K*WMasaw*»u INSTITUTES f-.f* PRACTICE OF SURGERY: OUTLINES OF A COURSE OF LECTURES, BY WILLIAM ^CUBSON, M.D., PROFESSOR OF SURGERY IN THE UNIVERSITY OF PENNSYLVANIA, ETC., ETC, ETC. Segnius irritant animos demissa per aurem, Quam qua? sunt oculis subjecta fidelibus.—Hor. EIGHTH EDITION, IMPROVED AND ALTERED. IN TWO VOLUMES. ^l.U.^d4 VOL. II. ~~' PHILADELPHIA: TAMES KAY, JUN. AND BROTHER, 193 MARKET STREET. PITTSBURGH: KAY & COMPANY. 1S50. V40 19S-0 Entered, according to the Act of Congress, in the year 1849, by William Gibson, in the Clerk's Office of the District Court of the United States in and for the Eastern District of Pennsylvania. war. s. young, printer. CONTENTS OF VOL. II. CHAPTER I. Diseases of the Nose and Antrum Sect. 1. Polypus of the Nose Treatment of Polypus of the Nose 2. Ozaena ..... Treatment of Ozaena 3. Lipoma ..... Treatment of Lipoma 4. Polypus of the Antrum Treatment of Polypus of the Antrum 13 . 14 14 . 17 18 . 19 19 . 20 21 CHAPTER II. Diseases of the Mouth .... Sect. 1. Labium Leporinum, or Hare-lip Treatment of Hare-lip 2. Ranula ..... Treatment of Ranula 3. Malformation of the Frasnum Linguae Treatment of Malformation of the Frasnum 4. Enlarged Tonsils Treatment of Enlarged Tonsils . 5. Elongation of the Uvula Treatment of Elongation of the Uvula . 6. Fissure of the Palate Treatment of Fissure of the Palate 7. Epulis, or Tubercle of the Gums Treatment of Epulis 25 . 25 26 . 28 28 . 29 Linguae 29 31 . 31 35 . 36 37 . 37 45 . 46 CHAPTER III. Diseases of the Neck ..... Sect. 1. Extraneous Bodies in the Oesophagus Removal of Foreign Bodies from the GEsophagus 2. Stricture of the CEsophagus Treatment of Stricture of the CEsophagus . 3. Extraneous Bodies in the Larynx and Trachea Removal of Extraneous Bodies from the Larynx and Trachea ..... 4. Ulceration of the Glottis Treatment of Ulceration of the Glottis 5. Bronchocele, or Goitre Treatment of Bronchocele . 6. Torticollis, or Wry Neck Treatment of Wry Neck 48 49 51 52 54 54 57 57 58 78 85 85 iv CONTENTS. CHAPTER IV. Diseases of the Thorax . . . • • .87 Sect. 1. Hydrothorax, or Dropsy of the Chest . • 87 Paracentesis Thoracis . • • .88 CHAPTER V. 90 91 91 94 95 98 102 104 108 111 115 117 119 Diseases of the Abdomen . . . Sect. 1. Ascites, or Dropsy of the Abdomen . Paracentesis Abdominis . 2. Poisons in the Stomach Treatment of Poisons in the Stomach 3. Hernia ..... General treatment of Hernia 4. Inguinal Hernia Treatment of Inguinal Hernia 5. Femoral Hernia Treatment of Femoral Hernia . 6. Umbilical Hernia Treatment of Umbilical Hernia . 7. Congenital Hernia . . . . .121 Treatment of Congenital Hernia . . 122 8. Varieties of Hernia ..... 124 Treatment of Varieties of Hernia * . 127 9. Artificial Anus ..... 128 Treatment of Artificial Anus . . . 129 CHAPTER VI. Diseases of the Rectum ..... 134 Sect. 1. Prolapsus Ani ..... 134 Treatment of Prolapsus Ani . . . 136 2. Tumours within the Rectum . . . 139 Treatment of Tumours within the Rectum . 140 3. Hemorrhoids . . . . . 141 Treatment of Hemorrhoids . . . 142 4. Fistula in Ano . . . . . 151 Treatment of Fistula in Ano . . . 152 5. Encysted Rectum ..... 158 Treatment of Encysted Rectum . . . 161 6. Stricture of the Rectum . . . 162 Treatment of Stricture of the Rectum . .164 7. Imperforate Anus . . . . . 165 Treatment of Imperforate Anus . . .167 8. Foreign Bodies in the Rectum . . . 169 Removal of Foreign Bodies from the Rectum . 170 9. Fissure of the Anus .... 172 Treatment of Fissure of the Anus . • 173 CONTENTS. V CHAPTER VII. Diseases of the Tunica Vaginalis and Testis . . 174 Sect. 1. Hydrocele . . . . . .174 Treatment of Hydrocele . . . 176 2. Haematocele . . . . .182 Treatment of Haematocele . . . 182 3. Orchitis . . . . . .184 Treatment of Orchitis .... 185 4. Irritable Testis . . . . .187 Treatment of Irritable Testis . . . 188 5. Chronic Enlargement of the Testis . . .188 Treatment of Chronic Enlargement of the Testis 189 6. Encysted Testicle . . . . .190 Treatment of Encysted Testicle . . 191 7. Tumours of the Scrotum .... 192 Treatment of Tumours of the Scrotum . 192 CHAPTER VIIL Diseases of the Penis . . . . . .195 Sect. 1. Wounds of the Penis .... 196 Treatment of Wounds ef the Penis . . 197 2. Ulcers of the Penis .... 198 Treatment of Ulcers of the Penis . . .199 3. Phimosis ...... 201 Treatment of Phimosis .... 202 4. Paraphimosis ..... 203 Treatment of Paraphimosis . . . 204 Sect. 1. Stricture of the Urethra Treatment of Stricture of the Urethra 2. Fistula in Perineo .... Treatment of Fistula in Perinseo 3. Enlarged Prostate .... Treatment of Enlarged Prostate 4. Retention of Urine .... Treatment of Retention of Urine 5. Incontinence of Urine Treatment of Incontinence of Urine 6. Sensitive Tumours of the Female Urethra Treatment of Sensitive Tumours of the Female Urethra ..... 7. Urinary Calculus .... Treatment of Urinary Calculus 8. Lithotrity ...... 9. Lithotripsy ..... VI CONTENTS. CHAPTER X. Diseases of the Eye . Sect. 1. Conjunctival Ophthalmia Treatment of Conjunctival Ophthalmia 2. Sclerotic Ophthalmia . Treatment of Sclerotic Ophthalmia 3. Iritic Ophthalmia Treatment of Iritic Ophthalmia 4. Psorophthalmia . . Treatment of Psorophthalmia . 5. Pterygium .... Treatment of Pterygium 6. Encanthis .... Treatment of Encanthis 7. Opacity of the Cornea Treatment of Opacity of the Cornea 8. Ulcer of the Cornea Treatment of Ulcer of the Cornea 9. Staphyloma .... Treatment of Staphyloma 10. Hypopion .... Treatment of Hypopion 11. Hydrophthalmia Treatment of Hydrophthalmia . 12. Obliterated Pupil Treatment of Obliterated Pupil 13. Procidentia Iridis Treatment of Procidentia Iridis 14. Cataract .... Treatment of Cataract . 15. Congenital Cataract . Treatment of Congenital Cataract 16. Amaurosis .... Treatment of Amaurosis 17. Hordeolum .... Treatment of Hordeolum 18. Encysted Tumours of the Eyelids . Treatment of Encysted Tumours of the Eyelids 19. Entropeon ..... Treatment of Entropeon 20. Ectropeon .... Treatment of Ectropeon 21. Fistula Lachrymalis . Treatment of Fistula Lachrymalis 22. Strabismus .... On Squinting—its Causes—The actual condition of the Eye—and the attempts to remedy the Defects Double Vision—the State of the Eye in Intoxication A Squint—How produced—The condition of the Eye . Additional Notes Treatment of Strabismus Operation .... Remarks on the Operation 328 335 336 344 348 350 351 CONTENTS. Vll CHAPTER XI. Diseases of the Ear ...... 355 Sect. 1. Diseases of the External Ear, and Meatus Auditorius 355 Treatment of Diseases of the External Ear . 358 Diseases of the Tympanum and Eustachian Tube 359 Treatment of Diseases of the Tympanum . . 360 Diseases of the Internal Ear . . . 362 Treatment of Diseases of the Internal Ear . 363 2. 3. CHAPTER XII. Diseases of the Arteries .... Sect. 1. Aneurism .... Treatment of Aneurism 2. Aneurism of the Aorta Treatment of Aneurism of the Aorta . 3. Aneurism of the Carotid Treatment of Carotid Aneurism 4. Axillary Aneurism Treatment of Axillary Aneurism 5. Brachial Aneurism Treatment of Brachial Aneurism 6. Inguinal Aneurism Treatment of Inguinal Aneurism 7. Popliteal Aneurism Treatment of Popliteal Aneurism 8. Aneurism by Anastomosis Treatment of Aneurism by Anastomosis 9. Varicose Aneurism Treatment of Varicose Aneurism 365 368 371 377 379 380 380 382 382 387 388 389 389 394 395 396 397 400 402 CHAPTER XIII. Diseases of the Veins Sect. 1. Varicose Veins Treatment of Varicose Veins 2. Cirsocele . Treatment of Cirsocele 401 405 406 408 409 CHAPTER XIV. Injuries of the Head .... Sect. 1. Fracture of the Skull Treatment of Fracture of the Skull 2. Concussion of the Brain Treatment of Concussion of the Brain . 3. Compression of the Brain Treatment of Compression of the Brain 4. Inflammation of the Brain Treatment of Inflammation of the Brain 5. Fungus Cerebri, or Encephalocele Treatment of Fungus Cerebri 411 412 413 414 415 416 417 421 422 423 424 Vlll CONTENTS. CHAPTER XV. Local Diseases of the Nerves Sect. 1. Neuritis Treatment of Neuritis 2. Neuralgia • • . Treatment of Neuralgia 3. Neuroma Treatment of Neuroma 4. Tetanus Treatment of Tetanus 426 426 427 429 430 432 434 435 437 CHAPTER XVI. Amputation .... Sect. 1. Amputation of the Thigh . 2. Amputation of the Leg 3. Amputation of the Foot . 4. Amputation of the Arm and Elbow 5. Amputation of the Forearm 6. Amputation of the Hand 7. Amputation at the Shoulder 8. Amputation at the Hip 9. Concluding remarks on Amputation . 440 447 . 451 454 . 456 457 . 459 461 . 462 465 CHAPTER XVII. Hysterotomy, or Cesarean Section 471 THE INSTITUTES AND PRACTICE OF SURGERY. CHAPTER I. DISEASES OF THE NOSE AND ANTRUM. The subjects embraced in the first volume of this work cor- respond with the arrangement of the anatomical lectures in the University, so closely, that by the time the latter are disposed of, the former may be entered upon. The same correspondence, however, has not existed, hitherto, in the arrangement of the matter of the second volume. To effect this, the distribution of the text in the last four editions has been altered. If upon any occasion, then, the diseases should appear in this volume disjointed, let it be remembered that accurate collocation has been sacrificed to convenience and expediency. With these views, I commence with the diseases of the nose and antrum. The mucous membrane which lines the cavity of each nos- tril, not only covers the spongy bones, but extends to the an- trum maxillare, to the frontal, ethmoidal, and sphenoidal si- nuses, and even to the mouth and throat. Hence, a similarity of disease is found to pervade each of these parts, the foundation of which may be said to be laid, generally, by inflammation produced by cold, specific diseases, and other causes. The most common diseases of these cavities, are polypous tumours, collections of purulent matter, and ulcerations. vol. n.—b 14 POLYPUS OF THE NOSE. SECTION I. POLYPUS OF THE NOSE. A polypus may spring from any portion of the Schneidenan membrane: it originates, however most frequently either from the superior or inferior spongy bone. In shape it is usually pyriform—being narrow at its root and expanded below; though this will depend very much upon the natural form of the cavity it occupies. Sometimes the base of the tumour is exceedingly broad. Not unfrequently a polypus originates high in the nose, and instead of falling forwards, or towards the anterior nares, takes a backward direction, hangs behind the palate, and some- times reaches the pharynx. One or both nostrils may be the seat of this disease. When both are filled, the patient breathes with difficulty, and with a peculiar rattling noise. In damp weather, the tumours often project beyond the nose, and con- tract and disappear as soon as the weather becomes dry. The consistence of polypus is not less variable than its form. Firm, fleshy, and very solid, in some instances, it is, upon other occa- sions, extremely soft, and so tender as to tear upon the slightest touch. The most common variety, as far as my experience goes, is that which bears, in consistence, shape, colour and size, a striking similitude to the common oyster. Most polypi are extremely vascular, and if rudely handled, bleed profusely. No age, or sex, is exempt from the disease, which sometimes assumes a malignant form, at other times destroys the patient, by exciting, from pressure, caries of the spongy and ethmoid bones, inflam- mation of the brain, &c. TREATMENT OF POLYPUS OF THE NOSE. Several operations, very opposite in character, have been practised for the removal of nasal polypus. I prefer in most cases the use of the forceps. These, when properly made, should be rather stouter than the common dressing forceps, with their extremities slightly curved, serrated, and a considerable slit POLYPUS OF THE NOSE. 13 or hole in each blade, about half an inch from its point. The patient being seated before a strong light on a low chair, with his head moderately thrown back and firmly supported by an as- sistant, the surgeon carefully introduces the instrument with its blades expanded, as far as the root of the tumour, takes firm hold of it, and by two or three turns of the instrument, instead of pull- ing in a straight line, twists it away. A copious gush of blood generally follows, especially if the tumour be partially removed. Clearing this away, the forceps are again and again introduced until the whole nostril be free, the strongest proof of which will be the freedom with which the patient can breathe or force air through the nostril. In performing this operation, great care must be taken not to use unnecessary violence, because it has sometimes happened that the ethmoid bone has been broken up and other mischief produced sufficient to lead to fatal conse- quences. This operation is chiefly adapted to polypi with nar- row necks, and confined to the cavity of the nostril. The operation of excision has been recommended by J. Bell, Whately, and others, for the removal of polypi of large size and broad base. There are very few cases, it appears to me, requiring such a measure. Independently of the difficulty of the opera- tion, the hemorrhage is always very profuse, and besides the un- certainty of removing the whole of the disease, the surgeon will run considerable risk of injuring the sound parts in the neighbour- hood of the tumour. Mr. Whately employs a sheathed knife, somewhat similar to Dr. Physick's bistoury for fistula in ano. The ligature, although recommended by some writers for every variety of polypus, can seldom be employed advantageously, ex- cept where the tumour arises by a narrow neck and hangs be- yond the posterior nares. In such cases, a silver or iron wire, or a piece of catgut, eighteen inches long, should be doubled so as to form a loop, and introduced into the nostril until it ap- pears below the palate, when it should be caught by a pair of narrow forceps, and drawn towards the mouth, and the loop at the same time expanded by the fingers of the surgeon. As soon as this is accomplished, the operator, still holding the loop with one or two fingers, draws the projecting ends of the wire with the other hand from the nostril, and thus by one simultaneous movement, carries the loop over the base of the polypus, and thence to its neck. The ends of the wire are next passed through the double cannula of Levret, and after being drawn so 16 POLYPUS OF THE NOSE. firmly as to constrict the neck of the polypus, are twisted upon the wings of the instrument and secured. In proportion as the wire becomes loose, from the shrinking of the tumour, its ends must be tightened every few hours until the polypus drops off, which it does sometimes so suddenly as nearly to suffocate the patient. If the surgeon should experience any difficulty, as he often does, in introducing the wire and noosing the polypus in the manner directed, he may resort with advantage to the cannula of Bel- locque. Whatever method may be practised for the removal of poly- pus, there are two points which must always be particularly at- tended to—the suppression of hemorrhage, and the removal of any portions of the tumour so situated as to elude the instruments directed against them. The first may be accomplished, gene- rally, by cold astringent solutions thrown up the nostrils by a syringe, or if these do not succeed, by passing a catgut, to which two or three dossils of lint are secured, through the nostril and mouth. The pressure thus created, hardly ever fails to stop the flow of blood. To guard against the return of the disease, from portions of the tumour being left behind, the argentum nitratum, repeatedly applied, will be found the most effectual remedy. Many attempts have been made, recently, to cure polypus of the nose without an operation, or simply by the introduction of astringent or stimulating articles into the nostril—such as sul- phate of zinc, strong snuff, muriated tincture of iron, solutions of alum. In oyster-like polypi, or those compared by Sir Astley Cooper to wet bladders hanging within the nose, or in simple re- laxation of the Schneiderian membrane, I have known these and various other remedies of the kind, prove more or less useful, but no permanent benefit to ensue where the polypus was large, fleshy, or solid, or was attached to the Schneiderian membrane, or spongy bones, by a broad base. It frequently happens that cherry-stones, beans, glass beads, pebbles, pieces of cork, and other foreign substances, are intro- duced by children into the nostril, where they may become firmly impacted and mistaken for polypus and other tumours. Some- times a thickening of the Schneiderian membrane, or displace- ment of the cartilaginous septum, is mistaken for a similar dis- ease. Where any doubt exists, careful examination should be made, and if foreign bodies are detected, they can be easily re- moved by a bent probe or by the urethral curette of Leroy OZ^NA. 17 d'Etiolles. When the septum is displaced, and nearly closes one nostril, leaving the other unusually large, I have sometimes succeeded by splitting it with a knife, partially, and keeping the portion thus rendered loose, pushed, by a tent or plug, towards the centre of the nose, until reunion has been accomplished. See Potts' Chirurgical Works, by Earle, vol. iii. p. 165; J. Bell's Principles of Surgery, vol. iii. p. 89; Whately's Cases of two extraordinary Polypi re- moved from the Nose, the one by Excision with a new Instrument, the other by Improved Forceps, 8vo. 1805; Callisen's Systema Chirurgiae Hodiernae, vol. ii. p. 207; Lassus's Pathologie Chirurgicale, torn. i. p. 528; Deschamps^s Traits des Maladies des Fosses Nasales, &c; C. Bell's Operative Surgery, vol. i. p. 208; Listen's Practical Surgery, p. 281, Lond. 1839. SECTION II. OZiENA. A troublesome ulceration of the lining membrane of the nos- trils, attended with fetid discharge, and sometimes followed by destruction of the cartilage and by caries of the bones of the nose, is denominated by most modern writers ozsena. The ori- gin of the disease is very obscure, though there is reason to be- lieve, that, in most instances, it is connected with the primary or secondary forms of syphilis. In other instances, marks of the purely scrofulous character are apparent. One of the most troublesome attendants of the disease is the accumulation of in- spissated mucus, or of incrustations in the cavities of the nose. These are sometimes so considerable in quantity, as to block up entirely the passages. After the ulceration is fairly established, >t not only takes possession of the cartilaginous septum, the eth- moid and spongy bones, and the other bones of the nose, but extends to the cheek. If the patient should recover after such ravages, he must for ever remain horribly deformed. 18 OZ^GNA. TREATMENT OF OZ5:NA. The remedies best adapted to the cure of ozsena are bark, iron, the mineral acids, muriate of lime, sarsaparilla, Fowler's solu- tion, and antimony. When there is any suspicion of the disease having originated from syphilis, mercury alone, or conjoined with other preparations, should be employed. During the height of the inflammation, solutions of opium and of the acetate of lead, may be injected into the nostrils, or applied to the ulcerated surface on lint. Some of the mild animal oils introduced into the cavities of the nose, will also prove serviceable, by soften- ing the incrustations and lessening pain. After the inflammation has abated, more stimulating materials may be employed, such as solutions of lunar caustic, sulphate of copper, the ointment of the red oxide of mercury, citrine ointment, &c. Within the last twelve years, chloride of lime has been parti- cularly recommended, in ozaena, by Dr. Horner. The first case in which it was tried was a very inveterate one of several years' standing, large quantities of very fetid matter being con- stantly discharged from both nostrils, and after passing into the stomach occasioning great sickness and loss of appetite. A tea-spoonful of chloride of lime was put into a wine-glass full of water; the clear solution was then injected into each nostril twice a-day, and the practice having been continued for a few weeks, a perfect cure was accomplished. Other similar in- stances have been reported, but time will show whether the medicine can be depended upon in the generality of cases. Fu- migation with iEthiops mineral I have known in several in- stances to alleviate the symptoms and correct the fee tor. Creo- sote injections also answer the same purpose. On the subject of Ozaena, consult Pearson's Principles of Surgery, p. 279; Horner's Case of Ozaena, in American Journal, No. xi., May, 1830; Craighie's Case of Pereostitis with Ozaena, in Edin. Med. and Surg. Journal for January, 1834; Lizar's System of Practical Surgery, p. 94, Edinburgh, 1838. LIPOMA. 19 SECTION III. LIPOMA. Hypertrophy, or serous enlargement of the cellular mem- brane and skin of the nose, with distention of the sebaceous crypts, is seldom met with in this country, but in many parts of Europe is rather a common disease. It is more formidable in appearance than in reality, and although productive of great deformity, and disgusting from the rank and fetid effluvium emanating from the fissures and cells filled with serum and lymph, never has been known, I believe, to assume a malignant character. The appearance varies in different subjects ac- cording to the duration and extent of the disease. In some there is a simple bulbous protuberance, rough and tuberculated on the surface; in others, one or more lobulated masses, crowded upon each other like the knobs of an artichoke, and so volumi- nous as to extend, in some instances, upon the cheek bones, and overhang the mouth, in the form of pendulous watery bags. In general they are so insensible as to admit of being roughly handled without causing pain. Venous trunks, knotted and distended, are conspicuously displayed over the surface of the tumours; but the arteries do not appear to be enlarged in pro- portion. Fifteen or twenty years sometimes elapse before the growth becomes inordinate. The causes of the disease are in- volved in great obscurity. Occasionally it seems to derive its origin from intemperance, gross feeding, and constitutional pe- culiarities. TREATMENT OF LIPOMA. Internal remedies, and local applications—with exception of the knife—prove of no service; and the sooner the operation is resorted to the better. There are two or three modes of doing it, but I prefer the following, having, in a few instances, suc- ceeded, without difficulty, in restoring the form of the organ, and with much less scar than could be imagined. An incision is made along the central line of the nose as far as necessary 20 POLYPUS OF THE ANTRUM. without injuring the tip or edges of the nostril through the sub- stance of the tumour, which is then seized with a forceps or double hook, and elevated by slow and cautious dissection; in- troducing the finger, from time to time, into the nostril, to pre- vent that cavity from being laid open. The opposite side is to be treated in a similar manner, and any irregularities left, trimmed off by the knife or scissors. In general, cicatrization soon commences, and although the surface for some weeks pre- sents a glazed and polished aspect, yet in the end the new- formed skin assumes a natural appearance, and the deformity is much less than might be supposed. There is sometimes a general oozing of blood, which may be stopped by external pressure, and by plugging the nostrils, but it is seldom necessary to secure by ligature many vessels. Mr. Hey, however, met with one instance, in which the patient nearly fainted from loss of blood, and another is reported by Liston, of death actually occurring from hemorrhage after an operation for lipoma by the late Sir William Blizzard. SECTION IV. POLYPUS OF THE ANTRUM. Fungus, or polypus of the antrum maxillare, is less frequently met with than abscess of that cavity—a disease already treated of in another place* It is, however, one of the most formida- ble affections in surgery, and unless speedily arrested, generally proves fatal. The tumour sprouts from the lining membrane of the antrum, from what cause it is always exceedingly difficult to determine, and grows with more or less rapidity, until it fills the whole of the cavity. By this time considerable pain is experienced in the cheek and eye of the affected side, and soon after a perceptible enlargement of the face may be observed. • See vol. i. p. 130. POLYPUS OF THE ANTRUM. 21 These symptoms are, in the course of time, followed by dis- tortion of the nose, projection of the eye, enlargement of the gums corresponding to the antrum, profuse discharges of sanious, fetid matter, and finally, by protrusion of the bones of the face and alveolar processes, and, as a necessary result, by hideous deformity. In consistence, the tumour is generally firm and fleshy, sometimes soft, and in a few rare instances, osteo-sarco» matous, or even bony. TREATMENT OF POLYPUS OF THE ANTRUM. If, instead of temporizing, as is too common, until the disease is so advanced as to leave no reasonable hope of effecting a cure, the surgeon were always to follow the practice of the en- lightened and fearless Desault, and operate at an early period, most patients, perhaps, would recover. As soon, therefore, as the nature of the tumour is ascertained, the surgeon should not only determine to remove it, but resolve to set no limits to the sacrifices it may be necessary to make, With this view, he must provide himself with several curved and angular scalpels, of unusual strength and thickness, two or three cauterizing irons, a key for pulling teeth, chisels, gouges, a mallet, &c. Every arrangement being made, the surgeon first separates, with a common scalpel, the cheek from the maxillary bone, by opening the patient's mouth as widely as possible, and cutting through the internal membrane. His next object should be to remove the molares teeth and their alveolar processes corresponding with the floor of the antrum. This may be done by the tooth- key, or by two or three strokes of a gouge and mallet. Having in this way exposed the cavity of the antrum and the surface of the tumour, the curved and anpuilar knives must then be em- ployed until every remnant of the disease is rooted out. The hemorrhage that follows the operation is sometimes extremely profuse, but may be instantly arrested, and with little pain to the patient, by one or two applications of the cautery. I have, however, performed several operations of the kind without ever being under the necessity of doing more towards stopping the flow of blood than plugging the antrum with lint or tow. If the operation prove successful, the antrum is filled in a few weeks with healthy granulations; but if the disease return, this 22 POLYPUS OF THE ANTRUM. is soon rendered evident by the reappearance and rapid growth of the fungus. To repress this, repeated application of caustic or the cautery, will be found necessary, or perhaps a second operation may be demanded. Sometimes the teeth and alveolar processes appear sound. In such cases, an incision should be made through the cheek from its outer surface, the anterior walls of the antrum perforated by a trephine, and the tumour removed through the opening. Within the last few years very different operations from the one just described have been practised by Lizars, Gensoul, Lis- ton, and others. In a small work on the diseases of the maxil- lary sinus, Gensoul contends, that by examination of the bones of the head, it will be seen that the superior maxillary bone is fixed to the adjoining one at three points—by its connexions with the nasal process, the os unguis, and the ethmoid bone, by the orbitar process of the malar bone, and by the opposite upper jaw, and corresponding bone of the palate. He was led to infer, therefore, that by separating the upper jaw bone, from these connexions at certain points, that the patient would not only be saved considerable pain, but every chance afforded of taking away the whole disease; inasmuch as the entire bone in which it was seated, would be also removed. Gensoul's particular mode of accomplishing these purposes is said to be complicated and tedious; the operation of Liston, therefore, is generally preferred. The following is an account of it, furnished by that distinguished operator himself. " The point of the bistoury is entered over the external angular process of the frontal bone, is carried down through the cheek to the corner of the mouth, and is guided by the fore and middle fingers of the one or other hand, as may be, placed in the cavity. A second incision made along and down to the zygoma, falls into the other. Then the knife is pushed through the integument to the nasal process of the maxilla, the cartilage of the alse is detached from the bone, and the lip is cut through in the mesial line. The flap thus formed, is quickly dissected up, and held by an assistant; the attachment of the soft parts to the floor of the orbit, the in- ferior oblique muscle, the infra-orbital nerve, &c, are cut, and the contents of the cavity supported and protected by a narrow bent copper spatula. The division of the bones is now under- taken ; with the cutting forceps the zygomatic arch, the junction of the os malse and frontal bone by the transverse facial suture, POLYPUS OF THE ANTRUM. 23 and the nasal process of the superior maxilla, are cut in succes- sion ; then a notch having been cut out of the alveolar process, the palatine arch is clipped through by strong scissors placed along it, one blade in the nostril of the affected side, the other in the mouth. Then it is that an assistant will be prepared to place his fingers on the trunk of one or both carotids. The tu- mour is now shaken from its bed, and as it is turned down, the remaining attachments are divided by the knife; the velum pa- lati is carefully preserved, and also, if possible, the palatine plate of the palate bone. Perhaps no vessel may require ligature, the branches of the internal maxillary having been elongated, and torn from the tumour; in fact, if the mass is large, there is no possibility of reaching these vessels with the knife. The patient is now removed from the sitting posture, which is the most con- venient for all parties during the operation, and laid on a couch or table. The cavity is sponged out and examined; if any vessel is seen hanging in the wound, though it does not bleed, it may be tied, and the ends of the ligature cut off. The space which was occupied by the tumour is then filled with lint, and the edges of the wound brought together by points of inter- rupted or twisted suture, but no dressings should be applied. After twenty-four hours, some of the sutures may be taken out, and replaced by narrow strips of plaster; and at the end of forty-eight hours, the remainder of the stitches are cut and the needles withdrawn—the whole track of the wounds, which will in all probability have adhered, being properly supported. A large void is necessarily left in the palate, but it is wonderful how soon and completely this is repaired by the return of the bones to their original situation, and by the granulation and con- traction of the soft parts." I say nothing of the modern proposal of curing polypus of the antrum by tying the carotid, because I have reason to believe that most attempts of the kind hitherto made, (in which the liga- ture of that vessel was entirely depended upon,) have proved abortive. I should conceive it equally unnecessary, and not less reprehensible, first to tie the carotid, and afterwards to extirpate the tumour, inasmuch as the patient's danger must be increased tenfold, and without any adequate compensation. Cases occur, now and then, in which spontaneous cures of this formidable disease are effected. Twelve or fourteen years ago, a mulatto man with a large fungus of the antrum, came to me 24 POLYPUS OF THE ANTRUM. from Petersburg, Virginia, but refused to submit to an operation, and returned home. From that period the tumour ceased to grow, and never afterwards, I have reason to believe, occasioned inconvenience. Ten years ago, a negro man from Frederick- town, Maryland, visited Philadelphia, and consulted me respect- ing a similar tumour of the antrum. I advised the operation, but he, also, refused to submit to it. A few. months afterwards, the inflammation subsided, and eventually the tumour was con- verted into bone. It has so remained ever since, is now entirely free from pain, and the health of the patient has long been ex- cellent. Consult Desault's Works by Smith, vol. i. p. 141; Desault's Parisian Chi' rurgical Journal, vol. i. and ii.; Traite des Maladies Chirurgicales, et des Ope- rations qui leurConviennent, par MM. Chopart et Desault, torn. i. p. 195; J. L. Deschamps' Traite des Maladies des Fosses Nasales et de leur Sinus; Suite d'Observations sur les Maladies des Sinus Maxillaire, par M. Bordenave, in Memoirs de l'Academie Royale de Chirurgie, torn. xiii. edit, duodecimo, p. 367; Abernethy's Account of a Singular Disease in the Upper Maxillary Sinus, in Transactions of a Society for the Improvement of Medical and Chirurgical Knowledge, vol. ii. p. 309; Gibson on Bony Tumours, in the Philadelphia Journal of the Medieal and Physical Sciences, vol. iii. p. 100; C. Bell's Sur- gical Observations, vol. i. p. 413; Velpeau, Nouv. El6m. de Med. Operat.; Gensoul, Lettre Chirurg. sur quelques Maladies Graves du Sinus Maxillaire, 8vo. Paris, 1833; Listen's Practical Surgery, p. 310; Lirar's Pract. Surg. p. 99, Edin. 1838. HARE-LIP. 25 CHAPTER II. DISEASES OF THE MOUTH. Under this head may be included several diseases, some of which have already been treated of in the preceding volume. The principal affections of the mouth, and of the parts in its im- mediate vicinity, are hare-lip, cancer of the lip,* cancer of the tongue,f ranula, malformation of the frsenum linguae, enlarge- ment of the tonsils, elongation of the uvula, epulis or scirrhus of the gums, and caries of the teeth. To give even a general ac- count of the diseases of the teeth, and of the various operations practised upon them, would alone occupy a volume. The present state of surgical science, however, and the subdivision of profes- sional labour, would seem to obviate altogether the necessity of treating these affections in a work of this description. SECTION I. LABIUM LEPORINUM, OR HARE-LIP. This is a congenital deformity, and takes its name from a sup- posed resemblance to the lip of a hare or rabbit. There are two varieties of the disease—the single and double. The former is the most common, and is a simple fissure or slit, extending from the edge throughout the substance of the lip to a greater or less extent: the latter is comparatively rare, and differs from the • See vol. i. p. 170. t Ibid. p. 172. 26 HARE-LIP. single variety chiefly in having a wider opening, and an inter- mediate hanging portion. Both varieties are often compli- cated with a cleft or opening in the bones of the palate. The upper lip is, in nine cases out of ten, the seat of the disease, and the borders of the fissure are invariably rounded, and covered with the red and delicate membrane peculiar to the edges of the natural lips. Hare-lip, independently of its deformity, to the in- fant proves a serious inconvenience, by interfering with its powers of suction, and to the adult by interrupting speech, and preventing the articulation of labial sounds. Sometimes two or more of the incisor teeth project from the upper part of the hare-lip nearly in a horizontal direction, and add very much to the deformity, be- sides increasing the difficulty of effecting a cure. Where there is a cleft in the bony palate, it often happens that one portion of the jaw is below the level of the other, and that the most promi- nent portion projects so far as to create not only great deformity, but to interfere with reunion after the operation, by producing ulceration. TREATMENT OF HARE-LIP. The only effectual remedy for hare-lip is an operation, and the sooner this is performed the better. If the fissure in the lip is single, it will be sufficient to remove each of its rounded edges in the following way. The infant being firmly held in the arms of a nurse, or laid on a pillow with its head elevated and securely fixed by an assistant, the surgeon having previously separated the internal membrane of the mouth and its frsenum, introduces between the lip and gums a narrow flat piece of wood five or six inches long. This being held by another as- sistant, the operator himself stretches the lip upon the board, and commencing near the nostril, makes an incision downwards, and at a single cut removes in a straight line the edge of the lip. The opposite edge is next detached in a similar manner, when the chasm left will resemble the letter V inverted. It only remains to draw the edges of the wound together, and retain them by the twisted suture, taking care to commence by pass- ing a pin first through the hanging edge or lower portion of the lip, instead of the upper. Two or three pins will generally be sufficient. They should be passed horizontally, at regular inter- HARE-LIP. 27 vals, and rather nearer the internal than the external surface of the lip. The close contact of the edges of the wound, and the pres- sure necessarily occasioned by the tightening of the ligatures, are sufficient to arrest the hemorrhage. Each pin should be surrounded by a separate ligature passed about it in the form of the figure 8. In four or five days, the adhesion is usually complete, and the pins may be withdrawn, to prevent them from exciting ulceration. Sir A. Cooper and some other surgeons' prefer the interrupted to the twisted suture, and Liston uses upon all occasions common sewing needles in preference to silver pins,—breaking off their points with nippers after the operation. When the operation for double hare-lip is performed, it should be conducted upon the principles just laid down. But four in- stead of two incisions should be made—one on each side of the intermediate projection, which may then be dove-tailed, as it were, with the outer edges of the lip by one or two pins passed entirely across. The cleft in the bony palate, should it exist, generally closes up, sua sponte, provided the operation be not too long delayed. When it is said, "the sooner the operation is performed the better," it should not be understood that it must be done immediately after birth. Infants of two or three weeks old, are very apt to die in convulsions from operations. Four or five months after birth, will be a favourable period for the operation, or three or four years. See Sabatier de la Medicine Operatoire, torn. iii. p. 273, 8vo. 1810; Lassus's Pathologie Chirurgicale, torn, iii, p. 451; Richerand'sNosographie Chirurgicale, torn. ii. p. 255; Dictionnaire des Sciences Medicales, torn. iii. p. 55, article Bee de Lievre; Desault's Works, by Smith, vol. i. p. 148; B. Bell's Surgery, vol. iv. p. 447; C.Bell's Operative Surgery, vol. ii. p. 38; Kirby's Cases in Surgery, p. 61; Listen's Surgery. 28 RANULA. SECTION II. RANULA. An obstruction of one or more of the ducts of the sublingual gland gives rise to the formation of a semipellucid soft tumour, denominated by the older surgeons ranula—from an imaginary resemblance to the belly of a frog. This tumour is generally filled with saliva, or with a viscid fluid resembling the white of an egg. Sometimes it attains so large a size as to interfere with speech and deglutition, and even to displace the teeth. It arises either from adhesion, or natural imperfection of the duct, or from the lodgement of a calculous concretion within its pas- sage. Children and infants are more subject to the complaint than adults. According to Dupuytren and others, it is doubtful whether ranula is seated in the salivary ducts, or whether it con- sists merely in a serous cyst. Breschet found these cysts in five dissections which he made to ascertain the fact. TREATMENT OF RANULA. A simple evacuation of the fluid with a lancet answers no purpose, inasmuch as the opening closes again in a few hours. To effect a permanent cure the cyst must be laid open freely, or a portion of it removed with scissors. The application of caustic may afterwards become necessary. But even these ope- rations do not always succeed. "I attended a young lady," says Professor Cooper, " who had a ranula, in which the plans of freely opening the cavity, of transfixing it with setons, of re- moving portions of the cyst, and of introducing into it lint wetted with a strong solution of nitrate of silver, all failed. The latter experiment caused a great deal of pain and some swelling of the glands of the neck." By puncturing the swelling, however, and keeping a small cannula in the opening for three weeks, a cure was effected. Dupuytren recommends for the same pur- pose, what he calls a " bouton a demeure,"—a small contrivance consisting of two buttons, connected by a pedicle, one of which is introduced into the cyst, through a small puncture made into MALFORMATION OF THE FR^NUM LINGUJE. 29 it, while the other remains in the mouth, and serves the purpose of draining off the fluid as soon as it is secreted. See Lassus's Pathologie Chirurgicale, torn. i. p. 402; C. Bell's Operative Sur- gery, vol. ii. p. 24; Callisen's Systema Chirurgiae Hodiernae, vol. ii. p. 108; Du- puytren Lemons Orales, torn, iii.; Malgaigne, Man. de Med. Oper. SECTION III. MALFORMATION OF THE FRJENUM LINGUA. It sometimes happens, though not so frequently as imagined, that children are born with the fraenum of the tongue so short, as to prevent them from sucking. To ascertain whether this be really the case, the surgeon should endeavour to raise the point of the tongue with a spatula. If he should fail in this at- tempt, and the tongue appears upon examining it on the side to be unnaturally confined, little doubt can remain of the fraenum being defective. TREATMENT OF MALFORMATION OF THE FR^NUM LINGUJE. Although the division of the fraenum linguae is usually looked upon as a trifling operation, it is one that should not be lightly performed, and upon every common occasion. Petit relates two instances, in which death followed from the fraenum being so much loosened, as to permit the tongue to fall back- wards into the pharynx, and suffocate the patient. Other cases are recorded of fatal hemorrhage from wounds of the ra- nine arteries and veins. To guard against accidents of this de- scription, the operator should use a pair of probe-pointed scis- sors, and take care to direct their points downwards, and di- vide no more of the fraenum than is absolutely necessary. Dr. Dewees, whose experience in the treatment of the diseases of vol. n.—c 30 MALFORMATION OF THE FR^NUM LINGU.2E. infants, was equal, perhaps, to that of any practitioner living, objected to the use of scissors in the division of the fraenum lin- guae, and employed, instead of them, a common gum lancet. He never met with a case in which the tongue was swallowed, or of hemorrhage, from the division of the ranine arteries, or other vessels. Hence it may be fairly inferred that such acci- dents must be exceedingly uncommon. According to the same practitioner, there are two causes that may give rise to an ope- ration, the one an adventitious membrane, which pursues the natural fraenum throughout its whole course, and even continues beyond the fraenum, and ties the tongue so completely down, that the child cannot raise the tongue, or carry it beyond the lips—the other, an actual shortening and thickening of the pro- per fraenum itself. It sometimes, though rarely, happens, that the tongue imme- diately after birth is found glued to the roof of the mouth by mucus or lymph, and the child thereby prevented from sucking. Care should be taken not to confound this case with that of shortening of the fraenum, otherwise an operation may be per- formed unnecessarily. All that can be required, generally, where the tongue clings temporarily to the roof of the mouth, is to separate it gently with a spatula or spoon, and afterwards to apply slightly astringent washes by a mop, until the secretion is corrected. Hypertrophy of the tongue is occasionally met with, but instead of executing the severe operation of excision, the sur- geon should follow the judicious practice first pointed out by Lassus, and recently carried into effect so successfully by Crosse of Norwich—compression, by bandages, of the tongue within the walls of the mouth. See Petit's Traite des Maladies Chirurgicale, torn. iii. p.260; Lassus's Pa- thol. Chirurg.; Burns' Surgical Anatomy of the Head and Neck, p. 264; C. Bell's Operative Surgery, vol. ii. p. 28; Velpeau, Nouv. Elem. de Med. Oper.; Mal- gaigne, Man. de Med. Operat. ENLARGED TONSILS. 31 SECTION IV. ENLARGED TONSILS. Enlargement of the tonsils is very common among scrofu- lous children, and arises from exposure or frequent attacks of catarrh and sore throat. Sometimes, however, the disease is slowly induced without being preceded by pain, swelling, or any of the characteristics of acute inflammation. If suffered to re- main for any length of time, the tumours occasionally attain so large a size as to interfere materially with respiration and deglu- tition. Persons troubled with this disease, have a peculiar hoarse, husky, or croaking voice, and when labouring under cold, wheeze excessively. treatment of enlarged tonsils. The knife and ligature have been frequently employed in the removal of enlarged tonsils. To the latter the preference is usually given, inasmuch as there is no risk of hemorrhage, a con- sequence sometimes apt to follow the use of the knife, even when employed with the utmost caution. Formerly the ligature was suffered to remain upon the enlarged gland for several days, or indeed until the tumour sloughed away, and from this practice great irritation about the fauces, tongue, and mouth, ensued. To obviate these inconveniences, Dr. Physick first suggested the following mode of practice. The operator takes a double can- nula, about four inches long, and passes through it, doubled, a piece of soft flexible iron wire, one twenty-fourth part of an inch in diameter, secures one end of the wire to an arm of the cannula and permits the other end to project about five or six inches be- yond the opposite barrel of the instrument. The cannula being thus armed, the loop of wire is spread out to a sufficient extent to pass over the tumour, and is bent a little to one side, that it may with the greater facility approach its base. An assistant holds down the patient's tongue with the handle of a large spoon, while the operator conveys the wire over the base of the tumour, and taking hold of its projecting end, draws it loosely, in order 32 ENLARGED TONSILS. to ascertain whether it is properly fixed. Finding this to be the case, and that the uvula is not included, the end of the wire is then seized with a pair of flat pliers, drawn as firmly as possible, and secured by wrapping it around the remaining arm of the cannula. The wire thus applied, should be permitted to re- main on the tonsil twenty-four hours, and then disengaged in the following way. The cannula being firmly held with one hand, the other is employed in loosening the end of the wire from the arm of the instrument; having accomplished which, the sur- geon straightens the wire with the pliers, and pushes it back- wards until it is removed from the tonsil. In a few days the tu- mour drops off entire, or in fragments, and the ulcer left heals without difficulty. For several years the late Dr. Physick pursued the above practice; but experience taught him that although the operation thus modified, was free, in a measure, from the inconveniences of the old method of using the wire, there were yet objections to the practice which he had not anticipated. In particular, he found that, in some instances, profuse ptyalism, swelling of the throat, difficulty of breathing and swallowing, (sometimes fol- lowed by ulceration of the soft palate and fauces,) were in- duced. Some years before his death he abandoned the ligature in toto, and employed the knife. The instrument he uses was originally invented by him for truncating the uvula. " In the operation for cutting off the uvula, Dr. Physick has, until very lately, used scissors; but being unable to complete the operation by one application of that instrument, several have been neces- sary to effect the division of the part. To obviate this difficulty, he determined to try the old instrument, as modified and repre- sented by Benjamin Bell, in his System of Surgery. He found, however, that although he could divide with that instrument the greater part of the uvula, a portion of the membrane that covers the back part of it was not always divided, making the use of the scissors necessary to cut it through. To remedy this incon- venience, he caused an instrument to be made having two plates instead of one, between which the knife was passed; but still the same difficulty was experienced in cutting through the mem- brane on its posterior part. He then thought of wrapping a strip of waxed linen over the semi-circumference of the opening, to support the membrane until it should be divided by the knife. Thus constructed, the instrument answered the purpose com- '•.'/ / •'/•••/./' Fhilell. lol.'J Vr.vrn A." Eru/d by JDrayton ENLARGED TONSILS. 33 pletely and cut through the whole substance of the part in an instant. Dr. Physick has since used an instrument of similar construction for the removal of scirrhous tonsils. He finds it easy to cut off the whole, or any portion that may be necessary, of the enlarged tonsil in this manner. The operation can be finished in a moment of time. The pain is very little, and the hemorrhage so moderate that it has not required any attention in four cases, in which he has lately performed it. The size of the perforated end of the two plates, and of course that of the knife, must be larger in the instrument for extirpation of the tonsils, than in that for truncation of the uvula."* The con- struction of this instrument will be better understood by ex- amination of Plate I. fig. 1 and 2. In a subsequent account of Dr. Physick's instrument, it is remarked, that, "occasionally there is some difficulty in passing the circular aperture in the extremity of the two plates completely and speedily over the tonsil to its base. In such cases the operation may be much facilitated, by using a forceps with a lunated extremity, to which teeth are adapted, invented by Dr. Physick, by means of which the tonsils may be seized and drawn through the aperture to any distance that may be deemed proper, when its extirpation can be immediately effected. It may not, however, be improper to observe that, under ordinary circumstances, the aid of the forceps is altogether unnecessary. The forceps is about seven inches long, curved near its extremity, which is lunated and armed with teeth."f (See Plate II.) Having experienced more or less difficulty in the removal of enlarged tonsils—owing chiefly to the number of instruments, such as spoons, hooks, forceps, &c, required—it occurred to me that an instrument might be contrived that would answer the purpose of all these—by keeping down the tongue, holding the gland firmly, and separating it nearly at the same moment. Such I accordingly projected, and ordered made, and upon trial found to answer my most sanguine expectations. For several years past I have used it, in a number of instances, and have seen it used by others, and can, therefore, speak of it decisively. It consists of a pair of forceps nine inches long, the eighth of an inch thick, half an inch broad, when shut, with extremities an inch and a half long, slightly serrated and somewhat curved, * American Journal of Med. Sciences, Feb. 1828. f Ibid. May, 1828, 34 ENLARGED TONSILS. including, when closed, an oval space half an inch wide, and terminating, at the other extremity, in handles which stand off obliquely from the shafts of the instrument. A knife, or blade, the length and breadth of the forceps, rounded on its cutting edge, and having a button placed perpendicularly to its axis on the opposite extremity, works backwards and forwards by means of a groove, to the extent of an inch and upwards, between the blades of the forceps, at one of which it is secured by screws. A sheath upon each end of the forceps, to keep the knife from starting off the moment it touches the tumour, completes the in- strument.* (See Plate I. fig. 3.) To apply the instrument properly, it will only be necessary to introduce it into the patient's mouth with the blades closed and resting flat upon the tongue, which is thus kept depressed. The instrument is then turned on its edge, still resting on the tongue, its blades expanded, placed fairly around, and completely behind the tumour, which is then seized, and firmly held, while the thumb, resting on the button-like extremity of the knife, pushes it forwards and instantly separates the enlarged tonsil, which is immediately brought away in the grasp of the forceps. To pre- vent any portion from being left, or the tumour from hanging by a narrow neck, the surgeon should see that the knife reaches to the very extremity of the forceps, and should be sure that the whole of the tumour is fairly within the grasp of the instrument. The instrument may be applied indifferently to either tonsil— care being taken always to place the surface of the forceps on which the knife rests to the base of the tumour. The instrument- makers, generally, do not make this instrument sufficiently wide and round between the jaws, and hence difficulties are occasion- ally met with by inexperienced operators. An immense number of instruments have been been invented in this and other countries, for the removal of enlarged tonsils, and it would be almost impossible to describe half of them. Hosack, Stevens, and Cox, of New York, and Fahnestock, of Lancaster, have each described particular kinds. Fahnestock's instrument, as it is called, was first devised by myself, as the model of it, still in the possession of Mr. Schiv.ely, will show. I abandoned it, however, from finding extreme difficulty in re- * This instrument, as well as Dr. Physick's for the same purpose, was ma- nufactured by Mr. H. Schiveb'. ELONGATION OF THE UVULA. 35 newing the cutting edge. My friend, Dr. A. E. Hosack, may be said to have been the first in this country to recommend cutting instruments for the removal of tonsils. Profuse hemorrhage sometimes follows the excision of the ton- sils. The surgeon, aware of the possibility of this, should take care not to apply the knife too near the base of the tumour. More than twenty years ago, I cut off an enlarged tonsil with scissors from a medical student, now a respectable practitioner at Bedford, Pennsylvania, and had great difficulty in preventing the hemorrhage from terminating fatally. Wiseman and Moscati point out danger from another source—the falling of the tonsil backwards, when partially cut, upon the rima glottidis—and re- late cases of suffocation from that cause. See Desault's Works by Smith, vol. i. p. 193; Sharp's Treatise on the Opera- tions of Surgery, p. 199,9th edit.; Chevalier's New Mode of Tying Diseased Tonsils, in vol. iii. p. 79, Medico-Chirurgical Transactions; Dorsey's Surgery, vol. i. p. 422; The Double Cannula and a Wire, recommended in the Operation of Extirpating Scirrhous Tonsils and Hemorrhoidal Tumours, by Philip Syng Physick, M.D., in vol. i. p. 17, of the Philadelphia Journal of the Medical and Physical Sciences; Case of Obstinate Cough, occasioned by Elongation of the Uvula, in which a portion of that organ was cut off, with a Description of the Instrument employed for that purpose, and also for Ex- cision of Scirrhous Tonsils, by Philip Syng Physick, M.D., Professor of Anatomy in the University of Pennsylvania, in Journal of Medical Sciences for 1828; Description of a Forceps employed to facilitate the Extirpation of the Tonsil, and invented by P. S. Physick, M.D., ibid. 1828; A. E. Hosack, in Philadelphia Med. Journ. vol. vi. SECTION V. ELONGATION OF THE UVULA. The uvula, from colds or other causes, is frequently enlarged or elongated. If it continues so for any length of time, trouble- some irritation about the epiglottis, nausea, vomiting, and even haemoptysis and phthisis pulmonalis may be induced. 36 ELONGATION OF THE UVULA. TREATMENT OF ELONGATION OF THE UVULA. To obviate some of these consequences, an operation has been practised from time immemorial—the excision or amputation of the uvula. This may sometimes be performed by a hook and common scissors, or by the particular scissors described and en- graved by Professor Cooper, in his " First Lines of the Practice of Surgery."* These are so contrived, as, by means of a trans- verse projection from one of the blades, to support the uvula, and keep it from falling backwards at the moment the operator at- tempts to divide it. Even with this instrument, however, the operator is extremely apt to fail, or else divide a part only of the uvula, which is immediately drawn upwards, and lodged behind the velum in such a way as to render it difficult afterwards to re- move it. It will be better, therefore, to resort to the late Dr. Physick's instrument for the removal of the tonsils, or to the one I have recommended for the same purpose. The instrument, however, should be made smaller for the uvula than the tonsil. Latterly, I have succeeded very well by seizing the uvula with Liston's artery forceps, and cutting it off with a pair of common scissors. Mr. Benjamin Bell states that he has known very profuse he- morrhage to follow amputation of the uvula. I have very often performed the operation, but never met with an accident of the kind. The real importance of amputation of the uvula has only been estimated of late years; and it remained for Dr. Physick to point out the cases to which it was peculiarly adapted. He had met with several instances of troublesome cough, followed by emacia- tion of the whole body, sometimes by hemorrhage from the lungs, and eventually phthisis pulmonalis, which were produced appa- rently by elongation of the uvula. This determined him to try the effect of an operation in the early stages of the disease, and the result was favourable in the extreme—the cough and other urgent symptoms disappearing almost immediately, and the pa- tients recovering perfectly in a very short time. From experience I can speak confidently of the value of the remedy, and have rea- son to believe that it seldom fails unless too By many this operation has lately been condemned as useless long delayed. * Vol. i. p. 526, 4th edit. FISSURE OF THE PALATE, 37 and unnecessary, but still I hold the opinion expressed above, and could relate a great many cases in proof of the correctness of it. The disease* generally requiring the operation, is, for the most part, met with among clergymen—but why, it is very diffi- cult to say. There is an analogous affection about the palate and pharynx, in shape of ulceration, of which I shall speak under the head of Ulceration of the Glottis. SECTION VI. FISSURE OF THE PALATE. A deficiency of the soft palate, or rather a division of it, either conjoined with, or independent of, a cleft in the palate bones, is a congenital malformation, almost as common as that of hare-lip, with which, indeed, it is not unfrequently associated. Like hare- lip, too, it not only, during infancy, interferes with the suction of the child, but in after life impedes deglutition, and in many in- stances renders articulation nearly unintelligible. Many pa- tients, indeed, fall a sacrifice to the disease, from extraneous matters getting into the windpipe, and bronchiae, and laying the foundation of pulmonary affections. At other times, the patient suffers extremely from fluids, and even solids, being thrown from the stomach, or mouth, into the nares, where they excite sneez- ing, great irritation, and even ulceration. TREATMENT OF FISSURE OF THE PALATE. Although surgeons had long been acquainted with the exist- ence and nature of malformation of the palate, few, if any, at- tempts were made to obviate the deformity, until Roux, the emi- nent Parisian surgeon, drew the attention of the profession to an operation which he denominated Staphyloraphy, and by which he had succeeded in reuniting the edges of the soft palate in twelve cases. These cases were published in 1825. Since that 38 FISSURE OF THE PALATE. period, Roux has performed, with more or less success, the opera- tion fifty-one times. Out of this number, but one case has been followed by death.* It occurred in a young female, who, on the evening of the operation, was seized with inflammation of the throat, and, subsequently, with that of the chest, and died on the eighth day. Roux's operations were soon followed by those of Graefe, Dieftenbach, and others, on the continent of Europe, by Alcock, in Britain, and, subsequently, by Warren, Stevens, Mettauer, and Hosack of our own country. The first case upon which Roux performed his operation, was that of a Canadian student, attending lectures in Paris. Before cutting away the edges of the soft palate, as in hare-lip, Roux determined to introduce three stout ligatures into the border of the palate, and at regular distances from each other. To ac- complish this he employed a small, curved needle, fixed in the porte-aiguille; passed it through the palate about a quarter of an inch from its edge, then seized its point with the common dressing forceps, and drew it, together with the ligature, forward. In like manner the other ligatures were introduced, always car- rying the needle from behind forwards. The edge of the palate was then cut away by the knife and curved scissors, to the ex- tent of a line in thickness. The same operation having been performed on the opposite side of the palate, the edges of the wound were approximated by drawing each interrupted suture, tying it, and then cutting off the ends of all the ligatures. To prevent the first knot from slipping, it was held by a pair of for- ceps, called pince a anneaux, until the second knot could be se- cured. The patient was kept on low diet, and not permitted to speak. At the end of the third day, the two upper ligatures were removed, and on the fourth day the remaining ligature. Lest the reunion, which had taken place throughout each edge, might be endangered, the patient was not permitted to speak until the eighth day. By that time, however, the adhesion was complete, the cicatrix firm, and the deformity with all its incon- veniences, namely, imperfect articulation, difficult deglutition, &c, completely removed. Roux's object in first inserting the ligatures, and subsequently paring the edges of the palate, was to prevent the hemorrhage from interfering with the operation by obstructing the view of the parts. Professsor Warren, of Boston, was the first to perform, there * Lancette Franqaise, 1830. FISSURE OF THE PALATE. 39 is reason to believe, staphyloraphy in the United States. The ligatures were introduced by an instrument, apparently very simple, resembling a common dissecting hook in form, with an eye near its extremity, through which passed a triple thread of strong silk. "The palate was pierced by the hook at one-third of the length of the fissure from the upper angle of the wound, so as to include about three lines of the edge of the soft palate. The eye, with the ligature, being seen, the latter was seized with a common hook, and drawn out. The eyed-hook was then drawn back, turned behind the palate, and the other edge trans- fixed in a similar manner." Two other stitches were made in a similar way, the edges of the palate drawn together, and the knots tied without difficulty with the fingers. Unlike Roux's operation, the edges of the palate were cut away by a bistoury previous to the introduction of the ligatures. The patient re- covered perfectly, and in a short time. In a second operation of the kind, performed by Dr. Warren on a boy during the prevalence of influenza, the inflammation, owing to that dis- ease, was so high as to require the ligatures to be removed. The operation consequently failed, although adhesion had taken place, but was afterwards destroyed by the fingers of the boy, in attempting to relieve his cough. Dr. Warren has improved, subsequently, his instrument, making the point removeable, so that the ligature and point can be drawn out together. The operation of staphyloraphy was performed by Dr. Stevens of New York, in 1826. The ligatures were introduced by a curved needle, attached to a handle by means of a screw, and the edges of the velum supported by forceps, afterwards dissected away by a cataract knife. Reunion speedily took place, and by the tenth day the patient returned home with the voice much improved, but not so perfectly restored as in some of the cases reported by Roux. In 1830, an ingenious instrument was contrived by Dr. J. P. Mettauer, an eminent surgeon of Prince Edward, Virginia, ap- parently well calculated to answer the purpose for which it was designed, an account of which I regret I am unable, for want of space, to introduce here, but which is fully described and figured in an interesting memoir on staphyloraphy, published by Dr. Mettauer, in the American Journal of Medical Sciences for 1838. But my friend, Dr. Alexander E. Hosack, of New York, an 40 FISSURE OF THE PALATE. excellent surgeon, has paid as much attention, perhaps, to staphy- loraphy as any one else in the United States. In a memoir by him on the subject, published in 1833, at the request of the Medi- cal Society of the City and County of New York, interesting observations are made, cases reported, and ingenious instru- ments invented by himself, described, which ought to be fami- liar to every one before undertaking one of the most difficult operations in surgery. Under these impressions I shall insert a short account of Dr. Hosack's instruments, which, together with the plate and explanation of them, cannot fail, I hope, to render them perfectly intelligible. "It occurred to me," says Dr. H., "that as the greatest diffi- culty and delay were experienced in the passing of the liga- tures,—arising both from the irritability and constant motion in the palate, as well as the unavoidable disposition to swallow,—an instrument might be constructed, calculated to lessen the incon- venience as well as shorten the time. I consequently caused one to be made, as represented in the plate, and which I have since improved, and find perfectly to surmount the objections. In the application of this instrument, the surgeon is enabled to fix his eye on the part through which the ligature is to pass; the palate is at the same time, and with the same instrument firmly held, so as to avoid displacement, by any involuntary motion that may occur. The time required for passing each needle is but an instant, and it can always be accomplished with the greatest accuracy, as regards the relative distances, as well from the borders as from each other. This point being de- termined, I directed my attention to the second step of the ope- ration, which is properly that of excision. The straight bis- toury, and the ordinary angular scissors, are as yet the only in- struments used for that purpose. In offering objections to them, I trust I may escape being censured for a great desire of finding fault, as well as from any unreasonable prejudice, in favour of invention. Having performed the operation, I feel myself at liberty to suggest an alteration in the scissors, which, while it embraces all the advantages possessed by the above instrument, offers facilities to the surgeon. He is at once enabled to follow with his eye every movement of the blades, until the borders are entirely separated, and thereby control the extent and amount of substances to be removed. Two scissors will be required— one for either side, six inches in length. When viewed in pro- nttu-jiLiw. s. II c , IUI1U ■ 11111II11111111 < J1111LLLU LLLU1IF] H i y/ iv:i T ~7 ir ■"!r.nm tyJD-aytw FISSURE OF THE PALATE. 41 file, their form inclines to that of the letter/. The blades form the junction to the point, and curved laterally and forwards, so as very much to resemble the beak of an eagle, or any other bird of that class, and which, when applied to the palate, adapt themselves to the arched sides of the cleft. No. 1 represents a front view of the instrument for passing the needle. A, the hol- low shaft with the curved extremity. B, an aperture, through which the eye is to direct the head of the needle into the thim- ble. C, the rod drawn out, with the chain, and thimble-like extremity attached to it. D, the bayonet fixture, adjusted upon the shaft, with the forceps for receiving the needle. E, a pro- file view of the forceps holding the needle. F, the rings for re- ceiving the first and second fingers of the right hand. G, the guard upon which the thumb of the same hand is to rest. H, the wheel, or the part of the bayonet fixture, by which its mo- tions are controlled. The index finger of the left hand is to be placed upon it; by which means it is turned, until brought op- posite to the crook in which the needle is concealed; it is then to be pushed quite up, holding the palate between. The thumb of the right hand is at that moment to glide through the guard upon the button of the rod, which is to be thrust forward, driving the needle, armed with a ligature, into the forceps; the bayonet fixture is then drawn back and turned off, carrying the needle with it. No. 2, a profile view of the same, in the act of receiv- ing the needle." (See Plate III.) On the 9th of December, 1840, I had occasion to perform the operation of staphyloraphy at the Philadelphia Hospital, upon a patient named Merrill, about thirty-five years of age. The fissure in the palate was a very extensive one, and so inter- fered with the patient's speech and deglutition as to render him very anxious for relief. In the presence of the class, in the large operating theatre, and on a day rather dark and cloudy, I accordingly undertook what would have proved extremely dif- ficult, even with the best light, and in the presence of only two or three persons. I commenced by seizing, with Liston's artery forceps, one hanging edge of the palate, and, by a long, narrow knife, cut it off to the extent of the eighth of an inch along the whole border. The opposite edge being removed in like manner, and the bleeding suffered to stop, I passed in succession, though not without great difficulty and repeated failures, three stitches through each border of the palate, and drew the edges 42 FISSURE OF THE PALATE. together so as to close the opening. The ligatures were con- veyed by crooked needles fixed in Physick's forceps for deep- seated arteries, were pushed from before backwards, and drawn forwards, by seizing their points with a pair of dressing forceps. During these attempts, several of the needles were broken at or near the eye, or became bent, so as to render it extremely diffi- cult, during the gagging and struggles of the patient—who was, in a measure, idiotic—for me to accomplish my purpose, which, indeed, was not effected until after the lapse of a long time, and with more exertion than would have been necessary for almost any other operation in surgery—the efforts alone to keep down the tongue being sufficient to try the strength of a common man. In the course of a week the stitches all came away, and the edges of the wound were found perfectly united, with the excep- tion of the upper part of the palate, in which an opening was left not quite half an inch long and a quarter of an inch wide. Two or three weeks were suffered to elapse, in hopes of this opening, also, closing by granulations from the opposite edges of the palate, to promote which, touches of lunar caustic were occasionally resorted to, but without effect. Reflecting upon the trials I had encountered in the operation, and finding them mainly owing to the difficulty of seeing the points of the needles, obscured as they were by the blood, depth, and darkness of the cavity behind the palate, and the motion and resistance of the tongue, as well as the struggles and move- ments of the patient, who was apprehensive of suffocation, it occurred to me that instruments might be contrived to answer the different purposes required, more simple than those hitherto employed, and calculated to serve for the different stages, without being multiplied to any extent. I accordingly turned my attention to these points, and assisted by a young and inge- nious cutler, Mr. Charles Schively, have succeeded, I believe, not only in constructing such as are likely to answer in all cases of the kind, but in enabling the surgeon to pass the needles and draw out the ligatures almost as well in the dark as by the best light. The whole apparatus consists of—1st. A moveable spatula, or glossocatochus, for keeping down the tongue. (See Plate IV. fig. 1.) 2d. Of a forceps six inches long, having two blades moveable on and separable from each other, with their extremi- ties turned up at a right angle to the extent of an inch—(fig. 2;) /'/,///< J/.'/o FISSURE OF THE PALATE. 43 of two long narrow knives, one double-edged and sharp-pointed, the other probe-pointed—(fig. 3 and 4;) and of a pair of long- handled scissors, with blades set off at an obtuse angle— (fig. 5.) The idea of the tongue spatula, I had derived partly from an instrument of the kind I had seen in the possession of Sir Philip Crampton, of Dublin, consisting of a moveable plate of silver or other metal, an inch and a half long, an inch and a quarter wide, and fixed upon the extremity of a handle seven inches long, arched near the plate to clear the teeth, so that being held like a spoon by the hand of the surgeon or assistant, every attempt on the part of the patient to move the tongue was frustrated by the mobility of the plate, and the close suction between it and the organ it compressed. The forceps I contrived for the two- fold purpose of seizing and holding fast the edge of the palate while the knife wTas passing through it, and for conveying after- wards the ligatures. The first object will easily be understood from the slightest inspection of the drawing; the second it will be more difficult to comprehend. Let it be observed, however, that at the top of the angular extremity of the lower blade of the forceps a short round needle having a shoulder near its point is fixed—(fig. 6;) that point being directed towards the handle of the instrument, and intended to be passed through the open- ing of a spring attached to the corresponding angular extremity of the upper blade,—(fig. 7.) A single ligature being attached by a knot to the eye of the needle, which has a deep socket to receive it, is carried behind the angular extremity of the lower blade, and held there by the left hand of the operator, while the right hand carries the whole instrument into the mouth, hooks the needle from behind forwaids, through the edge of the palate, and then, pushing the upper or moveable blade forwards, its shoulder becomes fixed in the spring; when it only remains to disengage the upper blade from the under, and drawing it out from the mouth, the end of the ligature and needle must neces- sarily come with it. To accomplish the removal and fixture at pleasure, of the two plates, a peculiar arrangement, by screws, and corresponding openings, has been contrived upon a principle easily understood. The ligatures being intro- duced separately into each edge of the palate, and as many as may be deemed necessary, it only remains to draw them together and close the opening. Leaden ligatures, preferred 44 FISSURE OF THE PALATE. by Graefe, and some others, may, if required, be used with equal facility. In a trial I made with the above instrument upon Merrill, with a view of closing the opening at the upper part of his palate, al- ready spoken of, little or no difficulty was experienced, except such as arose from the ungovernable state of the patient's mind at the time, and which afterwards caused him to tear out the stitches, and escape from the hospital. I was struck with one circumstance in his case, ten days after the first operation, which I do not remember to have seen recorded^-a thickening of nearly half an inch of the palate from inflammation. An interesting case of extensive wound of the soft palate, cured by drawing together with sutures the divided edges, is reported in the tenth volume of the American Journal, 1832, by Dr. Wells of Columbia, South Carolina. "A lad, aged five years," says Dr. Wells, " was running with one end of a piece of reed cane, a foot long, and about an inch in diameter, and square across at the extremities, in his mouth. He fell forward; the end of the cane coming in contact with the ground, it was thrust violently into his throat. I saw him very soon after the accident happened. There were two lacerated incisions, extending from the centre of the back part of the bony arch of the mouth back- wards and outwards on each side, something more than an inch, and terminating within less than half an inch of the inferior mar- gin of the velum palati. The soft parts were cut, or torn through, making a triangular flap, the apex of which had fallen forwards or downwards, and hung dangling upon the root of the tongue, leaving the posterior nares and pharynx fully exposed. There was considerable hemorrhage, and the child and his friends were extremely alarmed. A short common surgeon's needle was heat- ed in the flame of a lamp, bent to a proper curve, armed with a ligature, and confined in Dr. Physick's forceps for taking up deep-seated arteries. The patient was placed upon a table and held by assistants. The mouth was kept open by a large cork placed between the back teeth, and his tongue depressed with a spatula. The needle was passed through the apex of the flap, and then through a corresponding portion of the mucous mem- brane, and cellular substance on the roof of the mouth, and the ligatures tied by the common stems for such operations when the fingers have not access. It was not attempted to insert more than one suture, although this did not bring the parts into exact EPULIS, OR TUBERCLE OF THE GUMS. 45 contact; but the swelling which supervened in the course of a few hours, as was anticipated, fully obviated that difficulty. He was kept as quiet as possible—not allowed to swallow any thing for the first four days, except a little milk and toast-water, and then as seldom as practicable. At the end of this period, adhe- sion was found to have taken place at every point. There is not the slightest deformity of the parts remaining. There was considerable difficulty in this little operation, from the struggles of the patient and the contracted space left for us to act in—the mouth being already pretty well occupied by the apparatus for keeping it open and depressing the tongue; indeed, without the above instruments, or others equivalent, it would have been found impracticable either to pass the ligature or to tie it." Upon the whole, I may remark, that staphyloraphy seldom suc- ceeds perfectly, and of this the surgeon should be aware. On Staphyloraphy, consult Memoire sur la Staphyloraphie, ou Suture du voile, du Palais, par Phil. Jos. Roux, Paris, 1825; On an Operation for the Cure of natural Fissure of the soft Palate, by John C. Warren, M. D., Professor of Anatomy and Surgery, in the Medical Institution of Harvard University, in American Journal of Medical Sciences, vol. iii. 1828; Staphyloraphy, or Palate Suture, successfully performed, by A. H. Stevens, M. D., Professor of Surgery in the College of Physicians and Surgeons, New York, in North American Me- dical and Surgical Journal, vol. iii. p. 233,1827; A Memoir upon Staphyloraphy, with Cases and a Description of the Instruments requisite for the Operation, by Alexander E. Hosack, M. D., one of the Surgeons of the Marine Hospital, New York, 1833; Liston's Practical Surgery; Lizar's ditto, article Velu-Syn- thesis; On Staphyloraphy, by J. P. Mettauer, in Amer. Jour, of Med. Sciences, No. xlii. Feb. 1838. SECTION VII. EPULIS, OR TUBERCLE OF THE GUMS. This disease, like polypus of the antrum, sometimes assumes a malignant form, and involving the teeth and adjoining parts, is soon beyond the reach of surgery. This will show the pro- priety of attending, in the commencement, to every small VOL. II.—D 46 EPULIS, OR TUBERCLE OF THE GUMS. tumour about the gums, however harmless may be its appear- ance. Any one, indeed, who will peruse the melancholy but in- structive cases detailed by Messrs. John and Charles Bell, the only writers who appear to have taken a deep interest in the subject, will need no further proof of the importance of the disease. Epulis generally sprouts from the sockets of the incisor teeth of the upper or lower jaw. The teeth themselves are frequently sound and perfectly white, and in many instances long before the tumour is perceptible, are loosened and carried beyond the range of the adjoining teeth. In other cases, a small seed-like excrescence is seated upon the gum between the teeth. This remains stationary for months together, or grows so slowly, and is attended with so little inconvenience, as scarcely to attract the patient's attention. At last it loses its hard and solid feel and gristly appearance, becomes soft and rugged on the surface, bleeds upon the slightest touch, and throws out a pro- lific fungus. After this, no bounds are set to the increase of the tumour, the teeth are successively displaced, the lymphatic glands and other soft parts in the neighbourhood contaminated, the mouth filled with a mass of disease so large as to embarrass the breathing and swallowing, the texture of the bones of the face or lower jaw broken up, and the patient eventually de- stroyed by hemorrhage, suffocation or irritation. TREATMENT OF EPULIS. Extirpation of this tumour, in its very incipiency, is the only remedy likely to effect a permanent cure. In performing this operation the surgeon will find it necessary to provide himself with forceps and other instruments, for pulling teeth, one or two short and very strong scalpels, two or three fine watch-spring saws, tenacula, sponges, a vial of the muriated tincture of iron, lint, &c. If there is strong evidence of the tumour having originated deep among the sockets of the teeth or in the cells of the bone, the teeth surrounded by the tumour, however per- fect they may appear to be, must be sacrificed, and not only the teeth, but the alveolar processes also. The cut in this case should be made with one of the fine saws perpendicularly through EPULIS, OR TUBERCLE OF THE GUMS. 47 the bone on each side of the tumour. By these means it will be so loosened as to be easily detached with a pair of Liston's cutting forceps. The hemorrhage that follows is commonly very profuse, but may be speedily arrested by dipping a piece of lint in the muriated tincture of iron, and thrusting it to the bottom of the wound—placing above the lint a bit of cork or some elastic substance to support the lint,—closing the patient's jaws, and securing them by a bandage. In twenty-four or thirty-six hours the lint may be removed, and if necessary the application of the muriated tincture renewed at each succeeding dressing; or the lunar or vegetable caustics may, with the same view, be applied. By adopting this plan,—the one suggested and practised by Sir Charles Bell,—I have in several operations of the kind succeeded perfectly. In other instances, where I have merely removed the tumour with the knife and caustic, it has invariably returned. See John Bell's Principles of Surgery, vol. iii. p. 178; Charles Bell's Sur- gical Observations, being a Quarterly Report of Cases in Surgery, vol. i. p. 413; Gibson on Bony Tumours, in the Philadelphia Journal of Medical and Physical Sciences, vol. ii. p. 145; Liston's Practical Surgery, London, 1839. 48 EXTRANEOUS BODIES IN THE OESOPHAGUS. CHAPTER III. DISEASES OF THE NECK. The importance of the diseases of the neck can be fairly esti- mated only by those who possess an accurate knowledge of the structure and functions of its numerous and complicated organs. The student should use, therefore, in prosecuting his anatomical investigations of these parts, more than ordinary diligence. Be- sides the great blood vessels and nerves of the neck, the pharynx, oesophagus, larynx, trachea, and thyroid gland are subject to accidents and diseases of the most pressing and grievous nature. Wounds of these different parts have already been considered ;* but it still remains to treat of several other affections. These are the lodgement of foreign bodies in the pharynx and oeso- phagus, foreign bodies in the larynx and trachea, ulceration of the glottis, bronchocele, wry-neck, &c. SECTION I. EXTRANEOUS BODIES IN THE OESOPHAGUS. It frequently happens that persons, from hurry or voracious- ness, in attempting to swallow a large piece of beef, tripe, gristle, cheese, bread, and other similar substances, are choked, and in danger of suffocation. In other instances, fish bones, chicken * See vol. i. p. 108. EXTRANEOUS BODIES IN THE OESOPHAGUS. 49 bones, pins, and needles, pieces of coin, stick in the pharynx or oesophagus, and excite irritation in proportion to their size, shape, &c. There is reason to believe, in most cases of the kind, that the difficulty of breathing which ensues, arises from the spas- modic action of the muscles of the glottis by which this chink is preternaturally constricted. Death may follow from this cause, or from the foreign body distending the oesophagus to such a degree, as to press upon the trachea and interrupt the passage of air, or the patient may die at some subsequent period from inflammation or gangrene induced by the continued pres- sure of the extraneous body, or injudicious and violent attempts to remove it. REMOVAL OF FOREIGN BODIES FROM THE OESOPHAGUS. When a large substance is swallowed, it generally sticks in the pharynx or between the cornua of the os hyoides and thy- roid cartilage, and often may be seen or reached with the fin- ger. In like manner, fish bones and other small and irritating bodies, when similarly situated, may be removed by a pair of forceps, or by tickling the fauces w7ith a feather, or by holding a solution of tartar emetic in the mouth. These last, by ex- citing vomiting, have the effect of expelling the foreign body. There are, however, several regular instruments well adapted to the removal of articles lodged in the throat; but the surgeon, if suddenly called to a patient apparently choking, and in immi- nent danger of his life, should waste little time in searching for these instruments. On the contrary, he should seize upon any thing that happens to be in his way, calculated to dis- lodge the morsel—such as a horsewhip, the handle of a spoon, a rattan, &c. As a general rule, digestible articles, provided they are free from asperities, should be forced into the sto- mach by the probang—a whalebone rod, having a round piece of sponge fixed upon one end and a blunt hook upon the other. This instrument (its sponge being previously softened a little) may be easily introduced by thrusting it against the back part of the pharynx. The sponge imbibing freely moisture, fills up entirely the oesophagus, and carries the body before it, unless very firmly fixed. Copper coins and all sharp or ragged bodies, should, if pos- 50 EXTRANEOUS BODIES IN THE OESOPHAGUS. sible, be extracted by the gula forceps, probang hook, or by a hook made of a piece of bell wire, upon the spur of the occa- sion. Sometimes a rod of whalebone, with numerous loops of thread or horse-hair attached to one end of it, answers an ex- cellent purpose, by entangling fish bones and other sharp bodies. After extraneous substances have been pushed into the stomach, the patient should take, for several days successively, purgatives and mucilaginous draughts, to promote their passage through the intestines. For several years Dr. Physick was in the habit of prescribing rice, and other similar articles, in large quantities, with a view of defending the coats of the stomach from the ac- tion of foreign bodies—and usually with great success. Needles and pins that have been swallowed, not unfrequently perform extensive journeys throughout the body, and at last are discharged through the skin. Dr. Henry Bond,* of this city, has made a very ingenious im- provement on the common gullet forceps. That instrument, as is well known, is defective, chiefly, on account of the blades closing upon each other with a flat surface, thereby leaving, necessarily, four sharp or angular edges, well calculated to pinch the lining membrane of the oesophagus. To obviate this incon- venience and danger, Dr. Bond's forceps have been bevelled off from the edges to the centre of the inner surface of each blade, so as to produce two convexities, or ridges, which are slightly serrated, and meet each other at a single line. Besides holding the foreign body with sufficient firmness, the narrow rough line allows the article contained in its grasp, " to vibrate freely and to assume a position nearly parallel to the blades." A case occurred, some years ago in the Eastern States, where a fish-hook, with part of the line attached to it, was swallowed. In the attempts to remove it, by pulling upon the line, the hook became fixed in the side of the oesophagus. After much diffi- culty, it occurred to an ingenious person present, that the proper mode to extricate the hook would be, to take a large leaden bul- let, drill a hole in its centre, pass the line through it, and let it be swallowed by the patient. The experiment was accordingly- tried, and with success—the bullet, by its weight, first disen- * Observations on the Removal of Foreign Bodies lodged in the Oesophagus, by Henry Bond, M. D., in North American Med. and Surg. Journal for October, 1828. STRICTURE OF THE OESOPHAGUS. 51 gaging the hook, and then its point being afterwards brought in contact with the lead, was prevented from sticking again in the oesophagus, in the act of drawing upon the line, so that both the bullet and hook were drawn out together. These particulars were communicated to me formerly, by a very intelligent student, Dr. Bradley, of Maine; but I have forgotten the name of the surgeon concerned in the case. The operations calledpharyngotomy and cesophagotomy should seldom, I conceive, be performed; but in order to sustain the patient's breathing, during the attempts to remove a large body from the pharynx or oesophagus, it may possibly become expe- dient to resort to bronchotomy or tracheotomy, as will be ex- plained hereafter. It sometimes happens, however, that a fo- reign body can neither be gotten up nor pushed down. In that case, if it can be felt externally, it may be cut upon and ex- tracted, no matter whether upon the right or left side. Guat- tani long ago recommended the operation, and brought forward successful cases. But in modern times it has not been generally resorted to. It was executed in 1832 by Mr. Arnott, of London, upon a child two years old without difficulty, and would, no doubt, have proved successful, if performed sufficiently early. SECTION II. STRICTURE OF THE OESOPHAGUS. The oesophagus, like the urethra, is sometimes the seat of stricture, either of the spasmodic or permanent kind. Nervous and hysterical patients are most subject to the former disease, and the latter may occur in patients of every variety of constitu- tion. Occasionally, the two affections are combined. Perma- nent stricture is met with in two or three different situations. Its most common seat, however, is immediately behind the cricoid cartilage, or in the commencement of the oesophagus. The con- traction is generally found to consist of a fold of the internal 52 STRICTURE OF THE OESOPHAGUS. membrane of the tube. In advanced cases of the disease, the whole cavity of the oesophagus is often entirely closed, and to a considerable extent, arising, probably, from the effusion of lymph, or from the glans of the passage assuming a scirrhous or cancer- ous action. The symptoms of permanent stricture of the oeso- phagus are difficulty of swallowing, in proportion to the duration of the disease, pain in the stomach, nausea, troublesome eructa- tions, pain in the fauces, extending thence along the base of the skull. In addition to these symptoms, the patient often finds it impossible to pass either solids or fluids in the smallest portion, and as a necessary result, emaciation ensues. Some patients, however, can readily swallow fluids, especially when sipped in small quantities; others find it easier to swallow solids. The causes of this disease are very obscure. In most in- stances, there is reason to believe that the permanent stricture is the result of inflammation, howTever induced. By Dr. Burwell, an intelligent practitioner of Buffalo, I am informed that several cases of the disease have occurred in his neighbourhood, from drinking liquor of pearl-ash, kept by most housewives, to lighten their bread, and generally deposited in the same closet with spirits, for which it has been mistaken. Similar cases have been reported by Sir Charles Bell,* from the accidental swallowing of soap-lees. A disease very opposite in character to stricture of the oeso- phagus is sometimes met with—paralysis of the oesophagus. This occurs, for the most part, in old people, and frequently as a concomitant of palsy in other parts of the body. The power of the muscular fibres of the oesophagus being impaired or lost, the patient can take neither solids nor fluids, and, unless speedily relieved, must die of inanition. TREATMENT OF STRICTURE OF THE OESOPHAGUS. Bougies, either alone or armed with lunar caustic, may be con- sidered the only remedies for permanent stricture of the oeso- phagus. To ascertain the situation and extent of the stricture, a soft wax bougie is employed. This may be readily introduced by directing the patient to draw back his tongue and imitate the * Surgical Observations. STRICTURE OF THE OESOPHAGUS. 53 action of swallowing. If the stricture is ascertained, from the resistance and the impression made on the end of the bougie, to be a permanent one, the caustic bougie may be immediately car- ried down, and kept in contact with the stricture three or four minutes. In two or three days the operation may be repeated, and kept up occasionally till the stricture is destroyed, or until a common bougie will readily pass. For the relief of spasmodic stricture of the oesophagus, I have often employed the unarmed bougie, and with the happiest effect. In such cases, also, the internal use of valerian, camphor, opium, ether, will be found highly serviceable. Paralysis of the oesophagus may be sometimes removed by electricity. To nourish the patient during the cure, the gum elastic oesophagus tube is essential. The surgeon should take care that fluids conveyed through it are not too hot, otherwise the stomach may be scalded. From this cause, several patients have lost their lives. When the oesophagus, from stricture or any other cause, is so completely closed that a bougie or gum elastic tube will not pass, the patient must be nourished by clys- ters. The cardiac, as well as other portions of the oesophagus, is not unfrequently the seat of scirrhous and cancerous affections. The progress of the disease is generally very slow and gradual. Often it is mistaken for common stricture of the oesophagus, and treated accordingly; by which the symptoms are aggravated and the ulceration hurried on. Frequent vomiting, generally half an h^M^fter meals, and often without pain, is one of the most de- cisive symptoms. In many instances the disease extends to the stomach, all the coats of which, as well as those of the oeso- phagus, are indurated and often ulcerated to a great extent. Such affections are, of course, incurable. The celebrated Napo- leon died of cancer of the stomach. Tumours situated between the trachea and oesophagus, en- largement of the thyroid gland, indurated lymphatic glands, aneurism of the aorta, and other affections, may, by pressure, involve the oesophagus, and generally admit of no relief. 54 EXTRANEOUS BODIES IN THE SECTION III. EXTRANEOUS BODIES IN THE LARYNX AND TRACHEA. During the act of deglutition, articles of food instead of pass- ing into the oesophagus, are sometimes suddenly diverted from their course, and thrown into the glottis. An instantaneous, violent, convulsive cough, and laborious respiration, are the consequences. If the extraneous body should be detained in the glottis, death speedily follows from suffocation; but in many instances, the body passes entirely through the chink of the glottis into the trachea, or else it is forced by the cough into the laryngeal pouches. In either case the patient is saved for the time, or eventually may recover. The lodgement, indeed, of a morsel in the sacculus laryngeus, is comparatively harmless, and the irritation occasioned by its presence soon subsides. I have known extraneous articles to remain in these cavities for years, without inconvenience, and indeed, without the patient being sensible of their presence. When, however, the substance descends into the trachea, incessant irritation is kept up, and, although the patient, even under these circumstances, may sur- vive for weeks, months, or years, yet, in the end, unless relieved by an operation, he is almost sure to die—from effusion into the cells of the lungs, or from phthisis pulmonalis. REMOVAL OF EXTRANEOUS BODIES FROM THE LARYNX AND TRACHEA. It is very seldom that the surgeon succeeds in extracting by instruments an extraneous body lodged even in the vicinity of the larynx; of course, the removal of it from the larynx or trachea, by such means, is out of the question. But to obviate instantaneous suffocation, or to remove the foreign body, an ope- ration may be required. Laryngotomy and tracheotomy, (so denominated according as the larynx or trachea may be the seat of the operation) are both occasionally required. The former, however, is best adapted to the removal of extraneous bodies, and is performed in the following manner. The patient being laid on a table, with his head supported by a pillow, and thrown moderately backwards, LARYNX AND TRACHEA. 55 the surgeon feels for the membranous space situated between the thyroid and cricoid cartilages, makes a perpendicular inci- sion about an inch in length through the integuments, platysma- myoides, and between the sterno-thyroidei and sterno-hyoidei muscles. Any vessels that may have been divided, are next carefully secured, and the bleeding having entirely ceased, it only remains to push the knife through the crico-thyroid mem- brane, when the extraneous substance will be either immediately thrown out or presented at the wound. Sometimes it is too large to pass through the membranous space. In that case, the incision should be prolonged upwards by separating from each other the two lateral parts of the thyroid cartilage. As soon as the foreign body is removed, and the patient's breathing restored, the wound may be drawn together by adhesive straps, and per- mitted to heal. Tracheotomy is now seldom resorted to, both on account of the difficulty of the operation, and the danger of wounding im- portant blood-vessels. Should it ever become necessary, how- ever, it may be done in the following way. The surgeon makes an incision, from below the cricoid cartilage, and extends it through the skin and platysma-myoides, nearly as far as the sternum. The sterno-hyoidei and sterno-thyroidei muscles are next carefully pushed aside by the fingers, until the surface of the trachea is cleared, and when all hemorrhage has ceased, two or three of the rings of the trachea may be divided by a per- pendicular cut. These operations may be required for other purposes than the removal of extraneous bodies, and in that case the surgeon will generally find it necessary to keep the orifice of the wound open for some time afterwards. This should not be done, I con- ceive, by a cannula, which, independently of its liability to be- come clogged by the mucus of the passage, excites always a great deal of irritation. Upon two or three occasions in which I have found it necessary to open the membranous space, in order to sustain the patient's breathing, I have dissected away the corners of the crico-thyroid membrane, and instead of intro- ducing a cannula into the larynx, have merely prevented the in- teguments and muscles surrounding the opening from closing, by passing a piece of tape around the patient's neck, having attached to each of its extremities a piece of silver wire doubled, and bent in the form of a hook, and calculated, by pull- ing these parts in opposite directions, to keep them asunder—at 56 EXTRANEOUS BODIES, ETC. the same time covering with a bit of gauze the opening in the larynx, to prevent the admission of dust and other extraneous matters. Laryngotomy and tracheotomy will sometimes be ne- cessary on account of substances lodged in the oesophagus, for cynanche trachealis or croup, for enlargement of the tongue or of the tonsils, for ulceration of the glottis, for suspended anima- tion in persons apparently drowned, &c. In cases of croup, the operation seldom succeeds, owing to effusion having gene- rally taken place in the lungs before the expedient has been resorted to. The result of nine operations by tracheotomy, in cases of croup, was published in 1842 by Becquerel.* All the patients died, and two of them instantaneously. Blood did not enter the trachea in either case, and no difficulty attended the operation. In several of the cases the immediate effect of the operation was great relief; the false membranes were removed and did not form again; yet suffocation was endangered when the wound was closed. Very high fever followed almost every operation. Great quantities of muco-purulent matter were se- creted. Pneumonia followed in some of the cases. The causes of death, generally, were bronchitis, pneumonia, convulsions, and persistence of the original disease. Some surgeons, and particularly Desault, in place of opening the larynx or trachea, on account of obstructions in the oesophagus, introduce a gum elastic tube into the windpipe, from the nose or mouth, with a view of sustaining respiration until the obstructions are removed. The practice, in my estimation, putting the difficulty of the ope- ration aside, is injudicious and censurable. On Diseases and Accidents of the Oesophagus and Trachea, consult Pelletan's Clinique Chirurgicale, torn, i.; Desault's Works, by Smith, vol. i.; C. Bell's Operative Surgery, vol. ii.; C.Bell's Surgical Observations, vol. i.; Lawrence on some Affections of the Larynx, &c, in Medico-Chirurgical Transactions, vol. vi.; Chevalier's Case of Croup, vol. vi. of Medico-Chirurgical Transac- tions; Monro's Morbid Anatomy of the Gullet and Stomach; Burns' Observa- tions on the Surgical Anatomy of the Head and Neck; Hopkins' Case of a Shot in the Trachea, in Potter's Medical Lyceum. In this case, the shot was re- moved from the trachea of a young lady, by her mother, who, without ap- prizing the patient of her intention, suddenly seized her while lying over the edge of a bed, and forced her head and shoulders towards the floor. The shot being carried by this movement towards the glottis, was instantly discharged. On (Esophngotomy—Verdue, Pathologie Chirurgicale; Guattani, in Me- moirs de l'Acad.de Chirurg. torn. iii. 4to.; Arnott, in Med. Chirurg. Transact. vol. xviii.; Malgaigne, Man. de Med. Operat. • Bulletin Gen. de Therap., Jan. 1842. ULCERATION OF THE GLOTTIS. 57 SECTION IV. ULCERATION OF THE GLOTTIS. From syphilis, abuse of mercury, and from other causes, the glottis is sometimes ulcerated, the epiglottis destroyed, the bony portion of the thyroid cartilage rendered carious, and covered with abscesses. This disease originates in the glandular structure of the larynx and trachea, and increases gradually, if not arrested, until it destroys the patient. The symptoms are a troublesome, hacking cough, with purulent and bloody expec- toration, great difficulty of breathing, a peculiar, husky, wheez- ing, whistling, almost inaudible voice. After labouring under the disease for a few months, the patient dies from suffocation, from effusion upon the lungs or from irritation. Sometimes the disease appears to be hereditary; at least, I have upon several occasions known different members of the same family attacked by it in succession. Some years ago I attended, with Dr. Shaw, of this city, a female who laboured under the disease, and finally died from it. Her sister, a stout healthy young woman, was attacked a few months afterwards in the same man- ner, and also died. A similar ulceration I have often met with, extending to the pharynx, and throughout the oesophagus. TREATMENT OF ULCERATION OF THE GLOTTIS. When there is reason to suspect that ulceration of the glottis or epiglottis depends upon a syphilitic taint, mercury, sarsapa- rilla, the nitro-muriatic bath, and other remedies of similar cha- racter should be employed. As a local application, there is nothing so serviceable as a solution of the argentum nitratum in the proportion of forty grains to an ounce of water. The prac- tice originated, I believe, with Sir Charles Bell: his mode of applying the caustic is to attach a pad of lint to a piece of wire, dip it in the solution, and taking care to depress the tongue with a finger, place the lint in contact with the ulcerated sur- face. As a measure of necessity, Mr. Bell once performed the operation of laryngotomy, for ulceration of the glottis, with in- 58 BRONCHOCELE. stantaneous relief to the patient, who continued to breathe freely through the opening for six weeks, but at last died in conse- quence of closure of the aperture by fungous granulations, the growth of which it was found impossible to repress. = For the ulceration that attacks the pharynx and oesophagus, the nitrate of silver I have found to be, also, the best remedy. Many cases of the disease, however, I have met with, have proved intractable under any treatment, though the patient's health did not appear to suffer from the continuance of the ul- ceration. In some instances I have traced the disease to dis- order of the digestive organs, and have relieved it by diet and appropriate medicines. SECTION V. BRONCHOCELE, OR GOITRE. The terms bronchocele, tumidum guttur, hernia bronchialis, gongrona, hernia gutturis, and others of similar import, are em- ployed to denote a morbid enlargement of the thyroid gland. The word goter or goitre, was invented by the Swiss, and is probably a corruption of the Latin phrase guttur. In England, the disease is known, in popular language, under the name of Derbyshire neck, or monstrous craw. Bronchocele has prevailed in certain countries, from time im- memorial. It is noticed by some of the ancient poets, and by many of the early writers on medicine. It is met with oftener in mountainous than in level countries, and is frequently endemial and hereditary. According to Coxe, the disease is common in the neighbourhood of Berne, Friburg, Lucerne, Aigle, Bex, Dres- den, in the valleys of Piedmont and Savoy, in most parts of the Vallais, in the Valteline, &c* In the village of La Batia, Dr. Reeve saw many cretins and goiterous persons, who all lived * Coxe's Travels in Switzerland. BRONCHOCELE. 59 in adjoining houses.* The village of Villeneuve d'Aoste, which is surrounded by very high mountains, contains an immense number of persons who labour under goitres of enormous mao-ni- tude.f The late Dr. Howard of Baltimore, during his rambles in Switzerland, first met with goiterous persons and cretins near Sion. The number of each continued to increase as he approached Martigny and St. Maurice, at which places they were exceedingly numerous. As he descended the Rhone their numbers decreased. In the year 1800, the villages of St. Jean, St. Michael, St. Maurice, and the vicinity of Aiguebelle, ac- cording to Fodere, contained a greater portion of cretins and per- sons labouring under goitre than any other part of Switzerland. Dr. Howard was informed that both cretinism and goitre had diminished within the last few years, in consequence of the richer inhabitants sending their children, until their tenth or twelfth year, to the mountains, where their wives also remained during pregnancy, and for some time after parturition. In the mountainous parts of Spain and Germany goitre prevails to a considerable extent. In France, it is chiefly met with in the districts of Cevennes, Soissonais, Vosges, Rouergue, Doubs, and Ardeches. In England it is very common in the mountainous parts of Derbyshire, in Buckinghamshire, Surry, and in the county of Norfolk. Occasionally it is seen in Nottinghamshire. J Sir George Staunton says, that goitres are very common in those parts of Chinese Tartary which resemble the mountains and valleys of Savoy and Switzerland.^ "In Bengal," says Turner, "this unsightly tumour is known by the name of gheig and aubi; and in Boutan is called ba or ke ba, the neck swelling and forms itself immediately below the chin, extending from ear to ear, and sometimes growing to such an enormous size, as to hang from the throat down upon the breast. It is particularly observable among the inhabitants of the hills of Bou- tan, immediately bordering upon Bengal, and in the track of the low country watered by the rivers that flow from thence to the south, beyond the space of a degree of latitude. The same ma- * Reeve's account of Cretinism, in the Edinburgh Medical and Surgical Jour- nal, vol. v. p. 33. t Saussure's Voyages dans Les Alpes. t Clark's Reports from the general Hospital near Nottingham, in the Edin- burgh Journal, vol. iv. § Staunton's Embassy to China. 60 BRONCHOCELE. lady prevails among the people inhabiting the Morung, Nipal, and Almora hills, which, joined to those of Boutan, run in con- tinuation, and bound, to the northward, that extensive tract of low land embraced by the Ganges and the Burrampooter. The same disease is also more particularly met with in the low lands adjoining those hills. From the frontier of Assam, north lati- tude twenty-seven degrees, east longitude ninety-one degrees, it is to be traced through Bishee, Gooch, Bahar, Rungpore, Di- nagepore, Purnea, Tirrooto, and Betiah, along the northern boundary of Oude, in Gooracpore, Barraitch, Pillibeat, and on the confines of Rohilcund to Hurdwar, situated in north latitude thirty degrees, east longitude seventy-eight degrees twenty-five minutes. It has the effect, or is rather accompanied with the effect arising from the same cause, of debilitating both the bodies and the minds of those who are affected with it."* Park, in giving an account of the diseases of the Mandingo negroes, states that goitres are very common in some parts of Bambarra.f Throughout the island of Sumatra, bronchocele is met with as an endemic disease, and is particularly frequent in those valleys which are surrounded by the highest mountains.J In some of the Spanish settlements of America, goitres are so common that the greater number of the inhabitants labour under the disease; and at the village of Jacaltonango, near Sacapula, it is said that no individual can be found without an enlargement of the thy- roid gland.§ In Santa Fe, Guatemala, Nueva Gallicia, and Nicaragua, the complaint has long been known. It is common also among the Indians who inhabit the valleys of the Cordilieres. According to Humboldt and Bonpland, goitre is an endemic disease at New Grenada, and is so common at the small villages Hunda and Monpar, on the borders of the Magdelaine river, that it is difficult to find an individual who is exempt from it. It affects indiscriminately all classes of inhabitants, except the blacks and those who lead a very laborious life. The ferrymen at Carthagena are not subject to it. Females are oftener affected than males. At the Isthmus of Darien many persons are hor- ribly disfigured by enormous bronchoceles.| | In various districts and throughout whole tracts of country in North America, bron- * Turner's Account of an Embassy to Tibet. f Park's Travels in Africa, p. 413. t Marsden's History of Sumatra. § Barton's Memoir on Goitre. || Alibert's Nosologie Naturelle, p. 470. BRONCHOCELE. 61 chocele prevails as an endemic. It is very frequent in many parts of Lower Canada, especially near the marshes between St. John's and Montreal. At Detroit, Lake Ontario, Oneida, Erie, Huron, and among the Tuscarora, Seneca, Oneida, and Brothertown Indians, it is very common.* In many parts of the State of Vermont, especially Bennington and Chittenden, bronchocele is well known. It is also found at Camden, Sandgate, and Chester, in the same State. Sandgate, some years ago, contained one thousand and twenty inhabitants, and out of that number one- fourth of the females were affected with this disease-! Accord- ing to Dr. Trask, bronchocele is so common a disorder at Wind- sor, in Vermont, that hardly any female is exempt from it.J In the State of New York goitre prevails principally in the neigh- bourhood of Old Fort Schuyler, the Oneida village, the German Flats, Fort Herkimer, Fort Dayton, Henderson Town, Onon- daga valley, Cansaraga, Brothertown, the townships of Man- lius, and the whole of the military district.^ I am informed by Philip Church, Esq., who resides at Angelica in Alleghany county, State of New York, that goitre is a very frequent com- plaint in his neighbourhood and the surrounding country. In Pennsylvania where bronchocele is very common, it is found chiefly at Pittsburgh, on the waters of the Alleghany, Sandusky, Monongahela, French Creek, at Canonsburgh, Brownsville, and throughout the county of Somerset. In some parts of Virginia,|| * Barton's Memoir. t Dorr's Facts concerning Goitre, New York Medical Repository, vol. x. I Mease's Observations on Goitre. § Barton. || Dr. Gibson,— Sir, I take the liberty of communicating to you a fact, which has fal len un- der my observation, relative to the disease known by the name of goitre, or bronchocele, which, if it be not useful in throwing some light on the cause of this inexplicable affection, will at least prove curious to the surgeon and phy- sician. At King's Saltworks in the county of Washington, Virginia, and not far from my own residence, this disease has prevailed for a number of years: for any thing that I know to the contrary, its existence is coeval with the commence- ment of the manufacture of salt at that place. Hitherto it has been confined exclusively to females, and to those who reside at the very spot where the pro- cess of vaporization is carried on; the subjects of it consisting chiefly of the fa- milies of the immediate superintendents. Persons living at the distance of a half, or even quarter of a mile are not subject to the disease. Contrary to what might be supposed from the aspect of the neighbouring country, this disagreeable affection is of exceedingly rare occurrence in this part of the state, with the exception above alluded to. No satisfactory reasonhas VOL. II.—E 62 BRONCHOCELE. especially at Morgantown and on the banks of Cheat river, it is by no means unfrequent. In certain situations on the western shore of Maryland, and in North and South Carolina, the dis- ease is occasionally met with. It is probable, indeed, that goi- tre may be found as an endemic disease, in almost all the moun- tainous and marshy districts throughout the United States. All writers on the complaint, agree that it generally prevails in val- leys at the bottom of the highest mountains, which are particu- larly exposed to the influence of easterly and southerly winds. In those situations, moreover, where the temperature is mild and uniform—where the atmosphere is moist—in the neighbour- hood of rivers, of falls or lakes, or of the sea,—where the soil is rich, and the habitations surrounded by fruit trees, goitres are commonly found. Every age and sex is liable to goitre, but females are oftener affected than males. In children, it seldom occurs until after the eighth or tenth year, and old people are little subject to it. Three instances, however, are mentioned by Fodere, where it was found at birth, and another, in an infant fifty days after birth.* Dr. Sterndale has also furnished an example, where a child in Derbyshire was born with a goitrous tumour of con- siderable size.f Those females who are not subject to broncho- cele before marriage, generally perceive its commencement during pregnancy .J Persons of relaxed constitutions, of white and delicate skins, and whose complexions are red mixed with a brownish tinge, are most predisposed to the disease. Children who are to become goitrous, have large blue, sprightly eyes, beautiful skins, and fair hair. Their memory is very forward. been assigned for its existence at this place. It has, however, been ascribed to the water used for drinking. I have drunk of the same water myself, and found it insipid and unpalatable; but was unable to detect in it the presence of any other mineral but lime, which is the common character of the water of the country. It may, perhaps, be proper to state, that a removal to another si- tuation, is not attended with a removal of the complaint. Whatever may be the cause of this disease, as it exists here, which I think is entirely inscrutable, such is the certainty with which it attacks those who come within the sphere of its influence, that every woman who goes to King's Saltworks to live, previously makes up her mind to become sooner or later a subject of goitre. John T. Smith, M. D. December 22d, 1831. * Traite du Goitre et du Cretinisme. f London Medical Repository, vol. x. p. 200. i Fodere, p. 62. BRONCHOCELE. 63 When the disease appears, every thing is changed. As it advances, the eyes become dull, the face acquires a white colour and unmeaning look, and the faculties are at a stand. When the goitre is very large, respiration becomes difficult, the pronunciation of consonants imperfect, and the body ceases to increase except about the head and shoulders. In a goitrous country, the children are born goitrous after two generations of the intermarriage of goitrous parents. After the third marriage, the child becomes a cretin. A semi-cretin, weak and rickety, married to a goitrous woman, has children born goitrous.* During the winter, a goitrous tumour is diminished in size, but it augments with the return of warm weather, and is larger during autumn than at any other season. The disease is not confined to the human race; horses, horned cattle, calves, sheep, dogs and other inferior animals are subject to it."f In the commencement of bronchocele, a small tumour may be perceived, either on one or both sides of the trachea and larynx. Sometimes the swelling occupies each lobe of the thyroid gland together with its isthmus, so as to constitute a uniform tumour ; at other times, there is a depression at the centre, following the course of the trachea, and marking the natural division of the lobes. Occasionally the enlarged lobes are studded over with a number of lobules. The swelling generally continues small and circumscribed for a considerable time, and often extends, backwards, so as to render it difficult to ascertain, by inspection or examination, whether goitre exists or not. For the most part it is soft to the touch, and possessed of so little sensibility, that it may be rudely handled, without producing much uneasi- ness. It is sometimes closely compressed by the muscles which cover it, and is then elastic and firm. Although the thyroid gland, both in its natural and enlarged condition, is not very susceptible of inflammation, yet, when this state is once induced, it becomes exquisitely tender, and is accompanied with a diffi- culty of respiration and deglutition, which the most active anti- phlogistic measures can hardly subdue. Almost all the goitres which have come under my notice in America, have com- menced in one lobe of the gland—the other lobe in a short time * Fodere^ also Chapman's Notes on Allan's Lectures. f Coxe's Travels; Barton's Memoir; Clark's Reports. 64 BRONCHOCELE. being affected in a similar manner. Alibert says that he has found the right lobe oftener enlarged than the left.* In the worst cases of goitre I have seen, the tumour has exceeded in size a large cocoanut, and has become at particular times very troublesome to the patient, by its weight and pressure upon the trachea and adjacent parts. In countries where the disease is endemic, it is not uncommon for the tumour to attain an enor- mous magnitude. Fodere relates instances of such tumours weighing seven or eight pounds.f A case is recorded by Ali- bert of a man thirty-eight years of age, who had a goitre which extended below the middle of the chest and equalled in size a large pumpkin. "La poche enorme que s'est formee au dessous de son menton, resemble a celle de l'oisseau designe commune- ment sous le nom de pelican, et qui figure comme object de curiosite dans les cabinets des naturalistes." The same author details the case of a female, upwards of sixty years old, who had resided the greater part of her life near Chamouny at the foot of Mont Blanc, and who, from her infancy, had laboured under a bronchocele, which was divided into innumerable lobes, which extended from ear to ear, blocked up the cavities of each, so as to destroy the hearing, and finally descended on the chest, lower than the mammae, interrupting the breathing and swal- lowing to such a degree, as almost to produce suffocation, every time she attempted to take the least particle of nourishment, solid or fluid. But cases have been related by Mittlemayer and others, in which the goitrous tumours have descended below the umbilicus, and even to the knees.J We have no reason to suspect these accounts exaggerated, when we remember the reports of Sir Robert Wilson, Larrey, and others, respecting those prodigious tumours, common in Egypt and many warm climates, in consequence of the descent of the abdominal viscera, which in some instances, have reached the ground. The cases of enormous hydroceles, also recorded by Keate,§ and the voluminous cutaneous excrescences described by Mr. John Bell, and by Dr. Roper of Charleston, leave no doubt on the subject. Notwithstanding the peculiarities of goitre, it is not easy always to distinguish it from other diseases. It may be con- * Nosologie Naturelle. t Traite du Goitre, &c, p. 4.97. I Nosologie Naturelle, p. 468. § Dissertatio de Strumis et Scrophulosis, 1723. BRONCHOCELE. 65 founded with aneurism of the carotid artery, with scrofulous enlargement of the lymphatic glands, with encysted and sarco- matous tumours of the trachea and its vicinity, with dilatation of the internal jugular vein, and perhaps with other complaints. From aneurism it may be distinguished, in general, by want of pulsation, by the comparative insensibility of the tumour, by the softness of its texture, by its mobility, and by the circum- stance of the swelling accompanying the motions of the larynx and trachea, when the patient is desired to imitate the action of swallowing. But sometimes the goitre is so large, and is so identified with the adjacent cellular texture, that little or no movement of the trachea can be observed. When goitre is ex- tensive, and occupies one side of the neck only, and when, at the same time there is a pulsation in it from the enlarged and varicose state of the vessels, we shall not find it always easy to discriminate between it and aneurism. Occasionally a pulsa- tion is communicated from the carotid to a goitrous tumour, which happens to lie over it. One instance is noticed by Burns, where the carotid was deeply imbedded in the sub- stance of an enlarged thyroid gland. "The carotid artery being placed," says he, " in the body of the tumour, is neither very rare in occurrence, nor very difficult to explain. It is, indeed, a natural consequence of the extension of the tumour, laterally; yet it will not happen in every tumour: it will only occur in those cases where the consistence of the morbid parts is soft. When the tumour is firm, it pushes the artery, nervus vagus, and internal jugular vein aside. When it is soft, these, as in the present instance, sink into its substance." * In most instances of aneurism, however, the carotid is deeper seated than bronchocele, and the pulsation so strong as scarcely to be mistaken. Notwithstanding this, cases have been related where the most able surgeons have found it impossible to offer a de- cided opinion. A Creole negro had a tumour on the neck, which was submitted to the inspection of some of the most celebrated surgeons in America, Paris, and London; all of whom pronounced the disease an aneurism of the carotid artery; but it was afterwards ascertained by Boyer, that no such dis- ease existed—but simply an extensive enlargement of the lym- phatic and other glands of the neck.f The late Dr. Samuel P. * Surgical Anatomy of the Head and Neck, page 224. f Dictionnaire des Sciences Medicales, vol. xviii. p. 541. 66 BRONCHOCELE. Griffitts has furnished us with an interesting history of a tumour of the neck, bearing so strong a resemblance to carotid aneurism, as to be mistaken for the disease by himself, Drs. Chapman and Morgan, and the late Dr. Dorsey. Upon dissection by Dr. Par- rish, it was distinctly ascertained that the carotid was free from disease, and that the tumour was composed entirely of the thyroid gland. " It was elongated," says Dr. Parrish, " and had obtained a situation directly over the carotid artery; the patient's neck was very short, the pulsation in the carotid was imparted to the tu- mour lying over it; and, I am informed, there was a strong re- semblance to the aneurismal jar or thrill. We are aware that in dropsy of the chest and pericardium, the heart often palpi- tates most violently; and this morbid pulsation may explain the throbbing of the carotid, which bore so strong a resemblance to aneurism." * One circumstance which deceived Dr. Griffitts, was the impossibility of drawing the tumour from the artery. " I had frequently endeavoured," says he, " to remove, with my fingers, the tumour from the artery, wishing to think the dis- ease was glandular, but could not succeed, as the tumour was so firmly fixed over the vessel as not to be moved from it; and the pulsation was such as to convey the idea that there was no in- tervening substance." Under ordinary circumstances, this plan of drawing the tumour from the artery is excellent. It wTas by relaxing the muscles of the neck, and separating with the fingers the tumour from the artery, that Boyer was enabled, in the case referred to, to discriminate between the disease and aneurism. By similar means, I have often succeeded in distinguishing en- larged glands and other tumours situated over large arteries, in different parts of the body. Many writers have confounded goitre with scrofula: but there would appear to be no legitimate foundation for such a conclu- sion. In scrofula, the lymphatic glands of the neck and other parts of the body are particularly involved; and other marks in the system, too well known to require description, evince the existence of the scrofulous constitution. These symptoms do not generally accompany the goitrous tumour. Goitre is strictly a local complaint—scrofula affects the whole system, and appears at a much earlier period of life than goitre. In countries where bronchocele is endemic, the scrofulous are equally liable, no * Eclectic Repertory, vol. ix. p. 120. BRONCHOCELE. 67 doubt, with others, to the complaint. Persons who remove from settlements where goitre does not exist, into countries where the disease prevails, are subject to it; but on residing again for some time at their original home, the tumour disappears, gene- rally, in a short time. This is seldom the case with scrofula, which is little influenced by change of climate. The scrofulous tumour is harder to the touch, and more painful than the goitrous tumour. It is more disposed to suppurate than bronchocele; besides, goitre is nearly unknown in certain countries, where scrofula is the common disease. In Scotland, scrofula is almost universal,—goitre hardly ever met with. In Switzerland, goitres are very common, and affect all classes of society, while scrofula is comparatively rare. It is possible for an enlarged thyroid gland to extend so far beyond its natural boundaries as to occupy the situation of the lymphatic glands of the neck. Mr. Burns has furnished a very instructive case of this kind, in which it would have been impossible, perhaps, without dissection, to have as- certained the true nature of the swelling. " Beneath the sterno- mastoid muscle," says he, "the enlarged gland was lobulated and clustered into small processes, precisely resembling a chain of enlarged concatenated glands. Indeed, had I alone trusted to the impressions received before dissection, I would have been led to believe that the lymphatic glands of the neck were actually swelled, and, besides that, several of the conglobate glands, placed behind the sterno-mastoid muscle, between it and the trapezius, were also affected; for into that space processes from the left lobe of the thyroid gland extended."* A dilatation of the internal jugular Vein is not an uncommon disease, and may sometimes be mistaken for goitre. It may- be distinguished, generally, by its low situation—the swelling appearing just above the sternum. The tumour may also be known from goitre, by its softness and compressibility, by its pulsatory and tremulous motion—by the sudden return of the tumour when pressure is removed—by more or less tumes- cence, along the whole course of the vein. I once attended a patient, four or five years of age, with Dr. Jennings of Balti- more, upon account of a large swelling of the neck, the precise nature of which, it was difficult to ascertain for some time. It resembled in many respects the enlarged thyroid, and in others, diseased lymphatic glands, but turned out to be a dilatation of * Surgical Anatomy, p. 196. D~ BRONCHOCELE. the internal jugular. The interesting case of a tumour of the neck, detailed by Mr. Hey, the nature of which he could not ascertain, I have no doubt, was an enlarged vein, and probably the jugular.* The morbid distention of this vessel has been confounded occasionally with aneurism of the aorta.f An encysted tumour may occupy the anterior surface of the trachea; in many respects it is analogous to goitre—is free from pain—is soft and doughy to the feel—follows the motions of the larynx and trachea, and may attain a considerable size. It extends on the trachea as high as the thyroid gland, and de- scends behind the sternum. The disease has never been de- scribed, I believe, as occupying this situation. I have seen only two or three cases of it. An officer of the army consulted me, some years ago, respecting such a tumour, which had been shown, previously, to several practitioners, who could not give a decided opinion as to its nature. At first I suspected it to be a goitre, but the patient assured me that it had emerged originally, from behind the sternum, and was occasioned, so far as he could determine, by the pressure of a leathern stock, which had been worn unusually tight. This circumstance inclined me to believe, that the tumour had no connexion with the thyroid gland, and determined me to puncture it with a lancet. A thick, yellow, cheesy matter, extremely offensive, and three or four ounces in quantity, was discharged from the wound by pres- sure. The opening was then enlarged, and a probe could be passed to a considerable distance behind the sternum, and up- wards along the trachea. The cavity was filled with lint and stimulating injections were frequently employed. Suppuration was established with difficulty, and the cavity was filled up in the course of two or three months. I met with a similar dis- ease afterwards, in a young woman seventeen years of age, and removed it by the same treatment. The wound, however, re- mained fistulous for a considerable time, in spite of every reme- dy used. In both cases, these tumours extended so far up- wards, and were so deeply imbedded under the sternum, that any attempt at excision would have been hazardous, if not im- practicable. In its natural state, the thyroid gland is found to vary in dif- ferent subjects. In females, it is larger than in males. It is ge- * Hey's Practical Observations in Surgery, 3d edition, p. 448. t Burns on the Diseases of the Heart, p. 259. BRONCHOCELE. 69 nerally made up of distinct lobules, udiich are collected into nume- rous lobes or tuberculated masses, joined to each other by a very fine cellular membrane. Rounded vesicles containing a colour- less, but sometimes yellowish fluid, are mixed with the lobes. In many subjects these vesicles cannot be discovered, and the exist- ence of a fluid is ascertained, only by rubbing slices of the gland between the fingers, when a peculiar feeling of viscosity may be observed.* There is no proper investing membrane or cap- sule to the thyroid gland; but the cellular texture is slightly condensed on the surface, so as to furnish a very thin covering, from which processes proceed internally, and form septa or par- titions in various directions. The substance of the gland gene- rally consists of two portions, which are placed on each side of the trachea and larynx, and united to each other by a trans- verse band or slip of the same substance. Sometimes this band is wanting, and then there are two distinct thyroid glands.f No unquestionable excretory duct has yet been discovered. But small openings or canaliculi, described by Morgagni, Bor- deu, Walter, and some other anatomists, have been found on the internal surface of the trachea. These openings uniformly occupy one situation, and are two or three in number. They may be found about the middle of the internal surface of the first cartilaginous ring of the trachea. Bordeu, in speaking of this ring, says, " Nous avons aussi remarque, qu'il est, dans tous les sujets ou divise par une fente plus ou moins etendue et situee vers le devant du cartilage, on perce d'un ou deux, et meme de trois trous bien apparens et places aussi, vers le milieu du cerceau sur le devant, ou un peu & cote. " Ces trous nous frapperent la premiere fois que nous les vimes: c' 6toit a Montpellier, en 1741, en dissequant un larynx aupres du feu; la glande thyroide qui etoit extremement grosse, etant enlevee, nous trouvames le premier cerceau presque osseux, mais assez transparent pour laisser apercevoir, au moyen du feu, les deux trous qui n'etoient recouverts que par des membranes laches qu'on emporta facilement. "Apres bien des recherches, on trouva un sujet mort de morte violente; nous examinames d'abord la face posterieure du cerceau de la trachee, sans avoir touche la thyroide; la mem- * Anatomie Descriptive, par X. Bichat. t Soemmering de Corp. Hum. Fabric, vol. vi. p. 39. 70 BRONCHOCELE. brane interne de ce cerceau etoit pleine de petits trous difficiles a* apercevoir; nous introduisimes des soies dans cinq de ces trous, et en les conduisant legerement, elles allerent se rassem- bler en deux endroits, trois dans l'un et deux dans l'autre; ces endroits etoient precisement les deux trous du cartilage; ces soies allerent, en les poussant, se perdre dans la glande. M. Barbuot, medecin de Semur, etoit present a cette opera- tion."* From a perusal of these and other passages in Bordeu, some years ago, I was induced to examine the openings described, in a great many subjects, under an impression that they were the mouths of excretory ducts from the thyroid gland. To ascer- tain this, I made a number of experiments with the mercurial injecting apparatus, the small pipes of which were introduced directly into the openings in the cartilage, and found that the mercury sometimes passed with facility, through these small canals, but met with resistance when it reached the thyroid gland. In three or four instances I succeeded in pushing it to a considerable distance under the cellular covering of the gland, and even among the cellular texture into the substance of the gland, as I afterwards ascertained by cutting it open. But, in all probability, the mercury passed, in each case, from rupture of the cellular tissue, and did not follow the natural course of the duct. I endeavoured to find a communication between the thyroid gland and the ventricles of Galen, and with this view introduced the mercury into the bottom of each of these cavities. After several ineffectual attempts, I succeeded in filling the cel- lular texture of the thyroid, and to a much greater degree than from the openings of the trachea. I mention these circum- stances to corroborate the suggestions of Morgagni and Bordeu, that there are passages from the thyroid gland which serve to deposit its secretions in the trachea, and perhaps in other places. The observation may be useful to those who feel disposed to in- vestigate the subject further. In addition, I may state that, Fodere succeeded in blowing air from the larynx into the thy- roid gland so as to distend it considerably. In another instance he filled the trachea with spirit of wine, and upon cutting into the thyroid gland, the smell of the liquor was distinctly per- ceivable. * OZuvxes completes de Bordeu, par Richerand, torn. i. p. 98. BRONCHOCELE. 71 " Qu'on prenne," says he, " un larynx auquel, cette glande est attach'e, bien lave et n-Hoye avec une legere dissolution de potasse et ensuite scche, qu'on en bouche exactement l'extremite inferieure, puis qu'on adapte au trou de la glotte, un tube con- tigue a une vessie pleine d'air, et qu'on lutte bien 1'appariel; en comprimant la vessie, on verra la glande thyroide augmenter de volume. " La meme experience reussit, quoi qu' a un moindre degre, avec l'alcohol. En coupant la glande apres avoir comprime la vessie, on sent distinctment l'odeur de ce fluide."* Lalouette discovered an immediate connexion between the thyroid gland and the lymphatic vessels which pass along the thyroid and cricoid cartilages.! Many cases have been record- ed by different writers, where an enlargement of the thyroid gland has been suddenly produced in consequence of violent ex- ertions of the muscles of the neck in lifting heavy weights, or in consequence of laborious efforts of the patient during protracted and difficult parturition. It has been maintained, also, that goitre is produced among the inhabitants of certain European districts, from the habit, which is frequent among the lower order of people of dragging burdens up the hills by cords tied round the upper part of the chest. According to Mr. Heck- ewelder, who often met with goitre among the American In- dians, the disease never made its appearance among the girls until they began to carry heavy burdens on their heads.J These circumstances would favour the idea of Bordeu, Fodere, Mor- gagni, and others, of the existence of a direct communication between the trachea and thyroid gland.§ Many theoretical uses have been assigned to the thyroid gland, besides those already mentioned. It does not come, however, within the scope of my purpose to detail them.|| When a goitrous tumour is examined by dissection, several circumstances are presented worthy of notice. One or both lobes, and sometimes the middle lobe or isthmus of the gland, are found enlarged beyond their natural boundaries. Upon cutting into * Traite du Goitre et du Cretinisme, p. 58. f Haller, Elements Physiologiae. J Barton's Memoir, p. 46. § See Morgagni's Adversaria, v. p. 6. || Those who wish for information on the subject may consult Haller's Ele- menta Physiologiae, lib. ix. p. 22; Soemmering, de Corp. Hum. Fabr. vol. vi. p. 41; Coxe's Museum, vol. iii. p. 27. 72 BRONCHOCELE. their substance, the texture is found more or less compact, inter- mixed with numerous cells, containing a transparent glutinous liquor, which may be drained off in such quantity, by pressure, as to reduce considerably the bulk of the tumour. These cells vary in size; some being large enough to contain a pea, while others are exceedingly small. The fluid they contain becomes a solid transparent jelly, when the gland has been immersed for some time in proof spirits.* Although the thyroid gland in its natural state is abundantly supplied with large arteries, yet its capillary vessels are comparatively few, and the quantity of blood determined to its substance not so great as commonly sup- posed. In bronchocele all the vessels are greatly enlarged, and varicose, and the quantity of blood materially increased, as is evinced by the throbbing of the tumour during life, and by injec- tion of it after death. This preternatural accumulation of blood so frequently accompanies the kind of diseased enlargement of the gland wrhich I have described, as to cause some writers to rank it as a particular species of goitre,—denominated sangui- neous goitre. This distinction, as well as every other division of the disease into species, is, perhaps, improper, inasmuch as the ap- pearances presented on dissection are never sufficiently uniform to enable us to characterize with precision each morbid change of structure. It is certain, however, that an unusual determina- tion of blood generally accompanies the structure I have de- scribed, and which nosologists have called the sarcomatous bron- chocele. In all probability the other species mentioned are but varieties of this common and perhaps original form of the com- plaint. Sometimes the texture of the goitrous tumour, instead of beino- compact and solid, is soft and spongy, and large cavities or membranous vesicles are dispersed throughout, which contain a thin, limpid, or serous fluid. This has been called the encysted serous, or watery bronchocele. It is a modification only of the common disease; for sometimes the fluid changes into a yellowT, tenacious and melicerous matter. The cells of the thyroid gland are said to have been filled, occasionally, with hydatids; but such appearances may have been confounded with the watery collections just described. The bronchocele ventosa cannot be described as a variety of goitre, but only an emphy- * Baillie's Morbid Anatomy, p. 86; also Engravings, Fasciculus ii. p. 25. BRONCHOCELE. 73 sematous tumour of the gland, or of the adjacent cellular tex- ture. It is not uncommon to find in the substance of goitres, of long standing, bony particles, and even considerable masses of ossi- fied matter. Several examples of the kind are mentioned by Bonetus, Morgagni, Kerkringius, and other old writers. Dr. Baillie, in his Morbid Anatomy, speaks of the thyroid gland being sometimes converted, in old people, into a bony mass. In this respect the disease nearly resembles other sarcomatous tumours, in which we are accustomed to meet with cartilaginous and ossified productions. Calcareous concretions are said to have been dis- covered, in the substance of the thyroid gland, affected with goitre.* Pieces of tuftstone have been removed from the thyroid gland, in several instances, by a Swiss surgeon.f The substance of bronchocele is seldom converted into puru- lent matter. But cases have been recorded by Petit and Hevin, where spontaneous cures were effected in this way. Severinus relates a case in which purulent matter was discharged from a bronchocele mixed with a substance resembling charcoal.J Dr. Baillie has given a drawing of a preparation contained in the Hunterian cabinet, where an abscess formed in the right side of the thyroid gland and afterwards communicated by ulceration with the trachea, so as to suffocate the patient.^ Alibert relates the case of a patient in the hospital of St. Lewis, who laboured for years under an enormous bronchocele, and was eventually relieved of his burden by suppuration taking place in its substance. Ulce- ration was spontaneously established, and upwards of five pounds of purulent matter discharged.] | Burns gives an instance where suppuration took place in both lobes of the thyroid gland. The matter was slowly secreted and the integuments became gradually distended, until they formed a large pouch which hung over the sternum and contained several pounds of pus. The sides of the cysts united, and the patient was ultimately cured.IT In speaking of abscess, following bron- chocele, Portal remarks, that the cartilages of the larynx and rings of the trachea, are sometimes eroded by caries. "On a trouve dans des sujets qui etaient morts de suffocation, les carti- lages thyroide, cricoidc, et les anneux cartilagineux de la trachee * Haller,ElementaPhysiologiae,vol.iii.p.400. fCoxe's Travels. JDe Recondita AbscessumNatura, p. 194. § Series of Engravings, p. 27. || Nosologie Naturelle, p. 467. IT Surgical Anatomy, p. 188. 74 BRONCHOCELE. art^re, rouges par la carie, a la suite d'un abscess dans la thyroide. Valsalva, Morgagni, Lieutaud ont cite de pareils exemples dans leurs ouvrages."* I have had three opportunities of dissecting goitrous tumours. The first was in a man upwards of sixty years of age, who had laboured under a very large and tuberculated swelling of the thyroid, almost from infancy. The tumour occupied both sides of the trachea, and was very solid, and insensible to the touch. It produced very little inconvenience, and the patient died of another complaint. Upon dissection I found each of the en- larged lobes completely sarcomatous, without any membranous vesicles, or fluid, except a thick, yellowish, lardaceous or olea- ginous matter, in small quantity, which could be pressed, by force, from the diseased mass. Fibrous bands, similar to those which occur in the scirrhous breast, or testicle, intersected the tumour in various directions. The larynx and trachea were not altered in structure, but the mouths of the small muciparous ducts which open on the lining membrane of the trachea, were not perceptible, and the tracheo-thyroideal passages of Bordeu appeared less conspicuous than usual. Some years ago I had an opportunity of inspecting the body of a woman thirty-five years of age, who died of apoplexy. A large tumour occupied the left side of the thyroid gland. Upon turning aside the sterno-thyroidei and omo-hyoidei muscles the gland was brought into view, and presented an immense number of varicose veins distributed over its surface; all the parts in the neighbourhood seemed vascular in the extreme. Upon opening the gland a considerable quantity of thin greenish fluid was discharged, and the small cells which contained it were distinctly perceived. The right side of the gland, together with the isthmus, was slightly enlarged; but in other respects appeared to possess its natural structure. This woman, as her husband informed me, had suffered occasionally from inordinate pulsation in the tumour, and from its pressure on the trachea, but in ge- neral experienced little inconvenience. She was a native of Holland, where the disease commenced, about the tenth year of her age, and had slowly increased. It appeared to have had no connexion with the complaint of which she died. With the history of the third subject I am unacquainted. It * Cours d'Anatomie Medicale, tome iv. p. 564. BRONCHOCELE. 75 was a girl about fourteen years old, who was much emaciated, and had laboured, apparently, for a considerable time, under constitutional disease. Both sides of the thyroid were involved; but the disease was evidently in its commencement. The ves- sels of the gland were slightly varicose, and the cellular structure of the interior contained a small quantity of transparent fluid. The larynx and trachea were unaltered, and the small openings of the first cartilaginous ring were distinctly observable. The causes of goitre are involved in much obscurity. This will account for the numerous, diversified, and contradictory speculations on the subject. By many, the disease has been attributed to the use of particular alimentary substances, espe- cially poor and unwholesome diet;—to the drinking of cold or snow water, or water strongly impregnated with limestone, or other calcareous matters; the immoderate use of spirituous and vinous liquors, debauchery, the repulsion of cutaneous diseases, and many similar explanations have likewise been resorted to; all of which are too hypothetical, and so frequently contradicted by facts, as to deserve no attention. It is certain, that goitre prevails as an endemic disease chiefly in countries where the atmosphere is loaded with moisture, in valleys enclosed by lofty mountains, and which are exposed to the direct and reflected heat of a powerful sun. In some of these valleys, the fogs are visible every morning, rise with the sun in a thick body, and seldom disappear entirely until the afternoon.* It is, however, well ascertained, that those persons who do not reside in or near the valleys where goitre prevails, but live on the sides or tops of the adjacent mountains, do not labour under the disease. Again it is a fact established beyond all doubt, that the mere removal of a goitrous person from the valley where he acquired his disease, to the top of the contiguous mountain, will diminish the size of the tumour, and in time remove it entirely. The same observa- tions, perhaps, to a limited extent, may be applied to cretinism, a disease so often concomitant, but probably independent of goitre. "All the cretins that I saw," says Dr. Reeve, "were in adjoining houses, in the little village called La Batia, situated in a narrow corner of the valley, the houses being built under ledges of the rocks, and all of them very filthy, very close, very hot and misera- ble habitations. In villages situated higher up the mountains, no * Marsden's History of Sumatra. 76 BRONCHOCELE. cretins are to be seen, and the mother of one of the children told me of her own accord, without my asking the question, that her child was quite a different being when he was up the mountain, as she called it, for a few days."* Frequent opportunities are offered in this country, of observing the effects produced on goitre, by the removal of individuals afflicted with it into districts where the disease is unknown. Numerous cures, of very large goitres, have been effected in persons, who acquired the complaint at Pittsburgh—simply by spending a few months in Philadelphia, or other distant places. These circumstances indicate, beyond doubt something peculiar in the atmosphere or in the exhalations from valleys or other places where goitre is found. That the disease, at all events, is not owing to poor living or to the drinking of snow water, is sufficiently proved by the circumstance of its not prevailing in certain countries where the inhabitants are accus- tomed to subsist on a very meagre and scanty diet. Besides,— the rich inhabitants of the Vallais and of the State of New York, are equally subject to the complaint with the poorer people. In Greenland, and Lapland, where the inhabitants use snow water almost entirely, there is no goitre, while in Sumatra, in Bambarra, and in many other warm countries, where snow is never seen, the disease is very common ,f In those parts of the State of New York, New Hampshire, and Vermont, particularly along the course of the Connecticut river, where goitre prevails, it is remarkable that the disease is most common in those places which are covered with wrood and are uncultivated; but in proportion as the country is settled and the lands cleared, the disease is found to decline, and in many places is already nearly extinct.J In 1798, bronchocele was so common at Pittsburgh, that out of 1400 inhabitants, not less than 150 had the disease.^ Since that period, the complaint has so much declined, in the same place, that it is said very few now labour under it. The change is usually attributed by the citizens of the town, to the general introduction of coal fires. All these circumstances tend to show that bronchocele is produced by a peculiar atmo- sphere, or by certain morbid exhalations from marshes or other grounds. What the peculiar nature of this exhalation is, we have * Account of Cretinism, Edinburgh Journal, vol. v. p. 33. f Vide Marsden, Park's Travels, Humboldt and Bonpland, &c. % Mease's Observations. § Barton's Memoir. BRONCHOCELE. 77 no more means of ascertaining, than we have of finding out the constituents and mode of action, of marsh miasma, or of the agents which create yellow fever, or any similar disease. The late Professor Barton imagined goitre to arise from the same causes which produced intermittent and bilious fevers.* But it has been ascertained that goitre originates in many districts where inter- mittents are unknown, and intermittents, on the other hand, are frequent where goitre has never been seen. Along the shores of the Delaware and Chesapeake bays, intermittent and bilious feveis universally prevail, and goitre is seldom found. It is possible, however, that the cause of goitre may be allied to that of intermittent, but so modified by particular circumstances, which we shall probably never be able to ascertain, as to produce very different effects. But those who are anxious for information, respecting all the supposed causes of goitre, should consult the work of Fodere, Coxe's Travels, Saussure's Voyages, Gautieri de Tyrolensiura Struma, &c. Whatever may be the remote physical causes of goitre, I am inclined to believe, that the disease arises immediately from an obstruction of the tracheo-thyroideal passages of Bordeu, of the openings communicating with the sacculus laryngeus and the thyroid gland, of which I formerly had occasion to speak, or of other passages with which we are unacquainted. I am inclined to draw this conclusion from the circumstance of a watery fluid being found to occupy naturally, the cells of the thyroid gland— from this fluid being increased in quantity in almost every goitrous tumour, and from the passages of Bordeu being much smaller in the first dissection I made of bronchocele, than they are usually met with in subjects without such disease. This is a mere con- jecture. Neither is it original—but was advanced by one of the older writers on surgery. I mention it, merely to induce those who have frequent opportunities of investigating the structure of bronchocele by dissection, to attend to the appearances of these passages, and to endeavour to discover other communications with the gland. * Vide Barton's Memoir—also, Caldwell's Medical and Physical Memoirs, p. 279. VOL. II.--F 78 BRONCHOCELE. TREATMENT OF BRONCHOCELE. The remedies proposed for the removal of this disease are countless—the strongest proof of their inefficiency. It will be sufficient to enumerate the principal—burnt sponge, mercury, pumice-stone, muriate of barytes, sulphuret of potash, egg-shells, muriate of lime, digitalis, muriate of iron, belladonna, electricity, pressure, friction, issues, setons, blisters, caustic, excision, and ligature of the thyroideal arteries. In the commencement of my practice, I employed the burnt sponge in the form of powder, mixed with honey and other materials,—the lozenges of Ring, which consist of cinnamon, gum Arabic, syrup and burnt sponge mixed—the simple decoction of the sponge, as recommended by Herrenschward of Berne, in Switzerland,—but generally with- out any decided effect.* In two instances, I succeeded in re- moving small goitres by the use of sulphate of potash, continued for several weeks in large doses. This remedy is said to have effected many cures, in the hands of Fodere and other practi- tioners. The different preparations of mercury and antimony, muriate of lime and barytes, I have tried without the slightest advantage. In one case, after the inefficacious exhibition of many of the remedies mentioned, the late Dr. Cromwell, of Maryland, effected a complete cure in a patient upwards of twenty years of age, who had laboured for some time under a goitre,—by the repeated application of blisters. Mr. Benjamin Bell says, that he arrested the progress of a very large bron- chocele by the same means. Stimulating frictions with flannels, immersed in camphorated liniments, and other applications of a similar nature, are commended by Underwood. Fodere remarks that he frequently cured small Spanish dogs of goitre by the same means, at Maurice, where these animals are very subject to the complaintf Frictions with mercurial ointment and va- rious stimulating plasters, have been likewise extolled by dif- ferent writers. Boyer has employed, for many years, cataplasms, or bags of emollient herbs, applied directly to the tumour, and worn night and day for weeks or months, and often with suc- cess. Compression has sometimes been found serviceable by * For an account of the use of these remedies, see Fodere, p. 110; Ring, in 4th, 5th, and 11th volumes of the London Medical and Physical Journal. f Fodere, p. 115. BRONCHOCELE. 79 Foder6; and the late Dr. Physick once succeeded in effecting a complete cure of the disease, in a lady of this city, by keeping up a continued but moderate pressure, by means of a bandage, for several months. Mr. Holbrook, a surgeon of Monmouth, in England, where goitre is endemic, has cured a number of pa- tients, by the use of steady pressure, after the failure of other remedies.* But I have found no general or local remedies so efficacious as the extract of cicuta. Indeed, for several years, I have de- pended chiefly upon the use of this medicine, and may declare that I have seldom had recourse to it in the early stage of bron- chocele, without some benefit. I found by experience, that from the age of ten or twelve years up to twenty, and in cases where the goitre was large and spongy to the touch, and had not existed very long, that the cicuta was almost a certain remedy; but on the other hand, when it occurred in adults beyond the age mentioned, and in old people, that although it sometimes diminished the size of the swelling, yet, in general, it was pro- ductive of no advantage. The seton, employed so frequently by the older surgeons, and recommended a few years since, by Quadri of Naples, I tried repeatedly in the case of a German boy from Lancaster, whose neck was covered with a lobulated goitre of enormous dimensions—without any other benefit than the copious discharge of a thin greenish fluid, which diminished the tumour for a time, and relieved the patient of the uneasiness occasioned by its pressure on the windpipe. Within the last twenty years a remedy for goitre has been introduced into practice, by Dr. Coindet of Geneva, which has excited, in a great degree, the attention of the profession in al- most every European country, and in America. I allude to the preparation termed iodine. The reports of Coindet in favour of this medicine were soon fully confirmed by many other conti- nental surgeons; and its reputation rose speedily to the highest pitch; strange as it may seem, however, its decline has been almost as rapid as its rise, being now considered, in the estima- tion of many practitioners, nearly inert, and by others pro- nounced a most virulent poison. But from all the statements made on the subject, we have, I think, fairly a right to infer, that it is a medicine of great power, calculated, in some cases, * London Medical Repository, vol. viii. p. 2S8. so BRONCHOCELE. to produce a very strong impression on goitrous and other tu- mours, as many well attested cases decidedly show; and that, on the other hand, it is followed occasionally by tremendous symptoms, and even death. Again, it is equally certain, that upon other patients not the slightest impression has been made by its use, either upon the tumour or upon the constitution of the individuals who have taken it, sometimes for months toge- ther and in the largest doses. My own experience in its use is verv limited, but judging from this and from the reports made to me concerning it by my colleagues in the Philadelphia Hos- pital, I should feel inclined to doubt its efficacy. Still it is pos- sible we may have been deceived, either by the bad quality of the medicine, or by other circumstances. Lastly, it may be stated, that Dr. Coindet himself, has abandoned the internal use of the remedy, and merely employs it in the form of inunc- tion, from which he states that he has derived very beneficial results. Bronchocele sometimes disappears spontaneously. Occasion- ally, the tumour is removed suddenly. Several examples of the sort are related by Alibert. In one instance, during the French revolution, a woman was seized with a fit of melancholy, and a large bronchocele, from which she had suffered exceedingly, dis- appeared with the utmost rapidity.* Bronchocele may become so large as to endanger suffocation. In this case, extirpation, an operation first recommended by Celsus, has been resorted to, and sometimes with success. But such favourable terminations are extremely rare—as many of the older, and some of the modern French and English surgeons have sufficiently proved. Palfin, in his Surgical Anatomy, relates the case of a lady of rank in Paris, who perished from hemorrhage, in consequence of the removal of a large goitrous tumour, by an adventurous surgeon, who undertook the opera- tion in spite of the remonstrances of some of the most experi- enced practitioners. The operator had scarcely left the house, before the hemorrhage broke out, with tremendous violence, and destroyed the patient in a few minutes.f Gooch mentions three cases, in which the operation was performed contrary to his advice, and that of some other surgeons. Two of the pa- tients lost their lives from hemorrhage, and the third was only * Alibert's Noveaux Elemens de Therapeutique. f Anatomie Chirurgicale, tome ii. p. 313. BRONCHOCELE. 81 saved by constant pressure, kept up day and night for the space of a week, by the fingers of several persons employed for the purpose.* Mr. John Bell mentions more than one instance, where surgeons have opened tumours arising from or connected with the thyroid gland, from which the flow of blood has been so copious, as to oblige them to abandon the operation and close the wound as speedily as possible-! Desault, upon one occasion, undertook to remove a bronchocele from the neck of a woman, but the blood issued with such rapidity, as to force him to stop and endeavour to secure the vessels by throwing a ligature around a considerable portion of the tumour which he had dis- sected up. The patient died in a very short time, in convul- sions, occasioned, it was supposed, by irritation from the liga- tures.J Another case is recorded of a patient who had a large bronchocele, which was productive of no inconvenience to him, removed by the knife, by the advice of Desault, and contrary to the opinion of Baron Percy and Louis. It was found impossi- ble to stop the blood, and the gentleman expired almost imme- diately. Many examples of a similar nature are recorded by Bonetus, Severinus, and others of the older writers. But, per- haps, the most remarkable operation of the kind to be found in the annals of Surgery, was executed a few years ago in Paris, by the celebrated Dupuytren, on a young woman who had laboured for a great length of time under an enormous bron- chocele, which interrupted respiration and deglutition to such a degree as almost to destroy her. The patient had presented herself at the Hotel Dieu, in expectation of having the tumour removed by the knife. At several consultations held on her case by the most distinguished surgeons of Paris, it was unani- mously determined, that no operation could be performed with any prospect of success. The tumour, however, still continuing to increase in size, and the entreaties of the patient for its re- moval becoming more urgent, Dupuytren, at last, consented to engage in the undertaking. By slow and cautious dissection he succeeded in detaching the left side of the tumour, without dividing any of the large arteries, veins or nerves of the neck. The thyroid arteries, in particular, which were very much en- larged, were each drawn out and tied with two ligatures before * Chirurgical Works, vol. iii. p. 158. t Principles of Surgery, vol. iii. J Dictionnaire des Sciences Medicales, tome xviii. 556. 82 BRONCHOCELE. they were cut. The right portion of the tumour was then re- moved, in a similar manner, and the whole operation completed with the loss only of a few spoonfuls of blood. But the patient suffered extremely, as the operation was necessarily protracted, and the dissection carried on among parts of the utmost deli- cacy and sensibility. She never recovered from the shock com- municated to the nervous system, and expired in thirty-five hours after the operation.* The Archives Gen. de Med. for January, 1836, contains an account by M. Rufz of a case in which Professor Roux extir- pated the thyroid gland of a young man twenty-two years of age, affected with goitre for twelve years. The tumour did not produce any serious inconvenience to the patient: neverthe- less, it was determined to extirpate it. The operation seemed to have succeeded: that is, it was not followed by any of the serious primary symptoms which accompany serious wounds: but the patient died about fifty-six hours after the operation, after a short struggle. The post-mortem examination revealed no appreciable cause of death independent of the wounds pro- duced by the operation, except lobular pneumonia of the left luno-."f In 1836, a surgeon in this city, performed a similar operation without necessity, upon a young woman, who died in a short time, from hemorrhage and irritation. It would appear, from these details, that the extirpation of even a small tumour of the thyroid gland is attended with diffi- culties which should dismay the most expert and enterprising surgeon. Cases are recorded, however, where operations of the kind have been attended with success. Fodere states that a barber relieved his wife of a very large bronchocele by exci- sion. The same author mentions two other instances within his own knowledge, where Giraudi, an adventurous surgeon of Marseilles, succeeded in curing his patient, by the same means.| Desault dissected out the right side of an enlarged thyroid gland of a female patient in the Hotel Dieu, who recovered without a bad symptom in a month after the operation.^ Two cases of successful extirpation of bronchocele are detailed by Dr. Harris, of New York. In the first case the tumour was not larger than * Dictionnaire des Sciences Medicales; also, Pelletan's Clinique Chirurgicale vol. i. p. 215. f Hay's Journal of American Medical Science, No. xxxiii. p. 515. t Traite du Goitre, &c, p. 148. § Surgical Works, vol. i., p. 257. BRONCHOCELE. 83 a pullet's egg, in the second it was of considerable size. " About three months since," says Dr. Harris, " an application was made to me by a lady from South Carolina. I think the bronchocele was full as large as any I had ever seen. The tumour had been increasing for twenty-two years. It extended from the chin, which it buoyed up, along the trachea, until it descended an inch, or perhaps more, under the breast bone, and spread la- terally a medial distance to each ear."* No hemorrhage of con- sequence followed either operation, and both patients recovered in a very short time. There is great reason, however, to be- lieve, from the histories of these cases, that the tumours neither constituted a part of the thyroid, nor were connected with it. But from all the information I have been able to collect, on the subject of the removal of this gland by the knife, I am inclined to believe that less danger would attend its excision, as respects hemorrhage, than is commonly imagined. Our knowledge of the means of arresting hemorrhage has been greatly improved within a few years; and it will be seen, that Dupuytren, by adopting a practice long ago recommended and employed with the greatest success, in this country, by Dr. Physick (the tying of large arteries before they are cut) was enabled to extirpate an enormous bronchocele, with the loss of only a small quantity of blood. But I very much question the propriety of attempt- ing the removal of the goitrous tumour, in any case, inasmuch as I conceive that hemorrhage is less to be dreaded than the in- flammation and irritation which follow the operation. Under ordinary circumstances, the tumour may attain a very large mag- nitude, without endangering the patient's life or producing much inconvenience; and if it should increase to such a degree as to render death inevitable, there is very little probability that the patient can be saved by so severe an operation as must neces- sarily be encountered. But although I would not recommend the excision of the thy- roid gland, there is another operation to which I would not hesitate to resort in case of necessity. I allude to the tying up of the great arteries in the vicinity of the tumour, from which it chiefly derives support. Mr. Thomas Blizzard, of London, was the first, I believe, to execute the operation. The thyroid arteries on each side of the neck, were included in a ligature, * New York Medical Repository, vol. xi. p. 242. 84 BRONCHOCELE. and the tumour diminished, in the course of a week, one-third in size. The patient, however, did not recover, but died from repeated secondary hemorrhage, occasioned by an attack of hos- pital gangrene. But he lived long enough to evince the pro- priety and practicability of the operation.* In 1818, a similar operation was performed by Professor Walter, of the University of Landshut, on a man twenty-four years of age, who had an enormous bronchocele, from which he suffered extremely. The inferior thyroideal artery of the left side was taken up, and at the end of a fortnight the left portion of the tumour had di- minished so much in bulk as to induce the operator to include the superior thyroid of the right side in a ligature. No incon- venience followed either operation, and the bronchocele, in a short time, almost disappeared, leaving behind only the elon- gated skin which hung from the neck in the form of an empty sack.f On Bronchocele, consult A Memoir concerning the Disease of Goitre, &c, by Benjamin Smith Barton; Reeve on Cretinism, in Edinburgh Medical and Surgical Journal, vol. v.; Fodere, Traite du Goitre et du Cretinisme; Diction- naire des Sciences Medicales, vol. iii.; Gooch's Chirurgical Works, vol. ii.; Baillie's Series of Engravings to illustrate Morbid Anatomy; Alibert's Noso- logic Naturelle; Gibson on Bronchocele, in vol. i. of the Philadelphia Journal of the Medical and Physical Sciences; An Essay on the Effects of Iodine on the Human Constitution, with Practical Observations on its Use in the Cure of Bronchocele, Scrofula, and the Tuberculous Diseases of the Chest and Ab- domen, by W. Gairdner, M. D., 8vo., London 1824; Medical Researches on the Effects of Iodine, in Bronchocele, Paralysis, Chorea, Scrofula, Fistula La~ crymalis, Deafness, Dysphagia, White Swelling, and Distortions of the Spine, by Alexander Manson, M. D. * Burns' Surgical Anatomy, p. 202, t Bulletin de la Societe Medicale d'Emulation, 1818, TORTICOLLIS OR WRY NECK. 85 SECTION VI. TORTICOLLIS, OR WRY NECK. From exposure to cold, from rheumatism, twists of the neck, or strains of the platysma-myoides, and sterno-mastoid muscles, from the cicatrices of burns, &c, the head is sometimes drawn to one side, or towards the shoulder or sternum, in such a way as to produce great deformity. Occasionally the disease arises from paralysis; in other instances, it proceeds from some defect or malformation of the vertebrae of the neck. The clavicular is oftener affected than the sternal portion of the sterno-mastoid muscle; each, however, is liable to be converted into a substance resembling gristle. The whole of the muscle also is shortened, has an indurated, stringy feel, and is painful to the touch. Great pain is frequently experienced upon attempting forcibly to restore the head to its natural position. TREATMENT OF WRY NECK. When the disease depends upon paralysis of the muscles, or upon malformation of the vertebrae, it may be looked upon, generally, as incurable; but when it arises from morbid con- traction of the fibres of the platysma-myoides, or sterno-mastoid muscles, an operation will, in many instances, effect a cure. It should be done in the following manner. The patient is seated on a chair, and his head supported by an assistant standing behind him. An incision is then made two or three inches long, in the course of the muscular fibres, through the integuments; and the contracted portion having been fairly exposed, the handle of a knife,—or a small curved spatula,—is carried behind it, in order to protect the vessels beneath. By one or more cuts of a bistoury, the muscle is next separated, and when this is effectually done, the head may be restored immediately, in most cases, to its natural situation.* Very frequently it happens, * I performed an operation, several years ago, upon a girl sixteen years of age, whose head had been drawn for several months towards the right shoul- 86 TORTICOLLIS OR WRY NECK. that several strings of muscular fibres, in different places, require to be cut across. In such cases the surgeon must persevere until he has loosened the whole. After the operation, the head should be supported in its proper place by bandages, or a stock of leather, and the edges of the wound, for some time, kept sepa- rated by lint. Sometimes, especially in females, it may be deemed expedient, in order to obviate deformity arising from the cicatrix, to pinch up the contracted portion of the muscle, along with the skin covering it, and divide it with a narrow and sharp-pointed bistoury. Dupuytren has related a case in which he succeeded perfectly by adopting this plan. A method somewhat similar has been resorted to, repeatedly, since subcutaneous incisions have become fashionable, and may answer very well in the hands of a good anatomist and prudent surgeon; but it is evident that serious consequences may follow the attempts in this way, of careless operators. Professor Jorg, of Leipsic, has attempted the cure of wry neck by machinery, and, in several instances, it is said, with success. On Wry Neck, consult C. Bell's Operative Surgery, vol. i.; Gooch's Chirur- gical Works, vol. ii.; Sharp's Treatise on the Operations of Surgery; B. Bell's System of Surgery, vol. v.; Boyer's Traite des Maladies Chirurgicales, torn. vii.; Kirby's Cases, with Observations on Wry Neck, &c; Cooper's First Lines of the Practice of Surgery, vol. i. p. 558, in which will be found an En- graving and Description of Jorg's Apparatus. der, from a contraction of the clavicular portion of the sterno-mastoid muscle. As soon as the muscle was cut across, the head was instantly restored to its natural position, and has remained so ever since. HYDROTHORAX. 87 CHAPTER IV. DISEASES OF THE THORAX. Gtjn-shot and other wounds of the chest, emphysema, col- lections of purulent matter, and of blood, mammary abscess, carcinoma of the breast, fractures of the ribs and sternum, aneurism of the aorta, caries of the spine, having been treated of in other places, it only remains to notice hydro-thorax, and to describe the operation necessary for its removal,— after the physician has exhausted his skill in the trial of medi- cines. SECTION I. HYDROTHORAX, OR DROPSY OF THE CHEST. This disease is either idiopathic or symptomatic. The for- mer is very rare, the latter frequent. Idiopathic hydrothorax generally occupies one side of the chest only, and is frequently unaccompanied by dropsy in other parts of the body. The pleura itself is seldom much diseased, and merely contains a se- rous fluid. The lung of the affected side is collapsed, and the patient complains of great difficulty of breathing. Symptomatic hydrothorax is exceedingly common, and is characterized by the following symptoms. The patient finds it difficult, if not impossible, to lie in the horizontal position, or on the unaffected side. His respiration is hurried and laborious, pulse irregular, thirst incessant, urine diminished and high- 88 hydrothorax. coloured. In addition to these symptoms, a troublesome cough and palpitation of the heart usually attend the disease. One of the most certain symptoms, however, is a sensation resem- bling the movement of water within the chest. This particular sensation may often be discovered by the surgeon himself, while the patient is in the erect position, by forcibly striking the chest, and still better by the use of the stethoscope. A col- lection of water in the pericardium may give rise to all the symptoms of common hydrothorax. Sometimes both sacs of the pleura are filled with fluid. In other instances, the cavities are occupied by hydatids. The most common causes of symp- tomatic hydrothorax, are intemperance, gout, asthma, anasarca, paracentesis thoracis. This operation is seldom resorted to until the case is hope- less—a sufficient explanation of the unfavourable termination that generally awaits it. When performed early, however, and under favourable circumstances, it is calculated to afford great relief, even if it should fail to remove the disease. The situa- tion most favourable for the evacuation of the fluid, is between the sixth and seventh ribs, counting from above downwards. Having placed the patient nearly in an upright position, with his back supported by pillows or by an assistant, and the head and shoulders directed backwards, the surgeon makes an in- cision three inches long, with a small scalpel or bistoury, through the integuments, cautiously penetrates the layers of the inter- costal muscles, (keeping close to the upper edge of the seventh rib to avoid the intercostal artery,) and makes an opening through the pleura, large enough to admit a full-sized cannula or gum elastic catheter, which should be introduced as soon as the wa- ter begins to flow. Care must be taken, however, not to push the cannula too far, lest its extremity irritate the lungs, and ex- cite coughing. This happened to me during the winter of 1824, in the Philadelphia Hospital, in a case of hydrothorax under care of Dr. Jackson, and brought on immediately a most severe cough, that distressed the patient exceedingly. If a very large quantity of fluid has collected, it will be improper to remove the whole of it at a single operation—lest the patient suddenly HYDROTHORAX. 89 die from the pressure being taken off from the heart and lungs. When both sides of the chest are occupied by the fluid, an ope- ration will be required on each side; but they should never be performed simultaneously, inasmuch as the lungs generally col- lapse as soon as the chest is opened, in which case the patient must necessarily die. After the fluid has been evacuated, the lips of the wound should be closed by sticking plaster and made to unite as soon as possible, to prevent the introduction of air, and the formation of matter. Should the water accumulate again, as it often does, the operation may be repeated. " The operation for empyema, or paracentesis, is seldom resorted to in this country, or England," says Dr. Jackson, "for the relief of morbid effusions into the chest. Though of greater frequency on the continent of Europe, yet in comparison with the practice of former periods, it appears to be falling into disuse. The nature of these effu- sions, and their causes are widely different. The operation is not calculated to afford equal benefit in all cases in which they exist, while, in many, it is wholly useless. From a recurrence to it without discrimination, it has, no doubt, often proved of no service, and may have been sometimes of disadvantage; and, in consequence, the benefits that may be obtained from the apposite performance of this operation, have been too much underrated. Many striking instances of unequivocal relief, and some complete cures in desperate cases, are on record, as having been obtained by these means; nor can it be questioned, that, employed with judgment, it will seldom fail to afford relief from distressing symptoms, will often protract life, and, sometimes, prove auxiliary to the completion of a perfect cure. The ope- ration itself is simple, unattended with much hazard, being but little more formidable than the opening of a large abscess, and, when an effusion into the chest is clearly indicated, may with perfect propriety, be performed, merely with a view to alle- viate the distress and suffering of the patient, even when it holds out no expectation of an ultimate recovery." See B. Bell's System of Surgery, vol. v. p. 188; Laennec on the Diseases of the Chest; S. Cooper's First Lines of the Practice of Surgery, vol. i. p. 584; Archer's Case of Paracentesis, in vol. i. of Transactions of the King's and Queen's College of Physicians in Ireland; Jackson's Case of Effusion into the Chest, in which Paracentesis was performed, in the Philadelphia Journal of the Medical and Physical Sciences, vol. x. p. 19. 90 DISEASES OF THE ABDOMEN. CHAPTER V. DISEASES OF THE ABDOMEN. With few exceptions, the surgical diseases of the abdomen are as numerous, diversified and important, as those of any other part of the body. Many of them, too, are extremely intricate, and will require all the student's industry and skill to unravel them. This is strikingly the case with hernia, which, from the complicated anatomical relations of that disease, its extraordi- nary frequency, the numerous varieties of the complaint, the distinct modes of treating each recommended by some surgeons and condemned by others equally eminent, the necessity, upon many occasions, for delicate operations, called for often, upon the spur of the occasion, and without a moment's warning, should'be sufficient, as a distinguished writer has remarked, "to infuse fear into the heart, and agitation into the conscience of all who presume to call themselves qualified surgeons, without having first duly considered every thing relating to so important a branch of their profession." In the ensuing sections, I propose to consider dropsy of the belly, poisons in the stomach, and the principal varieties of her- nia. Abscess of the liver, lumbar abscess, and wounds of the abdomen, have been already treated of in their proper places. ASCITES. 91 SECTION I. ASCITES, OR DROPSY OF THE ABDOMEN. In the commencement, this disease is marked by difficulty of breathing, cough, dryness of the skin, constipation of the bowels, diminished secretion of urine, loss of appetite, prostration of strength. These symptoms are soon succeeded by general ful- ness of the abdomen, and by a sense of fluctuation easily per- ceived by laying one hand on the belly, and striking it with the other. Ascites, for the most part, is the consequence of organic dis- ease of the viscera of the abdomen, particularly scirrhus of the liver, pancreas, or spleen. Sometimes it arises from an accu- mulation of water in the cavities of the pleura or pericardium, at other times it follows an enlargement of the mesenteric glands. In general, the fluid is contained in the sac of the peritoneum, and sometimes accumulates in prodigious quantity. PARACENTESIS ABDOMINIS. By the internal use of volatile tincture of guaiacum, squill, gamboge, calomel, digitalis, elaterium, and other similar medi- cines, I have frequently succeeded in removing entirely, dropsy of the belly. The disease, however, often terminates fatally for want of timely operation. There are two situations in which this may be performed—midway between the spine of the ilium and umbilicus, or in the linea alba. The former has of late years been mostly abandoned, owing to the thickness of the mus- cular parietes, and to the epigastric artery, from irregular dis- tribution, having sometimes been wounded. A trocar, either rounded or flat, is the instrument commonly used in this opera- tion ; or a common lancet may be employed, as advised by Dr. Physick. Preparatory to the operation, the abdomen should be surrounded by a piece of flannel, broad enough to cover its whole surface, and sufficiently long to go twice round, the ends of which are split in three or four places. The middle of the bandage is placed over the front of the abdomen, and the ends are crossed upon each other, and left hanging on each side. 92 ASCITES. Having marked the spot in the linea alba best adapted to the operation—about two or three inches below the umbilicus—the surgeon makes a slit in the flannel, corresponding to the part, and through this penetrates with the trocar or lancet, the integu- ments, tendons, and peritoneum. The instrument being with- drawn, the water instantaneously follows the puncture, and, in proportion as it flowTs, assistants, placed on each side of the pa- tient, tighten the flannel by pulling at its ends. This serves the purpose of keeping up the general support of the abdomen and prevents the patient from fainting. If a very large quantity of fluid has accumulated, it may, perhaps, be imprudent to draw it all off at once, lest the patient be too much exhausted. On the contrary, the better plan will be to close the orifice from time to time, until the whole is evacuated; after which, the opening may be permitted to heal. Should the surgeon prefer a com- mon lancet for the operation, he must be prepared with a flat cannula, corresponding to the size of the instrument, and intro- duce it into the opening immediately after the lancet is with- drawn. Sometimes the flow of water is suddenly interrupted by the intrusion of a particle of fat within the cannula. When this happens, the obstacle should be removed by a probe. The operation of paracentesis abdominis, is one which in general requires frequent repetition. Incredible quantities of fluid have been drawn from some patients at once, or at separate opera- tions. Many patients sink under the disease in a few weeks or months; others live for as many years, and experience temporary relief from operations. A few recover perfectly. It sometimes happens that pregnancy so closely resembles abdominal dropsy as to be mistaken for it, and cases are related in which the uterus has actually been tapped. The following remarks on this subject by Sir Astley Cooper are well calculated to put the young surgeon on his guard. Speaking of encysted dropsy, he says, "I will here mention two circumstances, in one of which my character was exposed to considerable risk; of the other I was informed by a medical man who was invited to witness the operation. In the first case I was desired to see a lady who I was told laboured under dropsy. When I entered the room I saw a thin delicate female, with an immense abdomi- nal swelling, giving a distinct sense of fluctuation. I requested the physician accoucheur, whom I met, to examine if the lady was not with child; he said he thought it was unnecessary, ASCITES. 93 as the fluctuation was very distinct, but that he would do so and let me know the result in a few days. I heard no more of her for a week, and then I learned that she had been put to bed on the morning following my visit. I would not have performed the operation of paracentesis for the universe. The circumstances which were told me of the other cases were as follows: a sur- geon in a country town called upon another surgeon, and said, 'I am going to tap a woman to-morrow; perhaps your young gentlemen would like to be present.' As it was an operation they had never witnessed, they most readily accepted the invi- tation: they were shown into a room in which the patient was already prepared to undergo the operation; she was sitting at one end with her abdomen bare. The surgeon then taking his trocar and cannula, went to some distance, and walking up to the patient with the trocar presented, he charged, as it were with a bayonet, and plunged it into the abdomen; then with- drawing the trocar with an air of triumph, it was with no small chagrin he found not a drop of water escape; but, however, still undismayed, he withdrew the cannula, and again renewing his attack, he a second time introduced the trocar into the ab- domen, but was equally as unfortunate as before, in finding that no water followed. Waiting a few moments, he withdrew the cannula, and turning round to the gentlemen, he said, 'You may do her up;' by which he meant they might apply the ban- dages; and he added, 'This, gentlemen, is an operation which you probably never saw before, and which most likely you may never see again. This is wrhat we call the operation of dry- tapping!' "* The encysted, or ovarian dropsy, differs essentially in cha- racter and situation from common ascites. The latter is con- tained in the bag of the peritoneum, in the greater number of instances, in contact with the intestines; the former is confined to the ovarium, and originally contained in separate cells, the partitions of which are afterwards broken down or absorbed. A few of these cells, however, generally remain. The fluid of ovarium dropsy, also, is not commonly so thin and transparent as that of ascites. It is generally thick, tenacious and turbid, of a brown or yellow colour, and often resembles sero-purulent mat- ter. From an enormous tumour of this description, which I * Sir A. Cooper's Lectures on Surgery, by Tyrrel, vol. ii. p. 378. VOL. II.--G 94 POISONS IN THE STOMACH. opened some years ago, were discharged several gallons of fluid, of the consistence and colour of honey. But, in other cases, I have drawn off large quantities of perfectly transparent serum. When the ovarian dropsy becomes so extensive as to occupy the abdomen, it is very difficult to distinguish it from ascites; but after an operation the walls of the ovarium can be distinctly felt, in shape of a tumour large as a child's head, on one side of the abdomen. See C. Bell's Operative Surgery, vol. i. p. 318; Dorsey's Surgery, vol. ii. p. 364: Sabatier, Medecine Operatoire; Boyer's Surgery ; Larrey's Memoirs; Barlow, in Provincial Medical and Surgical Transactions, vol. iv.; Seymour's Illustrations of Diseases of the Ovary; Buchanan, in Glasgow Med. Journ., vol. i.; Darwall, in Cycloped. of Pract. Med. SECTION II. POISONS IN THE STOMACH. Accidentally, or by design, poisons are often taken into the stomach, and, according to their particular quality and quantity, produce in greater or less time, violent symptoms or death. Poisons from the mineral, vegetable, and animal kingdoms, are all capable of these effects. With few exceptions, however, mineral poisons are more active and deleterious than either ve- getable or animal. The principal mineral poisons are arsenic, corrosive sublimate and some other preparations of mercury, acids and alkalies, lead, tartrite of antimony, and lunar caustic. These, when taken into the stomach, operate by exciting violent inflammation, or by producing excessive vomiting, palsy, or convulsions. Arsenic and corrosive sublimate give rise nearly to the same symptoms; these are swelling of the tongue, extreme thirst, a burning sensation throughout the gullet, violent spas- modic pain in the stomach and intestines, incessant vomiting and purging, and the evacuation of viscid mucus mixed with blood. If relief be not speedily afforded, cold sweats, faintings, poisons in the stomach. 95 and twitchings of the limbs succeed and destroy the patient in a few hours. When examined after death, the stomach and oeso- phagus exhibit marks of violent inflammation, and are sometimes perforated with numerous holes. Among the vegetable poisons most deleterious, may be enume- rated opium, cicuta, aconitum, hyosciamus, digitalis, belladonna, hellebore, savin, laurus cerasus, and many varieties of fungus or mushroom. These, when introduced into the stomach in large quantity, occasion palpitation of the heart, stertorous breathing, vertigo, dimness of sight, torpor, distention of the stomach, convulsions and death. In addition to these symptoms, opium and laudanum, in large doses, have the peculiar power of inducing profound sleep, which generally terminates in apoplexy, paralysis, or death. The animal poisons capable of producing violent symptoms, or fatal consequences, by being taken into the stomach, are com- paratively few in number. The principal are cantharides, and certain varieties of fish. Prussic acid, which belongs both to the animal and vegetable kingdoms, is a most subtle poison, and, sometimes, even in very small quantity, produces instantaneous death. Cantharides is more protracted in its operation, but is capable of producing tremendous symptoms, and not unfre- quently proves fatal. Some poisonous fish, when eaten, destroy life in a few hours. Such fish are by no means uncommon in some parts of the West Indies. Those reputed the most dele- terious are the yellow-billed sprat, dolphin, the rock fish, barra- cuda, smooth bottle fish, the king fish, gray snapper, the white land crab, and conger eel. TREATMENT OF POISONS IN THE STOMACH. When the nature of the poison taken into the stomach can be ascertained, it may be possible sometimes, by antidotes, to ob- viate its deleterious effects. A large quantity of albumen, or white of eggs, for example," is looked upon as the proper cor- rective for corrosive sublimate; lime water, charcoal, or carbo- nate of magnesia, for arsenic; muriate of soda for lunar caustic; calcined magnesia for the mineral acids; acetic acid for the alkalies. It must be understood, however, that in general neither 96 POISONS IN THE STOMACH. these nor any other articles* of similar description are calculated to produce very beneficial effects, and that our reliance must be placed, mainly, upon speedy and copious vomiting, and upon the removal of the poison by means of the gum elastic tube and syringe. The last is a remedy of modern origin, and one of immense importance. By whom the idea was first suggested, is not positively knowTn. Renault, however, in his work on poisons,f expressly recommends an apparatus (somewhat similar to the one nowr in use) for removing arsenic from the stomach. Dr. Monro, afterwards, in his thesis,! gave drawings of instru- ments for the removal of laudanum from the stomach, and at the same time published a case in which the experiment had been tried—though without success. " Quo laudani effectus lenoires essent ei in ventriculum, instrumento in tab. XIV. depicto, per magnam aqua? tepidae quantitatem injeci, faucibus simulper ori- speculum diductus."§ It remained, however, there is reason to believe, for Dr. Physick to prove the utility of the invention; for until the successful issue of the experiment performed by him in 1812, on a child three months old, poisoned by laudanum,|| little importance was attached by the profession either to Renault's or Monro's proposal. Since that period every apothecary's boy in Philadelphia has become fully acquainted with the operation, which, perhaps, has been performed hundreds of times, with the most favourable result. Strange as it may appear, European, or at least British surgeons, are just becoming acquainted with the practicability of the operation; for we find from the statements of a Mr. Read, and from remarks in the periodical work called the "Lancet," that the proposal has been considered by Sir Astley Cooper, Messrs. Scott, Jukes, and other surgeons, as perfectly novel, and this so late as the year 1822! ! When called to a patient suffering from poison, whether cor- rosive sublimate, arsenic, or any other article of the kind, the surgeon should resort immediately to a powerful emetic, and, if this does not answer, to the gum elastic tube, (an instrument about two feet in length, and three-eighths of an inch in diameter,) * From experiments recently made on the human subject, and other animals, there is great reason to hope, that the hydrated oxide of iron, will be found a perfect antidote to arsenic, f Experiences sur les contre Poisons de 1'Arsenic, 8vo. % De Dysphagia, p. 95, Edin. 1797. § De Dysphagia, p. 95. I! See Eclectic Repertory, vol. iii. p. HI. POISONS IN THE STOMACH. 97 and by means of a common pewter syringe applied to its upper extremity, inject into the stomach a quantity of tepid water. The water mixed with the contents of the stomach, should be immediately afterwards withdrawn, and a fresh supply thrown in, and by this alternate injection and evacuation, the stomach may in a little time be thoroughly scoured out, the poison re- moved and the patient recovered—provided there has not been too great delay. The common syringe and tube I prefer to the more complicated and expensive instruments of Jukes and Read —after repeated comparative trials with each. Of late years, however, several instruments for pumping out the stomach have been invented, less complicated and more effectual than the ones just referred to. In particular, a syringe invented by Dr. C. Matthews,* of this city, is worthy of the praise which has been bestowed upon it. English surgeons, especially, I presume, must have been pleased with it; for soon after an account had been published of it in the London periodicals, Mr. Weiss, a celebrated cutler, manufactured one upon the same principle exactly, but without reference to the source from which he, pro- bably, derived it. Mr. Weiss's pump has since been introduced into general practice, and is, certainly, a very beautiful, simple and useful instrument. Consult Monro's Morbid Anatomy of the Human Gullet, Stomach, and In- testines, p. 79; Thomas' Modern Practice of Physic, 7th edit. p. 311; Diction- naire des Sciences Medicates, torn, xliii. p. 525; Orfila on Poisons; Chisholm on the Poisons of Fish, in vol. iv. of the Edinburgh Medical and Surgical Journal, p. 393; Brodie's Observations on the Action of Poisons on the Animal System, in Transactions of the Royal Society of London, 1812; Bostock's Ex- periments, showing that a Mineral Poison may produce sudden and violent Death, and yet be incapable of Detection in the Contents of the Stomach, in Edinburgh Medical and Surgical Journal, vol. v. p. 14; Account of a New Mode of extracting Poisonous Substances from the Stomach, by P. S. Physick, in the Eclectic Repertory, vol. iii. p. Ill and 381; Read's Appeal to the Me- dical Profession, on the Utility of the Improved Patent Syringe, &c; Lancet, vol. i. No. viii. * See American Medical Recorder for 1826. 98 HERNIA. SECTION III. HERNIA. A protrusion of any of the abdominal viscera, covered by the peritoneum, through natural or preternatural apertures in the tendinous or muscular parietes, may be denominated hernia. The term has been extended, though improperly, to several other diseases bearing no analogy to the one under present con- sideration. Hernia is a veryr common disease; so much so, that one-eighth of mankind, it has been imagined, is troubled with it—a propor- tion, however, immensely overrated. Certain general appella- tions, expressive of the particular condition or contents of a hernial tumour, are employed by most modern surgeons—redu- cible, irreducible, and strangulated hernia, enterocele, epiplocele, and entero-epiplocele. By reducible hernia is understood a tu- mour easily replaced by pressure, or by laying the patient in the horizontal position, but descending again as soon as the pres- sure is discontinued, or the upright posture resumed. The term irreducible hernia implies permanent protrusion from adhesion between the sac and its contents, or from extraordinary bulk. Strangulated hernia is that state of the disease in which the parts are confined by stricture, and are liable to mortify, unless the stricture be speedily removed. When the protrusion consists of intestine alone, the disease is denominated enterocele; when it contains omentum merely, it is called epiplocele; and if intes- tine and omentum together, entero-epiplocele. Herniae are, also, designated according to the situation they happen to occupy. Thus, we have bubonocele or inguinal hernia, oscheocele or scro- tal hernia, merocele or crural or femoral hernia, exomphalos or umbilical hernia, congenital hernia, ventral hernia, ventro-ingui- nal hernia, and several other varieties of comparatively rare oc- currence. Every hernia is furnished with a peritoneal investment, or sac; this is pushed before the protruded viscera, and passes through a natural or preternatural opening, to the margins of which it speedily forms an intimate adhesion. That portion of the sac communicating directly with the abdomen is called HERNIA. 99 its mouth; its lower extremity, or that most remote from the in- ternal surface of the belly, its fundus, and the part immediately surrounded by the aperture in the tendinous parietes, its neck. The sac, although originally thin as the rest of the peritoneum, soon acquires an increased thickness, and in hernia of long standing, is sometimes greatly condensed. On the other hand, it is frequently found attenuated to an extreme degree, or en- tirely wanting—as the result of absorption. That it is sus- ceptible of extreme extension, is proved by those enormous her- nial tumours, so common in very warm climates, and sometimes met with in this country. The causes of hernia are very numerous, and are either ex- citing or predisposing. Severe exercise on foot, or on horse- back, lifting heavy weights, playing on wind instruments, vomit- ing, costiveness, stricture of the urethra, the hooping-cough, crying, parturition, tight clothes, jumping, often produce the complaint either immediately or remotely. Among the predis- posing causes of the disease, hereditary conformation and pre- ternatural laxity of the abdominal apertures, may be considered the most common. Reducible hernia is distinguished from other varieties of the disease by the following symptoms. The tumour, as already mentioned, descends in the erect, and retires within the abdomen during the recumbent position, or when pressure is made upon it. If the sac should contain intestine, a peculiar rumbling or gurgling noise will be perceived both by the patient and sur- geon, at the moment the gut slips into the abdomen. The tu- mour will also be tense and elastic to the feel. Omentum, on the contrary, communicates to the finger a doughy sensation, and is with greater difficulty restored to the abdomen. Besides these indications a reducible hernia may be distinguished from other diseases by the circumstance of its being larger after a meal than when the stomach and intestines are empty, and by an impulse being communicated from the tumour to the sur- geon's finger when the patient is directed to cough. If suffered to increase, the reducible hernia may in time become enormously- large, and the patient will not only experience great disorder of the digestive organs, but his life will be endangered by strangu- lation of the gut. Irreducible hernia may arise from three different causes— from adhesion between the sac and its contents—from the for- 100 HERNIA. mation of membranous bands across the sac—and from an ex- traordinary enlargement of the omentum, or great increase in volume of the intestines. The last two causes are more com- mon than the first. Effusion of lymph upon the inner surface of the sac, and upon the outer surface of its contents, gives rise to the bands that intersect the intestine and omentum, and fasten them at different points to each other. When the omentum has resided for a long time in a hernial sac, it is apt to become en- larged and indurated, and in this state cannot pass through the neck of the sac and be restored to the abdomen. Sometimes a mass of hardened omentum serves as a truss, and prevents the descent of the intestines. Slow inflammation, from neglect, from blows upon the tumour, and other injuries, is the most fre- quent cause of hernia being changed from the reducible to the irreducible state. The symptoms of strangulated or incarcerated hernia, are, in most instances, so strongly marked, as to admit of no decep- tion ; yet it happens, now and then, that the disease is confounded with ileus and other intestinal affections. If, from irregularities of diet, especially the free use of flatulent vegetables, violent corporeal exertions, injuries, the accumulation of worms in the intestines,* or other causes, the contents of a reducible or irreducible hernia should become constricted, the fsecal evacu- ations will be suppressed, the patient will complain of general soreness of the abdomen, of pain around the navel, resembling * A remarkable instance of this kind occurred several years ago in South- wark. A woman between seventy and eighty had been subject from infancy to worms, which were so numerous as to be discharged per anum, and thrown up from the stomach upon many occasions. She had laboured, also, for many years, under irreducible femoral hernia, and at last was seized with symptoms of strangulation. Drs. Anderson and Wallace being called to her assistance, tried in vain to effect reduction by taxis, and requested me to see her. There being no other alternative, I performed the operation, and upon opening the sac discovered the intestine to be filled with a solid substance, which, upon being pressed and handled, was found to consist evidently of worms; for as soon as the stricture was divided, vermicular motion was perceptible and in a little while the animals being relieved from their imprisonment, returned to the abdomen, and the gut being left flaccid, was easily reduced. The ope- ration, however, had been delayed too long; mortification took place, and through openings in the sphacelated bowels numerous worms the next day escaped by the external wound. Upon post-mortem examination hundreds of these animals were found in the intestines. My friend Dr. Isaac Thomas, of West Chester, a most intelligent and experienced physician, has detailed in the American Medical Recorder a similar example of ileus produced by the same cause, and which also terminated fatally. HERNIA. 101 the sensation produced by a tight cord, of sickness at the stomach, and of severe pain in the tumour itself. To these symptoms are speedily added, vomiting of bilious, or sterco- raceous matter, hiccup, a quick, hard pulse, an increase of tension in the abdomen, cold sweats, and great anxiety of countenance. If by this time the patient does not experience relief, a remarkable change in the symptoms will soon take place. The pulse becomes small and thready, the patient feels suddenly easy, the tumour when pressed upon crackles beneath the fingers, and assumes a leaden colour. To these succeed enormous distention of the abdomen, a fluttering, intermittent pulse, and death. When examined by dissection, the intestine will be found of a dark brown or chocolate colour, interspersed with black or mortified spots, and coated in particular places with a brownish or bloody lymph. The omentum is seldom altered in appearance. The sac contains, in proportion to its size, and the duration of the strangulation, more or less of a bloody fluid. At the strictured part, the intestine is generally ulcerated or detached. Throughout, the peritoneum exhibits marks of high inflammation, and in numerous places the intes- tines are glued together, and their surface streaked with red vessels. It might, perhaps, be supposed that a stricture upon the omentum merely, would not give rise to constipation and the other symptoms of strangulation above enumerated. Expe- rience, however, proves the contrary. With regard to the length of time strangulation may continue, much will depend upon the duration and size of the tumour, and upon its contents. Recent and small hernia?, generally speaking, are more dange- rous, and terminate sooner, when strangulated, than the old and large. An intestinal hernia, also, runs its course quicker, and is more violent in its symptoms than an omental hernia. Some strangulated hernise prove fatal in six or eight hours; others con- tinue for as many days. The disease, when left to itself, is not invariably mortal. On the contrary, the parts exterior to the stricture, in some instances, mortify, and are thrown off in the form of slough, an artificial anus is established, and the pa- tient recovers. The seat of the stricture in strangulated hernia must depend upon the particular situation the hernia happens to occupy. 102 HERNIA. GENERAL TREATMENT OF HERNIA. Reducible, irreducible, and strangulated hernia? all require distinct and particular modes of treatment. For reducible hernia, an appropriate truss is the only remedy, and the sooner this is applied the better. Formerly an opinion prevailed that such instruments were not adapted to infants; the error has been amply rectified by modern experience, and much mischief thereby prevented. Trusses are either elastic or non- elastic: the latter are now seldom employed, and never can be to advantage. A well constructed steel truss often effects a perfect cure, especially in children and young subjects, by ex- citing a degree of inflammation sufficient to agglutinate the sides of the sac, or the edges of the opening through which the hernia has passed. To accomplish this purpose, great atten- tion must be paid by the surgeon in adapting the instrument to the parts, and by the patient in wearing it without intermission. The best mode of fitting a patient with a truss, is to try a num- ber of instruments, and select the one that adapts itself best to the hollows and projections about the abdomen and pelvis, and can be worn with the least inconvenience. When no oppor- tunity of selection offers, a measure may be taken by means of an annealed wire, doubled and passed around the body, taking care to leave the wire an inch or two longer than the size of the patient—to allow for the stuffing of the instrument. A well contrived truss will fit accurately in every part, and sit closely to the body, neither bulging in particular places, nor binding too closely. Every patient should be provided with a spare truss—in case of accident. To prevent the pad of the truss from imbibing perspiration and becoming hard, a bit of calico, muslin, or rabbit skin should be placed between it and the tu- mour. With a view, also, of obviating rust, to which the spring is very liable, the instrument may be thickly covered with durable leather, or some similar material, and with oil- cloth, or gum elastic, when the patient has occasion to bathe. A truss, to derive full benefit from it, must be worn night and day, and for months and years together. Particular varieties of truss will be noticed when the different species of hernia are described. I may mention here, however, that my friend Dr. Chase, a young and enterprising surgeon, who has paid particular HERNIA. 103 attention to the construction of trusses, and has, in fact, for the last four or five years, devoted himself almost exclusively, to the radical cure of hernia, and to the treatment of deformities, has made great improvement in such instruments; and, indeed, has already brought them to a degree of perfection that could not have been anticipated a few years back. . Irreducible hernia, particularly that variety of it dependent upon adhesion between the sac and its contents, very seldom admits of relief. Cases are recorded, however, by Arnaud, Ledran, and Hey, of the diminution and final restoration to the abdomen, of immense hernial tumours, by low* diet, blood-letting, purging, and confinement, for many months together, to the horizontal position. In most cases, a suspension of the tumour by a bag truss, and strict attention to diet, are all that can be done. For strangulated hernia, various remedies have been em- ployed—such as blood-letting, purging, the cold and warm baths, opium, fomentations, and poultices, the application of cold, the taxis, tobacco injections, and an operation. The last three only are to be relied upon. By taxis is understood an effort to re- store the protruded intestine or omentum, by manual pressure, to the cavity of the abdomen. This should be attempted always before any other plan, and is frequently successful. To increase the chance of success, the surgeon must endeavour to relax the abdominal muscles as much as possible—by elevating the shoul- ders and pelvis with pillows, bending the patient's legs on his thighs, and his thighs on the pelvis, and at the same time draw- ing them towards each other. Upon the tumour, steady, but not violent pressure should then be exerted and kept up unremittingly with the fingers or hands for half an hour. If this fail, the taxis must be discontinued, lest it increase the inflammation in the pro- truded parts. That this operation of taxis often hurries on the mortification, or bursts the intestines, there can be no doubt, especially when the patient happens to fall, as in hospitals, into the hands of young and inexperienced house pupils, who think it right to make strenuous exertions in this way, before they send for the attending surgeon. Dr. Sewall, of Washington, in several cases of strangulated hernia, reported in the fourth volume of the American Journal of the Medical Sciences, has extolled the use of spirits of tur- pentine; and Dr. Obrien, of Dublin, has lately called the atten- tion of the profession to the mechanical use of gum elastic tubes, 104 INGUINAL HERNIA. introduced into the rectum and carried as high as possible; but this practice, which I myself have employed for the last ten years with considerable benefit in numerous cases of ileus and strangulated hernia, originated, there is reason to believe, with Dr. Chapman, who, more than thirty years ago, in consultation with the late Dr. Bensell, of Germantown, succeeded in saving a patient by the introduction of a long and large wax candle that happened to lie on the mantel-piece. The surgeon, having failed in all these expedients, may next have recourse to the tobacco enema, which, (as it is a very powerful and dangerous medicine, if incautiously administered,) should be carefully prepared by infusing a drachm of tobacco in a pint of boiling water for a quarter of an hour. When cool, the liquor may be strained, and one-half of it thrown up the rectum by a syringe, and the remainder half an hour afterwards, should the first prove insufficient. The effect of tobacco, thus administered, is to prostrate the system, excite the action of the intestines, and relax the abdominal muscles. As soon as these ends are accomplished, a slight effort, in the way of taxis, will often succeed in overcoming the stricture, and in restoring the parts to the abdomen. If the tobacco fail, the knife is our only resource; but in the use of this, the surgeon must be governed by the particular seat of the hernia—as will be explained in the ensuing sections. SECTION IV. INGUINAL HERNIA. After the general account given of hernia and its treatment, it will be proper to consider the varieties of the disease, the principal of which are inguinal, crural, umbilical, and congenital hernia. To each of these, it will be necessary to prefix a short account of the surgical anatomy of the parts. When the integuments of the abdomen are turned back, a thin INGUINAL HERNIA. 105 but compact sheet of cellular substance, described by modern anatomists under the name of superficial fascia, will be found to cover the whole surface of the abdominal muscles. Not only does it cover these muscles and their tendons, but extends upwards to the chest, and downwards to the thighs, and, in fact, may with propriety, perhaps, be said to form a sort of general investment to the body. Its attachment to Poupart's ligament, and to the surface of the spermatic cord, is particularly close. On the surface of the fascia, and running over Poupart's ligament towards the umbilicus, an artery and vein may be observed. These are branches of the external pudic, and from being con- cerned in the operations for strangulated inguinal and crural hernia, should be noticed in the dissection of the parts. Besides these vessels, numerous inguinal glands will be seen lying beneath the fascia, and intermingled with its fibres. Under the superficial fascia, lies the tendon of the external oblique muscle. The lower margin of this constitutes Poupart's ligament, which extends from the anterior superior spinous pro- cess of the ilium to the pubes; and as it approaches that part, splits into two columns, the upper of which is inserted into the symphysis, the lower into the tuberosity of the bone; leaving between them a triangular space, called the external abdominal ring, out of which emerges the spermatic cord. When the tendon of the external oblique is cut away, or turned down upon the thigh, the internal oblique muscle is brought into view. The lower margin of this arises from the outer half and inner surface of Poupart's ligament, and passing above the spermatic cord, in a vaulted form, is fixed by a tendon into the symphysis pubis. From the edge of the internal oblique, the cremaster muscle arises, is inserted into the spermatic cord, and descends with it into the scrotum. The lower edge of the transversalis muscle, like that of the internal oblique, arises from the outer portion of Poupart's liga- ment, crosses over the spermatic cord, and uniting its tendon with that of the internal oblique, is inserted into the pubes. These three muscles—the external oblique, the internal oblique, and the transversalis—serve to cover the abdomen, and support the viscera. From the manner, however, in which the last two are formed, (being deficient, as it were, in part, or not wholly inserted into Poupart's ligament,) this support would be very inadequate, were it not for the co-operation of an additional struc- ture—the fascia transversalis. 106 INGUINAL HERNIA. This fascia consists of condensed cellular membrane, lines the internal surface of the transversalis muscle, and is interposed between it and the peritoneum. Its extent is very considerable, for it not only covers the whole of the lower part of the abdo- men and passes out along with the femoral vessels upon the thigh, but ascends to the diaphragm. In this fascia, an opening is left for the passage of the spermatic cord—called the internal abdo- minal ring. The spermatic cord, consisting of arteries, veins, lymphatics, nerves, the vas deferens, and a membranous sheath, enters the in- ternal abdominal ring—which is situated about half an inch above Poupart's ligament, and midway between the spine of the ileum and symphysis pubis—and taking a course inwards and down- wards, passes under the edges of the internal oblique and trans- versalis, and finally emerging at the external ring, descends nearly in a perpendicular direction into the scrotum. Along the under and inner side of the spermatic cord, and between it and the pubes, passes the epigastric artery, a vessel materially concerned in the operation for strangulated inguinal hernia. From the above account of the structure of the parts imme- diately concerned in inguinal hernia, it will appear—that there are two abdominal rings, the external, formed by a splitting of the fibres of the external oblique tendon, the internal, by an opening in the fascia of the transversalis muscle. To make this structure more intelligible to the student it will be proper to observe that these rings are distant from each other, in most full- grown subjects, about an inch and a half, that between them there is a canal for the passage of the cord, that the cord enters the internal ring, passes obliquely downwards, under the internal oblique and transversalis muscles, (not through them, as formerly supposed,) until it reaches the external ring, after which its course is perpendicular. To understand the reason of the cord not per- forating the internal oblique and transversalis, it will only be necessary to remember that these muscles are not attached to the whole of Poupart's ligament, but only to the outer half of it, and consequently that they may be said to be wanting from that part as far as the symphysis pubis. In most instances, the hernial sac and its contents enter the internal abdominal ring anterior to the spermatic cord, and having reached the origin of the cremaster muscle, pass between it and the cord. Sometimes, however, the cord is placed on the INGUINAL HERNIA. 107 side of the sac, at other times on its front. The epigastric artery runs along the under and inner side of the sac, and between its mouth and the symphysis pubis. In immediate contact with the sac, and on its anterior surface, is spread out from pressure, the cremaster muscle which forms one of the coverings of the sac. Above the cremaster is the superficial fascia, and next to it the integuments. If a dissection, therefore, is made of the coverings and contents of the inguinal hernia, commencing at the skin, the parts will be presented in the following succession—the inte- guments, superficial fascia, the cremaster muscle, the hernial sac, omentum or intestine, and perhaps both. The symptoms of reducible, irreducible and strangulated in- guinal hernia do not differ from those of hernia in general, and these have been already pointed out in the preceding section. But it is important to distinguish between this disease and others bearing to it some similitude. Inguinal, or rather scrotal hernia, may be confounded with hydrocele, cirsocele, enlarged testis, and some other affections. From hydrocele, it may be distinguished by the circumstance of the tumour commencing above the abdominal ring, and descending towards the scrotum, whereas hydrocele always begins in the lower part of the scrotum, and gradually ascends. Cirsocele sometimes bears a striking resemblance to scrotal hernia, but it may be distinguished from it by placing the patient in a recumbent position, pressing firmly upon the upper part of the ring, and then directing him to rise, when, if it be cirsocele, the tumour will re-appear, and of an in- creased size; if hernia, it will be retained within the ring until the finger be removed. An inguinal hernia, is sometimes contained within the canal leading from the internal to the external ring. It is then called concealed inguinal hernia. As in cases of this description there is commonly no external tumour, the surgeon should be on his guard, and suspect the existence of this disease, if the symptoms of strangulation be present. The hernial sac in such cases is generally covered, in addition to the usual investments, by the tendon of the external oblique, and edges of the internal oblique and transversalis. Scrotal hernia in shape is commonly pyri- form, and in size is very various, descending in some instances to the patient's knees, at olher times is not much larger than a natural scrotum. Occasionally the disease is met with on both sides. Males are more subject to inguinal hernia than females, 108 INGUINAL HERNIA. and when it occurs in the latter the tumour bears the same relation to the round ligament that it does to the spermatic cord in the male. TREATMENT OF INGUINAL HERNIA. For reducible inguinal, or scrotal hernia, an appropriate elastic truss should be selected. Above most instruments of this description, I prefer that of Wright of Liverpool, formed upon the principle of Whitford's truss, described in the work of Mr. Lawrence on hernia. The peculiarity of these instruments consists in their not forming a perfect oval, but in being straight or nearly so behind, where they cross the small of the back, and rising from the posterior part of the pelvis, and descending in front towards the groin. Of the truss of Salmon and Ody, —commonly called Hull's truss,—I have also a favourable opinion. This, instead of passing entirely around the pelvis, is formed of a semicircle of steel, with a pad at each extremity— one of which is adapted to the groin, the other to the back. In fitting a patient with a truss for inguinal hernia, the surgeon should take care to adapt the instrument to the lower part of the internal ring; for if it be placed, as is too often done, upon the external ring, it not only presses upon the cord, gives unne- cessary pain and injures the function of the testicle, but does not answTer the purpose of supporting the hernia. Every patient should habituate himself to return his own hernia, and to apply the truss; and the most convenient time for effecting this is in the morning before he rises, as the intestines and omentum, during the night, generally retire within the abdomen. For radical cure, Chase's truss will be found the best instrument. The irreducible scrqtal rupture subjects the patient, when it attains a large size, to great inconvenience, by impeding copu- lation and arresting the flow of urine, which, from the penis being buried among the integuments, excoriates the parts and gives rise to small abscesses. To prevent the growth or increase of the swelling, a bag truss is the only remedy. Strangulated inguinal or scrotal hernia, should the taxis and tobacco injection fail, will require an operation, and the sooner this is performed, after it has been determined upon, the better; for there is reason to believe that many lives have been lost by INGUINAL HERNIA. 109 delay, and few, if any, from the operation itself. The patient being placed upon a table of ordinary height with his thighs some- what separated, and each foot resting upon a chair, the surgeon sits before him, and grasping the tumour with one hand, makes an incision with the other, commencing at the upper part of the tumour, and extending downwards nearly to its base. Having divided the integuments, a branch of the external pudic artery generally springs, and may require the ligature. Immediately beneath the integuments, lies the superficial fascia: this should be divided by successive touches of the knife, until the cremaster muscle appears; the fibres of which may be elevated carefully by the dissecting forceps, or by running the directory beneath them, until the whole are cut through, and the sac exposed. To open this without risk of injuring the intestine, a portion of it may be pinched up and rubbed between the fingers previously to its division. As soon as the sac is opened, a quantity of fluid gushes out, and part of the intestine, or omentum, appears at the opening. Fluid, however, is not invariably met with, and it is highly important that the operator should be aware of this, otherwise he might, in expectation of finding it, continue to pene- trate with the knife, until he wounds the intestine. The open- ing in the sac should be enlarged upwards and downwards to the extent of two or three inches, and if its contents are found in a proper condition to be returned into the abdomen, the next step of the operation is to carry the forefinger of the left hand upwards between the sac and protruded parts, and search for the stricture, which will be found either at the edges of the ex- ternal ring, the internal ring, or the mouth of the sac. In very old and large hernise, the external ring is the most common seat of the constriction, but, in ordinary cases, the internal ring. By gentle pressure with the fingers upon the intestine or omentum, these parts may sometimes be restored without dividing the stricture; if the attempt fail, howTever, the operator then intro- duces a common curved probe-pointed bistoury, (the edge of which, with the exception of half an inch of its extremity, is covered by a piece of riband or muslin,) with its flat surface between the sac and its contents, and with the forefinger as the guide, carries its point beneath the stricture, turns up the edge of the instrument and divides it. A very slight incision, even the eighth or sixteenth part of an inch in extent, will be often sufficient to liberate the parts. The moment this is accomplished, repeated VOL. II.—H 110 INGUINAL HERNIA. and gentle efforts should be made to return them to the abdo- men, after which the edges of the wound must be brought together and retained by adhesive straps. In the course of three or four hours after the operation, should the patient not have a stool within that time, a dose of castor oil must be administered. During the cure the patient should be confined to bed, and not suffered to rise until the parts are so completely cicatrized, as to bear the pressure of a truss—an instrument still more neces- sary after an operation for strangulated hernia, than before. In dividing the stricture, in all cases of strangulated inguinal hernia, whether seated at the external or internal ring, or at the mouth of the sac, there is one rule extremely important to ob- serve—to carry the knife directly upwards, (a practice first suggested by Rougemont, and afterwards adopted by Sir Astley Cooper,) by which we avoid wounding the epigastric artery. If, in the ordinary situation, for example, of this variety of her- nia, the stricture be divided upwards and inwards, or towards the linea alba, and the incision prolonged to any extent, the epi- gastric will, almost to a certainty, be cut across. On the other hand, if the knife be carried upwards and outwards towards the ilium, and the hernial sac should descend, as it sometimes does, on the inner side of the epigastric, (constituting the variety of hernia called ventro-inguinal,) this vessel may possibly be di- vided. It is proper to observe, however, notwithstanding these precautions, that there are few examples of fatal hemorrhage from wounds of the epigastric, although the vessel has been cut in numerous instances by awkward and careless operators. With regard to the condition of the intestine or omentum, it may be observed—that if mortified spots appear on the former, they should be included in a fine ligature before returning them to the belly; and that if the omentum be in an indurated state, and form too large a protuberance to admit of repassing the ring, it should be retrenched, taking care to tie up any particular ves- sels that may spring, instead of including the whole mass in a ligature, as was formerly practised. Dr. Parsons, an intelligent surgeon of Providence, Rhode Island, informs me that he once removed six ounces of omentum without injury to the patient. Sir Astley Cooper, and some other surgeons have recom- mended, in large hernia? especially, to divide the stricture on the outside of the sac—leaving the sac unopened. To this plan, however, there are many objections, founded chiefly upon the FEMORAL HERNIA. Ill difficulty of the operation, and the impossibility of knowing the condition of the intestine or omentum unless they are exposed to view. The operation for small, or concealed inguinal hernia, does not differ materially from that of the common variety of the disease. If the operation for strangulated inguinal hernia has been so long delayed as to permit the parts to fall into gangrene, and they are found in this condition by the surgeon after having opened the sac, he should not think of pushing them, in this state, into the abdomen, even if he could effect it, because they would then act as extraneous bodies, and excite irritation. By the time, however, the process of sloughing is completed in the parts exterior to the stricture, it generally happens that the parts within the abdomen or its immediate vicinity are united by adhesion to the internal surface of the ring, and, therefore, that the protrusion could not be returned without previously breaking up those adhesions, upon which, indeed, the safety of the patient must now in a great measure depend. Some surgeons have attempted to cure inguinal and other varieties of hernia radically—by relieving the stricture, return- ing the protruded parts, and afterwards dissecting up the hernial sac, and either restoring it to the abdomen, or removing it en- tirely, and tying its mouth with a ligature. The practice, I con- ceive, is seldom justifiable. Many years ago I performed the operation, but the case terminated fatally. Experience proves, moreover, that a new sac, even if the patient recover, is almost sure to form. SECTION V. FEMORAL HERNIA. The contents of a femoral or crural hernia, instead of passing through the abdominal rings, are protruded beneath Poupart's 112 FEMORAL HERNIA. ligament, through an opening termed the crural ring. This ring is bounded on the outer or iliac side, by the femoral vein, on the inner or pubic side, by Gimbernat's ligament, anteriorly, by Poupart's ligament, and posteriorly by the pubes. Poupart's ligament arises from the spine of the ilium, and is implanted by a broad insertion into the symphysis pubis, into the tuberosity of the pubes and into the ligament of the pubes over the linea- ileo-pectinea. By this last insertion a sharp crescentic edge is formed, the concavity of which looks towards the crural vein, and is supposed by most waiters, to contribute mainly to the constriction in cases of strangulated crural hernia. From having been particularly described by Gimbernat, a Spanish surgeon, it is frequently called Gimbernat's ligament. There are two margins to Poupart's ligament, an anterior and pos- terior, the former of which is straight, the latter concave, in the vicinity of the pubes. The fascia lata of the thigh, as it approaches Poupart's liga- ment, divides into two portions—the iliac (sometimes called sar- torial) and pectineal. The former is connected to Poupart's ligament throughout the greater part of its extent; the latter is attached to the pubes, covers the muscles that spring from that bone, and unites with the iliac portion below, at the spot where the vena saphena major enters the femoral vein. In thickness and strength the iliac portion of the fascia lata greatly exceeds the pectineal portion. It lies, 'moreover, con- siderably above the plane of the latter, and covers the femoral vessels, the anterior crural nerve, and the iliacus internus and psoas muscles. Towards the pubes its edge is concave, and on this account was denominated by Burns of Glasgow, the falci- form process. Its superior horn received from Mr. Hey the appellation of femoral ligament, and is at the present day com- monly known under the name of Hey's ligament. " It has al- ready been stated," says Colles, " that the iliac portion of the fascia lata passes before the femoral vessels. We observe, in this part of its course, that it loses somewhat of its strength and firmness of texture; however, it generally retains a good deal of its ligamentous nature even when it has reached the pubic side of these vessels; except in the immediate neighbourhood of the vena saphena, where it differs but little from the cellular substance. Having passed before the femoral vessels, we find it now to descend on their pubic side; and here we see it attach FEMORAL HERNIA. 113 itself very intimately to the pectineal fascia. This attachment is made in a straight line along the pubic side of the vein, from the place of insertion of the saphena to within a quarter of an inch of Poupart's ligament. At this place we observe that the line of attachment is curved; and having here formed a sweep towards the pubes, that the attachment now takes place in a line across the top of the thigh."* In most subjects, I have found the iliac portion of the fascia lata to consist of two layers, the innermost of which passes backwards behind the femoral vessels, and is united with the pectineal portion—leaving the falciform process double, like the margin of the cuff of a coat, and forming a round instead of a sharp edge.f Beneath the fascia lata, and in immediate contact with the femoral vessels, lies the fascia transversalis. This fascia, as formerly mentioned under the head of Inguinal Hernia, not only lines the internal surface of the abdomen, but passes out upon the thigh under the posterior edge of Poupart's ligament. De- scending in front of the crural artery and vein, it becomes united to their sheath and forms for them an additional investment. On the inner side of the crural vessels numerous absorbents may be observed passing through the transversalis fascia, on their way to the abdomen. The fascia iliaca is but a continuation of the fascia transver- salis, and differs from it only in situation. It lines the surface of the iliacus internus and psoee muscles, adheres to the posterior margin of Poupart's ligament, descends with the crural vessels to the thigh, and affords them posteriorly a strong investment. The union of the fascia transversalis and iliaca has been com- pared,! not unaptly, to a compressed funnel, the expanded part of which may be said to occupy the lower part of the abdomen and hollow of the ilium, while the pipe is represented by the prolongation which covers the femoral vessels, and forms their anterior and posterior sheaths. Although the space between the os innominatum and Pou- part's ligament is filled up by the iliacus internus and psose mus- cles, these would not prove a sufficient barrier to the descent of * Surgical Anatomy, p. 68. t My observations have been lately confirmed by modern European autho- rity of great respectability. J Colles, p. 63. 114 FEMORAL HERNIA. a femoral hernia in various situations between the spine of the ilium and symphysis pubis. Such descent, however, is effect- ually guarded against, except at the crural ring itself, by the union of the fascia transversalis and iliaca. These fascia?, indeed, are so closely connected with each other, with the pos- terior edge of Poupart's ligament, and with the surface of the psoas and iliacus internus muscle, and send off so many parti- tions between the crural artery and vein, and the adjoining parts, as to preclude effectually the escape of any of the viscera between them. In dissecting the parts concerned in crural hernia, it is im- portant to notice particularly the situation of the spermatic cord and epigastric artery. The former lies about half an inch from the mouth of the sac, above Poupart's ligament; the latter runs upon the outside of the hernial sac, and takes a course upwards and inwards on its way to the rectus muscle. Sometimes the obturator artery is sent off by the epigastric, and, running along the inner margin of the sac, and sometimes encircling it, is liable to be wounded, in performing the operation for strangu- lated femoral hernia, if the incision be prolonged too far inwards or towards the pubes. A portion of omentum, or intestine, surrounded by the peri- toneum, having entered the sheath of the femoral vessels, formed by the union of the iliac and transversalis fascia?, passes along the inner edge of the crural vein, and carries before it the loose cellular membrane that naturally occupies the orifice of the crural ring. This membrane, (which has received from Sir Astley Cooper the name of fascia propria,) being pushed for- ward by the hernial sac, is carried along with it through one or more of the holes on the inner side of the crural sheath, and uniting with that sheath, the two fascia? are "consolidated into one." Above the fascia propria will be found the super- ficial fascia and the integuments. If a dissection, therefore, be made of a femoral hernia, commencing at the surface of the bend of the thigh, the parts will be presented in the following order:—the integuments, superficial fascia, fascia propria, her- nial sac. This last will be found resting in the hollow between the iliac and pectineal portions of the fascia lata, and consequently, on the outer surface of that aponeurotic expansion. There is a variety, however, of femoral hernia, (in which the sac with its contents, not passing through the absorbent holes, is continued FEMORAL HERNIA. 115 along the sheath of the femoral vessels,) covered by the fascia lata. Women are more subject to femoral hernia than men, owing partly to the great breadth of the female pelvis, compared with that of the male. In shape, femoral hernia differs entirely from inguinal—its longest diameter being placed transversely with respect to the thigh. In general, moreover, the tumour is much smaller than that of the inguinal. On this account it is parti- cularly liable to be confounded with other diseases, especially with enlargement of one or more glands of the groin, with varicose enlargement of the crural vein, psoas abscess, &c. In one patient, however, an old man in the Philadelphia Hospital, in 1833, I found the tumour as large as a child's head. Not unfrequently it is mistaken for inguinal hernia—owing to the tumour rising, from the oval space in the fascia lata, upon Pou- part's ligament. The edge of this ligament may, however, in femoral hernia, always be traced above the tumour, while in bubonocele it is below it. A very common symptom of re- ducible femoral hernia, is pain in the groin, extending from the thigh, which is sometimes so severe as to produce nausea and vomiting. TREATMENT OF FEMORAL HERNIA. The truss for reducible inguinal hernia, will answer also for femoral, provided the pad of the instrument be bent downwards about an inch, in order that it may rest on the top of the thigh instead of the groin. Irreducible femoral hernia, when its con- tents consist chiefly of omentum, sometimes attains such a bulk as to prove very inconvenient to the patient. Under these cir- cumstances it has been advised by Sir Astley Cooper to apply a hollow truss to the tumour, (taking care previously to reduce the intestine,) with a view of promoting, by pressure, the ab- sorption of the protruded parts. Strangulated femoral hernia must be treated upon the princi- ples formerly laid down. Instead, however, (in performing the operation of taxis,) of pressing the tumour directly upwards, as in strangulated inguinal hernia, the surgeon should first endea- vour to disengage it from the edge of Poupart's ligament, by pressing it downwards and inwards; after which a slight pressure upwards will often succeed in restoring the omentum or intes- 116 FEMORAL HERNIA. tine to the abdomen. If the taxis should fail, and an operation become necessary, there should be the least possible delay; for the disease runs its course with much greater rapidity than most other varieties of strangulated hernia. The patient being placed horizontally, on a table, the shoulders elevated by a pillow, the thighs somewhat relaxed and brought near to each other, the diseased parts shaved and the bladder emptied, an incision is made, commencing about an inch above Poupart's ligament, and extending downwards to the middle of the tumour, through the integuments. At right angles with this, another cut is made—the two representing in form the letter T reversed. The superficial fascia being exposed and carefully divided, the fascia propria is brought into view. This being likewise divided, more or less adipose substance will be gene- rally found between it and the sac. To open the sac, which should next be done, without risk of injuring the intestine, (for in this variety of hernia there is seldom much fluid in the sac,) a portion of it should be carefully pinched up and rubbed between the fingers, and divided by carrying the knife horizontally through it. As soon as the intestine, or omentum, is discovered, a finger may be introduced into the opening, and upon this a curved bis- toury, with which the sac may be enlarged, to the extent, if necessary, of one or two inches. The next object of the operator will be to ascertain the seat of the stricture. This will be found either at Hey's ligament, in the crural sheath, at Gimbernat's liga- ment, or in the mouth of the sac. When the hernial tumour is large, more or less constriction will always be made upon it by the falciform process of the fascia lata, and particularly by that por- tion of it called Hey's ligament. In ordinary cases, however, I am inclined to believe that the sharp posterior border of Pou- part's ligament, or the ligament of Gimbernat, as it is called, contributes more than any other part to keep up the symptoms of strangulation. But be this as it may, the surgeon must pro- ceed in his operation until he has removed every obstacle. With this view, passing the fore-finger of his left hand gently between the sac and its contents, he carries it upwards until he meets re- sistance. The bistoury should then be passed, with its flat edge towards the finger, until it is fairly within the strictured part, when its edge may be turned up and pressed lightly against the obstruction. If the parts are not sufficiently liberated to be re- turned by moderate pressure, the finger should be carried higher, UMBILICAL HERNIA. 117 and other obstructions sought for. These, if found, must like- wise be divided, taking care in making each incision to carry the bistoury upwards and slightly inwards. The operator, if re- gardless of this rule, might, by prolonging his incision outwards, or upwards and outwards, injure the crural vein and epigastric artery. On the contrary, by directing the knife too far inwards or towards the pubes, the obturator artery, in case it should hap- pen to spring from the epigastric and take an inward course, would be endangered. By the inward incision, moreover, there is great risk of wounding the intestines. Having relieved the stricture and restored the contents of the sac to the abdomen, the after treatment will not differ from that pointed out in some of the preceding sections. SECTION VI. UMBILICAL HERNIA. The umbilical vein, and its two arteries, in the foetus, perfo- rate the tendons of the abdominal muscles about the centre of the linea alba, and leave an opening called the umbilical ring. Soon after birth these parts are consolidated, and' a firm cicatrix is formed, externally, by the contraction of the integuments, in- ternally by the peritoneum, and between the two, by the re- mains of the umbilical vessels. The ring being thus closed and fortified, protrusions of the abdominal viscera, in most subjects, are guarded against. Sometimes, however, it happens, that the ring is imperfectly closed, or its edges so weak, as readily to yield to any force the viscera may exert against it. Under these circumstances, an umbilical hernia will be produced. It is still a disputed point whether the protrusion takes place at the centre of the umbilical ring, or at its edges. Sir Astley Cooper in- clines to the former opinion. There is reason to believe, how- ever, that both occurrences are not unfrequent. Many of the older writers believed the umbilical hernia to be destitute of a sac 118 UMBILICAL HERNIA. or peritoneal covering, erroneously supposing that the umbilical vessels were naturally situated behind that membrane, and con- sequently, that the abdominal contents were protruded through the imaginary opening, in the peritoneum, for the transmission of these vessels. The fact, however, that the arteries and vein, while on their way to the umbilical cord, lie between the abdo- minal tendons and peritoneum, has long been known. The infe- rence, therefore, is not less plain than true,—that the umbilical hernia, like most other varieties of that disease, is covered by a peritoneal sac. There is some variety in umbilical hernia, according as it occurs in the infant at birth, in the young subject, or the adult. The congenital umbilical hernia, as it is called, is often com- plicated with spina bifida, and with extraordinary enlargement of the liver and other abdominal viscera. The contents of the abdomen are protruded through the umbilical ring into a trans- parent bag, formed out of the cellular membrane that connects the vessels of the cord. So transparent, indeed, is this invest- ment, that throughout the greater part of the tumour, the her- nial sac may be distinctly seen. The umbilical hernia of young subjects is, unlike the conge- nital variety, covered by the common integuments of the abdo- men, and generally makes its appearance about the third or fourth month after birth. It seldom attains, unless very much neglected, a large size; indeed, in many instances, the tumour scarcely exceeds a common marble in bulk, and when pressed upon, readily retires into the abdomen; returning again, how- ever, as soon as the pressure is discontinued. Its figure is commonly round. A fold of intestine generally occupies the hernial sac, and omentum is scarcely ever met with. The dis- ease is often accompanied by disorder of the bowels and digestive organs. Amongst adults, the most common causes of umbilical hernia, are, pregnancy, laborious parturition, and inordinate fatness. Hence, women, and especially those who have borne many chil- dren, are most subject to the disease. The tumour, may, perhaps, remain stationary, or nearly so, for years; in the end, however, it is almost sure to attain considerable bulk, and sometimes exceeds in magnitude the patient's head. Nausea, eructa- tions, constipation of the bowels, are very common attendants UMBILICAL HERNIA. 119 upon this variety of hernia. In general, the omentum consti- tutes a very large proportion of the contents of an old umbilical hernia, and the colon is oftener found in the sac than any other intestine. TREATMENT OF UMBILICAL HERNIA. Congenital umbilical hernia, provided there be no extraordi- nary deficiency of the tendinous parietes, or other morbid com- plication, may be cured, frequently by a well contrived bandage, or by surrounding the sac and integuments, (having previously reduced the intestine,) with a ligature—drawn with sufficient firmness to occasion the parts included in its embrace to slough, and the edges of the umbilical ring to cicatrize. The last is the most certain and expeditious mode of effecting a cure. In- stead of the simple ligature, Dr. Hamilton, of Edinburgh, ap- proximates the edges of the ring by silver pins and adhesive straps. His example, however, should not, I conceive, be imi- tated. The ligature was frequently employed by the ancients, in the cure of umbilical hernia of young subjects, and in modern times, has been extensively used and highly extolled by Desault. In several instances I have performed the operation with complete success, and with little pain or inconvenience to the patient. There is no risk in the operation, provided the surgeon succeeds perfectly in restoring the protruded parts to the abdomen, before he ventures to apply the ligature; which should be of consi- derable thickness and strength, and drawn so firmly as to ensure the speedy destruction of the part surrounded by it. After the slough is detached, the sore that remains may be dressed with dry lint or some mild ointment until perfectly healed. For two or three months afterwards it will be proper to support the new-formed cicatrix by a compress or truss, to guard against its laceration, and the consequent reproduction of the disease. The disease frequently disappears of its own accord. To the reducible umbilical hernia of adults the ligature is not adapted. In such cases the surgeon must depend upon a truss, which, so long as it keeps the intestine or omentum within the abdomen, will at least prevent the increase of the tumour, 120 UMBILICAL HERNIA. and may, eventually, perhaps, by exciting a slow inflammation, effect a cure. Sir Astley Cooper, in small hernia?, prefers the common inguinal truss, which, if it form a perfect oval, will without difficulty adapt itself to the body, and furnish the re- quisite support to the tumour. For large umbilical hernia?, however, the trusses invented by Morrison, or Eagland, of Leeds, and described in most modern systems of surgery, will be found to answer a better purpose than any others. When the hernia is irreducible, and of very large dimensions, a hollow truss, or a wide belt, carried under the tumour and over the pa- tient's shoulders, may be resorted to advantageously. Strangulated umbilical hernia very frequently proves fatal, as much from disorder of the intestinal functions, as from the strangulation. When the usual remedies fail, an operation should be resorted to. This may be done in the following way. An incision, several inches long, is made very cautiously, through the integuments and superficial fascia, when the sac, if not absorbed, as it often is, will appear. Into this a small opening should be made, from which fluid in considerable quan- tity generally issues. The opening may then be enlarged, and a finger carried upwards between the omentum and intestine as high as the umbilical ring. Upon the finger a bistoury is next carried through the linea alba, to the extent of an inch, which, in most cases, will relieve the stricture sufficiently to enable the operator without much difficulty to restore the parts to their former situation. To guard against peritoneal inflammation, which is sometimes apt to follow the operation just described, Sir Astley Cooper, in two instances, adopted the following mode of procedure. " As the opening," says he, " into the abdomen is placed to- wards the upper part of the tumour, I began the incision a little below it, that is, at the middle of the swelling, and extended it to its lowest part. I then made a second incision at the upper part of the first, and at right angles with it, so that the double incision was in the form of the letter T, the top of which crossed the middle of the tumour. The integuments being thus divided, the angles of the incision were turned down, which exposed a considerable portion of the hernial sac. This being then care- fully opened, the finger was passed below the intestine to the orifice of the sac at the umbilicus, and the probe-pointed bis- toury being introduced upon it, I directed it into the opening at CONGENITAL HERNIA. 121 the navel, and divided the linea alba downwards to the requisite degree, instead of upwards." Dr. Physick has proposed, in strangulated umbilical hernia, to make a crucial incision through the integuments, as far as the neck of the sac, then open the sac at its upper part to an ex- tent sufficient to enable the operator to examine its contents, and reduce them, if possible, without dilating the umbilical ring. Should the latter expedient, however, become necessary, the stricture must be divided on the outside of the sac. After the omentum and intestine are restored to the abdomen, a ligature should be drawn round the neck of the sac, with a view of closing the cavity and obviating peritoneal inflammation. The late Dr. Wistar once performed the operation with success. In the case of a Mrs. N., a very respectable Jewish lady, I performed a si- milar operation about twenty years ago. The tumour, however, was as large as a child's head, and had been strangulated seve- ral days before I saw the patient, and, on this account, the ope- ration did not succeed. The patient, too, was advanced in years, extremely corpulent, and had long suffered from derangement of the functions of the stomach and intestines. Under these cir- cumstances, no operation, probably, wrould have answered the purpose, even if performed in the very commencement of stran- gulation. SECTION VII. CONGENITAL HERNIA. This, as its name implies, is met with at birth, or, as generally happens, a short time after birth. It differs from common ingui- nal hernia, in being destitute of a distinct peritoneal sac, and in being lodged in the tunica vaginalis, in contact with the testicle. " In a common rupture," says Professor S. Cooper, " the viscera push out with them a portion of the great bag of the peritoneum, which thus forming one of the most regular investments of the 122 CONGENITAL HERNIA. displaced bowels, is called the hernial sac. But in the congeni- tal inguinal hernia, the sac, in which the viscera lie, is not thrust forth in this manner, by the displaced bowels; on the contrary, it is a production of peritoneum originally formed and placed ready for the reception of the testes on their descent from the loins, but into which the bowels are sometimes accidentally pro- pelled, before the passage leading into it from the belly is duly closed. The congenital inguinal hernia, therefore, differs from the generality of ruptures, in having no hernial sac, formed and produced by the peritoneum being thrust forth from the belly by the displaced bowels themselves. There is, indeed, one very uncommon species of scrotal hernia, contained in the tunica vaginalis, yet included, also, in a common hernial sac, so that the protruded bowels neither lie in contact with the preceding membrane, nor with the albuginea. This particular case was first noticed and described by the late Mr. Hey. It seems to be formed after the communication of the cavity of the peritoneum with that of the tunica vaginalis has been obliterated, but pre- viously to the closure of the passage lower down."* In most respects, the anatomy of congenital hernia resembles that of the inguinal. The spermatic cord, and the spermatic artery lie be- hind the hernia. The testicle, from being surrounded by the in- testine or omentum, can seldom be distinctly felt. Congenital hernia sometimes resembles hydrocele so closely as to be mistaken for that disease—owing to water accumulating in the abdomen and passing along with the hernia into the tunica vaginalis. It is very important to. distinguish the one disease from the other; which may generally be done by placing the pa- tient in the horizontal position, returning the hernial contents to the abdomen, and there retaining them by a finger pressed upon the abdominal ring. In the mean time, the water alone remaining in the tunica vaginalis may be easily distinguished by its transparency and peculiar feel. TREATMENT OF CONGENITAL HERNIA. The reducible congenital hernia, if attended to, soon after the disease is discovered, may be readily cured by a well con- * " First Lines of the Practice of Surgery," vol. ii. p. 23, 4th edit. CONGENITAL HERNIA. 123 structed truss—inasmuch as there is a strong disposition in the tunica vaginalis at the ring to close of itself after the descent of the testicle. A spring truss can seldom be used in a child im- mediately after birth, but a linen compress, covered by a band- age, if well applied, will generally answer every purpose; and after the lapse of a few months a truss with a weak spring may be employed. It sometimes happens that the testicle is detained at the ring, and that the omentum or intestine is placed above or alongside of it. In such a case a truss should not be applied, as it will either prevent the descent of the testicle, or bruise the hernial contents. Strangulated congenital hernia, if not relieved by the usual remedies, will require an operation, which differs from that of common inguinal hernia, chiefly in this particular—that the incision of the sac should never be prolonged further than the upper part of the testicle, in order to obviate inflammation of the tunica vaginalis, to which this membrane is particularly prone. That inflammation is propagated, more readily, to the peri- toneum within the abdomen, after the operation for strangulated congenital hernia than for that of castration, is owing to the tunica vaginalis, in the former case, being continuous with the peri- toneum, whereas in the latter it is closed immediately after the descent of the testicle. In certain quadrupeds—as in the horse—the tunica vaginalis communicates directly with the ab- domen and is continuous with the peritoneum. If, therefore, in castrating such animals, care be not taken to sear the cord and edges of the tunica vaginalis, by hot irons, as practised, with propriety, by farriers, death will be very apt to follow. Many years ago, to oblige a friend, I performed the operation on a colt, and tied up the vessels as I would have done in the human sub- ject. Violent inflammation followed and the animal was saved with great difficulty. Sir A. Cooper mentions a similar instance. Searing obliterates the passage between the abdomen and tunica vaginalis, and produces the same effect as natural adhesion in the human subject. In large congenital hernia? that have long remained irreducible, Sir Astley Cooper advises the return of the parts without in- spection, provided the stricture can be removed without opening the tunica vaginalis. 124 VARIETIES OF HERNIA SECTION VIII. VARIETIES OF HERNIA. There are several varieties of hernia that differ from those already described, chiefly in situation, but which, from certain peculiarities growing out of that and a few other circumstances, require some notice. These are ventral, pudendal, vaginal, thy- roideal, perineal, ischiatic, cystic, mesocolic, phrenic, and mesen- teric hernia. Of each of these I shall endeavour to give a short account. Ventral hernia, or that variety of the disease which may take place at almost any part of the abdominal parietes, is seldom met with in the human subject, but is rather common among quadrupeds—being produced in them by blows, wounds, lacera- tion of muscles, tendons, &c. It is generally met with at the linea alba, at some point between the scrobiculus cordis and pubes, and is sometimes so near the umbilicus as to be with diffi- culty distinguished from exomphalos. At other times it occu- pies the linea semilunaris. It occurs most frequently above the navel, and wThen very high up the stomach may form part of the contents of the sac. Cases of the kind are reported by Sir Astley Cooper. Cloquet mentions an instance of ventral hernia, which occupied the whole of the linea alba. Besides being covered by the superficial fascia, ventral hernia has an additional investment. Pudendal hernia passes downwards between the ramus of the ischium and the vagina, displaces in its course some of the fibres of the levator ani, and forms an oblong tumour in the labium, which extends as far as the os uteri. It is sometimes confounded with thyroideal hernia. In vaginal hernia the viscera descend between the uterus and urinary bladder, or between the rectum and uterus. The tumour may be felt within the os externum, is elastic, free from pain, and may be pushed considerably upwards, but descends the moment the support is taken away ; hence most patients troubled with this disease are unable to take much exercise, and suffer wTith bearing-down pains. Thyroideal hernia, or hernia of the foramen ovale, was for- VARIETIES OF HERNIA. 125 merly considered very rare. Recently, however, several cases of the kind have been reported. It descends along with the obturator vessels and nerve, through an opening in the upper part of the obturator ligament, is covered, partially, by perito- neum, and met with more frequently in women than men. The tumour seldom attains a large size, and on this account, as well as its deep situation under the fascia lata, adductor and pecti- neus muscles, is not easily detected, and is therefore, when strangulated, frequently confounded with ileus. Cloquet has furnished the best account of the disease. Perineal hernia is that variety of the disease in which the sac and its contents descend between the vagina and rectum in women, and between the rectum and bladder in men. To dis- cover it in the former, examination by the rectum and vagina will be necessary, and in the latter by the rectum, conjoined with pressure on the perineum. Bromfield relates a case of this disease which arose from a wound of the peritoneum in lithotomy. Ischiatic hernia is rarely met with. It is sometimes congeni- tal, and males are said to be more liable to it than females. In a case reported by Sir Astley Cooper, the sac was found under the gluta?us maximus, its orifice before the internal iliac artery, below the obturator, but above the vein, and the ileum lodged in the pelvis on the right side of the rectum. The disease is liable to be mistaken for abscess, gluteal aneurism, and encysted tumour. Haller relates a case where the tumour attained such dimensions as to require to be supported on the patient's shoulder. Hernia of the urinary bladder, or cystocele, is by no means so uncommon as supposed. It has, at first, no proper peritoneal investment; but the bladder, from extraordinary lateral disten- tion or relaxation, passes into the inguinal or crural rings, or other natural or preternatural openings, and, at last, when the fundus descends, the portion of peritoneum belonging to it is also carried down, and forms a sac, in which intestine and omentum are afterwards lodged. "Cystocele," says Mr. Crosse, "dis- poses strongly to the formation of a urinary calculus, and in all the various situations in which this species of hernia has been found, as inguinal, femoral, ventral, ischiatic, pudendal, and perineal, a stone may be met with."* Many extraordinary * Crosse on Urinary Calculus, p. 5,4to., Lond. 1835. VOL. II.—I 126 VARIETIES OF HERNIA. cases of the kind have been reported, some, in which the bladder has been opened by mistake, or cut off, and others, in which the patients have suffered from the stone being compressed by a truss. Pregnant women are most subject to the disease. Strangulation seldom occurs. The tumour, however, varies in size, according as the bladder is full or empty. When distend- ed by urine, the patient experiences a good deal of irritation, and is obliged to evacuate the urine, to facilitate which he gets into the habit of pressing the tumour. Mesocolic hernia is that variety in which the intestines pass between the layers of the mesocolon. In like manner, when omentum or portions of intestine force their way through one layer of the mesentery, while the other remains entire, a mesen- teric hernia will be produced. From many other similar causes, hernial protrusions arise, but the nature of the disease is seldom ascertained during life, and is generally confounded with ileus and other affections. Phrenic hernia is sometimes congenital, and sometimes the re- sult of wounds, lacerations, or distention of the natural apertures of the diaphragm. In either case, the viscera of the abdomen, by being transferred to the chest, press upon and interfere with the heart and lungs, and give rise to asthma, palpitation and other violent symptoms. If strangulation should follow, other symp- toms will be superadded, and the patient cannot long survive. Children not unfrequently die an hour or two after birth from con- genital malformation of the diaphragm, and transposition of the abdominal viscera to the thorax. A remarkable case of the kind is recorded by Sir Astley Cooper, as having occurred to a Dr. Macauley. "The child was a full grown boy, remarkably fat and fleshy, and, when first born, started and shuddered, so that the nurse apprehended his going into fits; he breathed, also, with difficulty, and it was some time before he could cry, and when he did, there was something particular in the note. He seemed to revive a little in half an hour, and breathe more freely, but soon relapsed, and died before he was an hour and a half old. Upon dissection, when the sternum was raised, the sto- mach and greatest part of the intestines, with the spleen and part of the pancreas, were found in the left cavity of the thorax, having been protruded, through a discontinuation or rather an aperture of the diaphragm, about an inch from the natural pas- sage of the oesophagus." VARIETIES OF HERNIA. 127 TREATMENT OF VARIETIES OF HERNIA. For reducible ventral hernia, a well constructed truss is the proper remedy. When strangulated, the taxis and the ordinary remedies will generally answer; but if an operation should be re- quired, the stricture may be divided either upwards or down- wards, and caution observed in reference to the situation of the epigastric artery. Pudendal hernia is with difficulty supported by a truss or bandage; nor does the pessary, recommended by many surgeons, answer a very good purpose. In a woman, I once attended with Dr. J. G. Nancrede, I took a mould of the parts in plaster of Paris, and by forming a truss upon the exact model of the cast, succeeded in sustaining the rupture much better than with any other contrivance I ever resorted to. Should the parts become strangulated, and an operation be rendered necessary, an incision should be made in the labium, and the stricture divided inwards towards the vagina. Vaginal hernia is seldom strangulated, and may be generally reduced by taxis. It is more difficult to sustain however, by a truss, than even the pudendal variety. In thyroideal hernia, a truss can be adapted to the parts without a great deal of difficulty; should strangulation occur, however, the operation must prove both delicate and hazardous, as there would be risk of wounding the obturator artery, as well as the crural vessels. To avoid these, the division of the obtu- rator ligament and stricture should be made inwards, towards the ramus of the pubes; but there would, also, be some risk of wound- ing the obturator artery, in pursuing this plan, if it happened to come off from the epigastric. Perineal hernia, in the female, is best supported by a pessary, and in the male, by an elastic steel truss, with a pad " that goes between the thighs backwards and upwards to the loins, where it is attached to a steel belt encircling the body." When stran- gulated in the female, an incision should be made from the va- gina, and in the male over the tumour in the perineum. Ischiatic hernia is with difficulty kept up by the truss, and if strangulated, would require a complicated and dangerous opera- tion. For phrenic, mesocolic and mesenteric hernia, unfortu- nately, there is no relief. Cystic hernia may, in the commencement, be reduced, and prevented from protruding to any extent by a well contrived 128 ARTIFICIAL ANUS. truss; but when once it has become irreducible, will not admit of relief. If complicated with scrotal or other varieties of her- nia, and the operation for strangulation should be required, great care must be taken not to open the bladder instead of the hernial sac—as has happened in several cases. On Hernia, consult Pott's Works by Earle, vol. ii.; Hey's Practical Obser- vations in Surgery, 3d edit.; The Anatomy and Surgical Treatment of Inguinal and Congenital Hernia, by Astley Cooper, fol. Lond. 1804; Ditto the Anato- my and Surgical Treatment of Crural and Umbilical Hernia, part ii., 1807; Lawrence on Ruptures, 3d edit.; Scarpa's Treatise on Hernia, translated from the Italian, by John Henry Wishart, Edinburgh, 1814; J. Cloquet, Recher- ches Anatomiques sur les Hernies, 1817; A Treatise on Surgical Anatomy, part the first, by Abraham Colles, Philadelphia, 1820; C. Bell's Surgical Ob- servations; Drawings of the Anatomy of the Groin, by William E. Darrah, fol. Philadelphia, 1830; Treatise on the Radical Cure of Hernia by Instruments, &c, by Heber Chase, M. D., Philadelphia, 1836; Final Report of the Com- mittee of the Philad. Med. Soc. on the Construction of Instruments, &c, by Heber Chase, M. D., Philadelphia, 1837. SECTION IX, ARTIFICIAL ANUS. When the operation for strangulated hernia has been too long delayed, and the intestine has mortified, it sometimes happens that an artificial anus is formed. In such cases the inflammation, instead of extending throughout the peritoneum, and producing the patient's death, is limited to the neighbourhood of the stric- ture, and, terminating in the adhesive stage, glues the sound portions of intestine to the hernial sac. This adhesion becomes firmer and firmer, in proportion as the sloughing process, going on in the protruded parts, advances, until the sloughs are thrown off, and feeces are discharged externally. By this provision of nature, effusions into the cavity of the abdomen are, in nine cases out of ten, effectually guarded against. As in every case of her- nia the intestine is doubled upon itself, it follows that the two portions must lie parallel, or nearly so, with each other, and that ARTIFICIAL ANUS. 129 when an artificial anus is formed, an intermediate ridge or pro- jection will be the result. To the free admission of the faeces from the upper to the lower part of the canal, this ridge will prove in general, a serious obstacle; in most cases, indeed, there is a total cessation of fiaecal discharge by the rectum; so much so that the intestine is constantly empty, or, at most, contains only a glairy mucus. After a time, however, faeces in small quantity occasionally pass through the lower part of the canal, and are discharged from the rectum. This is owing, in part, to the contraction of the external orifice of the artificial anus, and, at the same time, to an enlargement of the passage, between it and the orifice of each gut. As soon, therefore, as the faeces leave the upper intestine, they fall into a "funnel-shaped" cavity, and meeting with some resistance from the contracted mouth of the opening in the integuments, are propelled by a circuitous route towards the orifice of the lower gut. An artificial anus, whether induced by a wound of the abdo- men, or by hernia, is a very grievous disease, not only subjecting the patient to great inconvenience, but endangering his life. Most patients, labouring under the infirmity, are troubled with colic and other derangement of the intestinal functions. Besides, they have no control, for want of a sphincter, over the faecal discharge. A prolapsus from one or both openings of the intestine, is by no means uncommon, and is sometimes exquisitely sensible. Artificial anus, when situated high up, or among the small intes- tines, is apt to terminate fatally—from inanition. TREATMENT OF ARTIFICIAL ANUS. Nature will often make surprising efforts towards restoration, and is sometimes abundantly successful. Aware of this, the sur- geon must not be officious, but patiently wait, so long as there is any prospect of a favourable termination. In the mean time, the patient should be supplied with a common truss, the pad of which must be broader than usual, and covered with a piece of bladder or oiled skin. This serves the purpose of restraining the fa?ces, and at the same time contributes, by blocking up the external opening, to direct them to the lower intestine. If it should be found, however, after the lapse of months, that there is no prospect of amendment, an operation may be attempted for 130 ARTIFICIAL ANUS. the relief of the sufferer. The indication to be fulfilled by this is to overcome the ridge-like barrier situated between the two intestines, and which prevents the direct descent of the excrement from one to the other. Desault, with this view, in- troduced into each orifice of the gut, plugs of lint or linen, add by these means frequently succeeded. A more expeditious, ef- fectual, and less troublesome operation, was proposed and exe- cuted by the late Dr. Physick, between the years 1808 and 1809. A crooked needle armed with a ligature, was passed for some distance within the orifice of one gut, and brought out at the other—traversing in its passage the coats of each. The ends of the ligature were then tied at the external opening, and formed a loose loop. This being suffered to remain for a week, caused the sides of the intestines to adhere to each other. Through the consolidated ridge, thus formed, an incision was afterwards made, and a direct communication established between the upper and the lower intestine. An operation, similar to that of Dr. Physick, was afterwards performed by the late Baron Dupuytren, in Paris, and to him the merit of the proposal is generally awarded by European writers—without the slightest foundation. Dr. Physick's claim to priority, as respects the operation for artificial anus above described, having, as just mentioned, been contested by European surgeons, the following statement on the subject from the able pen of Dr. Benjamin Horner Coates, of this city, must carry conviction to the mind of every unprejudiced person. "John Exilius, a Swedish sailor, aged nineteen years, was admitted into the Pennsylvania Hospital on the morning of the 20th of October, 1808, affected with a congenital hernia. He stated that he had passed the last fourteen days without having had a stool, and that on the 29th, he had been affected with sterco- raceous vomiting. These were renewed after his admission. After several other means had been employed to produce a re- duction of the hernia, the operation was proceeded to at half-past three o'clock the same afternoon, by the late Professor Wistar, in the presence of Dr. Physick. The sac being opened, the intes- tines were found firmly adherent to the testicle, and partially so, but with equal firmness, to the abdominal ring, so as to account for the impossibility of effecting a reduction by the taxis—they appeared to be a part of the ileum. A perforation existed in the side of one of them, of sufficient magnitude to permit the dis- ARTIFICIAL ANUS. 131 charge of a considerable amount of faeces. There were, however, no marks of mortification found, and the opening appeared to be the effect of mere ulceration. After the removal of the stricture and the application of a dressing, a dose of laudanum was admi- nistered, and the patient was returned to bed. Much enlarge- ment of the abdomen continued, accompanied with great general restlessness, and but a small quantity of the faeces was discharged from the wound, though various means were employed to pro- cure their expulsion. On the 22d and 23d, stercoraceous vomiting returned, and it was not till the 23d, that much relief was obtained. This was the result of a copious discharge produced by the injec- tion into the bowel of an infusion of senna. On the 24th, Dr. Wis- tar divided a small portion of the tendon of the transversalis abdo- minis, as well as of the neck of the sac, from which ensued much greater facility for the escape of the feeces. On the 30th of Oc- tober, the patient, by the regulations of the hospital, came under the care of Dr. Physick. On the 24th of December, the pro- jecting portion of the intestine was cut off close to the ring. This was done under the expectation that the open orifices thus left in the intestine would gradually be retracted within the ab- domen. On applying a ligature to a divided mesenteric artery, severe pain was produced in that cavity, which was relieved by rhubarb, laudanum, and aniseed. After waiting some time, and finding that retraction did not take place, as hoped for, another process was resorted to. A roll of waxed linen, such as is used in making bougies, and of the size of the fore-finger, was bent double and each end introduced into one of the orifices of the in- testine. The dresser then pressed the angular part of this tent backwards, in such a manner as to approximate the adherent in- testine to a straight position. So much pain, of a kind similar to colic, was produced by this pressure, that the plan was neces- sarily abandoned. The two ends of the intestine were found, by a careful examination, to adhere to each other for some distance, and the form, thus presented, has been compared in this case to that of a double-barrelled gun. The next method proposed by Dr. Physick, was to cut a lateral opening through the sides of the intestine where they were adherent. But not knowing the extent of the adhesion inwards, he thought it necessary to adopt some preliminary measure for ensuring its existence to such a depth as might admit of the contemplated lateral opening with- out penetrating the cavity of the peritoneum. By introducing 132 ARTIFICIAL ANUS. his finger into the intestine through one orifice, and his thumb through the other, he was enabled to satisfy himself that nothing intervened between them but the sides of the bowels. He was thus enabled, without risk, to pass a needle, armed with a ligature from one portion of the intestine into the other, through the sides which were in contact, about an inch within the orifices, which ligature was then secured with a slip-knot. This operation was performed on the 28th of January, 1809. The ligature was merely drawn sufficiently tight to ensure the contact of those parts of the peritoneal tunic which were within the noose. When drawn tighter, it produced so much pain in the upper part of the abdomen, of a kind resembling colic, that it became neces- sary immediately to loosen it. The ligature, in this situation, gradually made its way by ulceration through the parts which it embraced, and thus loosened itself. It was at several periods again drawn to its original tightness. After about three weeks had elapsed, concluding that the re- quired union between the two folds of peritoneum was suffi- ciently ensured, Dr. Physick divided with a bistoury all the parts which now remained included within the noose of the ligature. No unfavourable symptoms occurred in consequence. On the 28th of February, the patient complained of an uneasy sensa- tion in the lower part of the abdomen, and on the first of March he extracted with his own fingers some portions of hardened faeces from his rectum. On the 2d of March, two or three evacuations were produced in this manner. On the 3d, an enema, consisting of a solution of common salt, was directed to be given twice every day. The first of these occasioned a natural stool, about two hours after its administration. The same effect was produced on the 4th, 5th, and 6th, and the discharges from the orifices in the groin now became inconsiderable. Ad- hesive plasters, aided by compresses, were employed, not only to prevent the discharge of faeces from the artificial opening, but with the additional object of procuring the adhesion of the sides. This last effort was unsuccessful. On the 24th of June, an attempt was made to unite them by the twisted suture. Pins were left in for three days, and adhesion was, in fact, effected; but owing to the induration of the adjacent parts, the wound again opened. On the 27th of July, a truss of the common con- struction, furnished with a very large pad, and surmounted by a large compress, was applied to the wound. By these means ARTIFICIAL ANUS. 133 the discharge of faeces from the groin was completely prevented and the patient had regular evacuations per anum, except when from improper diet or cold, he became affected with diarrhoea. At such times a small portion of the more fluid matter escaped by the sides of the compress. Not satisfied with this state of things, Dr. Physick made several attempts to improve the patient's condition. On the 2d of August, a mould of the parts was taken in plaster of Paris, and being covered with buckskin, was employed as a pad for the truss. The expedient answered extremely well, as long as the patient continued in the same posture in which the mould was made; but as soon as the form of the parts was altered by a change of position, faeces escaped from the orifice. A bandage was then applied to the body, fur- nished with a thick compress, and having that part of it which crossed the patient's back formed of elastic, extensible wire springs, such as are used in suspenders. This, also, however, proved ineffectual. The truss with a compress and a large pad, stuffed in the common way, was then re-applied, and found to answer completely the purpose of preventing the discharge of faeces, the hope of an entire closure of the orifice being aban- doned. On the 10th of November, he was discharged from the hospital in good health and spirits, and applied himself with very good success to acquire the profession of an engraver. Dupuytren has invented a forceps of peculiar construction, called enterotome, for the purpose of bruising and breaking down by force the sides of the two intestines, and in this way opening a passage from one to the other. Dr. Physick's operation, it appears to me, in every respect merits the preference. Dr. Lotz of New Berlin, Pennsylvania, has succeeded, lately, in curing a case of artificial anus, by an ingenious improvement on the methods of Physick and Dupuytren. On Artificial Anus,Desault's Works, by Smith, vol. i., article Preternatural Ani, p. 306; Travers on the Intestines, p.295; Scarpa on Hernia, Memoir 4th, p. 288; Hennen's Military Surgery, 2d edit. p.407; Dorsey's Surgery, vol. i. p. !>6; Reybard sur les Traitement des Anus Artificiel, 8vo.; Account of a Case in which a new and peculiar operation for Artificial Anus was performed, in 1809, by Philip Syng Physick, M. D., then Professor of Surgery in the Uni- versity of Pennsylvania. Drawn up for publication by B. H. Coates, M. D., in North American Medical and Surgical Journal, vol. ii. p. 269; Lotz on Ar- tificial Anus, in American Journal, No. xxxvi. p. 367. 134 DISEASES OF THE RECTUM. CHAPTER VI. DISEASES OF THE RECTUM. It is but too common for students to pay particular attention to favourite subjects, and neglect others not less important. The diseases of the rectum, I have frequently perceived, are little relished; being considered not only loathsome and uninteresting, but very simple in their nature, and easily cured. Experience teaches the reverse. Many a patient has lost his life from an ill-managed fistula in ano, or from an operation upon it, unneces- sarily, or improperly performed. A small portion of dissecting- room labour,—too often wasted upon the muscles,—is the proper corrective for this error. The principal diseases of the rectum are prolapsus ani, tumours within the rectum, hemorrhoids, and fistula in ano: those less frequently met with, are imperforate anus, foreign bodies in the rectum, neuralgia, and spasms of the anus, atony and injuries of the anus, blennorrhagia, strictures and fissures of the rectum. SECTION I. PROLAPSUS ANI. From habitual costiveness, straining at stool, diarrhoea, dysen- tery, hemorrhoids, strictures in the urethra, stone in the bladder, drastic purgatives, irritation from ascarides, and various other causes, the lining membrane of the rectum, immediately above PROLAPSUS ANI. 135 the internal sphincter, is sometimes inverted, and protruded to a greater or less distance beyond the verge of the anus. Infants and very old people, are most liable to the complaint, which, if the tumour be large, recent, and accompanied by much inflam- mation, may terminate in gangrene, or give rise to symptoms of strangulated hernia. In general, however, this result is not to be apprehended, and the disease must .be considered as rather inconvenient and troublesome than dangerous. In some cases there is reason to believe that there is an intussusception of the gut itself, instead of an eversion of its lining membrane. In other instances, the sigmoid flexure, and other portions of the colon, may be invaginated and finally protruded at the anus. Even the ca?cum may undergo a similar displacement. Not unfrequently, the upper part of the rectum descends and lodges in the pouch of the same intestine. But these affections differ, in toto, from genuine prolapsus ani. To understand the true nature of prolapsus, it should be recollected that perpetual strain- ing from irritation, however induced, may give rise to infiltra- tion in the cellular tissue, beneath the villous coat, and that this congestion must have the effect, finally, of causing protrusion of the lining membrane of the gut. In chronic cases of the disease, or where unusually large protrusions have taken place, there is reason to believe that the folds of the inner coat, which line the pouch or natural sinus, above the internal sphincter, and which are uncommonly numerous and relaxed, are forced by the action of the abdominal muscles from their lurking-place, and carried in volumes beyond the verge of the anus. Several cases of the kind I have seen, and one especially during the winter of 1835, at the Philadelphia Hospital, in a man thirty-six years of age, named Dubois, in whom the protrusion, equal in bulk to the fist, and of a dark red colour, covered with irregular ridges and furrows, not unfrequently descended five or six inches beyond the margin of the anus. According to Mr. Mayo, of London, not only the mucous and submucous coats of the rectum are liable to eversion, but the muscular coat also—as is proved by a preparation in the Museum of King's College, of which Mr. Mayo has furnished a drawing. 136 PROLAPSUS ANI. TREATMENT OF PROLAPSUS ANI. In the treatment of this disease, it is highly important to return the protruded parts as speedily as possible. This is best accom- plished by placing the patient on his back, elevating the hips and shoulders, and pressing gently with the fingers,—previously oiled,—upon the tumour. Should the parts be very tender and inflamed, and offer much resistance, the efforts towards reduc- tion must be discontinued, until full benefit has been derived from general and local blood-letting, mild purgatives, cold poultices, astringent washes, &c. To support the protrusion after it has been reduced, and to prevent its recurrence, a piece of lint, covered with some mild ointment, should be applied to the anus, and over it a soft sponge and bandage. Rest, also, for some time in the horizontal position, will prove essential. Dr. Phy- sick has sometimes cured prolapsus ani by confining the pa- tient for a considerable time to a diet of rye mush and sugar. It must be obvious, however, from what has been stated, that much will depend upon the cause of the disease, as respects the prospect of a permanent cure; and that so long as many of the causes pointed out continue to operate, little advantage can be gained by any mode of treatment that may be instituted. The protruded parts, nowT and then, become indurated and incapable of reduction. Under such circumstances, it may be necessary to remove them, either with a ligature or knife. When the tumour appears to be very vascular, and is small, I should pre- fer removing it by the double cannula and wire, as used by Dr. Physick for hemorrhoids. But when it has long remained pro- truded, is disorganized and has, apparently, very little connexion with the parts within the rectum, I should resort to the operation long ago practised by Hey—the removal of one or more flaps, or of the whole mass, by excision. This I have practised suc- cessfully, in several cases, without inconvenience. At other times, considerable hemorrhage has followed the operation. The young surgeon should be on his guard, therefore, and take care how he ventures to cut off a large reducible prolapsus of the mucous membrane; and above all, that he does not ampu- tate an invaginated colon or cacum, under the idea that he is merely removing folds of the lining membrane of the rectum. An ingenious operation, first suggested and practised by Du- PROLAPSUS ANI. 137 puytren,—and for which, in a former edition of this work, I have failed to award him the credit he deserves,—is better cal- culated, so far as I can determine, by a few trials of it, to effect a cure of prolapsus ani than any other ever invented. Instead of cutting away the mucous membrane of the gut, Dupuytren seizes with a pair of small forceps a greater or less number of the radiating folds of skin which naturally surround the outside of the anus, and with a pair of curved scissors, cutting from without inwards, removes them. When the prolapsus is large, these folds should be pinched up in two or three different places, and cut off: but in small tumours of the kind, such as are gene- rally met with in children, the removal of two or three folds at a single spot will commonly prove sufficient. Occasionally it is necessary to prolong the incision into the rectum as far as the point where the radiating folds are fused insensibly into the mucous membrane of that gut. The object of this operation, as will be understood immediately, is to contract—through the me- dium of a cicatrix, which must necessarily form when the wound made by the scissors has healed up—the margin of the anus, or to diminish the size of that opening, and thereby to afford a support to the loose folds of the mucous membrane of the gut they were destitute of in the relaxed condition of the parts, as usually found in cases of prolapsus. In an obstinate case of this disease, in a girl three years old at the Philadelphia Hospital, during the winter of 1835,—and where the protrusion, the size of an egg, had been partially removed, previously, by dissecting off ribands of the lining membrane with a view of exciting the adhesive inflammation,—I succeeded in effecting a perfect cure of the prolapsus, merely by cutting away, in two places, the converging folds of skin, in the manner described. In the case of Dubois, referred to above, I performed a similar operation; but the long standing of the disease, and the extraordinary bulk of the tumour, prevented me from succeeding. M. Robert, of the hospital La Pitie, performed in June 1839, an operation on a washer-woman thirty-three years of age. " The patient having been prepared for the operation, by progressive diminution in diet and the use of opium in order to effect long- continued constipation, M. Robert proceeded to operate in the following manner. An incision was made on each side of the anus, each incision being commenced a few lines external to the orifice, and carried backwards towards the coccyx. The 138 PROLAPSUS ANI. fold of integument between the incisions, together with the por- tion of sphincter it covered, were removed, and the muscle was thus shortened by half its length. The wound was united from one side to the other by three points of suture. On the sixth day after the operation the sutures were removed. Union was nearly complete, but a fistulous passage remained from the anus to the coccyx. On the fifteenth day, the woman had not passed any faeces. On the next day, the want of* defecation being felt, in order to prevent any straining, the bowels were relieved by the curette. On the forty-first day the patient, who before the operation could not retain her faeces, kept an injection during the whole day; there was no more prolapsus, the opening had become one of the ordinary size ; but the finger, when introduced, did not experience the energetic contraction of the sphincter which oc- curs in the normal state. With the exception of a slight pro- trusion of mucous membrane, the cure was complete in August."* However, as regards the operations of Hey, Dupuytren, and Robert, it should be remarked, that if carried too far, there may be a possibility of producing such a contraction of the parts, within the rectum and at the anus, as to interfere, ever afterwards, with the evacuation of the faeces. Cases of the kind have been reported by Chesselden, and by the old anatomist Keil, where the patients could never procure a stool without the assistance of a clyster, and, even with that alternative, suffered immensely. It must not be supposed, from the remarks already made, that an operation will be required, necessarily, for the cure of pro- lapsus ani. On the contrary, many cases occur, in children es- pecially, where by early attention to the disease, the use of sa- turnine and astringent injections, keeping the bowels in a soluble state, and above all, by obliging the child to evacuate the fa?ces whilst in a standing position, perfect cures will be effected in a few7 weeks or months. Perforated ivory balls, gum elastic and other pessaries, the craw of a turkey, lint plugs, sponges, steel trusses, and other contrivances have been resorted to for sustaining the prolapsed parts, or for effecting radical cures through the medium of adhe- sive inflammation, but generally without effect. As some pa- tients, however, have derived benefit, undoubtedly, from them, * Journal of Medical Sciences, No. 1, new series, Jan. 1841, p. 228. TUMOURS WITHIN THE RECTUM. 139 they should in certain cases be tried. But if, upon trial, they are found, as is generally the case, to act as suppositories, they will do more harm than good, and should be abandoned. On Prolapsus Ani, consult Monro's Essay on Procidentia Ani. in Edinburgh Physical and Literary Essays, vol. ii. p. 353; Chesselden's Anatomy of the Hu- man Body, 1792; Chevalier on relaxed Rectum, in Medico-Chirurgical Trans- actions, vol. x. p. 401,1819; Sabatier Memoires sur les Anus Contre Nature, in Memoires de la Academie Royal de Chirurgie, torn. xv. 12mo. edit.; Hey's Practical Observations in Surgery, p. 438, London, 1814; A Treatise on the Diseases of the Urethra, Vesica Urinaria, Prostate and Rectum, by C. Bell, with notes by J. Shaw, p. 324, London, 1820; Dupuytren on Prolapsus of the Rectum, in Clinical Lectures on Surgery, at Hotel Dieu, &c, translated by Doane, p. 99; Observations on Injuries and Diseases of the Rectum, by Her- bert Mayo, p. 28, London, 1833; American Cyclopaedia of Practical Medicine and Surgery, edited by Isaac Hays, M. D., Partvi. p. 95, Philadelphia, 1S35; Colles' Surgical Anatomy, p. l'J9. SECTION II. TUMOURS WITHIN THE RECTUM. Sarcomatous and other tumours occasionally sprout from the surface of the lining membrane of the rectum, and according to their bulk and figure, excite more or less irritation, diarrhoea, &c. Sometimes they originate between the coats of the intestine. Mr. John Bell* speaks of enormous tumours of the rectum, soft, woolly, lubricous, of a shining red colour, involving the whole circle of the anus, extending beyond it many inches, and retiring deeply within the cavity of the gut. Such I have not seen. Polypi of the rectum are sometimes met with in young children. They are red and fleshy, and resemble a cherry in appearance. Gigon has lately furnished a detailed account of such tumours.f * Principles of Surgery, vol. iii. p. 188. f L'Experience, June 1st, 1843. 140 TUMOURS WITHIN THE RECTUM. TREATMENT OF TUMOURS WITHIN THE RECTUM. When the tumour originates by a very narrow pedicle, and moves freely about, it may sometimes be pulled away with a pair of forceps; but when its base is broad, the ligature will prove the safest and most effectual remedy. It will answer no purpose, however, merely to encircle the swelling with a single cord. Many years ago, I was consulted by a gentleman of Maryland, on account of a fleshy excrescence, about the size of an egg, which arose from the walls of the rectum an inch and a half above the sphincter ani. A surgeon of eminence had undertaken to remove the tumour by a single ligature; but, un- able to noose the base of the swelling, the anterior part only was destroyed, and the operation proved fruitless. I determined to proceed in a different way. Directing the patient to sit for half an hour over a tub of warm water, and by straining, to force the tumour as far as possible below the sphincter, I passed a crooked needle, armed with two ligatures, through its substance, as near as possible to the coats of the bowel, and tied one on each side. In four or five days the diseased mass sloughed away, and a perfect cure followed. By similar means I have removed, repeatedly since, both large and small tumours, and almost invariably with success. x The knife, upon such occasions, should never, 1 think, be em- ployed, on account of the hemorrhage which would be almost certain to follow the extirpation of a vascular tumour within the walls of the rectum, and the difficulty which the surgeon would experience, necessarily, in securing the vessels in that situation. The advantage possessed by the double, over the single ligature, is, that two portions of the tumOur being embraced at the same moment, the sloughing will be accomplished with greater rapi- dity than if the whole mass were encircled. Besides, the liga- tures having been passed through the substance of the tumour, cannot be detached until the tumour is removed. On Tumours of the Rectum, consult C. Bell's Operative Surgery, vol. i.; J. Bell's Principles of Surgery, vol. iii. p. 191; A Treatise on the Diseases of the Urethra, Vesica Urinaria, Prostate, and Rectum, by C. Bell, p. 3"3. - HEMORRHOIDS. 141 SECTION III. HEMORRHOIDS. Hemorrhage, occasional or periodical, from the verge of the anus, or from the cavity of the rectum, is very common among persons of indolent and sedentary lives, and of full habits of body. Costiveness, pregnancy, severe exercise on horseback, and many other causes may give rise to the complaint. It is still a disputed point whether the blood proceeds from varicose distention of the hemorrhoidal veins, or is poured into cysts formed of the cellular membrane, between the coats of the bowel, or beneath the integuments of the anus. Both opinions are, I am sure, well founded. In by far, however, the greater number of instances, hemorrhoidal tumours are formed by en- largement of the veins of the rectum. This varicose condition of the veins is brought about, there is reason to believe, by re- peated straining at stool, during which the sphincters are of ne- cessity relaxed, so that a column of blood, unsupported by valves, and driven by the action of the abdominal muscles against the mesenteric veins, dilates, and not unfrequently, bursts them. In the course of time, from repeated attacks of inflammation, coagulable lymph is thrown around the distended veins, their coats are thickened, and fleshy tumours created, which enclose the veins in their substance, and either diminish, or obliterate, altogether, their cavities. But more or less of the cavity of the vein generally remains concealed within the tumour, and often this cavity is much larger than the original vessel, and, if opened, will shed blood profusely. Hemorrhoidal tumours, so long as they remain within the cavity of the rectum, are mostly free from pain; when they protrude, however, beyond the anus, and are compressed by its sphincter, they frequently become exquisitely sensible and enlarged. The margin of the anus is sometimes surrounded by a cluster of tumours of a dark red or purple colour; at other times only a single protuberance is visible. VOL. II.—K 142 HEMORRHOIDS. TREATMENT OF HEMORRHOIDS. The remedies for this disease are either palliative or radical. Among the former may be enumerated leeches, cold astringent washes, astringent ointments, rest in the horizontal position, mild laxatives, general blood-letting. In several instances I have derived great benefit from a poultice made of the pulp of the green persimmon, and also from a decoction of the bark of the persimmon-tree. The extracts of stramonium and belladon- na, I have used for twenty years, and have found them, in parti- cular cases, extremely soothing, and useful. Internally admi- nistered, there is nothing better than the old remedy extolled by Benjamin Bell—the balsam copaiba?. When hemorrhoids become large and troublesome, or irre- ducible, an operation will be required. The knife, or ligature, will prove equally successful. The use of the former, however, is sometimes followed by profuse hemorrhage, violent inflam- mation, and even death. Three instances of fatal termination are related by Sir Astley Cooper. The first was that of a lady, who died in a week from peritoneal inflammation, induced by the removal of a single pile by the scissors; the second that of a gentleman who died from hemorrhage on the second day after the operation. In the third case Sir Astley removed a large hemorrhoid by the scissors from the anus of a nobleman. "In about ten minutes after the operation, he said, 'I must relieve my bowels,' and he rose from his bed and discharged into the close stool what he thought to be faeces, but which proved to be blood. In twenty minutes he had the same sen- sation, and evacuated more blood than before; in about the same lapse of time he again rose, and soon became very faint from the free hemorrhage. I therefore opened the rectum with a speculum and saw an artery throwing out its blood with free- dom. I, therefore, requested him to force down the intestine as much as he could, and raising the orifice of the bleeding vessel, with a tenaculum, secured it in a ligature and also compressed the artery with a piece of sponge. His lordship bled no more. On the following day he was low, his pulse very quick, and he had a shivering; on the next day he complained of pain in his abdomen; he had sickness and tenderness upon pressure, and in four days he died." My friend, Dr. William M. Fahnestock, HEMORRHOIDS. 143 an experienced physician of Bordentown, has obligingly furnished me with the following interesting detail. Bordentown, N. J., September 20, 1844. My dear sir:—Agreeably to your request,I embrace the ear- liest moment to give you a hasty sketch of the formidable case of internal bleeding, following the excision of an old hemorrhoidal tumour, which I named to you yesterday. On the first day of April last, I operated on Capt.----------, U. S. N., for an extensive Fistula in Ano; wThich opened exter- nally three and a half inches from the anus, and running a zig- zag course, penetrated the rectum about an inch above its termina- tion. Some weeks afterward, before the incision united, another sinus opened into the bottom of the wound, an inch from the bowel, and communicated with the gut about half an inch higher up and a little to the left of the first. In laying open this sinus, I endeavoured to come into the same line with the former cut, but the bistoury was turned aside by a small hardened tumour, which proved to be the remains of an old hemorrhoid, and which hung down into the crotch of the wound at its junction with the divided bowel, and interfered so much with the healing process, as to call for its removal. I first suggested caustic, and then the ligature, but the Cap- tain becoming somewhat impatient under his protracted suffer- ings, and the frequent applications and injections of solutions of sulphate of copper and corrosive sublimate, preferred the knife to the tardy process of either of the foregoing plans, and I yielded to his preference. Perfectly aware of the danger attendant upon the removal of tumours in this situation, (an inch within and above the verge of the anus,) still I did not apprehend much difficulty from this one, which was neither dark nor turgid, but of a re- markably light pink colour, and had the appearance of simple induration of the mucous and cellular tissue: twenty-five years having elapsed since he suffered any inconvenience from the he- morrhoidal affection; quite a sufficient time, we might suppose, to obliterate all the characteristics of its original organization. I seized the tumour, (which was little more than a half an inch in length, and one-third of an inch in diameter, and which resembled very much an ordinary uvula,) with a tena- culum, and removed it by a stroke of the knife. As there was less than a table-spoonful of blood lost, I waited at least ten 144 HEMORRHOIDS. minutes to observe whether there would be any further flow— then wiped the cut surface two or three times with a sponge, and not observing any further oozing, dressed it with lint. My patient was so slightly incommoded by its excision, that he got up and wralked about the room a full hour without experiencing any inconvenience, or the least appearance of hemorrhage: but having a hard evacuation from the bowel at the expiration of that time, it was followed by a gush of blood. I was sent for, but found very little blood issuing from the part. However, to guard against any recurrence, I introduced dossils of lint covered with powdered alum to the spot previously occupied by the tu- mour, filled up the whole chasm and secured it with a T band- age, making all the compression I could by these means. In the course of two hours I called to see the Captain, (having left particular directions to send for me immediately on the discovery of any return of the bleeding, but which they did not find ne- cessary to do;) and found him on the bed very pale and faint, pulse extremely weak and flagging. I apprehended, at once, internal hemorrhage, and on removing the dressings, was assailed by a gush of at least two pounds of clotted blood, followed by a stream of hot liquid. I instantly passed my finger up the bowel, and found that the cut surface had retracted from the situation it had occupied, up within the gut an inch or more above its for- mer position; which I discovered by the warm blood pouring into the bowel. Keeping my finger on the spot, I introduced a small tenaculum, (during which time both hands continued to be flooded with successive gushes of blood,) and was fortunate enough to secure the place with a ligature: which was accom- plished with a great deal of difficulty, as the bleeding surface was at the extreme reach of my finger, and which had to be kept on the spot. After the finger was removed from the bowel, there came away, again, two pounds more of dark, grumous, clotted blood, which had accumulated there: so that my patient lost, at the smallest calculation, five pounds of blood; and as he was almost entirely insensible to these proceedings, life must have succumbed, had the hemorrhage continued but a short time longer. The ligature came away on the seventh day, and my patient was delivered from all impending danger. But few persons can imagine the situation of a patient under these circumstances, without beholding the scene, and no one realize the feelings of a surgeon, who has to encounter a case V HEMORRHOIDS. 145 of this nature, without being placed in the same dilemma, and having the dread responsibility resting solely upon himself. Se- curing the bleeding surface in that situation, I deem ray most successful surgical achievement during a practice of twenty-two years; and when reflecting upon the fatal issue of three somewhat similar cases in the hands of Sir Astley Cooper, regard myself to be one of the most fortunate men who has had the temerity to make an incursion, with knife in hand, into this treacherous domain. Yours, very respectfully, &c, WM. M. FAHNESTOCK. Professor Gibson, Philadelphia. Similar cases have been reported by other writers, both in this country and in Europe. When we recollect, indeed, that piles consist, in nine cases out of ten, of dilated veins, and that there are no valves from the anus to the liver, so that the whole column of blood must press upon the rectum, it is only surprising that surgeons, knowing these facts, should undertake to operate as often as they do, with the knife and scissors, and that a much greater number of accidents have not been met with. The latter circumstance can only be accounted for by the fact that tumours, which were originally varicose veins, have become obliterated by adhesive inflammation, or been converted into disorganized masses of cellular membrane, veins and skin, and that when, under these circumstances, clipped off by a cutting instrument, have shed little or no blood. Such being the case, it is impor- tant to draw a distinction between a cluster of dilated veins, within the sphincter, or projecting beyond the margin of the anus, and those lifeless, indurated, growths, which so often occu- py the same situations. The latter may be safely cut away; but the former never can, without imminent risk of the patient's life. It is true that whilst most eminent surgeons are adverse to the removal of venous hemorrhoids by the knife, one or two others, equally eminent, have advocated the practice when conjoined with collateral means. Thus, Dupuytren, the magnus Apollo of French Surgery, has boldly recommended and practised not only the removal of piles by cutting instruments, but the application of the actual cautery, immediately afterwards, for stemming the 146 HEMORRHOIDS. torrents of blood. His own mouth has sufficiently condemned, we think, both the operator and the operation. "I have seen you," says he in his Lectures, " shudder more than once at the sight of the red-hot iron, and at the cloud of smoke which arises from the cauterized part; you may judge what an impression such a preparation would produce on the friends and relations of the patient, who are not, like you, accustomed to such scenes." Again: "It is also to avoid this disastrous occurrence—hemor- rhage—that we make it a rule not to apply the dressings for some hours after the operation, because it is to be feared that the dressings would only hinder the blood from flowing out, and thus cause it to flow back into the superior intestines." What we apprehended happened the next day; an internal hemorrhage manifested itself; the pupil of the ward was not mistaken. He gave him (speaking of a particular patient,) an enema, which brought away a great quantity of blood; a second enema brought a considerable clot. He then made the patient strain first to ex- pel any blood that might remain, and, secondly, to cause relax- ation of the sphincter, and exhibit the surface of the divided arteries: then he applied to the bleeding parts two red-hot iron instruments. The quantity of blood lost in this operation has been estimated to be three, four, and five pounds. It flows into the descending, the transverse, and the ascending colon, and as far as the caecum, but never beyond this. From the effect of the cauterization he experienced a retention of urine, and it was necessary to use the catheter. After the evacuation of a great quantity of urine, he felt violent pain, which did not cease until the organ returned to its usual state. Again: a very wealthy banker is attended by Dupuytren, who, with a pair of large for- ceps, pulls down the hemorrhoids and cuts them off. "At the end of a quarter of an hour, the patient became pale, fell into a state of extreme weakness, the pulse small and hard, a cold per- spiration covered the body, and he felt a sensation of heat in the abdomen, continually ascending. The professor immediately re- commended the patient to make expulsatory efforts, and a great quantity of scarcely coagulated blood was discharged. Cold in- jections were useless; the hemorrhage was not stopped: then a pig's bladder, stuffed with lint, was introduced. This succeeded completely: but it was not without great difficulty it could be kept in its place; involuntary expulsatory efforts tended incessant- ly to displace it, and actually did so several times. This hemor- HEMORRHOIDS. 147 rhage weakened the patient very much, and would undoubtedly have been fatal, if it had not been arrested so promptly." The banker's brother had a similar disease, is treated in a similar manner, and would certainly have died, but for the presence of mind of another brother, who in the absence of the surgeon, introduces the pig's bladder, and stops the blood. "But the loss of blood was so great that the patient was a long time before he recovered." In another instance, a Scotchman, an officer of dragoons, is subjected to excision. " There were three tumours not very voluminous, and as there was but a trifling effusion of blood, M. Dupuytren thought that cauterization might be dis- pensed with. About five hours after the excision, all the cha- racteristic symptoms of hemorrhage in the rectum were mani- fested : anxiety, rigors, inclination to vomit, cold perspiration, sinking of the pulse, convulsive contraction of the limbs, inexpli- cable agony, vertigo, syncope, tremors increasing, the patient went to stool, and the expulsion of a considerable quantity of partly coagulated blood, gave him visible relief. At the expira- tion of about an hour, the symptoms returned with increasing intensity; they produced complete collapse. The patient re- quested a notary should be sent for, and hastened to arrange his affairs, preferring death, which he thought inevitable, to caute- rization. With the aid of the speculum, the place from whence the blood flowed was easily found, and the effusion stopped by the application of a bent cauterie en haricot heated to a white heat; a wick was kept in the rectum, and in a few days the pa- tient was perfectly cured." Other cases are reported, in favour of excision and the cautery; but the details correspond so exact- ly with each other, that it is superfluous to state them. Besides, the disastrous effects of excision and the cautery, already pointed out, it should be mentioned, (and the fact is admitted by Du- puytren,) that contraction of the anus, to such a degree as great- ly to interfere with the patient having a stool, not unfrequently follows. Under all these circumstances, may we not exclaim, Cui bono? Why subject an unfortunate individual to such tor- ture? Why give rise to hemorrhage, merely for the sake, appa- rently, of showing our dexterity in stopping it? The ligature, then, in our estimation, is the only safe opera- tion, for the generality of hemorrhoidal tumours. As practised by the older surgeons, and by most of the moderns, there can be no doubt that inconvenience, and sometimes very severe pain, and other unpleasant symptoms, follow its application; but that 148 HEMORRHOIDS. any thing like the consequence spoken of by old Petit, and handed down from one generation to another,—symptoms of strangulated hernia, and death—ever follows from performing the operation as it ought to be performed, or even when per- formed in the most bungling manner, I am very far from be- lieving. To the late Dr. Physick we are indebted for the best mode of performing this operation. A double cannula of the ordinary form, but only two inches long, is selected, and "a piece of tough. flexible, pure iron wire, one twenty-fourth part of an inch, or rather less, in diameter, having firmness enough to allow of its being pushed backwards and forwards in the cannula," is passed through both barrels of that instrument, and whilst one end is secured at the ring of the cannula, the other remains loose. A loop being formed adapted to the size of the hemorrhoid, is passed around it, and then drawn as firmly as possible, by pull- ing upon the extremity of the wire projecting from the lower end of the cannula with a pair of flat pliers, and then securing its end to the opposite wing. In twenty-four flours, or some- times, twelve, the wire is loosened from the wing of the instru- ment, straightened by the pliers and cautiously pushed back, and its loop disengaged from the tumour, which by that time is commonly found black, shrivelled and free from pain. A poultice is then applied, and in a few days the tumour is entirely se- parated. The peculiarity, it will be perceived, of the above operation, consists in the unusual firmness with which the wire is drawn, and its being removed in a few hours, instead of being suffered to remain for several days. " No one can properly ap- preciate," says Dr. Physick, " the advantages resulting from the above method of removing hemorrhoidal tumours, who has not seen them treated, by allowing the ligature to remain during the separation of the part. Under that mode of operating, the patient is never at ease during the whole time; the discharge of the faeces is often excruciating, even moving in bed is dreaded, and in the last case in which I performed the operation in that manner, the convulsive twitchings of the lower extremities, which were induced, became so frequent and violent, that I was uneasy, through an apprehension of tetanus being the conse- quence. It seems to me probable, that one reason of the dif- ference between the effect of the wire, and a common ligature may be, that however firmly the waxed ligature may be drawn and tied on the base of the tumour, before a second knot can be HEMORRHOIDS. 149 tied to secure the first, the elasticity of the parts compressed opens the first knot a little, and of course the exclusion of blood, and nervous influence is not so complete as when the wire is used, which can be fastened on the arm of the instrument at the time when it is drawn round the swelling as tightly as possible. The pinch given by the wire is soon destructive, and any degree of restoration is rendered impossible. " It might be supposed, if a thread were used, it could be cut off after a short time; but the swelling comes on so speedily, the parts retract so much within the anus, and are so extremely ten- der to the touch, that it is difficult to find the noose: when found, the operation of dividing it either with knife or scissors, is pro- ductive of so much pain, that I have known some patients refuse to submit to it. The removal of the wire occasions no pain. It may be proper to mention, that when the tumour happens to be attached to the inside of the anus, anteriorly, some difficulty in voiding urine is often complained of; but this symptom, always, in my patients, has subsided immediately after the removal of the wire. Where," Dr. Physick further remarks, " hemorrhoidal tumours are only protruded in the act of evacuating the fa?ces, then their excision would be attended with great risk of hemor- rhage. This some have denied, but having twice witnessed the fact to a very alarming extent, I wish, on all occasions, to guard against it." For many years I have practised the operation just described, both on small and large hemorrhoidal tumours, and in a great many instances, and can positively declare, that, although I have often known very sharp, and severe pain to follow the tighten- ing of the ligature in some, that in others very little complaint Has been made, and that in all very perfect and speedy cures have been accomplished. In proof of this, I shall relate a case which, I think, will be acknowledged to be equal in extent to any reported by Dupuytren. Mr. B., a respectable merchant of Danville, on the Susque- hanna, had suffered for fifteen years with internal hemorrhoids. His constitution was naturally very fine and vigorous, but from repeated hemorrhages from the rectum, he had become ema- ciated, and so debilitated, and suffered so much pain from the protrusion of the tumours, that he could scarcely attend to his business, and life had almost become a burden to him. When I saw him, his skin was of a pale yellowish hue, and his whole 150 HEMORRHOIDS. aspect cadaverous. After resting a few days, to recover from the fatigue of his journey, he was directed to sit for half an hour over a bucket of warm water, and force down gradually the tu- mours. They came out, and as they descended became ravelled up into rolls, each as thick as the thumb, covered with blood and sero-purulent matter. There were two or three masses which completely surrounded the verge of the anus, but which pre- sented, when superficially examined, an irregular, tuberculated, dark purple, very vascular, highly sensitive tumour, as large as the fist. The patient was put to bed, a gentle aperient ordered, and the next day, immediately after the tumours (by straining over warm water) had been forced down, was laid on his side over the edge of a bed, and the largest and most painful mass selected, included in the iron wire ligature, as near its base as possible, and the wire drawn with all the force I was master of. The pain, for an instant, was agonizing; but soon subsided— owing to the death of the tumour, thus so suddenly brought about. In fifteen or twenty hours, the wire was removed, and a warm poultice applied to the parts. In four days the remains of the tumour were completely separated, and the patient returned home in a fortnight, perfectly cured of the protrusion and of the hemorrhages, and in a few months recovered his health. Eight or ten years have now elapsed since the operation; and I have never heard of his having had a return of this complaint. It may be asked what became of the remaining tumours. They were obliterated, by the supervention of the adhesive inflamma- tion—a fact very important to be known, and an occurrence by no means uncommon. Aware of this, the surgeon should always make it a rule never to include numerous hemorrhoids, or a very large mass, in a ligature, at a single operation, (in order to guard against violent symptoms,) but take his chance of curing all by one operation, and of repeating it, subsequently, should the re- maining tumour require it. A case, in some respects similar to that of Mr. B., I operated on, in presence of Dr. Physick, eleven years ago, and with the same happy result. The patient, Mr. W., long before and since the operation, a most valuable officer of the government at Washington, had determined to abandon his office, unless he could have obtained relief. In conclusion I may remark, that no surgeon can properly appreciate the value of the ligature unless he use it according to the principles first pointed out, and unless he fulfil the most im- portant indication—to draw the wire with very great firmness. FISTULA IN ANO. 151 It would be unfair, however, not to state, in addition to what has been said in relation to the ligature and the knife, that there are some surgeons in this country who still prefer the latter operation, notwithstanding the reported cases of serious conse- quences resulting therefrom. In particular I may remark, that Dr. John C. Warren, the distinguished professor of Boston— the extent of whose practice has been equal, perhaps, to that of any surgeon in the United States, and whose attainments, judgment and skill are unquestionable—informs me that he has removed by excision, one hundred and sixty hemorrhoids, and excised and tied thirty-five, without ever having met with an unpleasant symptom. Instead of the knife and ligature, a remedy has lately been furnished by Houston,* for certain varieties of hemorrhoids, likely to prove very useful and to come into gene- ral practice—the application of pure nitric acid to the tumours, after they have been fairly brought down by straining over warm water, while the patient is on the night stool. On Hemorrhoids, consult Abernethy on Hemorrhoidal Diseases, in Surgical Works, vol. ii.; Earl on Hemorrhoidal Excrescences, 1807; Kirby on the Treatment of Hemorrhoidal Excrescences; Ware on the Treatment of He- morrhoids ; A Practical Treatise on Hemorrhoids,&c. by George Calvert; The double Cannula and Wire recommended in the Operation of Extirpating Scirrhous Tonsils and Hemorrhoidal Tumours, by Philip Syng Physick, M. D., in Philadelphia Journal of Medical and Physical Sciences, vol. i. p. 17,1820; Excision of Hemorrhoidal Tumours, in Clinical Lectures on Surgery, by Du- puytren, translated by Doane, p. 105, Phil. J833; Observations on Injuries and Diseases of the Rectum, by Herbert Mayo, p. 53, London, 1833. SECTION IV. FISTULA IN ANO. When an abscess forms in the cellular membrane surround- ing the rectum, or about the verge of the anus, and leaves, after * Dublin Journal of Medical Sciences. 152 FISTULA IN ANO. its contents are discharged, one or more small openings com- municating with its cavity, the disease is denominated fistula in ano. Other appellations have also been invented, expressive of the particular situation of the fistulous orifice, and the extent of the disease. If the fistula opens upon the surface of the in- teguments, it is called an incomplete fistula; if it communicates with the rectum and not with the integuments, an internal fis- tula; and when there is an opening in the gut and another through the skin, a complete fistula. The formation of a fistula in ano is often denoted by rigors, a painful swelling about the ischium or perineum, difficulty of passing urine, and by irritation of the rectum and neck of the bladder. During the progress of the disease, the patient, in many instances, suffers immensely; at other times, the abscess forms and breaks almost without the patient being aware of its existence. Generally the abscess communicates with the in- teguments by a single opening; occasionally three or four are met with; and I once attended a case of long standing, in which there were no less than fifteen. In healthy constitutions the ab- scess does not differ from that of the common phlegmon, met with in other parts of the cellular tissue. In consumptive and scrofulous patients, however, the disease often assumes a dif- ferent shape. The surface of the integuments is covered wTith an erysipelatous inflammation, the fever, sickness, and pain are very considerable, the matter is discharged in small quantity, from a sloughy, ill-conditioned opening, or from a ragged un- healthy surface. The origin of fistula in ano cannot be always satisfactorily traced. Sometimes it arises from irritation about the rectum, from local injury, from the lodgement of undissolved articles of food taken into the stomach, and passed through the intestines as far as the rectum, such as the bones of fish or fowls. Severe and long-continued exercise on rough-going horses, I have sometimes known to lay the foundation of the complaint. Hemorrhoids, there is reason to believe, often contribute to the disease. The same may be said of severe colds and coughs. TREATMENT OF FISTULA IN ANO. An opinion very generally prevails that every fistula in ano requires an operation. There cannot be a greater mistake. So FISTULA IN ANO. 153 far from it, almost every sinus, I am inclined to think, in a pa- tient tolerably healthy, might be healed, if attended to in the commencement, and judiciously managed. Nothing will contri- bute more to this end than absolute rest, simple dressings, mode- rate diet, and mild laxatives. I have known a fistula,—protracted and kept open for months while the patient walked about,— healed in a week by perfect quietude, and the horizontal position. It frequently happens, however, that the surgeon is not called until the disease is firmly established, and an operation urgently demanded. But, before he undertakes it, the operator would do well to soothe the parts, and reduce the inflammation and callosity about the sinus by emollient poultices, and after the irritation has subsided, gradually enlarge the fistulous orifice by bougies, (if necessary,) before an examination with the probe is entered upon. If these precautions are neglected, and the fistula probed at once, the patient will suffer, as I have often witnessed, immensely, and, indeed, will experience infinitely greater pain than from the operation itself. It will still remain to inquire concerning the patient's general health. If consump- tive, the operation can answer, generally, no good purpose; on the contrary, it will aggravate, if the fistula should be healed, all the pectoral symptoms. When determined upon, the operation may be performed, by a common probe-pointed bistoury, by the sheathed bistoury of Dr. Physick, or by the knife of Cruikshank. The objection to the probe bistoury is that it will sometimes be necessary, when there is no opening between the gut and sinus, to make one. For this purpose an instrument with a sharp point will be re- quired. Dr. Physick's instrument was constructed with this view, and possesses the additional advantage, from being co- vered by a silver sheath, blunt on its edges, of not cutting the track of the sinus whilst passing along, until the operator desires so to do. Cruikshank's bistoury is constructed with a move- able stilet that can be pushed forward or retracted at pleasure, the point of which is intended to pierce the gut, and then to be withdrawn that the surgeon's finger may rest on the blunt ex- tremity of the knife. Previous to the operation, the rectum is emptied by a clyster, and the buttocks being turned towards the light, are held asun- der by assistants, while the patient stoops forward and rests his 154 FISTULA IN ANO. body and arms upon the table. The surgeon introduces a fore- finger, oiled, into the rectum, passes the probe into the sinus, examines carefully its situation and extent, and having satisfied himself thoroughly in this respect, carries the sheathed bistoury, (for example,) as high as the naked outer surface of the intes- tine, then disengages the sheath from the bistoury, and iemoves it from the sinus. The point of the bistoury is next pushed through the gut, and made to rest on the finger within the rec- tum. Both the finger and knife are next withdrawn, the latter dividing in its passage downwards, the wThole track of the sinus, the intestine, sphincter ani muscle, and integuments, and leaving a chasm of considerable extent. A dossil of lint should be next introduced between the lips of the wound, and the patient put to bed. The cure is afterwards completed by mild dressings. When there is an opening in the gut, and another at the margin of the anus, or on the buttock, with an intermediate communi- cation by a sinus, constituting complete fistula, no other instru- ment than the common probe-pointed bistoury will be required for the operation. In performing the operation for fistula in ano, simple as it is considered, the operator must remember that if he prolongs his incision too far upwards from an over anxiety to trace every ramification of the sinus,—a very unnecessary piece of work,— he may wound the peritoneum, lay open the cavity of the abdo- men, and also divide the internal hemorrhoidal artery. The ligature is frequently employed, instead of the knife, for the cure of fistula in ano. As it requires, however, a much longer time to effect its purpose, and is, withal, sometimes pain- ful and inconvenient, there are many patients unwilling to submit to the operation. But cases present themselves now and then, in which the knife could not be employed without risk of he- morrhage, or in which, from the number and depth of the sinuses, it would be impossible to trace them, or if traced, difficulty would afterwards be experienced in making them heal from the bottom or in preventing the formation of new sinuses. Under these, and some other circumstances, it has been customary, particularly among the French, from time im- memorial, to resort to the ligature. The material of which it is made, as well as the instrument for conveying it, have varied exceedingly in different ages. Hippocrates used a linen thread wound upon a horse-hair, others employed silver or iron wire, and many preferred leaden wire to any other kind of ligature. FISTULA IN ANO. 155 Some conveyed the ligature by means of a silver probe, others by a cannula. Forceps for seizing the wire within the gut, and stilets for making an opening into the gut for the transmission of the ligature, have also been used. But, in many instances, it will only be necessary, when this operation is determined on, to pursue the following simple plan, one which has been prac- tised for a great many years by Dr. Physick, and which expe- rience has taught him to be almost always successful. A com- mon pocket-case probe, of the same thickness throughout, is slightly ragged at one end with a knife or file, and a piece of braid secured to it by thread, in the same way that the line is fastened to a fish-hook, is introduced into the fistulous orifice and conveyed along the sinus into the gut. The probe is next bent upon a finger, (previously passed into the rectum,) and brought out along with the ligature at the anus. The latter is then removed from the probe and its ends loosely tied. After the lapse of a few days the ligature is moderately tightened, and oc- casionally afterwards, (once a week, for example,) the constric- tion is repeated and increased until the parts within its embrace are completely destroyed, and the cord, sua sponte, detached. The small ulcer left, soon heals up. Sometimes the ligature comes away in four or five weeks; at other times, eight or ten months elapse before the loop separates. In the meantime, how- ever, the patient is generally permitted to walk about and attend to his business. In cases where no communication exists between the rectum and fistula, Dr. Physick has been in the habit of making one, by means of a sharp-pointed sheathed knife, pre- viously to the introduction of the probe and ligature. In peculiarly irritable patients, however, I have found it very difficult to carry the eyed-probe and ligature through the orifice in the gut without producing excessive pain in the act of bending the probe within the rectum, and which must always be done before it can be brought out at the anus. To obviate this difficulty, I invented, ten years ago, the following instru- ment, which I have employed, ever since, upon all occasions where I have thought it necessary to use the ligature in pre- ference to the knife, both in hospital and private practice, and with the greatest success, and least possible inconvenience to the patient. A silver cannula, moderately curved, about five inches long, the eighth of an inch wide in its longest, and the sixteenth of an inch in its shortest diameter, is intended to con- 156 FISTULA IN ANO. vey a narrow watch-spring, ten inches long, having at the ex- tremity next the handle of the cannula an eye, and at the other a small bulbous silver point. An additional spring, differing only from the first in the silver end being small enough to pass along with the spring through the cannula, and intended for incomplete fistula, accompanies the instrument. A steel stilet, which fills up the cannula, and projects in the form of a small lancet, just beyond the extremity, completes the contrivance. (See Plate V.) If it be intended to operate on a case of incomplete fistula— that in which there is no opening in the gut—the cannula, armed with the stilet, and its point retracted, is entered at the fistulous orifice, conveyed carefully along the sinus until that portion of the side of the rectum is reached where it is designed to make the perforation. The stilet is then pushed through the walls of the gut, and is felt within by the finger previously introduced into the rectum. Having withdrawn the stilet, the spring with the flattened silver end, armed with very narrow braid, is con- veyed through the cannula, and, guided by the finger in the rec- tum, brought out at the anus along with the ligature, which is then separated from the eye of the spring, and its ends loosely tied. In cases of complete fistula, the stilet will not be required, and the spring, with the bulbous end, previously placed in the cannula, and armed, as already described, with braid, may be employed. In either case it must be obvious that the pressure which gives the patient so much pain when the probe is used, is taken off the fistulous orifice and borne by the cannula; and, besides that, the spring has a natural tendency, by forming a curve as it is pushed onwards, to avoid pressure, and to reach the anus with the greatest facility. / The ligature is often adapted to those cases in which a fistula follows, or is conjoined with phthisis pulmonalis. Under an im- pression that the pulmonary affection is dependent upon, or ag- gravated by, the fistula, many patients are extremely anxious to have an operation. I have invariably refused to employ the knife upon such occasions, but have sometimes gratified them by operating with the ligature, which, by being worn for months to- gether, is sometimes so far serviceable as to prevent the forma- tion of other abscesses in the neighbourhood of the rectum, and by keeping up a steady drain throughout a single track, to re- lieve the cough and other constitutional symptoms. The worst /'/ate J-.l'oi.->. f FISTULA IN ANO. 157 case of fistula in ano I ever saw, I attended along with Dr. Phy- sick, several years ago,—that of a Mr. W. from the neighbour- hood of Lynchburg, Virginia. The patient's whole family had been carried off by phthisis, and several of them had laboured under fistula in ano. In Mr. W., the only remaining one of his race, there were strong premonitory symptoms of consumption, and for months he had suffered from profuse discharges of sa- nious, gleety, offensive matter from the rectum, all the parts about which I found indurated, covered with sinuses, and fistu- lous openings, with extensive ulcerations within the gut, de- struction of all its coats in particular spots, and the whole rectum more or less insulated by the destruction of the surrounding cel- lular membrane, so that it might have been said to have floated loosely in a large bag of matter. I trimmed away many of the loose-hanging portions of the rectum and disorganized cellular tissue, and endeavoured to reach by the finger and by probes the bottom of the sinuses; but found it impossible, owing to their great depth. In consultation it was determined that there was every probability of the patient sinking under his disease, and all that could be done for his relief would be to introduce a large cord high up the gut, and let it remain several months. This was accordingly done by Dr. Physick, and the patient re- turned home. The seton, thus left, had the effect of consoli- dating, through the medium of adhesive inflammation, all the loose parts; and, finally, contrary to our expectations, the exter- nal fistulous openings were obliterated, the sinuses healed up, and the patient now enjoys, comparatively, good health. When the knife is employed for the cure of fistula in ano, it effects its purpose by promoting the granulating process, by first dividing the sinus, which, so long as it remained lined by a se- creting membrane, would never have been obliterated, and last- ly, by dividing the sphincters of the gut, thereby rendering them quiescent, and preventing that incessant motion about the anus, so well calculated to interfere with and to break up the granula- tions as soon as they are formed. Rest, then, so essential intheV~\ treatment of many other diseases, is peculiarly so in fistula in ano. \ ' Though the sphincters unite very readily, in most cases, after the \ operation by the knife, it sometimes happens that they remain separated, a deep fissure is left, and the patient cannot retain his I fa?ces as perfectly as he had been accustomed to do. It is extremely difficult, under these circumstances, to restore the use of the parts. VOL. II.—L 158 ENCYSTED RECTUM. In obstinate cases of the kind, I should think the surgeon justi- fied in cutting away the edges of the chasm, as in hare-lip, and endeavouring to unite them by suture. In conclusion I may state, that many very useless and compli- cated instruments have been invented for fistula in ano; that, ge- nerally, I have found a simple bistoury, having a shoulder and at the same time a small sharp point under it, sufficient for the pur- pose; that I have, also, used advantageously the French method —by the wooden gorget and silver director instead of the finger, a plan always employed by my intelligent friend, Professor May, of Washington—and upon the whole, have been particularly careful to use a knife not likely to break—an accident that has happened to Liston, myself, and others. On Fistula in Ano, consult Desault's Works, by Smith, vol. i. p. 330; Pott's Works by Earle, vol. iii., p. 45; A Treatise on the Diseases of the Urethra, Ve- sica Urinaria, Prostate, and Rectum, by Sir Charles Bell, with Notes, by John Shaw, Surgeon, Demonstrator of Anatomy, in the School of Great Windmill Street, London, 1820, 8vo. page 297; Copeland's Observations on some of the Principal Diseases of the Rectum and Anus, Philadelphia, 1811; Practical Obser- vations on the Symptoms, Discrimination and Treatment of some of the most Common Diseases of the Lower Intestines and Anus, by John Howship, Lon- don, 1820; Observations on Injuries and Diseases of the Rectum, by Herbert Mayo,p.28,London,l833; Sir Astley Cooper'sLectures,byTyrrel, vol. ii.p.336. SECTION V. ENCYSTED RECTUM. WitHin the cavity of the rectum, between the internal and external sphincters, commencing at the margin of the former, are naturally situated, a number of small sacs, or pockets, the orifices of which look upwards, while the bodies of the sacs de- scend towards the anus, perpendicularly, are about a quarter of an inch in length, and have a cul de sac termination. The number of these minute pockets is in proportion to the number ENCYSTED RECTUM. 159 of grooves, situated between the columns of the rectum, and each groove terminates in its corresponding pocket. In general, from seven to thirteen sacs are found, all which are covered and lined by the mucous membrane of the gut. These sacs are filled, there is reason to believe^ with mucus (poured out by the numerous adjoining follicles) which is pressed out of their cavi- ties during the passage of the fa?ces, and serves, probably, to lu- bricate that portion of the anus covered by cuticle. According to Ribes, such sacs had been noticed by Ruysch, Morgagni, and Glisson, as being accidentally met with in the rectum upon cer- tain occasions. Ribes himself wras unable to find them, although he had made numerous dissections for the purpose, during the period of twenty-five years. Subsequently, he was more for- tunate, and was able to find in one subject three, and, in ano- ther, four of these lacunae, but which he has not described with perfect accuracy. It remained for Dr. Horner to establish the fact by numerous and most satisfactory examinations, that— what the anatomists, referred to, considered as accidental oc- currences—these sacs exist invariably, and form a portion of the natural apparatus of the rectum. So far back as the year 1792, Dr. Physick met with a peculiar disease of the rectum, which had never been described or noticed by writers. It consisted of one or more sacs, of different dimen- sions, which, by bending a probe upon itself, introducing it into the rectum, and hooking it into the mouth of the sac, could be drawn down and made to appear on the outside of the anus. From that period he was accustomed to speak of this case—and others which he subsequently met with—in his surgical lectures in the University of Pennsylvania. From what has been said, it will be readily inferred that this disease, to which the attention of Dr. Physick was originally drawn, must consist in an expansion, or dilatation, of the small natural sacs of the rectum, described in the commencement of this section. Such we have every reason to believe, to be the fact, though, strange as it may seem, no dissection has ever yet been made, so far as we are acquainted, calculated to demon- strate that the preternatural pouch is an actual enlargement of the natural one. From the circumstance, however, of small portions of fa?ces, or foreign bodies, such as seeds, having been found in the dilated sacs at the time of operation, it is more than probable that these articles, by finding their way occasionally 160 ENCYSTED RECTUM. into the natural pockets, may, by irritating them, cause their ex- pansion and elongation, and produce the disease in question. Dr. Physick, himself, seemed inclined to believe that " they commence in the same manner with one of the forms of hemor- rhoidal tumour. The constriction of the sphincters which em- barrasses the venous circulation of the part, aided by the pres- sure exerted in passing different stools, frequently gives rise to ecchymosis beneath the integuments. The effused blood pro- duces no irritation of the cellular tissue in which it is placed, but forms for itself a simple inert receptacle. If the blood is neither absorbed nor discharged, but remains or becomes enlarged, by successive ecchymosis, it constitutes (certain authorities to the contrary notwithstanding,) one form of the hemorrhoid. If, on the other hand, some accident, or the absorption of the integu- ment, give exit to the blood, after the cavity has become ac- customed to its presence, the cellular tissue shows little disposi- tion to reunite, no obvious marks of inflammation appear, and a preternatural cavity is established. In support of this explana- tion, which is urged with characteristic caution, as an hypothesis, Dr. Physick states that in the early part of his practice, he has, in several instances, operated on hemorrhoidal tumours of the same part, in wThich, after the removal of the coagula, the part pre- sented precisely the same aspect with the preternatural cavities, wanting only the orifice. He refers, also, to the existence of similar cavities, after the discharge of ecchymoses of the scalp, such as most surgeons must have seen, particularly in children, and which often prove tedious and difficult of cure: he has also witnessed the same accident in other parts of the body. In most cases the first appearance of the cavities was preceded by trou- blesome piles."* It generally happens that patients troubled with sacculated rectum, have complained for weeks, or months, of uneasy, disa- greeable sensations, (resembling those created by the nestling of ascarides, within the gut,) or of extraordinary itching about the anus. Others complain of a sense of pressure or weight upon the extremity of the rectum. Pain is seldom felt until the disease has existed for some time, and even then is not generally noticed until a short time after the passage of the fa?ces. It does not, however, follow' every evacuation, and the patient may * Hays's Cyclopaed. of Pract. Med. and Surg. Part vi. p. 125. ENCYSTED RECTUM. 161 be free from it for whole days together. Sometimes it is ex- tremely severe. For the most part there is more or less smarting shortly after each stool—owing, in all probability, to small por- tions of fa?ces finding their way into the pouches, and there ex- citing irritation. The secretion of mucus within the rectum is usually increased, but pus, except in the advanced stages of the complaint, or when inflammation has supervened, is rarely noticed. Upon the whole, it may be stated, that this affection is often confounded with neuralgia of the rectum, and that, not unfrequently, even after examination, the patient's complaints have been pronounced, by practitioners, imaginary. TREATMENT OF ENCYSTED RECTUM. When the surgeon has reason to believe, from the absence of inflammation, or of free discharge of mucus and pus, from the want of spasm about the sphincters, that there is no internal or occult fistula in the rectum, and no neuralgic affection, and, above all, when the symptoms enumerated have been strongly marked* especially uneasiness and pain a short time after stool, he will naturally suspect enlargement of the rectal pouches, and proceed accordingly. The mere introduction of the finger into the rectum will not enable the surgeon to detect this disease. Dr. Physick, as al- ready mentioned, takes a probe with about half an inch of its extremity bent back upon itself, and by moving it upwards and downwards throughout that portion of the circumference of the rectum situated between the two sphincters, is able by patience to explore successfully every part of the surface of the mucous membrane. When the dilated pouches exist, the reverted ex- tremity of the probe drops readily into them, and each cyst may be drawn down to the verge of the anus, and distinctly seen—though not without producing severe pain to the patient. That the portion drawn down is really one of the rectal pouches may be known by its transparency, for the probe shines dis- tinctly through it—and by the exquisite pain which the bare ad- mission of the probe into its cavity occasions. Several of the enlarged pouches often exist simultaneously; at other times, they enlarge in succession, and months may elapse before a com- plete cure can be accomplished. Having drawn the cyst down 162 STRICTURE OF THE RECTUM. by the hooked probe, Dr. Physick then cuts off the whole of it, including the orifice where the probe entered, by a pair of scissors, so that its edges retract, and are soon obliterated and blended insensibly with the smooth surface of the rectum. Should other sacs exist, or form subsequently, they must be treated in a simi- lar manner, until a radical cure is effected. In the hands of Dr. Physick, the practice has invariably proved successful, and the remark is confirmed by my own experience. So far back as 1812, I attended the late Dr. S. of Baltimore, with this com- plaint. It was the first case of the kind I ever saw. The nature of the disease in this particular case had been previously detected by Dr. Physick, and by operating in the manner he ad- vised, I soon effected a perfect cure. I have operated subse- quently, and successfully, in numerous instances. For further observations on this subject, the reader is referred to an article by Dr. R. Coates,—drawTn up under the superintendence of Dr. Physick,—in the seventh number of a recent valuable publi- cation—the American Cyclopa?dia of Practical Medicine and Sur- gery by Dr. Hays. SECTION VI. STRICTURE OF THE RECTUM. Simple stricture of the rectum, like that of the oesophagus and urethra, may be either spasmodic or permanent. The former, however, is not very common, and when it does occur, is the re- sult, probably of disordered action of the sphincter muscles, of the levator ani, and also, not unfrequently, of the muscles of the perineum and of those surrounding the urethra. But the perma- nent or organic stricture of the rectum, if it be not so common as some other affections of that intestine, is, nevertheless, by no means rare. It may occupy any part of the rectum, but is com- monly met with at the upper margin of the internal sphincter; and consists of a fold of the mucous membrane or coat of the gut, which in the form of a tumid ring hangs, at first, loose into STRICTURE OF THE RECTUM. 163 the bowel, but in proportion as it acquires firmness from re- peated straining and irritation, projects horizontally towards the centre of the rectum, to a greater or less distance, so as to re- semble in some cases a septum with a hole in its middle. Some- times there are two or three of these folds, or ridges, within a short distance of each other, which either continue separate, or, in the course of time, approximate, and form an indurated tube which diminishes the capacity of the bowel and subverts its tex- ture. In either case, or in that of a single ridge protruded into the caliber of the gut from its walls, the effect must be a girding, or coarctation, well calculated to interfere with the passage of the fa?ces, or to produce wire-drawn-like stools. Hence, all pa- tients complain of their excrement being contracted; and this, indeed, will be found to be an almost certain accompaniment of the disease, though not an infallible diagnostic, or criterion. As the stricture increases, other symptoms are developed; there is per- petual straining or nisus, sometimes followed by mucus, sometimes by blood, either from rupture of small vessels about the rectum, or from superadded piles. The bladder, also, becomes involved, and great irritation and painful micturition ensue. Eventually, the rectum becomes extremely irritable, and so exquisitely sensitive, that the patient is often afraid to attempt the expulsion of the faeces; or, if they are passed at all, it is through the me- dium of purgatives, enemata, or diet, calculated to keep the con- tents of the bowels nearly in a fluid state. If not soon relieved, great distention of the bowels, from flatus and food, takes place, followed by more urgent symptoms, and the patient dies. Not unfrequently, he has lived for years in a miserable condition, the real nature of his case unknown to himself or his attendant, and has, finally, recovered under the management of some more skil- ful surgeon. Strictures of the extremity of the rectum, or rather, coarctations of the orifice of the anus, are occasionally met with. This dis- ease is often the result of operations, improperly performed, for hemorrhoids, prolapsus ani, fistula in ano, &c. Sometimes de- positions of coagulable lymph are thrown out either on the outer or inner surfaces of the radiated folds of skin around the anus, or immediately within the termination of the rectum, where the mucous membrane and radiated folds meet. From any of these causes the opening of the anus may be so contracted as scarcely to admit the passage of a common-sized urethra bougie. 164 STRICTURE OF THE RECTUM. TREATMENT OF STRICTURE OF THE RECTUM. Before attempting to overcome, by mechanical means, a stric- ture of the rectum, the causes of the disease should be carefully investigated, and, if possible, removed. Great attention should, in particular, be paid to the condition of the patient's stomach and bowels, through the medium of appropriate diet, gentle aperients, and enemata. Repeated ablutions of the rectum by tepid and cold water alone, or holding opium or other similar articles in solution, thrown to some distance up the gut by a well contrived syringe, will pave the way for bougies and other instruments, and sometimes, without the assistance of the latter, will effect perfect cures. But soft, well made, gum elastic or waxen bougies are more to be relied upon, in the majority of cases, than any other instruments or modes of treatment. The surgeon should take care, however, not to promise to accomplish too speedy a cure; for if, under the impression that he has no- thing to do but to break down by force the barrier opposed to him, he should introduce at once a large bougie and drive it home, and follow it up shortly afterwards by another still larger, he may either destroy the patient at once by tearing the bowel, or re- motely by inducing peritoneal inflammation. Very instructive cases of the kind have been published by Sir Charles Bell, Mayo, and other surgeons. The utmost gentleness, therefore, should be employed during the introduction of such instruments, and caution observed in increasing their size. The more gradual the dilatation, the less will be the irritation; and whenever it is found that the patient complains much of soreness or pain, the instrument should be diminished or withdrawn for a day or two. By prudence and discreet management, radical cures may be ef- fected in a few months: by rash and intemperate measures, the disease will be aggravated, or the patient killed in a few weeks. The bougie acts either by dilating the stricture, gradatim, or by exciting the ulcerative process, and thereby removing, through the medium of absorption, the superfluous mass of which it con- sists. It has been proposed, and by high authority, to introduce a bistoury and cut through the stricture at several points of its circumference. But I am at a loss to conceive what benefit can result from such a measure. If merely divided, will not reunion IMPERFORATE ANUS. 165 take place, almost immediately, and the ridge or septum con- tinue as firm as ever? We cannot cut out the whole of the ridge, from its base to its edge, by introducing the knife per anum, without great risk. But I have sometimes thought (should the urgency or peculiarity of the case require it,) that by laying open the muscles of the perineum, as in the lateral operation for lithotomy, and then slitting the rectum, as is too often done by ignorant or careless lithotomists, that the strictured portion of the gut might be completely extirpated. This, however, is a mere speculation, and as such must be received. The other operation—notching the stricture—has been performed, and successfully, it is said. For coarctation of the orifice of the anus, the knife appears to be the best remedy. It must be followed up, however, by the bougie; though the cure is allowed, by all familiar with the disease, to be very difficult and uncertain. Consult Howship on some of the most Important Diseases of the Lower Intestines and Anus, p. 1, London, 1821; Observations on some of the Principal Diseases of the Rectum and Anus, particularly Stricture of the Rectum, &c, by T. Copeland, p. 13, London, 1821; A Treatise on Diseases of Urethra, Vesi- ca Urinaria, Prostate and Rectum, by Charles Bell, London, 1820, p. 311; A Practical Treatise on Hemorrhoids, Strictures of the Rectum, &c.,by Calvert, London, 1824; Salmon's Practical Essay on Stricture of the Rectum, London, 1828; Two Clinical Lectures on Hernia and Strictures of the Rectum and Anus, in Lancet, London, 1827; Mayo on Injuries and Diseases of the Rectum, Lon- don, 1833; Hays's American Cyclopaedia of Medicine and Surgery, Part vi. 1835. .■or ■* SECTION VII. IMPERFORATE ANUS. This congenital imperfection is occasionally met with, both in the human subject and among inferior animals. Sometimes it is complicated with other malformations. In my cabinet there is an interesting specimen of imperforate anus, spina bifida, and club feet, all in the same subject—a child at birth. There 166 IMPERFORATE ANUS. are three or four varieties of imperforate anus—a mere closure by the common skin of the orifice of the rectum—a membranous septum occupying the same situation, or placed within the gut at a greater or less distance from its extremity—a cul de sac termination of the rectum—an entire occlusion of the sides of the rectum, or the conversion of the gut into a solid tumour. Along with these varieties, there is not unfrequently conjoined, a communication between the rectum and vagina or between the rectum and urinary bladder, so that the faeces and urine are commingled. Two years ago I received from Dr. George Ha- milton, a very intelligent and respectable physician of Centreville, New Castle County, Delaware, a very interesting preparation taken from a child, delivered at the seventh month, and which died about an hour after birth. There was no vestige of anus, but the rectum terminated distinctly in the fundus of the urinary bladder by free intercommunication. An uncommonly fine ex- ample of the same kind, I had an opportunity of witnessing some years ago in a thorough-bred colt the property of the late Dr. Thornton, of Washington. The animal was deficient in a tail,—its rump terminating as in the human subject at the os coccygis,—and the anus was completely shut up by integu- ments, and beneath by an apparently fleshy membrane. Along with the urine were discharged quantities of thick greenish matter, evidently of the nature of fa?ces. At this time the animal was a week old, sucked freely of its dam, and in other respects was perfectly healthy. Perceiving, at the natural site of the anus, a fluctuating tumour, I pushed a double-edged scalpel to the depth oj-h ,i^i.ch into the part, and immediately there was discharged"^ it q. gallon of greenish fluid, similar to that which had been accustomed to pass from the urethra. By means of plugs and tents, the orifice was kept open by the owner of the colt, for a few weeks; and, after that time, the use of them appeared unnecessary. The communication between the rec- tum and bladder closed of its own accord in a very short time. The animal was living and in perfect health not long since. This statement is made for the two-fold purpose—of record- ing an interesting fact, and of drawing the attention of students to the diseases of domestic animals, a subject in this country very much neglected and underrated. Country practitioners are often consulted, as friends, by their neighbours and patients, concerning epidemics, or local diseases, among their stock. IMPERFORATE ANUS. 167 Instead of considering their dignity insulted by such appeals to their feelings and humanity,—as is too often the case,—they should furnish cheerfully all the information they possess, or prescribe in obscure and difficult cases, according to the principles that would guide them in the treatment of a human being—for be- tween the two, as regards mere animal conformation, there is much greater correspondence than is generally imagined, and si- milarity of texture is commonly associated with similarity of dis- ease. Monro, Hunter, Jenner, Cline, and a host of other Eu- ropean physicians and surgeons, and the late distinguished Dr. Rush, in this country, have not thought it beneath them to in- vestigate the disorders of those domestic creatures, upon which so large a share of our comfort, convenience and pleasure de- pends, nor to recommend such studies to their pupils. TREATMENT OF IMPERFORATE ANUS. From want of timely aid, from the nature of the disease being undiscovered or misunderstood, many infants have perished that might have been saved. It is incumbent, then, upon the practitioner to investigate, speedily, the variety of the complaint the child may labour under, and to decide, promptly, upon the treatment; for after the lapse of a few hours, meconium and other fluids may accumulate in such quantities as to produce great distention and distress, which may soon be followed by pe- ritoneal inflammation and death. It is true, that a few cases have been reported where recoveries have taken place, although no operation has been performed until the tenth or twelfth day. In by far the greater number of instances, however, the child will not survive beyond the fourth or fifth day. When the anus is merely covered by a common skin, or where a membranous septum is visible, or felt, a short distance within the gut, a bistoury,—wrapped throughout the greater part of its edge, may be pushed through the skin, or through the septum, guided, in the latter case, by a finger per anum, and the obstruc- tion removed. But where the rectum is obliterated, to any ex- tent, by closure of its sides, or filled up by a fleshy tumour, a more delicate^nd difficult operation will be demanded. Either a regular dissection in the natural course of the rectum should be made until the open portion of the bowel be reached, or a 168 IMPERFORATE ANUS. trocar of large size thrust through the obstruction. Both opera- tions have been performed, and with success in some instances; though in other cases they have failed—owing to the great ex- tent of the obstruction, or the distance of it from the natural si- tuation of the anus. Under such circumstances, it was proposed by Littre to cut through the parietes of the abdomen, either in the right or left groin, open an intestine and establish an artifi- cial anus—by connecting the gut with sutures to the surround- ing parts. The operation was afterwards performed, and with partial success, by Duret, a French naval surgeon. It has since been repeated by Pring, an English surgeon, in the case of a lady, in whom the rectum was closed by a scirrhous tumour. The operation was performed on the colon near its sigmoid flex- ure, and proved successful, so far as the establishment of the ar- tificial anus was concerned, though the patient died a few months afterwards from the scirrhous affection. Jukes, of Birmingham, has lately performed a similar operation on a woman thirty years of age, in a case of carcinomatous stricture of the rectum. The patient lived sixteen days after the operation, and died from chronic peritoneal inflammation. If the surgeon, in any of the varieties of imperforate anus, should succeed, by the operation described, in making his way through the obstructed rectum, he will find it necessary, in order to preserve the tract or passage of suitable dimensions, to intro- duce plugs of lint, sponge tents, gum elastic bougies and other similar instruments, and gradually increase their size, until the requisite degree of dilatation has been effected. This, however, will be found, in many instances, the most difficult part of the treatment; as there will be great irritation from the long-conti- nued use of such instruments, and a perpetual tendency, in the artificial passage, to close up. On Imperforate Anus, consult Sabatier's Medecine Operatoire, torn, iv.; Callisen's Systema Chirurgise Hodiernae, torn. ii. edit. 1815; Ford, in Medi- cal Facts and Observations, vol. i.; Richerand's Nosographie Chirurgicale, torn, iii.; Chamberlaine in Memoirs of Medical Society of London, vol. v.; Wayte, in Edinburgh Medical and Surgical Journal, vol. xvii.; A. G. Hutchin- son's Practical Observations in Surgery, 1826. FOREIGN BODIES IN THE RECTUM. 169 SECTION VIII. FOREIGN BODIES IN THE RECTUM. Indigestible articles often pass from the stomach along the intestines, and are arrested by the sphincters at the anus. Pieces of gristle, of bone, of sponge, of apple-core, of toasted bread, and other similar substances, have been found within the rectum, and the cases reported. Still more numerous examples have been given of the lodgement of pins, needles, fish-bones, chicken- bones, all which have excited more or less irritation, and, in some instances, laid the foundation of fistula in ano, of extensive ulcerations, and even death. Upon other occasions foreign articles have been forced into the rectum from without, either by design, or by accident, sometimes producing death, at other times more violent symptoms—as exemplified in the case of the unfortunate Edward the Second of England, murdered by a red- hot iron being thrust up the rectum, and in the celebrated case reported by Marchetti, where the but-end of a pig's tail was forced up the rectum of a courtesan, and remaining for several days, had nearly destroyed her. "Des etudians avoient projette de jouer quelque mauvais tour a une fille publique; ils s'aviserent de lui mettre dans I'anus une queue de cochon qui etoit gelee; ils en couperent les poils un peu courts, afin qu'ils fussent plus piquans et plus roides; ils la tremperent dans l'huile, et l'intro- duiserent par l'extremite la plus grosse et a force dans le fonde- raent de cette fille, a la reserve de la longeur d'environ trois doigts qui resta a" l'exteriur de I'anus: on fit diverses tentatives pour l'oter; mais comme elle ne pouvoit etre tiree qu'a contre poils, les soyes entroient dans les membranes du rectum, et cau- soient a cette fille des douleurs inexprimables; pour les appaiser, on fit prendre k la malade divers remedes huileux par la bouche, et on-tacha de dilater I'anus avec un speculum assez pour retirer cette queue sans violence, mais on ne rcussit; il survint des ac- cidens enormes, un vomisseraent violent, une constipation opinia- tre, une fievre tr£s ardente, et des douleurs tres vives dans tout l'abdomen."* Although not to be classed, with strict propriety under the * Memoires de 1'Academie Royale de Chirurgie, torn, iii., p. 78, edit. 8vo. 170 foreign bodies in the rectum. head of foreign bodies, yet great irritation and even extreme distress are not unfrequently occasioned by the lodgement of ascarides within the rectum—especially in children and old people. These animals,—which probably find their way into the stomach and intestines, through the medium of fruits and unboiled vegetables, and have been found out of the body by Pallas in the waters of Siberia, and by Dr. Barry in certain springs in Ireland,—are so enveloped in mucus whilst in the rectum, which they sometimes almost choke up, as scarcely to be reached by medicine, or the most stimulating injections. That they may be gotten rid of, however, or the irritation they produce very much alleviated, by means I shall presently point out, I have had frequent opportunities of proving for the last twenty years, and on that account I notice them in this place. removal of foreign bodies from the rectum. When, from more or less irritation, difficulty of passing faeces, a peculiar pricking sensation within the rectum, whilst at stool, and at other times a discharge of purulent matter and blood, from the anus, there is reason to believe, that some foreign body occupies the gut, an accurate search should be made both by the finger and by instruments. If discovered, the extraneous ar- ticle may then be removed by a pair of forceps or by the scoop. The latter instrument, such as is used commonly for extraction of bullets, is peculiarly adapted to the removal of hardened fa?ces, which often accumulate in the rectum, and become so impacted that the patient is unable to force them out. But pins, needles, fish and chicken-bones may be removed with more facility by the forceps than any other instrument. In the ex- traordinary case reported by Marchetti, and detailed above, a most ingenious and successful expedient for the removal of the pig's tail, and the only one that could have been practised with probable success, was resorted to—the introduction of the end of the tail, hanging from the rectum, into a reed, the reed carried up the gut, made to press clown the bristles that stood like a chevaux-de-frise, and then the removal of the reed with the tail enclosed in its cavity. "Le sixi&me jour on eut recours a Marchetti: ce practicien instruit de tout ce qu'on avoit fait, in- venta un procede fort simple, mais fort ingenieux; il prit un foreign bodies in the rectum. 171 roseau creux long d'environ deux pieds, il le pr6para par une de ses extremites de manicre qu'il put l'introduire f.icilement dans I'anus, et enfermer entierement la queue de cochon dans ce roseau, pour la tirer ensuite sans causer de douleur; dans ce des- sein il attacha a cette queue, par le bout qui etoit hors du fonde- ment, un gros fil cire, et le passa dans le roseau; il poussa d'une main cette espece de canule dans le rectum et il retenoit de l'autre le fil, pour ne pas repousser la queue en enfoncant le ro- seau dans le fondement: il parvint a enfermer entierement cette queue dans la cavite du roseau, et delivra promptement la ma- lade, tant du danger de la mort que de l'etat cruel ou elle se trouvoit; elle rendit sur le champ une tres grande quantite de matieres stercorales qui avoient ete retenues pendant six jours par le corps etranger." In ancient times, when barbed arrows were used instead of fire-arms, an instrument somewhat similar to Marchetti's reed, was employed for removing them, in order to prevent the flesh from being torn during the extraction. There are many occasions, even now, when similar contrivances may prove useful. For the removal of ascarides from the rectum, I have em- ployed the bullet scoop, or a small instrument resembling a mustard spoon. I was first led to make the experiment by finding the disease to be exceedingly common, and sometimes productive of so much distress to the patient as to render life almost a burden. The scoop being oiled and introduced into the rectum, was found to bring away one or more of these ani- mals enveloped in its appropriate nidus, and to relieve at once the intolerable itching so annoying to the patient. Adults can use the instrument themselves, with the greatest facility, and are always directed to the spot where the animal is situated, by the itching and pricking sensation which it creates. Children will require the assistance of a physician or skilful nurse. Incredible quantities of these troublesome worms may be taken away in a short time, by this simple expedient—where medicines might be employed for months, and at last fail. Consult Memoiresde l'Academie de Chirurgie, torn, iii.; Precis d'Observations sur les Corps Etrangers,&c, par M.Hevin; Dictionnaire des Sciences Medicales, torn. vii. p. 35; On Painful Constipation from Indurated Faeces, in Lond. Med. Obs.andlnq. vol. iv. p. 123; Case of a Fork thrust up the Anus, and extracted,in Philosophical Transactions,abridged,17J.j; Harrison's Case of Apple Core, form- ing a Fistula inAnoeight months after being eaten, Memoirsof Medical Society 172 FISSURE OF THE ANUS. of London, 1796; Blair's Case of Hard Toast arrested in the Anus, in Medical Facts and Observations, vol. vi.; Gregory's case in which Death followed from a Fish-bone lodged for years in the Rectum, in Monro's Morbid Anatomy of Stomach and Gullet, p. 22, Ed. 1811. SECTION IX. FISSURE OF THE ANUS. The attention of the profession has been called to this disease only within the last few years. In this country, it is still com- paratively a rare affection; for although connected, for the last twenty years, with the largest hospital in America, and accus- tomed to attend during the winter months, when the patients are most numerous, I have seen very few cases which could be said to correspond in symptoms with the details furnished by writers, and therefore feel justified in asserting that the disease with us is seldom met with. By the term fissure is understood a superficial ulceration which occupies, in the form of a sulcus or irregular groove, the mucous membrane and radiated folds of fine skin that are fused into each other near the verge of the anus. It is not easy, always, to determine the extent of the furrow without the as- sistance of a speculum, or the introduction of a finger into the rectum. Generally, it is at least half an inch in length, but seldom penetrates through the substance of the mucous mem- brane. It commonly occupies the back and sides of the anus, is rough, irregular, and reddish on the bottom, when spread open, and its projecting margins indurated, protuberant, or ser- rated. The pain accompanying it is of a peculiar burning, lancinating kind, which gradually increases for hours after a stool, and at last becomes almost intolerable—from the spas- modic action of the sphincters and lodgement of acrid fiscal matter. The disease may be traced in some instances to the mechanical distention of the rectum by hardened fa?ces, in others to piles, and to the too frequent and unskilful use of FISSURE OF THE ANUS. 173 glyster pipes. According to Dupuytren, there are three varieties of fissure—above, below, and on a level with the sphincter. The last are the most painful and difficult of cure. Those above the sphincter feel like a hard cord, and those below are attended with pruritus rather than with pain. Each form of the disease is liable to be mistaken for affections of the urinary blad- der—from the irritation communicated from the rectum to that organ. TREATMENT OF FISSURE OF THE ANUS. Under the impression that spasmodic action of the sphincter muscles was the cause of fissure of the anus, Dupuytren ad- vised, in most cases of the kind, the introduction of rectum bougies, covered with an ointment composed of hog's lard, bel- ladonna, and acetate of lead; and states, that in a few days the symptoms were so mitigated generally as to supersede the necessity of other applications. In other instances, however, he concurred with other surgeons, that nothing less than the knife or caustic would answer the purpose of effecting a cure. In general, the lunar caustic should be tried for two or three weeks—after more simple remedies, such as opiate and mer- curial lotions, have failed—and if repeated applications of it— aided by a common speculum, that of Weiss, or still better by an ingenious contrivance of the kind lately invented by Dr. Pitney, of Auburn—do not cause the fissure to granulate and fill up from the bottom, then the furrow, along with the sphincter and gut, may be divided by the probe-pointed bistoury, as in fistula in ano, and a cure is almost sure to follow. I have sel- dom failed, however, with the caustic; and in an obstinate case, lately attended by Dr. Horner and myself, in a gentleman from Louisiana, after three weeks' use of the caustic followed up by rhatany injections, the patient returned home perfectly restored, and entirely rid of symptoms which rendered his life almost in- supportable. VOL. II.—M 174 HYDROCELE. CHAPTER VII. DISEASES OF THE TUNICA VAGINALIS AND TESTIS. Having treated on a former occasion* of cancer and of fungus ha?matodes of the testicle, and described the treatment and ope- rations necessary for each, some other affections of these organs will be noticed. These are hydrocele, hematocele, chronic en- largement of the testis, irritable testis, encysted testicle, tumours of the scrotum, &c. Among surgical writers, accounts will be met with, of the cedematous hydrocele or dropsy of the scrotum, of hydrenterocele or hydrocele combined with intestinal hernia, of encysted hydrocele of the spermatic cord, of the congenital hydrocele. These, however, are either the result of other dis- eases, or are so analogous, in many respects, to common hydro- cele, as not to require minute consideration. SECTION I. HYDROCELE. The tunica vaginalis is naturally bedewed with a thin serum, which, by lubricating its surface and that of the testicles, enables them to move freely upon each other. This fluid, when secreted in undue quantity, constitutes hydrocele—a disease of frequent occurrence, and met with in patients of every age and constitu- tion. If attended to in the commencement, the tumour will be * Vol. i. pages 188 and 194. HYDROCELE. 175 found to occupy the lower part of the scrotum, and gradually to extend towards the abdominal ring. In shape it is pyriform, and to the touch elastic—feeling like a bladder distended with water. When pressed upon, little or no pain is experienced by the pa- tient, except at the posterior part of the swelling where the testis is situated. The ruga? of the scrotum generally remain unaltered, even in hydroceles of the greatest magnitude, and sometimes the tumour attains an enormous bulk. In ordinary cases, however, the tunica vaginalis seldom contains more than a pint of fluid. This fluid, in colour, is either perfectly limpid, or else yellowish. The disease is usually confined to one side. It is sometimes dif- ficult to distinguish between hydrocele and other complaints that bear a resemblance to it. Much may be learned from the history of the disease. The hydrocele invariably begins below, and very gradually ascends. The swelling in sarcocele, or scirrhous testicle, is uniform throughout, is accompanied with pain, is in- elastic, and heavier when handled than hydrocele. When re- cent, hydrocele is generally transparent, if examined by placing the tumour between a lamp and the surgeon. From hernia it iliffers materially—the one commencing above, the other below. In hernia, moreover, an impulse is communicated to the finger when the patient is directed to cough. This is not the case with hydrocele. The causes of hydrocele are very uncertain. By some the disease is attributed to urethral excitement, by others to varicose enlargement of the spermatic vessels, to blows upon the scrotum, to rheumatism, cold, &c. I have met with it in in- fants immediately after birth. Hydrocele is often conjoined with enlargement of the testicle—constituting the disease called hydro- sarcocele. It occasionally happens that the cavity of the tunica vaginalis is occupied by one or more hydatids, or cysts, filled wTith trans- parent fluid; and that the tumour bears so close a resemblance to common hydrocele, as to be mistaken for it readily. A few cases of the kind I have met with, both in young and old sub- jects. Sometimes the two diseases exist simultaneously, and oc- cupy the same tunica vaginalis. In other instances the hydatids are connected with the epididymis, or substance of the testicle, and protrude when the tunica vaginalis is opened by a trocar or lancet. Hydrocele of the spermatic cord is now and then met with. It usually appears as a rounded or oval tumour, in the site of the 176 HYDROCELE. external abdominal ring; or it may be situated in the abdominal canal, between the internal and external rings. It is elastic to the touch, and retires in such a way from the finger, as to give the idea of the existence of hernia, with which it is often con- founded, even by experienced surgeons. A man forty years of age, in the Philadelphia Hospital, during the winter of 1833, had a tumour the size and shape of an egg, which occupied the left cord below the external ring. It was pronounced by some a hernia, by others a varicocele. I was satisfied, however, by its not retiring with a gurgling noise, by its being free from pain, and by its transparency and bluish colour, that it was a hydro- cele of the cord; and so it turned out to be; for upon thrusting a lancet into it, nearly an ounce of limpid serum was dis- charged. Under the title of congenital hydrocele, a variety of that dis- ease was first described by Vigurie and Desault, and was ascer- tained by them to be owing to the communication being kept up between the abdomen and tunica vaginalis, so that water accu- mulating in either of those cavities, might pass freely from one to the other. This form of the complaint is by no means uncom- mon ; but is not confined to children. Hence, the term conge- nital is not strictly correct. It may be distinguished from com- mon hydrocele by the fluid retiring into the abdomen when the patient is in the recumbent posture, and by its reappearing with more or less fluctuation in the erect position. The complaint is sometimes complicated with hernia. TREATMENT OF HYDROCELE. In very young subjects, and in recent cases, I have some- times succeeded in removing the disease by purgatives, and by bathing the tumour repeatedly with a mixture of sal ammoniac and vinegar. Sir Astley Cooper recommends, in similar cases, a suspensory bandage moistened with muriate of ammonia and liquor ammonia? acetatis, two drachms of the former to six ounces of the latter; and, after using it for awhile, to add to the mixture tinctura lytta?, or to apply tincture of iodine, in case the fluid is not absorbed. In the majority of instances, however, an operation will be required. This is either palliative or radical. The for- mer may prove necessary when there is any doubt respecting the HYDROCELE. 177 nature of the disease, or it may be performed to diminish the size of the swelling, and thereby enable a patient to pursue a journey without interruption. In a short time the fluid accumulates again; and, if necessary, the operation may be repeated. A common lancet, or a small trocar, answers equally well for the operation. The radical cure of hydrocele has been attempted in various ways—by laying open the tunica vaginalis, by passing a seton through it, by applying caustic to the surface of the tumour, by extirpating a part of the tunica vaginalis, by the introduction of a tent, and by the injection of the cavity of the sac, after having drawn off its contents. The latter operation is the one practised by most modern surgeons, and when properly performed, is gene- rally successful. The patient being seated on the edge of a bed, or table, with his thighs separated, the operator sits before him, and grasps the tumour so firmly with one hand as to render it perfectly tense, while with the other he introduces a trocar of moderate size, covered by its cannula, obliquely upwards and inwards, into the front of the tumour, near its lower part.* The trocar, thus held, is made to penetrate the integuments of the scrotum, and the tunica vaginalis, to the depth of an inch and a half, and is then withdrawn, leaving the cannula behind, through which the fluid is immediately discharged. The nozzle of the syringe, or gum elastic bag, is next adapted to the mouth of the cannula, and an injection, consisting of two parts of port wine, and one of water, thrown into the tunica vaginalis until it is distended to the size of the original tumour. The length of time the injection should be permitted to remain, must depend upon the patient's feelings. In general, a pain will be felt along the cord, extending into the abdomen; and when this becomes very severe, the wine and water must be evacuated; on the contrary, if the patient, as I have sometimes noticed, should experience no pain whatever, the injection may be renewed, and its strength increased. It only remains to withdraw the cannula, and close the wound by a * The opening is made in this situation, and the instrument directed oblique- ly with the view of avoiding the testicle, which is usually situated posteriorly. But it should be remembered that the testicle is sometimes placed in front, and will, therefore, be wounded if the above direction is followed. To avoid so unpleasant a consequence, the operator must endeavour beforehand to as- certain, if possible, its exact position. 178 HYDROCELE. bit of lint. In a few hours the parts swell, sometimes enor- mously, and may require the application of a poultice, the anti- phlogistic system, and the recumbent posture. But the swelling usually subsides in four or five days, and a cure is accomplished through the medium of adhesion—the tunica vaginalis being made to coalesce with the proper coat of the testicle. Various other injections are used by surgeons, but they have no advan- tages generally over the port wine and water. This operation, trifling as it is usually considered, is some- times, from inattention on the part of the surgeon, followed by serious consequences, owing to the end of the cannula being permitted to slip from the cavity of the tunica vaginalis, and rest among the cellular membrane of the scrotum, into which the vinous injection will pass, and, by exciting most violent in- flammation, cause gangrene and sloughing of the scrotum, and denudation of the testicles. This has repeatedly happened.to surgeons of the first eminence, and should be most carefully guarded against. Sir Astley Cooper mentions an instance in which a patient, from this cause, died in about a week after the operation, and I myself have knowm of one case of the kind, and heard of another in this country. If the operation of hydrocele, above described, should fail, as sometimes happens, it may be repeated; or the plan of Hunter may be pursued—which is simply to make an incision an inch long, into the upper and front part of the tunica vaginalis, eva- cuate the water, and sprinkle a little flour into the cavity. This generally excites the requisite degree of inflammation; and, after this purpose is accomplished, the flour may be washed out, or permitted to escape along with the pus. This operation, however, is followed, sometimes, by violent inflammation, and, in old people, by gangrene and death. In other cases the suppuration is so profuse that the tunica vaginalis is filled with matter. But I have known the same to follow, in one instance, the operation by injection. I performed, Novem- ber 22d, 1835, the operation for hydrocele on a negro fifty years of age, at the Philadelphia Hospital. Nearly three pints of fluid were drawn off and the vinous injection thrown in. The wound made by the trocar healed up, but the swelling did not subside, and the patient's constitution was rapidly sinking. On the 22d of December, I pushed a lancet into it, and evacuated nearly a HYDROCELE. 179 quart of thick offensive pus, and in a short time the man re- covered perfectly. I have had occasion to repeat the operation by injecting two or three times in different individuals, and, at last, only have succeeded by using spirits of wine, or turpentine, along with the port wine; and although no injurious consequences followed, yet I am not inclined to recommend the practice, but have preferred, latterly, where the injection has failed, not to repeat it, but to resort to the seton, of which, under all circumstances, I entertain a very favourable opinion. The plan I pursue is very simple. The water being drawn off, in the usual way, by a trocar, I per- mit the cannula to remain, and pass through its cavity a small narrow seton needle, six inches long, armed with French braid, and, pushing the needle through the tunica vaginalis and scro- tum, introduce the braid, and remove the cannula and needle— leaving a space of two or three inches between the orifices where the ends of the braid emerge, and tie the ends loosely together. Perfect cures having almost invariably resulted from this practice, in my hands, I have resolved, in future, where I have reason to believe that the requisite degree of inflammation will not be ex- cited by the injection, to employ the seton at once, and from the first. Indeed, I see no good reason why it should not supersede the injection in all cases; for in the hands of the celebrated Pott, and others, it scarcely ever failed; and was never followed, so far as I am acquainted, with serious consequences. In general, it will be sufficient to permit the seton to remain ten days, or a fortnight, and during that time no attempt should be made to draw it backwards and forwards, which would only create un- necessary pain and inflammation. The largest hydrocele I have ever seen in this country, was in the Philadelphia Hospital during the winter of 1840. The subject of it was a large powerful man, forty years of age, who had been injured eight years before, by a blow on the breast and back, from the tilting hammer of a forge. He had laboured, previously, under common scrotal hernia of the right side, and congenital hernia of the left. On the right side, the scrotum began to enlarge soon after the accident, and continued to increase until I saw him, when the tumour, which was pyriform and elastic to the touch, and evidently contained at the upper portion a re- ducible hernia, reached nearly to the patient's knees. I per- formed the operation before the clinical class, and drew off more 180 HYDROCELE. than three quarts of yellowish brown fluid, and- then passed the long gun-shot probe armed with a tape, through the tunica vagi- nalis—leaving a space of six inches between the orifices. The walls of the tunica vaginalis were nearly an inch thick in some places, and half an inch in others. Volumes of intestine came down immediately after the fluid was drawn off, and caused the tumour to be as large as ever. These were reduced, however, and kept up by a bandage. Profuse suppuration followed in two or three days, large lumps of cheese-like matter came away from the opening, along with extremely offensive pus, and under these debilitating discharges, the patient was obliged to be sustained for weeks, by brandy, ammonia, and nutritious diet. Creosote, and other astringent injections, were employed to correct the fcetor and diminish the discharge, and the patient finally reco- vered after the lapse of two or three months—the hernia on each side being diminished and kept up by the tumour, which served as a truss and was solidified and contracted to the size of a cocoa-nut. Of the other methods of treating hydrocele—excision, caustic, and the tent, I do not speak, because they are acknowledged, by all modern surgeons, to be either very severe, or else inert. Where hydatids occupy the tunica vaginalis, and fill it entirely, (a disease which cannot be distinguished, always, previous to operation, from common hydrocele,) the surgeon will discover that a very little fluid follows the push of the trocar, and that a membranous bag will protrude immediately afterwards from the opening. In such a case, he will find it necessary to enlarge the orifice an inch or two, and dissect away with the knife, or scis- sors, the different hydatids he may meet with. The operation is tedious, and painful, but generally successful. In cases, however, where ordinary hydrocele is associated with two or three floating hydatids, the water must first be drawn off, and the injection, or seton, introduced, and each hydatid afterwards pulled out, as it shows itself, (which it generally does,) at the orifice, and cut off. Should any smaller hydatids remain, the inflammation that follows the injection or seton will commonly obliterate them. If not, a small separate seton should, afterwards, be passed through them, and suffered to remain for a few weeks. For hydrocele of the spermatic cord, either incision or injec- tion has been usually employed. The former is painful and apt HYDROCELE. 181 to be followed by suppuration, and the latter almost sure to fail, even when repeated frequently. The seton is uniformly suc- cessful, and is decidedly, in every respect, the best remedy. Pott and other surgeons have reported cases where death has followed from laying open hydrocele of the cord. Congenital hydrocele, as it is improperly termed, may be cured, sometimes by a well contrived truss, which by obliterating through the medium of adhesion, the sides of the tunica vaginalis, shuts off the communication with the abdomen. Viguirie and Sir Astley Cooper report successful cases of the kind; but De- sault, having tried the plan ineffectually, was induced to substitute another proceeding, more complicated and painful, and fraught, I conceive, with considerable danger. He first drew off the water by a trocar, then directing an assistant to make firm pres- sure at the groin, injected the tunica vaginalis with warm wine, and having afterwards carefully removed every particle of wine, lest it should find its way into the abdomen, by firm compresses over the scrotum and groin, succeeded, in a short time, in oblite- rating the passage to the abdomen and in curing, at the same time, a hernia which happened to be conjoined with the hy- drocele. This example, however, should not I conceive, be imitated, on account of the risk of peritoneal inflammation from continuity of surfaces, and then the possibility of escape of the vinous fluid into the abdomen. Should a truss effect a cure, by producing an hour-glass-like contraction between the belly and tunica vaginalis, it may afterwards become necessary to draw off the fluid from the latter by a trocar and perform some one of the operations for ordinary hydrocele. But experience proves that the fluid is sometimes spontaneously absorbed after the com- munication between the two cavities has been cut off. In cases where ascites and hydrocele are conjoined, the scrotum will be found a convenient place for the operation of paracentesis. Hydrocele is removed, occasionally, by a blow upon the tu- mour, and, in other instances, by ulceration, or sloughing, from slow inflammation, or over-distention. I once performed the palliative operation upon a gentleman, and after the lapse of a few weeks, when the fluid accumulated again, ulceration took place at the spot pierced by the trocar, and left for a few days a fistulous orifice, from which the fluid drained off. In a few days the fistula closed and the fluid was again secreted, and again dis- charged, in a similar way; and after the process had been re- 182 HEMATOCELE. peated several times, a cure was effected. Something similar occurred in a patient upon whom I operated for stone; for in twelve months after the operation the perineum ulcerated at the place of incision, and a lump of calculous matter was discharged from the bladder along with urine. The ulcer then healed up of its own accord, and the patient never had a return of his complaint. SECTION II. HEMATOCELE. This disease, as its name implies, is a collection of blood— situated either in the tunica vaginalis testis, within the tunica albuginea, or in the cellular membrane of the scrotum. It may arise, according to writers, from several different causes—from wounding one or more of the large veins of the scrotum in per- forming the operation for hydrocele,—from wounds of the ves- sels of the scrotum, during the operation of lithotomy and cas- tration,—from rupture of branches of the spermatic vein,—from spontaneous rupture of a vessel within the tunica vaginalis, after the water of a hydrocele has been drawn off,—from blows, or injuries of the vessels of the testis, and consequent extrava- sation of blood within the tunica albuginea. This disease may be distinguished, generally, from hydrocele, by its great weight and solid feel, and by its want of fluctuation and transparency, by its often following the operation of hydro- cele, or by its arising suddenly from a blow, and sometimes, by the appearance of extravasated blood in the cellular mem- brane of the scrotum. TREATMENT OF HEMATOCELE. Unless the extravasation of blood should be very consider- able, it will probably be absorbed in a short time. If, in this HEMATOCELE. 183 respect, however, the surgeon is disappointed, an incision may be made into that part which contains it, and the coagulum ex- tracted ; after which, the parts will granulate and fill up. If any particular vessel continue to pour out fresh blood, it must be searched for and secured by a ligature. During the winter of 1830, I attended a patient in the Philadelphia Hospital, whose scrotum was distended to an enormous size. Upon opening the tumour, I found a large collection of blood mixed with se- rum. Three weeks previously, the patient had undergone the operation for hydrocele, and the surgeon who performed the operation had, in all probability, wounded with the trocar some large artery or vein. The man recovered perfectly in a short time. Effusion of blood under the tunica albuginea, is con- sidered by Pott, and some other writers, as requiring castration; but, as I conceive, without foundation. There is, indeed, more reason to apprehend that the surgeon may be too prompt in performing this operation; for cases have been reported where the testicle has been extirpated, and found, upon examination, perfectly sound. Sir A. Cooper, in particular, mentions an instance where a surgeon mistook a common hema- tocele for a diseased testis, and had so little curiosity, after cas- trating the patient, as not to examine the part. When dissected by Sir Astley, blood only was found in the tunica vaginalis, and the testicle in its natural situation and free from disease. On Hydrocele and Hematocele, consult Pott's works, by Earle, vol. iii: A Treatise on Hydrocele, by Sir James Earle, 1803; Bell's Operative Surgery, vol. i. p. 193; Ramsden's Practical Observations on Sclerocele, 1811; Dorsey's Surgery, vol. ii.; Richerand's Nosographie Chirurgicale, torn. iv. p. 262 and 258; Scarpa on Hernia, by Wishart; Observations on the Structure and Diseases of the Testis, by Sir Astley Cooper, 4to., London, 1830. 184 ORCHITIS. SECTION III. ORCHITIS. The usual form of this disease, which is an acute inflamma- tion of the testicle, has been noticed already* under the common, but unmeaning, appellation of hernia humoralis. A few addi- tional remarks upon it, however, in this place, seem to be re- quired. Whether arising from gonorrhoea, or from blows or wounds of the testis, or from other causes, the symptoms do not appear to vary materially. Sir Astley Cooper, however, has re- marked, that when acute inflammation of the testicle arises from sympathy with the urethra, it rarely proceeds to suppuration. On the other hand, it has been observed by the same high authority, that " a wound of the testis does not produce the pain and in- flammatory effects which might be anticipated;" that he had several times known a lancet and even a trocar thrust into its substance, which was followed by a sickening pain, and by vo- miting, but the wound healed readily and without suppuration; that in one instance, however, he had known the trocar twice thrust into the testis, and to be succeeded by violent inflammation and suppuration. If, then, from gonorrhoea, from irritation of the urethra, prostate or bladder, by bougies, or catheters, from cold, injuries, cynanche parotidea, or other causes, acute inflam- mation should arise, the following symptoms will display them- selves in greater or less time. At first there is irritation about the neck of the bladder and spermatic cord, which is soon fol- lowed by pain and swelling of the epididymis, then by diffused general enlargement of the testicle, with an acutely painful dragging sensation upon the cord, and such exquisite tenderness of the body of the testis—as if the part were forcibly squeezed in a vice—as to cause the patient most intense and agonizing suffering. After this the pain shoots into the abdomen, along the cord, and diffuses itself from the centre to the circumference, affecting the groin, hip, and loins, and inside of the thigh, in- volving, from intercommunication of the trunks and branches of nerves, all the parts in the neighbourhood of the pelvis and * See vol. i. p. 204. ORCHITIS. 1S5 thighs. Under such local suffering, the constitution is not likely to remain long passive. The pulse becomes quick, hard, and full, the tongue furred, the skin hot and dry, and the bowels con- stipated. These symptoms are often followed by rigors, and by the establishment of the suppurative process within the body of the testicle. At last the tunica albuginea ulcerates, and the matter is discharged through one or more openings, which are apt to become fistulous, and sometimes to throw out a fungus. Care must be taken, however, not to confound this excess of granulation with protrusion of the tubuli seminiferi, a conse- quence of injuries of the testis, long ago pointed out by Petit, and afterwards noted by Lawrence. Several cases of the kind I myself have seen, and one in particular I attended many years ago with Dr. Hartshorne, to which case we were both called, in consequence of an opening having been made, improperly, by a physician, into a testicle, and the tubuli seminiferi squeezed out, under the impression of there being purulent matter. In conse- quence of orchitis, from any cause, it not unfrequently happens, that atrophia of one or both testicles ensues—nothing but a small pea-like excrescence, or remnant of the testicle, being left. TREATMENT OF ORCHITIS. The remedies for orchitis are constitutional and local. Unless the inflammation, however, runs very high, general blood-letting will not be required, but the recumbent posture, and at the same time elevation and support of the testicles by a well contrived suspensory bandage, leeches, cold applications of the acetate of lead, of the muriate of ammonia, conjoined with the internal use of saline purgatives, nauseating emetics, and other similar means, will generally effect a cure in a short time. With some irri- table patients, however, a long-continued course of depletion, if it does not prove injurious, is not beneficial. The same may be said of cold saturnine lotions. In such cases the submuriate of mercury combined writh compound powder of ipecacuanha, admi- nistered internally, and warm applications to the part, will prove, according to Sir Astley Cooper, the most efficient reme- dies. A long time often elapses before the swelling and hard- ness of the testicle subside, even after the pain and other urgent symptoms have been entirely removed. Under these circum- 186 ORCHITIS. stances, oat-meal and vinegar poultices, mercurial frictions and plasters, ointment of the hydriodate of potash and iodine should be employed, and along with them, internally, the liquor potassa? and compound extract of colocynth. But the best local treat- ment, perhaps, of all others, is that extolled by Ricord—compres- sion by adhesive straps. I myself have not tried the plan to any extent, but from a communication recently made to me by a very intelligent and accomplished young surgeon, Dr. J. F. May, of Washington, I am inclined to believe that it has not yet met with that attention it deserves. "I will only say," Dr. May remarks, " that the method of treating orchitis by compression with adhesive straps, so vaunted by Ricord, I have found to be by far the most successful I have ever tried. I have treated a number of cases, both in the Baltimore Infirmary and in private practice in this city, in this way, and have invariably found that the swelling was much sooner removed and induration much less liable to remain than by all the other means that have been recorded put together. If properly applied, I find they give relief even in the acute stage of the disease." If pus is actually found under the tunica vaginalis, the sooner it is let out the better, to prevent it from being diffused, and from disorganizing the testi- cle. Should a fungus sprout from the opening, it may be re- peatedly sliced off or repressed by caustic, but no attempts should be made to force out what may be supposed pus, but which, in reality, will generally prove to be the tubuli seminiferi. Many patients entertain, and are alarmed at, the idea of losing the function of the testicle, in consequence of enlargement of the gland, after acute orchitis. From dissections, however, made by Sir Astley Cooper, Sir Benjamin Brodie, and others, it ap- pears that the parts are generally found in a healthy state, so far as the conveyance of the semen by the vasa efferentia and coni vasculosi to the epididymis is concerned, and that the in- creased swelling generally depends upon effusion of lymph into the interstices of the glandular structure, and does not injure the functions of the testicle. For atrophia of the testicle, unfortu- nately, there is seldom any relief. IRRITABLE TESTIS. 187 SECTION IV. IRRITABLE TESTIS. This disease has been particularly described by Sir Astley Cooper under the title of irritable testis. It is a most severe and distressing affection, but fortunately not very common. Some- times it follows hernia humoralis, or common inflammation of the testicle induced by injuries, though not, perhaps, until the in- flammatory symptoms have disappeared for months; at other times it comes on without evident cause, and may occur in per- sons of vigorous and healthy constitution. But, on the other hand, it is occasionally preceded or followed by paralysis, or de- rives its origin from the brain or stomach. That one or more of the nerves of the spermatic cord may be materially implicated in this affection is not improbable. The symptoms are excessive pain in coitu, pain in the groin and back, exquisite tenderness in the whole testicle, particularly upon the slightest motion of the testicle, or any pressure that may be made upon it by the clothes in walking. There is scarcely any general swelling, or enlarge- ment of the testicle, nor is the uneasiness or pain diffused throughout the gland. On the contrary, there is sometimes di- minution of the testis, and the pain occupies a single spot or point, and may shift from one part to the other in an instant. The cord is frequently the seat of suffering, and from it to the testicle the pain darts backwards and forwards, like a flash of lightning. The recumbent posture on the side opposite the dis- ease, is the only one the patient can generally bear. Nausea, vomiting, mental dejection, and extreme bodily distress, are apt to follow long-continued attacks of the disease, and in some in- stances months and years wear away without any perceptible amendment or alleviation of the sufferings. When removed and examined by dissection, the testicle is found unaltered in struc- ture and apparently sound. In other cases, it is entirely ab- sorbed, with the exception of the tunica albuginea and tunica vaginalis. This atrophy, however, I have known to follow other affections of the testis, particularly hernia humoralis, and that en- largement of the gland produced by cynanche parotidea, or mumps. In all cases of the kind I have met with, one testis, 188 CHRONIC ENLARGEMENT OF THE TESTIS. or both, has wasted away, gradually, the pain has subsided, and the patient recovered. TREATMENT OF IRRITABLE TESTIS. If the disease should reach the height I have described, it can seldom be removed except by the operation of castration. When only of a few weeks' duration, and the symptoms are moderate, benefit may be obtained, and a cure sometimes effected, by the internal use of carbonate of iron, arsenic, ammonia, quinine, camphor, opium, cicuta, stramonium, belladonna, compound de- coction of sarsaparilla, and by the local application of blisters to the groin, and thigh, and tincture of iodine, and pyroligneous acid, ice, &c, to the scrotum. Blood-letting, low diet, purga- tives, and other parts of the antiphlogistic system, generally ag- gravate the complaint. Several years ago I was induced, in an obstinate case of irritable testis, to cut down upon the spermatic cord and divide its nerves, leaving the cremaster muscle and vas deferens untouched. The operation proved very difficult, but eventually produced so much relief, that the patient does not re- gret having submitted to it. SECTION V. CHRONIC ENLARGEMENT OF THE TESTIS. From inordinate indulgence in venery, or masturbation, from any urethral excitement, from exposure to cold, from fatigue or mental inquietude, from intemperance, and from various consti- tutional causes, chronic inflammation is set up in one or both testicles, and is so insidious in its approach and so gradual in its advances, as often to escape the notice of the patient, and to deceive the surgeon. In particular, even after the disease has existed for weeks or months, the testicle may be handled roughly CHRONIC ENLARGEMENT OF THE TESTIS. 189 without exciting pain or any unpleasant sensation. Indeed, in many instances, the testicle attains a considerable magnitude, and yet is entirely devoid of uneasiness. The swelling commences in the epididymis, which slowly hardens and enlarges. From the epididymis, it extends to the body of the gland, and both preserve their natural smoothness and shape. Both testes may be simultaneously affected, or the swelling may remain stationary in one and increase in the other. With the swelling a hydrocele is often conjoined. The patient's gene- ral health is apparently good, and he is seldom debarred from exercise or prevented from attending to his business. In this state of the disease, it often happens that a blow, or some other injury is received, or that the patient has been drinking to excess, or exposed to cold, and from that moment great pain and swelling take place in the testicle, which are soon followed by pain in the loins, and febrile excitement. By the use of appropriate remedies these symptoms wholly subside, and for weeks, or months, the patient remains, apparently, well. He is very liable, however, to a repetition of the attack, and should this occur frequently, suppuration is established in the body of the testicle or epididymis, and the matter, of its own accord, is at last discharged through the scrotum, or let out by the surgeon. A sinus ending in a fistulous orifice, soon follows, and from this a discharge of seminal fluid issues, sometimes in considerable quantity, and is kept up, not unfrequently, for many months. From the mouth of the sinus, granulations in a fungous form, sprout forth, and often become very luxuriant. Indeed, in this, and other respects, there is reason- to believe that chronic en- largement of the testicle corresponds with fungus of that organ, described in former editions of this work. TREATMENT OF CHRONIC ENLARGEMENT OF THE TESTIS. In the commencement of this disease, or even after considerable swelling of the testicle has taken place, strict confinement for several weeks, to the horizontal position, elevation of the testicle above the pubes, and retention there by a bag truss, the applica- tion of leeches, followed up by cold saturnine solutions, or cam- phorated mixture, and vinegar, or the acetated liquor of am- monia, together with low diet, occasional purgatives, the inter- VOL. II.—N 190 ENCYSTED TESTICLE. nal use of mercury, and avoidance of venereal excitement or in- dulgence, will often effect a perfect cure. But should the patient afterwards neglect himself, and have repeated returns of the com- plaint, and suppuration of the testis, discharge of semen through fistula?, and fungous granulations follow, extirpation of the testicle will in many cases be required, and, indeed, will often be insisted on by the patient. In other cases the fungous granula- tions may be repressed by caustic, or should be cut away with the knife, or kept down by pressure, whilst injections of solution of sulphate of copper and other similar articles are thrown into the sinuses, to consolidate their sides and close the fistula?. It should be remarked, however, that the operation of castration has often been performed unnecessarily for chronic enlargement of the testis, under the idea of its being a specific or malignant disease, which, in reality, it is not, as is proved by the circum- stance of the cord not being liable to contamination, as it always is in the advanced stages of cancer of the testicle. SECTION VI. ENCYSTED TESTICLE. Cysts, containing a yellow, transparent serum, or else a turbid gelatinous fluid, are found to occupy, occasionally, the substance of the testicle within the tunica albuginea. They vary in size, some being not larger than a shot, and others equal in bulk to a pistol-bullet. The fluid contained in the larger ones is thick and muddy, and in the smaller transparent. Both the tunica vagi- nalis and albuginea are thickened, and in cases of long standing, the substance of the testicle is in a great measure removed, and its place occupied by the cysts. According to Sir Astley Cooper, these cysts are probably enlargements of the seminiferous tubes, and not animal hydatids. Patients from eighteen to thirty-five years of age are most subject to the complaint, which, however, is rather uncommon ENCYSTED TESTICLE. 191 than otherwise, and very liable to be confounded with other affections of the testicle, particularly with hydrocele. But the most striking symptoms of hydatid testicle are—conspicuous dis- tention of the veins of the scrotum and spermatic cord, no ten- derness, or pain, in the commencement of the disease, or even in the advanced stages, unless the part be forcibly squeezed; and then sickness of the stomach, pain in the groin, and that peculiar sensation which follows pressure on a sound testicle, arise. The testicle, too, retains its natural, or rounded shape, is heavier than usual, has a very obscure and limited sense of fluctuation, and the epididymis preserves, generally, its natural line of demarcation. In the end, the tumour becomes enormously large, but the cord and inguinal glands are never contaminated. Lastly, there is no transparency in the tumour. This, together with absence of distinct fluctuation, and the rounded, instead of pyriform, shape of the swelling, will be sufficient, in most cases, to distinguish the disease from hydrocele. Nevertheless, the most experienced surgeons have been frequently deceived, and have confounded one with the other. TREATMENT OF ENCYSTED TESTICLE- Before giving a decided opinion, the surgeon should make it a rule, to puncture with a lancet every tumour bearing a resem- blance to encysted testicle. In case a few drops of fluid issue mixed with blood, the nature of the disease will generally be made manifest. It will then become a question whether castra- tion should be performed or not. When the tumour is im- mensely large and inconvenient, or so unsightly as to annoy the patient, it may be removed; but, on the contrary, when it remains stationary for years, and the patient's mind is not filled with apprehension as to the termination of the case, he should be advised to submit with Christian resignation to his misfortune and to palliate the complaint as long as possible. On the other hand, should he determine, after mature deliberation, to lose the testicle, the surgeon has it in his power to assure him of the safety of the operation, and that the disease—which is not of a malignant nature,—will not return. It may happen, however, to be conjoined with fungus ha?raatodes, and in that case an ope- ration will prove fruitless. 192 TUMOURS OF THE SCROTUM. SECTION VII. TUMOURS OF THE SCROTUM. Sarcomatous, and other indurated growths are met with, occasionally, in the cellular texture of the scrotum, which sometimes are scattered about in the form of small tumours, and feel like a marble or piece of cartilage beneath the skin, being either firmly fixed or moveable; at other times, the whole texture of the scrotum seems to undergo a change, becomes unusually corrugated, thickened, and finally converted into enormous indurated masses. Such are often seen in the West Indies, and in Egypt, and interesting cases of the kind have been reported by Larrey, Titley, and others, but are rarely met with in the United States. When a single sarcomatous, or adipose tumour occupies the scrotum, or the outer surface of the tunica vaginalis, or is imbedded in either of these textures, it often presents the appearance of a third testicle, and has so been con- sidered by ignorant persons. An interesting case of the kind occurred several years ago in the practice of Dr. Heister, an eminent physician of Reading, in this state. The tumour had existed for a long time, was of the shape of a testicle, but much larger, and was so situated betwreen the testes as to inspire a belief on the part of the patient and his friends that it was really a third testis. Upon being removed, however, by Dr. Heister, it was found to be lodged in a cyst between the scrotum and tunica vaginalis, and to consist of adipose and fleshy matter. The preparation, obligingly presented to me by Dr. Heister, is still in my cabinet. TREATMENT OF TUMOURS OF THE SCROTUM. Those enormous growths described by Larrey, Hendy, Titley, Delonnes, although supposed to derive their origin from an in- curable disease—elephantiasis—have been extirpated, neverthe- less, with success. In particular, Titley removed, effectually, from a West India negro, a stupendous tumour, in the interior of which the genitals had long been buried, and which reached nearly to the ground, and weighed seventy pounds. Others of TUMOURS OF THE SCROTUM. 193 still greater weight and dimensions have been reported, and are said to have been successfully cut away. Larrey met with ten or twelve cases in Egypt weighing upwards of one hundred and twenty pounds. And in the German Ephemerides an in- stance is reported of a tumour which weighed more than two hundred pounds. In performing such operations, the surgeon should endeavour, if possible, to ascertain the condition of the testes and penis, in order not to injure, or remove them unnecessarily. Mr. Liston, however, who operated on an enormous tumour of this de- scription, many years ago, and with perfect success, says it was impossible to ascertain the situation of the genitals, and that he was more solicitous of preserving the man's life, than anxious about his organs of generation. The operation in some in- stances, proves quickly fatal, from irritation. This was the case in a Chinese, operated upon by Mr. Aston Key, about ten years since. A similar disease is occasionally met with in females, and requires the same treatment. When small tumours occupy the scrotum or surface of the tunica vaginalis, they do not always require extirpation; but, when necessary, the ope- ration is easily performed, and a cure soon effected. I have known, however, very large sarcomatous thickenings of the scrotum, and tunica vaginalis, and also enormous hydro-sarco- celes in West Indians removed in a short time by a change of residence. In December, 1816, Captain D-------was recom- mended to my care by Robert Harrison, Esq., United States consul for the Island of St. Thomas, on account of an immense scrotal tumour which involved each testicle, and spermatic cord, and was complicated with hydrocele. The patient stated that from long residence in Martinique and other islands, where he had been exposed from the nature of his occupations to hard- ships, and had drunk constantly of rain water, which was often in an impure state, his disease, as he believed, was to be at- tributed. While the patient was arranging his affairs and re- cruiting his health, to enable him to undergo an operation, the tumour gradually subsided, and in the course of twTo or three months was entirely absorbed—and all the parts affected restored to their natural state. Consult, on Diseases of the Tunica Vaginalis and Testis, Pott's Works, by Earle, vol. iii.; A Treatise on Hydrocele, by Sir James Earle, 1803; Bell's Opera- tive Surgery, vol. i. p. 193; Cooper's Lectures,by Tyrrel, vol. ii. p. 86; Observa- 194 TUMOURS OF THE SCROTUM. tions on the Structure and Diseases of the Testis, by Sir A. Cooper, p. 165. Ramsden's Practical Observations on Sclerocele, 1811; Richerand's Nosogra- phie Chirurgicale, torn. iv. p. 258 and 262; Observations on a Peculiar Affec- tion of the Testis, attended with the Growth of Fungus from that Organ, il- lustrated with Cases by W. Lawrence, in Edinburgh Medical and Surgical Journal, vol. iv. p. 257; Dupuytren, Legons Orales de Clinique Chirurg.; Sir B. Brodie, in Lond. Med. Gaz. vol. xiii. 1834; Cruveilhier, Anat. Patholog.; Cusack, in Dub. Journ. of Med. Science, vol. viii.; Wadd's Cases of Diseased Prepuce and Scrotum, 4to. 1817; Larrey's Surgical Memoirs; Case of Extraor- dinary Enlargement of the Scrotum, by J. M. Titley, Medico-Chirurgical Transactions, vol. vi. p. 73; Delonne's Case of Charles Delacroix, in Riche- rand's Nosographie Chirurgicale, torn. iv. p. 315; Liston's Practical Surgery, p. 340, Lond. 1839; Clot-Bey, in Travaux de l'Ecole de Med.d'Abou Zabel Egypte, Paris, 1833; Cheston's Patholog.Inquiries; Delpech,Chirurg.Clinique; A Practical Treatise on the Diseases of the Testes and of the Spermatic Cord and Scrotum, with Illustrations, by T. B. Curling, Lecturer on Surgery, and Assistant Surgeon to the London Hospital, edited by P. B. Goddard, M. D., Demonstrator of Anatomy in the University of Pennsylvania, Philadelphia, 1843. DISEASES OF THE PENIS. 195 CHAPTER VIII. DISEASES OF THE PENIS. A mistake into which writers, as well as practitioners, are extremely apt to fall,—that the penis, with one or two excep- tions, is subject only to specific disease—should be corrected. Possessing the same texture and organization, (modified by cer- tain peculiarities) as other soft parts, why should it not be liable to the same infirmities? That it is so, experience, our safest guide, has sufficiently proved; for, wounds and other injuries, simple and erysipelatous inflammations, — excoriations, — ab- scesses,—ulcers, simple, irritable and indolent,—warts,—tuber- cles, tumours, sarcomatous, encysted, steatomatous,—herpetic, and other eruptions, totally unconnected with syphilitic taint, or with other specific vitiation, sometimes the result of sexual inter- course, at other times entirely independent of it, the consequence often of abrasion, or mere mechanical injury, have been, always, more or less common in every country and in every age. It is not my intention, however, to treat of all these affections, but chiefly of simple ulcerations, of phimosis, paraphimosis, &c. Chancre, or the true syphilitic sore, has been noticed on a for- mer occasion.* * See vol. i. p. 211. 196 WOUNDS OF THE PENIS. SECTION I. WOUNDS OF THE PENIS. The penis is liable to incised, lacerated, contused, gun-shot, and other varieties of wounds. They may be the result either of design or accident, and numerous instances have been reported where maniacs, and persons under the influence of religious phrensy or hallucination, have removed both the penis and tes- ticles. An extraordinary instance where an attempt was made, under a different feeling, to inflict a punishment of this descrip- tion, occurred not long since, in the practice of an eminent sur- geon of New York. A woman who had long lived unhappily with her husband, and from whom she had been separated for a considerable time, became apparently reconciled to him, and through the intervention of friends the parties consented to renew their nuptial intercourse. Prompted, however, by jea- lousy and a diabolic spirit, the virago, having provided herself with a razor, took it to her bed, and while her unfortunate Abe- lard was in the act of consummation, seized the penis and with her weapon nearly severed it from his body. The penis has been shot off in duels, or swept away by cannon or musket-balls or grape-shot, or so bruised and lacerated by these and other missiles, that it has afterwards sloughed and been lost. A severe bruise, or contusion, may likewise produce a different effect or lay the foundation of a specific disease, as in the following case. "I. Wallace," says Sir Everard Home, " a married man, thirty-seven years of age, stout-made, subject to no general or particular complaints, and by profession a sailor, was admitted into St. George's Hospital, under my care, No- vember 18th, 1803. About four years since, during a violent storm at sea, the main-top-mast was shivered, and the upper portion was swinging backwards and forwards. It was neces- sary to cut away the upper piece, and Wallace was sent aloft for that purpose. He had on a pair of loose trousers at the time. The rolling of the ship was very great, which increased the motion of the mast, and while he was clinging to the stand- ing part, his glans penis was caught between it and the loose piece; he immediately fainted away and fell into the round top, WOUNDS OF THE PENIS. 197 from whence he was carried to the deck. On recovering, he was informed by his companions that when they first took him up his glans penis was as flat as a half-crown. The body of the penis and both testicles, as well as the glans began to inflame and swell, and were extremely painful. He kept his bed for three weeks, at the end of which time the glans had recovered its natural size and figure, having only a small pimple on that part to which the fraenum is attached. This was considered of no consequence, and was not at all troublesome until his arrival in England, six months afterwards, when it began to ulcerate and become very painful. It is proper to remark, that he never had the venereal disease, and from the time of the accident never had intercourse with his wife or any other woman."* From that period the ulceration increased, assumed the cancerous form, involved the greater part of the penis and groin, and after the lapse of a year, proved fatal. An interesting case was reported to me, five or six years ago, by Dr. Wm. S. King, of Russel- ville, Chester County, in which a young man, 17 years of age, had the genitals entangled in the machinery of a cotton factory, in such a way that the skin was completely stripped from the pubes, penis, testicles, and perineum, as far as the verge of the anus, and although replaced by Dr. King, shortly afterwards, finally sloughed away, and endangered the patient's life—by ir- ritative fever, and inflammation. TREATMENT OF WOUNDS OF THE PENIS. In cases of incised or lacerated wounds of the penis, the he- morrhage should be arrested by picking out the vessels with the tenaculum, or needle, and tying them, or by introducing a cathe- ter into the urethra and making firm compression with a bandage on the penis. After the hemorrhage has ceased, the edges of the wound must be drawn together by the interrupted suture, and supported by adhesive straps. The bandage should then be slackened or removed, as, if long-continued, it will be apt to cause swelling and to excite erections.. When the urethra is divided and the penis nearly cut through, as in the New York case, the catheter must be continued until reunion is established; * Home on Cancer. 198 ULCERS OF THE PENIS. otherwise, effusion of urine and sloughing may follow. Con- tused wounds of the penis will require poultices and fomenta- tions, and after full benefit has been derived from these, should ulcerations remain, mild dressings, such as are used in simple ulcers in other parts of the body, may be resorted to. But in all injuries of the penis, an important indication is to repress erec- tions—by the internal use of camphor, dulcamara, &c. SECTION II. ULCERS OF THE PENIS. The loose skin covering the glans, as well as that on the body of the penis, is subject to phlegmonous inflammation and abscess, which seldom, however, forms a large tumour, but upon break- ing, or being let out with a lancet, discharges freely, and leaves an ill-conditioned sore, with an indurated margin, and excavated edge. The whole aspect of the ulcer, indeed, is at first so un- favourable, as to cause it to be mistaken for chancre; though the rapid progress towards amendment, and the speedy filling up of the sore, will soon evince its true character. The Ulcus Erraticum is met with, almost invariably, in per- sons of bad constitution, in dram-drinkers, and in those who have suffered from the abuse of mercury. It may follow sexual intercourse or not, and is distinguished, generally, by this pecu- liarity—that the sore, which usually occupies the body of the penis, ascends in a spiral form, and, while it heals below, breaks new ground above, and in this way may encircle the penis, reach the groin and pubes, and devastate them. The edges of the ul- cer are everted and indurated, the granulations foul, and the pain severe and burning. Psoriasis Preputialis is an affection almost peculiar to those individuals who have the prepuce unnaturally long, tender, and succulent. It appears in the shape of deep fissures, or cracks, which pervade the edges of the prepuce, discharge at first a co- ULCERS OF THE PENIS. 199 hesive, and afterwards a purulent matter, bleed freely upon being irritated, are excessively tender or painful, and difficult to heal. Herpes Preputialis differs from the foregoing affection in toto. It commences in the form of vesicles, which, upon breaking, leave, when situated on the inner surface of the prepuce, a small round yellowish white ulcer, and when it occupies the outer skin of the prepuce, forms a scab. Each vesicle has its correspond- ing sore, which often unites with those adjoining it, until one unbroken surface of ulceration is established. From experi- ments made by Mr. Evans, it appears that the sore is not conta- gious. The same writer imputes the disease to derangement of the digestive organs. Excoriatio, or abrasion of the cuticle of the glans penis or pre- puce, may be the result of inordinate friction, of preternatural tenderness of parts, of undue secretion of that whitish, cream- cheese-like, sebaceous matter, which seems almost peculiar to certain persons, of filth, or want of accurate ablution, of con- nexion with foul and unwholesome women, particularly such as have laboured for years under fluor albus and other acrimonious discharges, of extraordinary inequality of size between the male and female genitals, &c. From any of these causes, trou- blesome ulcerations may arise, and are often confounded with syphilitic sores. But their external characters are sufficiently marked, in general, to enable a careful surgeon to distinguish them from other ulcerations. In particular, these ulcers are superficial, irregular, in separate patches, of a yellowish hue in the commencement, but surrounded, in the advanced stage, by a red areola. Extraordinary itching, together with undue serous or purulent secretions, followed in some instances, by sympathetic enlargement of the inguinal glands, are the re- maining symptoms. TREATMENT OF ULCERS OF THE PENIS. Phlegmonous inflammation of the penis is rarely susceptible of resolution. The sooner, therefore, the matter is evacuated by a lancet, the better. An emollient poultice of bread and milk, ground flax-seed, and particularly of the powdered bark of slip- pery elm, may then be applied, and renewed frequently for a day or two. Afterwards, the mildest unctuous dressing and lotions 200 ULCERS OF THE PENIS. may be employed. Should fungous granulations arise, the sul- phate of copper and lunar caustic will be required. Ulcus Erraticum, like the common irritable ulcer of other parts, frequently proves refractory. It should be coaxed and humoured by soothing and sedative lotions, such as the acetate of lead and sulphate of zinc blended with gum Arabic and opium. Very weak solutions of argentum nitratum, and nitric acid, ex- tremely diluted, will also prove useful. Acrid and stimulating applications generally fret and annoy it. The blue pill, as an alterative, and great attention to diet, with rigid observance, in plethoric patients, of other parts of the antiphlogistic system, will sometimes do more good than all the local remedies that can be thought of. In patients prostrated by intemperance, or other causes, a system of support or nourishment must be insti- tuted, and corresponding applications to the sore, and internal medicines employed. For Psoriasis Preputialis, various astringent lotions and oint- ments are generally used, and according to Evans, the best application is the unguentum hydrargyri nitrati, reduced to one- half of its ordinary strength. Herpes Preputialis is benefited by attention to diet, by the occasional use of gentle purgatives, and by the mildest local ap- plications. Keeping the parts perfectly clean, and suffering them, when disposed so to do, to form a scab, will effect a cure, in a very short time. Simple Excoriations, unconnected with specific disease, may be removed speedily, by guarding against erections, by the use of simple ointments perfectly fresh, by moderately astringent lotions, and when the sores become indolent, by gentle, occa- sional touches of argentum nitratum, and weak solutions of cor- rosive sublimate mixed with spirit of lavender or alcohol. PHIMOSIS. 201 SECTION III. PHIMOSIS. There are two varieties of this disease—the natural and pre- ternatural. The former exists at birth, and is therefore congeni- tal ; the latter may occur at any period of life. In both cases the prepuce is contracted in front, and cannot be drawn backwards over the glans penis. Natural phimosis is a very common complaint, and met with under two or three different forms. Sometimes, though rarely, the extremity of the prepuce is perfectly closed, and the urine cannot pass off, but collects between the glans and pre- puce, forming a large bag or tumour. The disease is of course discovered a short time after birth, but is often not understood, and from this cause several infants have perished that might have been saved by a trivial operation. Another form of natu- ral phimosis is that in which an opening exists at the extremity of the prepuce, but so small as not to permit the urine to escape from it with the same rapidity it issues from the urethra. Con- sequently, it collects between the prepuce and glans, and dis- tending the former to a great size, is then forced off gradually in a very fine stream, and to a great distance.* If the disease should continue in this state for several years, as I have known to happen, pus and calculi may collect within the cavity of the distended prepuce, and keep up a constant irritation. But, in most instances, there is no impediment to the flow of urine, no extraordinary elongation of the prepuce; yet the skin is so closely contracted around, as to prevent the patient from uncovering the glans penis. From this, other inconveniences result. A whitish sebaceous matter collects in large quantity between the glans and prepuce, and excites so much irritation, as to produce a disease resembling gonorrhoea—with which it is often con- founded. Besides this, the inflammation excited by this, or any- other cause, may produce an adhesion between the glans and prepuce, which can only be relieved, and that not always, by a most severe and tedious dissection. * I saw recently a case of the kind in a calf. 202 PHIMOSIS. Preternatural phimosis is commonly the result of inflamma- tion of the prepuce, by whatever cause induced. The disease often accompanies severe gonorrhoea, extensive chancres, and venereal warts. Sometimes matter accumulates behind the corona glandis, and is followed by ulceration of the prepuce, and a protrusion of the glans through the opening. The inflamma- tion attending preternatural phimosis, is sometimes of the erysipe- latous kind. Extensive sloughing of the prepuce is frequently the consequence, in bad constitutions, of the continued exhibition of immoderate quantities of mercury. TREATMENT OF PHIMOSIS. Natural phimosis, if it exist at birth, and be complete, will re- quire an immediate operation, in order to save the infant's life. A puncture with a common lancet in the most prominent part of the tumour, may answer every purpose, as the stream of urine will afterwards prevent the opening from closing. When the prepuce has become distended, from repeated collections of urine, the small opening in its extremity may be either enlarged, or the superfluous bag amputated. The latter will prove the most effectual, and should be resorted to generally. A simple phimosis, when only inconvenient to the patient by impeding copulation, may be relieved by slitting up the pre- puce at its middle as far as the corona glandis. The opera- tion can be performed with a sharp-pointed bistoury, or still better by the sheathed knife employed by Dr. Physick for fis- tula in ano. Hemorrhage sometimes follows the incision, but in general is easily suppressed by a dossil of lint. Before the parts are dressed, the surgeon must take care to tack the two layers of skin to each other by a single stitch of the interrupted suture. The edges of the prepuce, thus divided, retire from each other, and after they are healed, become continuous, and resemble the borders of a prepuce naturally formed. This has been denied by some surgeons, wTho allege that two flaps or angles are left, which afterwards prove very inconvenient to the patient. I have performed the operation very frequently, and never experienced such a result. Instead of splitting open the prepuce anteriorly, and thereby obviating deformity, Clo- quet, Liston, Wallace and some other surgeons, prefer passing PARAPHIMOSIS. 203 a director parallel with the fraenum, and dividing the two mem- branes at a single stroke of the knife—taking care, as suggested by Liston, that the director be not inserted into the urethra. Preternatural phimosis, when complicated with gonorrhoea, or chancres, and attended with high inflammation, should never be touched with the knife. The best remedies, under such circum- stances, are local blood-letting, emollient poultices, fomentations, and accurate ablution of the glans by means of a syringe. The continuance of mercury will prove immensely injurious. After the inflammation has entirely subsided, if adhesions should have formed between the glans and prepuce, uniting them firmly to each other, an attempt may be made to separate them by dis- section, provided the patient is willing to encounter a most se- vere operation,—one compared by Petit " to the skinning of an eel,"—rather than submit to his misfortune. The operation, however, I have often found absolutely necessary to perform. SECTION IV. PARAPHIMOSIS. Paraphimosis is the reverse of phimosis—the prepuce being retracted behind the corona, leaving the glans uncovered. The disease may be either congenital or acquired, but the latter is the most common. Sometimes it is the result of the successful re- traction of the prepuce in cases of phimosis; but generally it proceeds from inflammation induced by syphilis or gonorrhoea. So extensive is the swelling, in some instances, and so great the constriction produced by it, that the glans penis, or prepuce, oc- casionally mortifies and drops off. This termination, however, must be considered as comparatively rare. I have known para- phimosis to proceed, in some instances, from erysipelas, and in other, from collections of sebaceous matter between the prepuce and glans penis. In such cases, sero-purulent matter, or ill-con- ditioned pus, very abundant, and very fetid, has collected in the 204 PARAPHIMOSIS. cellular tissue of the skin of the penis, or in the cells of the cor- pus spongiosum, or cavernosum, and has been discharged from one or more fistulous orifices—giving rise, eventually, to conden- sations, and adhesions, which may interfere with erections and other functions of the penis. TREATMENT OF PARAPHIMOSIS. If called in time, or before the swelling attains a great height, the surgeon may often succeed in restoring, by steady pressure with the fingers, kept up for several minutes without intermis- sion, the prepuce to its natural situation. The application of very cold water to the parts will also contribute towards the same end. Punctures, too, when there is much oedema, as ge- nerally happens, afford great relief, by evacuating the serum and reducing the swelling. This treatment, together with an ob- servance of the antiphlogistic system, will usually effect a cure in a short time; should this not prove to be the case, and gan- grene of the parts be likely to follow, the division of the stric- ture must be attempted. To accomplish this, a fold of the skin should be raised and cut through, a director pushed beneath the stricture, and the latter divided by a bistoury. In cases of ery- sipelas of the prepuce, leeches, cold washes, slight incisions, followed by poultices, and by mercurial ointment, I have found useful. Steady purging, too, has proved exceedingly useful, especially in corpulent subjects, and those accustomed to luxu- rious living. On Phimosis, Paraphimosis, and other Diseases of the Penis, consult Petit's Traite des Maladies Chirurgicale, et des Operations qui leur Conviennent,tom. ii.; Hunter on the Venereal; Cooper and Travers's Surgical Essays, part. i. p. 145; Richerand's Nosographie Chirurgicale, torn. iv. p. 328; S. Cooper's first Lines of the Practice of Surgery, vol. ii. p. 176; Wadd's Cases of Diseased Prepuce and Scrotum, 4to.London, 1817; Pathological and Practical Remarks on Ulcerations of the Genital Organs, by James Evans, Surgeon to His Ma- jesty's 57th Regiment, London, 1819; Liston's Practical Surgery; Velpeau, Nouv. Elem. de Med. Operat. STRICTURE OF THE URETHRA. 205 CHAPTER IX. DISEASES OF THE URETHRA AND BLADDER. Volumes have been written on these subjects; and there is scarcely an eminent surgeon of any age who has not devoted some portion of his writings to their explanation. This will show the importance of these diseases, and the difficulties en- countered in their treatment. In a work professedly elementary, it will not be expected that more than a very general sketch on such topics can be furnished. Ample scope, however, must be taken in the lectures—such, I trust, as will abundantly supply any deficiency that may be here met with. The diseases of the urethra and bladder, that remain to be considered, are stricture, fistula in perinaeo, enlarged prostate, retention and incontinence of urine, sensitive tumours of the female urethra, and stone in the bladder. SECTION I. STRICTURE OF THE URETHRA. This is a very common complaint; more common, indeed, than is generally imagined. It may proceed from various causes—from gonorrhoea, or the remedies employed in the cure of that disease; from external violence; from irritation within the urethra, produced by the passage of calculi, or the application of blisters to the perineum or other parts of the body; from exces- sive indulgence in venery, or unnatural prolongation of the vene- VOL. ii.—o 206 STRICTURE OF THE URETHRA. real act; from enlargement of the prostate gland; from stone in the bladder, &c. It is somewhat remarkable, however, that the disease seldom makes its appearance until years have elapsed, and the effect of the causes above enumerated has appeared to cease. Many surgeons question the propriety of referring the origin of stricture to gonorrhoea, without, I conceive, sufficient foundation; though it must be acknowledged that the disease is sometimes met with in very young boys, and in adults wTho have led the most exemplary lives. Strictures have usually been divided into twro kinds—the per- manent and spasmodic. To these Mr. Hunter added a third variety—which is alleged to consist in a combination of the two. Permanent stricture may be said to consist of a thickening or change of structure in the urethra, induced by preceding inflam- mation. That spasmodic stricture frequently exists, there can- not be the smallest doubt, though it is still a question whether the spasm should be referred to the muscularity of the urethra itself, or to the muscles surrounding that canal; a question, however, in a practical point of view, of comparatively small importance. Yet I must confess my willingness, for various reasons, to subscribe to the latter doctrine. There is seldom much variation in the seat of a stricture; which is usually found behind the bulb of the urethra—about seven inches from the extremity of the glans. At the distance of four or five inches, also, and three inches and a half mea- suring from the outer orifice of the urethra, strictures may be often discovered. Sometimes the orifice itself is the seat of stricture. Most patients have but one or two strictures, others four or five. Strictures differ from each other in extent and consistence. The most common form of the disease is that which resembles the effect of a thread tied around the canal; it is likewise the most simple variety of stricture. Sometimes the canal of the urethra is regularly contracted or thickened, in one or more places, to the extent of an inch and upwards. The simple thread-like stricture, which does not always run in a circular direction, but sometimes splits and branches, may by irritation or bad treatment be converted into a callous induration. When examined by dissection, most permanent strictures will be found to consist of a dense, pure white, fibrous substance, like gristle— the result of previous and repeated depositions of coagulable STRICTURE OF THE URETHRA. 207 lymph. These views, which I have long taught, have lately been confirmed by Cruveilhier's* dissections. The symptoms of stricture of the urethra, are constitutional and local. Among the former may be enumerated, disorder of the digestive functions, general irritability of the system, various mental emotions, severe chills, followed by high fever and profuse perspiration. All patients, however, are not subject to the febrile paroxysm. The most common local symptoms are, a slight dis- charge of matter from the urethra; a frequent desire to evacuate the urine, which issues in drops, or in a forked, twisted, wiry, or thread-like stream; nocturnal emissions; scalding of the urine; uneasiness about the anus and perineum. Persons troubled with strictures, are extremely liable to cold, which greatly aggravates the symptoms. Excess in eating or drinking will produce the same result. During copulation, it frequently happens that a stricture, by interrupting the flow of semen, occasions it to be forced backwards into the bladder, from which it is afterwards discharged the first time the patient makes water. In bad cases of long standing stricture of the urethra, the walls of the bladder not only become thickened—sometimes to the extent of an inch, and the cavity of that viscus so much con- tracted as scarcely to contain any urine—but the ureters enlarge enormously; in some instances to the size of an intestine. Their coats, also, are much thicker than natural; and from the constant strain and pressure upon the kidneys, from the reflux or regurgi- tation of the urine, these organs suffer in proportion, and lay the foundation of great constitutional disturbance. Some fine spe- cimens of enlarged ureters from strictures, and stone in the bladder, are contained in my cabinet, both in old and young subjects. Stricture is often confounded with other diseases; especially with gonorrhoea, gleet, stone in the urethra or bladder, enlarged prostate, spasm of the muscles of the perineum, irritation or in- flammation of the lacunae, intermittent fever, &c. TREATMENT OF STRICTURE OF THE URETHRA. In the treatment of this disease, the first object of the surgeon should be to ascertain the situation and extent of the stricture. * Archives General. 1842. 208 STRICTURE OF THE URETHRA. This may be done by a bougie, catheter, or urethra sound* A soft white bougie of moderate size, well oiled, will excite as little irritation as any other instrument, and is well calculated, when softened by the heat of the urethra, to take an exact impression, with its point, of the form of the obstruction, and of its precise situation. Over the bougie, however, in many instances, the urethra sound possesses a decided advantage, since, from its me- tallic nature, and the small size of its wire rod, it communicates a vibration to the surgeon's finger, and passes easily along the urethra, while the ball at its extremity catches readily upon any irregularity of the canal, and in this way detects the slightest obstacle. With this instrument, moreover, the situation of several strictures may at the same time be ascertained—an advantage which the bougie does not combine. Having satisfied himself of the nature of the stricture, its po- sition and extent, the surgeon must next determine upon the means to be employed for its removal. There are three or four methods in common use—dilatation of the stricture by waxen, metallic, or gum elastic bougies,f destruction of it by the lunar or vegetable caustics, and its divisions by a stilet. Each is adapted to particular cases. When the strictures are numerous and of considerable length, neither the caustic nor stilet can be employed to advantage, and dilatation by the bougie must be mainly depended upon. In using this, the surgeon should make it a rule to proceed as gradually and cautiously as possible, commencing with an instrument of moderate size, such as will pass readily through the strictures without giving pain or pro- ducing hemorrhage. It should be worn morning and evening. while the patient is in bed, or at regular intervals during the * An instrument invented by Sir Charles Bell, made of silver wire, twelve or fourteen inches long, having at. one end a ball, at the other a ring: the former intended for the stricture, the latter for the surgeon to hold by while the instrument is introduced. f The finest bougies I have ever seen, were prepared by the late Dr. Balfour, of Norfolk, Virginia; a gentleman remarkable for his intellectual endowments, amiable character, and mechanical ingenuity, and whose death will long be deplored by the inhabitants of the district in which he resided. The wonder- ful dexterity which he possessed in the manufacture of instruments, of every description, is evinced in the splendid collection of splints and bandages, pre- sented to the museum of our university, in 1830, by his son, Dr. Eleazer Balfour, a most promising young practitioner of Norfolk. Many of the in- struments referred to are of exquisite finish and workmanship, such as would puzzle, if not defy, the best regular mechanic in the country to imitate or equal. STRICTURE OF THE URETHRA. 209 day, taking care not to continue it too long, but on the contrary to withdraw it when undue irritation is excited by its presence. Having derived full benefit from the use of one instrument, others should be introduced, proportioned in size to the extent of the dilatation—being gradually increased. In many instances, the constant use of these instruments, for a few weeks, will effect a perfect cure; in other cases, months or years will elapse, before the patient derives the necessary relief. Silver bougies, when well made, are better adapted to the dilatation of a stric- ture than most others. A set of instruments of this description of peculiar construction, manufactured under my direction by Mr. Warner of Greenleaf Court, I have employed for many years with great effect. Many patients, however, experience great benefit from the use of the flexible metallic bougie. For very long and narrow strictures, I have used, with much advan- tage for many years past, fine, highly polished, and very flexible whalebone bougies. Caustic has long been employed in the cure of strictures. It was a favourite practice with Mr. Hunter, and has since been highly extolled by his relation, Sir Everard Home. I have em- ployed the remedy, for many years, sometimes advantageously, at other times, with manifest aggravation of the symptoms. From all I have seen, I am disposed to conclude, that it is only adapted to strictures of small extent—such as the thread-like stricture. That much mischief has resulted from its indiscri- minate and injudicious application, I well know; but its strongest advocates, also confess, that in their own hands, false passages, hemorrhage, great irritation, severe paroxysms of fever, and other ill consequences, have often been induced. These remarks will apply to the vegetable as well as lunar caustic, although the former has been considered by some writers to be milder in its operation, and to act upon a different principle from the lunar caustic. When a stricture is very small, and situated near the extremity of the urethra next to the glans penis, and there is reason to believe, that one or two applications of the caustic will go through, it may be applied in the following way. The surgeon takes a common soft bougie, oils it, carries it nimbly down to the stricture, keeps it in contact with it a few seconds, and marks with his finger-nail the bougie at the external orifice of the urethra before he withdraws it. Another bougie, composed of firmer materials, is next taken, a hole about the eighth of an 210 STRICTURE OF THE URETHRA. inch in depth, scooped from its extremity by a sharp penknife, and a portion of lunar caustic inserted into it and secured by squeez- ing together the edges of the hole—leaving the central part of the caustic a little exposed. A mark corresponding to that on the soft bougie, (which is intended to designate the depth of the stricture, from the external orifice,) is then made upon the caustic bougie, and the latter at once oiled and carried down to the stricture, and kept in contact with it for one or two minutes, or for a shorter period, should the patient complain of its severity. In two or three days' time the operation may be repeated, and occasionally within the same period until the stricture gives way, or is entirely removed. The stilet, although used by some of the older surgeons, in the cure of stricture, wras not practised in modern times, until re- commended by Dr. Physick. In 1795, he first performed the operation, and ever after continued to employ the same means, and oftentimes with the greatest success. I myself have like- wise succeeded, in many instances, in effecting a perfect cure, after bougies, the caustic and other means, have entirely failed. Before the clinical class in the Philadelphia Hospital, some years ago, I perforated, with the stilet, a stricture of long standing, near the bulb, which had resisted for seven years the efforts of different surgeons, to introduce an instrument of any description into the bladder. In three minutes after the division of the stric- ture, a catheter entered, and the patient experienced the greatest possible relief. What renders this plan of treating strictures the more valuable, is the circumstance of the operation being attended with very little pain, and with no risk, provided the operator possess an accurate knowledge of the structure of the parts. In ignorant hands, false passages, ulcerations, and effu- sion of urine may follow. The instrument used by Dr. Physick, is a sort of lancet concealed in a cannula, that may be pushed forward or retracted at pleasure. When it becomes necessary to pierce a stricture situated near the bulb of the urethra, a curved instrument should be used. Upon several occasions I have used with success, in strictures seated near the anterior part of the urethra, a common couching needle, rendered blunt at the point, and sharpened at its edges. After the division of the stricture, a bougie or catheter must be worn for some time, to prevent the passage from closing again. From the use of bougies or the caustic, it very often hap- STRICTURE OF THE URETHRA. 211 pens that an unnatural route ox false passage is created. This is owing, generally, to unskilfulness on the part of the surgeon, or patient himself, or to the use of instruments so small as to enter the lacunae of the urethra, instead of following the natural course of the passage. When once established, a false passage is ex- tremely difficult to remove, and, on this account, great pains should be taken to guard against its formation. To the patient the disease is inconvenient, chiefly by preventing the easy introduc- tion of the bougie or catheter, and sometimes, on this account, dangerous in cases of retention of urine. The best plan, in ge- neral, of destroying the unnatural route, is to use the bougie larger than the one by which the disease was created, and to bend its point towards that part of the urethra opposite to the false pas- sage. A large catheter, very much curved, will also pass, in many instances, where no other instrument can be made to follow the natural course of the urethra. Mr. Hunter was in the habit, sometimes, of performing an operation for the removal of this disease; fortunately, however, such an expedient can rarely, if ever, prove necessary. But in three or four instances, I have succeeded in establishing the natural course of the urethra, where the false passage depended upon the resistance of a stric- ture, by piercing the stricture with a stilet, and afterwards pass- ing a catheter through it, and suffering it to remain in the blad- der for several days. Formerly, a few English surgeons of eminence were in the habit of forcing strictures, by driving bougies and catheters through them, and making an entrance by violence into the bladder. A similar practice for several years past has prevailed in France, where an instrument called sonde conique, is much in vogue. I will not condemn the proceeding, because I do not know it, from experience, to be hurtful; but I confess I have a feeling amounting to prejudice against it. Mr. Arnott's method of curing strictures, by the peculiar instruments named dilators, has gained few advocates among surgeons. One thing should be well understood in relation to this dis- ease—that it is always liable to return, unless the bougie be oc- casionally used. 212 FISTULA IN PERINiEO. SECTION II. FISTULA IN PERIN^O. From stricture of the urethra, from blows and other injuries, fistula in perinaeo is frequently produced. In proportion as a stricture increases, the urethra, at the diseased part, is dimi- nished ; while that portion of the canal immediately behind the obstruction, by the efforts of the bladder and the continual pro- pulsion of the urine against it, is enlarged. The irritation thus kept up gives rise to inflammation and ulceration, and an open- ing is at last made through the urethra, and communicates with the cellular membrane surrounding it. Into this opening the urine finds its way and lodges, and by its acrimony increases the irritation until an abscess is formed; which gradually en- larges, and finally discharges itself externally. The urine then passes out mixed with matter, both from the opening in the perineum and from the external orifice of the urethra. In the course of time, however, it frequently happens that the strictured part of the canal, no longer feeling a forcible impulse from the stream of urine, gradually closes, and is finally obliterated; after which the whole of the urine is evacuated through the fistula. Sometimes, instead of the ulcerative process first com- mencing on the internal surface of the urethra, an abscess is formed from irritation, in the cellular membrane exterior to the canal, into which the ulceration at last extends, and throws the two cavities into one. Fistula in perinaeo sometimes proceeds from a rupture of the urethra,—produced by external violence, or by the force of the urine upon the inflamed and tender part of the canal behind the stricture,—and the urine is instantly sent abroad into the loose cellular membrane of the perineum and scrotum, where it forms an enormous distention or tumour, and excites most violent inflammation, that terminates in a few hours in gangrene, and sloughing of the scrotum—leaving, in many instances, the testicles and the urethra bare, and endangering the patient's life. There is seldom more than one fistulous opening communicating immediately with the urethra, but from it nume- rous sinuses generally extend in various directions; and in cases of long standing, it is not unusual to find the cellular membrane FISTULA IN PERINJE0. 213 of the scrotum and of all the other parts through which the urine meanders, greatly condensed and converted into indurated tu- mours, upon the surface of which may be found innumerable small holes that discharge offensive urine and matter—render- ing the patient disagreeable to himself and disgusting to his neighbours. TREATMENT OF FISTULA IN PERIN^O. It will appear obvious, from what has been stated, that when fistula in perinaeo depends upon stricture, the first indication in the treatment of the disease should be to get rid of the ob- struction, and to enable the stream of urine to regain its natural route. This, if the canal anterior to the fistula is obliterated, can be accomplished only by an operation, and the one which I have usually performed, and frequently with success, is as follows. The urine being retained in as large quantity as possible, the patient is placed upon his back on a table covered with a mattress or blankets, the thighs bent upon the pelvis, and the legs upon the thighs, separated and supported by an assistant on each side. A female catheter or sound is then carried down to the stricture, and there held firmly by another assistant, while the surgeon introduces a probe into the largest fistulous orifice he can find, and the one nearest to the stricture, and endeavours to feel with it the extremity of the sound, through the walls of the urethra. An incision, proportioned in length to the extent of the disease, is next made in the perineum, along the course of the probe, until the urethra or its remains are laid bare, when the operator will be enabled to cut upon the extremity of the sound, and divide the stricture. The sound may be afterwards with- drawn, and a gum elastic catheter introduced at the glans penis, and carried along the urethra into the bladder, where it should be suffered to remain for several days. As soon as the natural route for the urine is thus re-established, the fistulas diminish, the indurated cellular membrane contracts, the wound begins to fill up, and is finally closed, and, through the medium of granu- lations, which form around the catheter, a new urethra is created; after which the sinuses all heal, and the patient recovers. In many instances, the operation is extremely difficult, and very 214 ENLARGED PROSTATE. painful, especially in irritable patients, and those who have suf- fered a long time from the complaint. Cases, indeed, are re- ported of patients having died under the operator's hands. When a fistula in perinaeo is complicated with pervious stric- ture, an attempt should be made by bougies, caustic, and other means, to destroy the stricture, or enlarge it, and afterwards to heal the fistulous opening by escharotics; the best of which, for this purpose, is the argentum nitratum. When the catheter can be passed through the stricture into the bladder, it should always be done, and an attempt made to heal the fistula without the knife. This mode, however, requires a long time to effect the purpose. Sometimes a fistula in perinaeo will contract to the size of a hair, and in that state remain for years, now and then shedding a few drops of urine. For this state of the dis- ease, I have found a blister the best remedy. Effusions of urine into the cellular texture of the scrotum, from rupture of the urethra, require very decisive measures. Aware of the nature of the disease, the surgeon should lose no time in making very free punctures and incisions into the skin and cellular membrane, from which he will soon find the urine to issue in considerable quantity. When performed in time, the operation may save the parts from sloughing. This, how- ever, is seldom the case. But it is astonishing how much na- ture does for the patient under these circumstances: for even after the testicles have been entirely divested of integument, a new scrotum is almost always formed out of the adjoining parts. The fistula, in general, heals spontaneously. SECTION III. ENLARGED PROSTATE. Although the prostate gland is subject to inflammation, ab- scess, scrofulous enlargement, and collections of urinary calculi within its substance, these affections are rare, compared with ENLARGED PROSTATE. 215 that commonly known under the name of scirrhus. To this disease old people are almost exclusively liable, and so frequent is it among them, that, according to Sir Everard Home, few subjects beyond the age of eighty are exempt from it. The middle lobe, as well as the two lateral, is often the seat of the disease; but the symptoms differ, in some respects, according as the former or latter happen to be affected. In proportion as the middle lobe enlarges, it pushes before it the internal mem- brane of the bladder, and by projecting into the cavity of that viscus immediately behind the inner orifice of the urethra, ob- structs the flow of urine; which, when the tumour, as it often does, attains considerable bulk, may be entirely suppressed. The enlarged lobe also, in many instances, becomes ulcerated, and gives rise to severe pain after passing urine, and to spasm about the neck of the bladder. When an enlargement of one or both of the lateral lobes of the prostate is conjoined with that of the middle lobe, the symp- toms are still more urgent. A discharge of a viscid, ropy mucus, is another attendant upon enlarged prostate, and a very common symptom of the disease of the lateral lobes. The left lateral lobe is more frequently enlarged than the right. When the late- ral lobes attain a considerable size, they project towards the rec- tum so as to diminish the capacity of that bowel, and may be distinctly felt by the finger per anum. The causes of enlarged prostate are exceedingly obscure. By many the disease is attributed to syphilis, repeated attacks of gonorrhoea in early life, strictures of the urethra, inordinate indulgence with women, high living, intemperance, &c. But these inferences are rather gratuitous than founded upon any certain data. TREATMENT OF ENLARGED PROSTATE. The remedies for this disease are palliative only. Opium, in- ternally administered, and in the form of an enema, will prove highly serviceable in subduing spasm about the neck of the blad- der, and thus enabling the patient to pass urine. Frequently, however, every effort of the kind will be unavailing, and the catheter must be employed. One of elastic gum, without the stilet, very flexible at the point, and of large size, will be found 216 RETENTION OF URINE. to give less pain, and enter with greater facility than a metallic instrument. It should be kept in the bladder for several days in succession, and after the urgent symptoms have somewhat sub- sided, introduced occasionally. Mr. Liston recommends a silver catheter, very much curved, and at least an inch and a half longer than the ordinary instrument, for drawing off the urine in cases of enlarged prostate. In addition to this treatment, the use of mild purgatives, and attention to diet, will be required. Many years ago an ignorant physician of Baltimore opened the fundus of the bladder, and attempted to extirpate the enlarged prostate—with what result I need not say. SECTION IV. RETENTION OF URINE. From severe gonorrhoea, strictures in the urethra, enlarge- ment of the prostate gland, spasm at the neck of the bladder, stone in the bladder, hemorrhoids, fistula in ano, rupture of the urethra, blows upon the perineum, stimulating diuretics, the ap- plication of blisters, injuries of the spine, paralysis of the bladder, stones in the urethra, and some other causes, a retention of urine frequently arises. The disease, when it occurs amongst old people from para- lysis, is not often followed by serious consequences, unless it should be mistaken for an incontinence of urine; a mistake which is apt, among the inexperienced, to arise from the circumstance of the urine constantly passing off by drops or in a small stream— one of the most decided symptoms of retention. Persons ad- vanced in age are extremely apt to neglect the calls of nature, and suffer the urine to collect in the bladder in large quantity, or when they do make water, are not particular enough in dis- charging the whole of it. From these, and other causes, the bladder at last loses its power of expulsion, and the urine accu- mulates. As a part of it, however, is in general continually pass- RETENTION OF URINE. 217 ing off by the urethra, that in the bladder seldom exceeds a cer- tain quantity, and in this way the disease may be kept up for weeks together. The retention which takes place in young people, from go- norrhoea, strictures, or any inflammation or excitement about the urethra, neck of the bladder, or neighbouring parts, is very dif- ferent in its character, and often in its result, from that just spoken of. The urine seldom escapes, even in the smallest quantity, by the urethra, and must of course accumulate, (unless the pa- tient be relieved,) until some part of the bladder gives way— either by ulceration or sloughing. It is astonishing, however, to what an extent the bladder will yield in some cases before its parietes are destroyed. Some years ago I was called to a child about two years of age, supposed to labour under ascites, and so strongly did the enlargement and feel of the belly resemble that disease, that I at first took it to be a case of the kind. But, upon inquiring into the history of the complaint, I ascertained that its duration had not exceeded seven days, and that during this period the patient had passed no urine. This induced me to examine the urethra, in the mouth of which I discovered a calculus that blocked up the passage completely. Upon enlarg- ing the orifice with a lancet, the stone was instantly pushed out, and followed, to the surprise of a medical attendant and myself, and to the great relief of the patient, in a little time, by two quarts of urine.* Many instances are related by writers, of the bladder becoming so distended by urine, as to rise above the umbilicus; and Sir Everard Home relates an instance in which the celebrated Mr. Hunter actually tapped the bladder, mistaking the swelling for a dropsy of the belly. But such cases are ano- malous; and in most instances, long before the bladder is dis- tended to a great size, it ulcerates, or sloughs at the fundus or neck, and the urine is sent abroad into the peritoneum, or dis- charged through the rectum, or into the cellular membrane of the scrotum or perineum. In either event the patient generally dies. During the progress of the distention the patient suffers exceedingly, grinds his teeth in agony, tosses about the bed, or walks his room with his body almost bent to the floor, is seized with chills, cold sweats, and fainting, which are followed by- fever, great restlessness, extreme thirst, intolerable anguish, * A case nearly similar is reported by Dr. Parrish. 218 RETENTION OF URINE. swelling of the abdomen, hiccup, delirium, and death. He sel- dom survives beyond the sixth or seventh day. TREATMENT OF RETENTION OF URINE. When retention of urine arises from stricture of the urethra, or from any inflammatory affection of the canal, or parts adjacent, blood-letting, the warm bath, purgatives, and opiate enemata, should have a full trial. If these fail, a gum elastic bougie may be carried down to the obstruction, and kept in contact with it a few seconds, after which, in many instances, the urine will flow. Should this, however, not produce the desired effect, the surgeon will then endeavour to introduce a catheter into the bladder. Than this, there is not, in all surgery, a more impor- tant, and, under certain circumstances, more difficult operation— an operation requiring the utmost gentleness, patience, perse- verance, and skill. Rudeness and force, indeed, independently of the unnecessary pain and punishment they inflict, seldom con- tribute towards the end in view7. It is true that some eminent surgeons, in difficult cases, advise the forcible entry of the ca- theter; but it should be remembered that a great majority of others, not inferior to them in authority, condemn the practice in the most pointed terms. In general the most favourable position for the easy introduc- tion of the catheter, is the recumbent. But a good rule to ob- serve on such occasions, is, if the surgeon does not succeed, readily, while the patient is in one position, to change it for ano- ther. The curvature of the instrument is also a matter of impor- tance; on this account, the operator should be provided with a number, varying in shape and size. Gum elastic catheters, with or without the stilet, are better suited to most cases than metal- lic instruments. Sometimes, however, I have succeeded, easily, with a silver catheter, when a gum elastic would not enter. In using the latter, there is an advantage now and then obtained, especially when the middle lobe of the prostate is enlarged—in withdrawing the stilet an inch or two, so as to leave the extre- mity of the instrument more flexible than it otherwise would be. With the same view, Dr. Physick was long in the habit of using a gum elastic catheter, with a flexible wax bougie fixed upon its extremity. Stilets made of brass, instead of iron wire, are in many respects the most useful. RETENTION OF URINE. 219 Having oiled the catheter, the surgeon takes hold of the glans penis, on its sides, immediately behind the corona, enters the in- strument, with its concavity towards the abdomen, at the urethra, carries it along steadily, and with one continued sweep,—the penis being drawn upwards at the same time upon the instru- ment, and laid nearly parallel with the abdomen,—until it reaches the bulb or triangular ligament of the urethra. Here the passage takes a sudden turn upwards, and it will be neces- sary to accommodate the point of the catheter to the curve. With this intention, the handle of the instrument is suddenly, but cautiously and without force, depressed. This manoeuvre elevates the point and causes it to start over the edge of the triangular ligament and enter the bladder. Should much diffi- culty be experienced, however, in this stage of the operation, it may be often overcome by placing a finger in the rectum, and, with it, lifting the end of the catheter. Whenever an obstruc- tion is met with in the urethra, which the catheter does not readily pass, instead of attempting to overcome it by force, it will be proper always to withdraw the instrument a little, elevate its point, and then push it on again. In retention of urine from paralysis, the introduction of the ca- theter is seldom attended with difficulty, and on this account the operation may be repeated two or three times a day, or as often as may become necessary. But when the surgeon finds it incon- venient to attend for that purpose, a flexible catheter may be left in the bladder, for two or three days at a time, and the urine permitted to flow off, at stated periods, in place of dribbling away constantly. After the bladder has recovered its tone, the catheter should be discontinued. Having experienced considera- ble difficulty in introducing the catheter, in some obstinate cases of retention of urine, it occurred to me, in 1811, that the resis- tance might, perhaps, be overcome by introducing the pipe of a syringe into the orifice of the urethra, and throwing in, gently, a stream of tepid water. Having accordingly tried the plan, successfully, in a few cases, I was induced to recommend the practice for several years, in my lectures. Subsequent expe- rience, however, taught me that very little reliance could be placed upon the method, and I have since abandoned it alto- gether. Amusat, of France, has, within the last few years, re- sorted to a similar expedient, and according to his own account, with great success. 220 RETENTION OF URINE. If, in spite of the efforts of the surgeon to relieve the patient, by the remedies pointed out, and it is found impossible to intro- duce the catheter, it will become necessary to puncture the bladder. The operation may be performed above the pubes, or • through the rectum. But it will be proper to premise that neither one nor the other is indispensably necessary once in a hundred times. The operation above the pubes is performed in the following way. The patient being laid upon a table, an incision, about an inch and a half long, is made in the linea alba, immediately above the pubes, through the integuments and fat, and between the pyramidales muscles, until the distended bladder is distinctly felt, when a curved trocar, six inches in length, covered by its cannula, is made to pierce the bladder as near the pubes as pos- sible. A vessel being held between the patient's thighs to receive the urine, the stilet is withdrawn and the fluid evacuated. To prevent the cannula from slipping out, tapes are fastened to its wings, and secured to a bandage passed around the body. Its extremity is also plugged up, to prevent the perpetual flow of the urine. The greatest objection to this operation, is the liability of the urine to escape, (after the bladder becomes flac- cid,) into the cavity of the abdomen. Besides this, the constant presence of the silver cannula is apt to excite irritation, espe- cially when it is so long as to rest upon the back part of the bladder. The puncture of the bladder, through the rectum, I should prefer, in every instance, provided the prostate was not so much enlarged as to require the instrument to be introduced high up the intestine. To perform this operation, (which is still more simple than that above the pubes,) to advantage, the patient should be placed in the position for lithotomy, and the fore- finger of the left hand carried up the rectum, as a guide to the trocar, which is held in the right hand, introduced into the rec- tum, and made to perforate the anterior part of that intestine, at its centre, immediately above the prostate. The stilet being withdrawn, and the urine evacuated, the cannula is plugged, and secured in its situation by tapes. The patient's bowels should afterwards be kept in a soluble state, to prevent the can- nula from being disturbed during an evacuation of the faeces. After the natural route through the urethra is restored, the can- nula may be withdrawn, and the opening in the rectum allowed INCONTINENCE OF URINE. 221 to heal. Whether the operation of puncturing the bladder be performed above the pubes, or through the rectum, it is very im- portant that it should not be delayed beyond the third or fourth day; for it has been found by experience, that after this period the case has usually terminated fatally. SECTION V. INCONTINENCE OF URINE. Incontinence of urine is the reverse of retention. There are two or three varieties of the disease. Sometimes the urine passes off by the urethra as soon as it is secreted; at other times the patient can retain it for a certain period, and is then obliged suddenly to evacuate. In a third variety of the complaint the discharge generally takes place during sleep. This is commonly confined to young children, while the other varieties are chiefly met with in adults, and are dependent, for the most part, upon general or local paralysis, general debility, injuries, malformation of the urinary organs, hemorrhoids, stone in the bladder, &c. Incontinence in old people is much less common than is imagined, the disease, as formerly remarked, being in them, really retention of urine—a fact which should never for a moment be forgotten by the young surgeon. TREATMENT OF INCONTINENCE OF URINE. For incontinence of urine, when it occurs in adults and depends upon local or general debility, the internal use of can- tharides, muriated tincture of iron, bark, and opium, conjoined with the cold bath and blisters to the sacrum, will sometimes effect a cure. But when the disease, from constitutional or local infirmity, is incurable, or not susceptible of relief from medicine, well-contrived instruments are capable of obviating VOL. II.—p 222 INCONTINENCE OF URINE. many of the unpleasant inconveniences to which the patients are liable. In particular, gum elastic vessels, moulded to the shape of the thigh and genitals, and suspended by tapes passed around the pelvis, often answer an excellent purpose by re- ceiving the urine, as it dribbles away, while the patient is walking about. Some of these instruments, however, are so very clumsy as to annoy the patient by their conspicuousness, or from the material of which they are made retaining and giving out an unpleasant odour. Latterly considerable im- provements have been made in the manufacture of them. "I was lately consulted," says Professor Cooper, "by a gentleman who showed me an admirable invention for the reception of his urine, which had been passing from him involuntarily for some years: it consisted of a water-proof oil-silk tube, about two inches and a half in diameter, extending from the penis down the thigh and leg, under his trousers, without causing any visi- ble bulging or disfigurement. It would serve for four or five hours at a time, and enabled this individual to mix with society. The machine was made by a German residing in Princess Street, Drury Lane." That variety of incontinence peculiar to children, gradually subsides, spontaneously, as they advance in age. Parents and children themselves, to guard against this infirmity, have some- times, most improperly, applied ligatures to the penis over night. From this practice I have seen numerous instances of ulceration of the urethra, or of sloughing of the penis, at the part embraced by the ligature. Some three or four years ago a case was sent to me by my friend Dr. Brown, an eminent physician of Fredericks- burg, Virginia, where a fine lad of fourteen had destroyed the urethra within an inch and a half of the extremity of the glans penis by the application of a ligature—producing the disease known by the name of hypospadias. It is almost impossible, in such cases, to restore the continuity of the urethra by caustic, incisions, or the introduction of gum elastic tubes—inasmuch as the remnant of urethra next the glans is apt to ulcerate through from the wearing of instruments. Such operations, however, should be attempted, and have been performed successfully by Liston, Cooper, Mettauer, myself and others. SENSITIVE TUMOURS OF THE FEMALE URETHRA. 223 SECTION VI. SENSITIVE TUMOURS OF THE FEMALE URETHRA. This disease has been considered by surgeons as comparatively rare. In all probability, however, it is more common than is ima- gined, owing to females, from natural delicacy, concealing it as long as possible, and in some instances, there is reason to be- lieve, never revealing their situation at all. Twenty-five years ago, I attended a widow lady of great respectability, who for a long time had suffered from a tumour of the urethra about the size and appearance of a strawberry, which filled up the urethra, and was so exquisitely sensible, and attended with such extra- ordinary pruritis, as nearly to drive her to desperation. Finding her health declining, and alarmed at the repeated hemorrhages which had lately occurred, she consented to an operation: but although I dissected out the tumour again and again, no benefit resulted, and as at each operation the hemorrhage was alarming, and required to be stopped by caustic, and upon one occasion by the actual cautery, I declined attempting more for her relief. She afterwards removed to a distance, and with the result I am unacquainted. Since that period I have met the disease occa- sionally, both in private and hospital practice, and in patients of all ages. In the Philadelphia Hospital, ten years ago, I had a patient, a single woman, fifty years of age, who suffered intensely from a small tumour of this description, but who never obtained perfect relief from any mode of treatment employed. Three years since I was consulted by Dr. Peachy Harrison, an eminent physi- cian of Harrisonburg, Virginia, in the case of a young woman similarly situated, and in whom he had tried, without effect, all the usual means. Supposing from these, and other circum- stances, the disease to be incurable, I should not have drawn the attention of the profession to it, but for a communication recently made on the subject, by my friend Dr. Alexander E. Hosack, of New York—son of the late distinguished Professor Hosack, of that city—a gentleman well versed in all the depart- ments of his profession, but particularly skilful in the treatment of surgical diseases, and in the invention and adaptation of in- genious contrivances for their removal or relief. This commu- 224 SENSITIVE TUMOURS OF THE FEMALE URETHRA. nication will be found in the first volume of the New York Journal of Medicine and Surgery, and in consideration of the value of its practical bearing, and the successful results attend- ing the operations referred to, I shall give it entire in this place. TREATMENT OF SENSITIVE TUMOURS OF THE FEMALE URETHRA. " In May, 1835, I was consulted," says Dr. Hosack, " by a servant woman in a family where I was in attendance, for a complaint which she said had caused her considerable distress, and, as she expressed herself, it appeared as if something had dropped into the passage immediately after making water, causing her great pain at the moment, and which frequently bled, particularly upon being touched by her linen. Upon the slight- est exertion, she was seized with bearing-down pains to such a degree, as to compel her to take to her bed. These difficulties, she said, had been gradually increasing upon her for two or three years, and being unmarried, she was from delicacy induced to conceal her sufferings until no longer able to bear them. " From this statement I was induced to make an examination, which clearly explained the cause of all her trouble. I dis- covered twro or three little tumours immediately within the meatus urinarius, to which they were attached by a narrow neck. They were of a florid red colour, and appeared to be covered by the delicate lining membrane of the urethra. They were exquisitely sensitive, and bled upon the slightest touch. In form they resembled a split pea, varying from that in size to a small kidney-bean, and placed upright, in such a manner, as to break the flow of the urine. The patient did not, however, com- plain of the pain upon urinating as her greatest distress, for it was not to be compared to that caused by exertion, or from con- tact of the dress, which was frequently excruciating. " By raising these tumours with a probe, I discovered their attachment to be limited to the margin of the urethra, and sug- gested to her the propriety of having them removed, which I assured her could be readily done, and with comparatively little pain. Having obtained her consent, I snipped them off with scissors: the hemorrhage was not excessive. In a few days the part was healed, and she appeared to be completely rid of the SENSITIVE TUMOURS OF THE FEMALE URETHRA. 225 evil, until about six weeks after, when the sensitiveness and other symptoms returned. In the course of three months I was again requested to relieve her, if possible, by a further operation. Upon examination, I found the margin of the urethra fringed with the same highly organized structure. It appeared as if the lining membrane had been prolapsed, and was turgid with blood ; or in other words had shot out like a fungus. Under these circumstances I determined to remove the diseased structure by excising the meatus urinarius, and this was accordingly done. The wound in due time was healed, leaving the parts apparently sound, with the exception of a few spots of discoloration in the folds of the nymphae, which I afterwards destroyed by caustic. " The extremity of the urethra remaining somewhat harder than might have been expected in sound parts, I expressed a doubt whether it might not be the incipient stage of scirrhus. The disease, however, in the course of a few months returned with all the distressing symptoms as before enumerated. The pa- tient being again willing to submit to any operation that I might advise, I determined to remove the urethra to an extent that would hold out a better prospect of success. My friend, Dr. Wilkes, with whom I consulted, confirmed this opinion, and assisted me in the operation. "The patient being placed upon the bed in a recumbent posi- tion, with the legs flexed upon the body, I began with measuring the length of the urethra, by introducing the female catheter, and marking it the instant the urine began to flow; this precau- tion I considered necessary, from the fact that the length of the urethra, in females, is very variable; at the same time, I was unwilling to encroach too much upon the bladder, which might endanger consequences more distressing to the individual than the existing disease. "The preliminaries being attended to, I seized the fungous excrescence with the pince of Museux, and drawing it out, I cir- cumscribed the urethra, with a knife, carried on the dissection until I had detached about three-quarters of an inch in extent, as I supposed. I then examined the urethra at the upper ex- tremity of the wound, and finding it perfectly natural and free from all hardness, I separated it at that point. The hemorrhage for the moment was very great; but by pressure constantly kept 226 SENSITIVE TUMOURS OF THE FEMALE URETHRA. up with a compressed sponge, it was arrested, or so much re- strained, as to do away with all anxiety on that account. " The patient having made water a short time previous to the operation, I did not consider it necessary to leave a catheter in the bladder, which I afterwards regretted, as I was obliged to draw off the urine the following morning, but not without con- siderable difficulty, as may be imagined. I determined, how- ever, for the future, to leave the catheter in the bladder, or at least until the urine should flow at its side; which took place on the sixth day, when I removed the instrument. Since which time, she has enjoyed full control over that organ, and voids urine with comparative ease. "It is now six months, and no return of the disease. No bougie was introduced to keep open the mouth of the urethra, as might, a priori, have been considered necessary. Indeed, I purposely avoided using it, lest the irritation might predispose the parts to a return of the disease. Upon examining the part removed, I found the urethra to be very much thickened and hardened at its extremity, but this circumstance not being ob- served in other instances of this disease as related by different authors, I must conclude that it had no agency in the growth of these tumours, but was probably the result of irritation. " I first met with this disease in the practice of my friend, Dr. Mott, who, several years ago, was consulted by a gentleman on account of his daughter, who laboured under this distressing complaint. The case was one of great interest, both from the circumstance of the patient being at the delicate age of eighteen, and on the eve of marriage. She had suffered from this disease for two years and upwards, and considering it an insurmount- able objection to marrying, had frequently deferred the nuptial ceremonies, at the same time not willing to break off her engage- ment, and unable any longer to conceal her actual situation, she disclosed the true cause to her father, the only surviving parent, who immediately came to New York, and placed her under the care of Dr. Mott. " In this case, Dr. Mott, after carefully examining the disease, determined upon removing the meatus urinarius, to the margin of which two or three small flattened and vascular tumours were attached. They were of the size of small beans, highly florid, and exquisitely sensitive. The wound healed kindly after SENSITIVE TUMOURS OF THE FEMALE URETHRA. 227 the operation; the result was perfectly successful, when she re- turned home to her friends, and afterwards married. "Although this disease is one of comparatively rare occur- rence, much has been written upon it; still, elaborate works on surgery and midwifery, have not, with but one or two exceptions, in any way noticed its existence. I confess it appeared to me to be quite a novelty; and as regards the excising of part of the female urethra for its removal, or for any other object, I do not recollect ever to have heard of a single instance; nor have I yet been able to discover that it has been done to any extent, beyond the mere margin of the external orifice of the urethra. This disease is first spoken of by Morgagni, who, under the head of excrescences and other diseases of the female urethra, re- marks: ' Examining the body of an old woman about the begin- ning of 1751, I met with a small triangular excrescence within the external orifice of the urethra, but it was not prominent;' and in another part of the same chapter, he goes on to state, ' that there is a red and fungous excrescence which is of the size of a bean, sometimes to be observed attached to the orifice of the urethra.' "This disease is also described by an Englishman by the name of Hughes, of Stroudwater, in Gloucestershire, in 1769. In a case described by that gentleman, he speaks of it as of ' a red colour, and of a softish, spongy texture, with an irregular, jagged surface; was sore when touched; and a bloody serum oozed from it.' The patient was eleven years of age, and of a very thin habit of body; it had existed for three years. In this case, Mr. H. removed the Meatus Urinarius, which com- pletely included the disease. The patient suffered for some time from retention of urine: only, however, during the healing process. Five years had elapsed since the operation, and the patient continued perfectly well. " On examining the fungus, after the operation, it appeared about the size of the nipple of an adult; its anterior part, being expanded, formed, as it were, a little cup, with its border indented like a cock's comb, having a hole in its bottom which was the orifice of the urethra, which ran through the body of the fungus; the internal membrane of the urethra was continued to the edge of the indented border, which was of a deeper red colour and softer texture than the other part of it." "In volume xiii. page 784, of the Lancet, Mr. Wardrop has 228 SENSITIVE TUMOURS OF THE FEMALE URETHRA. published four cases of this disease. The first was in a young girl thirteen years of age; the second in a lady of thirty years of age; the age of the third is not given; the fourth was upwards of sixty years old. In all of these cases Mr. Wardrop speaks of the exquisite sensitiveness as the most prominent symptom. In one of the cases above alluded to, the disease returned after mar- riage, when the patient again applied to Mr. W. for relief. " He states * that the tumour had now assumed the appearance of a bright scarlet fungus, encircling the meatus, and was attend- ed with such exquisite tenderness as to prevent sexual inter- course. The orifice, including the disease, was removed, and it did not return.' " Boyer makes mention of a fungus occurring in the female urethra. It is, however, noticed in a more particular manner by Bromfield, and according to Mr. Hughes, accounts are also given of it by Sharp, Warner, and Jenner. Mr. Wardrop also refers to Chaussier and Dubois, and states that it is particularly noticed by Madame Lachapelle as well as by Rosenmuller, Vogel, Kaldibrand, Prochaska, and some other German patho- logists. " In many of the instances referred to by the older writers, the symptoms were at first mistaken for those of stone in the bladder, and in the case just related by Mr. Hughes, the disease was mistaken by those who were first consulted for prolapsus of the uterus, and actually treated as such, nor was the error discovered until the patient was unable any longer to bear the pain consequent upon the pressure applied to that viscus. " By reference to the foregoing cases we arrive at the follow- ing conclusions:— " 1st. That the disease is characterized by peculiar symp- toms. " 2d. That it is not confined to any age. " 3d. That it is not accompanied with discharge, unless the parts be chafed or abraded. " 4th. That, in order to prevent a return of the disease, it is better to remove, at once, the external orifice of the urethra, in- cluding the tumours. " 5th. That it is a complaint of slow growth, and does not at- tain to any great size; for, in no instance yet recorded, so far as I am enabled to learn, has it been found larger than a small cherry." SENSITIVE TUMOURS OF THE FEMALE URETHRA. 229 Upon the whole, as regards the diseases of the urethra,—par- ticularly stricture,—I may state, that more skill, judgment, and experience are required than for almost any other affection in surgery; that, unfortunately, these diseases are, too often, placed in the hands of young and inexperienced practitioners, who are more prone to regard cutting or piercing instruments as the only alternative, and bold and decisive measures, as stronger proofs of talent and knowledge, than the slow and cautious proceedings of those, who, taught by the result of unfortunate cases, are con- stantly in dread, and with good reason, of similar terminations. I have heard the late Dr. Physick aver that he never approached a diseased urethra, especially in old and irritable subjects, with- out trembling and anxiety, and that there were very few whom he would trust with the management of such complaints. My own experience confirms, to the fullest extent, his statement. On Diseases of the Urethra and Prostate Gland, consult Hunter on the Vene- real; Home on the Treatment of Strictures of the Urethra and (Esophagus, vol. iii. 4th edit.; Whateley's Improved Method of Treating Strictures of the Ure- thra; 2d edit.; Letters concerning the Diseases of the Urethra, by Charles Bell; Principles of Surgery, by John Bell, vol. ii. p. 209; Howship's Practical Ob- servations on Diseases of the Urinary Organs, 1816; Wilson's Lectures on the Structure and Physiology of the Male Urinary and Genital Organs, and their Diseases, 1821; Desault's Works, by Smith; C. Bell's Surgical Observations, p. 86; C. Bell on the Diseases of the Urethra, &c. by J. Shaw; Bingham on Strictures of the Urethra, 1821; Home on the Treatment of Diseases of the Prostate Gland; Hey's Practical Observations in Surgery, article Retention of Urine, p. 388, 3d edit.; Dorsey's Surgery, vol. ii.; C. Bell's Operative Sur- gery, vol. i.; Colles's Surgical Anatomy, p. 159, article Passing the Catheter; Abemethy on the Operation of Puncturing the Bladder, in Surgical Works, vol. ii. p. 189; Cooper's First Lines, vol. ii. p. 215; Practical Observations on Strangulated Hernia, and some of the Diseases of the Urinary Organs, by Joseph Parrish, M. D., Philadelphia, 1836; Practical Observations on those Malformations of the Male Urethra and Penis, termed Hypospadias and Epis- padias, with an anomalous case by John P. Mettauer, of Prince Edward county, Virginia—in Philad. Journ. of Medical Sciences, No. vii., new series, July, 1842. 230 URINARY CALCULUS. SECTION VII. URINARY CALCULUS. Most calculous concretions are formed originally in the kid- neys, and thence find their way, along the ureters, to the blad- der, and when too large to pass off with the urine, remain in that viscus and serve as nuclei for other sabulous depositions. But any extraneous body, accidentally lodged in the bladder, may lay the foundation of a stone. A drop of blood, a portion of inspis- sated mucus, a pin, a piece of a bougie or catheter, a musket-ball, has often produced the disease. Many years ago, I operated on a boy four years old, and took from his bladder a stone, as large as a pullet's egg, in the centre of wThich was found the greater part of a needle. Dr. Stout, an eminent surgeon of Easton in this state, presented me in 1843 with a very large oval calculus, (removed by him from the bladder of a negro girl,) from one end of which a large darning needle projected more than half an inch. Urinary calculi vary exceedingly in form, size, colour, consist- ence, and chemical composition. Some are very rough on the surface, others perfectly smooth; in shape most of them are oval, a few quite round, whilst others are oblong or angular. The difference in magnitude is not less remarkable—being met with from the size of a pea to that of a cocoa-nut. Calculi differ from each other in colour as much as in size and form; the most com- mon variety is generally of a yellowish brown lint; some are nearly as white as chalk, and others, again, red or of a deep chocolate browrn. In consistence, also, there is the utmost varia- tion; for at the slightest touch some crumble into dust, whilst others almost resist the stroke of a hammer. Scheele and Wol- laston were among the first to investigate the chemical composi- tion of urinary calculi, and their discoveries have led others to pursue the same path. According to the latest and best writers, these substances are found to consist of the following materials: 1st, of the lithic acid; 2d, of the lithate of ammonia; 3d, of the phosphate of magnesia and ammonia; 4th, of the phosphate of lime; 5th, of the oxalate of lime; 6th, of the triple phosphate of magnesia, ammonia and phosphate of lime; 7th, of the carbonate of lime. Of these the lithic acid calculi are by far the most nu- URINARY CALCULUS. 231 merous. A very uncommon variety of calculus has been met with in this country, consisting of sabulous matter and hair, and resembling, closely, common plastering mortar. Only two in- stances of the kind have come to my knowledge. The first occurred about twelve years ago, in the practice of Dr. Physick, and the second, within the same period, in that of my friend, Dr. Lemoyne, an eminent physician, of Washington county, Pennsylvania. In both patients, the formation of this material was progressive, or kept up for months together. Almost all animals are more or less subject to calculous con- cretions in the kidney and bladder. They have frequently been found in the horse and cow. The hog is very subject to the dis- ease ; so is the rat. Even fish are not exempt. In the summer of 1843, a fine specimen was presented to me, by Dr. Hardy of New Bedford, one of our most intelligent graduates and hospital pupils, which was taken from the bladder of a whale. More than a bushel was found in that viscus. They were all of the phosphate variety—so far as external characters could be depended upon. Urinary calculi may be contained in the kidney, ureter, blad- der, prostate gland, or urethra; but the bladder is their most com- mon receptacle. Generally they lie loose within the cavity of that viscus, and at its most depending part. Sometimes they are contained in cysts, formed between the coats of the bladder, at the termination of the ureters, or between the folds of a con- tracted bladder; at other times they are fixed upon a fungous excrescence, the granulations from which shoot into the inter- stices of a rough stone, and hold it fast. The bladder may con- tain a single stone or a great number. Fifty-five were found in the bladder of the celebrated Buffbn after death. Two hundred were taken by Desault from the bladder of a priest. Sir Astley Cooper states that the greatest number he ever extracted, was one hundred and forty-two. Boerhaave and Beauchene, each record an instance of three hundred and upwards taken from different patients. Murat met with six hundred and seventy- eight. But the largest number ever removed, probably, from the human bladder, was taken by Dr. Physick, sixteen years since, from the late Chief Justice Marshall. More than one thousand, varying from the size of a partridge-shot to that of a bean, were counted, and many others were lost. They were all of an oval shape, and upon the end of each I examined, as it came out of the wound, there was a black spot of the size of a pin's head. 232 URINARY CALCULUS. Notwithstanding the frequent introduction of the forceps and scoop, the patients recovered, perfectly, in a short time. When numerous, they are generally smooth upon their surface, and sometimes, in particular places, highly polished, from continued friction upon each other. In many persons there is extraordina- ry tendency to calculus; so much so that it may be said to pre- vail in many families. A remarkable instance of the kind has been recorded in the twentieth volume of the Boston Medical and Surgical Journal, by my friend, Dr. Sewall, an eminent phy- sician of Washington. The symptoms of stone must depend, in a great measure, upon the particular situation it happens to occupy. When detained in the pelvis or infundibulum of the kidney, the concretion some- times attains a large size, without subjecting the patient to much pain or inconvenience; on the other hand, its presence is occa- sionally productive of so much irritation as to excite suppuration of that gland. During the passage of a calculus along the ure- ter, the patient suffers, in most instances, excruciating pain, has frequent desire to make water, and can pass only a few drops at a time, and those very high-coloured and sometimes mixed with blood. So severe is the pain, in some cases, that the patient finds it impossible to leave his bed, and is obliged, in order to obtain temporary relief, to bend himself almost double. Fever, eructation, nausea, vomiting, and spasmodic retraction of the testicle, are common accompaniments of the disease. As soon as the stone drops into the bladder, the symptoms subside. Some- times, however, the patient becomes easy for a few hours, even before the stone leaves the ureter, and then has a relapse. This may occur repeatedly. An encysted stone, so long as it continues encysted, seldom gives rise to any severe symptoms; but a stone that lies loose in the bladder, and is liable to move about, must alwrays excite more or less uneasiness, whether it be rough or smooth, large or small. One of the first symptoms of stone in the bladder, is a frequent desire to pass urine, and severe pain upon voiding the last drops of it. About the same period, also, the patient complains of an itching at the glans penis, to relieve which, he soon gets into the habit of pulling or elongating the prepuce. Another symptom is the sudden stoppage of the urine while passing in a full stream. This arises from the stone being carried, by the contraction of the bladder, or by the stream of urine, to the neck of the bladder, URINARY CALCULUS. 233 where it blocks up the inner orifice of the urethra; in proof of which, if the patient lie down or change his position, the water flows again. After these symptoms have continued for some time, the patient becomes troubled with tenesmus and prolapsus ani, induced by the constant straining and efforts to empty the bladder. When the stone is rough on its surface, there is often a good deal of fetid mucus discharged along with the urine, which is now and then mixed with blood. Sometimes the pa- tient is very sensible, when he turns upon his side, or suddenly changes his position, of something rolling in his bladder. The same sensation is experienced whilst on horseback, or in a carriage. Under the sufferings occasioned by the symptoms enumerated, the patient may live for a great number of years. Gradually, however, his health declines, the bladder contracts to a very small size, becomes thickened and diseased, and at last death takes place from long-continued irritation and derangement of most of the bodily functions. Some patients never experience pain or inconvenience from a stone in the bladder. Richerand removed, after death, a very large rough stone; but the patient during life wras never known to complain of a single unpleasant symptom. The father of a gentleman of this city died three or four years ago, and during post-mortem examination, for other purposes, a very large calculus was accidentally discovered in the bladder—the presence of which had never been suspected or referred to by the patient. When the prostate gland contains a number of stones, it may be possible to feel them through the coats of the rectum, by passing the finger within the gut. Dr. Marcet mentions a case in which Sir Astley Cooper was able, by this expedient, to de- tect a number of calculi moving in a cyst within the prostate, and to hear a distinct clashing as their surfaces were pressed toge- ther.* Calculi, when detained in the urethra, generally stop behind the bulb, or at the external orifice of the passage. From being pressed upon by the stream of urine, they are sometimes imbedded in the substance of the penis, and afterwards do not obstruct the urethra. At other times they find their way out, by exciting ulceration of the urethra, and produce a spontaneous cure. Cases of the kind have been reported by Crosse and others. I have known them, in a similar way, to be discharged from the * Marcet on Calculous Disorders, p. 19. 234 URINARY CALCULUS. bladder; and one instance of the sort was mentioned to me lately by Dr. Jackson, formerly of Northumberland, but now an emi- nent physician of Philadelphia. The causes of the formation of urinary calculi, although fre- quent attempts have been made to investigate them, have never been unravelled. We know, indeed, little beyond this,—that the disease prevails in certain countries and districts, more than in others, and that in some climates, especially very warm ones, it is seldom met with. Throughout the United States, which embrace a very extensive tract of country, fugitive cases may be every where seen; but, upon the whole, the complaint must be considered by no means common, if we except some portions of the western country, especially Kentucky, Alabama and Ten- nessee, where it is exceedingly frequent, and usually attributed, though, perhaps, erroneously, to the use of lime-stone water. That the complaint, however, is connected, more or less, with dyspeptic depravities, atmospheric changes, and peculiar diathe- sis, there can be very little doubt. Hence it has been commonly met with in cold, moist, and variable climates, and in families peculiarly subject to disorder of the digestive functions. Formerly it was supposed to be unknown in very warm climates. But this has recently been proved to be a mistake—by Burnard, Brett, Spry, Turner and Lindsay, who report numerous opera- tions as having been performed on adults and children, in Ben- gal and India.* TREATMENT OF URINARY CALCULUS. WThen a patient is suffering from a fit of the gravel, as it is usually called, or in other words, from the passage of a calculus along the ureter, the most decisive treatment must be at once adopted. If robust and vigorous, several ounces of blood may be taken from the arm, and a brisk purge administered imme- diately afterwards. These should be followed by immersion of the whole body in a warm bath. If, by these means, the pain is not diminished, ten or fifteen drops of spirits of turpentine may be given, three or four times a day. This remedy has been used by Dr. Physick, for many years, with the greatest success. A * See the Transactions of the Medical Society of Calcutta, and Crosse on Urinary Calculus. URINARY CALCULUS. 235 combination of turpentine and opium, according to Dr. Marcet, was formerly employed as a quack medicine, in England, with great benefit in this complaint. By my friend Dr. Samuel Bet- ton, a distinguished practitioner of Germantown, I am informed, that he has frequently employed, with the most decided benefit, pills of the inspissated Venice turpentine, to the extent of half a drachm in twenty-four hours, and that some of the patients have taken the medicine for weeks before an expected attack, and have thus guarded against it. By the advice of Dr. Physick, I prescribed, some years ago, the tincture of phytolacca—poke- berry—in an obstinate case of lithiasis, and with the most de- cided relief to the patient. It should be administered in doses of a dessert-spoonful two or three times a day. Sometimes I have known the patient much relieved by suddenly throwing up the rectum a stimulating enema. Opiate injections, also, in some cases, prove highly beneficial, as well as opium internally. The existence of a stone in the bladder, can only be deter- mined positively by sounding. This preliminary operation should, therefore, always be performed before the surgeon enters upon the treatment of the disease. By sounding is meant the introduction of a steel instrument,* resembling a catheter, —but solid instead of hollow,—into the bladder. The rules for- merly pointed out for the management of that instrument, in cases of retention of urine, should also be observed in the intro- duction of the sound. Very often the stone cannot be felt, in consequence of its lodging in a depending part of the bladder, below the reach of the instrument. In such cases the finger is put into the rectum and the lower part of the bladder pressed upwards, and the stone being carried by this manoeuvre along with it, rubs against the instrument. Or, the urine may be per- mitted to accumulate in large quantity, and the walls of the bladder being then distended, the stone w7ill be raised from its lurking-place and touched by the sound. But this expedient sometimes fails: in that event, the practice first pointed out by Dr. Physick should be pursued—by placing the patient "nearly on his head," so as to render the fundus of the bladder the lowest part, and thus bring the stone in contact with the point of the sound. The surgeon should take care not to mistake a stone in the urethra, or prostate gland, for one in the bladder. * The handle of a sound should always be smooth, in order that the slight- est sensation may be detected by the touch of the surgeon. 236 URINARY CALCULUS. He must particularly remember, moreover, never to sound a patient during a fit of the stone, or immediately after his arrival from a journey. Patients have been often injured, likewise, by unnecessary and harsh attempts at sounding. Having ascer- tained that the bladder contains a stone, its removal should next be determined upon. But, before this is resorted to, the sur- geon must endeavour to mitigate the symptoms as much as pos- sible, or, in other words, to prepare the patient for the opera- tion. Formerly, many attempts were made to destroy a stone, either by the use of internal medicines, or by the injection of fluids into the bladder. The practice, however, has long been abandoned—having been found ineffectual. But in another point of view it has proved highly useful—by relieving the symptoms, and thereby rendering the patient's chance of reco- very after an operation more certain. The best medicines, for this purpose, in most cases, are the alkalies, especially in the form of soda-water, or the carbonate of soda. Magnesia, also, has often proved very serviceable. Together with this treat- ment, the patient should be obliged, for two or three weeks before the operation, to live on a low diet, and take occasional purgatives. The operation should not, if it can be avoided, be performed during very warm, or very cold weather. A few hours previous to the operation, the rectum should be emptied by an enema, the perineum shaved, and a tape tied round the patient's penis to prevent him from making water. The latter is so important, that to ensure its observance, a careful attend- ant should watch the patient from the time the penis is tied, until the operation. Various modes of performing lithotomy have been practised from time immemorial; but it is merely my in- tention to describe the lateral operation as it is performed at the present day by the most eminent surgeons—with the gorget, and to notice briefly the high operation, and that upon females. The instruments are two or three scalpels, a curved probe- pointed bistoury, a straight sharp-pointed bistoury, a staff with a large deep groove, Physick's gorget,* several forceps, smaller than they are usually made, a scoop, tenacula, ligatures, sponges, a curved needle and forceps for the pudic artery, a large pewter injecting syringe with a pipe six inches long, tepid barley- * This instrument differs from the common gorget in having a moveable blade, or one that can be separated from the back, for the purpose of sharp- ening it to greater advantage. For a particular description of it, see Dorsey's Surgery, vol. ii. URINARY CALCULUS. 237 water carefully strained, strong bands of woollen or muslin, two inches broad and three or four yards long, and a bowl of warm oil. A narrow dining table is selected and the leaves turned down. Over the table is placed a thick blanket, several times folded. On this the patient, dressed merely in a shirt and loose night- gown, is laid—with a pillow under his head, his pelvis resting on the lowTer edge of the table, and his legs and thighs sup- ported by an assistant on each side. The surgeon unties the penis, dips his staff in warm oil, introduces it into the bladder, and having satisfied himself, and the other medical attendants, of the presence of a stone, gives the staff to a third assistant, with an injunction not to let its point slip from the bladder. He then passes each wrist through loops formed at the extre- mities of the bands or fillets, directs the patient to grasp the soles of his feet, and fastens them and the hands together by numerous turns of the bandage. The assistant, holding the staff steadily with one hand, and standing on the side of the patient, is then directed to raise and support the scrotum and testicles with the other hand—taking especial care that the end of the staff is fairly within the bladder. The assistants, appointed to secure the patient's limbs, must each place a knee in their arm- pit, grasp a foot with their hands, and sustain the thighs nearly in a perpendicular position, separating them at the same time, moderately. The surgeon then seats himself before the patient on a low stool, (having previously arranged his instruments in the order he will require them, on a small table placed within his reach,) takes a scalpel of moderate size, makes an incision in the left side of the perineum, commencing a little below the arch of the pubes, extending downwards with a slight obliquity, be- tween the rectum and tuberosity of the ischium, and terminating opposite the lower margin of the anus. This first cut is made, not with the point of the knife, but with its convex edge, through the integuments, fat, and perinaeal fascia. By repeated strokes of the knife, the transversales muscles are next unbridled, and the membranous part of the urethra and prostate gland laid bare. At this stage of the dissection, the operator will some- times find it necessary to stop and take up the transversalis perinaei artery.* The raembranons part of the urethra and * Usually this vessel does not require the ligature. VOL. II.---Q 238 URINARY CALCULUS. staff being distinctly felt by the fore-finger of the left hand, the surgeon next takes the sharp-pointed bistoury, carries it to the bottom of the wound with its back towards the rectum, and opens the membranous part of the urethra, to the extent of half an inch or more, by cutting from behind forwards, or from the prostate towards the bulb. As soon as the urethra is opened, a stream of urine, (provided the patient has retained it,) issues through the wound. Without loss of time the surgeon next lifts the gorget, fixes its beak in the groove of the staff, takes the handle of the staff from the assistant, depresses it, balances for a moment the two instruments on each other, runs the beak or the gorget backwards and forwards, two or three times, to be certain that it is fairly in the gutter of the staff, then with a slow but steady and decided movement carries the instrument onwards to the bladder through the prostate gland. A sudden gush of urine announces the completion of this stage of the operation. The gorget being withdrawn, the left fore-finger of the operator is immediately introduced, the stone felt, and the staff taken away. Still keeping the finger in the bladder, the surgeon then takes a small pair of forceps, and with the blades shut, carries the instrument through the opening in the prostate, alongside the finger, touches the stone, removes the finger, expands the blades of the forceps, seizes the stone —gently, lest it break,—parallel, if possible, with its longest rliameter, and gradually extracts it. As soon as it is removed, an accurate examination should be instituted, in order to dis- cover whether there be any other stones left behind. If so, the forceps must be again and again introduced, until the whole are extracted. To clear the bladder of any fragments, sand, or clotted blood, that may happen to remain, the pipe of the syringe should be introduced, and a quantity of tepid barley-water thrown in, repeatedly, until the bladder is completely rinsed out. Any vessel of importance, that may happen to have been cut, will probably continue to bleed after the stone has been extracted, and should be secured by ligature without delay. If the pudic ar- tery is divided by the knife or gorget, it will pour out blood co- piously, and from this cause many patients have lost their lives. The forceps and needle* used by Dr. Physick, for deep-seated * See vol. i. p. 63. URINARY CALCULUS. 239 arteries, will be found the best instrument for taking it up.* As soon as the hemorrhage has stopped, a gum elastic catheter, of large size, should be carried through the wound into the bladder, the bandage removed from the hands and feet, and the patient laid in bed on his left side—the thighs being slightly bound to each other, by two or three turns of the roller. The gum elastic catheter, projecting from the wound, serves to carry off the urine, which being received in a dish, the patient is kept constantly dry and comfortable. For several days the urine continues to pass by the perineum; at length, however, it is discharged through the penis, and very little runs through the wound. The catheter should then be removed, and, in a short time, the opening in the perineum will heal. In a few rare instances, indeed, the inci- sions have healed by the first intention; but in general, three or four weeks elapse before a cure is effected. The operation of lithotomy, as I have described it, must be understood as adapted to the adult, and as calculated for cases unattended with difficulty. The same rules should be observed in performing the operation on infants and children—the instru- ments and incisions, in such cases, being proportionally smaller. In such subjects, moreover, the surgeon may expect to expe- rience some trouble, from a frequent protrusion of the rectum, during the operation, inasmuch as most children afflicted with the stone, are subject to prolapsus ani. Upon the whole, how- * It sometimes happens that after the stone has been removed, and the patient put to bed, secondary hemorrhage takes place, and that the blood finds its way into the bladder, where it excites so much irritation, as to cause a contraction of that viscus, and a sudden discharge of urine and coagulated blood through the wound. In fifteen or twenty minutes the same accumulation and expulsion again take place, and may continue until the patient is exhausted, unless the surgeon understands the nature of the accident and the mode of treating it In all such cases, I have reason to believe, from what I have seen, that the he- morrhage proceeds from the venae vesicales, or from some of the arteries abou: the prostate. Under these circumstances, a very ingenious mode of arresting the flow of blood was executed many years ago by the late Dr. Physick, (in the case of a Dr. B.) by introducing a large gum elastic catheter into the bladder through the urethra, and at the same time a long slip of lint through the wound, between the lips of the prostate, so as to keep them in accurate apposition. The flow of blood being thus stopped, and the urine passing off by the catheter, instead of flowing through the wound, it follows that the hemorrhage will not return, so long as the lint retains its position; it is; im- portant, therefore, that it should be left for several days, or until suppuration takes place. By adopting this plan I have saved the lives of two patients, who otherwise, I am sure, must have perished. 240 URINARY CALCULUS. ever, the operation of lithotomy in children, is compared with that of the adult, attended with few difficulties. To guard against accidents, and to prepare the young sur- geon for difficulties, which at some period or other he may ex- pect to encounter, the following mementos should be carefully attended to. 1st. To examine minutely every instrument, before it is used, especially the gorget and staff. If the cutting edge of the former be not extremely sharp, it will not divide the prostate gland, but pushing it forward, will pass between the bladder and rectum, and deceive the surgeon, who, supposing that he has opened the bladder, thrusts the forceps into the wound, makes fruitless efforts to extract the stone, and, perhaps, may tear awTay, as has happened, the prostate and part of the bladder. If the gorget be not accurately fitted to the staff, it may be discovered during the operation,—and at the critical moment of pushing the instru- ment into the bladder, that the beak is too large for the groove. Under these circumstances, should the operator persevere in his attempts to thrust the gorget home, great mischief may ensue. The size of the gorget must always be proportioned to the age and size of the patient. A gorget, for an adult, should never exceed in breadth three-quarters of an inch, and, for most pa- tients one five-eighths of an inch will answer. Children seldom require an instrument beyond three-eighths of an inch in width. An unusually wide gorget always endangers the pudic artery. The most experienced lithotomists, however, of modern times, have always inculcated, and, as I conceive, justly, a free in- cision of the prostate and neck of the bladder, rather than tear these parts in attempting to get out a large stone. How then can this be accomplished unless a broad gorget be employed? The answer is very. easy. The chief object of the gorget is to make an opening into the bladder; if this opening is sufficiently large to admit the finger of the surgeon and enable him to touch the stone, this is all he can require. Finding, by the feel, the stone too large to come away through the track made by the gorget, the curved probe-pointed bistoury is at hand, and with this the wound may be instantly enlarged to the requisite extent, and without exposing the pudic artery. In running the gorget along the staff, through the prostate and bladder, care should be taken to depress its handle, in order that the blade may be sufficiently elevated to pass in a line corresponding with the axis of the P7«uVI. V.J. URINARY CALCULUS. 241 pelvis. This the operator sometimes finds it difficult to accom- plish, owing to the blade of the gorget being made as broad near the handle of the instrument as at its point, and, on this account, not calculated to rest in the lower angle of the incision. To obviate this difficulty, I have for several years past, had the blades of gorgets so constructed, as gradually to taper from the outer corner of the cutting edge to the handle of the instrument. (See Plate VI.) 2d. If the surgeon, from timidity, or any other cause, does not make his incisions in the perineum ample, but leaves some of the fibres of the transversales perinaei muscles uncut, he will find, in attempting to extract the stone, great resistance, and a constant tendency in it to slip from the grasp of the forceps. This resistance usually arises from the fibres of the transversalis perinaei alter. In such a case the fore-finger of the left hand should be carried towards the bottom of the wound to depress the rectum, while the remaining obstruction is removed by the knife. A wound of the rectum will not prove so serious an ac- cident as some have represented; nevertheless, it should be carefully avoided. 3d. The lithotomy forceps are, in general, made unnecessarily large and clumsy; so large, indeed, as often of themselves to fill up the opening through the prostate. The teeth, too, on the inner surface of the blades, are often so large as to act like wedges, and break the stone the moment it is grasped. For a child, a forceps very little larger than the common pocket-case instrument, will serve a better purpose than the one usually employed; and the smallest forceps contained in the lithotomy case, provided the handles be somewhat lengthened, will an- swer for an adult.* If a stone should be so large as to require breaking, a strong pair of forceps, with a screw in the handles, will prove more effectual than the complicated instrument of Mr. Henry Earle. Although I have had occasion, however, to break large stones, I have never experienced any difficulty in ef- fecting it with the common forceps, except in one instance. Fre- quently, a stone will break under very moderate pressure of the forceps, and when the surgeon is unwilling for it so to do. In this event, great patience and gentleness must be exercised in * The blades of stone forceps should never touch, but a small space be left between them, to prevent the bladder from being pinched. 242 URINARY CALCULUS. extracting the fragments by the scoop, and by injections of barley-water. It sometimes happens that one portion of a stone is imbedded in a cyst in the coats of the bladder, while the other projects into its cavity. This happened in a case upon which I operated at Alexandria, under the care of two distin- guished physicians of that place—Drs. Washington and Sims. Having seized the stone with the forceps, the projecting half broke off, and the remainder with great difficulty, I was obliged to scoop out of the cyst with my finger. The patient had long suffered from the disease, was greatly exhausted before the ope- ration, and died ten or twelve days after it. Some years ago I operated on a young man in the Philadelphia Hospital, and took from his bladder a stone about the size of a walnut, and afterwards introduced my finger to ascertain if there were any others left, when, to my great surprise, I discovered that the fundus of the bladder, for a considerable extent, was incrusted with calculous matter, which I peeled off in successive layers, some of which were nearly half an inch thick. This patient recovered perfectly. Under circumstances such as I have de- tailed, the surgeon should never, for a moment, lose his self-pos- session, but proceed cautiously and gently, but firmly, until he has effected his purpose. In the common operation of lithotomy, too, it should never be necessary to pull violently with the for- ceps, but the instrument must be humoured, and its position changed and twisted gently in a variety of directions. 4th. The after treatment of lithotomy is oftentimes more im- portant than the operation itself; and the surgeon would do well never to operate, unless he could attend the patient through- out the whole course of his confinement. I have now performed the operation of lithotomy more than fifty times, and have lost out of that number, only six patients. My success I attribute, in a great measure, to ample incisions, and to extraordinary care during the after treatment. Three out of the six patients died at a distance where I could not attend them, and the other three were greatly exhausted by the disease before the opera- tion was performed. Dr. Warren, the distinguished surgeon of Boston, has lost, as he informs me, but two patients out of seven- teen. The shock communicated to the system by the severity of the operation, is sometimes such as greatly to endanger the patient's life, and, indeed, some have actually died on the table, or a few7 hours after—reaction having never been established. URINARY CALCULUS. 243 Many years ago I lost a patient twelve hours after the opera- tion, purely from this cause, and the same thing occurred to the late Dr. Physick. So long as this state of the system continues, stimulants, particularly ammonia, must be employed. After re- action takes place, then inflammation must be guarded against, and to prevent this, the antiphlogistic system, to the necessary extent, will be naturally resorted to. The high operation of lithotomy, or that above the pubes, an account of which, it is said, was first given by Franco, in 1556, was formerly much practised, particularly by Frere Cosme, Douglass, and Chesselden. The unfortunate termination, how- ever, of numerous cases, caused it to be abandoned almost en- tirely. Still it has been revived at different periods, and latterly, by Souberbielle, of Paris, and Carpue, and Sir Everard Home, of London. But, even under the most favourable circumstances, it is an operation greatly inferior to the lateral, and, indeed, should only be practised, I conceive, in cases where the stone is ascertained to be of extraordinary magnitude, or where the prostate gland is very much enlarged. The principal objec- tions to the operation arise from the difficulty of preventing the escape of the urine into the cavity of the pelvis, and the danger of wounding the peritoneum. If the operation be determined on, I should prefer the mode of executing it devised by Sir Eve- rard Home, and as described by him in the following case. An incision was made in the direction of the linea alba, between the pyramidales muscles, beginning at the pubes, and extending four inches in length: it was continued down to the tendon. The linea alba was then pierced close to the pubes, and divided by a probe-pointed bistoury to the extent of three inches. The pyramidales muscles had a portion of their origin at the symphysis pubis detached to make room. When the finger was passed down under the linea alba, the fundus of the bladder was felt covered writh loose, fatty, cellular membrane. A silver catheter, open at the end, was now passed along the urethra into the bladder, and, when the point was felt by the finger in the wound, pressing up the fundus, a stilet, that had been concealed, was forced through the coats of the bladder, and followed by the end of the catheter. The stilet was then withdrawn, and the opening, through the fundus of the bladder, enlarged towards the pubes, by a probe-pointed bistoury suffi- ciently to admit two fingers, and then the catheter was with- 244 URINARY CALCULUS. drawn. The fundus of the bladder was held up by one finger, and the stone examined by the forefinger of the right hand. A pair of forceps, with a net attached, was passed down into the bladder, and the stone directed into it by the finger: the surface being very rough, the stone stuck upon the opening of the forceps, and, being retained there by the finger, was ex- tracted. A slip of linen had one end introduced into the blad- der, and the other was left hanging out of the wound, the edges of which were brought together by adhesive plaster. A flexi- ble gum catheter, without the stilet, was passed into the bladder, by the urethra, and kept there by an elastic retainer surround- ing the penis. The patient was put to bed, and laid upon his side, in which position the urine escaped freely through the catheter." Some years ago, I was called to Virginia, to operate for lithotomy. I found the patient very far advanced in years, and labouring not only under stone, but morbid enlargement of the middle and lateral lobes of the prostate. Knowing the difficul- ties I should have to contend with under these circumstances, I determined, instead of performing the lateral operation, to open the bladder above the pubes. Accordingly, assisted by Drs. Withers and James, two eminent practitioners of the neighbour- hood in which the patient resided, I performed the operation after the manner of Sir Everard Home above described, and suc- ceeded without difficulty in removing twTo calculi. The patient's chance of recovery, notwithstanding his age and the enlarge- ment of the prostate, was very favourable; so much so, that feeling himself, as he imagined, perfectly secure, and tired of re- straint and confinement to bed, he insisted upon the catheter being withdrawn,—contrary to very strict injunctions I had left with him,—and in consequence soon after perished from perito- neal inflammation induced by effusion of urine into the cavity of the pelvis. This was the first instance, I believe, in which the high operation had been performed in America. It has since been done, successfully, by Dr. Carpenter, of Lancaster, and also, as I understand, by Dr. Van Valzah, of Lewisburg, Union County, Pennsylvania—both eminent physicians. Females are subject to calculus as well as males, though the disease in the former is by no means so frequent as in the latter —owing to the female urethra being so short and large as rea- dily to permit the escape of the calculous particles before they URINARY CALCULUS. 245 become so large as to form a stone. The symptoms created by the presence of a stone in the female bladder resemble those which have already been pointed out as characterizing the dis- ease in males; in general, however, women suffer more than men from the disease. There are two modes of extracting the stone from the female bladder—by dilatation of the meatus urinarius, and by incision. The former was often practised by the older surgeons, and with- in the last twenty or thirty years, has been occasionally resorted to. It should be preferred, in general, to the knife, (especially when the stone is small,) inasmuch as it is not so liable to be followed by incontinence of urine. A bit of compressed sponge, or wax bougies gradually increased in size, will answer very well to dilate the passage with. When the stone is found to be very large, it will, perhaps, become necessary to divide the urethra, and the best mode of performing the operation, is, I think, the following. The patient is placed in the ordinary position for lithotomy, and her hands secured to the feet by bandages. The surgeon then introduces into the urethra a straight staff, with its groove directed towards the left ischium, and holding it firmly by the handle, passes with the right hand a straight bistoury through the urethra and neck of the bladder, obliquely downwards. The finger being introduced and the stone felt, it may be readily re- moved with the straight or curved forceps. As incontinence of urine has followed in all. the cases in which Sir Astley Cooper has performed or witnessed the operation, he has expressed his determination, in future, to try the effect of a suture upon the edges of the wound. I have already remarked, that I had never failed, except in one instance, to break a stone with the common forceps. As that instance was an extraordinary one, and the mode of crush- ing the stone not less so, perhaps, I will relate the circumstances in concluding the subject of lithotomy. A man, named Davis, was lithotomized at Cincinnati, by the late Dr. Godman, who failed to extract the stone on account of its immense size. The wound healed up, and the man walked from Cincinnati to Car- lisle, Pennsylvania, where he was subjected a second time to lithotomy by the late Dr. Given, and with similar result. He then walked to Philadelphia, and placed himself under my care, in the Philadelphia Hospital. Assisted by Dr. Physick, I performed the operation, and finding the bladder filled with an enormous 246 URINARY CALCULUS. stone, I applied a drill half an inch wide, fixed in a handle, and made an opening sufficiently deep to introduce one blade of a forceps, while with the other, on the convex surface of the stone, sufficient pressure was made to quarry it in a short time com- pletely. The patient recovered in two weeks, and walked home, as Dr. Chapman remarked, a stone lighter. The stone was soft and friable, or it could not have been thus disposed of. In conclusion I may state, it must not be forgotten that in many patients there is a strong tendency to return of calculus. This may give rise to a repetition of operations; and several eminent surgeons have operated a second, third, and even fourth time upon the same patient. Sir Astley Cooper operated three times in one case, and his nephew, Mr. Bransby Cooper also three times upon another individual, within the space of four years. Surgeons, therefore, are not to be held responsible, in such cases, for want of success by a single operation. Carpue's History of the High Operation, &c, 1819; Sanson des Moyens de Parvenirala Vessie par le Rectum, 1817; Dictionnaire des Sciences Medi- cales, torn, xxviii. p. 422; Traite Historique et Dogmatique de l'Operation de la Taille, par J. F. L. Deschamps, Paris, 1796, 4 tomes, 8vo.; John Bell's Principles of Surgery, vol. ii. part i.; Desault's Works, by Smith, vol. iii.; C. Bell's Operative Surgery, vol. i. p. 329; Earle's Practical Observations on the Operation for the Stone, 1803 ; Roux's Journey to London; Allan's Trea- tise on Lithotomy, 1808: Colles's Treatise on Surgical Anatomy, p. 145 and 169; Cooper's First Lines of the Practice of Surgery, vol. ii. p. 320,4th edit.; Dorsey's Surgery, vol. ii.; Dorsey's Inaugural Essay on the Lithontriptic Virtues of the Gastric Liquor, 1802; Marcet's Essay on the Chemical History and Medical Treatment of Calculous Disorders ; Prout's Inquiry into the Na- ture and Treatment of Gravel, Calculus, &c; Magendie on Gravel, &c; Wilson on the Urinary and Genital Organs, London, 1821, 8vo.; A Treatise on the Formation, Constituents, and Extraction of the Urinary Calculus, being the Essay for which the Jacksonian Prize for the Year 1833 was awarded by the Royal College of Surgeons in London, by John Green Crosse, Surgeon to the Norfolk and Norwich Hospital, and Lecturer on Clinical Surgery, Member of the Royal College of Surgeons, and Fellow of the Royal Medical and Chi- rurgical Society of London, Corresponding Member of the Societe Medicale d'Emulation of Paris, formerly Demonstrator of Anatomy in the University of Dublin, Member of the American Philosophical Society of Philadelphia, &c. A work replete with every variety of information on the subject it treats; and, as coming from a surgeon of acknowledged ability, industry, zeal, and experience, should be carefully studied by all desirous of obtaining the best pathological and practical information on calculus and its treatment. LITHOTRITY. 247 SECTION VIII. LITHOTRITY. Among the obsolete and musty records of ancient times, isolated scraps of valuable matter, plausible hints and specula- tions, ingenious instruments, and operations, are met with as " rari nantes in gurgite vasto." By the industry, however, of such men as Ploucquet, Sprengel, Good, Young, S. Cooper, and a host of German labourers, the golden sand has long been washed and picked from the rubbish that surrounded it, and whether dug from the caverns of Pompeii or Herculaneum, or collected from the deserts of Egypt or Arabia, or scraped from the ruins of Greece, has been preserved pure and unalloyed, and stored up for its rightful owners. But how few and unmerited are the claims of the ancients to those treasures which have been so unsparingly showered for the last fifty years upon every department of the healing art. And yet no sooner is a discovery made, or a new idea started, or a new operation performed, but the claim to priority is contested by a bold assertion that Hip- pocrates, Galen, or Celsus, or some other antediluvian, is entitled to the honour of the claim in question. This disposition to de- tract from well-merited fame, every where so prevalent, and in- herent, perhaps, in human nature, was strikingly displayed a few years since in France, in relation to the operation of Lithotrity; for when Civiale and Leroy, poor and obscure, but most meritorious and ingenious individuals, demonstrated that the stone could be destroyed in the human bladder, and removed, without the operation of lithotomy, it was immediately pro- claimed that there was nothing new about the affair, that they deserved no credit for the operation; for that a monk of Citeaux, and Martin, an English colonel, had both relieved themselves long before, by nearly the same means; that Gruithuisen, a Bavarian physician, had made similar experiments, and that even Ammon of Alexandria, Franco, Ambrose Par6, Hildanus, Sanctorius, Germanus, and Haller, were acquainted with lithotrity, that Amusat, and others, were all familiar, before Civiale and Leroy, with the operation. 248 LITHOTRITY. But in answer to all this, it may be said, (admitting that some obscure hints might have been thrown out, or nugatory experi- ments made by the individuals mentioned, or others,) that no brilliant discovery, or invention, ever was made, perhaps, that had not been previously imagined or thought of by some one, and that the men who, while struggling with poverty and almost overwhelmed with difficulties of every description, have energy enough to bear up and to persevere for years amidst privations and sufferings, and, finally, to bring triumphantly their experi- ments to successful issue, and adapt them to practice, are entitled fairly to the chief glory of discoverers. To whom but Fulton are we really indebted for steam navigation? To whom but Civiale and Leroy do we actually owe the operation of litho- trity? It is natural for us to look, in this age of project and trickery, with distrust towards proposals not sanctioned by long experience, and there were many, accordingly, disposed to undervalue the labours of these men. For myself, I candidly own, that for years I had no faith in the operation, as regards the full advantage to be derived from it, and the facility of exe- cuting it, and believed with many others, that it was adapted only to extraordinary cases. From the first, however, I never hesitated to speak of it, both in this work and in my lectures, as a " most ingenious and beautiful idea," and to say, that the time would probably come, when the operation would be so modified and improved, as to deserve all the praises then so inconsiderately lavished upon it. At the same time, the young surgeon was cautioned how he ventured to undertake the operation, (which from trials made by some of the most skilful surgeons of this country, was found to be extremely difficult, delicate and dan- gerous,) under the idea, then too prevalent, that any one of ordinary capacity and practice could perform it. That the advice I then gave was just, and such as ought to have been followed, experience has since proved; for although there are now many successful operators in Europe, and a few in this country, every one of them, I am sure, will acknowledge that lithotrity requires a tact, an attention to minute circumstances, a discrimination rarely possessed, and above all, instruments which not one cutler in a thousand can manufacture. Upon the whole, then, it may be stated, that lithotrity has become an established operation, that it is adapted to a greater number of cases than was, originally, supposed possible, that in the hands LITHOTRITY. 249 of skilful operators it is generally successful, and that when the patients are healthy, middle-aged, or advanced in years, the urethra large and free from disease, the stone small and soft, and when females are the subjects of it, the operation should always be attempted in preference to lithotomy. On the other hand, it must be remarked, that it is seldom adapted to children, or to very irritable and diseased patients, or to cases where the stone is large and extremely hard, and that in Europe, and in this country, in the hands of the late Dr. Physick, Dr. J. K. Mitchell, and others, it has been followed by the most lamentable results. Before describing lithotrity, it will be necessary to give an ac- count of the instruments employed in the operation. I have al- ready remarked that these are extremely difficult to make. Thoroughly convinced of this, I ordered a set from Paris, of the finest finish and construction, which, through the kindness of M. Civiale, were made under his own eye and direction by Char- riere, and every one examined by him and altered, until it met his approbation. Such of these, only, as are essential in the ope- ration I shall describe in this place. There are many instru- ments invented by Heurteloup, Leroy d'Etiolles and other lithotritists, that possess no advantage, I conceive, over Ci- viale's, and which, therefore, need not to be noticed in a work of this description. CiviaWs apparatus, or lithotripteur, consists, 1st, of a silver cannula, eleven inches long, and from two to four lines in dia- meter, open at its lower extremity, and having at its upper a cir- cular rim, connected with an oblong shoulder, intended to secure the cannula in a corresponding handle, or lathe, to be afterwards described. Attached to this extremity, likewise, is a cylinder of leather enclosed in a circular box, to render the cannula water- tight. 2dly, Of a steel cannula, longer than the silver one, made to fit and work on the inside of it, having at its lower end three elastic branches which curve inwards, are rounded at their ex- tremities, are intended to seize the stone, and are so contrived as, when drawn within the outer cannula, to pack closely together and form a smooth rounded end, well calculated to glide along the urethra, and enter the bladder. The upper extremity of this cannula is numbered, or graduated, to enable the operator to ascertain the degree of expansion of the litholahe or claw, and is connected by a screw, to a rim or circular box filled with leather, somewhat similar to the one on the silver cannula, and intended 250 LITHOTRITY. for the same purpose—to prevent the escape of fluid during the operation. Sometimes four pincers, or claws, are used instead of three; and in certain cases two only are employed. But Civiale has found three the most convenient, in the generality of cases. 3dly, Of the lithotriteur, or perforator,—which is a steel rod six inches longer than the litholabe, having upon one ex- tremity a crown wTith a number of cutting edges, or teeth, calcu- lated to pulverize, or grind the stone or reduce it to fragments, and upon the other a graduated scale intended to denote the size of the stone within the grasp of the claw. This extremity is rounded, and for half an inch beyond the scale is slightly ser- rated, or ragged, in order that it may be securely held in the jaws of a grooved pulley designed to communicate to the lithotriteur a rotary motion, when passed through the cannula of the litholabe. 4thly, Of a brass frame, or lathe, somewhat similar to that used by watchmakers, the curved extremity of which has a square cavity, with lateral grooves on its interior, intended to receive the corresponding oblong shoulder of the silver cannula and to be secured in it by a screw; while the other extremity, or straight square shank of the lathe, is designed as a bar upon which a popet- head slides backwards and forewards. Parallel with the bar, and fixed upon the superior extremity of the popet-head, is a cylindrical brass tube, which encloses a spiral spring connected with a steel pivot, the cup-like extremity of which receives the rounded end of the lithotriteur, and by the operation of the spring keeps its dentated crown in perpetual contact with the stone. The lathe, during the operation, is held by the hands of an as- sistant. 5thly, A steel drill bow, about twenty-five inches long, jointed in the centre, firm but elastic, and well designed to play upon the pulley connected with the lithotriteur, may be said to complete the apparatus. Three or four sets of the external cannula, and litholabe, of different sizes, and a proportionate number of the lithotriteur, (ten or fifteen,) should accompany each case of instruments. The patient having been sounded, the presence of a stone detected, the state of the health inquired into, the condition of the bladder, the size, consistence and situation, as far as practicable, of the stone ascertained, and lithotrity determined upon, the first step is to enlarge the urethra, gradually, by the introduction of bougies, sounds or catheters, commencing with small instruments, successively increasing their size, and suffering each to remain in LITHOTRITY. 251 the urethra ten or fifteen minutes at a time. This practice having been pursued for eight or ten days, the urethra, besides being dilated, becomes accustomed to instruments, and its natural sensibility thereby diminished. Some operators, however, and among them Leroy and Bancal, deem the preparatory treat- ment, unnecessary; but by Civiale it is considered, generally, indispensable. Immediately before commencing the operation, the bladder is explored by the sound, a second time, and the stone being felt, and appearing not too large to be embraced by the litholabe, the patient is laid on a bed and his hips elevated by bolsters, in order to make the stone gravitate towards the fundus of the bladder. A common catheter is then carried into the bladder, and the pipe of a syringe being adapted to its extremity, pro- jecting from the urethra, tepid water, or strained barley-water, is injected until the patient complains of a disposition to urinate. The catheter is then withdrawn and the lithotripteur, (with the branches of the litholabe retracted within the cannula, and all other parts of the instrument accurately adjusted,) well greased, is introduced into the urethra by the right hand—while the penis is depressed by the left, parallel with the thighs, which are slightly flexed. The instrument passes readily until it arrives at the bulb of the urethra; it then meets with resistance, which is only to be overcome by depressing the external portion of the lithotripteur, and elevating its point, which starts forward, glides along the membranous portion of the urethra and prostate, and enters the bladder. The stone is then searched for, and, in general, may be felt distinctly. When found, and its exact position determined, the blades of the litholabe are expanded by pushing downwards the rim attached to its upper extremity, taking especial care to keep one blade directed upwards towards the linea alba, and parallel with the graduated scale, which should always be uppermost, and correspond with the screw on the silver or external cannula, while the other blades lie along each side of the bladder, and in this position can hardly fail to enclose the stone. By attention to this rule, which is extremely important, it is impossible for one of the branches to fall verti- cally upon the stone, and the surgeon, instead of enclosing it by chance or accident, seizes it to a certainty, by drawing the litho- labe upwards with the right hand, while the left is employed in pushing down the external cannula. To secure the stone firmly 252 LITHOTRITY. in the grasp of the claw, the screw, which traverses the rim of the external cannula, should be turned, and the two tubes ren- dered immoveable or prevented from sliding upon each other. The next step is to attach the frame or lathe to the lithotripteur, or adjust trfb upper extremity of the perforator to the steel pivot projecting by the spiral spring of the popet-head, to apply the catgut to the pulley and rotate it by very slow and gentle move- ments. If the stone is found not to change its position by the action of the perforator upon it, and the patient does not com- plain of the motion of the bow, the rapidity of the drilling may be increased and continued until the stone is perforated. When soft this is soon accomplished, but when hard requires some time, and is attended with a good deal of fatigue to the operator. In general, it is best not to attempt too much at the first opera- tion. Having, therefore, succeeded in boring the stone at a sin- gle spot, the next step is to remove it from the claw of the in- strument. This is done by expanding the blades, pushing out the stone by the perforator, then closing them and removing the instrument from the bladder. In doing this, however, great care must be taken that no fragments are interposed between the blades and drill, as often happens, but may be discovered by the difficulty of withdrawing the instrument. A few turns of the crown of the perforator, in such a case, will be sufficient to pulverize and remove them. After the operation the patient should take a warm bath, keep quiet for some hours, and attend to his diet. The urine first discharged is generally found slightly tinged with blood, and along with it pass off more or less sand and fragments of the stone. In three or four days the patient is ready, in most cases, for a second operation. In the details just given, I have followed closely the directions of Civiale, and have reason to believe, that, if pursued with minute attention to all the points enumerated, much less dif- ficulty will be experienced by operators in this country, who may now resort to the operation, than has been the case hitherto; for I am persuaded that most of the mishaps recorded in former editions of this work, are imputable to want of attention to cer- tain indispensable practical manipulations, the neglect of which must still eventuate in inevitable failure. But to guard, as much as possible, against ill consequences, I shall endeavour still fur- ther to inculcate such precepts, from the best authorities, as will be likely to prevent error, and facilitate the efforts of those who LITHOTRITY. 253 may feel disposed to engage in this branch of surgery, and may not have access to those European productions which have issued, latterly, in such numbers from the press. Notwithstanding the facility with which, in many cases, the stone is seized immediately upon expanding the branches of the litholabe in the bladder, yet it sometimes happens, that it per- tinaciously eludes their grasp. This is owing, generally, to the stone resting near the neck of the bladder, so that it comes in contact with the smallest diameter of the branches—that which is next to the extremity of the cannula. This will be understood, easily, when it is recollected that the branches, when opened into the bladder, represent a triangular pyramid, the base of which presents to the sacrum, and the apex to the neck of the bladder. The course to pursue, under such circumstances, is either to withdraw the instrument and raise still higher the hips of the patient, in order to roll the stone towards the fundus of the bladder, or else to draw the instrument with its blades expanded towards the penis, which must have the effect of gaining room by expanding the neck of the bladder,—naturally elastic, and susceptible of dilatation,—and of bringing the claws at the point of their greatest divergence, over the sides of the stone. Still further to facilitate its enclosure, it may be necessary to raise the handle of the instrument, by which the two lateral blades must depress the prostate and embrace the sides of the stone, while the vertical blade descends and rests upon its summit. Having in this way succeeded in seizing the stone, the handle of the in- strument should be depressed, by which manoeuvre the stone will be suspended, as it were, in the centre of the bladder, and being sustained in that position while the drilling is going on, there will be no pressure or irritation on the walls of the blad- der. If the stone, as often happens, should be too large to be em- braced by the litholabe, this may be easily known by its retiring from the instrument when its claws are expanded to the utmost, and may be proved by examination of the graduated scale. In such a case the lithotripteur is removed, and another of larger dimensions substituted. When the stone does not exceed in bulk a hen's egg, it may be destroyed by the operation of litho- trity, but if larger the surgeon will act wisely in not attempting the operation. The most delicate and difficult part, perhaps, of the operation VOL. II.—R 254 LITHOTRITY. of lithotrity is the turning of the stone, in order to perforate it in different directions; for after the first operation, and in all sub- sequent ones, this will become an important indication. The assistance of the lithotriteur, upon such occasions, is of the ut- most importance. By moving this in different directions, some- times pushing it forward, sometimes rotating it, and making it bear lightly upon the stone, the latter can be made to shift its position while still in the relaxed embrace of the claw, and as soon as the operator finds that the crown of the lithotriteur bears upon a surface not previously bored, the stone may be again seized and the drilling renewed. Having, in this way, perforated the calculus in numerous directions, it becomes so hollowed out, and weakened, that it may often be crushed by the pressure of the claw. Soft and friable stones, indeed, as Civiale and others have proved, may be destroyed, sometimes by the litholabe alone, and without the aid of the perforator. Before attempting lithotrity, it is of the utmost consequence to measure, exactly, by means of a catheter—having on its side a graduated scale—the exact length of the urethra, which varies, as is well known, in different subjects. As soon as the urine begins to flow, the measurement may be taken. Knowledge thus obtained, will prevent the operator from attempting to open the blades of the litholabe whilst in the urethra, from which very serious mischief has ensued in several instances. Although the necessity of injecting the bladder, upon all occa- sions, whether for the purpose of exploring its contents,—which is sometimes done with the blades open as well as shut,—or for seizing the stone, has been mentioned already as essential, yet it may be well again to state in this place, that without such prelimi- nary measure, success can hardly be calculated upon. No differ- ence of opinion exists among lithotritists upon this point, and, per- haps, it may be owing to attention in this respect, that Civiale has never, as he declared some years ago, injured the sides of the bladder, although he had, at the time the declaration was made, introduced the lithotripteur upwards of five hundred times. Should the fluid then escape, upon any occasion, previous to the operation, there can be no safety unless the bladder is again filled before the introduction of the instruments. As regards the number of applications of the lithotripteur, that may be required before the cure is completed, it may be remarked, that this will depend upon the size and texture of the LITHOTRITY. 255 stone, upon the state of the patient's health, upon the condition of the bladder, and a variety of other circumstances. In gene- ral, wThen the stone is soft and small, from one to three opera- tions will be required, and a greater number when it is large and hard. In getting away the fragments, little difficulty is now experienced. They usually pass off along with the urine, from day to day, or are brought away by injections, or by the repeated introduction of the litholabe, or by forceps with two blades, and if too large to pass the urethra, may be easily crushed. Instru- ments, indeed, have been invented by Jacobson, Heurteloup, Weiss, and others for crushing stones, or for breaking them with a hammer, and have been found calculated, upon certain occa- sions, to supersede the lithotripteur. One of this description, admirably contrived for the purpose, either invented or modified by Civiale, was lately sent to me, by that distinguished opera- tor. An account of these instruments will be given under the head of Lithotripsy. Upon the whole, it may be stated that as lithotrity can never entirely supersede lithotomy, though it will undoubtedly greatly curtail it, the surgeon should strive to make himself so familiar with both operations, and with calculous disorders, as to be able to determine the kind of operation adapted to each particular case, and prepared to perform either, as occasion mayr require. Upon his judgment in this respect, I venture to predict, will his success or failure in a great measure depend. Death has followed both operations, in numerous instances, although performed by Civiale himself, less frequently, however, since the various modi- fications of the instruments, and the experience acquired in using them, than in the infancy of the art. Although Leroy, and some others, have performed lithotrity upon children of three and four years of age, and in a few cases, with success, as a general rule it should not be attempted on account of the sensibility of such subjects, and the difficulty of introducing instruments suffi- ciently large and strong to destroy the stone. In women, litho- trity is more difficult than might be imagined, owing to the very irritable condition in which the female bladder, when it contains a stone, is generally found, and to the difficulty of keeping it distended with fluids, during the operation. On Lithotrity, consult de la Lithotritie ou Broiement de la Pierre dans la Vessie, par le Docteur Civiale, 8vo. Paris, 1826; Expose* des divers procedes, 256 LITHOTRIPSY. employes jusqu'a ce jour, pour guerir de la Pierre sans avoir recours a l'Ope- ration de la taille, par J. Leroy, Paris, 1825, 8vo: Lettres sur la Lithotritie, ou Broiement de la Pierre dans la Vessie, par le Docteur Civiale, Paris, 1827, 8vo; Lettre sur la Lithotritie, &c. par le Docteur Civiale, Paris, 1828, 8vo; Lettre sur la Lithotritie Uretrale suivee d'une revue generale, sur l'etat actuel de la methode Lithotritique, par le Docteur Civiale, 8vo, Paris, 1831; Lettres sur la Lithotritie ou l'Art de broyer la Pierre, par le Docteur Civiale, 8vo, Paris, 1833; Manuel Pratique de la Lithotritie par A. P. Bancal, Paris, 1829, 8vo; Description of the new Process of Perforating and Discharging the Stone in the Bladder, &c, by James Atkinson, Esq., 8vo. London, 1831; Lithotrity and Lithotomy compared, being an Analytical Examination of the present Method of Treating Stone in the Bladder, &c.,by Thomas King, M.D., London, 1832, 8vo; Principles of Lithotrity, or a Treatise on the Art of Extracting the Stone without incision, by Baron Heurteloup, 8vo. London, 1831; Case of Lithotrity successfully performed by L. Deypere, in New York Med. Journal for Nov. 1830; A. G. Smith on Lithotrity, in North Amer. Med. and Surg. Journal, vol. xii. p. 256. This gentleman now resides in New York, but was instrumental, whilst living in the West, of introducing lithotrity into that region, by performing several successful operations. SECTION IX. LITHOTRIPSY. It is now generally admitted that the operation of lithotrity in the hands of prudent and experienced surgeons, possesses decided advantages in certain cases over that of lithotomy. But it is also admitted that, to perform lithotrity with any pro- spect of success, requires great dexterity, extraordinary caution, gentleness, perfect familiarity with the use and knowledge of the mechanism of the instruments; and above all, instruments so well constructed and tempered—so diversified in shape, size, number, and adapted to so many different purposes—as to place the operation within the reach of a very limited number of surgeons, however competent in other parts of their profession to excel and even distinguish themselves. Perhaps it will not appear strange, then, when asserted, that no man, now in exist- ence, can be called a perfect lithotritist, except Civiale, who, as conceded, by all that have witnessed his exploits, is as dexte- LITHOTRIPSY. 257 /q rous and successful with his litho- /.y lobe and other forms of appa- '$ ratus peculiar to himself, as can I /? ^e ™agme(i* From all this, it JV may be reasonably inferred, that / the cause of failure in so many 2 instances amongst European and American surgeons, is mainly pg.a. The termina- owing to intrinsic difficulties in tion of the same in-,, ,_ r strument, the beakstne operation itself, to want ot separated. experience, to deficiency in me- chanical ingenuity and tact, to want of proper instruments and skill in manoeuvring them, as well as to the idea so prevalent from the very moment of the discovery of lithotrity down to the present time, among physicians and others little accus- tomed to operations of any description, "that lithotrity is very easy and simple, and may be performed successfully by those who would not dare to venture on lithotomy." Fortunately, in this state of things, an important discovery has been made within the last few years, —that there is no longer absolute necessity for resorting to lithotrity, but that the same end may be accomplished by other means, not less efficient, within the reach of a greater number of surgeons, less painful to the patient, attended with little or no risk, (if the surgeon is careful, the case adapted to the operation, and the patient willing to conform to certain regulations,) and, under favourable circumstances, certain of suc- cess. I allude to the operation of lithotripsy, which may be said, perhaps, to have been invented by Baron Heurteloup. This operation is founded upon two principles— upon that of crushing and of percussion—the for- mer chiefly adapted to soft and friable stones, the latter to hard and compact. To accomplish ^.i.Heurte]oup's^nese PurPoses several instruments have been in- percuteur. vented, and various modifications of the same in- strument proposed and executed. It is not my intention, how- 258 LITHOTRIPSY. ever, to describe or comment upon any except the instrument of Heur- teloup and that of Jacobson, both of which have been used sufficiently long in Europe and America, to en- able us to arrive, with some degree of certainty, at conclusions respect- ing their merits and defects. Heur- teloup's "percuteur," "pince a deux branches," lithotripteur, as it should be called, is extremely simple in Fig. a Thetermi-it construction, remarkable for nation of the same ' with the loop open, strength, and consists chiefly of two portions—a male and female steel rod, about twelve inches long, the former enclosed in the latter, and calculated to move backwards and forwards at pleasure, about the size of an ordinary adult catheter, straight for eleven inches of its length, and at its lower extremity, turned up and gently rounded in the form of a beak, at an angle of about 55 degrees. Near the upper extremity of the male rod, there is a graduated scale, intended to indicate the size of the stone, and the summit of the rod is terminated by a steel bowl, designed to receive pressure of the hand in crushing the calculus, or the blow of a hammer. In the latter case, the instrument is held within the grasp of a vice, which is applied to a square shoulder on the female rod, corresponding in situation with the graduated scale on the male rod. Above this shoulder, for two inches and a half in extent, is a male screw, upon which works a small tripod handle, calculated to drive forward the male rod upon the female, and by graduated pressure to break the stone. The extremities of the beak are Fig. 3. Jacobson'^ serrated, (but, at the same time, so rounded off instrument. &n(j guardecl as to prevent the possibility of pinch- ing the bladder or urethra) and extremely well calculated to seize, retain, and fracture any stone of ordinary dimensions, and hardness. The entire length of the instrument, from the summit head to the beak, for a full-grown subject, is about 18 LITHOTRIPSY. 259 inches. For younger subjects and for children, it will vary proportionally, in length and diameter. (See Figs. 1 and 2.) Jacobson's instrument is not designed to act upon the prin- ciple of percussion, nor is it calculated so to do, but is used, when shut, to detect the presence of a stone, and when ex- panded, to close upon and crush it, and would seem, when superficially examined, admirably calculated for the purpose. It consists of a silver cannula, eight or nine inches long, a quarter of an inch in diameter, attached to the superior extre- mity of which is a circular steel plate or rim, an inch wide. Through the cannula passes a steel rod, which projects beyond its lower extremity, two or three inches, in form of an ordinary sound, flattened and serrated on its concave surface, and smooth and half round on its convex. Connected with this extremity by a hinge, resembling it in form and size, but only an inch in length, is a piece of chain, which, in like manner, is attached to a second and a third portion, the last of which is riveted to a straight rod, which, like the former, passes through the cannula, for the length of twelve inches, and is intended to retract or expand the links, so as to produce, at will, the form of a com- mon curved catheter or that of a loop. The superior extremity of the straight rod, last mentioned, for three inches in extent, is a male screw, corresponding with a female one, which passes through the centre of a double convex rim, intended to work the chain backwards or forwards, as may be required. (See Figs. 3 and 4.) With either of the instruments above described and figured, the operation of lithotripsy may be conveniently and successfully performed. In describing the mode of operating, however, I shall confine myself almost exclusively to the lithotripteur of Heurteloup, because I have been more accustomed to the use of it in practice, and because I think it possesses advantages over that of Jacobson, which I shall endeavour afterwards to point out, and which I think will be appreciated by all who are disposed to give trial to each, and are so situated as to be com- petent to decide between them. It is a matter of no little consequence, before undertaking lithotripsy, to determine upon the cases best adapted to it. To want of care in this respect, and perhaps to want of judgment in some cases, I may add, may be attributed, there is reason to believe, the mishaps which have occurred in so many instances, 260 LITHOTRIPSY. and which have been so sedulously concealed from the public eye, in Europe especially, while the successful cases have been as carefully blazoned forth. I shall not be accused, I trust, of making such remarks invidiously, when I assert that the refe- rence is not to individual cases, or to lithotripsy alone, but will apply particularly to lithotrity. At all events I shall set the example, if not already done by others, of stating the success- ful as well as unsuccessful cases, the only mode by which the profession will be able to form a correct judgment with re- spect to an operation still in its infancy, and, in many points of view so interesting to science and humanity. When applied to by a patient, supposed from the symptoms to have stone in the bladder, I would advise rest and quiet for three or four days,—especially if just from a journey,—the free use of diluents, and a gentle purgative. After this, and at a moment when the patient has less than his accustomed irritation about the region of the bladder and urethra, a simple steel sound, or a silver, or gum elastic catheter, may be introduced very cautious- ly and deliberately, and moved in various directions—for the purpose of detecting the stone, and judging, in a measure, of its size, situation, texture, shape, and for ascertaining whether it be rough or smooth, whether more than one, &c. It often happens that the sound is introduced with the utmost facility, and without much inconvenience to the patient, the blad- der carefully explored, and no stone felt. In such cases, the surgeon should not rest satisfied, but, discontinuing his exami- nation after a few seconds, should renew it again in a day or two, and sound at one time when the bladder is full, at another when empty, and endeavour to make his instrument, though in the most cautious, and careful manner, enter into every nook and corner of the bladder, where it would be possible for the stone to lurk. He should also place his patient, while sounding, in a variety of positions—sometimes on his side, sometimes on his knees, and upon other occasions, nearly on his head—never failing, in diffi- cult or obscure cases, to introduce a finger into the rectum, for the purpose of elevating the stone, or of removing it from some cyst or hiding-place, and of bringing it in contact with the sound. Very small stones, or fragments, may be touched repeatedly by a person unaccustomed to sounding, without his being sensible that there is a particle of foreign body in the bladder; and even LITHOTRIPSY. 261 an experienced surgeon will frequently find himself at fault in this respect. From having experienced more or less difficulty in detecting a stone, occasionally I have, latterly, employed an in- strument of peculiar construction for sounding, which I shall no- tice hereafter. If the stone is distinctly felt, is of small size, and has not ex- isted very long; if the patient is an adult, middle-aged, or even advanced in years, has, in other respects, a sound constitution, and the bladder and urethra are not remarkably irritable, litho- tripsy may always be resorted to, and with every prospect of success. But, on the contrary, if the stone is large, hard and rough, has existed for many years, the bladder extremely irrita- ble, contracted, its walls thickened, the kidneys and ureters dis- eased, the prostate gland enlarged, the stone imbedded in a cyst, or fastened upon a fungus; if there has been for months or years a discharge of purulent matter, or of large quantities of slime from the bladder, and the patient is advanced in years or en- feebled in constitution, there will be great risk in attempting lithotripsy; and the chance of recovery will be greater, per- haps, from lithotomy,—though from the latter operation, also, pa- tients thus situated will be extremely apt to die. Both of these are, of course, extreme cases; and betwreen the favourable and unfavourable, there are many intermediate grades, where success must depend, in a great measure, upon the judgment and expe- rience of the surgeon in the treatment of calculous complaints, whether by lithotomy or otherwise. Again, there are cases, as in children, or very young boys, where, from the very small size of the urethra, or the unmanageable dispositions of the patients, very little can be expected from lithotripsy, or any other opera- tion than lithotomy, which last, in such subjects, fortunately, is almost invariably successful. Upon the whole, it may be stated, that there are many cases, particularly in middle-aged and old people, which may admit of a cure by lithotripsy, if performed before the stone becomes large and the bladder diseased; and, in this point of view, the operation holds out many advantages; for there are hundreds of patients, who, if they could be per- suaded that their complaint, in its incipiency, admitted of relief by a process comparatively easy and free from danger, would willingly submit to it; but who would shrink from lithotomy until compelled by years of suffering to undergo it, and then, unfortunately, with little chance of success. 262 LITHOTRIPSY. Having ascertained the existence of stone in the bladder by accurate sounding, and determined to submit the patient to litho- tripsy, the next proceeding, on the part of the surgeon, is to pre- pare him for the operation, by a regular system of diet, by deple- tion, if necessary,—and there is nothing in the case to contra- indicate the measure,—and by the careful introduction of sounds, catheters, occasionally, in order to accustom the urethra and bladder to the use of instruments, to ascertain the exact position of the stone, its usual location, &c. In using such instruments, however, great care must be taken not to irritate the bladder, and to discontinue them the moment the patient complains; and, upon no occasion to rake the bladder, which cannot be done, even in the most insensible patient, without great risk of inflam- mation of that viscus, and even death. Diet, too, is of so much importance, previous to attempting the operation, as to be, in my estimation, almost a sine qua non, and ought to be strictly en- joined, in some cases, for weeks together, previous to any attempt to seize or break the stone. With most patients, I find a dish of black tea and a bit of dry bread for breakfast, and the same for tea, with boiled rice for dinner, together with a quart of bar- ley-water, (to which may be added, if required, a small quantity of cream of tartar to keep the bowels soluble,) in twenty-four hours, amply sufficient to support any ordinary adult, and admi- rably adapted to lessen irritability, keep down inflammation and soothe the urinary passages. By steady perseverance in these measures, almost every patient can be brought into a proper state to undergo the operation with fair prospect of success; but extraordinary vigilance is sometimes necessary to guard against irregularities and deviations, and to prevent a patient from de- ceiving himself as well as the surgeon. In this country, above all others, where food is so abundant that even beggars live luxuriously, and where the idea is so prevalent, among all classes, that strength is necessarily associated with plentiful sup- plies to the stomach, it is extremely difficult to persuade patients that they can go wrong in gormandizing. Unfortunately, in too many instances, they find out their mistake too late, and the sur- geon discovers, to his great mortification, that he has been de- ceived and trifled with.* * There is no establishment so much wanted in this and other large cities as a "maiso?i de sante," where patients, especially those from a distance, LITHOTRIPSY. 263 As an important preliminary to the operation, a firm, thick mattress, and several substantial pillows will be required, the former for preserving the patient in the most easy and comfort- able posture, and to prevent him from being overheated, which is so apt to be the case when smothered in feathers, the latter for elevating the pelvis to the requisite altitude, by which move- ment the stone will have a natural tendency to subside towards the fundus of the bladder, the only position in which it can be seized conveniently. Some surgeons, Heurteloup, in particular, recommend an arm-chair or a kind of sofa, for the patient to lie upon during the operation; but, independently of the trouble of carrying such a machine from house to house, more or less alarm is always created in the mind of the patient by such a formi- dable array in the shape of an apparatus, and as, in reality, there is no necessity for any but the most simple means, such as are within the reach of the surgeon in most families, he should avail himself of them with as little parade as possible. A time having been appointed for the operation, the patient should be enjoined to suffer the urine to collect in his bladder from two to four hours previously, and, upon no account, to permit any of it to escape. But some patients cannot retain their urine beyond an hour, or even so long a time. In that case, a gum elastic or silver catheter may be introduced, and the bladder injected with tepid water, by means of a syringe or gum elastic bag—taking especial care not to employ force or to distend the viscus too suddenly, or to throw in so large a quantity as to give the pa- tient pain, otherwise spasm of the bladder may follow, and a train of other alarming symptoms. If possible, it is best to dis- pense with the injection, inasmuch as the introduction of the catheter always renders it more difficult to pass any other instru- ment immediately afterwards. As a general rule, too, I would remark that the best period for the operation is in the morning, before the patient quits his bed; for I have almost invariably ob- could be subjected to a regular system of dietetic discipline. The boarding- houses, even the best of them, are unfit for invalids, and the respectable ladies who often keep them are too poor and too badly compensated to give the neces- sary attention to the sick. And as to nurses, they are often worse than useless, or only prove beneficial by consuming the deliacies, tit-bits, and potations in- tended by officious and foolish friends for their sick brethren. When will boarding-house ladies, moreover, divest themselves of the silly and pernicious idea, that by restricting the diet of invalids, they will incur the reproach of starving them for mercenary purposes, and thereby hurt the credit of their establishments? 264 LITHOTRIPSY. served, particularly in winter, the moment the patient rises and w7alks about his room, that there is a tendency to spasm about the neck of the bladder, and that an instrument cannot then be so readily introduced as it might have been a few moments before. These preliminaries having been settled, an assistant places one or more pillows beneath the patient's pelvis, another under his head and shoulders, and while the thighs are relaxed and brought nearly together, the body lying parallel with the bed and along its edge, the surgeon standing on either side or in front, having well oiled the lithotripteur, introduces the beak of it (the blades closely approximated) into the urethra, and by slow but decided movement causes the instrument to glide along the passage, to which its own weight partly contributes, as far as the triangular ligament, which it is known to have reached by the slight resistance met with, and then by depressing the handle gently between the thighs, the point starts suddenly forwards over the prostate gland and enters the bladder. In general, the introduction is effected immediately, but in some cases diffi- culties are experienced, arising, there is reason to believe, from the difference in the conformation of different patients, from some being more irritable than others, so that spasms are induced, or from rudeness or violence on the part of the operator, or from his being too sudden and rapid in his movements, from an over- anxious desire of aiming at feats of dexterity. If any such diffi- culties should arise, it is better not to persevere by forcible en- deavours to overcome them, but to postpone the operation to a future period. Should a stricture, either spasmodic or perma- nent, exist in the urethra, the surgeon must previously get rid of that before he ventures upon lithotripsy. The lithotripteur having been introduced, is not to be carried about roughly from side to side, or fore and aft, for the purpose of raking after and suddenly hunting up the stone, but should be carried very slowly and gently towards the fundus or most dependent part of the bladder, and by the slightest touches with the heel of the instru- ment, an attempt made in various situations from right to left, or vice versa, to detect the foreign body. During these manoeuvres, there should not be the slightest whisper in the room, or complaint, if possible to avoid it, on the part of the patient. An expe- rienced hand and an accurate ear will soon detect the stone, and be able to say by the peculiar sensation communicated through LITHOTRIPSY. 265 the vibrations of the instrument, whether the stone be rough or smooth, large or small, hard or soft, whether there be more than one stone, &c. However, cases now and then present themselves in which it is not so easy to feel the stone at once, and determine its cha- racter and position. This may be owing to a variety of circum- stances. The patient may be uncommonly irritable, spasm of the bladder may be induced, by which the urine is forcibly driven from the bladder along the urethra and instrument, or there may be an hour-glass contraction of the bladder, the stone being in one part and the instrument in the other, or the stone may be encysted, or may lurk under the prostate, or there may be naturally uncommon width in the lateral diameter of the bladder, or the rectum may project on one or both sides of the bladder, compress it and destroy its shape, or hemorrhoids or hardened feeces produce a corresponding alteration in its figure. Under these and other trying circumstances, the surgeon should never forget that the longer he gropes about, and the more determined he is not to be foiled, the greater will be his chance of failure. "Nullum numen abest si sit prudentia," should be his motto, and the sooner he acts upon it by withdrawing his instruments, the better. But suppose, on the contrary, that none of these dif- ficulties have been encountered; that the stone has been readily felt, without giving the patient much pain; that the instrument may be readily manoeuvred in the bladder, then the next object in view will be to loosen the blades of the lithotripteur, by turn- ing the tripod or handle of the vice, cautiously opening the claws by pushing back the male rod, and then endeavouring by short, sudden, but gentle lateral movements, with the heel of the in- strument, on the floor of the bladder, to pass the gutter of the fe- male rod beneath the stone, the situation of which, with respect to this part of the instrument, may be readily ascertained by de- pressing occasionally the male rod. It is astonishing with what facility, in some cases, the stone, by a slight lateral movement, may be shuffled into the jaws of the lithotripteur, so much so that the first attempt, sometimes, in the hands of a dexterous surgeon, will suffice for this part of the operation. Having secured the stone within the grasp of the forceps by quickly, but gently, pushing downwards the male rod, the surgeon next turns the tri- pod with one hand while he steadies the instrument with the other, and gradually strains upon the stone until he feels or hears 266 LITHOTRIPSY. it crack beneath the pressure of the serrated claws in which it is embraced. Soft and friable stones give way quickly under mo- derate pressure, and where no strain is perceived upon the tripod; hard and flinty stones, on the contrary, crack with a sudden jar or snap, and splitting asunder quickly, make a report like a dis- tant smack of a whip, while the tripod is suddenly loosened, but generally resumes its hold upon the remaining portion of the calculus. There are some calculi, however, too hard and solid to be thus broken by graduated pressure; and if the sur- geon, not aware of this, and possessing but little mechanical tact, or skill, should apply inordinate force to his screw, the beak of the male rod might be broken off, or so sprung as to prevent it from being disengaged readily from the stone. In such a case, then, instead of straining upon his instrument, in the vain hope of smashing the stone, the proper course to pursue is to loosen the tripod, and by gentle taps with a hammer upon the bowl on the summit of the male rod, to fracture the stone or quarry it. But let it not be supposed that such an exploit can be safely per- formed while the lithotripteur is merely held in the operator's hand. The percussion, in that case, would necessarily extend to the walls of the bladder, and might be followed by disastrous effects. Fortunately, these are readily guarded against by a vice (lined with lead, adapted to the shoulder of the female rod, and held by the surgeon and assistants,) admirably calculated, in every respect, to fulfil the purpose for which it was designed. Having broken the stone, either by graduated pressure or by per- cussion, the surgeon next closes his instrument and opens it re- peatedly, while, at the same time, he moves it quickly from side to side to crush and wash out any small fragments that may pro- ject from the edges of the groove, and might wound or lacerate the neck of the bladder and urethra in the act of withdrawing the instrument from that viscus. If he has reason to believe that by these manoeuvres, the fragments have not been gotten rid of, he may generally accomplish his purpose completely, by slight strokes of the hammer in the manner already directed. After this, the sooner the lithotripteur is removed from the bladder the better, and the shorter the time the surgeon has taken to perform the operation, the greater will be the chance of success. In gene- ral, by the time the operation is completed, there is an urgent desire, on the part of the patient, to let off his urine; but it seldom happens that large fragments come away in the first passage of LITHOTRIPSY. 267 the urine. In general, only a few small pieces are observed, together with a little sand, and now and then a few drops of blood, produced by the pressure of the shaft or fulcrum of the in- strument on the neck of the bladder. It is not desirable, indeed, that the fragments should come away until the soreness of the urethra has passed off, and, fortunately, most patients have the facility of detaining them by lying on their side, and not empty- ing the bladder completely at each time of evacuating, but al- ways retaining a small portion of urine. In a day or two, how- ever, they begin to present themselves at the neck of the blad- der, where they remain a short time, exciting more or less un- pleasant feeling, and are then suddenly carried forward and bolted out before the patient is aware of it. In this way, one after ano- ther, fragments may pass in rapid succession, and in a few hours amount to a large collection, the soreness gradually passes away, and after the lapse of five or six days, the patient is prepared to undergo another operation. Such, however, is not the invariable result of an operation for lithotripsy, for although the surgeon may have been abundantly successful in breaking up the stone, and may have been extreme- ly rapid and dexterous in his operation, and communicated as little irritation as possible, still the bladder is very prone to re- sent any offence, even the slightest, that may have been offered to it, and will vent its displeasure on the surrounding and even distant parts. Hence, a few hours after the operation, or, in some cases, in a day or two, a chill is induced, followed by fe- ver, profuse perspiration, spasms of the bladder, &c, or these symptoms may have been brought about by the lodgement of a fragment in the urethra. The best course to be pursued, I think, in this state of things, is to bleed the patient as soon as the fever has come on, to administer an opiate injection occasionally, to restrict the diet within the closest bounds, and not to permit the patient to get out of bed—a rule, indeed, which the lithotriptist would do well to observe after each operation, whether any bad symptoms show themselves or not. If a fragment has lodged about the neck of the bladder, and seems disposed neither to re- tire nor advance, the best plan is to push it back into the blad- der by a large catheter or sound; if it has advanced within a few inches or a short distance of the external orifice of the urethra, then it may be got away generally by a bent probe, by a pair of urethra forceps, or, still better, by the curette of Leroy— 268 LITHOTRIPSY. a most ingenious little instrument, admirably adapted to this and many other purposes.* When the irritation has entirely passed away, which gene- rally happens in four or five days, or, at furthest, a week, the surgeon renews his attempts to seize and destroy the stone, in the manner already described; but, as each operation generally becomes more difficult in proportion as the stone is diminished in size, owing to the greater difficulty of feeling a small foreign body than a large one, it will be proper to detail certain expe- dients which may be resorted to advantageously in most in- stances. The course to pursue, then, under such circum- stances, is to introduce the lithotripteur, and having reached the fundus of the bladder, to retract the male rod for half an inch and upwards, and fish about from side to side, or in various di- rections, with the groove of the female rod, and, by so doing, the operator will be very likely to collect one or more fragments, the presence of which can be readily ascertained by closing occasionally the jaws of the instrument, crushing the fragments, and then again expanding and making further search, until all the pieces that happen to fall within the gutter of the lithotrip- teur are completely broken up or pulverized, and may after- wards be thrown off by the action of the bladder. It is a leading principle, indeed, now, with all lithotriptists, to reduce the fragments by successive attempts, to the smallest compass, so as to facilitate their passing off quickly, and with the least possible risk of irritating, or tearing the urethra; and fortu- nately the bladder, in most instances, seems to understand the sur- geon's views, and is abundantly disposed to second them. But, in other cases, in old and debilitated patients, especially, there is sometimes so little power in the bladder, that it does not con- tract sufficiently to expel the foreign bodies which may have been broken up into numerous pieces, and by accumulating, may still keep up irritation, or in time, by the conglomeration and matting together of particles, lay the foundation of another stone. This was one of the strongest objections, some years since, both * " Elle est formee d'une canule plate, a l'extremite de laquelle est. fixee par une charniere une petite plaque creusee comme un cure-oreille. Son ar- ticulation avec la canule a lieu de telle sorte que, depassant un peu en arriere, elle forme un talon sur lequel est fixee une tige qui par court toute la longueur de la canule, et se termine par quelques pas de vis; suivant que cette tige est poussee ou tiree, la curette se coude ou se redresse."—De La Lithotripsie, par Leroy d'Etiolle, Paris, 1836, p. 300. LITHOTRIPSY. 269 to lithotrity and lithotripsy, so much so, that it was customary at that period to recommend lithotomy in patients thus situated, rather than either of the other operations. By the ingenuity of Heurteloup, however, this difficulty has been in a measure obvi- ated, by means of the " evacuating sound," an instrument of pe- culiar construction, and exceedingly well calculated to collect and bring away, without annoyance to the bladder and urethra, fragments of considerable size, as well as the sand, or debris, which accumulates, in such quantities in the hollows and certain rendezvous met with in most bladders. But, fortunately, there is another circumstance, independently of the advantage to be derived from the instrument referred to, which may serve to console patients in whom the power of the bladder to expel the urine with its accustomed force is diminished or destroyed— that there is reason to believe, in certain cases, that soft and friable stones are susceptible of solution in the urine, and are re- moved in the shape of sand or mud, mixed with slime and other matters. Heurteloup speaks of cases of the kind, and one of this description, I am very sure, has occurred in my own practice. I do not pretend, in this communication, to give more than a sketch or outline of lithotripsy, illustrated by a few cases; and if what I have said shall answer the purpose of drawing the atten- tion of the American surgeon to the operation, or clearing up the doubts of some and confirming the sentiments of others, my labour will not be in vain. It has been said, and is even now often reiterated, that I have decried the operation. This is a great mistake. I have never condemned lithotripsy; but have always doubted of the perfect success of " lithotrity," so far as the great mass of operators is concerned. In this text-book, v years ago, and in lectures, I have spoken of the original idea of destroying, by instruments, stone in the bladder, as a most inge- nious and beautiful one—have said that the time would come, when such instruments would be so modified and improved, as to deserve the highest commendation, and that the operation would become an established one, though it would never supersede, in toto, lithotomy. Have not my predictions been verified? Have not the most disastrous consequences followed lithotrity, even in the hands of Civiale himself, the prince of lithotritists, whose magic powTers are still unequalled and can never be surpassed in his particular line, and in the management of his own toolsl VOL. ii.—s 270 LITHOTRIPSY. Is not lithotrity now spoken of in Europe, constantly and with- out reserve, as the "old method," the "ancient operation?" That more or less of the same difficulty, though never, I trust, to the same extent, will attend lithotripsy, I have no doubt; that pa- tients will be subjected to the operation who are unfit for it; that mistakes will be committed by the inexperienced and ad- venturous; that the most wary and prudent operators will be baf- fled, and foiled, and deceived in their expectations, partly from perverse and obstinate patients, partly from neglect of those about them, and partly from the complicated nature of cases which no human wisdom could foresee, I am prepared to believe and admit.* But " Quia non omnes convalescunt idcirco nulla igi- tur est medicina," is a maxim of sound sense and truth, which should never be lost sight of—which will apply, now and then, to every operation in surgery, and to every medical case, from the most complicated to the most simple. Before proceeding to detail the cases of lithotripsy in which I have been engaged, and from which most of the foregoing re- marks have been derived, I purpose to make a few comments upon the instrument of Jacobson and to compare it with that of Heurteloup ; in so doing, however, I beg leave to declare that it is not my intention to unfurl the banner of opposition on the one hand or to be led captive on the other, but "to render unto Caesar the things which are Caesar's." One advantage at least, an American possesses over Europeans, amidst their contro- versies concerning inventions, improvements, discoveries,—that he can be impartial. Of Heurteloup, personally, I know nothing; of Jacobson nothing; of French and English lithotriptists, and anti-lithotriptists, their politics, parties and squabbles and acade- mical debates, with few exceptions, I know and care, if possi- ble, still less. With their instruments I am well acquainted, and equally wrell disposed to give them all the credit, in my poor judgment, they deserve. * In a letter lately received from my friend John Green Crosse, Esq., a dis- tinguished surgeon of Norwich, in England, it is remarked, "The use of litho- tripsy, as a substitute for lithotomy, is rather fading here. We hear less and less of the practice; it is, however, a most valuable resource in certain cases, and in dexterous hands; though by no means possessing the recommendations which some have represented, of being suitable to provincial su rgeons of small experience. These can, I think, better lithotomize than lithotrize, and nu- merous fatal instances from the latter method, under their hands, have come to my knowledge in this district." LITHOTRIPSY. 271 Jacobson1 s instrument is an ingenious and beautiful one; ex- tremely simple; remarkably strong; not too bulky; of the best form, seemingly, for easy introduction; readily withdrawn if any part of it should give way; better adapted, as regards facility, than any other instrument to catch and enclose a small stone and when seized, of great power to break it; and upon the whole, well calculated, apparently, for success. But withal, it is a dan- gerous weapon; for the natural tendency of the closing of the loop, or zigzag chain, which binds upon the stone, in the act of demolishing it, is to drag the folds about the neck of the bladder and prostate into the embrace of the steel rods, when they emerge from the mouth of the cannula, and to pinch them to excess. Nor is this all—the irregular loop, full of small angularities; the numerous joints, and rivets, and dove-tails; the prominent knots, and depressions, about each hinge; the inaccuracy and uncertainty, and lateral irregularity of the closing of the different joints; the long line of loop, turning from stem to stern along the perpendicular edges which frown from the serrated flat lining the interior of the chain; so well calculated to rake and harrow the plain surface of the bladder; so unadapted to descend into the nooks and hollows; to pass beneath the overhanging bank of the prostate; to enter into a cyst, or between the folds of a contracted bladder—together with the impossibility of enclosing a large stone; of the difficulty of picking up very small fragments after the stone has been quarried, and of applying the principle of per- cussion to the instrument, and thereby its inaptitude to very hard stones ; of the certainty of numerous small fragments being drawn into the cannula between it and the chain, so as to render the removal of the instrument from the bladder difficult and painful; to say nothing of the difficulty of fixing the stone securely and of preventing it from shifting from side to side of the instrument in the act of closing the chain; which want of steadiness, in part, arises from the great length of the chain, which gives it a serpen- tine motion when dragged upon, and in part, from the chain not hugging the stone closely over its entire surface, but standing off,—particularly if the stone is flat, as most stones are,—at every part of the loop corresponding to a joint in the chain; and lastly, the complaint of most patients when the loop is expanded in the bladder, and an attempt made to scoop the stone within the bow of the instrument—a complaint so characteristic, that when I passed it upon one occasion, the patient cried out, without know- 272 LITHOTRIPSY. ing the conformation of the instrument, that " I had put a basket into his bladder." These objections are the result of my own observations; I have not hunted European publications to cull them from; I have seen, indeed, but one publication on this particular subject, and from that I will venture to make an extract, as it seems to confirm the view I have taken:—" La decouverte de cette instru- ment, etait precieuse lorsque celui de M. Heurteloup n'existait pas, car on pouvait commencer avec l'instrument a trois branches et continuer avec le brise pierre de M. Jacobson: mais a present il est devenu absolument inutile: l'instrument de M. Heurteloup le remplace toujours: et j'ai prouve, dans le chapitre precedent, que le percuteur peut s'appliquer, avec le moins de danger, et le plus de facilite possible, dans tous les cas ou la lithotritie est practicable; c'est pourquoi il est evident que l'instrument de M. Heurteloup est preferable a tous les autres, et que M. Velpeau a eu tort de choisir l'instrument de Jacobson comme le meilleur. La preuve la plus manifeste de la verite de mes paroles est que cet instrument n'est employe par aucun lithotriptiste connu."* Not to be unjust, however, to Jacobson's instrument, (what- ever my own impressions of it, or those of others may be) it is but fair to state, that it has been employed successfully in this country, in several cases by Dr. Jacob Randolph, of this city, and Dr. Nathan Smith, of Baltimore;! and the inference, there- fore, is plain that it must be an instrument of some merit,—and this I am not disposed to deny, whilst, at the same time, I am in- clined strenuously to contend that the lithotripteur of Heurteloup is a better one—and for the following reasons: 1st. That in ad- dition to its working upon the principle of gradual pressure, it combines the important power of concussion; 2d. That it does not give the patient so much pain, either during the introduction or whilst manoeuvred in the bladder; 3d. That it can grasp a larger stone; 4th. That its beak can descend behind the pros- tate and enter every corner or pocket of the bladder; 5th. That it is extremely well adapted to seek out and pick up fragments; 6th. That it is so constructed as to render it almost impossible to pinch the bladder, even were the surgeon disposed to do so; 7th. That although not so strong, perhaps, as Jacobson's chain, * Sur La Lithotripsie et La Taille, par M. P. Doubovitzki. Paris, 1835. t Both these gentlemen, as I learn, now employ Heurteloup's instrument in preference to that of Jacobson. LITHOTRIPSY. 273 it would be next to impossible, when well tempered, to break it; 8th. That the only inconvenience I have ever experienced from it, is the liability of the groove, in the female rod, to become clogged with sand and small fragments, so as to give the patient pain in withdrawing the instrument—that this, however, is easily obviated, after a little practice, by opening the forceps, and by slight lateral movements, washing out the fragments, and after- wards crushing the remainder by a few taps of the hammer.* One remark, however, may be made in conclusion, and should not be lost sight of, as regards the employment of instruments in general—that almost every surgeon, when once accustomed to a particular instrument, even although that instrument may be an awkward and ungainly one, will perform better with it than another surgeon equally skilled but unaccustomed to it. The modifications of Heurteloup's and other instruments, indeed, are almost endless, and there is scarcely a lithotriptist but has some instrument peculiar to himself. Hence, probably, the great variety of opinions on the subject, and the endless and bitter con- troversies which have been for some time past, and still are, waging among them. Time, the great instructor in all things, will be able " tantas componere lites." Many of the foregoing remarks will be illustrated by the following cases. CASE I. Dr. F.-------, of North Carolina, consulted me on his case in June, 1835, which, in several respects, was a distressing one. He had submitted to lithotomy some months before I saw him; the wound, however, never healed, but remained fistulous, and in a little time the stone made its appearance again, and seemed to be enlarging with rapidity. He had been making attempts, I found to crush it, by means of Jacobson's instrument, but had never succeeded—owing to the severe pains and spasms which followed each trial—in seizing it, or in detaching fragments. I proposed the employment of Heurteloup's lithotripteur, and ex- plained to him its mechanism, with which he was so much pleased as to consent to its introduction a day or two after. So extremely * This difficulty has latterly been overcome by the large window at the ex- tremity of the instrument. 274 LITHOTRIPSY. sensitive, however, was the bladder, and so great his apprehen- sion, that he would not suffer the instrument to be introduced, except in the slowest and most deliberate manner, consuming five or six minutes, frequently stopping its progress with his own hands, and, in fact, almost performing the operation himself. Having at last reached the bladder and felt the stone, I expanded the forceps to an inch and upwards in width, seized the stone and broke off a large piece of it. All this was effected so quickly, according to his ideas of time, as greatly to delight him, and determined him to submit to further efforts to obtain relief. Ac- cordingly, a few days afterwards, another trial took place; and although the operation was performed partly by me and partly by himself, it proved equally successful as the first attempt, and encouraged him to proceed with other trials, at one of which Dr. Hays and other gentlemen were present. After each ope- ration, however, there was always more or less chill and fever; and as the patient's constitution had been greatly impaired by long suffering previous to my having seen him, I was almost afraid, after each trial, to touch him again. In proportion, however, as the fragments were gotten away, (though sometimes by sticking in the urethra they gave him great uneasiness,) his constitution improved so rapidly as to enable us to renew attempts with greater frequency, but always with more or less success. To- wards the end of July, however, I was obliged to leave town, and to take my instruments with me, which put a stop to further proceedings for several weeks. During my absence, the patient had procured an imitation of Heurteloup's litho- tripteur, and assisted by some of his friends, had succeeded in removing other fragments. From that period, during the whole of the last winter, he was engaged in operating on himself, with occasional assistance from myself, and was enabled, by great industry and perseverance, to make in the spring a collection of fragments and sand amounting to 2 3 12 grs. in weight. By this time his health w7as so much improved as to enable him to return to Carolina. Such is the tendency, however, in his particular case, to generate calculous matter, that it is very ques- tionable whether he will not be liable always, to its formation, unless by change of diet, water, and climate, he can effect such a change in his constitution as to get rid of the diathesis.* * This patient, as predicted, had a return of his disease, and died some months after. LITHOTRIPSY. 275 CASE II. At the request of Dr. Tyndale, a respectable practitioner, whom I had the pleasure of meeting during a visit of a few days at the White Sulphur Springs, of Virginia, in the summer of 1835, I saw, in consultation with him, W. T., Esq., of Pittsylvania. Believing, from the symptoms, that the patient had stone in the bladder, I was induced to sound him, and discovered a calculus of considerable size, under which he had laboured, in all probability, for several years. From this and other causes, his health had been long impaired and his constitution had become irritable. In some respects, however, his case appeared to be adapted to lithotripsy, but totally unfit for lithotomy. Having my instruments with me, and wishing to ascertain whether the stone was hard or soft, I prevailed on Mr. T. to submit to the introduction of the litho- tripteur of Heurteloup; and although the bladder had not been fully distended with water, or the patient prepared by diet for the operation, I succeeded in detaching small portions of the stone, which were brought away in the gutter of the instrument, and which proved to be soft and mortar-like, but full of sharp, needle-like points. A slight chill and fever followed this at- tempt; from which, however, after a few days, no inconvenience resulted. I then took leave of the patient, and advised him to repair to Philadelphia the ensuing autumn and undergo the ope- ration of lithotripsy, enjoining upon him at the same time the necessity of regular preparation, by appropriate diet, for several weeks previous to leaving home. Shortly after my departure from the Springs, Mr. T., from eating boiled corn and other un- wholesome articles of food, had a violent attack of cholera mor- bus, and with great difficulty recovered from it. From that period his constitution became enfeebled, and he suffered more than ever from the disease in his bladder, passing occasionally lumps of sabulous matter, like mortar in consistence, but full of so many sharp crystallized points as to create great pain and soreness in passing them. During the whole winter he remained at home unable to set out for Philadelphia; but towards the spring, finding his health somewhat improved, he made the attempt, and arrived, after encountering bad roads and very unfavourable weather, on the 27th of April, 1836, exhibiting great marks of 276 LITHOTRIPSY. fatigue and long suffering, and very much changed in appear- ance since the period I had first seen him. Finding that Mr. T. had been making no preparation in the way of regimen to facilitate the operation of lithotripsy, and to guard against irritation and inflammation, I placed him at once in lodgings, as near to my own residence as possible, in order that I might watch him closely and be with him at a moment's warn- ing in case of difficulty, impressing at the same time upon his land- lord the necessity of the strictest attention to diet, &c. Having consumed nearly a month in subjecting him to dietetic discipline, and dilating the urethra by gum elastic catheters, I commenced regularly, May 24th, with the operation of lithotripsy; introduced Heurteloup's instrument, touched the stone, but could not seize it, owing to the small quantity of urine contained in the bladder, but which, notwithstanding, the patient informed me, had been collecting for several hours. From this operation no incon- venience followed, and the patient was ready on the 26th for another trial. The lithotripteur being introduced, the stone could not be felt, owing to the small quantity of urine contained in the bladder. To obviate this difficulty I withdrew the instrument, injected the bladder with tepid water, again introduced the litho- tripteur, seized a portion of the stone, which readily crumbled beneath the pressure exerted upon it, and brought away small mortar-like fragments. Other pieces of similar appearance were discharged along with the urine in the course of the day. To facilitate the seizure of the stone upon this occasion, I found it necessary to introduce a finger into the rectum, and raise the stone from the fundus of the bladder, or the bed, or cyst, into which it had been accustomed, as I had reason to believe, to lurk. Four hours after the operation the patient complained of having a slight chill; this- continued for an hour, and was fol- lowed by a little fever. The^e symptoms, I thought, might be attributed in part to the weather being uncommonly cold, raw and damp, from the continued prevalence for some time of easterly winds. Towards night the constitutional symptoms passed away, and the only complaint the patient made was of unusual soreness along the urethra, which I accounted for by the passage of the mortar-like substance, armed with its crystal- lized points. Upon visiting the patient next day, (27th,) I found him com- plaining of desire to evacuate urine every twenty minutes, and LITHOTRIPSY. 277 of a discharge of ropy mucus of yellowish tint. These symptoms continued throughout the day, more or less, and were unabated on the next day, (28th,) which induced me to order the hip-bath and 30 drops of black drop, and a weak opiate injection per anum. Under the influence of these, Mr. T. slept soundly until 3 o'clock, P. M. During the afternoon, however, more or less of drowsi- ness continued, and the desire to make water had nearly ceased, and so remained throughout the night, but in the morning (26th) returned with its former urgency. To combat this as soon as possible, the opium was again resorted to, both in form of injec- tion and black drop, internally. In the afternoon, also, an aloe- tic pill was administered, and a blister applied to the sacrum. Under the influence of these the patient passed a good night almost undisturbed by spasms. On the next morning, (30th,) the desire to pass urine, accompanied by spasms, returned and continued all day, at intervals of fifteen or twenty minutes. At five o'clock P. M., a suppository, consisting of three grains of cicuta and two of opium, was administered. At eight o'clock, P. M, the pulse, for the first time, became full and bounding, owing to too much nourishment (consisting chiefly of raw oys- ters) having been taken, and to the room being filled with the gas of anthracite coal, which is as deleterious in its operation as that of charcoal. To remove these symptoms, the patient was bled to ten ounces. Notwithstanding the bleeding, the pa- tient passed a restless night, and on the next morning (31st,) the spasms returned with more violence than ever. In the course of the afternoon, a laxative enema was administered two or three times, and produced copious evacuations. At 3 o'clock, P. M., it became necessary, on account of frequency of alvine discharges, to administer an opiate enema. This checked the diarrhoea and spasms for the night, but in the morning (June 1st,) the spasms returned again, and continued with more or less violence through- out the day. Various remedies, besides the opiates and other means detailed, were tried ineffectually, and, although the symp- toms varied from time to time, the spasms and pain in passing urine were the prominent ones, and came on at last with such violence, and at such short intervals, as to prostrate the patient beyond the possibility of recovery. Two days afterwards (June 3d) he died. Permission could not be obtained to examine the bladder and its relations, a circumstance much to be re- gretted, especially as lithotripsy is still in its infancy and requires 278 LITHOTRIPSY. all the light that can be shed upon it. But, although denied the opportunity of examining the condition of the bladder, and of ascertaining positively the cause of death, there are several cir- cumstances connected with the case exceedingly well calculated to unravel a part of the mystery. From the history of it I have detailed, it will be seen that extraordinary pains were taken to prepare the patient for the operation, by restricting his diet in every possible way—by confining him to his room, and by the use of instruments calculated to enlarge the urethra and accus- tom it afterwards to those to be employed for the destruction of the stone. Unfortunately, however, the interesting sufferer was not aware of his own danger, and with the best possible inten- tions, in deceiving me in wThat he supposed to be little matters of no moment, he deceived himself, and led to results which I am very confident would not otherwise have followed. Instead, then, of attending strictly to the regimen I had prescribed, (as I have since ascertained from the best authority,) instead of living entirely on barley-water, black tea, dry bread, and rice, and avoiding altogether animal food during the entire month of preparation preceding the operation, his meals were taken with the family with which he lived, and every article on the table he happened to fancy freely indulged in. This course, together with undue exercise, either in his room or abroad in the streets, was calculated, as I am sure every experienced surgeon will admit, to produce the worst effects, especially in a patient ad- vanced in years, of irritable constitution—one who had long suffered from violent attacks of other diseases—whose bladder had been thickened and contracted by the lodgement, for years, of a large stone—whose kidneys, in all probability, were also diseased, besides other organs, more or less important in the animal economy. I trust it will not be supposed that I men- tion these facts by way of exculpation or for the purpose of casting a veil over any errors I may have committed. Those who know me, I think, will acquit me of such intentions. Nor would I have it supposed that I am casting unjust and unneces- sary censure upon the respectable patient for whom I felt the highest personal regard and respect, and in whose case I took the most sincere and lively interest. My only motive in detail- ing such circumstances, is the public good, and for the benefit of those who may be now engaged in treating similar cases, or who may do so hereafter; for there is nothing more likely, than LITHOTRIPSY. 279 that patients similarly situated with Mr. T., who, (from having always been accustomed to plentiful and luxurious living—to all the comforts and delicacies of life,) will not voluntarily re- frain from such enjoyments, especially if they can persuade themselves that the indulgence in them cannot interfere, mate- rially, with their complaints and the mode of treating them. CASE III. At the request of Dr. Joseph G. Nancrede, I saw, in consul- tation with him, in April, 1836, Mr. Charles O'H., sixty-three years of age, who, for the last few years, had led a sedentary life, and complained latterly of symptoms of stone in the bladder. Upon sounding the patient, a stone of large size was distinctly felt, both by Dr. Nancrede and myself, and the case pronounced, in every respect, suitable for lithotripsy. The patient having consented to the operation, was accordingly prepared for it, by being placed on a diet of rice, barley water, and black tea; very little time, however, was required for this purpose, inasmuch as he had abstained, for some time previously, from animal food, by advice of Dr. Nancrede. On the 1st of May, I commenced the operation in presence of Dr. Nancrede, and Dr. J. Y. Hollingsworth of Maryland, by introducing a large silver catheter, and injecting the bladder with tepid water, until the patient complained of uneasiness from a sense of distention. The catheter was then withdrawn, and the lithotripteur of Heurteloup introduced, but the stone not felt until the patient turned a little on his side; I then perceived it to roll over the instrument heavily, which convinced me, at once, that it was large. Upon placing the patient on his back, and elevating his hips with pillows, the heel of the lithotripteur came in contact with the stone, which was readily seized, (though not until I had expanded the blades of the instrument beyond an inch and a quarter,) and by a few turns of the tripod, broken it into several large fragments, the cracking of which, as they were rent asunder, could be distinctly heard. During these manoeuvres the patient remained perfectly still, experi- enced not the slightest uneasiness, except that arising from over- distention of the bladder, and was conversing cheerfully, during the whole operation, which did not exceed in duration five mi- 280 LITHOTRIPSY. nutes. Upon withdrawing the lithotripteur, and directing the patient to stand up and evacuate his urine, numerous small frag- ments were discharged, besides those contained in the blades of the instrument. The catheter being again introduced, and the bladder injected, other fragments were brought away. Neither, pain, chill, nor fever followed the operation; the frag- ments, in small quantity, continued to pass away, but not with as much rapidity as if the muscular powrers of the bladder had been greater. On the 16th of May, I repeated the operation in presence of Drs. Nancrede and Horner, seized, without difficulty, fragment after fragment, and fractured them, without giving the patient any pain whatever, except upon withdrawing the instrument, which, from being a little clogged with pieces of the stone, pro- duced slight irritation at the external orifice of the urethra. No constitutional disturbance followed, and the patient, as hereto- fore, passed again small fragments. May 19th, in presence of Drs. Nancrede, Hays, Caldwell, and Bush of Kentucky,—Cabell, of Virginia, and several medical students, I renewed my attempts upon the fragments of Mr. O'H.'s stone, with the success I had hitherto met, and without the operation having been followed by a single unpleasant symp- tom. Fewer fragments, however, than usual, passed away, im- mediately after the operation, and for several succeeding days, owing to continued inactivity of the bladder, or want of muscu- lar power. 24th, in presence of Dr. William Crump, a distinguished phy- sician of Powhattan County, Virginia, Drs. M'Crea, Stewardson, Pennebaker, Smith, Mr. W. Tunstall, of Virginia, and many me- dical students, I performed upon Mr. O'H. the operation he had, upon former occasions, undergone. Previous to commencing it, however, it was necessary to remove a fragment from the urethra, which lodged about an inch beyond the glans, and was easily removed by a bent probe. Several of the fragments in the blad- der, notwithstanding the former operations, measured, by the graduated scale, half an inch, and even three-quarters. These were distinctly heard to crack, by several of the gentlemen pre- sent, under the pressure of the tripod. This, like the former operations, was followed by no unpleasant occurrence. 29th. (Drs. Nancrede, W. P. Johnson, and J. Wallace being present,) I performed lithotripsy for the fifth time on Mr. O'H., LITHOTRIPSY. 281 and without injecting the bladder, seized upon fragment after fragment, and instantly reduced them to pieces so small, that scarcely a particle could be caught larger than a quarter of an inch, though, in the commencement of the operation, two or three fragments, exceeding half an inch in size, were met with. As usual the patient bore the operation without a murmur. Seve- ral fragments and a good deal of debris came off in the blades of the forceps. But several days elapsed, after this operation, before any pieces of consequence were discharged with the urine. Early in the morning, however, on the 1st of June, I was sent for to remove a fragment that locked up the urethra near the neck of the bladder, which I thought best to push back with a catheter. June 12th. Accompanied by Drs. E. Peace, and W. P. John- son, I again visited Mr. O'H., introduced a large silver catheter and drew off a small portion of urine, which the patient could not expel by his own efforts, injected the bladder with tepid water, and introduced the lithotripteur of Heurteloup, with a view of crushing any fragments that might remain, but, much to my sur- prise, found that none could be detected; not satisfied, however, with this examination, I determined to explore the bladder with the common sound; but still with the same result. This was accounted for by examination of the bottle containing the dis- charged pieces, which had accumulated since the last operation, (May 29th,) so considerably, as to add largely to the portions previously expelled, and which, taken collectively, from first to last, would have been sufficient to form a stone of the size of a walnut, and one much larger might have been formed, if the patient had taken pains to collect all the pieces—but owing to inaccuracy in this respect, a great deal of sand and numerous fragments, there is reason to believe, must have been lost. As usual, no inconvenience resulted from this examination; but, four days afterwards, (June 16th,) I was sent for, early in the morning, to visit the patient, who felt alarmed at the idea of a fragment being lodged in the urethra; such, however, upon passing the instrument, I could not discover, and, therefore, con- cluded that irritation had been created by the patient having changed his diet too suddenly, after having been told that he was nearly rid of his calculus. Upon this occasion, indeed, I found him over a large bowl of coffee, and surrounded by piles of bread and butter. By directing him to resume his tea and 282 LITHOTRIPSY. barley-water, all uneasiness about the bladder and urethra dis- appeared in a few hours. On the 20th of June, I paid him ano- ther visit, and found him complaining of slight tenderness in one testicle and a pricking sensation in the urethra. Suspecting the lodgement of a fragment, I introduced a pair of small for- ceps and extracted a piece about a quarter of an inch in length. In the presence of my friend, Dr. Norcom, an eminent phy- sician of North Carolina, Dr. Chase, Dr. Nancrede, and Mr. Schively, I repeated the operation to-day, (June 29) on C. O'H., by injecting the bladder, introducing the lithotripteur, and searching for the stone; but, after moving the instrument in every direction, within the bladder, I could not touch a frag- ment. The lithotripteur was withdrawn, and the patient rose and passed his urine. It then occurred to me, that by sounding the patient with the bladder empty, I might be able to feel the stone and crush it. Upon so doing, accordingly, a fragment about half an inch thick, was distinctly felt, and almost imme- diately seized and demolished. Another was also caught, and as readily destroyed. In the groove of the instrument, as usual, portions of mortar-like matter were found. Fully con- vinced, from the accurate examinations made at different pe- riods, that the fragment destroyed to-day was the only one the bladder contained, I felt very confident that the patient would soon be entirely rid of his complaint. For the last eighteen months he has been perfectly well. CASE IV. H. M., of Virginia, thirty-four years of age, arrived at Phila- delphia on the 29th of April, 1836, and consulted me on his case, which in some points of view was a singular one. Ac- cording to the patient's statement, a persimmon-seed had been introduced into his urethra, and found its way into the bladder, where, in all probability, it had served as the nucleus for a stone: for, in a short time after, symptoms resembling those of stone were manifested. Upon sounding the patient, I discovered a calculus of small size, and, judging from the feel communicated to the sound—of soft consistence. Anxious to undergo litho- tripsy, or lithotomy, if I preferred it, he was placed, at once, LITHOTRIPSY. 283 upon appropriate diet, directed to drink plentifully of diluents, and while pursuing this course, had the urethra dilated with bougies, catheters, &c. After persevering in this system for three weeks, the patient became extremely desirous of submit- ting to the operation itself, and, as he possessed considerable mechanical skill and ingenuity, and had examined with great curiosity the instruments for lithotripsy, expressed a decided preference for that of Jacobson. To gratify him, therefore, it was employed, and with the utmost caution and gentleness, attempts made to seize the stone; but, so great was the irritation, and so severe the spasmodic action of the bladder, induced by its presence, that it appeared to me it would have been forcibly expelled from that viscus. I was obliged, therefore, to with- draw the instrument, after the lapse of a few seconds. This attempt was followed by severe chill and fever, which confined the patient for several days. On the 26th of May, I commenced regularly with Mr. M., and, at his request, again employed the instrument of Jacobson, notwithstanding the suffering it had previously occasioned him. Accordingly it was introduced,' but created so much pain and inconvenience that he peremptorily demanded its removal. Upon withdrawing the instrument, the urine which had been retained three or four hours, escaped, and rendered it necessary, before proceeding further, to inject the bladder with tepid water. After this, the lithotripteur of Heurteloup was introduced, and the stone almost immediately seized and crushed under the pres- sure of the tripod or screw—creating a sound similar to that of chalk, when broken between the fingers. In the groove of the instrument, numerous small fragments were found, and, in the course of the day, several large pieces discharged along with the urine, some of which were encrusted with a dark browrn or black skin similar to the husk of a persimmon. The stone, as I had predicted, was of rather soft consistence, and apparently composed of the ammoniaco-magnesian phosphate. Before the completion of the operation, the patient suffered a good deal from pain and spasm of the bladder, but these soon ceased, and were not followed, as in the former attempts, by chill and fever. Two days (May 28th) after the operation, however, the pa- tient complained of great pain in the urethra, and was suddenly relieved by the discharge of a large fragment, in the centre of which was a hollow or depression, corresponding in shape and size with a persimmon-seed. 284 LITHOTRIPSY. On the 29th, another fragment was discharged, but, as no other made its appearance from that period until the 6th of June, I introduced on that day, in the presence of Dr. Saltmarsh, the instrument of Heurteloup, and used it as a sound, but could not detect any portion of stone. However, the next day, (June 7th,) a fragment half an inch long, and hollowed out in the centre, passed off with the urine. At the same time, a portion of black skin resembling the rind of a persimmon was thrown off. On the 9th of June, the lithotripteur was introduced, but without detecting a fragment. The same operation was repeated four days after, (June 13th,) in presence of Drs. Johnson and Peace, but with no better success. Having experienced no incon- venience from the last two examinations, another was made (June 17th) in presence of Dr. Saltmarsh, and a fragment about the size of a bean felt at the fundus of the bladder, which was readily caught and crushed. In the course of the day, three oblong fragments, a quarter of an inch thick, passed away with the urine. With the view of ascertaining whether other frag- ments still remained in the bladder, the lithotripteur was again introduced, (June 20th, Dr. Saltmarsh being present,) but nothing could be felt. Soon after this examination, the patient changed a pair of cloth pantaloons for thin ones, and walked about the streets for some time, and, w7hen he returned to his lodgings, was seized with chill, followed by a high fever, which rendered it necessary to bleed him and restrict his diet more than ever. Since that period he has been confined to his room with sore throat, cold and more or less fever, which, for the present, pre- vent the operations from being continued. That any fragment of stone remains in the bladder, seems to me extremely doubt- ful ; it is more than probable, however, that the persimmon-seed is still there, inasmuch as no portion of the substance of the seed has yet been discovered, and, as he complains, after passing urine, of something presenting itself at the neck of the bladder. Whether the lithotripteur will be able to destroy the texture of such a substance,—which closely resembles softened horn,—I am at a loss to say. In truth, until I saw the pieces of black skin discharged along with the fragments, I did not believe that such a foreign body had found its way to the bladder, and had placed the patient's account of the mode of its getting there to the effect of imagination. On the 28th of June, the patient having recovered, in a great LITHOTRIPSY. 285 measure, from the effect of his cold, another examination was made with the lithotripteur, but smaller in the shaft and shorter m the beak than the one commonly employed. This did not enter with facility, but met with considerable obstruction at the neck of the bladder; it finally started forward, very suddenly, and was completely introduced. Some hours after, the patient discharged, along with the urine, more or less venous blood, the result, no doubt, of the pressure of the short-beaked instrument upon the prostate and neck of the bladder. To-day (June 29th) the urine is colourless and the patient free from soreness in the urethra, and, as the weather is becoming warm and oppressive, and he complains of being weakened and reduced, I have ad- vised him to postpone further operations for the present, and retire for a few weeks to the country. In the following autumn he returned to town and submitted to two or three more opera- tions, and was soon perfectly cured,—by the removal of the per- simmon-seed—and has remained so ever since. case v. P. P., Esq., about forty-eight years of age, of literary and se- dentary habits, troubled more or less with dyspepsia, came to Philadelphia in 1835, by advice of my friend, Dr. Thomas, a distinguished physician of Westchester, to consult me about symptoms resembling those of stone in the bladder. His en- gagements, however, at that period, were such as to prevent him from being sounded, and from remaining in town. About the middle of May, 1836, he returned to Philadelphia, and upon sounding him I discovered a stone, and concluded from its ring- ing distinctly when struck by the sound, that it was a hard one. Believing the case adapted to lithotripsy, I advised the opera- tion, placed him in suitable lodgings, and commenced a system of diet, which, indeed, he himself had been observing, in a mea- sure, for some time before, having anticipated the necessity of such a course. After using, also, gum elastic and other instru- ments to familiarize the urethra with such guests, I commenced the regular operation, (May 21,) by introducing Jacobson's in- strument, which, however, gave excessive pain, brought away blood, created severe chill and fever, and rendered the patient so ill, as to induce me to advise him to return to the country, VOL. II.— T 286 LITHOTRIPSY. after the symptoms had abated, and remain until he recovered sufficiently to undergo a trial with another instrument. Accord- ingly, he left town on the 26th of May, and returned on the 4th of June, improved in appearance and health. On the 8th of June, I introduced the lithotripteur of Heurte- loup; and after searching for the stone a few seconds, disco- vered, seized, and fractured it, as it lay in the fundus of the bladder on its right side. During the turning of the screw, the fragments could be heard cracking distinctly, the report being very sharp and sudden, like that of a distant whip. Upon re- moving the instrument, numerous small fragments were found in its claw and gutter, of a yellowish or gamboge tint, intermixed with harder portions of dark brown fragments; which from ap- pearance I should suppose were made up of oxalate of lime and lithic acid. During the operation, the patient scarcely com- plained of pain, and remarked that the uneasiness arose more from a sense of distention, from having retained his urine two or three hours previous to the operation, than from the instrument. Neither chill nor fever followed this operation ; and on the next day, sand and several small fragments were discharged with the urine. On the 14th of June, the patient felt well enough for another trial, which was accordingly made, and with the same happy re- sult—the stone having been seized instantly and crushed with an audible noise. Numerous fragments came away in the groove of the lithotripteur, and the next day three larger than a pea were discharged along with the urine—the whole collection from the two operations, being sufficient, if put together, to form a stone the size of a large almond. During the operation, the patient did not complain of pain or spasm of the bladder; more or less of which last he had usually experienced while the in- struments remained in that organ. On the 17th I visited Mr. P. again, (accompanied by Drs. Peace, Chase, and Johnson,) with the view of searching for fragments; but the patient not having allowed the urine to col- lect in sufficient quantities to seize them with safety, I declined the operation, but merely used the lithotripteur as a sound, to determine the size and situation of the pieces. On the 22d of June, in presence of Dr. Saltmarsh, 1 made another examination, but without being able to detect a frag- ment, and repeated the effort on the 25th and 29th, but with no LITHOTRIPSY. 287 better success. That there is still a fragment in the bladder, however, is rendered probable by the circumstance of the patient feeling an obstruction occasionally, about the neck of the blad- der, after walking or remaining for some time in the erect posi- tion, an obstruction sufficient to impede the flow of urine for a moment, or until removed by a change of position. But the patient's engagements are such as to prevent him from staying longer in town at present; and as he is desirous of recovering, also, from the effects of his restricted system of living, he returns to his farm, and, after harvest, intends to have the bladder still further explored. He came back, accordingly, after the lapse of a few weeks, and by one or two more trials with the lithotrip- teur, was restored to perfect health, and so continues to the pre- sent time. The above account of lithotripsy was published, two or three years ago, in the American Journal of Medical Sciences, and has been transferred to these pages with few alterations. Since that period I have not had occasion to vary much the opinions I then formed on the subject. The instrument, however, which I at first employed, I have altered, more or less, to suit my conve- nience, especially the beak of the lithotripteur—by enlarging, considerably, the opening, or slit, near its heel, to permit the free passage of fragments. Other cases I could here detail, if neces- sary, in proof of the advantages of Heurteloup's over other in- struments, especially trials I have seen made with it in Paris by Civiale and Leroy D'Etiolles. Its reputation, however, is now so well established, as to render such details unnecessary. I cannot avoid mentioning, however, that a great improvement has been made in the instrument by Civiale, especially by short- ening and widening the beak, to enable the operator to pick up fragments with the more facility. On Lithotripsy, consult Case of Lithotripsy, successfully performed by L. Deypere, in New York Med. Journal for Nov. 1830; The Operation of Litho- tripsy, by Jacob Randolph, M. D., in Amer. Jour, of Med. Sciences, No.xxix. Nov. 1834, and in subsequent numbers of same journal; Parallele des divers moyens de traiter les Calculeux, &c. &c, par le Docteur Civiale, Paris, 1836; De la Lithotripsie, par Leroy D'Etiolles, Memoires, No. 1, Paris, 1836; Lithotripsie, Memoires sur la Lithotripsie, par percussion, et sur l'instrument appele percuteur courbe a marteau, qui permet de mettre en usage ce nouveau systeme de pulverization des pierres vesicales, &c. &c, par le Baron Heurte- loup, Paris, 1833. 28S diseases of the eye. CHAPTER X. DISEASES OF THE EYE. The eye, from its delicate and complex structure, and the number and diversity of its diseases, was formerly much ne- glected, especially in Europe, by the regular members of the profession, and attended to almost exclusively by ignorant and itinerant oculists. Within the last thirty years, however, the value of this important branch of surgery has been duly esti- mated, in proof of which it need only be mentioned that Ware, Saunders, Gibson, of Manchester, Adams, Wardrop, Travers, Vetch, Lawrence, Guthrie, Middlemore, in Britain, and Scarpa, Beer, Schmidt, and others on the continent, have contributed largely by their writings and operations to elevate this depart- ment to a most respectable rank. Many of these gentlemen, indeed, forsaking the general practice of their profession, have devoted their whole attention to ophthalmic surgery, and w7ith a result truly honourable to themselves, and glorious to their coun- try. It would be impossible in a work of this description, which, for the most part, may be considered a mere skeleton, to give an account of all the diseases of the eye; diseases which are so numerous and important, which have occupied the exclusive attention of so many distinguished individuals in all countries, and upon which volumes have been written in all languages. All that can be done, then, is to present the most important in a condensed and tangible form, so divested of technicalities and intricacies, and so simplified in the treatment as to make them intelligible to the youngest student—reserving for the lectures the illustrations by diagrams and magnified drawings, through which alone the morbid appearances and more difficult opera- tions can be shown and explained. To attempt, indeed, to teach a class of more than four hundred pupils—which number for the CONJUNCTIVAL OPHTHALMIA. 289 last thirty years has, during many sessions, occupied seats in the University of Pennsylvania—by mere description, or by the ex- hibition of preparations of the eye of its natural size, would be irresistibly ridiculous. The most common affection, perhaps, of the eye, is ophthal- mia. Of this, therefore, it will be proper first to treat. Oph- thalmia is employed by most modern writers as a generic phrase—denoting ocular inflammation. For the sake of pre- cision and accurate discrimination, other terms have been in- vented, some of them simple and expressive enough, others for- midable in the extreme, or altogether monstrous.* To eluci- date the varieties of the disease, I shall not follow the exact arrangement of any individual author, but endeavour to simplify as much as possible, and oppose every distinction which is not perfectly clear and obvious. SECTION I. CONJUNCTIVAL OPHTHALMIA. Conjunctival inflammation, to denote which some writers employ the word ophthalmitis, is the most common form of oph- thalmia, and is characterized by the following symptoms—a sense of uneasiness, or itching, an impatience of light, diffused redness of the conjunctiva, pain, heat, and swelling of the globe of the eye, an epiphora or increased secretion of tears, a pun- gent pain proceeding apparently from the lodgement of a particle of sand or some other extraneous body, but in reality from one or more bundles of enlarged vessels. To these symptoms are * Nothing short of affectation or pedantry will enable us to tolerate, in many instances, the phraseology of Beer and Schmidt—such as ophthalmo-blennor- rhcea, blepharo-ophthalmo-blennorrhcea, dacryoadenitis, blepharophalmitis idiopathica, anchyloblepharon, symblepharon, and a hundred more, either of which surpasses in complexity the old anatomical mouthful, baseochondro- ceratoglossus, &c. 290 CONJUNCTIVAL OPHTHALMIA. superadded, if the inflammation continues to advance, deep- seated pulsatile and violent pain in the eyeball, which extends to the forehead, accompanied by fever and other general indis- position. Very often, moreover, the conjunctiva becomes thick- ened and projects in a fungous form beyond the margin of the cornea. At other times blood is extravasated between the con- junctiva and sclerotic coat. In the still further advanced stages of the disease, suppuration is liable to ensue, followed by de- struction of the cornea, evacuation of the humours, and abolition of sight. It is seldom, however, that a simple conjunctival ophthalmia terminates so unfavourably; on the contrary, the symptoms gradually decline, and the eye is restored to its na- tural state, though sometimes the disease assumes a chronic form, and is then very difficult to manage. The causes of conjunctival ophthalmia are, for the most part, exposure to extremes of cold and heat, sleeping in the open air, without cover, too intense and vivid a light to the eye, whether direct or reflected, blows, wounds, irritation from the lodgement of extraneous bodies upon the globe, or between the eyelids, disorder of the digestive organs, &c. Catarrhal ophthalmia is a variety of conjunctival inflamma- tion exceedingly common on the continent of Europe, and sometimes met with in this country. It is frequently epi- demic, and occasionally accompanies influenza. It is marked, in the early stage, by a peculiar dryness of the eye and eyelids, and by a pungent pain near the caruncula lachrymalis. In a few days these symptoms diminish, and are followed by a copious flow of tears, and a mucous discharge, which is gene- rally so acrid as to excoriate the eyelids and adjacent parts of the cheek. The patient is scarcely ever free from fever. In severe cases of the disease the whole conjunctiva is covered with small pustules, containing purulent matter or a yellowish serous fluid. Purulent ophthalmy differs from the catarrhal in many respects. It is a very formidable and destructive disease, and sometimes destroys one or both eyes in the course of a few hours. Adults, as well as children, are liable to it, but especially the latter. It usually commences four or five days after birth, by a slight red- ness and tumefaction of the conjunctiva lining the eyelids. This is speedily followed by the secretion of a thin adhesive matter, which glues the lids together. In a few hours the discharge be- CONJUNCTIVAL OPHTHALMIA. 291 comes very copious, thicker in consistence, acquires a yellowish or greenish cast, and is so acrid as to excoriate the cheeks. From the lids the inflammation extends to the conjunctiva covering the ball of the eye, and the whole membrane is converted into a thick fungous mass; which, when the eyes are opened, projects beyond the lids, and obscures the cornea. If the disease should continue to spread, the cornea is next involved, and either ulcer- ates or sloughs, the humours are discharged and the eye is lost. A great deal of constitutional irritation attends the early stage of the disease, but this subsides in three or four days, and the oph- thalmia then assumes a chronic form. To assign any satisfactory explanation of the origin of puru- lent ophthalmia is very difficult. Some writers suppose it to be closely allied to the gonorrhoeal ophthalmia, others that it pro- ceeds from leucorrhcea; the matter of which, in both instances, is applied, it is imagined, to the eyes of the child during its pas- sage through the vagina. Mr. Saunders is inclined to believe that the inflammation is of the erysipelatous kind. Gonorrhceal ophthalmia, another variety of conjunctival inflam- mation, bears a striking similitude to purulent ophthalmy, that form of it especially which is so prevalent in Egypt and other eastern countries, and from which the British and French troops3 a few years back, suffered so severely. The symptoms, how- ever, are, in every respect, more vehement, and such as ter- minate almost invariably in the loss of one or both eyes. That it follows, in many instances, the direct application of the go- norrhceal virus, I have the strongest proofs; having had, at dif- ferent times, patients under my care in whom the disease was produced by the practice, so common among the vulgar, of wash- ing inflamed eyes with urine. There is reason to believe, also, that the disease is sometimes induced by sympathy or a metasta- sis, in consequence of suppressed gonorrhoea. Scrofulous ophthalmy, a disease very common among scrofu- lous children, may be distinguished from other affections of the conjunctiva by a peculiar morbid irritability of the eye, or into- lerance of light, unaccompanied with pain, which obliges the pa- tient to keep the lids constantly in a half closed state, and confine himself altogether to a dark room. In addition to this, nume- rous distinct vessels may be seen running towards the cornea, some of which pass to the centre of that tunic, and terminate in a small pustule or ulcerated spot. The disease may continue 292 CONJUNCTIVAL OPHTHALMIA. for months together, without much alteration, and is very apt to be followed by corneal specks. TREATMENT OF CONJUNCTIVAL OPHTHALMIA. In the early stage or acute form of simple inflammation of the conjunctiva, the disease may be removed, in a short time, by general and local blood-letting, mild purgatives, nauseating doses of antimony, low diet, blisters behind the ears, or on the back of the neck, lotions of tepid water, a solution of opium, or of the acetate of lead. If, in spite of this treatment, the inflammation should not terminate, but run into the chronic stage, cold as- tringent washes and stimulating ointments may then become ne- cessary, such as the vinous tincture of opium, the citrine oint- ment, the ointment of the red oxide of mercury, &c. For catarrhal ophthalmia the best remedies are moderate de- pletion at first, and afterwards highly stimulating collyria and ointments. Purulent ophthalmia, in the commencement, should be treated upon common antiphlogistic principles, and by moderately astrin- gent washes, introduced into the eye by means of a syringe. The best lotion for this purpose is the undiluted liquor of the acetate of lead. In advanced stages of the disease, an infusion of two drachms of the leaves of tobacco in eight ounces of water, was found highly serviceable by Mr. Vetch, in restraining the discharge, relieving pain and removing watchfulness. The aqua camphorata of Bates' Dispensatory has been praised as ex- tremely efficacious in the chronic form of purulent ophthalmy: I have often tried it, however, without benefit, and sometimes with manifest aggravation of the symptoms. Gonorrhceal ophthalmia, unfortunately, admits of no relief; at least, in several instances of the kind which have fallen under my care, and in others which have occurred in the practice of Dr. Physick, no benefit whatever has resulted from any mode of treatment that could be devised. Mr. Vetch, however, with great confidence states, that the disease may be certainly cured by those remedies adapted to the treatment of Egyptian ophthalmia. Scrofulous ophthalmy seldom requires antiphlogistic measures; on the contrary, a tonic plan of treatment will generally be in- SCLEROTIC OPHTHALMIA. 293 dicated. In the commencement of the disease, however, it may be necessary to purge the patient, regulate strictly his diet, order warm clothing, moderate exercise in the open air, &c. To alleviate the intolerance of light, which is so much complained of by all patients in this disease, blister at the back of the neck, kept open by savin cerate, will be found the best remedy. Sometimes the internal use of mercury will be required. The best collyria are those composed of weak so- lutions of the argentum nitratum, of sulphate of zinc, alum, &c. SECTION II. SCLEROTIC OPHTHALMIA. An inflammation of the sclerotic coat, described by many writers under the name of rheumatic ophthalmia, is often met with. That it is closely allied to rheumatism is exceedingly probable, both from the circumstance of its being a frequent con- comitant of that disease, and from the nature of the texture which it occupies. The pain in the commencement of the dis- ease, is generally seated in the temple, and extends thence to the eyebrow, cheek and eye of the affected side. It is con- stantly present, but commonly most severe during the evening and late at night. The eyeball itself, when examined, does not present the common appearances of conjunctival inflammation. There is no purulent discharge, nor does the patient complain of intolerance of light. The vessels, moreover, instead of fol- lowing a tortuous course, run in parallel lines upon the sclerotic coat, and terminate at the margin of the cornea. These ves- sels are small and very numerous, and from being distributed over the whole albuginea, give it a uniform red colour; the redness, however, is not of the bright scarlet or vermilion hue, but of a dingy, brick-dust tinge. More or less fever, and de- rangement of the digestive organs, generally accompany the 294 IRITIC OPHTHALMIA. disease; and in bad cases, the inflammation may run so high as to involve the cornea and destroy the eye. TREATMENT OF SCLEROTIC OPHTHALMIA. The chief indications in the treatment of this disease are to restore, by means of emetics and purgatives, the functions of the stomach and biliary organs, or, if the inflammation has been induced by exposure, to excite the skin by antimonials. After- wards bark may, perhaps, be employed with advantage. The best local applications are a blister behind the ears, and the free use of the vinous tincture of opium as a collyrium. General, as well as local blood-letting will, in certain cases of this disease, prove serviceable, but in others injurious. Hence the variety of opinions entertained on the subject by different surgeons; some contending that the depleting system should never be pursued, others, that it is indispensable. When accompanied by a full pulse, and met with in plethoric patients, general blood-letting, leeches to the temple, or forehead, or around the eye, will almost always relieve the pain and other urgent symptoms; but when the complaint occurs in thin, and debilitated subjects, has been of long standing, or connected with genera] rheumatism, little or no benefit may be expected from venesection. Opiate frictions to the temples are extolled by Beer and other oculists, and belladonna to the eyelids and superciliary ridges. Applications to the ball of the eye, with exception of wine of opium, so useful in other forms of ophthal- mia, are seldom of much service in this variety of the com- plaint. SECTION III. IRITIC OPHTHALMIA. The term iritis was employed by Mr. Saunders to denote a variety of ophthalmic inflammation which previous to his time IRITIC OPHTHALMIA. 295 had been very little attended to. From the peculiarity and dis- tinctness of the symptoms, there can be no question as to the propriety of considering the disease purely an inflammation of the iris, and totally independent of every other species of oph- thalmia. The symptoms are severe lancinating pain extending from the eyebrow to the orbit; and shooting thence through the globe of the eye towards the optic nerve, extreme impatience of light, and an extraordinary morbid sensibility of the eye. Un- like most other varieties of ophthalmia, iritis is unaccompanied by redness of the conjunctiva, but the sclerotic coat is covered with numerous red vessels, which are particularly conspicuous on that portion of it connected with the margin of the cornea. On the iris, also, at least on its anterior surface, red vessels may be distinctly seen; but the most remarkable change that this membrane undergoes, is the loss of its brilliancy, and a change from its natural colour to that of a reddish or greenish hue. At the same time the pupil becomes contracted and irregular, and its edge is turned backwards towards the crystalline lens. In- stead of terminating in suppuration, the inflammation generally stops at the adhesive stage, and lymph is deposited upon the outer surface of the iris in one or more spots, and is sometimes secreted so copiously as to fill the anterior chamber. From this cause, incurable obliteration of the pupil often ensues. The causes of iritic ophthalmia are various. Sometimes the disease is induced by exposure of the eye to intense or vivid light; sometimes it proceeds from wounds of the iris made by the cornea knife or couching needle; at other times it appears to arise from some constitutional affection, such as gout. In the greater number of instances, howTever, it is the result of syphilis or of the abuse of mercury. TREATMENT OF IRITIC OPHTHALMIA. The antiphlogistic system, carried to its full extent, will barely prove sufficient, in many instances, to arrest the progress of this severe disease. Hence the propriety of resorting to it as speedily as possible after the inflammation has set in. To guard against obliteration of the pupil, by breaking up the bands of coagulable lymph which extend across it, the extracts of belladonna or stramonium will be found immensely serviceable. They should 296 PSOROPHTHALMIA. be applied to the outer surface of the eyelids, or over the eye- brows, two or three times a-day, and kept on for half an hour at a time. Care should be taken, however, not to employ them during the height of the inflammation. For the removal of syphilitic iritis, the moderate use of mercury, followed up by sarsaparilla, will generally prove an efficient remedy. For other varieties of iritis, also, mercury will often be found indispensable, and is chiefly useful in promoting the absorption of lymph, and even in preventing its deposition. Cantharides and oil of tur- pentine, as local applications to the forehead and temples, are likewise useful. Quinine in chronic iritis is sometimes employed advantageously. SECTION IV. PSOROPHTHALMIA. Some of the German writers understand by psorophthalmia, a variety of inflammation of the eyelids, induced by psora or itch. In the usual acceptation of the term, however, nothing more is implied than simple inflammation or ulceration of the lids, whether induced by small-pox, measles, scrofula, erysipelas, sties, or any other cause. Children, particularly those of scrofulous constitution, are very subject to this disease; adults, however, are not exempt from it. The inflammation first appears on the edges of the lids, and extends thence along the conjunctiva towards the globe of the eye. The pain is sometimes very severe, and the redness con- siderable, but the most distressing symptom is the intolerable itching, to relieve which the patient is obliged constantly to rub the affected part; and in this way only aggravates the disease. Sometimes the inflammation runs so high as to terminate in sup- puration. This is followed by troublesome ulceration of the tarsi, and frequently by great deformity. The Meibomian glands are always more or less affected in this complaint, and pour out an adhesive fluid, that glues the lids together during sleep. To PTERYGIUM. 297 open these, in the morning, some force is usually employed, and this keeps up constant irritation, and frequently renders the dis- ease chronic, causing the formation of small crusts or scabs along the tarsi and the cilia to drop out. In bad and long-standing cases of the disease, the puncta lachrymalia are sometimes per- manently obliterated, and an incurable epiphora is produced. TREATMENT OF PSOROPHTHALMIA. In the early stage of this disease, purgative medicines and a moderate diet will contribute very much towards a speedy cure. Weak solutions of the acetate of lead, of the sulphate of zinc, or sulphate of copper, will also be found useful as collyria. To prevent the lids from adhering, a very important indication in the treatment, a little fresh cream or butter should be placed between them every night before the patient retires to rest. After the inflammation has, in a measure subsided, and is verging towards the chronic stage, the unguentum hydrargyri nitrati, applied to the edges of the lids, two or three times a day, will prove singularly useful in relieving the itching, and in healing the ulceration. With the same view, an infusion or decoction of the pith of the sassafras is sometimes used, and in many instances with decided advantage. Not unfrequently the disease resists, for a long time, every remedy, and, indeed, con- tinues for years together. Under these circumstances, blisters behind the ears and neck, and a course of mercury may prove useful. SECTION V. PTERYGIUM. The pterygium, or eye-wing, is a thin membranous expansion seated upon the conjunctiva. It commonly occupies the inner angle of the eye, in the shape of a triangle, the apex of which 298 PTERYGIUM. looks towards the cornea. The disease is very common, but in most instances productive of so little inconvenience, that many persons are subject to it for years together, without being aware of its presence. In the early stages it resembles a globule of fat, and appears to possess little vascularity; a slight cold, how- ever, or an inflammation of the conjunctiva, renders its vessels very distinct. Although the disease may remain stationary, or nearly so, for many years, it is always liable to increase, and in this case may extend over the surface of the cornea. But it is somewhat remarkable, that it seldom, if ever, passes beyond the semi-diameter of the cornea. Sometimes a pterygium originates at each angle of the eye, and approaching the cornea in opposite directions, covers the whole of its surface. The disease is then called a pannus. There are two varieties of pterygium—the membranous and fleshy. TREATMENT OF PTERYGIUM. So long as this membranous excrescence continues small, and does not encroach upon the cornea, it will seldom be necessary to resort to an operation for its removal. When, however, it has attained considerable bulk, and is a frequent source of irritation, it should be dissected off either by a small scalpel or curved scissors. The scissors will generally be found the most conve- nient. To perform the operation advantageously, an assistant should stand behind the patient and support his head firmly upon his breast, and with one or two fingers elevate the upper eyelid, whilst another assistant depresses the lower lid, and keeps it fixed. The surgeon then taking a pair of small forceps, should elevate the pterygium from the conjunctiva, and by a few strokes of .the scissors separate the whole of it from the globe. A smart and sometimes violent inflammation follows the operation, and this must be subdued by the usual remedies. Where the ptery- gium covers a part or the whole of the cornea, it will be impos- sible to restore the transparency of that tunic, however accu- rately it may be dissected from the surface. It is proper to know this, and to inform patients of it, in order to guard against dis- appointment and censure. ENCANTHIS. 299 SECTION VI. ENCANTHIS. The encanthis, an enlargement of the lachrymal caruncle and semilunar fold, is a very uncommon, but sometimes most malignant disease. It proceeds, in some instances, from obsti- nate and protracted ophthalmia; at other times the gland as- sumes a cancerous action, and terminates, like most diseases of this description—unfavourably. In every disease of the kind, whether benign or inveterate, the caruncula lacrymalis presents a granulated and livid aspect. In proportion, however, as the tumour increases, its surface becomes less rugged, and is covered with varicose vessels. From the caruncle the disease extends sometimes to the cornea, and along the inner surface of each eyelid. When the tumour attains a large size, the puncta lac- rymalia are commonly compressed or obliterated, and a trouble- some epiphora ensues. TREATMENT OF ENCANTHIS. Excision of the caruncula and of the valvula semilunaris is the only remedy for this disease; but the operation frequently fails, either from the whole of the tumour not being taken away or from the malignant character of the complaint. In perform- ing the operation, the surgeon will find it most convenient to secure and control the tumour, by introducing a small hook into its substance, and then dissecting it out writh a narrow scalpel. Care must be taken to avoid the puncta lacrymalia. If the tumour has taken on the cancerous action, is very large, and has involved the surrounding parts, it may become neces- sary to extirpate the globe of the eye. 300 OPACITY OF THE CORNEA. SECTION VII. OPACITY OF THE CORNEA. There are three varieties of corneal speck, noticed by most writers under the names of nebula, albugo, and leucoma. By ne- bula is commonly understood a "superficial opacity of the cor- nea, preceded and accompanied by chronic ophthalmia, through which the iris and pupil are seen, and which does not, there- fore, entirely take away from the patient the power of seeing, but only causes the surrounding objects to be seen as if covered w7ith a veil or cloud."* The whole cornea is sometimes covered by a nebula; in other instances, several distinct specks appear in spots upon its surface, each of which is generally supplied with one or more vessels from the conjunctiva, or other coats of the eye. These vessels, indeed, serve to nourish or keep up the disease. The albugo differs in several respects from the common nebula. It is more deeply seated and occupies the lamellae or substance of the cornea; it is also of a white or pearl colour, is frequently unaccompanied by ophthalmia or by red vessels, and is always the result of an abundant effusion of lymph. Leucoma is a dense callous speck of the cornea, of a pure white or chalk colour, and polished aspect. It is usually the result of a cicatrix from a wound or ulcer. Sometimes it follows small- pox or measles. TREATMENT OF OPACITY OF THE CORNEA. A simple nebula or cloudiness of the cornea, may often be dispersed by slightly astringent collyria, such as are calculated to subdue the ophthalmia that usually accompanies the disease. But, in many instances, a division of the vessels supplying the speck is rendered necessary. If the trunks are large, they should be elevated by forceps, and a piece taken out of each by the curved scissors. * Scarpa. ULCER OF THE CORNEA. 301 The treatment of an albugo of long standing will always be found very difficult, and nothing short of highly stimulating ap- plications will effect a cure. One of the best for this purpose is the unguentum hydrargyri nitrati, applied by means of a camel's hair pencil to the surface of the speck once or twice a day A weak solution of argentum nitratum, will, in most cases, prove very serviceable. The same may be said of sulphate of copper and of corrosive sublimate. Red precipitate ointment, also, is a very useful remedy. Finely powdered loaf sugar, calomel, and other similar articles, are frequently blown into the eye, and pro- duce most salutary effects. A drop of molasses between the lids night and morning, has frequently dispersed both nebula and al- bugo. In several obstinate cases of the disease which have resisted all the usual remedies, I have known a speedy absorp- tion of the speck accomplished by the repeated ablution of the eye and eyelids with diluted vinegar. In addition to the local treatment, the internal use of calomel and other preparations of mercury should be resorted to. The leucoma is seldom, if ever removed. SECTION VIII. ULCER OF THE CORNEA. The cornea, as well as the fine lamina of conjunctiva cover- ing its surface, is liable to assume the ulcerative action. In either case, a very troublesome, and, perhaps, destructive dis- ease may be induced. This ulcer is commonly the result of the different varieties of ophthalmia, or it may proceed from the introduction of acrid or caustic substances into the eye. Sometimes the whole cornea is covered by the ulceration; at other times, a small dimple-like cavity, not larger than the head of a pin, occupies some particular part of the cornea, and instead of spreading towards its margin, penetrates the layers until it lays open the anterior chamber of the eye. An ash-coloured VOL. ii.—u 302 ulcer of the cornea. slough, resembling wet pasteboard, generally covers the surface of the corneal ulcer. The edges of the ulcer, also, are high and serrated. treatment of ulcer of the cornea. To relieve the excessive pain that usually attends this disease, and to promote healthy granulation, there is no application so effectual as the argentum nitratum. The sore should be lightly touched with the caustic, until an eschar forms on its surface, and when this drops off, which it generally does in twelve or eighteen hours, the application should be renewed—taking care to wash away with milk and water, any superfluous caustic that may happen to lodge about the eye or eyelids. When the ulcer assumes a healthy aspect, the caustic may be discontinued, and mild collyria or ointments substituted. "In all cases," says M'Kenzie, "we endeavour, of course, to check the ulcerative process, by those measures which are fitted for subduing the inflammation in which the ulcer took its origin. So long as there is an appearance of activity in the inflamma- tory disease, and much pain of the eye, local blood-letting must be employed. The bowels must be kept freely open, and opium administered in such a combination as shall be likely to operate on the skin. In strumous cases, sulphate of quinine operates very advantageously. In chronic superficial ulcer, calomel, given so as to affect the mouth, is sometimes necessary. In almost all cases of ulcerated cornea, counter-irritation will be found useful. As the inflamed state of the eye abates, the pa- tient finds the pain greatly relieved, and we observe the ulcer clearing and beginning to contract." M. Tavignot has recently recommended in ulcerations of the cornea the chloride of soda, applied either in a solid form, in powder, or mixed with ointments, and states that it has proved more efficacious than the argentum nitratum. Cabrier, also, commends in similar cases, and in opacities of the cornea, the cyanide of zinc, in the proportion of one part of the salt to twenty- five of lard. staphyloma. 303 SECTION IX. STAPHYLOMA. In the sense affixed to it by most modern writers, the term sta- phyloma implies a thickening and opacity of the layers of the cornea, together with a greater or less projection of the anterior surface of that tunic. Children, in whom the cornea is propor- tionably thicker than in adults, are most subject to the disease. One eye or both may be affected at the same time or in succes- sion. Small-pox, purulent ophthalmia, wounds of the eye by the couching needle or extracting knife, blows, and other injuries, are among the most frequent causes of staphyloma. In the ad- vanced stages of the disease, the tumour of the cornea is some- times partially absorbed, and both the anterior and posterior chambers of the eye appear to be filled with a serous fluid. Two forms of the disease are met with—one in which more or less transparency of the cornea is preserved, and, along with it, a slight degree of vision; the other, in which the whole cornea is perfectly opaque. The former is denominated partial, the latter total staphyloma. Again; staphyloma has been divided into conical and spherical. TREATMENT OF STAPHYLOMA. There is no remedy, unfortunately, for this disease; at least the transparency of the cornea cannot be restored, and the pa- tient, therefore, must for ever remain blind. But the surgeon, generally, has it in his power to alleviate the severe pain and inflammation (caused by dust and other extraneous bodies lodging upon the portion of the cornea projecting beyond the eyelids) by an operation. The object of this is to evacuate the humours, and permit the eye to collapse. To accomplish this purpose most effectually, and prevent a return of the disease, a section of the most prominent part of the cornea, by the knife used for extracting the cataract, should be made. The humours having escaped, the flap of the cornea may be removed with 304 HYPOPION. curved scissors. A circular opening will thus be made large enough for the contents of the eyeball gradually to drain away, whereas, if the surgeon were merely to puncture the cornea with a needle, as formerly practised, the opening would soon close, and the disease return. However, it has been recommended, and practised, by many- modern oculists, not to evacuate the contents of the eye, if it can be avoided, but suffer the humours to remain, and endeavour to produce cicatrization of the cornea, in order that the rotundi- ty of the eye may be preserved, and the deformity arising from the collapse of the organ obviated. With this view, all pres- sure upon the eye after the section of the corneal tumour must be avoided, the lids immediately closed by court-plaster, and not opened for several days. In conical staphyloma it is more diffi- cult to prevent the humours from draining off than in the sphe- rical variety. SECTION X. HYPOPION. In consequence of violent deep-seated ophthalmia, it some- times happens, that purulent matter is formed within the poste- rior or anterior chamber of the aqueous humour—constituting the disease known under the name of hypopion. Besides ex- treme redness of the conjunctiva, a yellowish crescent-shaped spot may also be observed at the bottom of the anterior cham- ber, which gradually increases in size until the whole of the ca- vity is filled. During the height of the inflammation, the pain, intolerance of light, &c, are intensely severe, and the matter copious; but as these symptoms decline, the pus is proportiona- bly absorbed, and sometimes disappears in a few days without material injury to the eye. In other instances, it remains for weeks together, after the inflammation has entirely subsided, in HYPOPION. 305 the anterior chamber, mixed with the aqueous humour, which it renders turbid. It is seldom, however, that the disease termi- nates so favourably. On the contrary, in bad cases of the kind, ulceration and sloughing of the cornea are apt to ensue, followed by discharge of the humours and destruction of the whole eye. When the matter is lodged between the lamellae of the cornea, the disease takes the name of onyx—from its resemblance to the white spot at the root of the nails. TREATMENT OF HYPOPION. The proper mode of managing this disease is not to puncture the cornea and evacuate the matter, as some advise, but to sub- due the accompanying inflammation, after which it will be found, commonly, that the matter is slowly absorbed, and will, in time* entirely disappear. When, however, the collection of pus is so large, and the inflammation so violent, as to leave no hope of saving the eye, it may become expedient to open the cornea and discharge the matter, in order to relieve the patient from unne- cessary pain and irritation. Nevertheless, cases have been reported by Wardrop, Mon- teith, and others, where, in the early stage of onyx and hypo- pion, the aqueous humour has been evacuated, and the purulent matter discharged, with speedy relief to the patient, and pre- servation of the eye. From statements made by Monteith, in par- ticular, it also appears, that what, in many instances, seems to be pus, is, in reality, lymph, as is proved by its consistence, and other properties, and that its removal checks the disposition to suppuration. Scarpa, long ago, maintained, that the fluid poured out into the anterior chamber, in cases of hypopion, was gene- rally lymph, secreted by the choroid coat. 306 HYDROPHTHALMIA. SECTION XI. HYDROPHTHALMIA. Dropsy of the eye, a disease rarely met with, may originate either in the anterior or posterior chamber of the eye. It is, for the most part, dependent upon some constitutional affection, and is frequently connected with general dropsy. The most striking symptom of the disease is a gradual enlargement of the globe of the eye, without much pain or injury to vision. When the globe, however, begins to protrude from the socket, and the coats of the eye are rendered tense by the accumulation of serum within their cavities, a considerable degree of pain is experienced, which ex- tends in some instances to the head. At the same time the vi- sion becomes impaired, the aqueous humour acquires a turbid appearance, and the iris appears more deeply seated than usual, and trembles upon the slightest motion of the patient's head. finally, if not evacuated by an operation, the humours accumu- late in such quantity as to excite violent irritation and suppura- tion, and the eye is irrecoverably lost. Collections of serum be- tween the sclerotic and choroid coats, and between the choroid and retina, are occasionally met with—the former termed sub- sclerotic, the latter sub-choroid dropsy. Conversion of the retina into a cord, and absorption of the vitreous humour, may be the result, from pressure, of sub-choroid dropsy, which is much more common than the sub-sclerotic. TREATMENT OF HYDROPHTHALMIA. When hydrophthalmia depends upon general dropsy, and is attended to in the commencement of the disease, some benefit may be derived, perhaps, from internal remedies—such as digi- talis, squill, volatile tincture of guaiacum, calomel, cicuta, &c. But after vision has been materially injured, or destroyed, and the eye projects beyond the lids, the operation of paracentesis is the only mode of treatment calculated to afford relief. This must be considered, however, as merely palliative. It may be performed with a common lancet or couching needle, and the operation oc- OBLITERATED PUPIL. 307 casionally repeated, or whenever the accumulation of water is such as to require its evacuation. When the disease proceeds from local causes, such as blows upon the eye or superciliary ridge, and the fluid is confined to the anterior chamber, friction with mercurial ointment around the eyelids, and blisters to the temples will now and then stop the progress of the complaint, and effect a cure. To relieve the violent pain accompanying sub-choroid dropsy, puncture of the eye with a grooved needle at the place where couching is usually performed, should be resorted to. Ware and other ocu- lists report interesting cases, where great benefit followed this mode of treatment. SECTION XII. OBLITERATED PUPIL. From common ophthalmia or from iritic inflammation, whether induced by operations for cataract or by other causes, closure or obliteration of the pupil frequently takes place. The iris, under such circumstances, becomes wrinkled or puckered, and the pupil is either entirely effaced or contracted to a very small compass. If complicated with cataract, the opaque lens or its capsule may generally be seen behind the pupil, of a whitish or bluish aspect; but if the lens and capsule remain transparent, the pupil, although contracted, still retains its natural black colour; and vision, per- haps, to a certain extent, is still preserved. TREATMENT OF OBLITERATED PUPIL. This disease can be relieved, or cured, only by an operation. Since the time of Chesselden, who was the first to resort to such an expedient, various methods have been practised. Chesselden's operation, in his own hands, proved eminently successful; with others it often failed, and was at last abandoned altogether. 308 OBLITERATED PUPIL. Recently, however, it has been revived by Sir William Adams, and as modified by him is better calculated, I conceive, for most cases of closed pupil than any other operation. "The patient being seated as in the operation for cataract, and the eye ren- dered steady by a gentle pressure with the concave speculum, placed under the upper eyelid, the artificial pupil knife should be introduced through the coats of the eye about a line behind the iris, with its cutting edge turned backwards, instead of down- wards. The point is next brought forwards through the iris somewhat more than a line from its temporal ciliary attach- ment, and cautiously carried through the anterior chamber until it has nearly reached the inner edge of that membrane, when it should be almost withdrawn out of the eye, making a gentle pressure with the curved part of the cutting edge of the instru- ment, against the iris in the line of its transverse diameter. If in the first attempt the division of the fibres of the iris is not suffi- ciently extensive, the point of the knife is to be again carried forward, and similarly withdrawn, until the incision is of proper length, when the radiated fibres will immediately contract, and an opening of a large size will be formed. After the operation is thus completed, the eye should be covered over with a plaster of simple ointment, spread on lint, and the patient put to bed with his head raised high."* If the obliterated pupil should be combined with an opaque lens or capsule, the surgeon should make it a point at the time he divides the iris, to cut up or lace- rate these textures, and thrust them forward through the pupil, which they will assist in keeping open. Wenzel, Gibson, of Manchester, and many other oculists, pre- fer in cases of closed pupil, a section of the cornea and the re- moval of a portion of the iris with scissors. Under particular circumstances I should select this operation in preference to that of Chesselden. Several years ago, Dr. Physick invented a small instrument, resembling a saddler's punch, for cutting out a piece of the iris; but he never, as he informed me, used it. It will sometimes become necessary to make an artificial pupil—even although the natural one remain of its usual size—on account of corneal opacity. Beer, Schmidt, Reissinger, Maunoir, Flagani, Assalini, Scarpa, * Adams's Practical Observations, &c. p. 137. PROCIDENTIA IRIDIS. 309 have all particular modes of operating for obliterated pupil; they possess no advantages, it appears to me, over those in common use. SECTION XIII. PROCIDENTIA IRIDIS. A prolapsus, or projection of the iris through an ulcer or wound of the cornea, is by no means unfrequent. The pain at- tending the disease is extremely severe, and the intolerance of light so excessive that the patient cannot bear the exposure of the eye for a moment. The pupil, in this disease, always as- sumes an unnatural shape; its particular form, however, will de- pend very much upon the situation of the opening in the cornea. Generally, it is of an oval figure. Sometimes there are two or three projections of the iris, each of which passes through a dis- tinct opening of the cornea. After the protrusion has continued for some time, an adhesion is apt to ensue between the cornea and iris, and the part of the iris that projects beyond the cornea becomes dry and hard, and sometimes sloughs away. TREATMENT OF PROCIDENTIA IRIDIS. WThen this disease follows a wound of the cornea, the iris may always be replaced at the time the edges of the wound are adjusted; but when it proceeds from an ulcerated openings the surgeon will find it impossible to retain the iris in its natural situation so long as the ulcer exists. The great object, therefore, in the treatment should be to heal the ulcer, and this will be most speedily accomplished by repeated touches of the argentum nitratum. The caustic will serve the additional purpose of subduing the morbid sensibility of the iris, and of removing the superfluous portion of it projecting beyond the cornea. 310 CATARACT. SECTION XIV. CATARACT. The ancients entertained very erroneous notions respecting the nature and seat of cataract. They supposed it to be formed by an adventitious membrane in the posterior chamber of the aqueous humour. Dissection, and operations on the living sub- ject, afterwards proved that the disease was confined to the crystalline lens or its capsule, which becoming opaque, prevented the rays of light from passing to the retina. Cataracts differ from each other as much in consistence as colour. Sometimes the lens is rendered perfectly fluid, and resembles milk, and on this account has been called the milky cataract. Sometimes it is found of the consistence of jelly or cheese, and hence the terms gelatinous and caseous cataracts. Not unfrequently the lens is perfectly hard, or ossified, so much so, that the sharpest instrument will make no impression upon it. When the anterior or posterior capsule is rendered opaque, and the lens remains transparent, or is absorbed, the disease is called capsular cataract. When a cataract exists at birth, the appel- lation congenital is applied to it. Most cataracts are of a bluish or pearl colour; some are gray or green; others white as snow. In a few rare instances the lens has been found of a brownish tint or perfectly black. The formation of cataract has never been satisfactorily ex- plained. By some the disease has been attributed to inflammation of the lens and its capsule, by others to hereditary transmission. That it may proceed from blows upon the eye and from wounds of that organ is very certain. In all cases of the kind there is reason to believe that the anterior capsule of the lens is either ruptured or cut, so that the lens itself is brought into immediate contact with the aqueous humour, which possesses the well known property of dissolving its texture as well as that of its capsule. It is remarkable, however, that an injury or destruc- tion of one eye, as I have several times witnessed, will frequently give rise, at a subsequent period, to cataract in the other. Old persons are most subject to cataract, though the disease may /•/.//. ry/ i: !it|i;i ill "it >i % CATARACT. 311 occur at any period of life; indeed, new-born infants are not exempt from it, and it has sometimes happened that all the chil- dren of a numerous family have been born with cataracts in both eyes. Persons whose eyes are much exposed to vivid and reflected lights are said to be particularly liable to cataract. The existence of cataract may be determined, generally, by the following symptoms. In the commencement, the patient is often sensible of a diminution of sight long before any opacity can be observed behind the pupil. Objects, moreover, espe- cially white ones, appear to him as if enveloped in mist or smoke, and when the eye is suddenly exposed to a strong light, vision is nearly destroyed. In a dull light, on the contrary, vision is more distinct, because the pupil being expanded the rays of light, besides their increased quantity, pass through the thin mar- gin of the lens. When the lens is completely opaque, its colour will commonly indicate the nature of the disease. The black cataract, however, is very liable to be mistaken for amaurosis. Cataracts are said to have been formed very suddenly, or in the course of a night, without any obvious cause; but I am inclined to believe this to be erroneous, and that the disease has existed, at least in one eye, for some time, without the patient being aware of its presence, and that the discovery of it has been purely accidental. TREATMENT OF CATARACT. Although repeated attempts have been made, both by internal remedies and by local applications, to remove cataract, there is no well attested instance, I believe, on record, of a cure having been effected, except by an operation. There are two or three different operations now in use, each of which it will be proper to describe. Couching or depression of the cataract, an operation practised, there is reason to believe, long before the time of Celsus, is usually performed by the modern surgeon either with a curved or straight needle. The former is preferred by Scarpa—the lat- ter by Hey. (See Plate VII. figs. 1 and 2.) The patient being seated on a low stool, with an assistant behind to support his shoulders and head, the operator sitting or standing before him, passes the speculum of Pellier (Plate VII. fig. 3,) beneath the up- per eyelid, and directs the assistant to hold it steadily, while with one or two of the fingers of his own hand he depresses the 312 CATARACT. lower lid. He then takes the needle, and if Scarpa's be used, (which I prefer to any other,) holds it in his fingers like a pen, and laying the handle of the instrument nearly parallel with the patient's temple, directs its point backwards, and its convex sur- face forwards, and penetrates the coats of the eye, at its external angle, about two lines posterior to the iris. The needle is next pushed towards the superior margin of the crystalline lens, and thence in the direction of the pupil, until its point is distinctly seen. It only remains to lacerate freely, but cautiously, with the point of the needle, the anterior capsule of the lens: which being done, the lens itself should be pressed downwards and backwards by the needle, and lodged in the vitreous humour. Instead of withdrawing the needle immediately after from the eye, as is too often done, it should be suffered to remain a few seconds, lest the lens re-ascend, in which case the surgeon should again depress it, and then carefully remove his instrument and close the eyelids. Extraction of the cataract is performed by a knife instead of a needle, and the opening made in the cornea in place of the sclerotic coat. There are two knives in general use—the one invented by Wenzel and improved by Ware, straight and blunt on the back, convex on the edge, five-eighths of an inch in width, and in other respects shaped like a wedge, or gradually tapering from the handle to the point—the other invented by Beer, and differing from that of Wenzel chiefly in having a tri- angular shape (See Plate VII. figs. 5 and 6.) With either, the operation may be equally well performed. The necessary arrangements being made, the patient is placed on a low chair or stool, and his head committed to an intelligent assistant, (one accustomed to the office and in the habit of per- forming the operation,) who with his fingers, instead of a specu- lum, elevates the superior eyelid, and supports it against the superciliary arch. The surgeon himself taking charge of the lower lid, which he depresses with one or more fingers, and waiting until the patient rolls the eye towards the inner canthus, and holds it steady, enters the knife above the equator of the cornea and about a quarter of a line anterior to its junction with the sclerotica, with the edge downwards, passes it slowly and steadily along through the anterior chamber until its point emerges at the inner edge of the cornea. This completes what has been called the punctuation of the cornea, and to finish the section it is CATARACT. 313 still necessary to push on the blade of the instrument until it cuts itself out. As soon as this is accomplished, the aqueous humour is discharged, the knife is withdrawn, and the lids are closed for a few moments. The next step of the operation, and the most important one, is to separate the lids, gently raise the flap of the cornea with the curette, (Plate VIII. fig. 7,) pass a gold or silver wire through the pupil, and cautiously lacerate the anterior cap- sule of the lens precisely in its centre. If this part of the opera- tion be well managed, and care taken to avoid any thing like pressure upon the globe of the eye, the lens, after its capsule is broken, will gradually approach the surface and be discharged through the opening made in the cornea, without bringing with it any portion of the vitreous humour. As soon as the lens is removed, the flap of the cornea should be adjusted, the lids closed, and a bandage applied lightly over both eyes. It some- times happens, owing, principally, to the cornea knife being dull and ill-constructed, that the aqueous humour flows before the section of the cornea is completed, and that the iris falls under the edge of the knife, and is liable to be wrounded. To guard against this, Baron Wenzel suggested an expedient which has proved extremely important—friction of the cornea with the end of the finger during the passage of the knife. If this plan be adopted, the iris will immediately retire from the edge of the knife, and so remain as long as the friction is continued. The absorbent practice, as it is denominated by Sir William Adams, may be said, perhaps, to have originated with Mr. Pott; at least, that eminent surgeon was fully aware of the solvent power of the aqueous humour, and frequently took ad- vantage of the circumstance, by pushing fragments of the lens which happened to be detached, during the operation of couching, into the anterior chamber. Gleize, also, as well as Scarpa, Hey, and others, followed the same practice. But it is chiefly owing to Saunders, Conradi, and Adams, that this mode of removing the cataract has been brought to its present degree of perfec- tion. There are two operations in use, each founded upon the absorbent principle—the anterior and posterior. The first, or the operation of Conradi, as it is usually called, is chiefly adapted to the soft or fluid cataract, and may be performed in the following way. The pupil being dilated by the application of the extract of belladonna or stramonium to the eyebrow, an 314 CATARACT. hour or two before the operation, the patient is seated, and the eye secured as in the operation of couching or extraction. With a straight spear-pointed needle, an inch in length, rounded in the shank, and tapering from the shoulder towards the point, (Plate VIII. fig. 1,) the surgeon penetrates the cornea, at its lower and outer part, about a line anterior to its union with the sclerotic coat, carries the needle along the plane of the iris and through the pupil as far as the centre of the crystalline lens, the capsule of which is first lightly scratched over its whole surface, then freely torn, after which the lens itself may be broken up, and some of its fragments brought by the needle into the anterior chamber. It is highly important, in perform- ing this operation to guard against wTounding the iris; the sur- geon, therefore, should not attempt to accomplish too much at a single operation, but calculate, in most instances, upon a second or third being necessary. In general, several weeks elapse before the remains of the capsule and lens entirely dis- appear. The posterior operation is distinguished from the anterior by the circumstances of the opening being made in the sclerotic coat instead of the cornea. Mr. Saunders wyas in the habit of performing this as well as the anterior operation; but for many valuable improvements in the mode of executing it, and for the invention of ingenious instruments adapted to the purpose, we are particularly indebted to Sir William Adams. The needle (Plate VIII. fig. 2,) chiefly employed by that surgeon for "solid cataract in children and adults," is spear-pointed, eight-tenths of an inch long, the thirtieth part of an inch wide, and slightly convex throughout the blade. The eye being fixed by a concave speculum, (Plate VIII. fig. 3,) the needle is passed through the sclerotic coat, about a line behind the iris, perpendicular to its edges, until it reaches the anterior chamber and the nasal mar- gin of the pupil. Its edge is then turned backwards, and at a single stroke made to divide the capsule and its lens. After this, repeated cuts are made in different directions, so as to divide the cataract into numerous pieces, most of which should be pushed afterwards by the flat surface of the needle into the an- terior chamber for solution. Formerly, Sir William Adams, in cases of very hard and solid cataract, was in the habit of introducing a knife similar to that recommended by him for artificial pupil, but smaller, and of n.ih'Vm. v.2. ■ / II I jwj CATARACT. 315 slicing off pieces of the lens; finding, however the operation very difficult and sometimes impossible, and having known, in several instances, violent inflammation and even destruction of the eye to follow the lodgement of an entire lens, or of large portions of it in the anterior chamber, he has latterly performed the ordinary operation with his spear-pointed needle, with which he pushes the whole of the lens into the anterior chamber, and thence immediately afterwards extracts it through the cornea by making a section of that tunic with a knife of peculiar shape, (Plate VIII. fig. 4,) enlarging the incision, should he find it ne- cessary, with a blunt-pointed curved knife, (Plate VIII. fig. 5.) Besides couching, extraction, and the absorbent practice, other operations have been proposed for the removal of cataract. For the most part, however, they are entitled to so little attention, as to render a description of them unnecessary. But a question naturally arises respecting the merits of the operations in com- mon use, and how far one should be preferred to another; though there is little probability of such a question being ever satisfac- torily determined; for, on both sides, it has been customary to extol the merits of one, and exaggerate the inconveniences of the other. Perhaps, it may be fairly stated, in relation to the operation of extraction, that under favourable circumstances— where the subject is young, healthy, the eye prominent, the vitre- ous humour sound, &c,—this operation, when dexterously per- formed, possesses advantages over every other, inasmuch as the cataract is at once removed, and a speedy cure follows. But, on the other hand, it must be recollected that the operation is always extremely difficult, and that if it once fail, it cannot be repeated. As respects the operation of couching, it appears to me that the chief objection to it arises from the difficulty of keeping the lens below the axis of vision; in addition to this, from its lodgement, in many instances, upon the retina, great pain and incurable amaurosis have not unfrequently ensued. Under most circum- stances, therefore, I am inclined to prefer the " absorbent prac- tice," principally, because the operations are easily executed, give little pain, and if necessary, may be repeated again and again without injury to the eye, and are the most likely to prove successful. There are many patients, however, who never can be brought to submit twice to an operation, and others, who, from not recovering their sight immediately, seek other aid; so that the surgeon may lose the credit he might otherwise gain, if 316 CONGENITAL CATARACT. permitted to carry out his plans. When there is any probability of difficulty of this kind I generally resort to couching or ex- traction. It should be remembered that previous to the performance of any operation for cataract, the patient must be prepared by diet, purging, &c.; that the stramonium or belladonna be invariably used; that means be taken to subdue inflammation after the operation, and that the eye be not prematurely exposed to too strong a light. As a general rule, too, no operation should be undertaken so long as the patient enjoys the perfect sight of one eye. SECTION XV. CONGENITAL CATARACT. This disease is more common than is generally imagined; indeed, many examples are recorded of all the children of a numerous family being born with cataracts in each eye. In the District of Columbia, there is a family of six children, all of whom are blind from congenital cataract. Sometimes only one eye is affected. There is a peculiarity attending this disease which is seldom observed in common cataract—an extraordinary mobility or incessant rolling motion of the eye which increases with the age of the patient, and is seldom, if an operation be long delayed, entirely gotten rid of. It is somewhat remarkable, also, that, unlike ordinary cataract, the lens of the congenital variety, in most instances, is gradually absorbed, and the two capsules approach each other, and are at last identified, forming a tough elastic membrane. This fact was first particularly noticed by Saunders. CONGENITAL CATARACT. 317 TREATMENT OF CONGENITAL CATARACT. Formerly, surgeons entertained the opinion that congenital cataract did not admit of relief until the patient attained the age of eight or ten years. Gibson, of Manchester, and Saunders, of London, were among the first to correct this erroneous doctrine. Independently of the importance of an early operation, as respects education of the child, it is equally necessary to correct the mobility of the eye, and to guard against decay of the retina, which, for want of its natural exercise, is apt to fade and die. For the removal of congenital cataract, I prefer, with the exception of the mode of securing the patient, the anterior operation as performed by Saunders, and described in the pre- ceding section. Instead of four or five assistants to hold the child, some of whom must necessarily be in the way of the operator, I am inclined to recommend, from experience, the plan of Mr. Gibson, of Manchester, which is simply to enclose the body, arms, and legs of the patient in a bag open at each end, and furnished with tapes or strings to secure the limbs. Thus situated, the child may be laid on a large pillow placed on a table and firmly held by one or two assistants. The operation may be performed, if necessary, on infants a month or six weeks old. Before concluding the subject of cataract, it may be proper to state that the anterior capsule of the lens sometimes adheres to the iris, and occasions an immobility of the pupil. Under these circumstances, I should still prefer the posterior operation, and the use of the curve-pointed needle of Sir William Adams, (Plate VIII. fig. 6,) taking especial care to be as gentle as possible in separating the adhesion, lest the iris be so injured as after- wards to cause obliterated pupil. It now and then happens, that after operations for cataract,—and operations, too, that have succeeded for a time,—secondary cataract is produced. This arises from capsular opacity. The posterior operation will, for this variety of the disease, also be found the most suitable. vol. n.—w 318 AMAUROSIS. SECTION XVI. AMAUROSIS. Amaurosis, gutta serena, or an insensible state of the retina, a disease of frequent occurrence, and always extremely difficult to cure, may be distinguished, generally, from other affections of the eye by the following symptoms. The pupil is of a greenish black colour, greatly expanded beyond its natural size, irregu- lar in shape, and its edges undulating. When exposed to the strongest light, no perceptible contraction can be observed. Sometimes, however, instead of being dilated, it is unnaturally contracted. In other instances the iris retains its sensibility so far as to be obedient to the stimulus of light, and contracts and dilates as usual, and yet the retina is completely insensible. In addition to these symptoms, the general aspect of the eye is pe- culiar, its natural lustre and intelligence are diminished or lost, and in a bad case of the disease, the patient is unable to direct his eyes steadily at any object, but turns them towards it ob- liquely. Most patients, in the incipiency of the disease, are ex- ceedingly annoyed by fantastic figures, called by most writers muscae volitantes, which are constantly flitting before their eyes, especially when white and shining objects are looked at. Se- vere pain about the superciliary ridge and orbit is a frequent con- comitant of the disease. The causes of amaurosis are either local or constitutional. Among the former may be enumerated blows upon the head, wounds of the supra-orbitary nerve, exposure of the eye to vivid lights, long-continued fatigue of the eye from examination of mi- nute objects, the use of powerful magnifying glasses, confine- ment in dark cells or dungeons, pressure upon the optic nerve from tumours, hydrocephalus, &c. The constitutional causes are derangement of the digestive organs, violent mental emotions, suppression of accustomed or periodical discharges, immoderate venery, manstupration, excessive indulgence in opium and other narcotics, frequent attacks of syphilis, repeated mercurial courses, and a great variety of similar sources of excitement. There is a singular variety of amaurosis, called nyctalopia, or AMAUROSIS. 319 night blindness, in which patients see objects with perfect dis- tinctness during the day, but lose their sight as soon as it becomes dark, remain blind throughout the night, and upon the approach of morning again recover their vision, which continues perfect until the return of evening. This disease sometimes arises with- out any evident cause; generally, however, it is endemic, and prevails to a greater extent in the East and West Indies than in other countries. Sometimes it appears to be hereditary; at least there are instances of whole families for several generations being subject to it. In Maryland there are now two distinct families in which the disease has existed from time immemorial. Persons having black eyes are said to be more subject to the complaint than others. When examined, the eyes do not commonly ex- hibit any visible defect, except that the pupil is unusually large, and less moveable than natural. TREATMENT OF AMAUROSIS. This must depend in a great measure upon the cause of the disease. When it arises from any organic defect, and from most of the local causes above enumerated, there will be very little probability of affording permanent relief. If it proceed from gastric derangement, or from passions of the mind, emetics and purgatives will prove the most useful remedies, and after full benefit has been derived from these, tonics may be resorted to. For nyctalopia, repeated purgatives and a succession of blis- ters to the temples, are highly recommended by Mr. Bampfield,* the most experienced writer on the subject. * Medico-Chirurg. Transactions, vol. v. 320 HORDEOLUM. SECTION XVII. HORDEOLUM. The hordeolum, or stye, is a red, inflamed, and painful tumour involving one or more of the Meibomian glands. It is similar, in many respects, to the common furuncle or boil, met with in other parts of the body, and is usually seated upon the lower eyelid near its inner angle. The disease is very common, and arises for the most part, from some disordered action of the stomach. Like the furuncle, it seldom terminates in suppura- tion. TREATMENT OF HORDEOLUM. Purgative medicines and attention to diet will often, without the aid of local applications, remove hordeolum. When the tumour, however, continues stationary for some time, and is painful, an attempt should be made, by warm emollient applica- tions, to excite suppuration in the cellular membrane surrounding it. By these means we sometimes succeed in detaching the core or slough that occupies the centre of the tumour, after which the opening left will soon heal. When the inflammation has sub- sided, and the tumour becomes indolent, the application of lunar caustic or of nitric acid will frequently effect a cure. SECTION XVIII. ENCYSTED TUMOURS OF THE EYELIDS. Steatomatous and melicerous tumours from the size of a pea to that of a large bean, are frequently met with beneath the con- junctiva, or imbedded in the substance of the eyelid. They are ENTROPEON. 321 generally, soft, devoid of pain, and roll under the finger. The upper eyelid is the most common seat of the disease. When the tumour attains a very large size, it is liable to interfere with vision, or it may produce eversion and other diseases of the eye- lids. TREATMENT OF ENCYSTED TUMOURS OF THE EYELIDS. Extirpation is the only remedy, and this, when the tumour has acquired a moderate size, is easily accomplished, especially when it is seated on the inside of the lid immediately beneath the conjunctiva. The surgeon everts the lid with his finger, secures the tumour by a fine hook, then makes an incision with a diminutive scalpel over its surface parallel with the eyelid. As soon as the external covering is fairly divided, the tumour is easily loosened from its bed, and by a few strokes of the knife or scissors entirely removed. When it is deeply seated within the substance of the orbicular muscle, or lies exterior to it, the operator will find it most convenient to extract the tumour by cutting through the lid on its outer side—taking care to separate the muscular fibres longitudinally. SECTION XIX. ENTROPEON. By the term entropeon is understood an inversion of the tar- sus or its cilia. Trichiasis is also used, though improperly, to denote the same disease. The upper eyelid is commonly the seat of entropeon, which, in proportion to its duration and the extent of the inversion, is productive of more or less irritation by encroaching upon the ball of the eye. In general, the entro- peon proceeds from protracted ophthalmia, or psorophthalmia, and from other causes capable of producing a morbid inclina- tion of the tarsus, or a wrong direction of the cilia. 322 ENTROPEON. TREATMENT OF ENTROPEON. An evulsion of the eyelashes by a pair of fine forceps or tweezers, when the entropeon depends upon their unnatural position, is the only remedy calculated to remove the complaint, and this does not succeed always. For inversion of the tarsus itself, several different operations have been practised. In sim- ple cases, especially where the disease appears to be owing to inordinate relaxation of the skin of the eyelid, the removal of an oval portion of this superfluous skin by the forceps and curved scissors will generally effect a cure, provided the sur- geon take care to cut as closely as possible to the tarsus, and afterwards draw the edges of the wound together by a fine su- ture. The cicatrix that ensues will afterwards prevent the tar- sus from falling inwards upon the globe of the eye. But this operation does not commonly answer for cases of long standing, unless a cicatrix be made by caustic or a red-hot wire, an ope- ration I have several times performed successfully. Sir Philip Crampton, the celebrated Irish surgeon, has proposed to dissect off the thickened conjunctiva, which he conceives to be the most common cause of entropeon. On the other hand, Mr. Saunders and Dr. Dorsey advise the entire or partial removal of the tarsus. I have, however, tried these different operations, and have found them painful and difficult, and not always successful. I am in- clined to think more favourably of an operation proposed by Dr. Jaeger, of Vienna, though I have had no opportunity of fully testing its merits. The surgeon, instead of removing the whole tarsus, merely dissects off its anterior edge, and along with it the cilia, thereby removing a considerable source of irri- tation, at the same time preserving that portion of the cartilage which serves to guide the tears towards the puncta lacrymalia. There are several other operations for entropeon, according to the different causes producing it, which, for want of space, I cannot give an account of. ECTROPEON. 323 SECTION XX. ECTROPEON. The ectropeon is the reverse of the entropeon,—the eyelid being turned outwards instead of inwards. Sometimes both the upper and lower eyelids are simultaneously affected, but in most instances the lower lid is the seat of the disease. Like the entropeon, it may proceed from repeated and long-con- tinued attacks of ophthalmia, and in such cases the conjunctiva lining the lid is generally thickened or in a furfgous state. Oc- casionally, the ectropeon arises from burns or wounds in the neighbourhood of the eyelids, the cicatrices of which, by con- tracting and distorting the tarsus, evert the lid and expose its inner surface. In all cases of the kind, the deformity arising from the red and exposed surface of the conjunctiva is consi- derable, and the irritation to the globe of the eye such as not unfrequently to produce opacity or ulceration of the cornea. TREATMENT OF ECTROPEON. Excision of the fungous conjunctiva, and the application of various caustics, have been advised by most writers. The only operation, however, likely to afford permanent relief, is that practised by Sir William Adams. It is performed in the fol- lowing way. A portion of the lid, in the shape of the letter V, is removed from the outer angle of the eye by a pair of straight sharp scissors. The thickened conjunctiva is next carefully dis- sected off, when there will be no obstacle left in most cases to the replacement of the lid. To retain it in its situation and to promote adhesion, a fine interrupted suture should be passed through the edges of the wound, and supported by a compress. The size of the portion to be removed must depend upon the extent of the eversion. It needs hardly be mentioned that the base of the triangular incision should look towards the edge of the tarsus. When the ectropeon depends upon a cicatrix, from loss of substance near the lid, or from a burn, it may become necessary to make incisions parallel with the lid through 324 ECTROPEON. the contracted integuments, and afterwards interpose lint to pre- vent their reunion. But the operation seldom succeeds per- fectly—owing, perhaps, to ignorance, want of attention, miscal- culation as to the quantity of substance to be removed, or to the incisions being made in the wrong direction, and other causes. In some cases the removal of the cicatrices themselves will effect a cure. Six years ago, assisted by Dr. Clark, of New York, and my son, Dr. Charles Bell Gibson, of Baltimore, I performed a ble- pharoplastic operation on Mr. Freeman Scott, of Penn Town- ship. In consequence of a severe burn in the face, some months before, great deformity arose in each eyelid, from the^contraction of the cicatrices following that injury. The left lower eyelid in particular, was drawn down upon the cheek more than an inch, and became so everted, red and painful, as to annoy the patient exceedingly, and to distort his features in the most horrible man- ner. After dissecting up the lid as much as possible from the cheek, to which it had formed attachments, I cut out of its centre a piece in shape of the letter V, and bringing the edges together with very short and fine hare-lip pins made for the occasion, suc- ceeded in a few days in uniting the parts, and restoring the form of the lid so completely as to render it difficult for any one to observe that an operation had ever been performed on the part, or that any such deformity as I have described had ever existed. Operations founded upon the same principle, but differing some- what in the mode of execution, have recently been successfully performed by Dr. J. Mason Warren, an accomplished young sur- geon of Boston, who has already, perhaps, effected more in the restoration of mutilated parts than any other American practi- tioner.* * See Warren on Restoration of the Lower Eyelid, in vol. xxiv. of Boston Med. and Surg. Journ. No. x.; Warren on Rhinoplastic Operations in same Journal, &c. &c. FISTULA LACHRYMALIS. 325 SECTION XXI. FISTULA LACHRYMALIS. Epiphora or stillicidium lachrymarum, and fistula lachrymalis, have been used by some writers indiscriminately to denote the same disease; by others they have been looked upon as essen- tially distinct; they may, however, I conceive, be ranked with propriety as varieties or stages of the same complaint; but it by no means follows that every epiphora must necessarily terminate in fistula lachrymalis, although fistula lachrymalis may be said to be preceded invariably by epiphora. Epiphora may arise from several different causes—from an undue secretion of tears—from closure of the puncta lachrymalia or obliteration of the canaliculi lachrymales—from inflammation of the lachrymal sac, and from stricture of the nasal duct. These in their turn may be the result of other agents, especially of the different varieties of ophthalmia. When the puncta lachrymalia are closed, the tears constantly flow over the lids, and spreading upon the cornea, produce a morbid refraction of light, which obliges the patient constantly to wipe them away. On the contrary, when the nasal duct is obstructed, the tears accumulate in the sac, and form a tumour immediately below the tendon of the orbicular muscle; and upon pressing this tumour, the tears regurgitate through the puncta mixed with flocculent matter. So long as the disease continues in this state, the terms epiphora, and stillicidium lachrymarum are strictly applicable to it. Should the sac, however, inflame and ulcerate, and an opening be established between it and the in- teguments, then a fistula lachrymalis is produced. In such cases the inflammation generally extends to the globe of the eye, and in some instances to the side of the face and head. If neglected, the disease may continue for months or years, or indeed during the patient's life, sometimes better, sometimes worse, and in the end may be followed by caries of the os unguis, and injury of the ethmoid and spongy bones. 326 FISTULA LACHRYMALIS. TREATMENT OF FISTULA LACHRYMALIS. A simple epiphora, dependent upon obstruction of the nasal duct, or as sometimes happens, upon a morbid secretion from the Meibomian glands, may be generally removed by the re- peated introduction of Anel's probes into the puncta and duct, and by the application of the unguentum hydrargyri nitrati, and other astringent ointments, and washes to the lids and edges of the tarsus. After the obstruction has been overcome by the probes, the passages should be syringed out two or three times a day, taking care to introduce the curved pipe of the syringe into the lower punctum, and at the same time, with the point of a finger to stop the upper punctum, and thereby to prevent the regurgitation of the fluid. Tepid water, at first, and after- wards a weak solution of the sulphate of zinc, or acetate of lead, will be found the most suitable wash. When the epiphora depends upon obliteration of the puncta or canaliculi lachrymales, the disease may be considered incurable. Fistula lachrymalis can be removed only by overcoming the obstruction in the nasal duct, or by establishing a new route for the tears through a perforation of the unguis. The first mode should, if practicable, be always resorted to. The surgeon in- troducing into the fistulous orifice a common pocket-case probe, carries it, at first, horizontally, until it is fairly introduced into the cavity of the lachrymal sac; the handle of the instrument is then raised, and made to rest nearly in a perpendicular direction against the superciliary ridge, while the point is directed down- wards in the course of the duct, and pressed firmly but steadily against the stricture. As soon as this is overcome, the probe passes easily into the nose, and a few drops of blood and matter issue from the nostril of the affected side. The probe is then with- drawn, and a silver style (an instrument resembling in shape and size the probe, but only an inch and a quarter in length, and having a head obliquely placed upon its top) introduced in its place. This is permitted to remain in the passage, and serves the purpose of conducting the tears by a sort of capillary attrac- tion into the nostril. In the mean time, the fistulous orifice gra- dually contracts around the neck of the instrument, the head of which afterwards prevents it from falling into the nose. Occa- FISTULA LACHRYMALIS. 327 sionally the style should be withdrawn, and the passage syringed out. Some patients find it necessary to wear the style several months, others are cured by it in a few weeks. Where the fistulous orifice is so small that the probe will not enter, it should be enlarged by a spear-pointed lancet. Sometimes it is neces- sary to make an opening into the sac, where the fistula is not properly situated, or does not exist. Under these circumstances, the surgeon should always take as his guide, the small tendon of the orbicularis, and immediately beneath this make his inci- sion. Some surgeons, among the rest Dupuytren, leave the style or a cannula, permanently, in the duct, and heal the fistu- lous opening. I have tried the plan, but found so many incon- veniences from it, as not to have practised it for several years. In several instances the cannula has worked out by causing ul- ceration of the sac, or by passing into the nose, after having caused abscesses, ulceration, and caries of the bones. My friend Professor Mussey, of Cincinnati, in cases of fistula la- chrymalis, employs a gold tube, but leaves a style in the tube until all irritation and purulent secretion have ceased, and then withdraws it. If, as sometimes happens, the nasal duct be permanently closed by stricture, or by an exostosis from the surrounding bony canal, it will become necessary to perforate the os unguis. This can be most conveniently done by the perforator of Cruikshank,—an instrument, resembling, in some respects, the shoemaker's punch —which is carried through both sides of the lachrymal sac, and made to bear upqn the inferior part of the unguis. To prevent the instrument from passing too far inwards, a narrow piece of horn should be carried up the nostril, and upon this, the perfo- rator will rest and perform its office with great facility. After the opening has been made through the sac and bone, a silver or leaden style, somewhat shorter than that used for the natural duct, should be introduced and worn as long as may be found necessary. When the operation is properly performed, the opening will always be made between the superior and inferior spongy bones. There are other operations practised for the cure of fistula lachrymalis, but they seldom prove so effectual as those I have described. 328 STRABISMUS. SECTION XXII. STRABISMUS. Among a small parcel of manuscript and other papers I re- ceived two or three years ago from my old master and friend, Sir Charles Bell,—requesting me to make what use of them I thought fit, as some of them might not possibly be published by himself,—I found an interesting essay on the philosophy of stra- bismus. As the subject is one, which, from its importance, is now exciting very great interest both in and out of the profes- sion, I insert the essay entire, in this place, in hopes that it will furnish a greater amount of information to my pupils, than they can get, at this time, from any other source. "ON SQUINTING—ITS CAUSES—THE ACTUAL CONDITION OF THE EYE—AND THE ATTEMPTS TO REMEDY THE DEFECTS. " It is pleasant to turn from the contemplation of the effects of violence, and the more severe operations of surgery, to a deli- cate operation which remedies a defect, (which at least gives great uneasiness) and is really a triumph of art. But, while it is agreeable to witness the rapidity with which information is re- ceived and acted upon, and the eagerness of surgeons to put in practice a new operation, it is to be regretted that the physio- logical principles relating to the cure of this deformity have not been more attentively studied. " Vision is a subject of high interest in a physiological point of view. It has been studied by our philosophers in every age, and now a correct knowledge of the functions of the eye becomes more especially of practical importance, by enabling us to judge of the propriety of operations for the cure of squinting. "I have to confess that when, formerly, I endeavoured to show the strict relation which exists between the action of the muscles of the eye and the impressions on the retina, I met with criticism from one, whose authority bears great weight in these inquiries. But my respect for that gentleman does not over- STRABISMUS. 329 come the conviction that on this question, and on all that regards the exercise of the eye, we must hold in view twTo distinct pro- perties of the organ,—the reception of light on the retina, and the consentaneous action of the muscles of the ball of the eye. This relation becomes a matter of the first consequence in en- deavouring to comprehend the subject of squinting, and to enable us to judge of the propriety of the operation for remedying the defect. " There are in the retina two spots distinct in their properties from the general surface. Though not antipodes in place, these spots are opposed to each other in respect to sensibility, one be- ing exquisitely sensible to the impression of light, and the other absolutely insensible. The sensible point is in the axis of the eye, and is the foramen of Soemmering; the insensible spot cor- responds to the insertion of the optic nerve.* When the rays from an object impinge on the sensible part, animation and effort are immediately given to the guiding muscles of the eye. When the rays fall on a part of the retina removed from this centre of sensibility, and more so when they strike on the absolutely in- sensible spot, the stimulus to a correct action of the muscles is lost. We shall presently find that the defect of the weak eye of one who squints, is mainly in the tonicity of one muscle, and that it is at this time of comparative inaction that the other mus- cles prevail against it. " Take the plan, Fig. 1, as representing the right eye, and the small circle A as the sensible spot; the rays from the object falling upon A are seen and animate the organ. Suppose Fig. 2 to represent the left eye distorted to the degree that the rays fall on B, that being the insensible spot, the object is not per- ceived with that eye. "The farther from the sensible spot in the axis of the eye the rays from the object fall, the less distinct is the image. Thus, in the common experiment by which an object is seen double, that is, of looking on another object beyond it, so that the rays are made to fall on the inside of the central and sensible spot of the retina, these double impressions are weak, compared with the single image. Accordingly, it is not required that the rays should fall on B alone, to be neglected. If the point on which they do fall be considerably removed from the spot A, the mus- * See Mariotti, and the Experiments of De La Fond, Cours Experimental, t. iii. § mdcccxcvii.; Haller, Picturae Locus, lib. xvi. t. v. 330 STRABISMUS. cles of the eye will be without their sufficient stimulus to correct vision; and, being left uncontrolled, the weak muscles will yield to the prevailing tonicity of the others. "We ought not to leave this subject without noticing the ad- vantage derived from the central spot of the retina being more sensible than the general field. Were the whole surface of the retina equally susceptible of the impressions of light, we should be dazzled, and see nothing; the direct light, whether of the sun or of a lamp, would overcome, by its intensity, the reflected light from the object to which the eyes were directed. That ra- pid search which the eye makes in surveying a scene,—the de- sire to have the object which is faintly seen on the general field of the retina presented to the sensible centre, as well as the hap- py consequences of that perfect vision which results from the sensation on the retina, being combined with the voluntary di- rection of the eye, would be lost. " Leaving this department, let us give more attention to the muscles of the eye. And I shall be excused in stating here what I have already taught on this subject.* The eye-ball is sus- pended in a cellular and adipose membrane so loosely, that it is like a thing floating in water, ready to move on the slightest im- pulse. It is surrounded with muscles: the four recti embracing it, and terminating forwards; the two obliqui embracing it, and terminating backwards; while it is covered anteriorly by the or- bicularis of the eyelids. We contemplate these muscles in two conditions—a passive and tonic state, during which the eyeball * " Nervous System." STRABISMUS. 331 is poised between them; and the more animated and active state, when the axis of both eyes are directed to an object. When the muscles are left in their passive state, their unexcited condition, the eyelid is dropped, and the pupil a little turned up; this is the state in sleep. "But of these muscles a certain class is voluntary. At the moment of awakening, the attollens palpebrae lifts the eyelid, and the recti muscles direct the axis of the eye ball to an object, or search for it; and that search is to place the centre of the retina in such a relation to the object as that the reflected rays from it shall fall on the sensible spot, and then the object becomes dis- tinctly visible. Vision thus obtained is the conjoint operation of the voluntary muscles of the eye and of the impression on the retina; and this double operation is necessary to perfect vi- sion. It is that state of speculation which implies scrutiny; the motion, and sense of the eye being combined; and the cor- respondence in motion and in sensation of both eyes being per- fect. "When a child has never seen, as in the case of congenital cataract, when there may be sensibility to light, without an image seen,' the eyes roll in different directions, and without corre- spondence.'* " But certain of the muscles of the eye have another all-im- portant office, without the performance of which we should not long enjoy sight,—the protection of the organ. For this the ex- quisite and peculiar sensibility of the surfaces of the eye, and of the roots of the cilia, is bestowed; and under this sensibility the action of the muscles is arranged. For example, in couch- ing, the surgeon entreats the patient to command himself, and to look straight forwards, which he does; but the instant that the eyeball is touched with the point, it is involuntarily turned in- wards and upwards. What is the object of this in nature, and how accomplished ? Is not this the position of the eye of one who has a decided squint? May not the investigation of the one con- dition tend to the understanding of the other? " How directly the cornea is turned towards the inner canthus, may be determined by a simple and harmless experiment. If, on closing the eye, and placing the point of the finger on the eyelid so as to feel the convexity of the cornea through the * « See the cases, No. cvi. of Nervous System." 332 STRABISMUS. eyelid, we make an effort more firmly, and, as it were spasmo- dically, to shut the eyelids, as if something were entering the eye,—it will be found that the cornea slips from under the finger towards the inner canthus. On ceasing to exert the eye- lids, the cornea returns again under the point of the finger to the centre. " The apparatus for throwing out what is offensive to the eye is not so perfect in man as in quadrupeds; but the mechanism is in some degree the same. The caruncle with its glands, and the membrana semilunaris, are less perfect than the haw, and the muscles of the human eye are deficient in the retractor muscle; but the action of those which we possess is the same, when there is irritation of the surfaces. The eye is dragged towards the os planum, the cornea is turned to the caruncle, and the fold of the conjunctiva, called semilunaris, is thereby thrust forwards. By this means the dust which is floated towards the inner angle of the eyelids, is extruded. " It is obvious that this motion implies the combined action of all the muscles of the eye and eyelids, with the exception of one, most material to our subject,—that is, the external rectus. Without the relaxation of this muscle, the cornea could not be turned into the inner canthus; and without the alternate motion of the cornea to and fro, by the successive contraction and re- laxation of the external rectus, the eye could not by any action free itself of the offending body. We come to the conclusion, then, that the external rectus has something to distinguish it from the other muscles; and so far we are on our way to com- prehend its peculiar defects. We perceive that, in an obstinate squint, the eyeball is exactly in the position into which it is thrown in the sudden action of guarding the eye! " We may observe here, that the operation of cutting across the rectus internus muscle for the cure of a squint, was not un- dertaken on a deep consideration of the condition of the rectus externus; but it was to cut across what appears to the patient's feelings to tie the eyeball, and confine it towards the nose. Sometimes the patient, when you examine the eye, and desire him to turn the eye outwards, says he cannot do so beyond a cer- tain degree; and he will add that it seems tied. But this is not a common attendant on squint. " Neither is there a doubt but that the internal rectus, by its continued action, acquires strength; while its antagonist, the exter- STRABISMUS. 333 nal rectus, by the reversed condition of relaxation, becomes weak. The opposite effects which have followed the operation of cut- ting the muscles, and the disappointments, after much experi- ence, call for a more philosophical investigation of the subject. " Every person understands, "that to act, requires a stimulus to the contracting muscles. But it is only a physiologist who can comprehend that in every such action, there must also be relaxa- tion of the opposite set of muscles. And I have elsewhere* said, that this is not a relaxation like the throwing loose of a rope. The relaxation of a muscle is as fine, or rather a more delicate administration of power than the contraction. It is the derange- ment of this relaxing influence which produces squinting. "Many of the actions or motions which, in a morbid condi- tion, or resulting from accident, appear irregular, and cannot be accounted for, may be explained by a careful study of the na- tural functions. Thus, in No. ciii. of the cases in the Appendix to my volume on the Nervous System, we find this passage,— ' There lies in the hospital a patient with a fracture of the base of the skull, in whom there is a regular motion of the eyeball, as regular as the motion of a pendulum, from right to left.' In case cv., the same motion is noticed,—' It is not so much upwards and downwards, as in a transverse direction.' This is a de- rangement in the condition of the rectus externus, imitative of its natural function. " I must now advert to some of my experimentsf on these muscles: a more objectionable mode of inquiry, perhaps, from its cruelty; yet I thought I was making it unnecessary for others to have recourse to the same. Experiments must be made on the monkey; the only animal that has the same muscles as man. The possession of the powerful retractor oculi will render all ex- periments on quadrupeds unsatisfactory. " I divided the rectus superior; the animal lost the power of raising the eye, when he raised the eyelids, and turned up the other eye. The eyelid was held open, and the eye touched with a feather; the cornea was instantly turned up, and in a greater degree than in voluntary action. " This was surely sufficient proof to show that the recti and obliqui were distinct in office,—that there were two distinct mus- cles employed in raising the eye; the one, the rectus superior, * "The Hand, a Bridgewater Treatise. t" See Nervous System. VOL. II.—X 334 STRABISMUS. directing the eye in vision, and voluntary; and the other, the inferior oblique, acting involuntarily, for the protection of the eye, and for wiping the cornea, and dipping it in the fountain of the tears. Those who could not assent to the argument, that the oblique muscles perform their motions more rapidly than the straight, and, therefore, that these different classes could not cor- respond in any combined actions; or who could not see that, if there was a necessity for oblique muscles to direct the eyeball, there should have been four muscles and not two, might still have given their belief to so decided a proof of difference be- tween them as this experiment afforded. " I cut the superior oblique muscle of the monkey. He was very little disturbed by the experiment, and turned his eyes in all directions, with his characteristic inquiring looks. On hold- ing open the eyelid, and waving the hand before him, as threat- ening the eye, the eye turned up further than the other eye; and there was a hesitation and apparent difficulty in bringing it down again. " The division of the inferior oblique mus.de did not in any sensible degree impede the voluntary motions of the eye. "If any one will give a moment's consideration to the subject, he will see that the eyeball must be rolled upwards by different muscles. When we look upwards, the eyelid, as well as the cornea, is elevated; and there must be a perfect accordance in the action of the superior rectus and of the attollens palpebrae, or the pupil will be hid under the eyelid. But as the cornea is raised in the other action, for preserving the eye, while the eye- lid is depressed, it must be effected by another muscle, namely, the inferior oblique, which consents in action with the orbicu- laris oculi. The one muscle accords with the elevation of the eyelid, the other with its depression.* "It would appear that our operators sometimes think phy- siology a matter foreign to their pursuits. Yet, in this subject, we cannot comprehend the most common occurrence without a knowledge of function. There is a squint, for example, that puzzles not a little, and obscures the reasoning in common cases * " If the intelligent reader will peruse the cases of involuntary motions of the eyes, consistently with perfect and steady vision, he will have addi- tional reason to conclude that vision is a double operation, combined, of the impression on the retina, with the sensible operation of the muscles of volition. See Nervous System, p. 374. IT Nystagmus bulbi. STRABISMUS. 335 of true strabismus. The cornea is directed upwards, attended with adhesion to the eyelid. This is one of the effects of the ac- tion of the inferior oblique, in turning up the eye during irrita- tion. In inflammation, the irritation being excessive, the cor- nea is turned up, and often it is permanently fixed by adhesion in that position. In such distortion of the eye, the interior has probably suffered; often the eyeball is small and sunk.* "Out of these experiments there arises a question:—When one of the recti muscles is divided, the pupil is directly and per- manently drawn in the contrary direction; why does not the same follow the division of the internal rectus, in those that squint? We know nothing until this be explained. DOUBLE VISION--THE STATE OF THE EYE IN INTOXICATION. " In soporific affections, the brain influences the muscles un- equally. In intoxication, we have demonstration of what we may also perceive in the end of fever, and in acute hydrocepha- lus. By our best physiologists, the position stands thus,— When the brain is oppressed, the muscles which are most di- rectly under the will are the soonest affected, and to the greatest degree. The progress of the drunkard, from the first stage, when he attempts, in vain, to snuff the candle, to his finally falling under the table, gives proof of the gradual manner in which debility encroaches on the muscular system. First of all, his sight is affected, and he sees double;! because the recti * " We ought to have a term for this permanent distortion, and Lucitas is by some applied. But authors use it in different senses. ' Strabismus est, quando uterque oculos ad exteriora conversus est, Lucities quando introrsum ad nares.' —Boerhaave. The conclusion of the paragraph I like better,' Omnes hi morbi nunquam intelliguntur nisi cognitis conditionibus, quae ad visum requiruntur.' The unequal action of the muscles moving the eye is Strabismus. The unstable and frequent motion of the eye, Hippos, by Galen. See Histoire de Chirurgie, De Gorter, &c. " The eye may be tied by adhesion, so as to be drawn from the true parallel, and so produce double vision. The adhesion may be stretched, or the eyelid may be so relaxed, as to admit the ball to resume its place. See Langius as quoted by Porterfield, Ed. Medi Essays, vol. iii. p. 159. Such adhesions, when the interior of the eye is sound, admit of operation. t " It is classical. Pentheus driven to fury by the Bacchanals, is made to see double; two suns. Virgil JEneidos, iv. 369; Eurip. Bacchae, 918; and Juvenal, Sat. 6. ----jam vertigine tectum Ambulat, et geminis exurgit mensa lucernis.— 336 STRABISMUS. muscles, those of direct volition, soonest yield to the influence, and the obliqui, the involuntary muscles, prevail, so as to dis- turb the adjustment of the eyes. " Double vision, then, is the deranged condition of the mus- cles of the eyes, by which the rays from an object are made to fall on points of the retina which do not correspond; and two weaker images, instead of one stronger, are presented to the mind.* Still this distortion of the eye is not a squint, nor does it depend on the same cause. " I have known a person who squinted, to be sensible of two images, one distinct and the other very feeble. But, in general, he who squints sees single. The difference is manifest between double vision and squinting. In the former, both eyes are dis- torted, and on both the image is faint, because rays from the object do not fall on the central points,—the sensible spots of the retinae. In the latter, that is, squinting, the defect is in one eye. It is distorted, and the rays fall on the less sensible part of the retina; whilst the sound or unaffected eye has the rays falling on the sensible spot, and the sensation is distinct. By and by, the stronger image is alone contemplated, to the exclu- sion of the weaker, and single vision is the con sequence .f A SQUINT—HOW PRODUCED—THE CONDITION OF THE EYE. " A person who squints has one eye distorted; notwithstand- ing which, he sees single, and is sensible of any defect. If the * " In hemicrania and sympathetic pains of the head, the eyes suffer. Dex- ter oculus visu tantum non omni privatus si cum sinistro simul ad videndum ape- ritur omnia objecta sistit duplicata: hinc aliquid lecturus, scripturus aut exacte consideratus, dextro clauso solo sinistro uti valet oculo, &c. Hoffman, Cent. i. Sectio i. Cas. iii. Double vision coming on in the adult, we fear that gutta serena may follow. Disput. Inaugural. Halleri, De visu Duplicate Obs. iv.; Ratione eventus in visum duplicatum curalilem, Obs. 1, 2, 5, 6; incurahilem, Obs. 4, 11; lethalem, Obs. 7; see also Briggs. With double vision we have Vertigo. It disappears when the patient shuts one eye and sees single, if it proceeds from derangement of the action of the muscle. A person with double vision from slight cerebral affection cannot see, he is afraid of losing his way. But on closing one eye, he sees perfectly. Here, when both eyes are used, the impressions are not made on the centre of either eye, and hence weakness and confusion of sight. See cases by Dr. Mackenzie of Glasgow, p. 302. t " I beg the reader to peruse the case cxii. of the Nervous System and to reason upon it. STRABISMUS. 337 stronger eye be shut, he readily turns the weaker to the object. Nor must it be forgotten that, when looking with both eyes, the weak eye accompanies the strong in every motion, but always preserving the same relation,—the axis of the weak eye devi- ating in a certain constant degree from that of the stronger one. These facts do away with the idea that there is any one of the recti muscles incapable of action; or that the cause of squinting is any thing more than a certain degree of imperfection of the muscular power. " The following is a frequent occurrence, and it shows how liable the external rectus is to derangement, and the effect of weakness in it. An elderly lady complains that she sees double. It appears that this is only when she directs her eyes to the left side. I place myself before her, and she sees me correctly and distinctly. I move to the right side, and she still sees me single. But when her head is kept steady, and I move to her left side, and direet her to follow me with her eyes, she sees me double,— she sees two figures, one-half of the one figure over the other. I move a little farther to the left, and the images separate. Still as I move farther to the left, the images are more separate, and one is faint compared to the other.* " We see here in an elderly person the progress of that defect in the rectus externus, which leads to squinting. When the ex- ternal rectus of the left eye is relaxed, the imperfection is not perceptible. The muscle is defective only inasmuch as it cannot fully contract, and therefore the eye cannot be directed outward to the degree that the other eye is directed inwards. The con- sequence is, that the impressions on the two retinae no longer cor- respond,! and the more the right eye is turned towards the left, the farther are the impressions on the retina apart, and the farther the images seem to separate. " With this state of the ball of the eye, the upper eyelid is sometimes relaxed and fallen. Nor should it surprise any one who has observed that there is a natural connexion between the shutting of the eyelids and the inversion of the cornea, that both conditions should take place from the same influence,—the re- laxation of the rectus externus and of the attollens palpebral. The relaxed eyelid and the inverted cornea are frequent conco- * " See a case precisely similar, in the author's Nervous System, No. cxviii. f " See Halleri Disp. Anat. v. iv. De visione qua oculo fit gemino. 338 STRABISMUS. mitants, however we may account for it. In every step of the inquiry we shall find occasion to revert to the natural conditions and actions of the eye. " I have just examined a lady who sees naturally well, when the objects are near; but at ten feet off, they are double. The reason is, that the eyes have a due power of converging; but to be directly parallel, requires more action in the abducentes; and they being weak, the parallelism is not perfect.* " I have watched the commencement of a squint in a child, and have observed it from occasional distortion, to the confirmed strabismus. At first, mamma said, 'Sir, you are squinting;'— master was stuffing with apple-pie. The occurrence gave it the more interest to me; and the parents being my friends, I watched the boy. When challenged, he could, by attention, look straight; but after a time, he lost the power, and a most determined squint was the consequence, which now disfigures the man. " I prefer when I can obtain it, the opinion of an unbiassed observer. A friend writes—' To-day I had the opportunity of observing an incipient strabismus in a boy of eight years of age, while waiting with his mother in the hall of the hospital, I no- ticed the squint which was in his left eye, to be most manifest while he was sitting listlessly, apparently in a day-dream. On calling to him, and having his attention awakened, there was an obvious difference; the squint almost disappeared.! " In confirmed strabismus, joined to the distortion, there is a defect in the retina itself. When the sound eye is shut and the squinting eye turned towards you, the sight is seldom strong; very often when you hold up a watch, the patient cannot tell the hour,—perhaps not see the bars of the window. Here a question of practical importance arises—Is squinting purely a defect in the action of the rectus externus; and is the weakness in the retina consequent on the distortion, from want of use? * " The same kind of defect was observed by Sir Everard Home, quoted by Mr. Mackenzie on diseases of the Eyes. Diplopia, and Phil. Trans, for 1797, part i. p. 7. f " Porter field believed that squinting might in some cases depend on the sensible spot of the retina being somewhat removed from the axis,—Edin. Med. Essays, vol. iii. p. 153,—a fancy to which I can give no credit. He spe- culates too much on the displacement of the humours of the eye in causing strabismus. STRABISMUS. 339 or does the retina participate in the original defect? Is the imperfection of vision concomitant or consequent ? "When I examine a true case of strabismus, with the view of determining on the propriety of dividing the internal rectus, I find the pupil turned towards the nose, and after a time it is turned inwards and upwards. This proceeds from the relaxa- tion of the superior oblique, and consequent prevalence of the inferior oblique. " This, however, is no reason against the division of the inter- nal rectus. But let it not be supposed a reason for dividing either of the obliqui. These are muscles provided for the pre- servation of the eye, and ought not to be deranged. " Every thing tends to show that, in strabismus, the proper and common squint, the defect is in the relaxation of the rectus externus, and that the action of this muscle is impaired, not lost. It is the tendency of this muscle to relax, and not the increased power of the rectus internus, which is the cause of distortion. Were the action of the first altogether lost, then would the cor- nea be turned towards the caruncle; and there it would remain, as when the muscle is accidentally divided in a wound.* "In experiments on the monkey, the division of one of the recti muscles gives the ball entirely up to the action of the op- ponent. That the division of the internal rectus of the human eye, in those who squint, does not cause a distressing squint outwards, is owing to the weakness of the external rectus, and is an additional proof that the defect is there. An intelligent correspondent informs me, that a surgeon having cut the internal rectus of both eyes, the patient 'looked like a vicious mare going to kick.' This change from the ' bull-eye/ few would deem a happy effect of the operation .f But such must be the effect of cutting the internal rectus, if the external possesses all its power. There are circumstances in the anatomy of the orbit which explain the property in the eyeball of turning towards the *"The complete division of the rectus externus causes the eyes to turn in- wards. See Sennertus, as quoted by Boerhaave, Pralectiones, t. vi. dcccxlvi. The man had received a wound in the orbit, which cut the rectus externus— This turned the pupil towards the inner canthus. He afterwards had a wound which perforated his nose; 'et tota vita sua per vulnus et nasum, tanquam op- ticum tubum objecta vidit!' t"The bull, when he levels his horns to the ground, has his eyes directed inwards and upwards. In death, especially in bleeding to death, the eyes are so distorted. 'Ita Plato ait, Socratem cum brevi ante mortem de anima dis- seret, taurinum inspexisse.' 340 STRABISMUS. nose when the rectus internus muscle has been divided. The orbit is oblique: the foramen opticum is nearer the mesial or central line than the eyeball, and the muscles diverge obliquely outwards to their insertion. By this position the superior and inferior recti have a power over the eyeball when the internal rectus has been divided. If we consider the habitual position of the eyeball in those who squint, it will appear that this action of the superior and inferior recti will be increased.* Such, I apprehend, is the reason that the pupil is not immediately turned out on the division of the internal rectus. It has not escaped the reader's attention, that the united action of the whole mus- cles of the eye is to turn the pupil inwards, and to squeeze the eyeball of the inner canthus when the organ is irritated. " If the definition of a squint be correct, that the patient sees with one eye only, while the other is distorted and neglected, then he cannot squint with both eyes, though he may squint alternately with one or the other. A patient will look at an object with one eye only, and it is indifferent with which. If the object be on the right side, he will look at it with the left eye ; if on the left, he will look at it with the right. Here there is no defect of the retina, and the abducens muscle of both eyes is weak, and hence the prevalence of the internal rectus in both, so that the left eye is easily directed to the right, and the right to the left side. " In a case of this kind, Dr. Darwin supposed the defect to arise from a depraved habit. I think it more probable that the influence which deranges the action of the rectus externus of one eye, should affect both; my surprise being that, if the cause be in visceral disorder, and operating through the large connex- ion of the sympathetic nerve with the abducens nerve, both eyes should not be oftener affected. [See note at the end.] "A respected friend and old pupil writes thus:—'The gen- tleman did not present any appearance whatever of squinting, till about the time when the ladies withdrew, namely, when we may presume the process of digestion was established. " 'Both eyes were equally affected, and the squint consisted in each eye occasionally turning too much inwards. "'After much watching, and observing the effect of his di- recting his orbs (which were unusually prominent) to the objects * " See Note xvi. STRABISMUS. 341 on the table, I satisfied myself that he could direct either eye, with the natural degree of power, in any particular direction. But it seemed that, on each occasion of turning his eyes, he re- garded the impression on one eye exclusively; that is, one eye ap- peared fixed in a true line on the object under his view, while the other eye squinted inwardly. "' For example, if he looked on a dish or decanter to his right side, the right eye had the object truly covered, but the left was penetrating to the cavities of his nose, or was turned to the glabellum, and vice versa. "' The explanation seemed to be this:—When looking to the objects on his right side, he employed the right eye, as being the one most favourably placed for viewing objects on that side, with a greater amount of volition, or a more positive effort of the will, than the left eye. He preferred, as it were, exercising this eye and attending to its impression, to using the eye situated un- favourably.' " My friend proceeds to argue the matter ingeniously. I may state it thus:—The defect is in the rectus externus of both eyes. In looking aside, say to the right, the recti externi are in oppo- site conditions; the rectus externus of the right eye is active, the strong stimulus of the will is upon it in a state of contraction; the rectus externus of the left eye is in a state of negative ac- tivity or relaxation. It is in this state that it exhibits imper- fection, betrays weakness, and relaxes too much; consequently the other muscles prevail, and the eye is distorted inwards. Matters are precisely reversed when this gentleman looks to the left side. " These cases, differing from the common, one of pure stra- bismus, show that to judge of the precise condition of the eye requires both knowledge and natural acumen, which, as I am proud to say of a pupil, this last communication evinces. " I have the less difficulty in believing that, in some rare in- stances, the violent crying and convulsive struggling of a child shall produce squinting, because in that state of excitement, what we may call the natural condition of the eye is exactly that of strabismus; the cornea in passion being drawn inwards and up- wards. But, in common cases, every thing tends to persuade us that the defect consists in a certain weakness of the rectus externus. We see a squint produced under a crapulent state of stomach; and at an early period, it is cured by attention to diet 342 STRABISMUS. and the state of the abdominal contents. As I have just said, the relation between the great class of visceral nerves, the sym- pathetic, is most direct with the sixth nerve, in its course to this single muscle; so that the deduction from the anatomy corre- sponds with our experience of symptoms.* " The more that any one knows of the fine adjustment neces- sary to correct vision with both eyes, or the more he thinks of the combination of muscles accessary to vision, the greater must be his surprise that an operation so rude as that of dividing one of the muscles, should have the effect of curing squinting. Reason- ing a priori, one would say, that the effect must be to produce double vision, by bringing the images on the retina nearly, and not absolutely to a correspondence; and the surprise is rather increased than allayed by the fact, that in some instances it has the effect referred to. Why, then, is it not the same in all? Because the person continues to see with one eye only. " In the last twelve patients whom I have carefully examined, operated on by different hands, one only has vision of the eye which was cut. In that case, the sisters inform me, that she * "Squinting is attributed to many causes. It is said to be hereditary; and so it may be considered. But the cause is rather to be looked for in the dis- position to a certain disorder of the abdominal functions, than to a direct in- fluence on the eye. It is attributed to the position of the infant in respect to light, or to some attractive object; to the habit of looking to its nose: to im- proper education, &c. All this is misplaced ingenuity. It is equally an error to suppose, that when the eye is defective in sensation, it is left to wander. The distortion is not a wandering, but a necessary consequence of a certain defect of the outer rectus muscle, in nineteen out of twenty cases. " In treating of squinting, we must not forget that the muscles of the eye are subject to a variety of derangements; and although the external rectus is most frequently deranged, the other muscles are not exempted. " ' Palpebrarum quoque et bulbi oculi, musculi non raro afficiuntur, ubi imi ventris nervi irritantur. Quanta mutatio in oculis infantum observatur quo- rum prima regio saburra acri repleta est? inordinate et rapide hinc inde mo- ventur, nunc sursum nunc deorsum, abconditis sub palpebris pupillis, modo ad latera attrahuntur, modo extra orbitam pelluntur, vel intra ipsam deprimuntur; in aliis palpebrae distrahuntur, bulbi figuntur, ut attente objecta aspicere cre- deres, somno licet correptos haec omnia horrorem adstantibus injicientia spec- tacula evanescunt, simul-ac alvus subducitur, vel vomitu acria expelluntur.' — Rahn de miro inter Caput et Viscera Abdominis Commercio, § xiv. " A case is related by Pamard, Journ. de Medecine, t. xxiii. p. 63, of a spasmodic squint cured by a critical evacuation of the bowels; and Borelli, Hist, et Obs. Rar. Med. Cent. ii. Obs. i. has a case of strabismus occurring in a woman on every recurrence of pregnancy. STRABISMUS. 343 did not always squint, but only occasionally; and, 'as mother thought,' only when her stomach was deranged. "It is one thing to cure the distortion, another to cure the squint and restore the perfect use of the eye. In the other cases, the individuals do not use the eye operated on. The sensibility of the retina is weak, and the image is obviously not regarded. Perhaps this is a happiness, since, in certain instances, double vision has been produced; and, to see correctly, the person has had to put his hand on one eye. " The effect of cutting the internal rectus is not to destroy its action finally and altogether; but after a time the divided mus- cle must form adhesions more or less directly to the eyeball.* In a case seen whilst I am writing, the internal rectus was di- vided, and I was disappointed in finding no effect at the first. It is now the fourth day, and the distortion is quite removed. We must conclude that the division and reunion diminishes the power of the muscle, and reduces it to that state of action in which it is equivalent to the external rectus, and no more. Its reunion to the side of the eyeball, through the intervention of the cellular membrane, must be attended with considerable cur- tailment; and the happiest result is when that curtailment and consequent diminution of power correspond with the state of debility in the external rectus. " The subject is highly interesting; the result truly surprising and beautiful. Here is an operation which removes a great and striking deformity. We have yet to wait for results: ingenuity has been baffled; we must be patient for experience. Let not the operator promise perfect success as to the restoration of vi- sion in the eye. What I have said will, I hope, stay the hands of those who, without reflecting on the distinct action of the muscles, and devoid of the necessary experience, divide other muscles than the internal rectus. Before dividing the internal rectus, let the operator deliberate well on the condition of its op- posite, the external rectus. If the affected eye be incapable of turning outwards when the other is shut, let it be ascertained whether this proceeds from weakness in the rectus externus, or * "It is said we have no proof of the reunion of the muscle; but we see it in other instances; at all events, it is pertinent to observe, that some of my friends divide the tendinous insertion, others go back to the belly of the mus- cle and divide it. See the last of the additional notes on the action of the rectus superior and inferior. 344 STRABISMUS. from an adhesion on the inner side. Let the operator well con- sider whether deformity has arisen from disorder of the muscles merely, or from disorder attended with inflammation and with adhesion. "lama little skeptical on the subject of adhesion causing a squint, and its division being attended with perfect success. In a common squint there is nothing to produce inflammation and adhesion. The defect is in the muscles. That the internal rec- tus should be increased in powTer is not improbable; nor is it impossible that it should degenerate: but, as in squinting, the weak eye moves freely when the strong eye is covered, it is evi- dent that the distortion does not proceed from that cause. ADDITIONAL NOTES. " The manner in which I have studied the subject lately has been to note the cases as they occurred, keeping to the facts simply. The reader may ap- ply to them the reasoning in the text as an exercise. "I. This young woman desires to know if she should have the 'new ope- ration ' performed upon her eye. The left eye squints—not always—it is ir- regular in its movements—the vision in the left eye is imperfect. She can- not tell the hour with it on my watch—nor see the bars of the window:— when she puts her hand on the right eye, she can distinguish me with the left—on raising the hand from the right eye, the left turns slightly towards the nose. "My opinion is, that the operation will not improve her sight—the squint is not complete—it is more an unsteadiness from want of acute sensation. The effect on her countenance is hardly a blemish. II. " I am requested to decide for or against the operation in this young lady's case. The left eye squints,—it is turned towards the nose, and a little upwards—a confirmed squint. On closing the right eye, she sees with the left, and can direct it fully in the circle. It was after the measles that she was observed to squint. "The feebleness of the impression on the retina is no objection to the ope- ration. I think she should submit. "I saw this lady eight days after the R. internus m. was divided—the effect was good—the eye was unsteady; but nothing to deform an agreeable countenance. The fungus, which sometimes rises in the place of incision, is in this case very large; having been touched with caustic, it is at present ugly. It will disappear. "III. Mrs.----squints inwards, not upwards, with her right eye. Some- times she sees double; when I retire from her to the distance of nine feet, she sees two objects; when I hold the watch near, she does not see double,—in read- ing, she does not see double. She says, long before this proposal of cutting for squinting, she wished that something was cut which tied her eye. The eye is large; it is in consequence of the white part being turned forwards. When I STRABISMUS. 345 make her cover the sound eye, and look at me, the eye appears to be diminished. She says, the double image is like the double rainbow, one distinct, and the other like its shadow.—Operate. "[Eight days had passed.] The eye cut is now direct in the centre—she moves it outwardly to the full extent. It is with pain that she directs it to the nose. On the day succeeding to the operation she felt as if at sea, with an inclination to retch,—the room moved up and down—felt as if the room was unsteady. " There is no such affection as authors describe, where particular objects are seen double, and not others: