminence in the profession, to no purpose; the complaint grew rapidly worse, and she was obliged to take to her bed. The thigh was now drawn up to the pelvis, the knee turned inward, 384 ON THE PALSY OF and the appearance was as if the head of the femur was dislocated; the parts surrounding the hip were turgid and enlarged, exquisite- ly painful to the touch, and on the smallest motion; blisters, em- brocations, fomentations, &c. were tried in vain. The pain was now become almost incessant, the disease continued to increase, and bore the appearance of matter forming in the joint. Though this was not a case in which Mr. Pott recommended an issue, I was determined to give her the chance of one: a caustic was according- ly applied below and posterior to the great trochanter. She did not appear to be much served by it at first, though we remarked that her pain was not so violent: in about six weeks she seemed to have derived some benefit, and though the limb was still contract- ed she could straighten it better. I now found that the issue had been neglected and nearly suffered to close. I recommended it to be enlarged, which was done the beginning of September: in about a week after, when the suppuration was fairly established, she began to grow better, the joint became unlocked, and in a few weeks she had lost the pain of the hip, and was able to straighten the thigh and leg perfectly; soon after she walked across the room without help, only complaining of a little tenderness in the joint, and in no great length of time afterward was perfectly recovered. No other method having been of the least service to her, as she ap- peared to receive some advantage from the first application of the caustic, and got well after the repetition of it, we may reasonably infer that they were the causes which produced the alteration and subsequent cure. As this was the first case of the kind I had tried it in, I regarded it with some degree of diffidence, but have now no doubt of the fact; as I have since seen several cases nearly si- milar, and have one at present under my care, which have received great benefit from the application of caustics. In those cases in which Mr. Pott succeeded, a much longer time elapsed before the effect was produced. Mr. Pott also used caustics in scrophulous swellings of the joint of the knee, where there was suspicion of beginning caries: they were applied just above and below the joint: in some cases they appeared to be materially serviceable in preventing the increase of the swelling; in many others they failed. THE LOWER LIMBS. 385 In similar diseases of the joint of the ankle he also tried them: but the caustics seemed to have less effect, as the part affected was at a greater distance from the trunk: in these joints no advantage appeared to be derived from them. The idea, however, is wor- thy of its author, and deserves further trials; indeed, whatever has the least chance of being beneficial ought not to be neglected in those desperate cases, which, if their progress be not prevented, terminate in the unavoidable loss of the life or limb. E. vol. n 3 c AN ACCOUNT OF TUMORS WHICH RENDERED THE BONES SOFT. COMMUNICATED TO THE ROYAL SOCIETY, BY MR. POTT, SURGEON; AND PRINTED IS THEIR TRANSACTIONS, VOL. XL* AN ACCOUNT OF TUMORS WHICH RENDERED THE BONES SOFT, &c. &c. &c. In November 1737, a gentleman aged 27 complained to me of a swelling in the inside of his right thigh (being in every other re- spect in perfect health). Upon examination, it appeared to be an encysted tumor of the steatomatous kind, lying loose between the sartorius and vastus intemus muscles. I told him I could propose no way of curing it, but by taking it out; which was accordingly done, and he wa« very well in six weeks. After this he continued well for near a year, (except that he now and then complained of a slight pain in the joint of that hip, which went off and returned at different times,) and then fell into such a disposition to sleep, that no company or diversion, nor his own endeavours to the contrary, could keep him awake, after eight or nine o'clock in the evening, if he sat down. This continued on him for three or four months, and then the pain in his hip grew worse; for which he used the cold bath, flesh brush, and riding on horseback, but without any effect. Hereupon he asked the advice of Dr. Beaufort, who put him into a course of aethiops mineral, cinnabar of antimony, and gum guaiacum, with the Spa water, and purging with calomel by intervals. This method he pursued for a considerable time, but without any benefit. 390 AN ACCOUNT OF TUMORS After this, by the advice of some acquaintance, he took half a drachm of salt of hartshorn, night and morning, in a draught of warm whey, for some time, but without any sensible effect, even by perspiration. Some little time after this, he began to complain of a slight periodical heat and thirst, which returned every night, with a quick hard pulse, but which was not so great as to make him uneasy. It was now September 1739, when, having an opportunity of going with some friends, he determined to try what Bath would do for him: in his journey thither, the nocturnal heat and thirst in- creased so much as to prevent his sleeping; but in the few days that he spent in recovering from the fatigue of the journey, they seemed to go off again. He then began to use the waters, both internally and externally; upon which the last mentioned symptoms again appeared, and he was obliged to desist, and use cooling medicines. His physicians then advised him to bathe the affected limb only, upon which they returned again, and with such violence, that the further use of the waters was thought highly improper, and he then left them off. During this time the sight of his left eye grew dim, which dim- ness increased gradually for some little time, till he became quite blind of that eye; the bulb of it being considerably enlarged, and thrust forward out of the orbit. For the most part of the time he had been at Bath, he had gene- rally been very costive; and upon leaving off the water, had no stool for some days; for which reason a common clyster was given, and produced so profuse a discharge of serous matter, and con- tinued for so many hours, (almost incessantly,) that he was reduced as low as possible. For some time past several small tumors had appeared in dif- ferent parts of him; viz. five or six on his head, two or three in his back, and one in the neck; all lying just under the skin, and sensibly increasing every day, till they came to a considerable size. December the 2d, 1739, he returned to London. His chief complaints now were an excessive langour, an inability to move his right hip, and, when moved by another person, a very WHICH RENDERED THE BONES SOFT. 391 acute pain in it, an incapacity of sleeping when in bed, and an intense thirst in the night, with a quick hard pulse. He now took the advice of Dr. Hartley and Dr. Shaw, who prescribed him the cinnabar of antimony three times a day, to drink the Seltzer waters, and keep to a cooling regimen; and allowed him a moderate dose of the pill Matthaei every night; by means of which he got some sleep, of which he had for some time been absolutely deprived. When he had taken the cinnabar five or six days, and during that time had no stool, it was thought proper to give him a clyster, which brought away all the medicine, without the least alteration; nor was there ever after this time any appearance of any mucus being secreted by the intestinal glands, he never going to stool above once in a week; and then there came away a few lumps of excre- ment as hard as pieces of wood, which were expelled with such labour and fatigue as can hardly be imagined, though he generally took an oily clyster to render it more easy, and washed down his medicines with a soapy draught. The joint of the hip was now become quite stiff, all the inguinal glands being loaded with the same kind of matter, of which the other tumors seemed to be composed; and a large cluster more of them might be felt under the glutaei muscles, and behind the trochanter. The cinnabar was now left off, and mercurial unction proposed and consented to; and accordingly a proper quantity was rubbed in every night, stopping now and then to see what turn it would take; and in this course he continued for more than a month, but without any benefit; nor did the mercury produce any visible effect on him. Sir Edward Hulse, being called in, directed the burnt sponge, which he took for some time, till growing worse and weaker he determined to try Mr. Ward. He took his sweating and purging medicines two or three times, but found no sort of effect from them; and being now quite tired of physic, and reduced extremely low, he determined to pass the rest of his time as easily as he could, by gradually increasing his opiate; and in this manner languished, incapable of stirring or helping himself, till the 2d of May, 1740, and then died. 392 AN ACCOUNT OF TUMORS For a considerable time before he died, he was nourished by fluids only; yet, as soon as ever they were received into the sto- mach, in however small quantity, they gave him an acute pain at the bottom of his belly, just above the pubis. For two months, or more, before his death, he could never make any water while he was up, but always made a good deal at different times when in bed. Soon after his return to London I opened the tumor I had taken out of his thigh two years before, and found the inside of it ossified. Upon dissection, the first thing that offered itself was a large tumor on the sternum, which had been perceived about three months before he died: it was as large as a turkey's egg, and so hard and immoveable, that I was in doubt whether it was upon or under the bone. Upon removing the skin, it appeared covered by the expansion of the tendons of the intercostal muscles, and the periosteum: this coat being taken off, it was of a suetty kind of substance for about half an inch deep; and below this was a kind of cartilage inter- mixed with a great many bony particles. I then shaved off all this diseased body even with the surface of the rest of the ster- num but found no bone, it being quite dissolved and confounded with the mass of matter that composed the tumor, which was equally protuberant within the thorax, and composed of the same materials. Part of the fifth and seventh ribs were dissolved in the same manner into a kind of substance between bone and cartilage, with a thick coat of steatomatous matter. Within the cavity of the thorax were thirty-seven of these dis- eased bodies, most of them attached either to the vertebrae or the ribs; and wherever they were attached, the cortex of the bone was destroyed, and its internal cellular part filled with the dis- eased matter. Immediately above the diaphragm was a large scirrhous body, lying across the spine and the aorta, the latter of which lay in a sinus formed in its lower part: it had no attachment to any other part, and weighed thirteen ounces and a half; and from its situa- WHICH RENDERED THE BONES SOFT. 393 tion, I think, must have taken its rise from some of the lymphatic glands lying about the thoracic duct. From the origin of the aorta, from the heart quite up to the basis of the cranium, all the blood-vessels were surrounded with these scirrhous bodies, and the thyroid gland was diseased in like manner, and bony within. On the left side' was another of these bodies, made out of the glandula renalis, weighing nine ounces and three quarters. On the right, the glandula renalis was in a natural state; but the cellular membrane, which surrounds the kidney, was filled vvith a large cluster of these bodies of different sizes, some of them entirely suetty, others intermixed vvith bony particles. Three or four of them were attached to the body of the kidney, and these were a sort of cartilage, beginning to ossify. The pancreas was quite scirrhous and very large. One very large tumor sprung from the spongy body of the third vertebra of the loins; the bony texture of which was so dis- solved, and mixed with the matter of the tumor, that the knife passed through it with great ease. The inner side of the os ilium, all the ischium and pubis, were covered with these appearances; and, upon removing them, the bone was found in the same state as the sternum and ribs; the middle of the right os femoris was surrounded with a mass of the same matter, and the bone underneath in the same state. In the bottom of the orbit, surrounded by the recti muscles, was a pretty large steatoma, which occasioned the protrusion of the eye; and, by pressing on the optic nerve, (in all probability,) the blindness. VOL. II. 3 D AN ACCOUNT OF A HERNIA OF THE URINARY BLADDER, INCLUDING A STONE; COMMUNICATED TO THE ROYAL SOCIETY, BY MR. POTT, SURGEON; READ FEB. 16, 1764.—INSERTED IN THEIR PHILOSOPHICAL TRANSACTIONS, VOLUME HV. AN ACCOUNT, Sic. &c. A healthy boy, about six years old, was suddenly seized with a most acute pain at the bottom of his belly: during the time he pain lasted he could not discharge a drop of urine, though he fre- quently endeavoured. After about an hour and a half, he became perfectly easy on a sudden, and pissed very freely. A few days after this, a small tumor, about the size of a large pea, was disco- vered, in the upper part of the spermatic process, just below the groin. As this tumor was perfectly indolent, and gave the child no kind of uneasiness, no notice was taken of it. By slow degrees it descended lower and lower; and, as it descended, it seemed to increase in size: the boy was observed to make water oftener than usual, but without pain or difficulty. He was looked at by two or three practitioners in the country, who, not knowing what to make of it, advised the letting it alone: at last, in the space of five years, it got to the lower part of the scrotum; and, after it was got thi- ther, it was observed to increase in size much faster than it had done before. The boy was at a great distance from London, and his friends could ill bear the expense of going thither vvith him; so that another year passed away after the tumor was got into the last mentioned situation. At last, when he was about thirteen years old, the swelling becoming troublesome, and the people in the country not caring to meddle with it, he was brought to London. Two or three gentlemen of the profession, to whom he was showed, took it for a scirrhous testicle, and advised the extirpa- tion of it; to which the child's friends would not consent. When he was brought to me, I examined him very carefully, and was satisfied that the tumor, (which was now about as big as a middling chesnut,) was not formed by the testicle; but, though 398 an account of a hernia I was clear that it was not formed by that gland, yet I could not find any testis on that side. The swelling was still perfectly void of pain; had a stony, in- compressible hardness; was troublesome to the child when at. play, or using any brisk exercise, but never gave him any uneasiness when he sat, or stood still. It had all the appearance of being dependent from the spermatic process; but the process, though it had neither the look nor the feel of being diseased, was yet too large and too full for a child of that age, and larger and fuller than that of the other side. The perfect equality and smoothness of the tumor, its extreme incompressibility, and its being perfectly free from pain, even when pressed vvith some force, were the cir- cumstances which induced me to believe that it was not the tes- ticle; but though I was, in my own mind, satisfied of that, yet I cannot say that I was by any means clear what it was; and all that I could determine was, that it certainly ought to be removed; as well on account of the trouble it now gave, and its manifest dis- position to increase, as that I could not foresee any great hazard that was likely to attend its extirpation. From the uncertainty in which I was concerning the true nature of the case, I determined to act very cautiously. I made an incision through the skin and cellular membrane, from the upper part of the scrotum quite down to the lower; by which I discovered a firm, strong, white mem- branous cyst, or bag, connected loosely with the skin by means of the dartos; I dissected all the anterior part of this cyst quite clean; and found that, as I traced it upward, it became narrower, and seemed lo proceed from the groin: this determined me to try if I could not free the posterior part of it also. In doing this I discovered the testicle, which was much compressed, flat, very small, and lay immediately behind the tumor. The dissection of the testicle, and of the spermatic chord from the bag. and from its neck, (which I was obliged to do in order to preserve the testis,) took up some time, and gave me some trou- ble; but when I had finished it, I found that the cyst was depend- ent from, or continuous with, a membranous tube, or duct, of about the breadth of a large wheat straw, which seemed to pass out from the abdomen, through the opening in the oblique muscle, along with the spermatic vessels. OF THE URINARY BLADDER. 399 When I had perfectly freed this duct from all connexion, I cut it through immediately above the tumor: upon the division of it a quantity of limpid fluid (not less than two ounces) followed, and the mouth of the cyst expanding itself discovered a large stone, exactly resembling the calculi found in the urinary bladder; which stone was closely embraced by the said cyst. As there was not the least appearance of any fluid either in the bag or duct, before it was cut off, this discharge, together with the stone, induced me to suspect that the case was a hernia cys- tica. In order to be certain, I staid some time; and, when I thought it was probable that some urine was derived into the bladder, I desired the boy to make water: he endeavoured so to do, and a full stream of urine flowed out through the wound in the groin, which put the case beyond all doubt. I dressed him superficially; he had no bad symptom; his urine all passed out by his wound for a fortnight, or twenty days; at the end of which time, the wound gradually contracted; all the urine came through the urethra; and at the end of a month he was per- fectly well. OBSERVATIONS ON HEMORRHOIDAL EXCRESCENCES. BY THE EDITOR. VOL. II. 3 E OBSERVATIONS, §c. §c. In the account of Mr. Pott's life, prefixed to my edition of his works, I asserted that he had been remarkably successful in the treatment of those painful excrescences which are produced from within the verge of the anus, and the removal of which, when large, firm, and indurated, has generally been thought dangerous and unadvisable. Mr. Pott had entertained a design of writing on this subject, to lessen the apprehension of practitioners, by pointing out in what cases an operation may be safely performed. The method which he employed was not new: it has been de- scribed and recommended by writers, and has been frequently practised on piles in a small and flaccid state; but he often as- serted he knew no one who would attempt to apply it to the ad- vanced state of the complaint: as far as my experience leads me, I believe his assertion strictly founded, or if it be practised by some, it is by no means generally adopted. During the last ten years of Mr. Pott's life, he had many opportunities of performing this operation: most of the patients I attended with him, and found that several of them had previously consulted other eminent sur- geons, from whom they had not met with a proposition for a radi- cal cure; in others the disease had been absolutely abandoned as an incurable cancer. For these reasons Mr. Pott often remarked, that he thought it a subject well worthy of being brought forward for the consideration of practitioners. It is certainly a disease which, whoever labours under, must en- dure a miserable existence; consequently, every attempt towards the relief of it must be proportionably valuable; and as the sub- ject had escaped Mr. Pott's superior pen, I thought some account 404 ON HEMORRHOIDAL EXCRESCENCES. of it from the editor of his works would not be unacceptable: it was therefore inserted in my former edition, as an appendix to his Treatise on the Fistula in Ano. By some accident it has been omitted in this; but as it still appears to me too important to be left out, I have thought proper to subjoin it in this place. My description, however, only professed to give a sketch of the com- plaint, and an account of Mr. Pott's method of treating it; and at present I see no reason for altering my plan, as it appears to me sufficiently to point out the leading characters of the disease, and those circumstances in the operation which chiefly deserve atten- tion. The intestinum rectum is well known to be subject to a variety of diseases, from various causes; from its structure, use and office; and from its situation, which renders it liable to be pressed upon by the whole power of the abdominal muscles: it is also sensibly affected by its connexion with other parts in its vicinity, and it often affects them. The diseases we are to treat of are tumors, originally formed within the rectum, and produced by a distention of the haemorr- hoidal vessels: in this state they are considered as inward piles, and give little trouble or uneasiness. In more or less time the tu- mors, being increased in size, are forced down in going to stool, and return back when the abdominal muscles cease to act. Soon after, grown larger, they return with difficulty, and require a con- siderable time and pressure before they will return: by degrees they are more irritable and painful to the touch; at length they become indurated and stationary, and are not to be reduced by any means, but are extremely inconvenient, and painful in the greatest degree. In some cases, while they are in this situation, the sphincter ani binds so tight round their basis as to produce a mortification of them, and thus effects a natural cure, analogous to that which we recommend—but certainly attended vvith much more pain and danger. These tumors, on their first production, contain nothing but co- agulated blood; perhaps this blood, at first either stagnating in the haemorrhoidal vessels, or possibly effused under the internal coat of the rectum, may, in time, become organized. This organic mass ON HEMORRHOIDAL EXCRESCENCES. 405 being irritated by frequent and severe pressure, may enlarge, and become firm and fleshy excrescences: in this state they frequently furnish a disagreeable sanies, or bloody discharge, and acquire an irritated, malignant appearance. There are other tumors produced in this part, from various causes; as an enlargement of the sebaceous glands, at the verge of the anus, and excrescences arising from a venereal or cancer- ous disposition in the habit, which, in general are easily distin- guishable from those here described. The venereal vcrrucae or excrescences are a frequent symptom of that poison, and are well known to practitioners. They differ in every respect from the tumors we treat of: the basis of them is generally broad; they do not arise from the intestine, nor particu- larly from the verge of the anus, but indiscriminately from thence and from the skin in the neighbourhood. They are rather flat than elongated; they may be tender to the touch, but, unless when ex- asperated by stimulating applications, are seldom productive of pain. In females, the same species of excrescence frequently sur- rounds the anus, covers the external parts of the labia pudenda and the internal of the thighs, seeming to be propagated in moist parts by contact; by neglect they sometimes spread over the groins and pubis, making a large fungous mass, separable into distinct excrescences. It is useless to attempt the removal of them, until the poison be eradicated from the constitution; when, though some- times obstinate and liable to reproduction: they may generally be made to shrink away by proper topical applications. Those which arise from a cancer within the rectum, and being thrust out, appear externally, are more liable to be confounded with the complaint I mean to describe, as they resemble each other in many circumstances: both are hard,swelled, and painful; both at times furnish a disagreeable sanious discharge; in both cases Uie patients have the same leaden, pallid countenance. There are, however, some leading features of distinction which may be noticed: in the cancerous protrusions the basis is generally harder, more incompressible, and broader; and has its origin higher up in the rectum, commonly occupying the whole circum- ference of the intestine, which so straitens the passage that the faeces are expelled with difficulty, and are compressed into a flat 406 ON HEMORRHOIDAL EXCRESCENCES. or angular form. In the cancerous affection of the rectum, the parts sometimes feel soft, like a rotten substance. The pain of the cancerous, or malignant fungi, is unremitting: whether they are external, or returned within the sphincter, the patient is never at perfect ease, but complains of shooting pains in the region of the loins. The pain attending the haemorrhoidal tumors is sometimes great while they are external; but when this arises from the stricture of the sphincter, if they can be returned within the rectum, it soon ceases. When they have been long protruded in an unreturnable state, by degrees they become accommodated to frequent pressure; and unless irritated by an access of inflammation to the constitu- tion, from exercise, wine, improper food, or other causes, they are commonly not so painful as at their first exit. In both species of tumor anodyne injections give ease, but less in the cancerous: the return of pain also in the cancerous tumor is more immediate, more violent and lancinating. In the present state of medical knowledge, we are confined to a description of this dreadful disease: any chirurgical attempt to remove it, would but aggravate the mischief. A protrusion of the rectum is also not an uncommon complaint in persons of a debilitated constitution. People who have accus- tomed themselves to aloetic purges, are particularly subject to this complaint; and it is sometimes only a symptom of a generally re- laxed state of the internal coat of the intestine, through the whole extent of the canal; in which case lime water, joined with the bark, has been found to be very materially serviceable. This complaint may often be entirely removed by anodyne clysters; but astringent applications to the part frequently do harm. Fortunately the procidentia ani is not easily confounded with the complaint we are now considering. The two diseases are perfectly distinct; the one is a protrusion of the gut; the other is an excrescence or enlargement of the vessels at the verge of the anus, protruded in many distinct portions or lobes; of a dark, dusky red colour; and in every respect different from the proci- dentia above mentioned. When, by long continuance, and repeated irritations, these tumors are^ formed into large unreturnable excrescences, nothing ON HEMORRHOIDAL EXCRESCENCES. 407 but the hand of surgery can give relief: this is the state of the com- plaint, in which I think the practice of Mr. Pott deserves our attention. However large and formidable the appearance of the excrescences, if there was no symptom of cancerous malignity, nor any contraindication in the constitution or habit of the patient, Mr. Pott always recommended the removal of them. Having seen profuse and dangerous haemorrhages from the use of the knife in these cases, particularly in one instance, in which the patient nearly lost his life, he always preferred the ligature. The fol- lowing was his method of performing the operation:—When the patient, by straining, as if going to stool, had forced out the tumors as far as could be done, he laid hold of one of each tumor or lobe, separately, with a blunt double hook, and drew it gently out- wards until he discovered the basis of it, which is usually smaller and less indurated than the part which has been exposed to friction: then giving the hook to be held by an assistant, he slipped a liga- ture, previously tied in a loose knot, as near to the basis as possible. When he was satisfied that the ligature comprehended the whole lobe, he drew it tight, taking particular care to discriminate be- tween the natural skin and the tumor: none of the former, however elongated, should ever be included in the ligature; for, when the tumor is removed, this will corrugate, and retire to its proper place, while the loss of any considerable portion of it, by contract- ing and straitening the parts, would create an inconvenience severely felt in riding, or any other exercise, and also in the natu- ral functions of those parts. In the same manner Mr. Pott pro- ceeded to treat the remainder of the lobes, one after another, taking care not to include more in each ligature than was necessary: if the basis was very broad, a circumstance which seldom happened, he passed a needle, armed with a double ligature, through the mid- dle, and tied them on each side. In this manner I have seen him treat successfully several cases, in which the tumors had increased to a considerable magnitude, particularly two, where they were at least from eight to ten inches in circumference: they had been of long standing, and were ex- quisitely sensible. The patients had long been in a state of hope- less misery, almost wholly excluded from society, debarred from all exercise, and notable to sit but in & chaise perch: the appear- 408 ON HEMORRHOIDAL EXCRESCENCES. ances in both these cases were very similar, from the turgidity, at first sight uniform; but on examination they were divided into distinct tumors; which Mr. Pott carefully separated; and treated as has been described. The operation succeeded perfectly well in both; and from that time neither of the patients has experienced the least inconvenience, or return of the disease. I never saw any kind of mischief or alarming symptom from this method of extir- pating this disease, except in one unfavourable subject, who had been liable to complaints about the neck of his bladder: in him the operation brought on a return of his old maladies—strangury and suppression of urine, which induced a necessity of using the ca- theter for some time; but this subsided, and left him as soon as the tumors were separated. I do not mention this case as a prohibition to the operation, but to show that it is right to attend carefully to the parts contiguous, which are liable to be affected by the neces- sary inflammation; that if the patient has been subject to complaints about the bladder, proper care may be taken to obviate and prevent them. Except this, I know of no harm which ever does, or can arise, from the operation. Particular care should be taken to draw the ligature sufficiently tight: if it be at all too slack, some vessels remaining pervious, the circulation will be continued in some part, by which the duration of the pain, and the existence of the tumors, will be protracted. In general, the parts, losing their nourishment, die and drop off in four or five days. I need not men- tion that a proper antiphlogistic regimen, both before and after the operation, should be observed. An anodyne injection, thrown up the rectum half an hour previous to the operation, will be effi- cacious in lessening the subsequent uneasiness. A soft poultice will be found to be the best topical application. The following cases were obligingly communicated to me by Mr. Harvey, who attended them with Mr. Pott, and took notes of them at the time: they will greatly tend to elucidate the nature of the complaint, and the excellence of the remedy which I have endeavoured to describe. "N ilERMORRHOIDAL EXCRESCENCES. 409 CASE I. A gentleman of about fifty years of age, and of a nervous, irritable constitution, had been during many years of a costive habit of body, and generally had recourse to aloetic pills to procure stools. About two years before Mr. Pott saw him, he first per- ceived a pain and swelling within the rectum, which was very troublesome whenever he attempted to discharge his faeces; until at length the difficulty of evacuating them became so great, that he was obliged to inject oil, and to sit over the steam of warm water, be- fore he could obtain any natural relief. He was obliged to be very strict in his diet, as any food which was apt to occasion hardened faeces most certainly gave him excruciating pain. The frequent strainings had made a prolapsus of the gut habitual; neither could he get rid of the faeces, unless the excrescences were first protruded beyond the anus. In this situation he travelled from Cork to London, for Mr. Pott's advice. I should have observed, that the surgeons he had before consulted were led to believe, from the usual remedies for the piles not having benefited him, and from the unalterable hardness of the tumors, that they were cancerous. When I first saw him, he was much weakened by the constant irritation, and probably by thp continual ichorous discharge, which was so profuse as to wet through many folds of linen in the course of a few hours. Mr. Pott immediately proposed the operation for removing them; and in this case, as in the others, he preferred doing it by ligature, rather than by the knife or scissors: round the anus there hung a loose flaccid skin, which Mr. Pott supposed had been a double fold of the inner coat of the gut protruded, and which had lost its natural texture and colour. The first excrescence which appeared seemed large enough to have filled the circum- ference of the intestine: it had a broader basis than I have usually since seen; therefore Mr. Pott passed a double ligature through; and tying them on each side, left it to slough off, which it did in a few days. Afterwards two smaller ones came forward, were vol. n. ,0' p no ON HEMORRHOIDAL EXCRESCENCES. held by the hook, and surrounded by the ligature: they also came away in the poultices, and the gentleman returned home, in the course of three weeks, perfectly cured. The progress and symptoms of the other cases were nearly the same; therefore I need not be minute in describing them. 9 CASE IL Mrs.-----had been many years dreadfully afflicted vvith this disease, and the surgeons of the town where she resided pro- nounced it absolutely to be a cancer: her pain prevented her from walking or sitting upright, and she lay on a sofa, patiently expect- ing a painful death. Mr. Pott saw her during one of his excur- sions to Worcester: she followed him to London; and the opera- tion was performed so successfully, that not only the excrescences were removed, but her health and spirits, which were before wretchedly reduced, were again perfectly restored. The excres- cence in this case was large, rugged, and unequal in its surface:. it had an ulcerous appearance, and very well authorized the opinion which the surgeons in the country had given of it. CASE III. A gentleman between thirty and forty came from Carlisle, on account of this complaint, to Mr. Pott. I have seldom seen a man more debilitated or nervous: the least surprise made him hysteri- cal: he had laboured under the disease about a year; and from his peculiar irritability, it was accompanied with spasms at the neck of the bladder, pain in the urethra, and a discharge from the penis, as vvell as from the rectum, which was also protruded. Two excrescences were removed; and afterwards two lesser ones, not having their support, came forward, and were likewise taken away. This gentleman suffered more pain at, and after the ope- ration, than in any instance I have seen: he had a small fever, and a great tendency to strangury. With the exhibition of anodyne and proper antiphlogistic remedies he recovered; the pro- ON HEMORRHOIDAL EXCRESCENCES. 411 tVuded intestine returned, the irritation of the neck of the bladder left him, and he gained a very improved state of health. The foregoing observations, as has already been stated, ap- peared in my edition of Mr. Pott's works, published in 1790; since which a great number of cases, of a similar nature, have been submitted to my care. The attending progress and symptoms were so nearly similar to those which have been described, that it is needless to enter on a minute description of them: yet I cannot avoid mentioning the case of a young lady, who had the complaint to a great degree, and who resided at a very considerable distance from the metropolis. The case was described to me by letter, in which it was said that the excrescence was very large, and fur- nished so much blood, at every exertion of going to stool, that her constitution was impoverished to the most extreme degree. From the hopes I gave her friends, they were induced to bring her, by short journeys, in a kind of litter, to London. When she arrived, she had lost so much blood during the journey, that she was al- most exhausted: her lips were nearly colourless; and the blood which continued to be evacuated from the part would scarcely tinge linen. I do not know that I ever saw a nearer termination of existence which did not really prove so. To maintain the small remains of life, Madeira, brandy, and strong broths were given, and eagerly called for. On examination, the tumor was about nine inches in circumference, separable into several lobes, and altogether like a piece of sponge, bleeding from every pore. It was, however, of a healthy appearance, soft and compressible. I lost no time in comprising it in a sufficient number of ligatures: from that moment the bleeding ceased. The next day she found herself better, her strength improved, she gradually lost the de- sire for wine and spirits, which before were necessary to keep her from fainting. By the assistance of the bark, nourishing food, and proper attention, her constitution, which was naturally good, soon recovered itself, and in about six weeks she was able to re- turn home, in good health, which she has now enjoyed several years. I am informed that her florid complexion is returned, and that she rides, dances, and partakes of all the diversions which the country affords. 412 ON HEMORRHOIDAL EXCRESCENCES. I think this was the most alarming case I ever met with, though I have seen several nearly as large, and which had reduced the patients to an extreme degree of debility. After all my expe- rience, the best advice which I can give, is, that whoever is af- flicted vvith this complaint, should apply early for surgical relief: for, from the time that the protrusion is once established, it be- comes an increasing evil, which never diminishes, but gradually grows larger and larger. Now, if it cannot be removed by any means but an operation, the difficulties attending such operation must be greater in proportion to the increase of the tumors; con- sequently it must be more easily performed, and attended vvith less pain when the tumors are of small size. Flate f'h '■ 4fS £™,*ty J.M7J. l'late-3. &u,*h.l.HUi. JyfiyJ.Ml/. FlairS Eyf iyj.mit Pf/rtr 6. v'ljfT At<4 ****<> &A<--m/t,uM MeAreAyj/^ n/'K■ f?t- M'<\t m*zt//e'/^evynmeKAli/eaf/ne- ^Ato unt<.A-A l 430 INDEX. Suppuration, the act of nature, and always best executed when she is least disturbed, I. 203. Surgery, common or practical, deserving of more attention than is usually paid to it, I. 176. Haste in operations censured, ibid. Danger of paying too great deference to ancient opinions, 220. Difference between the ancient and modern stated, 300. Bad effects of erroneous notions of disorders on practice, II. 10. Brutality of the ancient surgeons, 89, note, 308. Suture, when proper to be used in a lacerated wound of the scalp, 1.36. Sutures, of the cranium, no obstruction to the extension of fractures from one bone to the other, I. 131. The trephine not to be set upon a suture if it can be avoided, 132. Circumstances in which such restrictions, are to be disregarded, 140. Swellings, white. See Scrofulous joints. Tears, not secreted by the caruncle of the eye, I. 180. Their origin explained, 182. Tenesmus, attending inflammatory defluctions on the parts about the rectum, how to be relieved, II. 213. Testicles, uncertain time of their descent from the belly, I. 373. Description of, II. 14. Origin of the disorder called the hy- drocele, 16. Cases of a hydrocele, where one of the testicles had never descended into the scrotum, 18. An indurated scirr- hous testicle distinguished from a hydrocele in the tunica vagi- talis testis, 55. State of the testicle in the latter case, 58. The true venereal sarcocele, and the scirrhous testicle, require different treatment, 59. Operation on the tunica vaginalis, to obtain a discharge of the water, described, 70. Remarks on Serjeant Wiseman's caution against the puncture in adults, 72. Remarks on those applications termed dissolvers of induration, and removers of obstructions, 88, note. A scirrhous testicle not produced by a simple hydrocele, 121. Signs of a scirr- hous testicle, 122. Distinctions between this case and a sim- ple hydrocele, ibid. Description of the hydrosarcocele, ibid. Mistakes of ancient writers on this subject, pointed out, 127. Description of the epididymus, 129. Castration not a danger- ous operation when performed in time upon a proper subjects 132. But is no cure when a testicle has become cancerous, ibid. Caution against delays in scirrhous cases, 136. Cir- cumstances which prohibit the attempt, 13S. The state of the spermatic chord the principal object of consideration, 139. Castration, how performed, 144. Cases of scirrhous testi- cles, 151. Their natural situation in the scrotum describ- ed, 174. The disorders of, ill understood by the ancient sur- geons, 180. INDEX. 431 Theodoric, his account of the effects of a contused head, I. 50, note. Tibia, the nature and important use of that bone, I. 247. Cir- cumstances attending its fracture, ibid. Tinctures, spirituous, the application of to a bare bone, tends to produce exfoliation, I. 38. Tobacco clysters, the smoke or infusion, efficacy of, in ruptured cases, I. 411. The infusion, how made, 412, note. Toes, that kind of mortification beginning in, generally incu- rable, II. 297. First appearance and symptoms of, 298. Progress of, ibid. Common method of treatment, ibid. The bark unsuccessful in stopping it, 299. Efficacy of opium in this case, 300. Proposed alterations in the chirurgic treatment of the disorder, 302. The removal of the mortified toes, a useless and painful operation, 304. Trephine, the propriety of applying it in certain doubtful cases inquired into, 1. 61. Especially necessary in gun-shot wounds, even though the skull should not be broken, 62. See Cases. Why necessary to be used in simple fractures of the cranium, 97. Ought not to be too long deferred, 98. Reasons why the ancient surgeons were unwilling to perforate the bone, 107. Argument against iron handles to these instruments, 112, note. Why preferable to the trepan, 113, note. Ought to be fixed immediately over the fracture, 117. The crown or saw should not be too small, ibid. Circumstances to determine the num- ber of perforations, ibid. Ought not to be set upon a suture if it can be conveniently avoided, 132. Application of to a fractured cranium accompanied with depression, 137. An- cient restrictions as to parts to which it ought to be applied, when to be disregarded, 140. Trocar, curved, method of perforating the os unguis with, I. 211. Trusses, their operation in rupures explained, I. 322. Steel, may be worn at all ages, 324. Cautions respecting the use of them, 325. Danger attending their not fitting truly, 326. The necessity of using a truss not often taken away by the chirur- gical operation, 354. When improper in the congenial rup- ture, 374. Tumors, produced by contusions of the scalp, danger of mistaking them for fractures, I. 42. Four kinds of, from injuries to the scalp, distinguished, 43. See Cases. Tumors, scirrhous and cancerous, from external violence, their nature considered, II. 133. Extirpation proper, but not al- ways effectual, 134, note. Why caustics are generally preferred to the knife, ibid. note. Why they are really worse, ibid. note. Rendering the bones soft, 389. Tunica communis, description of this membrane, II. 31. A hy- 432 INDEX. drocele in the cells of, how produced, 32. The true nature of this disorder, not generally understood, ibid. Symptoms of, 33. Cases of, 34. The encysted hydrocele of, 42. Modes of cure in infants and in adults, 45. Cases of, 46. Tunica vaginalis testis, that membrane described, I. 308. Origin of the scrotal hernia, 309. Hydrocele of, II. 51. Symp- toms, 52. Cases of, 60. Cases of the dispersion of a con- firmed hydrocele, 48. The palliative and radical methods of cure, 69. Operation for discharging the water described, 70. Means for a radical cure, 77. The seton the best me- thod, 80, note, 173. Cure by caustic, and by incision, 82. Objections to the caustic, 83. The preference due to incision, 84. Method of operation, 86. Is an object of choice rather than of necessity, 91. Objections to the tent, 93. And to the cannula, ibid. Advantages of the seton, ibid. Uses of the lymph between this membrane and the tunica albuginea, 174. Consequences of a failure or redundancy of this secretion, 175. Cure of the hydrocele of, by injection, 191, note, E. Turner, Dr. Daniel, his mistaken account of the aegylops, I. 194, note. His method of treating the fistula in ano, II. 226, note. Van Swieten, Baron, his advice to defer amputation in desperate cases, unadvised and dangerous, I. 266, note. Varicocele, seldom an original disorder, II 6, 114. Venereal disease, in old or neglected stages, often produces a se- paration of a portion of both tables of the cranium, I. 85. This kind of caries incurable, 86. The continued use of mercury after the lues is cured, fatal to the constitution, ibid. Some- times produces a fistula lychrymalis, 191. Umbilical rupture. See Rupture. Urethra, caution to be observed in the cure of strictures of, 1.201, note. Urine, a retention of, when attending abscesses near the rectum, how to be treated, II. 211, Efficacy of opium in, ibid, note Useless state of the lower limbs, further remarks on, II. 347. Success of the proposed method of cure, 348. Description of the disease, ibid. Its distinction from palsy, 349. Beginning and progress in a child, 350. In an adult, 351. True cause of the disease, a morbid state of the spine, 352. Nature of the curvature, 353. Arms as well as legs affected, ibid. note. In- efficacy of various means, and pieces of machinery, 354. Man- ner in which the bones are affected, 355. The morbid state of the spine the cause as well of the curvature as of the other symptoms, 356, and note. Bones affected, not enlarged, but eroded, 357, note. Method of cure simple, consisting only in procuring a sufficient drain, 359. Time required for relief INDEX. 433 very various, 360. Progress of the cure, 361. Deformity re- maining, 362. Cause of the disease a scrofulous indisposition, 364. Various affections of the spine, 365. Concluding obser- vations, ibid. The advantages of mechanical assistance in these cases, 372, note, E. Ware, Mr. his nail headed style for the fistula lachrymalis, I. 214, note, E. Wiseman, Mr. Serjeant, his mistaken account of the aegylops, 194, note. Remarks on his account of instruments for extension in fractured limbs, 221, note. Words, bad consequence of annexing false ideas to them, I. 252. Wounds, lacerated, of the scalp, how to be treated, I. 32. By puncture, 39. Contusions, 42. Of the brain, 142. THE END. 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