A SYSTEM OF SURGERY. BY BENJAMIN BELL, MEMBER OF THE ROYAL COLLEGES OF SURGEONS OF IRELAND AND EDINBURGH, ONE OF THE SURGEONS TO THE ROYAL INFIRMARY, AND FELLOW OF THE ROYAL SOCIETY OF EDINBURGH. IN FOUR VOLUMES. ILLUSTRATED WITH ONE HUNDRED COPPERPLATES. VOLUME I. THE FIRST AMERICAN EDITION, CORRECTED. PRINTED AT WORCESTER, MASSACHUSETTS, By ISAIAH THOMAS. Sold by him in WORCESTER, and by said THOMAS and ANDREWS, FAUST'S STATUE, No. 45, Newbury Street, BOSTON. MDCCXCI.  PREFACE. IN an undertaking so arduous and so extensive, as a General System of Modern Surgery, it may be proper to explain the reasons which induced me to enter upon it, and to point out the plan upon which I have proceeded. The learned and judicious Heister publish- ed the last edition of his System of Surgery so long ago as the year 1739. In this work, the author comprehends whatever the experience of former times had approved as useful; and adds such observations as his own knowledge in Anatomy and practice in Surgery suggested. This was the first, and it still remains the only, complete System of Surgery of which we are possessed. Since this publication of Heister's, many valuable discoveries and important improve- ments have been introduced; and the Public has at different times been favoured with ac- counts iv PREFACE. counts of them by their respective authors. But these publications treat of various sub- jects, and are all necessarily unconnected with each; so that the additional knowledge with which our art has been of late enriched, lies in a very diffused, and to many perhaps in an inaccessible, situation. It is true, that some attempts have been made towards a full systematic arrangement of chirurgical subjects. Platner published his Institutes of Surgery in the year 1745; and Ludwig favoured the world with a similar pub- lication in 1767. But both these works may be properly considered as heads of lectures which were read by those celebrated professors at Leipsic; and although possessed of much mer- it, they are too concise to give a clear and dis- tinct idea of the various topics of which they treat. In consequence of this, the young student in the art, as well as the intelligent practition- er who is desirous of information, is obliged to consult a great variety of publications, which he frequently finds much difficulty in procur- ing, and which his other occupations will not always allow him sufficient time to peruse. Induced PREFACE. v Induced by these considerations, and having frequently experienced much inconvenience from the want of a well digested System of Surgery, I have been led to attempt the present work: Which, though it may not afford much new information to practitioners of experience and reflection, who are accustomed to peruse every publication that appears; yet to the younger part of the profession, and to all those whose opportunities of acquiring knowledge have not been considerable, I flatter myself it may prove serviceable. I have exhibited a view of the art of Surge- ry, as it is at present practised by the most expert surgeons in Europe, as far at least as my own observation in the course of attending different Hospitals, joined to the advantages of reading and correspondence, have enabled me so to do. It may be proper to remark, that a number of improvements suggested at different times in various parts of Surgery, are here purpose- ly omitted. Within these last thirty or forty years, such a rage has prevailed for the inven- tion of new instruments, that it has become fashionable to accompany every publication with vi PREFACE. with something new and singular of this kind. Some of these have undoubtedly been produc- tive of much advantage: But the greatest part of them tend more to evince the ingenu- ity of their authors, than to render the opera- tions for which they were intended, more easi- ly accomplished; for, although facility in performance is one great object in every sur- gical operation, yet the ends we have in view are in general attained by very simple means. Indeed, one object of the present publica- tion is, an endeavour to divest the art of all that useless machinery with which it has been encumbered; and to retain only what appears evidently to rest upon the solid basis of ex- perience. I have therefore been particularly attentive, in admitting nothing which I have not myself found confirmed by trial, or which I have not known to prove useful in the hands of others. My connection with a large hospital, the Royal Infirmary of Edinburgh, to which the greatest part of the poor in Scotland requir- ing the assistance of chirurgical operations, are accustomed to resort, together with that private practice which has fallen to my share, have PREFACE. vii have given me opportunities both of re- peatedly performing every operation myself, and of being frequently present when they were performed by some of the most expert surgeons of this place; a circumstance which enables me to speak with some degree of confi- dence, though, I hope with due caution, of each. Without such advantages, I should not have thought myself justifiable in under- taking the present Work; for it is chiefly by hospital practice that any individual can ac- quire such experience in the great variety of chirurgical operations, as to be able to form any accurate ideas concerning them. I have not in the course of the following Work, attempted a particular systematic ar- rangement of the subjects of which it treats. Arrangements of this kind have indeed been employed with advantage in different branches of science: The study of natural history has been much facilitated by their means; and a knowledge of the more general diseases to which the human body is liable, is perhaps acquired with more ease by the comprehensive views which a well digested nosological system gives of them. But, as disorders of every kind requiring viii PREFACE. requiring the assistance of the operative part of Surgery, are perfectly local and unconnect- ed with one another by means of symptoms common to each; and as it seldom happens, that there is much similarity in the means necessary for the removal of such diseases; the parade of classification under such circumstan- ces, although it may serve to display the fancy of an author, can have no effect either in ren- dering the study of Surgery more easy, or the practice of it more attainable. Yet when one subject is naturally connect- ed with another. I have not any where at- tempted to separate them; and when the de- scription of any operation can be more easily understood from what has been said concern- ing another, I have considered them in imme- diate succession: But, in other instances, where no connection can be traced between the different articles treated of, no methodical arrangement can be with advantage attempted. Were I to endeavour to trace the successive improvements which have been made in sur- gery within these last fifty or forty years, I should often find it difficult, and sometimes impossible, to determine by whom the prac- tice PRACTICE. ix tice, as it is now established, was introduced; and in order to give a fair account of the progress of the different operations of surgery from their rude to their improved state, I should be under the necessity of entering into a full chronological history of each. While inquiries of this kind could serve no useful purpose, they would tend to render more pro- lix, a work which, from the variety of its sub- jects, must necessarily extend to a great length. I shall therefore in general decline them. On some occasions, however, when the author or any remarkable improvement is known with certainty, I shall not fail to give him all the credit which his discovery seems to merit. Such of my readers as are fond of theoreti- cal disquisitions, will, I am afraid, be frequent- ly disappointed. When the subject under consideration can be rendered more clear and intelligible by it, I have occasionally employ- ed such reasoning as experience and common sense seem evidently to support; but I have every where studiously guarded against enter- ing on the discussion of doubtful and specu- lative opinions. In B x PREFACE. In considering the different subjects, the appearance or symptoms of the disorder-—the usual causes known to induce it-—its probable consequences-—and the best method of treat- ment-—are particularly described in succes- sion: And when an operation of importance is to take place, the parts which lie contigu- ous, but which the operator ought to avoid, are pointed out, as well as those which he is under a necessity of dividing. In describing the different operations, I have uniformly adhered to the method at pres- ent practised by the best surgeons, excepting in such instances where improvements of my own are proposed; and none of these are any where recommended, the utility of which has not been ascertained by repeated trials. In a work of this nature, it must unavoid- ably happen, that on several occasions; I differ in opinion from various respectable authors; but wherever I do so, no other motive, I hope, will appear for it, than a wish to render more perfect an art which I am attempting to describe and illustrate. I was fully aware of the difficulties to be encountered in carrying on and completing this PREFACE. xi this design; and was so diffident of my abili- ties to do justice to the undertaking, that, even after a considerable part of the materials were prepared, I chose the mode of pub- lishing it in separate volumes, that I might thereby have an opportunity of discovering the sentiments of the public with regard to its merit and utility; a circumstance, by which I was in a great measure determined in the farther execution of my plan. CONTENTS, xii CONTENTS, OF VOL. I. CHAPTER I. Page. Of SUTURES, 17 Sect. I. Of Sutures in general, 17 Sect. II. Of the Interrupted Suture, 18 Sect. III. Of the Quilled Suture, 21 Sect. IV. Of the Glovers Suture, 22 Sect. V. Of the Twisted Suture, 23 CHAPTER II. Of the LIGATURE of ARTERIES, and other means employed by Art for putting a stop to HEMORRHAGIES, 29 CHAPTER III. Of BLOODLETTING, 50 Sect. I. Of Bloodletting in general, 50 Sect. II. Of a Thrombus or Ecchymosis, 66 Sect. III. Of Wounds of the Arteries, 68 Sect. IV. Of Wounds or Pricks in the Nerves and Tendons, 72 Sect. V. Of Bloodletting in the Arm, 87 Sect. VI. Of Bloodletting in the Jugular Vein, 91 Sect. VII. Of Bloodletting in the Ankles and Feet, 93 Sect. CONTENTS. xiii Page. Sect. VIII. Of Arteriotomy, 94 Sect. IX. Of Topical Bloodletting, 97 CHAPTER IV. Of ANEURISMS, 104 Sect. I. General Remarks on Aneurisms, 104 Sect. II. Of the Treatment of Aneurisms, 128 CHAPTER V. Of HERNIÆ, 144 Sect. I. Of Hernia in general, 144 Sect. II. Of the Bubonocele, 174 Sect. III. Of the Hernia Congenita,195 Sect. IV. Of the Crural or Fæmoral Her- nia, 197 Sect. V. Of the Exomphalos, or Umbilical Hernia, 203 Sect. VI. Of Ventral Herniæ, 206 Sect. VII. Of the Hernia of the foramen Ovale, 206 Sect. VIII. Of the Hernia Cystica, or Her- nia of the Urinary bladder, 208 CHAPTER VI. Of the HYDROCELE, 212 Sect. I. General Remarks on the Hydrocele, 212 Sect. II. Of the Anasarcous Hydrocele of the Scrotum, 2l7 Sect. III. Of the Hydrocele of the Tunica Vaginalis Testis, 224 Sect. IV. Of the Hydrocele of a Hernia Sac, 254 Sect. xiv CONTENTS. Sect. V. Of the Anasarcous Hydrocele of the Spermatic Cord, 258 Sect. VI. Of the Encysted Hydrocele of the Spermatic Cord, 260 CHAPTER VII. Of the HÆMATOCELE, 267 CHAPTER VIII. Of the VARICOCELE, CIRSOCELE, SPER- MATOCELE, and PNEUMATOCELE, 273 CHAPTER IX. Of the SARCOCELE, Or SCIRRHOUS TES- TICLE, 277 CHAPTER X. Of the DISEASES of the PENIS, 293 Sect. I. Of the Phymosis, 293 Sect. II. Of the Paraphymosis, 297 Sect. III. Of Amputation of the Penis, &c. 299 CHAPTER XI. Of the STONE, 304 Sect. I. General Remarks on Urinary Cal- culi, 304 Sect. II. Of Sounding or Searching for the Stone, 311 Sect. III. General Remarks on the operation of Lithotomy, 321 Sect. CONTENTS. xv Page. Sect. IV. Of the Operation of Lithotomy by the Lesser Apparatus, 325 Sect. V. Of Lithotomy by the Greater Ap- paratus, 330 Sect. VI. Of the High Operation for the Stone, 333 Sect. VII. Of the Lateral Operation, 340 Sect. VIII. Of Nephrotomy, 375 Sect. IX. Of Stones in the Urethra, 378 CHAPTER XII. Of INCONTINENCE of URINE, 386 CHAPTER XIII. Of a SUPPRESSION of URINE, 390 CHAPTER XIV. OBSTRUCTIONS in the URETHRA, 400 CHAPTER XV. Of the FISTULA in PERINÆO, 420 EXPLANATION of the PLATES, 433  A TREATISE ON THE THEORY AND PRACTICE OF SURGERY. CHAPTER I. OF SUTURES. SECTION I. Of SUTURES in General. AS sutures of one kind or another are found necessary, not only in every large wound, but in almost every operation of importance, the consideration of this sub- ject seems first to require our attention. A variety of sutures have been practised by sur- geons, each of which has from long experience been applied to a particular purpose, viz. The interrupt- C ed 18 Of Sutures. Chap. I. ed suture; the quilled suture; the glover's and the twisted suture. Many others are enumerated by ancient writers: But the four now mentioned are the only species of sutures at present in ordinary use; and even of these, some, we think, might with propriety be omitted. The intention of every suture, is to unite parts, which either by accident or design have been divid- ed. Another mode of effecting this, is through the intervention of adhesive platters: And this by sur- geons has been termed the false or dry suture, in opposition to the others performed by the needle, which are denominated the true or bloody suture.-— But as the consideration of this subject, namely, the use of adhesive plasters in wounds, will be more properly introduced in a subsequent part of this work, we shall not in this place enter upon its dis- cussion. SECTION II. Of the INTERRUPTED SUTURE. IN deep wounds, when a reunion of the divided parts is intended, this is the suture to which we gen- erally have recourse; but from what will be after- wards more fully explained when treating of wounds, and from what will presently farther appear, it does not seem to be so well adapted to this purpose as the twisted suture. When it is determined, howev- er, to make trial of the interrupted suture, the fol- lowing is the easiest mode of doing it. In every wound where sutures are found necessa- ry for the retention of parts, it has commonly been considered as good practice, to carry the needle and ligature to the bottom of the sore, so as to give as little room as possible for matter collecting under- neath; and the usual mode of effecting this, is by introducing the needle from without inwards, and again Sect. II. Of Sutures. 19 again from the bottom of the wound to the same distance on the opposite side. But this suture, it may be remarked, is much more neatly, and at the same time more easily performed, by passing both ends of the thread from within outwards; which is readily done by using two needles upon each thread, instead of one. A needle being put upon each end of the same thread, and each needle being inserted at the bottom of the sore, and pushed outwardly so as to pass out at a proper distance from the edge of the wound, the needles are then to be taken off, and the threads allowed to remain till all the ligatures are passed which the extent of sore seems to require. The number of ligatures necessary for any wound, must in a great measure depend upon the extent of divided parts. By authors in general it has been laid down as an established rule, that one suture is fully sufficient for every inch of wound. It will frequently indeed happen, that this number is found sufficient; but in some instances, particular- ly where muscular parts are deeply cut transverse- ly, and where consequently a great degree of retrac- tion occurs, a greater number of stitches are necessa- ry: Whenever a number of angles, too, occurs in a wound, more ligatures are required than in a straight wound of the same extent; for, at every angle, however inconsiderable it may be, there ought to be a suture. In passing the ligatures, great care is necessary to pierce the skin at a sufficient distance from the edge of the wound: For if they do not comprehend a thickness of parts in some measure proportioned to the depth of the wound, and to the extent of retrac- tion which may be expected, they will very readily cut through the parts entirely.-—By some authors we are directed to enter the ligatures, at a distance from the edges of the sore nearly equal to the depth of the wound. This rule, however, will be no means be found to answer in practice. Thus, in a very 20 Of Sutures. Chap. I. very deep wound, for instance of about three inches, no necessity can occur for carrying the ligatures three inches from the edges of the sore, and again, in very superficial cuts, it sometimes happens that the ligature ought to be passed out at a distance from the edges of the wound greater than its depth. It ought not, in almost any case, to be less than half an inch from the edge of the sore; and it will sel- dom happen, even in the largest wounds, that an inch is not found to be a sufficient distance. It will be readily understood, that the strength of the ligature and size of the needle ought always to be proportioned to the depth of the sore and re- traction of parts. The several sizes of needles represented in Plate I, are such as have been found necessary in practice; and the ligatures to be used along with them ought to such as nearly, though not entirely, to fill the eyes of the different needles. In order to make the ligatures pass more easily, to render them more durable, and at the same time to make them more susceptible of a flattened form, which does not so readily cut through the contained parts as a round one, they ought all to be well cover- ed with fine beeswax. As soon as the threads are all passed, the lips of the wound ought to be pressed together and sup- ported by an assistant till all the ligatures are firm- ly tied; beginning either in the middle of the wound, or at one end, as the operator inclines. In tying the knots, it is usual to pass the ends of the threads twice through the first noose, in order to prevent their yielding; and when this is done, it is alleged by some that there is no necessity for more than one knot upon each ligature; but as two knots are very easily made, and as every chance of their yielding is thereby effectually prevented, this pre- caution ought never to be omitted. It is a practice with some surgeons, to insert a piece of lint between the first and second knots, or between the first knot and Plate I.  Sect. III. Of Sutures. 21 and the skin below, in order to save the parts un- derneath from the pressure of the knots; but as in reality all such means of protection afford no ad- vantage of importance, and as they prevent the knots from being made with exactness, they ought there- sore to be laid entirely aside. By some writers on this subject, we are desired not to bring the knots of ligatures immediately upon the edges of the wound, but rather to carry them to one side, over upon the sound teguments: But whoever has tried both methods, will at once be sen- sible, that this is by no means an improvement; for in no way can both sides of the sore be equally sup- ported, but by the knots being passed immediately above the lips of the divided parts. SECTION III. Of the QUILLED SUTURE. AS the quilled suture is still employed by some practitioners, it is here thought necessary to describe the mode of performing it. In deep wounds attended with much retraction, it is always a necessary precaution, to assist the ope- ration of the ligatures, by means of bandages so applied as to afford as much support as possible to the divided parts: But, even with every assistance of this nature, it now and then happens, that the divided parts cannot be kept together, retraction oc- curs to a greater or lesser degree, and the ligatures of course cut asunder the soft parts they were at first made to surround. With a view to prevent this receding of the tegu- ments and other parts, it was long ago proposed to add to the interrupted suture what was supposed would afford an additional support; viz. quills, or pieces of plaster rolled up into the form of quills; one of which being placed on each side of the wound, 22 Of Sutures. Chap. I. wound, the doubling of the ligature is made to in- clude the one, and the knot to press directly upon the other, instead of being made immediately on the edges of the sore as was directed for interrupted sutures. It is at once evident, however, that the ligatures must here make the same degree of pressure on the parts though which they pass, as they do in the in- terrupted suture; and this being the case, it is equal- ly obvious, that the interposition of these substances cannot be of any use. This suture is accordingly now very rarely practised, and it is probable that it will be soon laid entirely aside. SECTION IV. Of the GLOVER'S SUTURE. THIS suture receives its name from being that which the glovers commonly use. As it is exceed- ingly simple, and very universally known, it does not here require a particular description: We shall therefore just shortly observe, that it consists in a series of stitches all connected with one another, and continued in an oblique spiral direction along the course of the divided parts intended to be kept to- gether. This suture has hitherto been universally employ- ed for reuniting such parts of the interlines as have been divided by wounds: But, when treating of ac- cidents of this kind, I shall endeavour to show, that the same end may be more perfectly attained, and probably with less danger, by means of the interrupt- ed suture; so that as this suture has almost never been applied to any other purpose, it will likewise in all probability soon fall into disuse. SECTION Sect. V. Of Sutures. 23 SECTION V. Of the TWISTED SUTURE. BY the term Twisted Suture is meant, that spe- cies of ligature, by which parts, either naturally or artificially separated, are united together, by means of strong threads properly twisted round pins or needles pushed through the edges of the divided parts. This suture is commonly employed for the pur- pose of uniting the parts in cases of harelip; and this indeed is almost the only use to which it has been hitherto applied: But we may here remark, that it may with great advantage be put in practice in a variety of other cases, particularly in all artificial or accidental divisions either of the lips or cheeks; and, in every wound in other parts that does not run deep and in which sutures are necessary, this su- ture is preferable to the interrupted or any other. In very deep wounds, for instance in all wounds extending to a greater depth than an inch and a half, the interrupted suture is the only one that is admissible; for, in all such deep cuts, the pins nec- essary in the twisted suture cannot with propriety be employed, as they cannot be introduced to such a depth, and afterwards so twisted with ligatures as to reunite the divided parts, without great pain to the patient. In such wounds, therefore, we must of necessity have recourse to the interrupted suture. But it may be here remarked, that wounds of this depth requiring the aid of sutures, are very rarely met with: So that, in by much the greatest pro- portion of wounds where sutures are advisable, the twisted suture will be found practicable; and whenever it is so, it ought certainly to be preferred to every other, as being obviously better calculated, even than the interrupted suture, for the retention of 24 Of Sutures. Chap. I. of divided parts. The pins made use of for twist- ing the threads upon, ought to be made of a flat form, so as not to cut the parts through which they pass, so readily as the ligatures employed in the in- terrupted suture: And thus one great objection to the latter is very effectually obviated; for, every practitioner must be sensible of this being the great- est inconvenience attending the interrupted suture, that when muscular parts are divided, so as to pro- duce much retraction, the ligatures employed for retaining them, almost constantly cut them through before a reunion is accomplished; whereas, the flat- ness of the pins used in the twisted suture, and upon which, it may be remarked, the whole pressure pro- duced by the ligatures is made to rest, proves in gen- eral a very effectual preventative against this occur- rence. The pins used in this operation have commonly been made of silver; and, in order to make them pass with greater ease, steel points have been added to them. As gold pins, however, are capable of receiving a sufficient degree of sharpness, which renders the intervention of steel points quite un- necessary; and as gold is more cleanly than silver, from its not acquiring so readily that kind of crust which immersion in fluids is apt to produce upon the other; pins of this metal are therefore prefer- able. The form and size of pins represented in Plate II, are what experience has shown to be the most useful for every ordinary purpose; but, for par- ticular uses, the size must no doubt be subject to variations. The manner of performing this operation is as follows: The divided parts intended to be reunited, must by the hands of an assistant be brought near- ly into contact; leaving just as much space be- tween the edges of the sore, as to allow the sur- geon to see that the pins are carried to a proper depth.  Plate II. Sect. V. Of Sutures. 25 depth. This being done, one of the pins must be introduced through both sides of the wound, by en- tering it on one side externally, pushing it forwards and inwards to within a little of the bottom of the wound, and afterwards carrying it outwardly through the opposite side, to the same distance from the edge of the sore that it was made to enter at on the other. The distance at which the needle ought to enter from the edge of the sore, must be determined by the depth of the wound, and by the degree of retraction produced in the divided parts. In gen- eral, however, it is a proper rule in deep wounds, to carry the pins to a distance from the edges of the sore, nearly the same with the depth to which they penetrate: And it may be also remarked, that, whatever the deepness of the wound may be, the pins ought to pass within a very little of its bottom; otherwise the parts which lie deep will run a risk of not being united; a circumstance which will fre- quently give rise to troublesome collections of mat- ter. In passing the pins through the different sides of the wound, if the skin and other teguments are not more firm than ordinary, it may commonly be done by the fingers alone, and particularly if the pins are made with small heads or knobs for the fingers to press upon; but when firmness of parts and other circum- stances render the entrance of the pins difficult, the instrument termed Porteaiguille very effectually re- moves this inconvenience.-—In Plate II. is repre- sented the most convenient form of this instrument that has yet been invented. The first pin being passed in this manner very near to one end of the sore, and the parts being still supported by an assistant, the surgeon, by means of a firm waxed ligature passed three or four times round and across the pin, so as nearly to describe the figure of 8, is to draw the parts through which it has passed into close contact; and the thread be- D ing 26 Of Sutures. Chap. I. ing now secured with a loose knot, another pin must be introduced in the same manner at a proper dis- tance from the former; and the thread with which the other was fixed, being loosed, and in the same manner carried round this pin, others must be in- troduced at proper distances along the whole course of the wound, and the same ligature ought to be of a sufficient length for securing the whole. The number of pins to be used, must be deter- mined entirely by the extent of the wound. When- ever the suture, however, is practised, whether the wound be large or of very small extent, a pin ought to be introduced very near to each end of it, other- wise the extremities of the sore are apt to separate so as not to be afterwards easily reunited. In large wounds, if the pins be introduced at the distance of three quarters of an inch from one another, it will in general be found sufficient; but, in cuts of smaller extent, a greater number of pins become necessary in proportion to the dimensions of the sores. Thus, in a wound of an inch and half in length, three pins are absolutely requisite; one near to each end, and another in the middle of the sore: Where- as, five pins will always be found fully sufficient for a wound of three inches and a half in extent, al- lowing one to be within a quarter of an inch of each extremity of the wound, and the others to be placed along the course of the sore at the distance of three quarters of an inch from one another. The pins being all introduced and secured in the manner directed, nothing remains to be done, but to apply a piece of lint wet with mucilage, all along the course of the wound, with a view to exclude the external air as effectually as possible. In order to prevent the ends of the pins from pressing upon and hurting the skin below, it is usual to apply a small bolster of linen or charpie under each of them; but as this always does mischief, by tending to press upon the pins, so as to force them to Sect. V. Of Sutures. 27 to act upon the soft parts through which they have passed, every thing of this kind ought to be omitted. When, however, the patient happens to complain of being hurt by the ends of the pins, this may be easily prevented by introducing between them and the skin pieces of thin linen spread with any ad- hesive plaster. In order to give every chance of success to this op- eration, it has been commonly advised, immediate- ly after the pins are secured, to apply the uniting bandage over the whole, so as to afford as much support as possible to the contiguous parts. The least reflection, however, renders it evident, that every degree of pressure made in this manner must do mischief; for, the bandage being made to rest immediately upon the pins, a considerable degree of pain and consequent inflammation must of course be produced by it: And in fact this is so much the case, that, in every instance in which I have seen this bandage applied, it either did harm, by excit- ing inflammation in consequence of too much pres- sure upon the pins; or, if that effect was not pro- duced, no advantage was received from it, from the bandage not being applied with such tightness as to afford any support whatever to the parts below. The next point to be determined, is, the time the pins should be allowed to remain. When they re- main long, they generally do harm, by the unnec- essary irritation and consequent retraction of parts with which they are always attended; and again, if they are not continued for a sufficient length of time, that degree of adhesion is not produced be- tween the divided parts that is necessary for their suture retention, so that the effect: of the operation comes to be in a great measure, if not entirely, lost. In wounds of no great depth, for instance of about three quarters of an inch, a sufficient degree of adhesion always takes place in the space of five days; and six, or at most seven days, will general- ly 28 Of Sutures. Chap. I. ly be found sufficient for wounds of the greatest depth. But with respect to this circumstance, it must al- ways be understood, that the patient's state of health will have a considerable influence on the time nec- essary for producing adhesion between divided parts. In specifying the time required for this purpose, the operation is supposed to have been done in a sound and healthy state of the constitution. When the patient labours under any disorder which affects the general system, by cutaneous eruptions or other- wise, it is impossible to ascertain this circumstance with precision: In such cases we must be determin- ed by the nature and state of the disease present at the time. As soon as the pins are withdrawn, the uniting bandage may be applied with great advantage in order to serve as a support to the parts newly united; but, as slips of leather spread with ordinary glue, when applied to each side of the cicatrix, may, by means of ligatures properly connected with them, be made to answer this purpose in a more effectual manner, this mode of supporting the parts ought of course to be preferred. As the twisted suture when properly performed is a very neat operation, as its consequences are in general of importance, and as it may with much advantage be made supersede the use of almost every other suture, a few instances only excepted, I have therefore thought proper to consider it with more attention than has hitherto been com- monly bestowed upon it. CHAP. Chap. II. Of the Ligature, &c. 29 CHAP. II. Of the LIGATURE of ARTERIES AND OTHER MEANS EMPLOYED BY ART FOR PUTTING A STOP TO HEMORRHAGIES. IN every species of wound, whether ac- cidentally produced, or affected by the hands of a surgeon, the first circumstance to be attended to, is the degree of hemorrhagy that takes place. In all such occurrences, the blood is discharged, either from one or more large arteries; or, is produced by a general oozing from the smaller vessels over the surface the sore: To the former of these causes we shall first attend, and shall afterwards proceed to the consideration of the latter. A surgeon being called to a person losing much blood from the division of any of the larger vessels, the first step to be taken, is, by means of strong com- pression, to effect a temporary stoppage of the dis- charge, till by the application of ligatures a more effectual remedy is obtained. In the head, as well as in the trunk of the body, the easiest method of applying pressure of this kind, is, by means of dos- sils of lint or of soft linen, held firmly upon the mouths of the bleeding vessels, either by the hands of an assistant, or by the use of a proper bandage: Or, when pressure can be effectually applied to the superiour part of the artery, it answers better; as it not only secures the vessel equally well, but admits of the necessary ligature being applied with greater freedom. When, again, accidents of this nature occur in any of the extremities, and where pressure can be made with ease on the superior parts of arteries, for such cases we are in possession of a remedy, which, when skillfully applied, never fails to put an immediate 30 Of the Ligature Chap. II. immediate stop to all farther loss of blood. What is here meant, is, the Tourniquet. Till the invention of this instrument, which was not known before the last century, Surgery re- mained extremely defective indeed. No operation of importance could be undertaken on any of the extremities but with great hazard to the patient; and the effects of large wounds must frequently have proved mortal, from the want of this assist- ance, which otherwise might not have been in any degree hazardous. As the invention of the tourniquet is claimed by different persons, and even by different nations, we shall not here pretend to say from whence it orig- inally came: But whoever had the merit of it, the first instrument of this kind with which the world was made acquainted, was exceedingly simple; so much so, indeed, that it now appears very surpris- ing that the discovery should have been left for such a late period. A small cushion being placed upon the course of the principal artery of a limb, a cir- cular rope or bandage was made to pass twice round it; and a small wooden handle being then intro- duced between one of the folds of the bandage, for the purpose of twisting it, the cushion by these means was pressed with so much force upon the artery, as to put an effectual stop to the course of the blood through the under part of the limb. Mr. Petit, an eminent surgeon of Paris, was the first who proposed a considerable improvement on this instrument, by connecting the circular bandage with a screw, which was so contrived as to produce the pressure chiefly on the principal arteries, with- out materially affecting the rest of the limb. It had this advantage over the other instrument, that the operator himself could manage it, without be- ing under the necessity of employing an assistant; but it was liable to one great inconvenience from the very circumstance which by the inventor was considered  Plate III. Chap. II. Of Arteries, &c. 31 considered as an improvement. This instrument of Mr. Petit being made to act upon the principal arteries only, the smaller vessels communicating with these, by not being properly compressed, discharge blood freely from the instant they are cut; and as this proves a very troublesome circumstance in the course of operations, different improvements have of late been made upon it. The pattern in Plate III. is the result of all these. By means of this instrument in its now improv- ed state, the blood in any limb is very easily and ef- fectually commanded; and as it grasps the whole member equally, all the collateral branches as well as the principal arteries are equally compressed by it. It has this material advantage, too, over every other instrument of this kind, that, when properly applied, a single turn, or even half a turn of the screw, is sufficient for producing either a flow of blood, or for putting a total stop to -—The manner of using it is this. Let a cushion of three inches in length by one inch and half in diameter, be prepared of a linen roller, and be made tolerably firm, but yet not so hard as to render the pressure produced by it very painful: This being placed upon the course of the principal artery of the limb, is to be firmly secured in that situation by one or two turns of a circular roller, of the same breath with the cushion itself. The instrument A, with the strap connected with it, being now placed upon the limb, with the han- dle of the screw B on the side of the member op- posite to the cushion upon the artery, the strap C is to be carried round the limb directly over the cushion, and to be firmly connected on the other side to the buckle D. In thus connecting the strap and buckle together, particular attention is necessa- ry in doing it with great firmness, so that the screw may afterwards operate with as much advantage as possible, in producing a sufficient degree of pres- sure. When proper attention is paid to this cir- cumstance, 32 Of the Ligature Chap. II. cumstance, a single turn of the screw, as we have said, proves sufficient for putting an entire stop to the circulation of blood in the limb: But when the strap has not at first been made very tight, several turns of the screw become necessary; an occurrence which may be always easily prevented, and which, when not attended to, proves often very embarrass- ing in the course of an operation. Whenever it is determined, therefore, that any farther loss of blood from a divided artery is to be prevented, pressure on the superior part of the vessel ought to be immediately applied by the hands of an assistant, or a proper bandage, when the cut is on the head or trunk of the body; and by means of the tourniquet, when any of the extremities are wounded. The patient being in this manner secured from immediate danger, the practitioner must now pro- ceed to the easiest and most effectual mode of pre- venting a return of hemorrhagy on the removal of the tourniquet. The ancients, as we have seen, were ignorant of the use and application of the tourniquet, and they were equally deficient in the employment of means for giving a permanent security against the flow of blood from divided vessels: It will therefore readily occur to every modern practitioner, that in this im- perfect state of Chirurgical knowledge, when any capital operations were attempted, they must have run a much greater risk of doing mischief, than of procuring any advantage to their patients. To the smaller vessels they applied fossils of linen covered with astringent powders; and for the larger arteries, searing with hot irons was their only resource. Of this last remedy, however, although it com- mands a temporary stoppage of the blood in every case of hemorrhagy, the effects are by no means to be depended on: For, in general, the pulsa- tion of the larger arteries very soon overcomes all the Chap. II. Of Arteries, &c. 33 the resistance produced by the application of the cautery. In ancient times, however, when this was the most effectual remedy with which the world was acquainted, practitioners were under the necessity of having recourse to it; and, at that period, it is not surprising to find them exercising their ge- nius in inventing a variety of styptic applications: But since surgery became enriched with that mate- rial improvement of securing the larger arteries by means of ligatures, a practice easily effected, and with very little pain to the patient, it is surprising to find that remedies of this kind are still searched after. If the use of ligatures were in itself attend- ed with much difficulty, if by experience it had been found to be productive of many bad conse- quences, or, if it had been frequently known to fail in answering as a full security against the he- morrhagies of the larger arteries; in any of these events, it ought to be the business of practitioners to endeavour to procure a more effectual remedy. But, as the ligature of arteries is very simple in its nature; as the pain arising from it is trifling; as few instances occur of any thing bad being produc- ed by it; and especially as, when properly perform- ed, it never fails of proving a sure preventative against all loss of blood from the larger arteries; there can be no good reason for anxiously seeking after other remedies. Agaric and other fungous substances have been much extolled for their styptic powers; and cha- lybeate solutions, as well as all the variety of mine- ral acids, have in different forms been held forth to the publick as effectual remedies of this nature; not only as nostrums by those of less liberal prin- ciples, but, what is more surprising, in some instan- ces by practitioners of character. With the former class of men this happens as a common occurrence in the course of their profession, E and 34 Of the Ligature Chap. II. and is therefore to be expected; but a perseverance in quest of any new remedy of this kind on the part of Surgeons of reputation, who are already well acquainted with the effects of ligatures in cases of hemorrhagy, and who also know that the practice is seldom attended with bad consequences, must proceed from a degree of nicety and refinement, which may create much trouble to themselves, and which in all probability can never be productive of any practical advantage. We shall therefore venture to lay it down as an established maxim in surgery, That in every case of hemorrhagy from any of the larger arteries, no styptic application whatever ought to be trusted to, the ligature being the only remedy to be depended on. We now proceed therefore to the consideration of the easiest and most effectual mode of carrying this application into execution. Various methods have been invented for securing arteries by means of ligatures. The practice now in ordinary use, is, by means of a curved needle, to pass a ligature of sufficient strength round the mouth of the bleeding vessel, including a quarter of an inch all round of the contiguous parts*, and afterwards to form a knot of a proper tightness up- on the vessel and other parts comprehended in the noose. One great objection, however, to this method is, that the nerves accompanying the blood vessels, to- gether with a considerable portion of the muscular substance through which they pass, must always be surrounded with every ligature formed in this manner. From this circumstance much more pain is produced than is necessary, by the nerves and other parts being at the same time compressed with the arteries; and, on some occasions, the same cause has evidently given rise to violent convulsive affections, * Sharp's Surgery-—On Amputation. Chap. II. of Arteries, &c. 35 affections, not only of the part chiefly affected, but of the whole system. Spasmodic twitches are frequently found to oc- cur after the amputation of limbs, and are often the source of much distress. In some instances they are no doubt to be considered as the effect of other causes; but in various cases it has happened, that demonstrative proof has been obtained of their arising from the ligatures of arteries applied in an improper manner. When such convulsive affec- tions occur after amputations, and the usual means of preventing them are found to fail, effectual re- lief may be frequently obtained by destroying the ligatures altogether, so as to remove the compres- sion upon the nerves; care being taken at the same time to renew the ligatures upon the arteries imme- diately, without comprehending any of the contig- uous parts. Thus, it is not to the simple ligature of vessels, but to the improper manner in which the operation is performed, that is, the including of nerves and other parts, instead of tying the arteries alone, that the bad symptoms occurring in such cases are to be attributed. Practitioners have commonly afraid of ty- ing up blood vessels by themselves without the in- tervention of some of the surrounding parts, on this supposition, that the coats of arteries are not of sufficient firmness to bear that degree of com- pression necessary for the prevention of hemorrha- gy. This, however, originates from an idea that the coats of arteries are not so strong as they really are; and that a great degree of force is necessary for compressing their sides into close contact with one another. But it is now well known, that even very small arte- ries are possessed of much firmness; and it is also cer- tain, that even in the largest arteries of the arm or thigh, 36 Of the Ligature Chap. II. thigh, a very flight degree of compression is Sully sufficient, not only for restraining hemorrhagy, but for Securing the ligature on the very spot to which it is first applied: And in small vessels the force nec- essary for this purpose is trifling indeed; being far less than is commonly applied. Although the circumstance we are now infilling upon may not at first fight seem to be of much importance, yet in fact it merits very particular at- tention. Even of itself it is a matter of no small consequence, but it is the more material when we consider it as connected in many instances with circumstances on which the life of a patient may in a great measure depend; and we know well too, that success in surgical operations depends more on a minute attention to every circumstance relating to them, than on particular dexterity in any one part of them. It has also been objected to this mode of secur- ing blood vessels by themselves, that the ligatures, although they should not cut the arteries through, yet that they are more apt to slip than when some of the surrounding parts are comprehended along with them; and, in some instances, it is said that ar- teries retract so far, that they cannot in any other way be laid hold of, than by means of the crooked needle in the ordinary method. Long and repeated experience, however, of a few individuals, in regard to this mode of taking up ar- teries by themselves, has put the fact beyond a doubt, that it is as secure as any other yet invented*. -—Fatal hemorrhagies after capital operations, either from inattention, or some other cause, do now and then indeed happen in the hands of the most able practitioners; but occurrences of this nature have as frequently happened when the curved needle was employed, as when the blood vessels were secur- ed * See an essay upon this subject, by the ingenious Mr. Aitken, surgeon in Warrington. Chap. II. of Arteries, &c. 37 ed by themselves without any of the contiguous parts being included. From the result of my own experience, indeed, I should be induced even from this consideration, to draw a conclusion in favour of the method we have been endeavouring to recommend. For, in the course of practice, both among hospital patients and in private, I have known different deaths occur from the bleeding of stumps after the amputation of members: Whether this proceeded from the liga- tures having slipped from some of the arteries; or from this circumstance, that some of the vessels which did not appear during the operation, had been of course passed over without being observed and had afterwards burst out, I shall not pretend to determine: But in all of these, the crooked needle only had been used during the operation; and it has so happened, that I never met with a single instance of a similar occurrence where the arteries were se- cured by themselves by means of the tenaculum; an instrument to be afterwards taken notice of. In a few instances it may happen, that a bleeding vessel, from lying at the bottom of a deep wound, cannot be laid hold of in any other manner than by the curved needle being made to pass round it. Such occurrences, however, are exceedingly rare: Insomuch that I have seldom known an instance in which hemorrhagy could not be as effectually re- strained by the mode now to be pointed out, as by the use of the crooked needle. In all operations whatever, to save unnecessary pain ought to be a very capital object. In every business of this kind, the object in view ought no doubt to be attained in the most complete manner; but that mode of operation, which is as complete as any other, at the same time that it is the least pain- ful to the patient, is undoubtedly in every instance to be preferred. Now, with respect to the point in question, as we have already clearly shown, that ar- teries 38 Of the Ligature Chap. II. teries may be tied with as much safety in every re- spect, by themselves, as when connected with any of the neighbouring parts, the difference of pain produced by the two modes of operating, ought at once to determine in favour of the former. When any of the contiguous parts, particularly when the nerves which generally accompany the blood vessels, are included in the same ligature with an artery, which when the curved needle is employ- ed is a circumstance scarcely to be avoided, every practitioner knows that tying the knot in this man- ner is frequently complained of by the patient in very severe terms. I have on many occasions known patients who have borne the amputation of limbs, and of cancerous breasts, without shrinking, complain bitterly of the severe pain produced by the method of securing arteries with the crooked needle. And on the contrary, the pain attending the method now proposed, is so trifling, that, when properly done, even the most timid patients very seldom complain of it. For some time after I first began to use the tenac- ulum, curiosity induced me, on different occasions, to put the matter under consideration to the test of experiment: And to render the trial as fair and de- cisive as possible, it was always made upon the same subject, under the same operation. Different vessels were secured in the ordinary manner by the crook- ed needle; whilst others were laid hold of by the tenaculum: But so great was the difference in point of pain, that the one was uniformly allowed to give very little uneasiness: Whereas it frequently hap- pened, that the other was complained of as the most painful part of the whole operation. Among other advantages which the tying of ar- teries by means of the tenaculum has over the old mode of operating, there is still one we have not yet taken notice of. It often happens after am- putations, and other operations where the larger arteries Chap. II. Of Arteries, &c. 39 arteries have been tied, that the ligatures do not come easily away, from being made to run so deep as with the curved needle is commonly necessary. In some instances much pain and trouble has oc- curred from this circumstance, the ligature remain- ing quite immoveable for a great many weeks: And after all, I have seen it necessary for the surgeon, to put the patient to a great deal of pain, by being obliged to cut out the threads with a scalpel. But when the tenaculum is used, every risk of this kind is avoided, from the ligatures generally dropping of their own accord, in the course of the third or fourth dressing of the sore. From what has been said, therefore, we shall con- sider it as a practice that ought to be established, that in forming the ligature of arteries, the nerves and other contiguous parts should be carefully a- voided. For the purpose of effecting this with ease and safety, various kinds of the instrument termed a Forceps have been invented; with these, the arte- ries of a sore are laid hold of and pulled out, so as to admit of the application of ligatures. For the larger blood vessels, the forceps has been found to answer conveniently enough; but, in the smaller arteries, they are by no means so fit for the purpose as the instrument or hook I have been rec- ommending, termed a Tenaculum, and represented in Plate I. And as a hook of this form answers equally well in the larger arteries likewise, the use of the forceps may therefore be laid entirely aside. The manner of using the tenaculum is this. In order to detect the arteries to be tied, the tourniquet with which they are secured, must be slackened a little by a turn or two of the screw; and the moment the largest artery of the sore is discov- ered, the surgeon fixes his eye upon it, and imme- diately restrains the blood again by means of the tourniquet. An assistant now forms a noose on the ligature 40 Of the Ligature Chap. II. ligature to be made use of; and this noose being placed immediately over the end of the artery, so as to include it with certainty, the operator then pushes the sharp point of the tenaculum through the sides of the vessel, and at the same time pulls so much of it out, over the surface of the surrounding parts, as he thinks is sufficient to be included in the knot which the assistant is now to make. In forming this ligature, the surgeon's knot, as it is termed, which consists in passing the thread twice through the first noose is certainly preferable to every other, from its being less liable to yield or slip. And as some additional security is obtained by forming a second knot above the first, this precaution ought never to be omitted. It is easily done; and on se- curity in this point the patient's life may in a great measure depend. The degree of strength of the ligature must al- ways be proportioned to the size of the vessels; but this is a circumstance to be at all times determined by the judgment of the practitioner, as must also the force to be employed in forming the knots. To what was already said upon this point I shall just add, that a very small force is fully sufficient for se- curing even the largest arteries: And that, after such a force has been applied as evidently restrains the farther loss of blood, a very trifling additional com- pression is all that is necessary. The principal artery being in this manner secur- ed, all the vessels of the part must one after another be taken up in the fame manner, by first loosening the tourniquet in order to discover them, and after- wards applying the ligature to each in the manner directed. It often happens, however, that the loss of blood the patient has sustained; a tendency to deliquium which may take place for the time; the fear he la- bours under; and the degree of cold to which the sore is exposed, have altogether such an effect upon the Chap. II. Of Arteries, &c. 41 the smaller arteries, as to prevent them for the time from discharging their contents; and as arteries left in such a state without being secured, generally burst out on the removal of these causes, a circum- stance which always occasions much trouble to the practitioner, as well as a great deal of pain and risk to the patient, every surgeon ought to pay the nicest attention to this point. The tourniquet should be made perfectly loose; any coagulated blood on the surface of the sore ought to be carefully washed off with a sponge and warm water; and the patient, if faintish, ought to get a glass of wine, or some other cordial; and after all, the surgeon ought to examine, with the most minute attention, the usual course which the vessels of the part are known to take. This being done, every artery of the part, even the smallest that can be distinguished, ought to be secured with a ligature: For such vessels as appear exceedingly trifling while the part is yet exposed to the air, nay even the small branches of arteries that happen to be neglected, will be capable of discharg- ing very considerable quantities of blood after the patient becomes warm in bed, when the solids are thereby relaxed and the fluids expanded; and, as little or no injury can ever be done by the proper application of ligatures to all the arteries that pre- sent themselves, the greatest attention ought at all times to be paid to this circumstance. I have insisted the more on this, from having fre- quently observed much uneasiness and distress pro- duced by a want of proper attention to this part of an operation. When the principal arteries of a stump have been taken up, and a little blood continues to be dis- charged, but appears to come from a few small ves- sels only, the surgeon, unless he is much accustomed to occurrences of this nature, is induced to think, that as they are very trifling to appearance, so he need F not 42 Of the Ligature Chap. II. not be at the trouble of tying them, as the necessary compression of the bandages proper for the wound will in all probability effect a total stoppage of the hemorrhagy. In a general oozing of a small quan- tity of blood from the whole surface of a sore, and when no particular vessel can be distinguished, there is a necessity for trusting to this remedy; but, when- ever an artery can be discovered, of whatever size it may be, it ought unquestionably to be secured by a ligature. It very rarely happens that any inconve- nience occurs from ligatures when properly appli- ed; but many lives have been lost from a remissness in this article. I have known different instances of this, and the same must have occurred to others. When, from the deepness of a wound, or from any other cause, some particular artery cannot be properly secured by the tenaculum; in this case we are under the necessity of employing the crooked needle, and the following is the mode of using it. The operator ought to be provided with needles of various sizes, and of different forms. The needles in ordinary use, are for many purposes quite too much crooked; for, in general, they are more easily managed when their curvatures are not so consider- able. The same kinds of needles that are found necessa- ry for the interrupted future, as represented in Plate I, answer equally well for the ligature of arteries. The needles in common use are made triangular with three edges, one on each side, and a third on the concave part of the needle. There is no real necessity, however, for more than two: Indeed the needle enters more easily with two than with three edges; and as the third edge on the concave side, renders them more liable to injure arteries and oth- er parts in the course of their introduction, this ad- dition ought to be omitted. A needle of this shape, armed with a ligature of a size proportioned to itself and to the vessel to be taken Chap. II. of Arteries, &c. 43 taken up, is to be introduced at the distance of a sixth or eighth part of an inch from the artery, and pushed to a depth sufficient for retaining it, at the same time that it is carried fully one half round the blood vessel. It must now be drawn out; and be- ing again pushed forward till it has completely en- circled the mouth of the artery, it is then to be pul- led out, and a knot to be tied of a sufficient firm- ness, as was already directed when the tenaculum is used. In this manner, either by the use of the crooked needle, or of the tenaculum, every hemorrhagy de- pending upon a division of one or more large arte- ries, may in general be very easily restrained; but it frequently happens, that considerable quantities of blood are discharged, not from any particular vessel, but from all the small arteries over the sur- face of the sore. In wounds of great extent, partic- ularly after the extirpation of cancerous breasts, and in other operations where extensive sores are left, this species of hemorrhagy often proves very troub- lesome from being exceedingly difficult to suppress. Bleedings of this kind seem evidently to proceed from two very different and opposite causes; a cir- cumstance which, in the treatment of them, is a mat- ter requiring very particular attention. FIRST, We now and then find effusions of this nature occurring in strong robust people, where they evidently proceed, either from too great a quantity of blood contained in the vessels, or from an excess of tone in the vessels them- selves; or, perhaps, from a combination of both these causes. But, SECONDLY, Such evacuations undoubtedly happen most frequently in constitu- tions quite the reverse of the former, viz. in such as are very relaxed and debilitated; either from a putrid dissolved state of the blood, or from a want of tone in the containing vessels, or in some instances from a concurrence of both. In 44 Of the Ligature Chap. II. In constitutions perfectly healthy, when the fluids are not tainted with any degree of putrescency, and the solids are possessed of their natural tonic powers, on the occurrence of wounds even of the most exten- sive nature, as soon as the larger arteries are secured, all the small vessels that have been divided, in conse- quence of that contractile power with which in a state of health they are endowed, and from the stim- ulus of the external air to which they are now ex- posed, are diminished not only in their diameters, but also in their length; in consequence of which, they recede considerably within the surface of the surrounding parts. This cause of itself would probably in the great- est number of instances prove sufficient for restrain- ing all loss of blood from the smaller arteries; but in the sound state of constitution of which we have now been speaking, another very powerful agent is provided by nature for producing the same effect. From the extremities of the divided vessels which at first discharged red blood only, there now, in their contracted state, oozes out a more thin, though viscid fluid, containing a certain proportion of the coagulable parts of the blood; and this being equal- ly distributed over the surface of the wound, by its balsamic agglutinating powers, has undoubtedly a very considerable influence in restraining all such hemorrhagies. In constitutions altogether healthy, where neither of the states of disease we have alluded to prepon- derates over the other, we find, that, as soon as the larger arteries of wounds are secured, nature, in the manner already described, generally puts a stop to all farther discharge. So that, whenever the contrary happens, by a tedious oozing continuing from the sur- face of the sore, we ought then to pay particular at- tention to the habit of body with which it is connected. When such an occurrence happens in a patient, young and vigorous, and where the tone of the mus- cular Chap. II. of Arteries, &c. 45 cular fibres is evidently great, the most effectual means of putting a stop to the discharge, is to relax the vascular system, either by opening a vein in some other part, or, what gives still more immediate relief, by untying the ligature on one of the principal ar- teries of the part, so as to allow it to bleed freely: Those violent spasmodic twitchings too, so frequent after operations on any of the extremities, when they do not depend on a nerve being included in the ligature with the artery, are in this manner more effectually relieved than by any other means. By the same means, the patient, from being in a febrile heat and much confused, soon becomes very tranquil: The violent pulsation of the heart and larger arteries abates, and the blood not being pro- pelled with such impetuosity into the smaller vessels of the part, they are thereby left at more liberty to retract; and as in this state they do not pour forth red blood so freely, they are the more readily cover- ed with that viscid glutinous fluid which we have al- ready shown to be one of the most important means intended by nature for the prevention of such hem- orrhagies. At the same time that by the means recommended we endeavour to allay the commo- tion produced in the system, the patient ought to be kept exceedingly cool; wine and other cordials should be rigidly avoided; cold water, acidulated either with the mineral or vegetable acids, ought to be the only drink; motion of every kind, particu- larly of the part affected, should be guarded against; and the wound being gently covered with lint or soft charpie, ought to be tied up with a bandage so applied as to produce a moderate degree of pressure on the extremities of the divided parts. In every extensive wound attended with hemor- rhagies of this kind, and particularly when violent spasmodic affections of the muscles supervene to- gether with the means already recommended, large doses of opiates are found highly beneficial; for whatever 46 Of the Ligature Chap. II. whatever hurtful effects may have been apprehend- ed from opiates in some inflammatory affections, ev- ery practitioner who has ventured on a free use of them must admit, that in all occurrences of this na- ture their influence far surpasses that of any other remedy. As soon therefore as a sufficient quantity of blood has been discharged, and the wound is dressed and the patient laid to rest, a dose of opium proportion- ed to the violence of the symptoms ought to be ex- hibited. It should be remarked, however, that, in all such circumstances, much larger doses of the remedy are necessary, than in ordinary cases requir- ing the use of opiates. Small doses, instead of an- swering any good purpose, seem frequently rather to aggravate the various symptoms; so that, when- ever they are here employed, they ought always to be given in quantities sufficient for the intended ef- fect. Although hemorrhagies of this nature do now and then occur in firm vigorous constitutions; yet they undoubtedly happen much more frequently in re- laxed enfeebled habits, where the solids have lost part of their natural firmness, and the fluids have acquired some degree of putrescency. As the ves- sels in this situation are supposed to have been de- prived of that degree of tone of which we wish them to be possessed, instead of restraining the patient from the use of cordials, as is done usually in every case of hemorrhagy, a moderate use of generous wine ought to be immediately prescribed; for nothing, it may be observed, tends so much in such circum- stances to restrain hemorrhagies, as a well directed use of proper cordials. By intending to invigorate and brace the solids, they thereby enable the arte- rial system to give a due resistance to the contained fluids; and the same cause, it may be observed, has a considerable influence in restoring to the fluids that Chap. II. Of Arteries, &c. 47 that viscidity of which in all such instances we sup- pose them to be deprived. Whenever, therefore, such tedious hemorrhagies occur in relaxed debilitated habits, a free use of Port, Madeira, or any other wine whose strength and goodness can be depended on, ought to be im- mediately allowed; a nourishing diet also becomes proper; the patient ought to be kept cool; and the mineral acids, from their known utility in every species of hemorrhagy, ought also to be prescribed. Rest of body is here proper too; and opiates, when indicated either by pain or spasmodic affections of the muscles, ought never to be omitted. Together with these remedies adapted to the gen- eral system, particular dressings, appropriated to the state of the parts to which they are to be applied, have been found very beneficial. We have already remarked, that in firm healthy constitutions, as soon as the discharge of blood which naturally occurs in every large wound is over, the parts come soon to be covered with a viscid coagulable effusion from the mouths of the now retracted arteries; but in constitutions of an opposite nature, where the solids are much relaxed, the blood in general is found in such a dissolved state as to afford no secretion of this nature. In order therefore to supply as much as possible the deficiency of this natural balsam, different arti- ficial applications have been invented. Dusting the parts with starch or wheat flour has sometimes been found of use; and I have known gum arabic in fine powder to answer when these have failed. Applications of this kind, indeed, have been used with success in all such hemorrhagies, with what- ever habit of body they happen to be connected; but they have always proved more particularly ser- viceable in relaxed constitutions, attended with a dissolved state of the blood and an enfeebled muscu- lar system. We may here use with freedom too, a remedy 48 Of the Ligature Chap. II. remedy which in such circumstances generally proves serviceable, but which in constitutions of an oppo- site nature ought never to be employed. The rem- edy alluded to is alcohol, or any other ardent spirits, impregnated with as great a quantity as they can dissolve of myrrh or any other of the heating viscid gums. The balsamum traumaticum of the shops, a remedy of this nature, has long been famous for its influence in such cases: But that indiscriminate use of this and similar applications which has long pre- vailed with some practitioners, I am confident has done much harm; for, as they are all possessed of very stimulating powers, they of course tend to ag- gravate every symptom in wounds connected with a tense state of fibres, when much pain, and especial- ly when spasmodic muscular affections, prevail. But, in constitutions of an opposite nature, where the blood appears to be in a dissolved state, and where the arterial system seems evidently to require a stim- ulus, remedies of this class come to be very useful: Insomuch that, in every constitution of this kind where hemorrhagies prove troublesome, no applica- tion whatever is found to answer better, than char- pie immersed in an agglutinating spirituous balsam of this nature. By a due perseverance in one or other of the plans here pointed out, it will seldom happen that hemorrhagies of this nature are not at last restrain- ed: But when the contrary does occur; when, not- withstanding the use of the remedies recommended, a discharge of blood still continues; together with the means already advised, an equal moderate pres- sure ought to be applied over the whole surface of the sore, to be continued as long as the necessity of the case seems to indicate. In finishing the dressings of such wounds, after the char pie and compresses have been applied, a bandage ought to be adapted to the part in such a manner as to produce as equal a degree of pressure over Chap. II. Of Arteries, &3c. 49 over the surface of the sore as possible. But it some- times happens, that no bandage whatever can be so applied as to produce the desired effect; and in such cases, the hand of an assistant is the only resource. In such instances, a person's hand being firmly ap- plied over the dressings, so as to produce a very equal degree of pressure, will commonly succeed when no other remedy is found to have much influence. Having thus endeavoured to point out the most effectual means of putting a stop to morbid hemor- rhagies, we shall now proceed to consider the dif- ferent modes employed by art, for effecting a dis- charge of blood when indicated by the presence of some disorder in the constitution. G CHAP. 50 Of Bloodletting. Chap. III. CHAP. III. OF BLOODLETTING. SECTION I. Of BLOODLETTING in GENERAL. BLOODLETTING, whether we consider it as to its influence on the system, or with respect to the niceness and even difficulty of the mode usually employed for effecting it, is perhaps one of the most important operations in surgery. From its being so frequently put in practice, and from every pretender to any knowledge in the heal- ing art being able to perform it without any appa- rent difficulty, the publick have been induced to con- sider it as trivial with respect to its execution; but every practitioner of character must acknowledge, that, in order to perform this operation properly, the greatest nicety, steadiness, and exactness, are necessary. All the other operations in surgery I have frequently seen well performed; but I can with freedom say, that I have seldom seen bloodlet- ting with the lancet done very correctly: When properly performed, it is really a neat operation; but when not done with exactness, it is the very reverse. It is not here to enter into the considera- tion of the various causes which in different circum- stances point out the propriety of abstracting blood from the system; nor is it intended to enter upon a particular discussion of the different effects produc- ed by general and topical bloodletting: These con- siderations, as being highly important, would of themselves Sect. I. Of Bloodletting. 51 themselves extend to a very great ; and be- sides, are of such a nature as renders it impossible to enter minutely upon their discussion in any system of surgery. All that is here intended, is to describe as clearly as possible the various modes of perform- ing the operation of bloodletting. In all inflammatory affections producing a gene- ral disorder of the system, the method of taking a- way blood as now established by immemorial prac- tice, is, by such means as discharge the quantity to be taken in a short space of time, by an opening made with a lancet, either in an artery or in a vein. Whether there is any real difference in the effects produced by these two modes of discharging blood, it may be difficult to determine with any precision; but there is reason to suppose, that, independent of the quantity taken, the difference is of less import- ance than is commonly imagined. The latter of these termed Phlebotomy, and the former Arteriot- omy, are the means employed for what we term general bloodletting; the particular consideration of which we shall presently attend to. But it often happens, in disorders of an inflam- matory nature, where there is evidently a fixed lo- cal affection, and where no great degree of fever takes place, that general bloodletting has not much influence in mitigating the symptoms; and in such circumstances considerable advantage is frequently obtained by discharging blood from the part imme- diately affected, by dividing a number of the small vessels which supply it; and this we term Topical or Local bloodletting. The means employed by art for discharging blood in this manner shall be afterwards treated of, and we now return to the particular consideration of phlebotomy. Wherever a vein of a tolerable size can be reach- ed with safety, an opening for the discharge of blood may be made in it with a lancet; but the follow- ing are the parts from whence blood is usually tak- en 52 Of Bloodletting. Chap. III. en in this manner; viz. from the veins of the arm at the flexure of the cubitus; from the jugular veins; and from the veins of the ankles and feet. On particular occasions, too, blood is advised to be taken from the veins of the hand, of the tongue, &c. There are some general rules and observations which relate equally to this operation in whatever part of the body it is practised; these we shall in the first place point out with as much accuracy as pos- sible, and shall afterwards proceed to treat particu- larly of bloodletting in the arm and other parts. I. In this as in every other operation, the situa- tion of the patient, and of the operator likewise, ought to be precisely fixed. As the situation of a patient during the operation of bloodletting, has a considerable influence on the effects produced by the evacuation upon the system, this circumstance therefore merits our particular attention. In some disorders, it is the object of this remedy, to evacu- ate a considerable quantity of blood without induc- ing fainting: When this is the case, and when from former experience it is known that the patient to be operated upon is liable during the evacuation to fall into a faintish state, a horizontal posture, either upon a bed or on a couch, ought to preferred to every other; for every practitioner is now well ac- quainted with this fact, that fainting does not so readily occur in a horizontal as in an erect posture. It now and then happens, however, that one ma- terial advantage expected from the operation of bloodletting, is the inducing a state of deliquium; as for instance, in cases of strangulated hernia, where a general relaxation of the system is sometimes de- sirable. In all such circumstances, instead of a hori- zontal posture, the more erect the patient is kept, the more readily will a state of fainting be induced: So that the particular object in view from the ope- ration, must at all times determine this matter. While we thus attend particularly to the posture of Sect. I. Of Bloodletting. 53 of the body at large, the particular position of the limb or part to be operated upon must not be neg- lected. In every operation, it is a matter of much importance to have the patient seated in a proper light, but in none is it more material than in blood- letting. The best general rule that can be given upon this point is, that the patient ought to be so placed, as that the principal light of the apartment shall fall directly upon the part to be operated up- on, so that the vein to be opened may be made as- apparent as possible. When clear day light can be obtained, it ought to be preferred; but when this cannot be procured, one or more candles should be used. But, whatever may be the position of the part it- self, and whether the patient is to be placed on a bed or on a chair, the surgeon ought always to be seated. The operation may, no doubt, be done while the surgeon is standing; and it is most fre- quently indeed performed in this manner: But it can never be done either with such steadiness or neatness, as when the operator is firmly seated on a chair. II. From the coats of veins being more flaccid than those of arteries, and from the blood not circu- lating with such rapidity in the former as in the lat- ter, an opening made in one of these will seldom discharge blood freely, unless the vein be either cut entirely across, which in general would be produc- tive of disagreeable consequences, or unless the blood be prevented from returning to the heart, by means of a ligature placed between the heart and that part of the vein in which the opening is to be made. The patient being properly seated, the next step must therefore be, by means of a proper bandage so to compress the vein intended to be opened, as to prevent the blood from returning to the heart; and for the same reason, an equal degree of pressure, it is 54 Of Bloodletting. Chap. III. is obvious, ought to be applied to all the other veins of the part; for, if this circumstance should not be attended to, the communication preserved by the collateral corresponding branches would render the pressure upon any one particular vein of very little importance. But, independently of its producing a more free discharge of blood than could be other- wise obtained, this pressure upon the veins, by caus- ing an accumulation of their contents, tends to bring them more evidently into view, and consequently renders it easier for the operator to affect a proper opening than he would otherwise find it. Although compression, however, to a certain ex- tent, is necessary for this purpose of accumulating a quantity of blood in the veins, and for afterwards discharging it at an opening made by the lancet, it is at the same time perfectly evident that any con- siderable degree of pressure, instead of forwarding these purposes, must obstruct them entirely; for, if the pressure intended to be applied to the veins only, should accidentally be carried so far as to rest mate- rially upon the arteries connected with them, all farther access of blood to the veins would be there- by cut off, so that no evacuation of importance could take place at any opening to be made in them. Whenever it is intended, therefore, to evacuate blood in this manner, a good deal of nicety is requisite in applying this pressure upon the veins: It ought al- ways to be carried so far as effectually to compress the veins of the part, but never to such a length as to obstruct the circulation in the corresponding arte- ries. When we see that the pressure has the effect of raising the veins, and if at the same time the pul- sation of the artery is distinctly felt in the inferiour part of the member, we may then be certain that it is applied to a very proper degree, and that it ought not to be carried farther: For by the swelling of the veins, we are sure that they are sufficiently compress- ed; and by the arteries continuing to beat, it is ev- ident Sect. I. Of Bloodletting. 55 ident that a continued flow of blood may be ex- pected. III. The reflux of blood to the heart being in this manner prevented, the next point to be deter- mined, is, the best method of making an opening into the vein. Different instruments have been in- vented for this purpose; but there are two only which have been retained in use, and which are all, therefore, that here require to be mentioned. These are, the Lancet and the Phleme. This last, on be- ing placed immediately on the part to be cut, is by means of a spring struck suddenly into the vein, and produces an opening of the exact size of the instru- ment employed. The phleme, in many parts of Germany, has ac- quired some reputation, particularly in taking blood from the jugular vein: But there are various ob- jections to this instrument, which will probably prevent it from ever coming into general use; and these particularly are, that we are obliged, from the nature of the instrument, to regulate the deep- ness to which it is to go, before it is applied: Now we know well, that in bloodletting this is a cir- cumstance of which we are never by any means cer- tain; for we frequently, after the introduction of a lancet, find it necessary to go much deeper than was at first expected; so that when a phleme is used, un- less we employ one on every occasion of a length which cannot be frequently required, we must often meet with disappointments. But the most material objection to this instru- ment is, that where there are arteries or other parts lying below the veins, and in any danger of being hurt by the operation of bloodletting, the risk is much greater with the phleme than with the lancet: For when the lancet is used, after the vein is once opened, the orifice may be enlarged at pleasure without any additional risk, merely by carrying the instrument forward along the course of the vein at the 56 Of Bloodletting. Chap. III. the same depth to which it was at first introduced; whereas the phleme, as soon as it enters the vein, must for certain pass directly downwards as far as its length will permit it to go; a circumstance which adds greatly to the risk of wounding the parts underneath. Independently of this too, by the use of the lan- cet, we have it much more in our power to com- mand an orifice of a determined size than when the phleme is used: So that without hesitation, we may venture to pronounce the phleme to be an instru- ment in no degree necessary; but for such as incline to use it, the most convenient form of one is repre- sented in Plate III, fig. 2. The manner of using the phleme is as follows. The bandage for producing the turgescency of the veins being applied in the manner already di- rected, the point of the instrument A, with the spring properly bent, must be so placed upon the part of the vein to be opened, that an orifice of an oblique direction may be made in it on the spring B being let loose. The subsequent management is the same here as when the lancet is used, and will be presently pointed out. When it is determined to employ the lancet, the form of the instrument is evidently the first circum- stance requiring our attention; although we may here remark, that this point is seldom so particularly attended to as it ought to be. The form of the lancet in ordinary use, as represent- ed in Plate IV, fig. 5. is an instrument which ought to be laid entirely aside. For opening abscesses it is very well calculated, but for the operation of blood- letting it ought never to be used. The capital objection to this form of lancet, is, that the broadness of its shoulders produces always a wound in the external teguments of perhaps three times the size of the opening made in the vein; a circumstance which adds no advantage whatever to the Plate IV.  Sect. I. Of Bloodletting. 57 the operation: On the contrary, it produces much unnecessary pain in the first instance; it renders it frequently a very difficult matter to command a stoppage of the blood; and the wounds produced by it are commonly so extensive as to render them very liable to terminate in partial suppurations; an occurrence which always proves painful and disa- greeable to the patient. The spear pointed lancet, on the contrary, as rep- resented in Plate IV, fig. 3 and 4, is an instrument in every respect well calculated for the purpose of venæsection. From the acuteness of its point, it en- ters the teguments and vein with very little pain; which we may here observe, is with many patients a circumstance of no small importance: We are sure of making the opening in the vein equal, or nearly so, to the orifice in the external teguments: And the discharge of blood produced by an opening made with one of the lancets, is commonly put a stop to with great ease, immediately on removing the liga- ture upon the vein. For these reasons, therefore, the spear pointed lan- cet is highly preferable to every other: And al- though, with timid practitioners, the acute point of this instrument may appear to require more dexter- ity in using it than the broad shouldered lancet; yet the difference in this respect is so inconsiderable, that very little experience must, with every practitioner who gives it a fair trial, very soon counterbalance all such objections. Indeed no surgeon ought to be trusted in letting blood with the one, whose steadi- ness and dexterity would be in any degree doubted with the other. IV. The form of lancet being thus fixed up- on, we come now to speak of the method of using it. The surgeon and patient being both properly seated, and the ligature having been applied for a short space of time in order to produce some degree of swelling in the veins, that vein is to be made choice of, which, H at 58 Of Bloodletting. Chap. III. at the same time that it appears conspicuously e- nough, is found to roll less than the others on being pressed upon by the fingers. There are some veins which roll so much, from being loose and uncon- nected with the cellular substance of the part, that although they may rise sufficiently, yet are much worse to operate upon than others which lie at a much greater depth. That vein therefore is to be preferred which not only rises so as to become per- fectly evident, but which appears to be connected with some degree of firmness to the contiguous parts. It is scarcely thought necessary to observe here, that when a vein appears to be so immediately connect- ed with a contiguous artery or tendon, as evidently to produce some risk of wounding these parts in the operation, if another vein not liable to such hazard can be procured, it ought undoubtedly to be prefer- red. Veins may lie directly above both arteries and tendons, and yet no manner of risk be incurred by opening them, provided the operator is sufficiently steady and attentive; but it does now and then hap- pen, that veins are so nearly and intimately connect- ed with these parts, as to render it hazardous even for the most dexterous surgeon to attempt this op- eration. The vein being at last made choice of, the sur- geon, if he is to use his right hand in the operation, takes a firm hold of the member from whence the blood is to be drawn, with his left, and, with the thumb of the same hand, he is now to make such a degree of pressure upon the vein, about an inch and half below the ligature, as not only to render the skin and teguments somewhat tense, but at the same time to interrupt for a little all communication be- tween the under part of the vein, and that portion of it lying between the ligature and the thumb plac- ed as thus directed. The Sect. I. Of Bloodletting. 59 The lancet being bent to somewhat more than right angles, the operator now takes it between the finger and thumb of his right hand; and, leaving at least one half of the blade uncovered, he rests his hand on the middle finger, ring finger, and little finger, all placed as conveniently as possible in the neighbourhood of the vein from whence the blood is to be taken; and having pushed the point of the instrument freely through the skin and teguments into the vein, he now carries it forward in an oblique direction, till the orifice is of the size he inclines to have it; taking care, during the time of pushing on the lancet, that its point be kept in as straight a di- rection as possible, for fear of dipping into the parts below. The instrument is now to be withdrawn, and the surgeon removing the thumb of his left hand, is to allow the vein to empty itself freely into the cups provided for the purpose. It is here of importance to observe, that, during the time the blood is discharging, the member ought to be kept in exactly the same posture it was in when the lancet was first introduced: Otherwise, the ori- fice in the skin is apt to slip over the opening in the vein; a circumstance which always proves inconve- nient, and on some occasions produces a good deal of trouble by the blood from the vein insinuating itself into the surrounding cellular substance. In taking hold of the lancet, we have directed the scales to form rather an acute angle with the blade of the instrument. It will even answer when they are at right angles; but a farther separation proves always troublesome, by throwing the scales too much back upon the operator's hand. The length of instrument left out from between the finger and thumb is another circumstance requiring our at- tention; for unless a sufficient quantity of it is left uncovered, the operator cannot act with free- dom. In lancets of an ordinary length, one half of the 60 Of Bloodletting. Chap. III. the blade, as I have already remarked, or very near- ly that quantity, ought always to be left out. The entry of the lancet into the vein is the next circumstance we have desired to be attended to. By very little attention the entrance of the instrument into the vein may be distinctly perceived; for as soon as its point has entered the cavity of the vessel, the resistance to its farther progress is evidently found to be much diminished; and immediately on the opening being in any degree enlarged, the blood be- gins to rush out, which is the clearest proof of the operation being so far complete. On being thus rendered sure that the lancet has got into the vein, we have also desired that it may be carried forward in an oblique direction, taking care to keep the point of the instrument in the same degree of elevation from the instant it has passed fairly through the coats of the vein; and to this part of the operation we would beg the most particular attention. To the want of necessary caution in this matter, or rather to the improper regulations held forth upon it by eve- ry writer on this subject, much of the risk attending this operation ought to be attributed. The propriety of an oblique direction for the course of the orifice is very obvious: For, when made altogether longitudinal, the sides of the wound. are apt to fall immediately together, so as not to ad- mit of a free discharge of blood; and, on the other hand, when the vein is cut entirely across, trouble- some consequences commonly ensue from the wound being very difficult to heal: An orifice somewhat oblique with respect to course of the vein, is therefore preferable to either. But the material cir- cumstance to be kept in view is the direction of the point of the lancet after it has got fairly into the vein. By almost every author who has written up- on bloodletting, as soon as the lancet is known to have got into the vein, in order to extend the orifice to a sufficient length, we are directed, very properly, to Sect. I. Of Bloodletting. 61 to carry the instrument forward: But in what man- ner are we desired to do so? By raising the heel of the lancet, as it is termed, at the same time that the point and edge of it is in some degree pushed for- ward, so as to make the point of the instrument the centre of motion. The reason of this last precaution is, that the in- ternal orifice of the vein may not be farther extend- ed upwards than the external wound in the skin and other integuments; as ecchymoses, or effusions of blood into the cellular substance, have with the broad shouldered lancet been found frequently to occur from a contrary management. But when the spear pointed lancet is used, this is an occurrence which may be always avoided; as, from the narrow point of the instrument, it may with safety be car- ried on in the cavity of the vein as far as is necessa- ry. The orifice produced by it in the vein, must, when the operation is properly done, be always of very nearly the same extent as the external wound in the teguments: And by the same management we avoid that capital risk which it is evident must always occur from an implicit obedience to the di- rection alluded to; for one certain effect of raising the heel, or back part of the lancet, is, that the point of the instrument must in the same proportion be depressed; and the consequence of lowering the point of the lancet, already perhaps sliding along the under side of the vein, must at once appear to be very hazardous. For in such circumstances, if the point of the instrument be depressed, which must undoubtedly happen if the back part of it be elevat- ed, it must for certain pass through the back part of the vein; so that if either an artery, nerve, or ten- don, lie contiguous, they must of necessity be wound- ed; and I am perfectly convinced, that this cause a- lone has frequently been the origin both of wound- ed arteries, and of pricks in the nerves and tendons. So that as the hazard of the practice, whenever it is 62 Of Bloodletting. Chap. III. is attentively considered, must at once appear evi- dent, and as the supposed inconvenience arising from a contrary mode of operating is effectually prevent- ed by the use of the spear pointed lancet, all such risks therefore should be carefully avoided. With respect to the size of orifice in cases of bloodletting, this circumstance must at all times be determined by the nature of the disorder for which the evacuation is prescribed. When a sudden loss of a considerable quantity of blood is intended, ei- ther, with a view to produce a state of fainting, or for any other reason, a free large orifice is absolutely necessary; but in ordinary practice, no necessity oc- curs for this. In using a spearpointed lancet, an orifice of about an eighth part of an inch in length will in general answer every purpose; but when a lancet with broad shoulders is used, an opening of twice that size is little enough; for with such an instrument the orifice in the vein can seldom be above half the ex- tent of the external opening. After withdrawing the lancet from the orifice, we have directed the thumb of the left hand to be re- moved from the place it was made to occupy. Many circumstances may appear to be related here with unnecessary minuteness, and this among others may possibly be considered as one; but in an ope- ration of importance, every particular requires much attention. Now, one material use of the thumb placed below the part where the lancet was directed to enter, is, to keep the teguments and vein firm, so as to prevent the latter from rolling. But another advantage occurring from it is, that by making a sufficient degree of pressure upon the vein, it there- by prevents any considerable quantity of blood from escaping between the time of removing the lancet, and the application of one of the cups for receiving the blood from the orifice in the vein. During this period it frequently happens, that a good Sect. I. Of Bloodletting. 63 good deal of blood is discharged, to the great an- noyance both of the patient, the operator, and by- standers; a circumstance which, with a little atten- tion, may be always effectually prevented. V. When the vein is properly cut, and the ori- fice is made sufficiently large, it rarely occurs that any difficulty is experienced in procuring all the blood that is wanted. But it now and then happens otherwise, either from the orifice of the skin and other parts having receded from the opening in the vein, or from the patient having become faintish; a situation always unfavourable to a free discharge of blood. When this last circumstance occurs, a stream of fresh air ought to be admitted to the apartment, wine or some other cordial should be administered, and the patient ought to be laid into a horizontal posture. By these means the faintishness will in general be soon removed; but if still the blood should not flow freely, the member ought to be put into all the variety of positions that can probably assist in bringing the opening of the skin and other teguments to correspond with that of the vein, which will soon be known to have happened by the blood beginning instantly to flow. Throwing the muscles of the part into constant action, by giving the pa- tient a cane or any other firm substance, to turn frequently round in his hand when the operation is done in the arm, will often answer in producing a constant flow of blood from a vein, when every other means has failed: And lastly, when the pulse in the inferior part of the member is felt very feeble, or especially if it cannot be distinguished at all, we may be thereby rendered certain that the ligature is too tight, and may in general have it in our power to produce an immediate flow of blood by removing the compression thus improperly made upon the ar- teries of the part. VI. A quantity of blood proportioned to the circumstances of the disorder, being thus discharged, the 64 Of Bloodletting. Chap. III. the pressure upon the superior part of the vein should be immediately removed; and this being done, if the spear pointed lancet has been used, all farther discharge of blood will in general stop im- mediately. The contrary, however, sometimes oc- curs, and blood continues to flow freely even after the ligature is removed. When this is the case, the operator ought to compress the vein both above and below the orifice by means of the finger and thumb of one hand, so as to prevent any farther loss of blood: And this being done, the limb ought to be washed and entirely cleared of any blood that may have fallen upon it; and the orifice being also clear- ed of every particle of blood, the sides of it should be laid as exactly together as possible, and a piece of what is named court plaster, or any other that is sufficiently adhesive, being so applied as to retain them, it will seldom happen that any kind of band- age is necessary: But when the blood has issued with uncommon violence during the operation, and has been difficult to command after the removal of the ligature, in such instances it will be prudent to apply a small compress of linen over the plaster, and to secure the whole with a linen roller properly ap- plied round the member. Before applying the plaster, we have directed the orifice to be perfectly cleared of every particle of blood; and this, it may be observed, is a circum- tance of more importance than is commonly imag- ined; for, by not attending particularly to this point, and from want of exactness in closing the lips of the orifice, painful swellings and consequent sup- purations are often induced, which a very little at- tention would have easily prevented. In every in- stance when the operation is properly done, the wound ought to heal by what surgeons call the First Intention, that is, by the parts adhering to one another without the formation of matter; but this can seldom happen if the lips of the sore have not been Sect. I. Of Bloodletting. 65 been very neatly laid together after all the blood has been perfectly cleared away. Another argument of importance, too, occurs for neatness in this matter. Among other troublesome consequences arising now and then from bloodlet- ting, inflammation produced in the cavity of the vein has in some instances been known to occasion much mischief; and as nothing tends more to pro- duce it than the admission of air to the part, by the orifice in the vein not being properly closed, this circumstance of itself strongly points out the propri- ety of the caution here given: For although such inflammatory affections in the internal surfaces of veins are not by any means to be considered as fre- quent, yet it is certain they do now and then occur; and as the consequences arising from them, especial- ly if suppuration is induced, must commonly ter- minate fatally, they ought certainly, by every means in our power, to be strictly guarded against. VII. We come now to speak of some troublesome consequences which on some occasions are found to occur from bloodletting, and which every operator ought to be as much as possible prepared to remedy. The most material of these are, small tumors occa- sioned by effusions of blood from the orifice of the vein into the surrounding cellular substance; wounds of the artery lying contiguous to the vein; pricks of the nerves and tendons; and lastly, inflammation, induced in the internal cavity of the vein, as we have just now mentioned. These we shall now, under separate heads, proceed to treat of particu- larly*. I SECTION * Among other reasons which we have given for preferring a spear pointed lancet, it was observed, that by means of it the operation of bloodletting is attended with much less pain than when the broad shouldered lancet is used: And the prevention of pain is a matter of such importance, that nothing should be omitted that can in any degree contribute to it. In every operation it is of much consequence to have all the nec- essary instruments in the most complete order; but in no instance is it of such importance to attend to this circumstance as in bloodletting. Well 66 Of Bloodletting. Chap. III. SECTION II. Of a THROMBUS, or ECCHYMOSIS. WE have already desired, that in the operation of bloodletting, the member should be retained in the very same posture it was in when the lancet was introduced, till the whole quantity of blood intended to be taken is evacuated. When this direction is not duly attended to, it commonly happens, that a small tumor is raised immediately above the orifice in the vein, by the blood insinuating itself into the cellular substance of the neighbouring parts. Such a tumor, when round and small, is termed a Throm- bus; and when more diffused, an Ecchymosis. Immediately on the appearance of such swellings, the ligature ought to be removed from the superior part of the vein; and the member being brought into that posture which it was in when the lancet was first introduced, the ligature may be again re- newed; and it will thus be frequently found that a free return of blood will be induced, which com- monly carries off the swelling altogether, or at least prevents it from producing any further obstruction to the discharge of blood. But it does now and then happen, that these swellings come at once to such a size, as entirely to preclude every possibility of fin- ishing the operation at the orifice first made in the vein. Even here, however, the ligature ought to be Well-tempered lancets will no doubt answer tolerably well, even after they have been frequently used; insomuch that I have heard even well employed surgeons assert, that they have used one or two lancets only during the course of many years practice, without ever having them touched by a cutler. But it is very certain that every time a lancet is used, it must be injured more or less; so that, as the prevention of pain is with most patients a matter of no small conse- quence, I think it ought to be laid down as a fixed rule never to use the same lancet twice, without putting: it into the hands of a cutler. This I have long been in the practice of doing, not only with lan- cets, but with every cutting instrument; and the trouble and ex- pense attending it is very inconsiderable, when compared with the advantage resulting from it. Sect. II. Of Bloodletting. 67 be immediately removed, as the most effectual meth- od of preventing an increase of the tumor. By con- tinuing the bandage on the vein, the blood still con- tinues to be forced in great quantities into the sur- rounding cellular substance; and by the same means such swellings are induced, as now and then give a great deal of trouble, which by a contrary man- agement might easily have been prevented from com- ing to any considerable height. In such occurrences, as it is in vain to expect any considerable quantity of blood from the orifice first made, the next step to be taken, is, to finish the op- eration, not by another opening in the same vein, which in such circumstances would seldom be found to bleed freely, but in any other that lies most con- venient. When tumors of this kind do not arrive at any great size, very little is necessary to be done for their dispersion, as the effused blood is commonly soon absorbed. When it is found necessary, however, to have recourse to discutient remedies, those of the astringent kind are by far the most effectual; and of this class brandy or any other ardent spirits are perhaps as useful as any. Compresses wet in a weak solution of crude salt ammoniac in vinegar, and applied with a very moderate degree of pressure, have likewise been found very effectual in discuss- ing such swellings. Instances, however, do now and then occur, though by no means very frequently, of the blood collected in swellings of this nature being in too great quantities to be all absorbed: And when this happens to be the case, as no good suppuration can be induced where there is nothing but red blood contained in the tumor, it ought to be immediately laid open as soon as there is reason to suppose that no farther diminution of size will probably occur from absorption. This being done, and the coagu- lated 68 Of Bloodletting. Chap. III. lated blood being evacuated, the sore falls to be treated like any ordinary wound. But occurrences of this nature, are in general of very little importance when compared with other accidents which now and then proceed from bloodlet- ting. The first of these we are to treat of are wounds of arteries. SECTION III. Of WOUNDS of the ARTERIES. IN the smaller arteries, as for instance in any branch of the temporal artery, openings may be made without much risk; but we know from long and repeated experience, that wounds in the larger arteries often prove hazardous, and very seldom heal without a great deal of trouble. When in bloodletting we have reason to suspect that an artery has been wounded through the orifice made in the vein, and that blood is discharging at the same orifice both from the artery and the vein, it becomes a matter of importance for an operator to know with precision whether it is so or not. There is only one method by which a complete de- gree of certainty can be obtained on this point; and it is this: When the blood is discharged from the vein only, if a degree of pressure be applied both immediately above and below the orifice sufficient for compress- ing the sides of the vein together, all farther evacu- ation of blood should instantly stop, even though the pressure is not so considerable as to affect the artery below; but on the contrary, if part of the blood be thrown out from the wounded artery, this pressure upon the vein, instead of putting a stop to the discharge, should rather tend to make it more considerable. When at the same time the blood is discharged per salium, this will no doubt serve as a corroborating Sect. III. Of Bloodletting. 69 corroborating circumstance: But this test of itself, we may remark, is by no means so decisive as is commonly imagined; for, an orifice made in a vein lying directly above and immediately contiguous to a considerable artery, receives the influence of the arterial pulsation to such a degree, as to discharge blood very nearly in the same manner as if the arte- ry itself was cut. No other proof however, is nec- essary of the artery being wounded, than the one we have already mentioned; for, if after the vein is thoroughly compressed both above and below the orifice, blood still continues to be discharged in great quantities and with any considerable force, our sus- picions of the artery being wounded are then reduc- ed to the utmost degree of certainty. Allowing this to be the case, that in such circum- stances we are rendered certain of the lancet having pierced the artery, What remedy ought we to have recourse to? Not the means usually advised, but the very reverse. In all such occurrences, we are constantly direct- ed to tie up the part with as much firmness as possi- ble, in the first place with different compresses placed over the orifice of the vein; and lest these should not produce a sufficient degree of pressure, a piece of money or other hard substance is desired to be add- ed, and the whole to be secured with a roller very tightly applied. But what effect ought we reasona- bly to expect from much pressure applied in this manner? We cannot suppose it was ever intended that any pressure of this kind should be so consider- able as to compress the artery itself; for by that means when the principal artery of a part is wound- ed a total stop would be put to the circulation in the whole limb: And if the pressure, on the contra- ry, is to be applied in such a degree as to compress the sides of the veins only, one certain effect of this must be, to occasion a considerable resistance to the flow of blood from the artery; and that fluid being thus 70 Of Bloodletting. Chap. III. thus obstructed in its natural course, will necessarily be much more readily effused at the opening in the artery, than if the veins had been all left free and pervious to receive and transmit it. In all such cases, therefore, instead of applying much pressure, we ought to attempt every means of relaxing the veins to the utmost; and in order to command the blood, the lips of the wound should be laid together, and retained by straps of adhesive plas- ter only, without any bandage whatever. And as there is not a more effectual method of relaxing the system at large, and the vascular system in particu- lar, than by discharging large quantities of blood very quickly, so soon as it is known that an artery has been accidently opened, it ought to be immedi- ately determined to evacuate by the orifice newly made, as much blood as the patient can easily bear to lose. By these means, and by enjoining strict at- tention to rest of body, in order to prevent as much as possible the undue action of the arterial system, and by keeping the body cool, with the use of gentle purgatives, a low diet, and farther bloodlettings when necessary, there may always be at least some chance of such wounds in arteries being brought to reunite: Whereas a contrary management, in which much pressure upon the veins is advised, must uni- versally do mischief, by forcing the artery to emp- ty itself at the only passage the blood in such cir- cumstances can be discharged at, viz. the opening newly made by the lancet; and by such treatment many aneurismal swellings, I am confident, have been produced, which by the management now pointed out might easily have been prevented. In cases of wounded arteries, however, it will fre- quently happen, that no treatment whatever will suc- ceed; the orifice in the artery will not reunite, and blood in considerable quantities is effused into the contiguous parts. Even in this state of the com- plaint, strong pressure is advised, with a view to dis- sipate Sect. III. Of Bloodletting. 71 sipate the tumor: But unless the swelling is of a very soft nature, and unless the blood contained in it still remains in a state of fluidity, no pressure whatever can have any influence in discussing it; for, whenever the accumulated blood has acquired any moderate degree of firmness, we cannot suppose that pressure will have any effect in driving it back by the passage from whence it originally came. Nor does it appear, that in such circumstances, compres- sion is of any use in forwarding the absorption of extravasated blood. From theory alone we might readily be induced to draw this conclusion; but in fact we do not know a single instance in which pres- sure in such cases appeared to be productive of any advantage. There is indeed a particular species of swelling, which now and then occurs on an artery being in this manner wounded by a lancet that has previous- ly passed through a neighbouring vein, and in which moderate pressure has proved serviceable. When an artery thus wounded, lies quite contiguous to the corresponding vein, the opening between the two vessels on some occasions continues pervious after the external orifice in the vein is closed, so as to produce a direct communication between the one and the other; and the vein in this manner receiving the full force of the arterial pulsation, at the fame time that its coats are not possessed of a firmness sufficient to resist it, a swelling of the vein comes of course to be produced. In all such instances, moderate preffure, we may readily suppose, must be of very great use, by serving as a support to the distended vein, and by thus preventing any farther increase of its bulk ; but in no other swelling arising from blood effused from an artery can pressure be of any us; on the contra- ry indeed, for the reasons already enumerated, there is great cause for suspecting that it has frequently done much mischief. When we are rendered quite certain that an artery has been opened, and that the tumor 72 Of Bloodletting. Chap. III. tumor produced by it is owing to blood collected in the cellular membrane around it, if keeping the limb in an easy relaxed posture, and the veins per- fectly free from pressure, together with the other means formerly pointed out, do not prevent a far- ther increase of the swelling, no other mode of treat- ment with which we are acquainted will have much influence. The tumor still continuing, by the communica- tion between it and the artery being constantly kept up, and none of the means employed for its disper- sion having any influence, the disorder in that state is to be considered as forming a species of aneurism, an ailment of which we will treat more particularly afterwards. SECTION IV. Of WOUNDS or PRICKS in the NERVES and TEN- DONS. THE disorder we have now been describing, viz. wounds of the arteries, as well as similar affections of the tendons, ought never to happen in the hands of a surgeon who pretends to any tolerable degree of steadiness; for, as the arteries and tendons are both parts which previous to the operation may be easily distinguished by the finger, so as that their situation may be ascertained with exactness, it must always be the fault of the surgeon, if the point of his lancet is not so directed as to avoid them. One principal cause of such accidents occurring in bloodletting, is, as we have already shown, the ordinary practice of depressing the point of the lancet, after it has entered the cavity of the vein. This, however, we have demonstrated to be always unnecessary, and in many instances to be productive of very pernicious effects. But although, by proper attention to this part of the operation, we may always with certainty avoid the arteries Sect. IV. Of Bloodletting. 73 arteries and tendons; yet it may be said, that the nerves, which in general are so small as not to be previously distinguished, run at all times a great risk of being wounded, and that the accidents which now and then occur from wounded nerves, are well known to be productive of as dreadful consequences as have ever succeeded to the operation of blood- letting. But although the nerves from the smallness of their size cannot previously be distinguished by the fingers; yet, if sufficient attention be given to the direction of the point of the lancet, so as to avoid with certainty carrying the instrument through the back part of the vein, the same means which tend to secure the arteries and tendons, will with almost equal sureness prove a safeguard to the nerves: For, if the operator enters his lancet, as he ought always to do, on the superiour part of the vein, and if he does not cut the vein entirely across by pushing the lancet through to the opposite side of it, he can never run any risk of wounding the contiguous nerves: For these, though they run so near to the veins, yet either lie immediately below them, or at least are situated so far down upon their sides as to be out of all risk of being wounded, if the lancet is made to enter where it ought to do; and it must always be the surgeon's fault if the instrument is pushed out at the opposite side of a vein. I may venture to assert, that no inconvenience of this kind ever happens, from the wound made by a lancet in entering the anteriour part of a vein: It is always on the opposite side of the vein that any mischief of this kind is produced, when the lancet, as we have al- ready observed, is pushed entirely through; which it never ought to be, and which every surgeon ought to have steadiness enough to prevent. But although a very ordinary degree of caution would easily prevent every occurrence of this na- ture; and although, when accidents of this kind do K happen, 74 Of Bloodletting. Chap. III. happen, the surgeon is almost in every instance to blame; yet experience has on different occasions evinced, that, either from the want of attention, or from the operator not being possessed of a sufficient degree of steadiness, however easily such inconve- niences ought to be prevented, yet still they do fre- quently occur. Nerves, and even tendons, are some- times pricked; and the dreadful train of symptoms which such accidents commonly produce is almost inevitable. It sometimes happens immediately on the intro- duction of the lancet, that the patient complains of a most exquisite degree of pain; and when this oc- curs, we may rest assured that either a nerve or ten- don has been wounded. On some occasions, by proper management, such as evacuating a considera- ble quantity of blood at the orifice newly made, by keeping the part at perfect rest, and preserving the patient in as cool a state as possible, the pain at first complained of will gradually abate, and at last go off entirely without any bad consequence whatever. At other times, however, this pain which occurs instantaneously on the introduction of the lancet, instead of abating, begins soon to increase; a fullness, or small degree of swelling, takes place in the parts contiguous to the wound; the lips of the sore be- come somewhat hard and inflamed; and in the course of about twenty four hours from the opera- tion, a thin watery serum begins to be discharged at the orifice. If, by the means employed, relief is not soon ob- tained, these symptoms generally continue in nearly the same state, for two, or perhaps three days long- er. At this time the violent pain which at first took place becomes still more distressing; but instead of being sharp and acute as before, it is now attended with the sensation of a burning heat, which still goes on to increase, and proves during the whole course of the ailment a source of constant distress to the patient. Sect. IV. Of Bloodletting. 75 patient. The fullness and hardness in the lips of the wound begin to increase, and the swelling in the neighbouring parts gradually extends over the whole member; from the foot upwards over the thigh, when the operation has been done in the lower ex- tremity; and from the elbow down the forearm, and along the humerus over to the pectoral muscle and other contiguous parts, when the accident has oc- curred at the usual place of bloodletting in the arm. The parts at last become exceedingly tense and hard; an erysipelatous inflammatory colour fre- quently appears over the whole member; the pulse by this time has generally become very hard and quick; the pain is now intense, the patient exceed- ingly restless; twitchings of the tendons occur to a greater or lesser degree; on some occasions, a locked jaw and other convulsive affections supervene; and, all these symptoms continuing to increase, it most frequently happens, that the sufferings of the unfor- tunate patient are terminated by death only. Bloodletting, from being so very generally prac- tised, may by many be considered as an operation by no means either so difficult in execution, or so dreadful in its consequences, as is here represented. Such instances indeed are not to be considered as frequent occurrences; but they happen often enough to convince us of the necessity of very great caution in this operation. In the course of my experience I have known several instances where the conse- quences of bloodletting have proved fatal, and the dreadful train of symptoms we have already enu- merated uniformly occurred in all of them. Different opinions have prevailed respecting the cause of these symptoms: By some they have been imputed to wounds of the tendons; and by others the tendons are supposed to be so entirely destitute of sensibility, as to be quite incapable of producing so much distress; so that wounds of the nerves they consider 76 Of Bloodletting. Chap. III. consider in all such occasions as the true cause of the various symptoms we have mentioned. On one or the other of these suppositions the va- rious phenomena which occur in this disorder have been explained, till a different opinion was at last suggested by the ingenious Mr. John Hunter of London. Mr. Hunter supposes, that all the symp- toms thus induced by the operation of bloodletting, may be more readily accounted for, from an inflam- ed state of the internal surface of the vein, than from any other cause. Such a state of the vein he has often traced in horses that have died of such symp- toms from venæsection, where the internal coat of the vein was always found much inflamed, not only in the neighbourhood of the part where the orifice was made; but on some occasions the inflammation extended along the whole course of the vein, and seemed at last to reach the heart itself. Some in- stances too have occurred, of the same appearances in the human body, where the veins after death were found in a state of high inflammation. And on other occasions, inflammation having in this manner been once excited, has been known to terminate in suppuration; and the matter thus produced, being in the course of circulation carried to the heart, Mr. Hunter supposes that in such cases death may have been induced by that cause alone. There can be no reason to doubt the fact held forth by Mr. Hunter, that in such instances, the vein in which the orifice has been made, has frequently after death been found greatly inflamed: But however ingenious his arguments may be, for concluding that this state of the vein is the original cause of all the bad symptoms enumerated; and although we must allow, that such an inflammatory affection of a vein must have a considerable influence in aggravating the various symptoms previously induced by other causes; yet I think we may very fairly conclude, that it could not probably in any one instance be able to account Sect. IV. Of Bloodletting. 77 account in a satisfactory manner for their first pro- duction. In all the instances of this dreadful complaint which I have had an opportunity of seeing, the pa- tient at the very instant of the operation felt a very unusual degree of pain. In some cases, the vio- lence of the pain was almost insupportable. Now this we can never supposed to have been produced by the mere puncture of a vein; for although the coats of veins are not perhaps entirely destitute of feeling, yet we know well, that they are not endowed with such a degree of sensibility as to render it probable such intense pain could ever be induced by their be- ing punctured in any way whatever. This inflam- ed state of the veins therefore, as detected by Mr. Hunter after death, must be considered rather as be- ing produced by, than as being productive of, such affections; and that such ailments should frequently produce an inflammation of the contiguous veins, is a very probable conjecture. In the course of about forty eight hours the operation, when the fe- brile symptoms are just commencing, such a degree of hardness and evident inflammation is induced over all the parts contiguous to the orifice, that it would be surprising indeed, if the vein, which is thus per- haps entirely surrounded with parts highly inflam- ed, should not be inflamed likewise. We shall therefore proceed upon the supposition of this inflamed state of the veins being a conse- quence, rather than the cause, of such ailments; and of course we now revert to one or other of the opinions long ago adopted on this subject, that all the train of bad symptoms found on some occasions to succeed to venæsection, proceed either from the wound of a nerve or of a tendon. That a partial wound of a nerve will now and then produce very distressing symptoms, no prac- titioner will deny: But it has been attempted to be shown, as we have already remarked, that tendons are 78 Of Bloodletting. Chap. III. are almost totally destitute of sensibility; and it has therefore been supposed, that their being wounded, can never account for the various symptoms known to occur in such cases. There is great reason, however, to think, that in different instances the same train of symptoms have been induced by different causes; that in one in- stance a wounded nerve, and in others pricks of the tendons, have given rise to them. Being decidedly of this opinion myself, I think every person must be so, who has paid much attention to the subject; but as the same method of treatment proves equally ap- plicable, whether the disease has originated from the wound of a nerve or of a tendon, we do not think it necessary to enter here into a more minute discussion of the question. Having already in a former section shown how such accidents may be al- most always avoided, we shall now proceed to con- sider the means best calculated for preventing the symptoms coming to a great height, when it is dis- covered that either from inadvertence or any other cause the mischief has actually happened. Whenever a patient at the time of the operation complains of a very exquisite degree of pain, we may always be certain that some parts have been wound- ed which ought not to have been touched. When this unfortunately happens, if proper attention be given immediately, much may be done to obviate the accession of those symptoms which such a cause will otherwise certainly induce. In order therefore to prevent as much as possible the consequent inflammation and other symptoms which usually ensue, a considerable quantity of blood should be immediately discharged at the orifice just made; the limb, for several days at least, ought to be kept in a state of perfect rest, care being at the same time taken that the muscles of the part be all pre- served in as relaxed a state as possible; the patient should Sect. IV. Of Bloodletting. 79 should be kept cool; on a low diet; and, if necessa- ry, gentle laxatives ought to be administered. By such management alone, the fatal symptoms we have enumerated may frequently be prevented; and when they do occur in cases where the above precautions have not been taken, they may be con- sidered to be as much the consequence of negligence in the subsequent treatment, as of any thing pecu- liarly bad in the nature of the original accident. When notwithstanding, however, of the means recommended, the symptoms, instead of diminishing, rather become more violent, if the lips of the ori- fice turn hard and more inflamed, if the pain be- comes more considerable, and especially if the swelling begins to spread, other remedies come then to be indicated. In this state of the com- plaint, topical bloodletting, by means of leeches applied as near as possible to the lips of the wound, frequently affords much relief; and when the pulse is full and quick, it even becomes necessary to eva- cuate large quantities of blood by opening a vein in some other part. The external applications usually employed in this state of the complaint, are, warm emollient fomentations and poultices, and in similar affections of other parts no remedies with which we are ac- quainted would probably be found more successful; for as warm fomentations and cataplasms tend in general very powerfully to promote the formation of pus, and as nothing would so certainly relieve the symptoms which usually occur here as a free suppuration, applications of this nature were made therefore with some apparent propriety: But from all the experience I have had in affections of this kind succeeding to bloodletting, I am now perfect- ly convinced, that little or no advantage is ever to be expected from remedies of this class. On the idea of being able to induce a free and kindly suppuration on the wound, and having great son 80 Of Bloodletting. Chap. III. son to think, from its effects in similar cases, that all the symptoms would be thereby rendered more mild, I must own that in several cases I went into the use of applications of this kind to the greatest possible degree. Unfortunately, however, the ad- vantages resulting from them never answered my expectations; so that at last I was induced to make trial of a very different set of remedies. Although, at the time of thus using applications of the warm emollient kind, I did not attend par- ticularly, to the cause of their failure, yet I now think that this circumstance may be very easily ac- counted for. The parts here principally concerned being almost entirely membranous, and being there- fore, as we have elsewhere shown*, incapable of yielding purulent matter, a continued course of warm applications, instead of producing the wished for effect, must in all probability rather tend to ag- gravate all the symptoms; for when such remedies do not induce a free suppuration, the heat they convey to the parts, by acting as a perpetual stimu- lus, must rather tend to increase the inflammation: And in fact we find, in the complaint now under consideration, that all such applications, instead of being productive of any advantage, rather do harm. The heat of the part is here one of the most distress- ing symptoms; so that, instead of affording relief, warm emollient applications rather tend to augment this very tormenting source of uneasiness. The lips of the wound, from not being capable of producing a good suppuration, are, by the additional heat ap- plied to them through the medium of such appli- cations, rendered still more hard, swelled, and of course more painful, and the swelling of the con- tiguous parts also becomes more diffused over the rest of the member. By Ambrose Paré, Dionis, Heister, and others, instead of emollient remedies, oil of turpentine, tincture * Vide Trsatise on Inflammation and its consequences. Sect. IV. Of Bloodletting. 81 tincture of myrrh, and other heating applications, are recommended. That these would not prove effectual, I cannot from experience pretend to say; for, suspecting their powerful stimulating effects might in cases of this nature prove too irritating, for parts already by disease rendered exquisitely sensi- ble, I have never ventured to use them: But I can from repeated experience assert, that cooling astrin- gent applications afford much more ease, and, upon the whole, in all such ailments, prove much more effectual, than warm emollients; and of this class, the most effectual I have ever used are the saturnine applications. The parts chiefly affected being al- ternately covered with cloths wet with a solution of saccharum saturni, and pledgits spread with Goulard's cerate, are kept more cool and easy than by any other remedy I have ever happened to use. In all such cases, therefore, as soon as a number of leeches proportioned to the violence of the symp- toms have been applied to the parts chiefly affected, and have discharged a sufficient quantity of blood, the swelling ought to be covered with pieces of soft linen wet in the saturnine solution; and these being kept constantly moist for the space of a few hours, should be succeeded by Goulard's cerate; and thus every part in any degree affected, ought to be al- ternately covered with one or other of these appli- cations, as long as any degree of swelling remains. The febrile symptoms which occur, must at the same time be attended to, by keeping the patient cool; on a low diet; preserving a lax state of the bowels; and, if necessary, farther quantities of blood ought to be evacuated. For the violence of the pain, which is sometimes so excessive as to destroy the patient's rest entirely, opiates ought to be freely exhibited; and when twitchings of the tendons and other convulsive symptoms supervene, medicines of this kind become still more particularly necessary. In order, howev- L er, 82 Of Bloodletting. Chap. III. er, to have a proper influence in this state of the complaint, opiates ought to be given in very full doses; otherwise, instead of answering any good pur- pose, they constantly tend to aggravate the different symptoms, not only by increasing the heat and rest- lessness, but by having an evident influence in ren- dering the system more susceptible than it was be- fore of the pain and other distressing effects produc- ed upon it by the wound: Whenever opiates there- fore are in such circumstances employed, the doses ought always to be considerable. It often happens, however, in this very alarming disorder, either from neglecting the matter altogeth- er on the accident first happening, as is too fre- quently the case, or from an improper subsequent treatment by warm emollient applications, that opiates and all the other remedies enumerated are afterwards used without any advantage whatever: The fever, pain, and swelling of the parts continu- ing, convulsive affections of the muscles at last oc- cur; all tending to indicate the most imminent dan- ger. In this situation, if we have not immediate re- course to some effectual means, the patient will soon fall a victim to the disorder; and the only remedy from which much real advantage is to be expected, is a free and extensive division of the parts in which the orifice producing all the mischief was at first made. We know well from the repeated experi- ence of ages, that much more pain and distress of every kind is commonly produced by the partial division either of a nerve or of a tendon, than from any of these parts being at once cut entirely across. Now the intention of the operation here recom- mended, is, to produce a complete division of the nerve or tendon we supposed to have been wounded by the point of the lancet, and which we consider as the sole cause of all the subsequent distress. The operation now recommended being amended with a good deal of pain, and being put in practice for Sect. IV. Of Bloodletting. 83 for the removal of symptoms from which it is per- haps difficult to persuade the patient that much danger is to be apprehended, all the remedies we have mentioned should be first made trial of before it is proposed: But at the same time, care ought to be taken, that the disorder be not allowed to proceed too far before we have recourse to it; for if the patient should be previously much weakened by the feverish symptoms having continued violent for any length of time, neither the remedy now propos- ed, nor any other with which we are acquainted, would probably have much influence. As soon therefore as the course already prescribed has been fairly tried, and is found to be inadequate to the ef- fects expected from it, we ought immediately to have recourse to a free division of the parts chiefly affected; and the manner of doing it is this: As all the contiguous parts are now supposed to be much swelled and in a state of high inflamma- tion, it is impossible to get proper access either to the nerve or tendon, cut by means of a large and extensive incision; and as this cannot be affected without some risk, of opening at least some large branches of arteries, the first step to be taken in this operation is, to secure the parts, against the effects of such an occurrence, by the application of the tourniquet on the superior part of the member. This precaution is necessary, not only for guarding against the loss of blood which would ensue from a division of any of the large arteries, but for prevent- ing that interruption which would otherwise be oc- casioned by a constant discharge of blood from the smaller vessels during the operation. The tourni- quet indeed is more particularly requisite with a view to the prevention of this last inconvenience, than for any other reason; for although it is proper by means of it to guard against the effects to be ex- pected from a division of any of the large arteries, yet 84 Of Bloodletting. Chap. III. yet with proper caution such an occurrence may in most cases be very easily avoided. The tourniquet then, being properly applied, a transverse incision should be made with a common scalpel*, upon the parts chiefly affected, and it ought to run in a direction exactly across the orig- inal orifice in the vein. In every surgical operation, rashness is undoubt- edly improper, and is often productive of disagreea- ble consequences; but unnecessary caution, which almost constantly proceeds from the operator being inaccurate and confused in his ideas of the anatomy of the parts, generally produces such a degree of timidity, as ultimately proves more hurtful to the patient, than even an unusual degree of boldness; for in every operation where an incision is necessary, if the first cut is not made fully sufficient for the in- tended purpose, all the subsequent steps of it are commonly either much retarded, or perhaps ren- dered entirely ineffectual. In no operation whatever, is it more necessary than in this, to act with proper freedom in laying the parts sufficiently open by the external incision. A small incision puts the patient to nearly the same degree of pain as a larger cut; and it has this mate- rial inconvenience, that the surgeon cannot go on with the future steps of the operation with so much ease and expedition as when an extensive opening is made at first. The external teguments being thus freely divid- ed, the operator is now to proceed in a gradual manner, making one flight incision after another, taking care, if possible, to avoid wounding either the larger arteries or veins; and he is to go on in this way, to endeavour to detect the wounded nerve; or if there is no possibility of doing so, even by great caution and nicety in wiping away with a sponge every particle of blood as he goes along, he must still * For the most proper form of a scalpel, see Plate IV. Sect. IV. Of Bloodletting. 85 still continue to proceed in this slow gradual man- ner, till he has divided every part between the skin and periosteum; the tendons, larger arteries, and veins excepted. At this time the tourniquet should be loosened; and in all probability the patient will be found to express much satisfaction at what has been done: For, if the part is thus divided which originally had been pricked by the lancet, and from whence all the subsequent distress proceeded, an immediate relief will now be obtained; but, on the contrary, if the pain still continues violent, we are thereby rendered almost certain that the mischief lies altogether in one or other of the tendons. An accurate exam- ination, therefore, must now be made, by clearing the parts effectually with a sponge; and that ten- don lying most contiguous to the vein in which the orifice was made, will in all probability be found either wounded, or in an evident state of inflam- mation; but at all events, whether any such ap- pearances are detected or not, no hesitation what- ever should occur as to the propriety of dividing that tendon which lies most contiguous to the vein; or if two or even three tendinous extremities should happen to lie in the way, and to be all therefore equally liable to suspicion, they ought all un- doubtedly to be cut entirely across; and this be- ing properly effected, it will seldom happen that re- lief is not immediately derived from it: And at any rate, this being done, every attempt will have been made from which we could expect any benefit. The parts having been thus freely divided, the tourniquet must now be made as slack as possible; and such arteries as have been wounded must be properly secured. The parts are then to be cover- ed with soft easy dressings, and to be afterwards treated in the same manner as a wound from any other cause. The 86 Of Bloodletting. Chap. III. The remedy here recommended, if every circum- stance is not duly attended to, may probably be considered as severe; for such an incision carried to such a depth, must no doubt be attended with much pain; and the division of one or more tendons runs a considerable risk of producing at least a partial lameness, and that too probably for life, of the whole member: But if we consider for a moment the importance of the object in view, every consid- eration of this kind must immediately lose all weight. It is not a trifling advantage we are in pursuit of, nor can such a painful operation be ever, with propriety recommended except in very urgent circumstances. In the present instance, however, it is clear that the patient's life is in all probability to depend on the event of this operation; so that the most timid operator, if he is at all capable of re- flection, must admit the propriety of putting it in practice; and from the event of almost every case of this nature, that has once advanced to the length for which we have recommended the operation in question, it may with great certainty be pronounc- ed, that every patient in such circumstances is in the utmost hazard of his life; so that in such a des- perate situation, no remedy that affords any tolera- ble chance of a recovery, however painful it may be, can with propriety be condemned. From reasoning alone, we would readily con- clude, that in all such circumstances no remedy whatever would more probably prove successful than the operation we have now advised; but when the propriety of the measure is enforced by the suc- cessful issue of repeated trials, no argument adduced against it ought to meet with much attention. In different occurrences of this kind, of less import- ance, I have seen much advantage ensue from the practice here recommended; but in one instance, where the patient had been blooded in the median cephalic vein of the arm, the disorder had got to such Sect. V. Of Bloodletting. 87 such a height, and had so obstinately resisted every other remedy, that there was every reason to sup- pose death must have ensued, had it not been for the effects of a free and very deep incision made into the parts affected. The patient, from being evidently in very great hazard, and in exquisite pain, experienced almost instantaneous relief; and the swelling, which had previously resisted the ef- fects of every other remedy, and had even contin- ued to spread, began soon to abate, and a perfect recovery was obtained in a much shorter space of time than could have been expected. There is not therefore a point in surgery that I am more satisfied of, than the propriety of such an operation in all such desperate cases as the one we have been treating of; but too such as have not hap- pened to meet with occurrences of this nature, the remedy proposed will not only appear to be too vi- olent for the disease, but they will also be induced to consider the length of discussion here gone into to be much more prolix than is necessary: A sin- gle instance, however, of the dreadful symptoms now and then induced by accidents of this kind, will be fully sufficient to convince any man, that the subject now under consideration is perhaps one of the most important in the department of surgery. All that has hitherto been said on bloodletting relates to the operation in general: We shall now proceed to consider the operation as it is put in practice in particular parts; and first of bloodletting in the arm. SECTION V. Of BLOODLETTING in the ARM. BLOODLETTING is more frequently prac- tised on the forepart of the arm at the joint of the elbow, than in any other part of the body. The veins 88 Of Bloodletting. Chap. III. veins are in general more conspicuous in this place; but no other reason can be assigned for this prefer- ence: On the contrary, the near contiguity of nerves, tendons, and of large arteries, to these veins, makes the operation more hazardous here than in any other part. From this circumstance, therefore, I have often been induced to consider the fixing on this part for the ordinary operation of bloodletting, as a very capital error; and the more especially as blood may be drawn from veins in other parts with the same ease as from those of the arm, and with much less danger; particularly from the veins of the neck, from those of the under part of the legs, ankles, and feet. Bloodletting in the lower extremities has indeed in general been confined to a particular set of dis- orders; chiefly to those of females: But no good reason, I imagine, can be assigned for this; for it is now well known, that, in general bloodletting, the place from whence the blood is drawn, is of little importance, and that the effects of the operation de- pend almost solely upon the quantity of blood that is discharged in a longer or shorter space of time. Bloodletting at the arm may be safely performed by a surgeon of steadiness and attention, as in the hands of such a man there can be little or no risk of the lancet going deeper than the vein, and in this case nothing bad can ensue: But, in ordinary prac- tice, I should at all times rather incline to have the operation done in some other part. It may almost always be done with ease in the feet and ankles; and if the operation is properly performed, the same quantity of blood may be drawn from the veins of these parts, as from veins of an equal size in any other part of the body. But whether the idea now suggested should ever be generally adopted or not, this is so far evident, that if the cautions we have pointed out are proper on every occasion when venæsection is practised, they Sect. VI. Of Bloodletting. 89 they are necessarily much more so when the operation is done in the arm, where the veins lie so very contig- uous to parts which cannot be wounded without pro- ducing very alarming symptoms. Having already considered with minuteness the various steps of the operation of bloodletting, so far as they relate to it in a general way; in order to avoid repetitions, nothing will now be pointed out but what is particularly required in performing this operation in the arm. In applying the ligature for the stoppage of the cir- culation, it ought to be placed about an inch or an inch and half above the joint of the elbow: and, in order to prevent the ends of it from interfering with the lancet, the knot should be made on the outside of the arm. In general, one knot might answer; but a slipknot being made above the first, renders it more secure, and it is very easily done. In making choice of a vein from whence blood is to be taken, the general rules we have already laid down upon this point must be here particularly at- tended to. That vein which appears most conspicu- ous, at the same time that it rolls least under the skin, should in general be fixed upon; but when an artery is found to lie immediately below, and quite contigu- ous to such a vein, the operator, if he is not perfectly satisfied with his own steadiness, ought rather to take some other. In general, however, the artery lies so low in this place, that the median basilic vein, under which it commonly runs, may be opened with perfect safety; and as this vein in general appears more con- spicuous than any of the others, probably from the continued pulsation of the artery below obstructing in some measure the passage of its contents, it is for this reason therefore to be made choice of rather than any of the rest. Other circumstances occur too, which render the median basilic preferable to the cephalic or median cephalic veins for the operation of blood- M letting. 90 Of Bloodletting. Chap. III. letting. The former, viz. the median basilic, is less deeply covered with cellular substance, and by lying towards the inner part of the arm it is more thinly covered with the tendinous expansion of the biceps muscle, than either of the others. From these cir- cumstances the operation is always attended with less pain when done in this vein than in any of the others; and that consideration alone ought to have a good deal of influence in determining the choice of an op- erator. In bloodletting at this part of the arm, although the operation may be done with the right hand either upon the right or left arm of the patient; yet it is much more neatly done by performing with the right hand upon the right arm, and with the left hand upon the left arm of the patient; and whoever attempts the contrary, must find that it cannot be done but in a very awkward manner, as the operator can never in any other way apply his hand properly to the patient's veins. In very corpulent people, it sometimes happens, that all the larger veins lie so deep as not to be dis- covered by the eye; but when they are sensibly felt by the fingers, even although they cannot be seen, they may be always opened with freedom. In a few instances, however, it is the case, that they can neither be distinguished by the eye, nor by the finger: In such a situation, as they may in general be met with about the wrist, or on the back part of the hand, the ligature should be removed from the upper part of the arm; and being applied about half way between the elbow and wrist, the veins below will thereby be brought into view; and wherever a vein can be evi- dently observed, there can be no danger in having re- course to the operation. SECTION. Sect. VI. Of Bloodletting. 91 SECTION VI. Of BLOODLETTING in the JUGULAR VEIN. FOR inflammation of the throat, disorders of the eyes, and other affections of the head, when it is wished to evacuate blood from vessels near to the parts af- fected, it is frequently judged proper to open the ex- ternal jugular veins; and the manner of doing the operation is this: There is only one ramification of this vein, viz. its principal posterior branch, which can easily be brought so much into view, as to be with propriety opened; and even this lies deeply covered with parts, not only with the skin and cellular substance, but with the fibres of the platisma myoides muscle, so that a considerable degree of pressure becomes necessary in order to raise it to any height. With a view to pro- duce this, the operator's thumb is commonly advised to be placed upon the vein, so as to compress it ef- fectually about an inch or inch and half below where the opening is to be made. This, however, seldom proves sufficient for the purpose, as the blood, on being stopped in its progress through this branch, easily finds a passage to the other veins; so that un- less the principal vein on the other side of the neck be also compressed, the vein to be opened can never be fully distended. In order to distend it sufficiently, a firm compress of linen should be applied on the larg- est vein on the opposite side of the neck; and an or- dinary garter, or any other proper ligature, being laid directly over it, should be tied with a firm knot below the opposite armpit; taking care to make such a de- gree of pressure, as to put an entire stop to the circu- lation in the vein, which in this way it is easy to do without producing any obstruction to the patient's breathing. This 92 Of Bloodletting. Chap. III. This being done, and the patient's head being prop- erly supported, the operator, with the thumb of his left hand, is now to make a sufficient pressure upon the vein to be opened, and with the lancet in his right hand is to penetrate at once into the vein; and, be- fore withdrawing the instrument, an orifice should be made large enough for the intended evacuation. It may be proper to observe, that a more extensive opening ought always to be made here than is neces- sary in the arm, otherwise the quantity of blood is generally procured with difficulty: And besides, there is not the same necessity for caution on this point here that there is in the arm: For it seldom or never hap- pens, that any difficulty occurs in this situation, in put- ting a stop to the blood after the pressure is removed from the veins; all that is commonly necessary for this purpose being a slip of adhesive plaster, without any bandage whatever. In order to bring the vein more clearly into view, so as afterwards to be able to open it with more ex- actness, it has been directed, that the skin, cellular substance, and muscular fibres covering the vein, should be previously divided with a scalpel before at- tempting to push the lancet into it. There is not, however, any necessity for this precaution, as it rarely happens that any difficulty is experienced in procur- ing a free discharge of blood by opening the vein and teguments at once in the manner directed: And it is here, as in every instance where it is necessary to take blood by a lancet, if it be not done at once, the pa- tient is much disappointed, and is sure to attribute the failure entirely to a fault in the operator. SECTION. Sect. VII. Of Bloodletting. 93 SECTION VII. Of BLOODLETTING in the ANKLES and FEET. WHAT has already been said on the operation of bloodletting, renders it quite unnecessary to be here in any degree minute. When blood is to be discharg- ed from the veins of these parts, it will be readily un- derstood, that the first step to be taken is a proper compression of the veins, so as to produce an accumula- tion of their contents. The ligature for this purpose being applied with a sufficient degree of tightness a little above the ankle joint, all branches of the vena saphena, both in the inside and outside of the foot, come at once into view; and as this vein lies every where very superficial, being in general covered with skin only, wherever a proper vein appears con- spicuously it may with safety be opened. With a view to encourage the discharge of blood, it has been a constant practice in bloodletting in these veins, to dip the feet into warm water immediately on the orifice being made. But this is a very inaccu- rate method of proceeding, as the quantity of blood taken in this manner can never be ascertained with precision; for the blood being all mixed with the wa- ter, the operator can never be in any degree certain as to this point: And besides, there does not appear to be any necessity for this assistance; for, when the compression of the superior part of the veins is made effectual, and the orifice is of a proper size, I never found more difficulty in obtaining a full discharge of blood from veins of these parts, than from any other veins of the body. On removing the ligature, the discharge is gener- ally stopped at once; so that a piece of adhesive plas- ter applied over the orifice, answers all the purposes of a bandage. These 94 Of Bloodletting. Chap. III. These are the several parts from whence blood is usually taken by venæsection; but on some occasions, where the contiguous parts have been particularly af- fected, it has been thought advisable to open the veins of other parts, viz. those of the tongue, of the penis, the external hemorrhoidal veins, &c. When it is found necessary to discharge blood in this manner from the penis, the veins can be easily brought into view by producing an accumulation of their contents in the same manner as in other parts of the body, through the intervention of a ligature: But, in the tongue, in the hemorrhoidal veins about the anus, and other parts where compression cannot be applied, all that the surgeon can do, is, to make an orifice of a proper size in that part of the vein which shows itself most evidently; and if a sufficient discharge of blood is not thus produced, as there is no other method of effect- ing it, immersing the parts in warm water may in such circumstances be a very necessary measure. Having thus considered the various modes of dis- charging blood by venæsection, we now proceed to arteriotomy. SECTION VIII. Of ARTERIOTOMY. WHATEVER particular advantages may in the- ory have been expected from arteriotomy, and how- ever some of its supporters may in their closets have recommended it, not only as being in many instances preferable to venæsection, but as an operation perfect- ly safe even in vessels of considerable size; yet the most strenuous friends to the practice, have shrunk from attempting it on the larger arteries. Instances have no doubt occurred of large arteries having been opened without any danger ensuing; but these are so exceedingly rare, that no practitioner of experience will Sect. VIII. Of Bloodletting. 95 will be induced by them, deliberately, or from choice, to open any considerable artery. The smaller branch- es of arteries may indeed be opened with great safety when they are not deeply covered, and especially when they lie contiguous to bones, as in such situations, so soon as the quantity of blood intended to be taken is discharged, all farther loss of blood may be very easily prevented by compression; but the opening of any of the larger arteries must be always attended with so much hazard, and the advantages to be expected from it in preference to venæsection are apparently so trifl- ing, as must in all probability prevent it from ever being carried into execution. There are very few arteries, therefore, which with any propriety can be opened; the different branches of the temporal are the only arteries indeed from whence blood in ordinary practice is ever taken: But, if a fanciful practitioner should at any time in- cline to take blood in this manner from a different part, it may be done with great safety from one of the arteries running on each side of the fingers. About the middle of the last phalanx, this artery is sufficient- ly large for discharging a considerable quantity of blood; in most cases it lies very superficial, and in this situation there can seldom much difficulty occur in putting a stop to the evacuation. In performing this operation on any of the temporal branches, if the artery lies superficial, it may be done with one push of the lancet, in the same manner as was directed for venæsection; but, when the artery lies deeply cov- ered with cellular substance, it always necessary to lay it fairly open to view, before making the orifice with the lancet: For in all the smaller arteries, when they are cut entirely across, there is little chance of being able to procure any considerable quantity of blood from them: As, when divided in this manner, they retract considerably within the surrounding parts, which commonly puts a stop to all further evacuation. Some 96 Of Bloodletting. Chap. III. Some degree of nicety is also necessary in making the opening into the artery, of a proper oblique direc- tion, neither quite across, nor directly longitudinal; for a longitudinal opening never bleeds so freely, ei- ther in an artery or in a vein, as when its direction is somewhat oblique. If the opening has been properly made, and if the artery is of any tolerable size, it will at once discharge very freely without any compression; but when the evacuation does not go on so well as could be wished, the discharge may be always assisted by compressing the artery immediately above the orifice, between it and the corresponding veins. The quantity of blood being thus discharged, it will commonly happen, that a very slight compression on these smaller arteries will suffice for putting a stop to the evacuation. But any degree of pressure that is found necessary may be ap- plied here as in venæsection, by means of a linen com- press and roller; the orifice being first entirely clear- ed of blood, and properly covered with a bit of ad- hesive plaster. If that should not be found to answer, a compress of linen should be applied over it, the whole being then to be secured with a roller. It happens, however, in some instances, that this does not succeed, the orifice continuing to burst out from time to time, so as to be productive of much distress and inconvenience. In this situation there are three different methods by which we may with tolerable certainty put a stop to the farther discharge of blood. 1st. If the artery is small, as all the branches of the temporal arteries commonly are, the cutting it entirely across, exactly at the orifice made with the lancet, by allowing it to retract within the surrounding parts, generally puts an immediate stop to the discharge. 2d. When that is not consented to, we have it always in our power to secure the bleeding vessel with a ligature, as we would do an artery accidentally divided in any part of the body. Sect. IX. Of Bloodletting. 97 body. And, lastly, if neither of these methods is a- greed to by the patient, we can, by means of a con- stant regular pressure, obliterate the cavity of the ar- tery at the place where the operation has been per- formed, by producing an accretion of its sides. Differ- ent bandages have been contrived for compressing the temporal artery; but none of them answer the pur- pose so easily and so effectually as the one represented in Plate VI. fig. 3. As some time, however, is required to obliterate the cavity of the artery, this method is accordingly more tedious: But to timid patients it generally proves more acceptable than either of the other two. Having thus finished the consideration of the va- rious methods employed for evacuating blood from the larger arteries and veins, we now proceed to the consideration of topical bloodletting. SECTION IX. Of TOPICAL BLOODLETTING. WHEN, either from the severity of a local fixed pain, or from any other cause, it is wished to evacu- ate blood directly from the small vessels of the part affected instead of opening any of the larger arteries or veins, the following are the different methods employ- ed for affecting it, viz. By means of leeches; by slight scarifications with the shoulder or edge of a lan- cet; and, lastly, by means of an instrument termed a Scarificator, containing from one to twenty lancets or more, fixed in such a manner, that when the instru- ment is applied to the part affected, the whole num- ber is by means of a spring driven suddenly into it, and to a greater or lesser depth at pleasure. This being done, as it is the smaller blood vessels only that by this operation are ever intended to be cut, and as these do not commonly discharge freely, some means N or 98 Of Bloodletting. Chap. III. or other become necessary for promoting the evacua- tion. Various methods have been proposed for this pur- pose. Glasses fitted to the form of the affected parts, with a small hole in the bottom of each, were long ago contrived; and these being placed upon the scar- ified parts, a degree of suction was produced by a per- son's mouth sufficient for nearly exhausting the air contained in the glass: And this accordingly was a sure enough method of increasing the evacuation of blood to a certain extent*. But, as this was attended with a good deal of trouble, and besides did not on every occasion prove altogether effectual, an exhaust- ing syringe was at last adapted to the glass, which did indeed answer as a very certain method of extracting the air contained in it: But the application of this in- strument for any length of time is very troublesome; and it is difficult to preserve the syringe always air tight. The application of heat to the Cupping Glasses, as they are termed, has been found to ratify the air con- tained in them to a degree sufficient for producing a very considerable suction. And as the instrument in the simple form answers the purpose in view, with very little trouble to the operator, and as it is at all times easily obtained, the use of the syringe has therefore been laid aside. The glasses for this pur- pose, it is evident, must be entire; for if there is the least communication allowed between their cavities and the surrounding atmosphere, no effect whatever will be produced by them. There are different methods employed for thus ap- plying heat to the cavity of the glass. By supporting the mouth of it for a few seconds above the flame of a taper, the air may be sufficiently rarified; but if the flame is not kept exactly in the middle, but is allow- ed to touch either the sides or bottom of the glass, it is * Celsius, lib. 2. cap. II. Sect. IX. Of Bloodletting. 99 is very apt to make it crack and fly in pieces. A more certain, as well as an easier method of applying the heat, is to dip a piece of soft bibulous paper in spirit of wine, and having set it on fire, to put it into the bottom of the glass, and, on its being nearly ex- tinguished, to apply the mouth of the instrument di- rectly upon the scarified part. This, degree of heat, which may be always regulated by the size of the piece of paper, and which it is evident ought to be always in proportion to the size of the glass, if long enough applied proves always sufficient for ratifying the air very effectually, and at the same time, if done with any manner of caution, never injures the glass in the least. The glass having been thus applied, if the scarifi- cations have been properly made, they instantly begin to discharge freely; and as soon as the instrument is nearly full of blood, it should be taken away, which may be always easily done by raising one side of it, so as to give access to the external air. When more blood is wished to be taken, the parts should be bath- ed with warm water; and, being made perfectly dry, another glass exactly of the size of the former should be instantly applied in the very same manner; and thus, if the scarificator has been made to penetrate to a suf- ficient depth, so as to have cut all the cutaneous ves- sels of the part, almost any necessary quantity of blood may be obtained. It sometimes happens, however, that the full quantity intended to be discharged can- not be got at one place: In such a case, the scarifica- tor must be again applied on a part as contiguous to the other as possible; and this being done, the appli- cation of the glasses must also be renewed as before. When it is wished to discharge the quantity of blood as quickly as possible, two or more glasses may be applied at once on contiguous parts previously scarified; and on some occasions, the quantity of blood is more quickly obtained when the cupping glasses are 100 Of Bloodletting. Chap. III. are applied for a few seconds upon the parts to be af- terwards scarified. The suction produced by the glasses may possibly have some influence in bringing the more deep seated vessels into nearer contact with the skin, so that more of them will be cut by the scar- ificator. A sufficient quantity of blood being procured, the wounds made by the different lancets should be all perfectly cleared of blood; and a bit of soft linen or charpie dipped in a little milk or cream, applied over the whole, is the only dressing that is necessary. When dry linen is applied, it not only creates more uneasiness to the patient, but renders the wounds more apt to fester than when it has been previously wetted in the manner directed. Although this operation is by no means difficult in the execution, yet a good deal of practice is necessary to perform it in a neat and successful manner; but with a little attention, any operator may soon become so expert, as to be able to take any quantity of blood by it that can ever be necessary. In some cases of local pains, and in others where suppuration of the part has been wished for, an opera- tion termed dry cupping has been proposed, and in some instances its advantages are said to have proved considerable. This consists in the application of the cupping glasses directly to the parts affected, without the use of the scarificator. By this means a tumor is produced upon the part; and where any advantage is to be expected from a determination of blood to a particular spot, it may probably be more easily accom- plished by this means than by any other. In Plate VI. are represented a scarificator, and dif- ferent sizes and figures of cupping glasses, with which every operator ought to be amply supplied, so as to be able to adapt a glass to every part from whence it may be proper to discharge blood in this manner. When the part from which it is intended to produce a local Plate V.  Sect. IX. Of Bloodletting. 101 local evacuation of this kind is so situated that a scari- ficator and cupping glasses can be applied, this method is greatly preferable to every other; but it now and then happens, that parts are so situated as not to ad- mit of their application: Thus, in inflammatory af- fections of the eye, of the nose, and of other parts of the face, the scarificator cannot be properly applied directly to the parts affected. In such instances, leeches are commonly had recourse to, as they can be placed upon almost any spot from whence we would wish to discharge blood. In the application of these animals the most effect- ual method of making them fix upon a particular spot, is to confine them to the part by means of a small wine glass. Allowing them to creep upon a dry cloth, or upon a dry board, for a few minutes before application, makes them fix more readily; and moist- ening the parts on which they are intended to fix, ei- ther with milk, cream, or blood, tends also to cause them to adhere much more speedily than they otherwise would do. So soon as the leeches have separated, the ordinary method of promoting the discharge of blood, is to cover the parts with linen cloths wet in warm water: In some situations, this may probably be as effectual a method as any other; but wherever the cupping glasses can be applied over the wounds, they answer the purpose much more effectually: When- ever the figure of the part, therefore, will admit of their application, they ought undoubtedly to be employed. Among other methods of effecting what we term Local Bloodletting, scarifications with the edge or shoulders of a lancet was mentioned as one: There are not many instances in which this proves very nec- essary; but now and then cases do occur in which blood may be taken in this manner, when it cannot with pro- priety be discharged by any other means. This is par- ticularly the case in some inflammatory affections of the eye, where the ball of the eye is chiefly affected, and where 102 Of Bloodletting. Chap. III. where general bloodletting and evacuations from the neighbouring parts do not prove effectual. In such affections it frequently happens, that scarifying the vessels of the tunica conjunctiva of the eye, so as to evacuate perhaps only a very few drops of blood, is productive of much advantage. The mere division of the vessels in such cases, has indeed been supposed to be of use; but I have constantly observed, that the advantage produced by this operation, has been in general nearly in proportion to the quantity of blood discharged by it. Different methods have been proposed for perform- ing it, but the easiest and most effectual, is by means of the edge or shoulder of a lancet. For this purpose, the upper eyelid being supported by the hand of an assistant, and the under palpebra being secured by the fingers of the operator's left hand, with the lancet in his right hand, a number of slight scarifications should be made through the different vessels that seem to be most turgid. In order to secure the eye properly, it has been advised to have it previously fixed by a spec- ulum before attempting to scarify the vessels. There is not, however, any occasion for this precaution, as the eye may be always made sufficiently steady for this operation, by gentle pressure with the fingers in the manner directed; and besides, in this inflamed state of the eye, the pressure produced by a speculum is very apt to do mischief. To such as have not seen this operation put in prac- tice, it may perhaps appear to be too hazardous to be attempted by those who are not much accustomed to it; but a very moderate degree of steadiness renders it very easily and safely practicable. All the vessels in- tended to be cut, being freely divided, bathing the eye in warm water is the most effectual method of encouraging the discharge. In the same manner, scarifications of this kind may at times be usefully employed in removing inflam- matory Sect. IX. Of Bloodletting. 103 matory affections of the eyelids; and the same rem- edy may now and then, perhaps, be used with advan- tage in similar affections of other parts. Among other methods that have been proposed for scarifying the blood vessels of the eye the beards of rough barley were at one period much extolled, and are still employed by some individuals. By draw- ing them over the surface of the eye, in a direction contrary to the sharp spiculæ with which they are furnished, a considerable discharge of blood is thereby produced. But the pain attending this operation is exquisite; and as it does not possess any superior ad- vantage to the method with the lancet, it is now fall- ing into general disuse. We have thus finished the consideration of the va- rious means employed in surgery for evacuating blood from the system; and as the disorder termed Aneu- rism is frequently produced by an unguarded manner of performing one of the operations we have just been describing, the farther consideration of this subject cannot, we think, be any where more properly intro- duced than in this place, where one of the principal causes tending to produce it has been so lately treated off. CHAP. 104 Of Aneurisms. Chap. IV. CHAP. IV. OF ANEURISMS. SECTION I. GENERAL REMARKS on ANEURISM. THE term Aneurism, was original- ly meant to signify a tumor formed by the dilatation of the coats of an artery; but by modern practition- ers, it is made to apply not only to tumors of this kind, but to such as are formed by blood effused from arteries into the contiguous parts; a circumstance which may happen either from an artery being punc- tured with a sharp instrument, or from a rupture of its coats produced by any other cause. The first species of the disorder, viz. that which depends on the extension or dilatation of the coats of an artery, has been denominated the True Aneurism; and the latter, or that which proceeds from an effu- fion of arterial blood into the surrounding parts, has been commonly termed the False Aneurism. As the introduction of new appellations frequently tends to produce confusion, necessity alone can justify the attempt; and accordingly it will rarely happen in the course of the present work, that any innovation of this kind is made. In the present instance, however, as the nature and treatment of the disorder may be rendered more clear and distinct by a change of terms applied to the different species of aneurism, an attempt of Sect. I. Of Aneurisms. 105 of this kind may, for such a reason, it is hoped, be made without any impropriety. In that species of the disorder depending upon the dilatation of an artery, as the tumor is always circum- scribed, and contained within coats peculiar to itself, it may therefore properly enough be termed the En- cysted Aneurism; and the other, from the swelling spreading extensively over the neighbouring parts, may with equal propriety be termed the Diffused Aneurism. As these two species of the disorder are very dif- ferent from one another, not only in their causes, ap- pearance, and effects, but even in the treatment nec- essary for their removal; it will be proper, therefore, to enter into a separate consideration of each of them. In the true or encysted aneurism, when externally situated, the tumor when first observed is commonly very small and circumscribed; the skin retains its natural appearance; when pressed by the fingers, a pulsation corresponding with that of the artery below is evidently distinguished; and with very little force the contents of the swelling, while they are yet soft and fluctuating, may be easily made to disappear entirely. If means properly calculated for the removal of the disease are not now put in practice, or if upon trial they should be found to fail, the swelling begins to increase, becomes more prominent, and continues in a gradual manner to acquire a larger size. For a considerable time the skin and teguments retain their natural appearance; the patient does not complain of pain, not even on pressure; the tumor continues of an equal softness; and its contents are still compres- sible, yielding considerably, and in general disappear- ing entirely on the application of pressure. At last, however, when the swelling becomes very large, the skin loses its ordinary colour, becomes pale, and, in the more advanced stages of the disease, even œdema- tous: The pulsation still continues; but the tumor O although 106 Of Aneurisms. Chap. IV. although soft in some parts, yet in others is firm, and cannot now be made to yield much upon pressure, part of the contained blood having in this stage of the disease become hard by coagulation. The swelling continuing to increase, in a gradual manner it becomes more painful, and produces much distress; the skin turns livid, apparently verging to a gangrenous state: At last, an oozing of bloody serum occurs from the teguments; and if a real mortifica- tion does not take place, the skin cracks in different parts; and now the force of the artery not meeting with so much resistance as before, in a very short space of time, if the vessel is large, a period is put to the patient's existence, by the blood bursting out with such violence as to produce almost instantaneous death; at least in the larger arteries of the trunk of the body, this is the ordinary event of all such affections. In the extremities, however, the arteries are not so large as by their rupture to be capable of producing effects so immediately fatal; and besides, we can here, in general, by means of the tourniquet, be always certain of preventing this sudden termination of the disease. In aneurismal affections of the larger arteries, the effects produced upon the neighbouring parts, by the constant pulsation and gradual augmentation of the tumor, are often surprising. The softer parts we might, à priori, expect to yield to a very considerable ex- tent; but the hardest parts of the body, probably from the very circumstance of their not being capable of yield- ing evidently suffer more from the effects of this kind of pressure, than either membranes, muscles, or liga- ments. Even the bones frequently undergo a very great degree of derangement, by the pulsation and distension of contiguous aneurisms: Sometimes they are separated entirely from one another at the differ- ent joints: On some occasions they are elevated much out of their natural situations; and in many instances they have been found entirely dissolved. Occurrences Sect. I. Of Aneurisms. 107 Occurrences of this kind are not common in any of the extremities, as it is the strong pulsation of the aorta only, or of some of the larger arteries at no great distance from the heart, that we can ever sup- pose should be followed by such consequences. Now and then, however, similar effects of an aneurism have been observed in the thigh, and superior parts of the arm; even the bones of these parts having been found much affected by aneurismal swellings of the neigh- bouring arteries. The appearance and termination of encysted aneu- risms, are in general very nearly as is here represent- ed: One exception, however, occurs in a particular species of the disorder, which will afterwards be more accurately described. Various causes may be supposed necessary to the production of encysted aneurisms. 1. We know from daily experience, that partial debility frequently oc- curs in different parts of the system: Thus, there is nothing more common than œdematous swellings of the extremities, even in constitutions otherwise healthy; and swellings of this nature, we justly supposed to de- pend most frequently on a local weakness of the parts in which they occur. Now, why may not a debility of a similar kind fall upon part of the arterial system? And, if it should ever do so, we can easily see how in almost every instance it must necessarily terminate in aneurismal swellings: For the force of the heart con- tinuing the same, if any particular part, of an artery has lost its tone, as it is thereby rendered incapable of resisting the pulsations of the heart, a yielding or dilatation of its coats, must at these weakened parts naturally ensue; and as soon as a morbid enlargement of its cavity is thus fairly commenced, as its power of resistance will of course proportionally diminish, while at the same time the vis à tergo still continues equally powerful, the farther increase of the swelling is a con- sequence that must necessarily ensue. This 108 Of Aneurisms. Chap. IV. This cause of the disease may be considered as the most frequent origin of aneurisms that do not evident- ly depend upon external injuries: All such swellings as occur in the course of the aorta, seem clearly to depend on this cause; as is in general the case, indeed, with all such as happen internally, in whatever part of the body they may be situated. 2. The external coats of an artery being destroyed by a wound with any kind of instrument, a partial weakness of the part will be thus produced; and this must render it liable to be acted upon to advantage, by the heart and other parts of the arterial system, in the same manner as if it had been previously debili- tated by disease. In dilatations of an artery produced by this cause, the disorder proceeds in the manner we have already described. The blood, from being still confined; within the coats of the artery, continues to form a cir- cumscribed tumor. In the beginning of the disease, the swelling is easily made to disappear upon pressure; but on advancing farther, part of its contents become so firm by coagulation, as to render it impossible to discuss it by any degree of pressure that can with pro- priety be applied. This species of the disorder may now and then occur from other causes, but it is most frequently produced by bloodletting in the arm; by the lancet, after having passed through the vein, going so deep as to divide the external coats of the artery. 3. A similar effect has been sometimes produced, by the matter contained in neighbouring sores and ab- scesses, proving so corrosive as to destroy the external coverings of the contiguous arteries: When this hap- pens to occur, the same train of symptoms, it is evi- dent, must succeed as if the outer coats of the vessel had been destroyed by a lancet or any other sharp in- strument. 4. The bones, muscles, ligaments, &c. with which arteries are surrounded, all serve as a support to these vessels, Sect. I. Of Aneurisms. 109 vessels, so that it is not surprising, that the destruction of any of these parts should tend to the production of aneurisms; and accordingly instances have occurred, where affections of this kind seemed evidently to de- pend on such a cause; Indeed the firmness and sta- bility of any set of parts naturally connected together, depends so much upon a found state of the whole, that any one of them becoming weak and diseased, gener- ally terminates in a diseased state of all or part of the remainder. In the thigh of a patient where part of the muscles and other soft parts had been destroyed by an extensive mortification, different aneurismal swell- ings occurred in the course of the femoral artery which had thus lost part of its support; and no other cause appeared to be concerned in their production. 5. In bloodletting at the usual place in the arm, it was already remarked, that arteries are sometimes wounded, by the lancet passing quite through the vein into the artery below; and when the artery happens to be directly in contact with the vein, the blood dis- charged from the orifice made in the artery, by pass- ing directly into the vein, serves to keep up a com- munication between the trunk of the one, and a prin- cipal branch of the other. In this manner, a direct passage being produced between the artery and vein, and the coats of the lat- ter not being sufficiently firm for resisting the impulse of the former, a preternatural dilatation of the vein is a consequence that must necessarily follow: A tumor accordingly is very soon produced, which is at first small and circumscribed, but by degrees it extends considerably both above and below the orifice; not only along the course of the vein originally wounded, but, on some occasions, all the veins lying contiguous come to be equally distended. This species of the disease was first accurately de- scribed by that celebrated anatomist Doctor William Hunter; and may with great propriety be termed the Varicose 110 Of Aneurisms. Chap. IV. Varicose Aneurism. Since that period it has been frequently observed by different practitioners; so that its nature is now very generally understood. Although the coats of the artery are here supposed to be all cut fairly open, so as to produce an imme- diate discharge of blood; yet by the blood being con- tained within the cavity of the veins, this species of the disease may with equal propriety be considered as encysted as any of the preceding; and as the treat- ment of it coincides much with that of other encysted aneurisms, the farther consideration of the subject could not, it was imagined, be any where more prop- erly introduced. In this species of aneurism, the swelling is confined entirely to the veins. Soon after the injury produc- ing it has been received, the vein communicating im- mediately with the artery begins to swell: In a gradu- al manner, this enlargement becomes more remarka- ble; and when any considerable anastomosis occurs near to the part affected, between it and the contigu- ous veins, these also become much enlarged. By press- ing upon this swelling of the veins, it may be made to disappear entirely, the blood contained in them being in part pushed forward in its course towards the heart, while part of it may possibly be forced into the artery itself; and, when the tumor happens to be of a con- siderable size, the blood, when it is thus forced out of it, is heard to make a very singular hissing kind of noise. This, when it occurs, is a very characteristic symptom of the disease; but as it is not met with in every case, it becomes necessary to point out particu- larly, such circumstances as more certainly serve to distinguish this species of aneurism. In the varicose aneurism there is a very singular tremulous motion dissevered in the dilated vein, at- tended with a perpetual hissing noise as if air was pass- ing into it through a small aperture. If a firm liga- ture be applied upon the under part of the limb, im- mediately Sect. I. Of Aneurisms. 111 mediately below the swelling, and be tied so tight, as even to stop the pulse in the under part of the mem- ber, the swelling in the veins, on being removed by pressure, returns instantaneously on the pressure being taken off, and does not appear to be in any degree af- fected by the ligature below; which it undoubtedly would be, was it not for the direct communication be- tween the trunk of the artery and corresponding vein. The swelling being removed by pressing the blood forward to the heart, and a slight pressure being made with the point of the finger on the orifice in the artery, the veins remain perfectly flaccid, without any swelling whatever being produced, until the pressure is remov- ed from the orifice, when they fill again immediately; and this even happens, although the pressure on the artery is not so firm as to stop the circulation in the under part of the limb. In the same manner, too, if the trunk of the artery be compressed above the orifice, so as to stop the cir- culation effectually, that tremulous motion and hissing noise in the swelling of the veins ceases instantly; and, if the veins are now emptied by pressure, they will certainly remain so till the compression upon the ar- tery is removed. On some occasions, too, it happens, that if two ligatures be applied, one an inch or two a- bove, and the other as much below the swelling, and are made so tight, as to stop entirely the circulation of the blood in the tumor lying between them; if the swelling is now compressed, all the blood contained in it is made to pass into the opening in the artery, from whence it instantly returns again on the pressure be- ing removed. This, however, does not always hap- pen; and it's not doing so, is no proof whatever of that species of aneurism now under consideration not actually existing; for if all or several of the leading circumstances of the disease which we have just enu- merated ever take place, the nature of the disorder is thereby rendered clear and evident. In 112 Of Aneurisms. Chap. IV. In addition to the other characteristic symptoms of the varicose aneurism, it may be remarked, that when it has continued for any length of time, so as to have produced a considerable dilatation of the veins, the trunk of the artery above the orifice generally be- comes preternaturally large, while the branches below become proportionally small; and of consequence, the pulse in the under part of the member is always more feeble than in the sound limb of the opposite side. The reason of this last circumstance is obviously this; that the blood, by finding a direct passage be- tween the trunk of the artery and the principal branch of the corresponding vein, passes more readily in that way, than by the common course of circulation along the under part of the member; so that the quantity of blood sent to the inferior extremities of the artery being thus much diminished, the pulsation produced by it must of course become proportionally feeble: But why the superior part of the artery should be en- larged, by the blood passing thus so directly and easily from it into the vein, is a circumstance not so ea- sily accounted for. The resistance to the blood pass- ing through the artery, is by this direct communica- tion between it and the vein very much diminished; and this has been suggested as the cause of the phe- nomenon. But this circumstance, of the resistance to the passage of the blood being thus diminished, we might more readily expect to have a very contrary effect. In other parts of the circulating system, we frequently find, that resistance to the passage of the fluids terminates in a dilatation of the containing ves- sels; and that swellings thus produced, can be remov- ed by no other means than the removal of that resist- ance which first gave rise to them. Nothing that can be said upon this subject, however, will afford much satisfaction, as it is merely a speculative point; and as it can have no great influence on the practical treat- ment Sect. I. Of Aneurisms. 113 ment of the disorder, we shall not here attempt a far- ther investigation of it. Having thus enumerated the ordinary appearances of the different species of encysted aneurism, together with the various causes which are found to produce them, we shall now proceed to describe the symptoms and causes of the diffused aneurism, and shall conclude with the treatment of the various species of the disease. The Diffused, or what is commonly termed the False Aneurism, consists in a wound or rupture of an artery, producing, by the blood thrown out from it, a swelling, more or less diffused, in the contiguous parts. Great bodily exertion has frequently proved an evident means of inducing a rupture of very consid- erable arteries seated internally: This we know to be particularly frequent in those of the lungs, probably from their being in that organ surrounded with such soft contiguous parts as do not afford them much sup- port; and probably from the contrary reason, that here the arteries are more firmly supported, such ac- cidents seldom or never occur in the external parts, where alone they could ever become the object of a surgeon's attention. We shall therefore confine our description of this disorder, entirely to that kind of it which we know to be most frequently produced by a wound made directly into an artery, and which it is commonly in the power of art to relieve. When treating of the consequences of venæsection in the arm, wounding the contiguous artery was par- ticularly mentioned as one: In a few instances, by the treatment then pointed out, any bad effects which might otherwise occur from this circumstance, will be entirely prevented by the wound in the artery healing without any of the usual consequences being produced by it. Such happy terminations, however, of this ac- cident, are exceedingly rare, and can never with any degree of certainty be depended on. P When 114 Of Aneurisms. Chap. IV. When a punctured artery resists the means em- ployed for preventing the ordinary effects known to result from it, it will then for certain terminate in a swelling of the aneurismal kind; and the following is the usual progress of the disorder. A small tumor, of about the size of a horse bean, generally rises just at the orifice in the artery, soon af- ter the discharge of blood has been stop by compres- sion: At first the tumor is soft, has a strong degree of pulsation, and yields a little upon pressure. It is never, however, so compressible as the swelling of an encysted aneurism: For in the latter, except in the more advanced stages of the disease, the blood re- mains perfectly fluid, and there is a regular circula- tion of it through the whole cyst; whereas, in the diffused aneurism, the blood forming the tumor is at once extravasated; and as in that state it soon begins to coagulate, it is not long in acquiring a very firm degree of consistence. In this state of the disorder, if the swelling be not improperly treated by the application of much pres- sure, it generally remains nearly of the same size for several weeks, when it begins gradually to increase; and if seated in the usual place of bloodletting in the arm, it proceeds rather farther up than the orifice, and extends rather more inwardly than towards the outer part of the arm, probably from the expansion of the biceps muscle not being there so firm and compact as in the external and under part of the arm. This enlargement of the tumor, too, proceeds with much more quickness in some instances than in others, and on some occasions the swelling is much more diffused and extended than in others. Both these circumstances, it is probable, depend upon the same cause. If the blood poured out by an artery, is thrown into a very lax cellular substance, we can easily suppose, that its increase will not only be more rapid, but that the diffusion of the tumor must for Sect. I. Of Aneurisms. 115 for the same reason be much more considerable, than when the artery is immediately enveloped by firm membranous or ligamentous parts, which do not so readily yield to the impulse of the blood. There is, from this circumstance alone indeed, such a remark- able difference in the progress of the disorder, that in some instances swellings of this kind have been many months, nay even years, in arriving at any considera- ble size; and on the contrary, some instances have occurred of the blood from the orifice in the artery, being diffused over the whole arm from the elbow up to the shoulder in the space of a few hours from the operation. A particular laxity of cellular substance, has un- doubtedly, in all such instances, a great influence in promoting this rapid diffusion of the extravasated blood; but the ordinary practice in every case of a wounded artery, of applying very tight compression, I am convinced, has also a very great influence in producing the same effect. In addition to what was said upon this point in the chapter on Bloodletting, I shall here just observe, that if it was possible to pro- duce a moderate degree of pressure upon the orifice in the artery alone, some advantage might now and then perhaps be derived from it; but in order to ap- ply a degree of compression sufficient for producing any influence upon the artery, the principal veins in the limb must by the same means be all so much act- ed upon, as to occasion much obstruction to the re- turn of blood from the corresponding artery. And whatever tends in any degree to obstruct the refluent blood, must in an equal proportion distend the wound- ed artery, and increase the quantity of blood which es- capes by the orifice. Many machines have indeed been contrived for producing a partial compression upon the artery without affecting the rest of the limb: But however much these may have been extolled by their several inventors, yet none hitherto discovered answers 116 Of Aneurisms. Chap. IV. answers the purpose of compressing the artery, with- out at the same time tending greatly to obstruct the circulation in the veins; insomuch that a great deal of mischief has on different occasions been produced by all of them. Whoever inclines to have recourse to the use of these instruments, will find a variety of them deline- ated in Heister's System of Surgery, and in Dionis and Platner's works. Mr. Dionis, an eminent French surgeon, although in cases of wounded arteries he recommends the usual practice of compression, yet relates a case which happened to a surgeon of his acquaintance, in which the bad effects produced by it were so strongly mark- ed, as must convince any person of the general im- propriety of such a remedy. A surgeon having in bloodletting opened an artery, the usual method of tight compression was immedi- ately employed. By this means the discharge of blood externally was very soon stopped: But some blood continuing to escape from the orifice in the ar- tery, passed up towards the superior part of the arm, which it filled to such a degree, that on the operation for the aneurism, which was soon found necessary, being performed, upwards of four pounds of coagu- lated blood was discharged from it; and for this pur- pose it became necessary to lay the parts open along the whole course of the arm.* When, again, compression has not been applied to such tumors, unless there is a very unusual degree of softness and laxity in the surrounding parts, the swel ling proceeds to increase in a more gradual manner: As it becomes larger, it does not, like the true aneu- rism, become much more prominent, but rather spreads and diffuses itself into the surrounding parts: By degrees it acquires a very firm consistence; and the pulsation, which was at first considerable, always di- minishes * Vid. Dionis's Course of Chirurgical Operations. Sect. I. Of Aneurisms. 117 minishes in proportion to this difference of consistence, and to the increase which the tumor receives in point of size; insomuch, that in large aneurismal swell- ings of this kind, it sometimes happens, that the pul- sation of the artery is scarcely perceptible. In the first stages of the tumor, if the blood thrown out from the artery lies very deep, the skin preserves its natural appearance, and does not change its colour till the disorder is much advanced. It frequently hap- pens, however, that the blood is at first thrown out with so much violence, as to get into immediate con- tact with the skin; and when this occurs, the colour of the parts becomes instantly livid, as if tending to a state of mortification. A real sphacelus, indeed, has on some occasions been induced where the extravasation of blood has been considerable, and where the means best suited for its removal have either failed or have been entirely neglected. It must be considered, however, as a piece of un- pardonable negligence, in any practitioner, to allow a patient, from this cause, to run that degree of risk which always attends mortification; for the hazard at- tending the operation of the aneurism, is in general trifling when compared with the danger accruing from an extensive gangrene. As the tumor in this species of the disease proceeds to increase, the patient, who during the first stages of it did not complain of much uneasiness, is now much distressed not only with severe pains, but with stiff- ness, want of feeling, and immobility of the whole member: And these symptoms, continuing to aug- ment, if the tumor is not previously operated upon, the teguments at last burst; and if the artery is of any considerable size, and if we have not immediate recourse to effectual means for preventing it, death must for certain ensue, in consequence of the very profuse hemorrhagy which must thus be produced. Various 118 Of Aneurisms. Chap. IV. Various causes were enumerated, as being frequently under certain circumstances productive of the encysted aneurism; some variety occurs too of causes which terminate in the diffused species of aneurism. I. Violent bodily exertions may be considered as the most frequent cause of the rupture of arteries situated internally; but as these do not properly belong to a work of surgery, we shall not here enter at any length into their consideration. II. The corrosive matter of sores and abscesses, by entirely destroying the coats of a contiguous artery, may in this manner be productive of the diffused an- eurism. III. The sharp spiculæ of a fractured bone being pushed into a neighbouring artery, have, on different occasions, produced aneurism. IV. Violent blows have been known to produce aneurismal swellings of this kind. This, however, can scarcely happen in any other situation than on the head, where the arteries lie more exposed than in other parts to the effects of such injuries, by their being here very thinly covered, and from a blow in this situation ad- ing with great advantage, by falling on the artery ly- ing almost in close contact with a firm hard body, the cranium. V. If the arterial covering of an encysted aneurism, should ever burst before the external teguments of the tumor, in that case the blood contained in it would dif- fuse itself into the contiguous parts; and in such an event, the disease would no doubt become a real diffused an- eurism. Such an occurrence, however, we have rea- son to think, very rarely, if ever happens; for, instead of the internal coverings of such tumors first breaking; so far at least as I have had opportunities of observing, it is the very reverse. The swelling going on to in- crease in a gradual manner, the teguments at last be- come so tense and overstretched, that they lose their tone entirely; the skin becomes soft and œdematous; on Sect. I. Of Aneurisms. 119 on some occasions, it comes into a gangrenous state; and on others, although it retains its natural white colour, yet its usual powers are as evidently destroyed as they ever are in the last stage of mortification. In this state it generally remains for a longer or shorter space of time, according to the strength of the arterial pulsation below. At last, however, the skin begins to crack, and a thin serum oozes out; the edges of this small fissure in the teguments gradually separate from one another; and the contents of the tumor having lost a considerable part of their support, the force with which they are impelled, by degrees becomes too powerful for the remaining coverings, which accord- ingly soon burst, so as to discharge their contents ex- ternally, without producing any effusion among the neighbouring parts. I should therefore suspect, that authors in general have all along been under some mistake on this point: The Encysted, or True Aneurism, as it is termed, has been always supposed in its last stages to burst inter- nally, and so to produce the diffused or false species of the disease; from what has been said, however, there is good reason to presume, if ever it does happen, that it is at least a very rare occurrence. The progress and termination of the encysted aneurism, in every case I have either seen, or known well authenticated, has been very nearly as we have just described; not by the arterial sac first bursting, but by a rupture being pro- duced in the external teguments after they have been greatly overstretched; the blood being soon thereafter discharged outwardly, without producing any effusion into the surrounding parts. As it has been alleged, however, by very respectable authors, that the contra- ry does now and then happen, and as there is a possi- bility of this being the case, I could not here avoid considering it as one of the causes of diffused aneurism. VI. The most frequent cause, however, of this spe- cies of aneurism, are punctures with sharp instruments, such 120 Of Aneurisms. Chap. IV. such as swords, cutlasses, and particularly the lancet; which last may be considered as having been produc- tive of at least nine tenths of all the aneurismal swell- ings that ever occurred. Under one or other of these heads, almost every cir- cumstance may be comprehended, that can ever tend to the production of such affections. On many occasions, it has unfortunately happened, that tumors of the aneurismal kind having been mis- taken for abscesses and other collections of matter, their contents of course have been laid open by incis- ion. The consequences of such practice, may be more readily conceived than described. With a view to prevent such dreadful occurrences, it would be a matter of very great importance to practitioners, to have such a set of diagnostic symptoms of aneurism pointed out, as would with certainty determine the nature of the complaint. In the commencement of the disorder, there is in general no great difficulty in determining, as the pulsation in the tumor is com- monly so strong, and other concomitant circumstances tend so obviously to point out the nature of the disease, that little or no doubt respecting it can ever occur; but, in the more advanced stages of the disease, when the swelling has become very large, and has lost its pulsation entirely, nothing but a very minute atten- tion to the previous history of the case can enable us to form a judgment of its nature. Those swellings, with which aneurisms are most likely to be confounded, are, soft encysted tumors, scrophulous swellings, and abscesses containing either purulent or other matter, situated either immediately above, or so nearly in contact with an artery, as to re- ceive the influence of its pulsation; and when any such tumor happens to be nearly connected with an artery of considerable size, the pulsation communicat- ed to it is frequently found to be so very strong and distinct, as to render it impossible from this circum- stance Sect. I. Of Aneurisms. 121 stance alone, to form any just idea as to the nature of its contents. But there is one symptom which, when present, and when connected with a strong pulsation in the tumor, may always lead us to determine with a great degree of certainty, that the swelling is of the aneurismal kind; and it is this; the contents of the tumor being made easily to disappear upon pressure, at the same time that they return instantaneously on the compression being removed. But although the presence of this circumstance, when connected with other characteris- tic symptoms of aneurism, may lead us to conclude, that every tumor is of that nature in which these hap- pen to be combined, yet they want of it ought by no means to convince us that it is not of that kind; for it very frequently happens, particularly in the advanced stages of aneurisms, that their contents become so firm and compact that no effect whatever is produced upon them by pressure. Upon the whole, therefore, as in many instances of this disease, no certainty what- ever can be obtained as to its real nature, in all such cases where there is any considerable degree of doubt, practitioners ought to lay it down as an established rule, to proceed as if the tumor was in reality of the aneurismal kind. By adhering to this rule, they may perhaps in a few instances be deterred from opening tumors of an ordinary nature, which they may after- wards find might have been laid open with safety; but any lesser inconvenience that may thus be occa- sioned, will be much more than compensated, if, even in a single instance, a surgeon be saved from those dis- agreeable reflections which he must experience if he should have the misfortune to open an aneurism in- stead of a collection of matter. But it is in the trunk of the body only, it must be observed, or in the neck, axilla, upper part of the thigh, or groin, that so much caution in the treatment of tumors of this doubtful nature can be ever neces- Q sary. 122 Of Aneurisms. Chap. IV. sary. For when situated on the under part of any of the extremities, or even on any accessible part of the head, as in such cases, when the swellings have pro- ceeded to any considerable size, the operation for the aneurism ought always to be performed, so there can never in such circumstances be any impropriety in having recourse to it; for if, on laying the tumor open, it is found to be of the aneurismal kind, we are possessed of a very certain method of saving the pa- tient from immediate danger, namely, the application of the tourniquet. In forming a prognosis in cases of aneurism, three important circumstances chiefly require our attention. The manner in which the disease appears to have been produced: The part of the body in which the swel- ling is situated: And lastly, the age, and habit of body, of the patient. If an aneurism has come forward in a gradual man- ner, without any apparent injury having been done to the part, and without having succeeded to any violent bodily exertion; there will then be great reason to suppose, that the disease depends upon some paralytic or other general affection either of the trunk of the vessel in which it occurs, or perhaps of the whole ar- terial system; so that no great success is to be expect- ed from any means to be attempted for the patient's relief; for the operation of the aneurism being per- formed on the part affected, there would be much reason to suspect that the same cause which originally produced it here will have the effect of producing similar dilatations in other parts of the artery: Where- as, there is great reason to expect, if the tumor has evidently succeeded to a bruise, puncture, or other ex- ternal accident, that the operation will be attended with complete success, provided the circulation of the part is not altogether destroyed by the ligature to be put upon the artery. In Sect. I. Of Aneurisms. 123 In that species of the disorder we have termed the Varicose Aneurism, we may generally venture on a more favourable prognosis than in any other kind of aneurism: For it has been found in different instances, that the aneurismal tumor does not here proceed so rapidly as in other cases; that as soon as it gets to a certain length, it does not afterwards acquire much additional size; and that any inconvenience produced by it may be sustained with tolerable ease for a great number of years. It is in this circumstance alone, we must observe, that any advantage occurs in the treatment of aneu- risms from Dr. Hunter's discovery of this species of the disease: And a very important discovery it is; for by means of it, a patient may be saved; not only from a very painful operation, but from that great degree of risk which must always attend the destruc- tion of the principal artery of a limb. In the event of a swelling of this nature arriving at such a size as to produce much real distress, the operation ought no doubt to be had recourse to; but, so long as any inconvenience arising from it can be easily submitted to, the hazard which almost always attends this opera- tion, and which nothing but necessity ought to indi- cate, should certainly be avoided*. The * In Volume II. Art. XXXVI, of London Medical Observations, two cases are related of the varicose aneurism, by Dr. Hunter. One of them at that time was of fourteen years standing, and the other had subsisted for five years, without being productive of any necessity for having recourse to the operation. And in Vol. III, of the same work, Art. XIII, a similar case of five years duration is related by Dr. Cleghorn. As it has been alleged by some practitioners, that no advantage results from the discovery of this species of aneurism, from their supposing that the usual operation is as necessary in it as in any oth- er variety of the disease; and as in different instances the operation lras been put in practice even in the incipient stages of the disorder, where no real necessity we think could occur for it; it therefore be- comes a matter of such importance as to merit a very attentive ex- amination; and it is with much satisfaction that I communicate the following facts, as they tend to establish as a certainty, that in the varicose aneurism, the usual operation of obliterating the cavity of the artery, is seldom, if ever, necessary. In 124 Of Aneurisms. Chap. IV. The situation of the tumor is the next circumstance of importance requiring our attention. When an aneurismal swelling is so situated, that no ligature or effectual compression can be applied for putting a stop to the circulation in the part, if the artery be large, there would be the utmost hazard in opening it; as the patient, in all probability, would lose more blood than his strength could bear, before the artery could be secured. In aneurisms so situated, therefore, par- ticularly on any part of the trunk of the body, on the neck, axilla, or groin, there can never be any good foundation for a favourable prognosis. On the con- trary, indeed, in such situations, the greatest danger is always to be apprehended: For the force of the arte- rial pulsation will at last certainly overcome the resist- ance of the coats with which the tumor is surround- ed; and in such an event, the most fatal consequen- ces are to be apprehended. In the upper parts of any of the extremities, too, where In a letter I am favoured with from Dr. Hunter, he says, "The Lady in whom I first observed the varicose aneurism is now living at Bath in good health; and the arm is in no sense worse, although it is now thirty five years since she received the injury." And the Doctor farther observes, that he never heard of the operation being performed for the varicose aneurism that was known to be such. In a letter from Dr. William Cleghorn of Dublin, I am informed, that the case of varicose aneurism abovementioned, as related in the 3d Volume of London Medical Observations, remains nearly in the same state as at the time that account of it was made out, which was at least twenty years ago; only that the veins are rather more en- larged. The patient recovered, and the limb became nearly as strong and serviceable as the other. The man has all along contin- ued his business of shoemaker, and has lately recovered from a sprain in the affected arm, which he received in lifting a heavy burden. In a letter from Mr. Pott, whose opportunities for observation are great, he says that he has met with three different instances of this species of aneurism, and that the operation never became nec- essary in any of them. Among other instances of varicose aneurism which have appeared here, a young, man from Paisley, who had the misfortune to meet with it several years ago was examined by different surgeons of this place. The disease was very clearly marked, and no operation was advised. In a letter from Mr. Hamilton professor of Anatomy in Glasgow, I am informed, that this man is now serving in the Navy, where he undergoes great fatigue without any inconvenience from the aneurism, although it is now of thirteen years standing. Sect. I. Of Aneurisms. 125 where all the arteries of the limb are centred in one common trunk, the success of the operation for the aneurism must always be doubtful. But although this is undoubtedly the case in the superior parts of the extremities, yet in lower situations of the same parts, even the principal artery of the limb may be operated upon with a very fair prospect of success; for after the great artery of a member has crept along the upper part of it, a number of small branches are always sent out, which anastomozing not only with similar branches below, but by their means with the under part of the large artery itself, these, in the event of the common trunk from whence they sprung being destroyed, come to dilate to such an extent as to car- ry on the circulation in the inferior part of the limb much more completely than could à priori be expected. We would not naturally suppose, after the principal artery of a part has been obliterated, that the circula- tion would there be afterwards carried on with any tolerable degree of force; and yet numberless in- stances have occurred of the large brachial artery be- ing completely destroyed by ligature, without be- ing productive of much inconvenience to the parts below; and the same circumstance has also happened, where the operation for the aneurism has been per- formed on the trunk of the great femoral artery*. From * In one case, the operation for the aneurism was performed with the most complete success, on the trunk of the femoral artery, about two hand breadths from the groin, by the late Mr. Hamilton pro- sessor of Anatomy in Glasgow. And what rendered this case more remarkable, was, that after the trunk of the large artery was secur- ed by the ligatures, it was necessary to perform the operation again upon a small branch of an artery which had been wounded, even farther up than the principal trunk. . For some time after the operation the limb remained colder than the other, and it was upwards of a week before any pulsation could be felt in the artery at the ankle. In two months from the opera- tion, the wound was completely healed, and the circulation and heat returned: and in a short time thereafter the patient had so far re- covered the use of his limb, as to be able to take very violent exercise. These particulars I thought it right to communicate, as the case of this patient is one of a very few well authenticated instances, of this 126 Of Aneurisms. Chap. IV. From what has been said, therefore, it must ap- pear, that when an aneurism is so situated, that com- pression cannot be applied so as to secure the patient from the loss of much blood when the artery is laid open, the operation should not be attempted; and in such cases the prognosis ought certainly to be very unfavourable. And on the contrary, whenever an aneurism, produced by external violence, is seated on any of the extremities, where we are sure of com- manding the circulation, the operation ought always to be undertaken, as soon as, from appearances, there is the least reason to suspect that the tumor if left to itself might burst so as to endanger the life of the pa- tient. The success of this operation, depending in a great degree upon the probable chance there is for the cir- culation afterwards going on in the under part of the member, our prognosis, in every case of aneurism, ought cæteris paribus, to be more or less favourable, accord- ing as the disorder is seated higher or lower on the different extremities: For the risk of the circulation being hurt by it, is always in proportion to the height of the tumor; according as it is higher or lower, this risk is always increased or diminished. But lastly, whether an aneurism has been produced by an external injury, or by the effects of internal dis- ease, and whatever may be its situation, the habit of body and age of the patient ought to have a consider- able influence, in determining the opinion of practi- tioners this operation having been attempted on the femoral artery so near to its origin; and the success attending it surely points out the pro- priety of having recourse to the operation, in every aneurism of these parts that does not evidently arise from a general debility of the coats of the artery. And as I am favoured with this account of the case from the present professor of Anatomy in Glasgow, Mr. Hamilton, son to the late professor, its authenticity may be depend- ed on. In Vol. Ill. Article XII, of the London Medical Observations, there is another instance related of the operation for the aneurism having been performed on the trunk of the femoral artery, by Mr. Burchal surgeon in Manchester; the patient recovered, and the limb became nearly as strong and as serviceable as the other. Sect. I. Of Aneurisms. 127 tioners as to the effects to be expected from the opera- tion. In no operation, indeed, that we are acquainted with, are the advantages derived from health and youth more conspicuous than in this; for in the earlier periods of life, all the softer parts accommodate them- selves much more readily to the circumstances attend- ing any great change that may take place, than they ever do in the more advanced stages of life: In old age, all the animal fibres have acquired such a degree of firmness and solidity, as to be rendered almost in- capable of distention; and this seems to be particular- ly the case with the arterial system, some parts of which are often known to proceed even to a state of ossifica- tion: So that at this period of life, we may readily suppose the smaller arteries to be rendered altogether incapable of that degree of distention necessary for sup- plying the want of the principal artery of a part, and which in the more early periods of life they might with great ease have admitted of. This operation having been performed with various degrees of success, even where the aneurismal tumors were apparently in every respect similar both as to sit- uation and other circumstances, various reasons have been suggested to account for this. With some the operation has succeeded, even under circumstances ap- parently more unfavourable, than with others where it failed. Thus it has been known to answer, as we have lately remarked, several inches above the knee, when the trunk of the femoral artery was for certain taken up by the ligature; and in others, it has failed when done in the ham: That is, in the former, the circulation in the under part of the leg was still pre- served, and the patients recovered; while in the lat- ter, where success might more readily have been ex- pected, the limbs remained cold after the operation, no return of circulation took place, mortification at last was induced, and the patients died. From 128 Of Aneurisms. Chap. IV. From this variety of success attending it, we find very contradictory opinions held forth respecting this operation. While one condemns it as being never productive of any good, except in the very extreme parts of a member; others assert, that even the larg- est artery of a limb may be operated upon with great probability of success. This contrariety of opinion, however, may, I think, be easily explained, by what has been said above re- specting the age and habit of body of those on whom the operation is performed; for, to the different pow- ers of distention with which the arterial system is en- dowed at different periods of life, the good or bad suc- cess attending it may with sufficient reason be attrib- uted: So that, although in an old infirm person, it may have been found to fail perhaps in the under part of the leg or arm, this should by no means deter us from having recourse to it, even in much higher situ- ations, by patients that are young and healthy. Having thus considered the usual appearances and causes of aneurism, together with the grounds upon which a just prognosis is to be formed, we shall now proceed to the method of cure. SECTION II. Of the TREATMENT of ANEURISMS. IN every case of aneurism the use of pressure has been indiscriminately recommended, not only in the incipient period of the disease, but even in its more advanced stages. In a former chapter on Bloodlet- ting, as well as in some parts of this, different oppor- tunities occurred for introducing the consideration of this subject: To these we must now refer; and shall at present attend to such points only as were not be- fore so particularly entered into. In Sect. II. Of Aneurisms. 129 In the diffused or false aneurism pressure has been universally advised, not only with a view to dissipate the swelling already induced, but in order to produce a reunion of the wound in the artery: We have al- ready made it appear, however, as pressure in such cases cannot be applied to the artery alone, without at the same time affecting the veins; and as this cir- cumstance, by producing an increased resistance to the arterial pulsations, must undoubtedly force an ad- ditional quantity of blood to the orifice in the artery, that therefore no advantage is to be expected from it; but, on the contrary, that on many occasions there is reason to suppose it has been productive of bad con- sequences. But although pressure ought never to be attempted in any period of the diffused aneurism, yet in some stages of the other species of the disease, it may be oft- en applied with advantage. In the early stages of encysted aneurism, while the blood can be yet pressed entirely out of the sac into the artery, it often happens; by the use of a bandage of soft and somewhat elastick materials, properly fitted to the part, that much may be done in preventing the swelling from receiving any degree of increase; and on some occasions, by the continued support thus giv- en to the weakened artery, complete cures have been at last obtained. In all such cases, therefore, particu- larly in every instance of the varicose aneurism, which we have already endeavoured to show can very seldom require the usual operation, much advantage may be expected from moderate pressure. But although pressure to a certain degree has fre- quently in cases of encysted aneurism proved very use- ful, it ought never to be carried to any great length; for tight bandages in all such affections, by producing an immoderate degree of reaction in the containing parts to which they are applied, instead of answering the purpose for which they were intended, have evidently R the 130 Of Aneurisms. Chap. IV. the contrary effect. Moderate compression, therefore, is more eligible than a great degree of it; and indeed the greatest length to which pressure in such cases ought to go, should be, to serve as an easy support to the parts affected, and no farther. While at the same time we have recourse to this remedy of compression, other means ought not to be omitted: The patient should be kept upon a low diet; when necessary, some blood should be evacuated; the bowels should be kept lax; and all violent exer- cise, particularly of the part affected, should be care- fully guarded against. In the latter stages of aneurism, when much tension and pain are induced, opiates are found very useful; and in many such ailments they are the only class of remedies from which any relief is ob- tained. The treatment here recommended applies to every aneurism not intended to be operated upon; but it is particularly proper in all swellings of this kind situated on the trunk of the body and other parts where the operation is inadmissible. In such situations, indeed, an easy support by means of gentle compression; a low diet in order to prevent a plethorick state of the ves- sels; repeated bloodlettings when plethora actually exists; a total abstinence from exercise; and the use of opiates when indicated by pain; are the only rem- edies from which much benefit is to be expected. Having thus pointed out the different remedies to be employed where the operation is either not considered as proper, or where it is rendered inadmissible by the situation of the swelling, we shall now proceed to de- scribe the operation itself, on the supposition of its having become necessary, either when the means re- commended for the previous treatment of the disor- der have failed, or when the tumor has made too great progress before proper assistance was procured. The first step in this operation ought to be, to ob- tain a full command of the circulation in the inferior part Sect. II. Of Aneurisms. 131 part of the member by means of the tourniquet ap- plied above. This being effected, the patient should be so placed, that the diseased limb, on being stretched on a table, is found to be of a proper height for the surgeon, who, as the operation is generally tedious, ought to be seat- ed. The limb being in this situation properly secur- ed by an assistant, the operator is now with a scalpel to make an incision through the skin and cellular sub- stance, along the whole course of the tumor, and as it is a matter of much importance to have a sufficient command of space for the remaining parts of the op- eration, it is even of use to carry this external incision about half an inch both above and below the extrem- ities of the swelling: No mischief can occur from the first incision being made very free and extensive; and I have seen different instances of the operator being much embarrassed in the subsequent steps of the op- eration, by too much timidity or perhaps ill judged lenity in this part of it. This being done, the ordinary method is, to pro- ceed in a very slow, cautious manner, dissecting away one layer of the membrane after another, till the ar- tery itself is laid bare. In this manner the operation is always rendered exceedingly tedious, as the thickness of parts with which the artery is found covered, is often re- ally astonishing, by one layer of a membranous substance having been formed after another, from the coagula- ble lymph of the blood contained in the tumor. In reality, however, there is no necessity for this degree of caution, as the operation may in the following man- ner be equally well performed, in a much shorter space of time, and with much less pain to the patient. As soon as the external incision has been made in the manner directed, so as to divide the skin and cel- lular substance, all the effused blood ought to be wip- ed off by means of a sponge; and the softest part of the tumor being discovered, an opening ought there to be made 132 Of Aneurism. Chap. IV made into it with a lancet, large enough for admit- ting a finger of the operator's left hand. This being done, and the finger introduced into the cavity of the tumor, it is now to be laid open from one extremity to the other, by running a blunt pointed bistoury a- long the finger from below upwards, and afterwards from above downwards, so as to lay the whole cavity fairly open. In Plate VII, fig. 1, there is an exact representation of this bistoury, with a curve much less than usual, as a very flight concavity answers every purpose, and cuts more easily than a greater degree of curvature. The cavity of the tumor being thus laid freely open, all the coagulated blood is now to be taken out: For which purpose, a number of instruments, partic- ularly scoops, have been invented by different opera- tors; but no instrument answers this intention so ef- fectually, and with so much ease to the patient as the fingers of the operator; who having in this manner removed all the coagulated blood, together with those tough membranous filaments commonly found here, the cavity or the tumor is now to be made quite dry, and cleared of the blood which on the first opening of the swelling is discharged into it from the veins in the inferior part of the member; and this being ef- fectually accomplished, the tourniquet must be made perfectly slack and easy, in order to discover not only the artery itself, but the opening into it from whence the blood collected in the tumor has been all along discharged. This being done, the next point to be determined, is, the manner of preventing any farther effusion of blood into the aneurismal sac. Various means have been proposed for accomplishing this; but the effects of all of them may be comprehended under the three following heads. I. The effects of ligature upon a large artery, hav- ing in some instances occasioned the loss the infe- rior part of the member, it was long ago proposed, that Sect. II. Of Aneurisms. 133 that so soon as the opening into the artery has been discovered, instead of applying a ligature round it, which for certain is to obliterate its cavity entirely, a piece of agaric, vitriol, alum, or any other astringent substance, should be applied to the orifice, in order if possible to produce a reunion of its sides. II. Upon the same principle with the preceding, viz. that of still preserving the circulation in the ar- tery, it was several years ago proposed by an eminent surgeon of Newcastle, Mr. Lambert, that the orifice in the artery should be secured by means of the twisted suture. A small needle being pushed through the edges of the wound, they are then directed to be drawn together by a thread properly twisted round the needle, in the manner formerly advised when treating of su- tures*. Strong objections, however, occur to both of these methods. In the first place, no astringent application with which we are acquainted, is possessed of such powers as to deserve much confidence; for, although different articles of this kind have on various occa- sions proved a means of putting a temporary stop to hemorrhagies, yet there are very few instances prop- erly authenticated, of their having produced any per- manent advantage. In almost every instance in which they have been used, the hemorrhagy has recurred again and again, so as to prove very distressing, not only to the patient, but to the practitioner in attend- ance; so that from this want of success, little or no attention is now paid to remedies of this kind in ordi- nary practice. With regard to Mr. Lambert's method of stitch- ing the orifice in the artery, it is certainly a very in- genious proposal, and would in all probability, at least in most instances, prove an effectual stop to all farther discharge of blood; but as it has hitherto, at least so far as I have heard, been only attempted in one * Vide London Medical Observations, Vol. II, Article XXX. 134 Of Aneurisms. Chap. IV. one instance, farther experience of its effects is necessary before it can with propriety be either rejected or ap- proved. But if in such a matter reasoning may be indulged, we would beg leave to observe, that two material objections occur to this practice. One is, that in the operation for the aneurism, in almost ev- ery instance, a very few only excepted, the artery lies at the back part of the tumor; so that when all the collected blood is removed, there is such a depth of wound, that it must be always a very difficult matter, and on many occasions quite impracticable, to per- form this nice operation upon the artery, with that attention and exactness which, in order to insure suc- cess, it certainly requires. It has now and then hap- pened indeed, that in this operation the artery has been found to be on the anterior part of the tumor, and in such a situation the wound in it would no doubt prove accessible enough. This, however, is a very rare occurrence, as in almost every instance of diffus- ed aneurism the artery lies at the very bottom of the tumor, the blood being collected between it and the common teguments; and accordingly I have seen several instances of this disorder, in which, after the tumor was laid freely open, the artery was found to lie so deep as would have rendered it quite impossible to perform this operation. But there is another very material objection which à priori evidently occurs to the practice recommend- ed by Mr. Lambert. By introducing a needle through the sides of the orifice, and drawing these to- gether by a ligature, the cavity of the artery must un- doubtedly be at that point much diminished. In- deed Mr. Lambert, in his account of the case in which this operation was performed, acknowledges that the diameter of the artery was thereby diminish- ed. Now, the passage of the blood being thus con- tracted at one point, the impulse upon that particular part must be very considerable: So that the very remedy Sect. II. Of Aneurisms. 135 remedy employed for the cure of one species of aneu- rism, will in all probability prove a very powerful agent in inducing another; for the blood being thus obstructed in its usual course, there will be no small danger incurred, of a dilatation being produced im- mediately above this preternatural stricture. I must fairly acknowledge, however, that all I have advanced, proceeds from reasoning alone, and is not as yet supported by experience. But, if farther trials of this operation tend to show that the objections now stated against it are not well founded, no person what- ever will be more ready than I shall be in adopting it; for, if these objections were removed, this operation, as proposed by Mr. Lambert, I should consider as deserving to be ranked among the most important improvements which in modern times surgery has acquired. In the treatment of aneurism by the com- mon operation, if the principal artery of a limb is concerned, some risk is always incurred, not only of injuring the parts below in a most material manner, but even of destroying them entirely, by depriving them of the quantity of blood necessary for their sup- port. Now, by Mr. Lambert's improvement, an ef- fectual stop is put to the farther evacuation of blood, while at the same time the circulation in the diseased artery is still preserved; so that if farther experience of its effects shall show that the objections we have ven- tured to bring against it are not well founded, it will deservedly be admitted as a very material improve- ment in the treatment of this species of aneurism. III. Neither of the methods we have yet been con- sidering, being found eligible for securing the orifice in the artery, we shall now proceed to describe the or- dinary manner of performing this operation, which consists in obliterating the arterial cavity entirely, by means of ligatures; and the method of doing it is this. The artery being laid bare in the manner directed, and all the coagulated blood being carefully removed from 136 Of Aneurisms. Chap. IV. from the cavity of the tumor, on the tourniquet being now slackened so as to bring the orifice in the artery into view, a small probe is to be introduced at the opening, with a view to raise the artery from the neighbouring parts, so as that the surgeon may be en- abled with certainty to pass a ligature round it with- out comprehending the contiguous nerves, which in general run very near to the large blood vessels of a limb. By this precaution, the nerves may be always avoided; and by doing so, a great deal of mischief may be prevented, which otherwise in all probability, might supervene. When the disorder is situated ei- ther in the ham, or in the usual place of bloodletting in the arm, bending the joints of the knee or of the elbow, as it relaxes the artery a little, renders this part of the operation more easily effected, than when the limbs are kept fully extended. The artery being thus gently separated from the contiguous parts, a firm, broad, waxed ligature must be passed round it, about the eighth part of an inch above the orifice, and another must in the same man- ner be introduced at the same distance below it. Much harm, I am convinced, has been done by pas- sing the ligature so far distant from the orifice as is commonly practised; for the risk of losing the bene- fit of anastomosing branches will be always increased in proportion to the extent of artery included between the ligatures. The easiest method of introducing the ligatures, is by means of a blunt curved needle; and the form represented in Pl. V, fig. 2, will be found more con- venient for this purpose than any other. An ordina- ry sharp needle is commonly made use of for this pur- pose; but it does not answer the intention so well as the one here recommended: By the sharpness of its points it is apt to injure the contiguous parts; and when the common crooked needle is used with a sharp edge on its concave side, there must even be some risk Sect. II. Of Aneurisms. 137 risk of its wounding the under part of the artery, as in this situation it cannot be introduced without mak- ing part of the needle pass quite in contact with the coats of the artery. The blunt needle is not liable to either of these objections; and besides, when of the form here represented, it is more easily introduced than any of the needles commonly used in this op- eration. The ligatures being both passed in the manner di- rected, the upper one is now to be tied with a firm- ness sufficient for compressing the sides of the artery. The directions formerly given for forming the knot upon bleeding vessels in other parts, will apply with equal propriety here: The ends of the ligature ought by all means to be twice passed through the first noose, and this should again be farther secured by a single knot made above it. By many writers on this sub- ject, a small bolster of linen is ordered to be inserted between the artery and the knot, in order to prevent the artery from being cut by it. This, however, is a very unnecessary precaution; for if the whole artery is not surrounded with the bolster, it will be just as liable to be cut by the ligature at any other part as where the knot is fixed: And besides, as we have al- ready very fully remarked, there is no occasion what- ever for making the ligature so tight on arteries as to run any risk of dividing them; a much less degree of pressure than is either commonly applied, or could have any influence in hurting them, being fully suffi- cient for compressing them in the most effectual manner. The upper ligature being thus finished, before the knot is passed upon the other below the orifice, the tourniquet ought to be untwisted, in order to see whether any blood is now discharged by the wound in the ar- tery or not. If blood flows in any considerable quan- tity, it affords a pleasant prospect of the success with which the operation will in all probability be attended, S as 138 Of Aneurisms. Chap. IV. as it clearly shows, that the anastomosing branches from the superior part of the artery are considerable enough for carrying on at least a tolerable degree of circulation in the under part of the member. At the same time, however, although blood should not be discharged at this time by the orifice, we are by no means, from this circumstance alone, to despair of success; for it frequently happens that the operation succeeds in a very effectual manner, although no blood whatever is discharged on the trial now recommended. But whether any blood should be discharged by this trial or not, we are not to rest satisfied with one ligature; for unless the ligature below the orifice be also tied, there is always a risk, on the return of cir- culation to the under part of the artery, of blood pass- ing out at the orifice: This precaution, therefore, should never be omitted; it is easily done, and it renders the patient quite secure against all farther evacuation of blood by the orifice. After the knots have been put upon the ligatures, these should be cut of such a length that their ends may lie fully out over the edges of the wound, so that when necessary they may be more easily withdrawn. By way of greater security in this operation, it has been advised to insert other two ligatures quite con- tiguous to the former, and to leave them untied, so that if any of the others should happen to fail its place may be immediately supplied. There is not, however, any necessity for this pre- caution, for, if the first ligatures are properly applied, there can be no doubt of their answering the purpose; and in case either one or both of them should give way, they can be very easily renewed: In the mean time, too, the patient is rendered safe against any sud- den loss of blood by the tourniquet being left loose upon the upper part of the member, which it ought by all means to be for several days after the operation, so that, in the event of blood bursting from the wound, it Sect. II. Of Aneurisms. 139 it may be secured by means of it, much more readily than if it depended on the tying of a ligature. The ligatures being both finished in the manner directed, the tourniquet is now to be made quite loose; and if no blood is discharged at the orifice in the ar- tery, we may then rest satisfied that the operation is so far properly completed. The wound is now to be lightly covered with soft lint, with a pledget of any emollient ointment over the whole; and a compress of linen being applied over the dressings, all the bandage in any degree re- quisite, is, two or three turns of a roller above, and as many below the centre of the wound, making it press with no more tightness than is absolutely necessary for retaining the applications we have just now mentioned. The patient being now put into bed, the member should be laid in a relaxed posture upon a pillow, and ought to be so placed as to create the least possible uneasiness from the posture in which it is laid. As the operation for the aneurism is always tedious, and produces much pain and irritation, a full dose of laudanum should be given immediately on the patient being got into bed. In order to diminish sensibility during some of the more capital operations, I have made different trials of opiates given about an hour before the operation: On some occasions, this prov- ed evidently very useful; but on others, it seemed to do harm; particularly in weak, nervous constitutions, in which with any doses I ever ventured upon, the pa- tients appeared to be rendered more irritable and more susceptible of pain, than if no opiate had been given. Immediately after this operation, however, an opiate ought to be exhibited, and repeated occasionally ac- cording to the degrees of pain and restlessness. In some few cases of aneurism it has happened, that the pulse in the under part of the member has been perceptible immediately after the operation. This, however, is a very rare occurrence: For as this dis- order 140 Of Aneurisms. Chap. IV. order is seldom met with in any other part than at the joint of the elbow as a consequence of bloodlettings, and as it rarely happens that the brachial artery di- vides till it passes an inch or two below that place, the trunk of this artery is therefore most frequently wounded; and when accordingly the ligature in this operation is made to obstruct the passage of almost the whole blood that went to the under part of the arm, there cannot be the least reason to expect any pulsation at the wrist, till in a gradual manner the a- nastomosing branches of the artery have become so much enlarged, as to transmit such a quantity of blood to the inferior part of the member, as is sufficient for acting as a stimulus to the larger branches of the artery. Immediately after the operation, the patient com- plains of an unusual numbness or want of feeling in the whole member; and as it generally for a few hours becomes cold, it is therefore right to keep it properly covered with warm soft flannel; and in or- der to serve as a gentle stimulus to the parts below, moderate frictions appear to be of use. In the space of ten or twelve hours from the operation, although the numbness still continues, the heat of the parts gen- erally begins to return; and it frequently happens in the course of a few hours more, that all the inferior part of the member becomes even preternaturally warm. Although physiological discussions are not immedi- ately connected with our subject, and although for that reason we shall not often enter into them; yet we can- not here avoid remarking the very clear proof which after this operation always occurs, of the great depen- dence one part of the human frame has upon another. The nerves we know to be the instruments of sense and motion; but on being deprived of their usual support from the sanguiferous system, their influence immediately diminishes. Immediately Sect. II. Of Aneurisms. 141 Immediately after this operation, the want of feel- ing in the parts is often very great; and in proportion as the circulation in the under part of the member be- comes more considerable, the degree of feeling also augments. If we could suppose the nerves of the parts below to be always included in the ligature with the artery, that numbness which succeeds immediately to the operation, might be easily accounted for; but I have known it happen, when I was certain that nothing but the artery was secured by the ligature: And be- sides, although the knot upon the nerves would ac- count for the immediate loss of sensibility which suc- ceeds to the operation, it would not in any degree serve to explain the return of feeling on the circula- tion being again restored; for the nerve having been destroyed by the effects of the ligature, if they want of seeing produced here originated entirely from that circumstance, it could not be expected to be much in- fluenced by the return of blood to the part. In the mean time the patient being properly attend- ed to as to regimen, by giving him cordials and nour- ishing diet when low and reduced, and confining him to a low diet if his constitution is plethoric, the limb being still kept in an easy relaxed posture, towards the end of the fourth or fifth day, sometimes I have known it much sooner, a very weak feeble pulse is discovered in the under part of the member, which becoming stronger in a gradual manner, the patient in the same proportion recovers the use and feeling of the parts. As soon as there is an appearance of matter having formed freely about the sore, which will seldom hap- pen before the fifth or sixth day, an emollient poultice should be applied over it for a few hours, in order to soften the dressings, which may be then removed. At this time, too, the ligatures might be taken away; but as their continuance for a day or two longer can do no harm, it is better to allow them to remain till the 142 Of Aneurisms. Chap. IV. the second or third dressing, when they either drop off of themselves, or may be taken away with perfect safety. The dressings, which should always be of the softest materials, being renewed every second or third day according to the quantity of matter produced, the sore is in general found to heal very easily; and al- though the patient may for a considerable time com- plain of a great degree of numbness and want of strength in the whole course of the diseased limb, yet in most instances a very free use of it is at last obtained. It will be readily supposed, that the termination of this operation as we have here described it, is the most favourable that can possibly happen. In some in- stances, the success attending it is far from being so complete: Instead of a return of circulation, and of the feeling and use of the parts, they remain cold and insensible, and no marks of returning life are perceiv- ed. From a mere want of blood, therefore, morti- fication at last commences; and as nature is here de- prived of one of her principal agents for the removal or separation of gangrenous parts, I mean the efforts of the sanguiferous system, whenever the parts in such circumstances begin to mortify, nothing can prevent their progress to the ultimate stage of that malady. Whenever mortification ensues, therefore, as a con- sequence of this operation, if the patient survives the immediate effects of it till a separation occurs between the healthy and diseased parts, amputation of the member will then be the only resource. That this operation when practised upon the prin- cipal artery of the superior part of a member, does now and then terminate in this manner, no practition- er of experience will deny; but its doing so in some instances, is not a sufficient reason for rejecting it in every case. The event of every capital operation we know to be very uncertain; and in this, as in every other of equal importance, as we cannot in any case say with precision how it is to answer, so we are never to Sect. II. Of Aneurisms. 143 to put it in practice where means of a less hazardous nature will succeed: And on the contrary, whenever these are found to fail, and the patient's life comes to be in danger, it ought undoubtedly to be performed without farther hesitation. CHAP. 144 Of Herniæ. Chap. V. CHAP. V. OF HERNIÆ. SECTION I. Of HERNIÆ in GENERAL. THE term Herniæ might with pro- priety be applied, to every swelling occasioned by the dislodgment of parts from those boundaries within which in a state of health they are contained; but the term in its general acceptation, implies, a tumor pro- duced by the protrusion of some part or parts from the cavity of the abdomen. The parts in which these swellings usually appear, are the groin, scrotum, labia pudendi, the upper and fore part of the thigh, the umbilicus, and different points between the interstices of the abdominal muscles. If the situation of such tumors be various, the viscera which they contain are still more so; instances having occurred of the stomach, uterus, liver, spleen, and bladder, being found to form their contents. But a part of the intestinal canal, or a portion of the omentum, are from experience known to be the most frequent cause of their formation. From these circumstances of situation and contents, all the different appellations are derived by which hernias are distinguished. Thus they are termed In- guinal, Scrotal, Femoral, Umbilical, and Ventral; from Sect. I. Of Herniæ. 145 from their appearing in the groin, scrotum, thigh; navel, or belly. When the tumor is confined to the groin, the hernia is said to be incomplete, and is term- ed Bubonocele; but, when the swelling reaches down to the bottom of the scrotum, the rupture is then sup- posed to be complete, and the disease obtains the name of Scrotal Rupture, or Orchiocele. When a portion of gut alone forms the tumor, it is called an Enterocele, or Intestinal Hernia; when a piece of omentum only has got down, it is termed Epiplocele, or Omental Hernia; and if both intes- tine and omentum are down, it is called an Entero epiplocele, or Compound Rupture. As all the abdominal viscera are apparently con- tained within the cavity of the peritonæum, and as it was thought impossible for that membrane to admit of such a degree of distention, as to surround tumors containing such large portions of the different viscera as are at times protruded, it was therefore commonly supposed, that in at least the greatest number of cases of hernia, the peritonæum must certainly be burst or ruptured; and from this the term Rupture was in all such instances supposed to be applied with propriety enough. The idea was farther confirmed too, from its having been observed, that in cases of scrotal hernia, the protruded viscera were in some instances found in contact with the testicle; a circumstance, which it was supposed could not possibly happen, if the peritonæum had not been previously ruptured. Since the anatomy of these parts, however, was better understood, this circumstance, of parts protrud- ed from the abdomen being on some occasions found in contact with the testicle, is explained in a more sat- isfactory manner than on the supposition of a rupture of the peritonæum; an occurrence which we suppose will very rarely happen, in any other manner than from external violence: But as the nature of these disorders cannot be properly understood without a T previous 146 Of Herniæ. Chap. V. previous knowledge of the anatomy of the parts con- cerned, it will be proper, before proceeding farther, to describe such as here become the more immediate subjects of operation; and these are, a part of the ab- dominal muscles; the peritonæum; testicles; and spermatic vessels. The sides and other fleshy boundaries of the ab- domen are formed by five pairs of muscles; viz. the recti, pyramidales, transversales, obliqui interne, and obliqui externi. In some subjects, the pyramidales are wanting; and as the obliqui externi are in general those which in cases of hernia come to be most connected with the disor- der, we shall here confine our description to the anat- omy of these only. The obliqui externi are two thin, broad muscles: On their posterior and upper parts they are fleshy; and tendinous on their anterior and lower parts. They originate from the eighth, ninth, and inferior ribs, by fleshy portions which intermix in a serrated manner with corresponding parts of the latissimus dorsi, serratus major anticus, pedorales major, and in- tercostales: And afterwards becoming tendinous, they form the greatest part of all the anterior surface of the abdomen, and are inserted into the linea alba, the spine of the os ilium, and into the os pubis. On each side of the under part of the abdomen immedi- ately above the pubes, two openings are met with in these tendons, intended for the passage of the spermatic vessels in men, and for the ligaments of the womb in women. These openings, or rings as they are term- ed, which seem to be formed merely by a separation of the fibres of the tendon from one another, are of an oval figure, and have an oblique direction from the spine of the ileum downwards; they are somewhat wider above than below, and are rather of a larger size in men than in women. Although Sect. I. Of Herniæ. 147 Although these rings or openings have been com- monly described as passing through not only the ex- ternal oblique, but the transversales and internal ob- lique muscles also; yet it is now certainly known, that it is in the tendinous parts of the external oblique muscle only, that any such opening exists. It is of some importance to the student to be thoroughly ac- quainted with this circumstance: For, by the accounts received of it from books, one is led to suppose, that, instead of one distinct passage, there are always three to be met with here. These muscles are likewise perforated in the middle by the umbilicus, which af- fords a passage for the connecting vessels between the mother and uterine fœtus, and which is continued through life, being filled up by cellular substance only. From the inferior border of the tendinous part of the external oblique muscle, a detachment of fibres is sent off, which, after affording a firm covering to the inguinal glands, are lost in the fascia lata of the thigh: And the under edge of this tendon being folded in- wards, obtains the appearance of a ligament, which stretches from the fore part of the os ileum to the pubes, forming a kind of arch, through which pass the great blood vessels of the lower extremity. It is this ligamentous like portion of the external oblique muscle, which is known by the appellation of Pou- part's or Fallopius's ligament. This passage for the blood vessels of the thigh, being larger in women than in men, owing to the greater size of the pelvis in the former, by which the arch formed by Poupart's ligament is rendered both long- er and wider; so in them the crural hernia, or that species of the disease formed by a protrusion of parts through this passage, is found to occur much more frequently than in men. The internal surface of the muscles of the abdomen, together with every other part of that cavity, is lined with a smooth somewhat elastic membrane, termed Peritonæum, 148 Of Herniæ. Chap. V. Peritonæum. This membrane, besides lining the cavity of the belly, furnishes the external covering to almost every viscus contained in it; but, in so singu- lar a manner are these coverings produced, that al- though at first fight the different viscera appear all to be contained within the cavity of the peritonæum, yet on a minute examination they are in reality found to lie behind it. The peritonæum, after having completely lined the cavity of the abdomen, is continued or reflected over all the viscera, so as to give an external covering to each. After surrounding one viscus, it stretches a- long to the most contiguous, forming in its course the supporting membranous ligament of the liver and other viscera; and affording in its duplicature a kind of support or connection to the various blood vessels, as they stretch along to their destined situations in the intestinal canal and other organs. Behind the peritonæum lies a quantity of loose cel- lular substance, by authors commonly termed its Ap- pendix. In some parts this substance is filled with fat; and in others it is empty, and can easily be filled with air. The testes in the fœtus are, till near the period of delivery, lodged in the cavity of the abdomen, in the same manner with the rest of the abdominal viscera. They are situated immediately below the kidneys, on the fore part of the psoæ muscles, near to the upper end and by the side of the rectum, where their exter- nal covering adheres by its posterior surface to those parts of the peritonæum on which they rest, while all their anterior and lateral surfaces fie loose in the ab- dominal cavity in contact with the other viscera. Even in this situation, however, a connection takes place between the testes and scrotum. This is form- ed by means of a substance, which runs down from the under end of the testis to the scrotum, forming a kind of pyramidal shaped ligament; its large bul- bous. Sect. I. Of Herniæ. 149 bous head being fixed to the lower end of the testis and epididymis and its under extremity, after having passed through the ring is the external oblique mus- cle, being lost in the cellular membrane of the scro- tum. This ligament is evidently vascular and fibrous, and seems in part to be composed of the cremaster muscle turned inwards*. All that portion of the ligament contained within the parietes of the abdomen passes behind the perito- næum, and receives a covering from it in the same manner with the testes and other viscera; and the pe- ritonæum even gives a coat to a portion of the liga- ment after it has got into the groin, by passing down along with it from the abdomen into the upper part of the inguen. At this place, viz. at the annular opening of the external oblique muscle, the peritonæum is very loose; and when the ligament and scrotum are drawn downwards, an aperture is observed from the cavity of the abdomen all around the fore part of the liga- ment, which seems ready to receive the testis; and this aperture gradually becomes larger as the testis de- scends behind the peritonæum in its way to the scro- tum. While the testicle is ready to descend, it does not fall down, as has been commonly imagined, along the fore part of the peritonæum, between it and the other viscera; but this ligament we have now described as lying behind the peritonæum, and which is connected with the testis at its under and posterior parts, by di- recting or pulling it down as it were from behind, brings it in this manner along the psoas muscle be- tween it and the peritonæum; and that part of this membrane to which we have shown that the testicle adheres, being necessarily drawn along with it, a kind of pouch or bag, somewhat resembling the finger of a glove, is thus formed by this elongation of the per- itonæum * See a very accurate account of the Anatomy of these parts by Mr. J. Hunter, in Dr. Hunter's Medical Commentaries. 150 Of Herniæ. Chap. V. itonæum; the under extremity of which still contin- ues to surround the testis as it goes along, in the same manner as it did when that viscus rested upon the psoas muscle; and the entrance from the abdomen to the cavity of this process, is exactly at that point where the testis was originally situated; for it is there that this process commences when the testis begins to descend. The peritonæum being in a fœtus remarkably lax and dilatable at this part, and being connected poste- riorly, as we have seen, with a quantity of very loose cellular substance, its elongation produced by the de- scent of the testicle is in this manner provided for by nature, and of course is easily admitted of. It must not, however, be supposed, that the testis and peritonæum in coming down fall loosely and without connection; for, as they slide down very gradually, they still continue to adhere to the parts lying behind them as they did when in the abdomen. The precise time at which the testis passes down from its original situation in the abdomen, cannot be exactly determined; but in general, this change takes place about the eighth month. About this period, the testis surrounded with the peritoneal process, moves downwards till it's under extremity comes into contact with the most inferior point of the abdominal parietes; and by this time the passage through the tendon of the external oblique muscle is found a good deal enlarged, by the ligament of the testis having sunk downwards so as to produce a considerable dila- tation of it. After the testis has passed the tendon of the muscle, it commonly remains for some time by the side of the penis, and by degrees only descends to the bottom of the scrotum; and even when it has got entire- ly into the scrotum, its ligament is still connected with it, and lies immediately under it, but is shorten- ed and compressed. The Sect. I. Of Herniæ. 151 The process of the peritonæum, which we have shown to descend with the testicle, continues to cover it when it has reached the scrotum: And it is this loose covering or bag which is afterwards converted into what Anatomists term the Tunica Vaginalis Testis; and from the description we have given of it, it is evident, that the cavity of this bag must at first communicate with the great peritoneal cavity of the abdomen. This it accordingly does, as a probe may be passed readily and easily along this process or bag, from the belly down to the bottom of the scrotum; and if it be laid open through its whole length on the fore part, it will be plainly seen to be a continuation of the peritonæum; the testis and epididymis will be found at the lower part of it without their loose coat the tunica vaginalis; and as the spermatic vessels and vas deferens, while the testicle remained in the ab- domen, entered the body of it behind, and between the reflected lamina of the peritonæum, so here when in the scrotum they will be found covered by the pos- terior part of the bag, in their whole course from the commencement of that process down the groin to the testicle. This passage from the cavity of the abdomen to the scrotum is in general very soon cut off, by a firm ad- hesion being produced between the sides of the perito- neal process at its upper extremity where it descends from the abdomen. What the cause of this adhesion may be, is uncertain; perhaps it may proceed from some slight degree of inflammation being excited up- on the contiguous parts by the forcible passage of the testis; but whatever the cause may be, the fact is, that at the time of birth this passage in general is com- pletely obliterated.* It * The descent of the testes from the abdomen is a phenomenon very difficult to account for, and its immediate cause may probably always remain a mystery; but their being in almost every instance found in the scrotum before birth, is a clear proof of their not being forced down by the effects of respiration, as has been commonly supposed. 152 Of Herniæ. Chap. V. It is in the neck only, however, or superior part of this process, that such an adhesion takes place; as the lower extremity of the sac remains open and loose through life, and forms, as we have already said, the tunica vaginalis testes: The common seat of a hy- drocele. If the smallest attention be given to this description, it must appear evident, that if immediately upon the testicle descending from the abdomen, and before the passage is sufficiently contracted, any portion of the alimentary canal or omentum should like wise fall into the opening, such parts must for certain lodge in the same bag or covering with the testis itself; and that as long as they remain there, they must effectually pre- vent the usual obliteration of the passage from being accomplished. It is this occurrence, of a portion of some of the abdominal viscera getting into the tunica vaginalis testes, which forms that species of hernia to which new born infants are liable, termed by Haller the Hernia Congenita. The teistcle and protruded in- testine being here in contact with one another, the tunica vaginalis testis forms the hernial sac. If the gut, or other parts which have fallen down, be again pushed into the abdomen, and are retained there by proper bandages or any other means, in that case the passage is soon closed up, and no return of the disorder is observed. But this being neglected, and the gut being allowed to remain long down, the parts forming the passage seem thereby in a great measure to lose that power of adhesion which natural- ly they are known to possess; instances of such cases having occurred where no art has been able to pro- duce this wished for obliteration of the opening. The hernia congenita is usually produced in the manner now described; it is probable, however, that the same disorder may, and frequently does, occur, from this passage between the abdomen and testicle, after Sect. I. Of Herniæ. 153 after having been once closed, being again rendered pervious, in consequence of the parts being over stretched by those violent fits of coughing, crying, and other convulsive affections to which children soon after birth are now and then liable. The intestinal canal and other viscera, being on such occasions push- ed with violence against all the containing parts, these will most easily give way where the least degree of firmness occurs; and this we may readily suppose will most probably happen in such parts as have been most recently united. In this manner it is probable that the greatest proportion of those cases of hernia are produced which occur in the early months of infancy; and I am even inclined to think, that on some occa- sions in more advanced periods of life, the same spe- cies of hernia may likewise occur from the same cause. It is evident, then, in what manner the hernia con- genita is produced; we shall now inquire into the causes which tend to the production of hernia in its more usual form. I. The containing parts of the abdomen we know to be elastic and compressible; whatever, therefore, tends to produce a diminution of capacity in the cav- ity of the abdomen, must occasion a proportional de- gree of risk, of some of the contained parts being push- ed from their natural situations. Violent coughing, crying, laughter, or great bodily exertion, are attend- ed with more or less contraction of the abdominal muscles, and particularly of the diaphragm; and as the contraction of these muscles, must always dimin- ish the abdominal cavity, these causes therefore are frequently found to be productive of hernia. II. Falls, in consequence of the derangement they produce in the abdominal viscera, from the sudden and violent shock with which they are often attended, are not unfrequently the immediate causes of hernia. III. Persons of a preternatural laxity of frame, are very liable to hernia. The containing parts of the U abdomen 154 Of Hernia. Chap. V. abdomen, from the want of a sufficient tone and firm- ness, are unable in such people to resist on all occa- sions the weight of the different viscera; and they are therefore more particularly exposed to disorders of this kind on the slightest application of any of the causes already mentioned. IV. Sprains are apt to induce a laxity of the part injured; and have therefore a similar influence in in- ducing herniæ, with general laxity. V. It has been observed, that the people of those countries where oil is much used as an article of diet, are particularly liable to herniæ. In whatever parts the parietes of the abdomen hap- pen to be weakest, these various causes will most read- ily operate in producing herniæ; and accordingly we find, that descents of the bowels usually occur only in such parts. The parts which from anatomy we would à priori suspect to be most liable to such protrusions, are, the openings already described in the external oblique muscles; the arch formed by Poupart's ligament for the passage of the great blood vessels of the thigh; and the umbilicus, where the same degree of firmness does not take place as is met with in the rest of the tendi- nous expansion of the abdominal muscles. These, as we have already said, are the usual seats of hernia; but it sometimes happens that parts of the viscera are protruded between the interstices of the different muscles of the abdomen: These, however, are not frequent occurrences. In whichever of these situations a protrusion of any portion of the intestines occurs, except in the case of the hernia congenita, as all the viscera are contained in the manner already described within the peritonæ- um, a portion of that membrane, it is evident, must be carried down together with the parts protruded; and in every such instance, it is this portion of the peritonæum which goes down along with the gut that is Sect. I. Of Herniæ. 155 is termed the Hernial Sac. The size of this sac is various in different subjects, and in different stages of the same disorder. On the first appearance of the disease, the sac is commonly of no very considerable size, as such swellings seldom acquire any great bulk at once: But by re- peated descents of the bowels, the sac comes to be pushed lower and lower, till in some instances its bulk becomes very considerable indeed; and when in this advanced period of the disorder the sac happens to be laid open, it is found to contain either large quantities of omentum or intestine, and frequently large portions of each. As the peritonæum has this property in com- mon with many other parts of the body, of thicken- ing according to the degree of any gradual extension applied to it, so in many instances the thickness and firmness of the hernial sac are often really astonishing. Although every instance of a bowel protruded from its natural situation is to be considered as a derange- ment, and as such demands our attention, yet daily in- stances occur, both of recent herniæ, and of those of longer standing, in which no bad symptoms are pro- duced by such protrusions of the viscera. Thus it is well known, that hernial swellings of every kind very frequently happen, without the patient suffering in any other manner, than from the inconvenience arising from the bulk of the tumors. But in general this is otherwise; troublesome symptoms most fre- quently occur; and at all events, when the reduction of a hernia can be accomplished with any kind of propriety, it ought always to be effected as quickly as possible. All the bad symptoms which are found to occur in herniæ, proceed, as may be readily supposed, either from obstruction to the passage of the feces when the intestinal canal forms the tumor, or from a stoppage of circulation occasioned by stricture on the prolapsed parts; 156 Of Herniæ. Chap. V. parts; so that the attending symptoms, it is evident, will be always more or less hazardous, according to the nature of the parts so protruded. Thus, when a portion of the omentum alone forms the substance of hernial swellings, as that organ does not appear to be so immediately necessary to life as many of the other viscera, such tumors accordingly are not so frequently productive of bad consequences, at least they are seldom in any degree so hazardous, as when a part of the alimentary canal is either protrud- ed by itself, or along with omentum. Although this, however, is in general the case; yet it does sometimes happen, that even an omental rup- ture is productive of no small degree of danger. When a stricture so complete upon it occurs, as to occasion a stoppage of circulation in the protruded part, mortification with all its bad consequences must be the certain event: And besides, the connection be- tween the omentum, stomach, and other viscera, is such, that a sudden descent of any considerable portion of the former sometimes brings on vomiting, hickup, and other troublesome symptoms: And lastly, al- though a rupture containing omentum only, might not of itself produce any thing bad; yet as the pas- sage through which the omentum has slipped, must of necessity continue open as long as that viscus remains protruded, and as that circumstance alone must as long as it continues render it more easy for a portion of gut likewise to get down, this of itself is a sufficient reason for bellowing even upon this species of hernia our serious attention. But whatever the contents of such swellings may be, as their remaining in some instances for a consid- erable length of time without being productive of any bad symptoms, must proceed entirely from the cir- culation continuing to go freely on, notwithstanding the derangement of parts; so, whenever a stricture occurs upon the protruded viscera, sufficient to pro- duce Sect. I. Of Herniæ. 157 duce either a stoppage of the circulation, or of the fæcal contents of the alimentary canal when a portion of gut forms the disease, the following in general are the symptoms which accrue. An elastic colourless swelling is observed at the part affected; a slight pain is felt not only in the swelling itself, but, if part of the alimentary canal is down, an universal uneasiness is perceived over the whole abdo- men; and this pain is always rendered worse by coughing, sneezing, or any violent exertion. The patient complains of nausea; frequent retching; can get no discharge by stool; becomes hot and restless; and the pulse is commonly found quick and hard. If the swelling is entirely formed by a portion of gut, and if no feces are contained in it, it has a smooth, equal surface; and is easily compressible, but instant- ly returns to its former size on the pressure being re- moved. But, in gut ruptures of long standing, where hard feces have collected in the protruded bowels, con- siderable inequalities are detected. When again the tumor is composed both of gut and omentum, its appearance is always unequal, it feels soft and somewhat like dough, and of course is not so elastic as when part of the intestinal tube only is down; for although like the other it is compressi- ble, it does not so readily regain its former dimensions on the pressure being taken off. It has been a received opinion, that in cases of strangulated hernia, the symptoms should be less vi- olent when the interline is accompanied by a portion of omentum, than when gut alone is down. Little or no difference, however, is produced by this cir- cumstance; for when a gut becomes obstructed and inflamed, the symptoms thereby induced are nearly the same whether the omentum be down with it or not. It will be readily supposed, however, that the symp- toms we have described never can happen from the presence of omentum only: For although stricture produced 158 Of Herniæ. Chap. V. produced on a portion of omentum, even when no part of the intestinal tube is down, does now and then occasion a good deal of distress, such as pain in the part, sickness, vomiting, and twitching pains through the whole belly; yet no obstruction of the gut ever occurs from this, and of course none of the symptoms ever prove so alarming as when any part of the gut is concerned. If these symptoms we have described as being pro- duced by a strangulated gut, are not now obviated by a removal of the stricture which produced them, the nausea and retching terminate in frequent vomitings, first of a bilious, and afterwards of a more fetid mat- ter; the belly becomes tense; the pain turns more violent; a distressing convulsive hickup comes on; and the fever, which before was not apparently of much consequence, now becomes very formidable, and a total want of rest with a very disagreeable state of anxiety continues through the whole course of the complaint. These symptoms having gone on with violence for some time, the patient is at last for the most part sud- denly relieved from all manner of pain, when he flat- ters himself every risk is for certain over. But instead of that, the pulse, from having been hard and fre- quent, becomes languid and interrupted; cold sweats break out over the whole body, but especially on the extremities; the eyes acquire a kind of languor; the tenseness of the abdomen subsides, and the swelling of the part affected disappears; the teguments covering the parts, which before were either of a natural ap- pearance, or had somewhat of a reddish inflamed cast, now acquire a livid hue, and a windy crepitous feel is distinguished all over the swelling. If the protruded parts have not of themselves gone entirely up, their return is now in general easily ef- fected by a small degree of pressure; and the patient then discharges freely by stool; but the cold sweats increasing, Sect. I. Of Herniæ. 159 increasing, the hickup turns more violent, and death itself is at last ushered in by its usual forerunners, sub- sultus tendinum and other convulsive twitchings. These are the ordinary symptoms of what is term- ed a strangulated or incarcerated gut hernia; that is, when the parts protruded become so affected by stric- ture, as to produce pain; and do not either return to their natural situations on the patient getting into a horizontal posture, or cannot even be immediately re- placed by the hands of a practitioner. In whatever situation a strangulated hernia occurs, the only rational method of cure, it is evident, must consist in the removal of that stricture which prevents the return of the protruded parts. It is that which ought to be considered as the cause of all the mischief; and unless it be removed, nothing effectual can be done for the relief of the patient. Various methods have been attempted by practi- tioners for the removal of stricture in these disorders; all of them, however, may be comprehended under two general heads. I. Such as effect a reduction of the protruded parts, without the interposition of incision or any chirurgi- cal operation properly so called; and, II. A division of the parts producing the stricture, so as to admit of a replacement of the deranged vis- cera, constituting what is termed the Operation for the Hernia. The remedies to be employed for accomplishing the first of these, are, a proper posture of the patient, with the manual assistance of a practitioner; bloodlet- ting; stimulating glysters; opiates; the warm bath; and proper applications to the tumor itself. As soon as the assistance of a practitioner is desired for the removal of symptoms in cases of hernia, the first circumstance requiring his attention, is, the plac- ing his patient in such a posture as will most probably favour the return of the protruded parts. Thus, when the 160 Of Herniæ. Chap. V. the tumor is in the groin, or in the fore part of the thigh, the patient ought to be so placed, as to raise his thighs and legs considerably higher than his head and trunk; that is, he should be placed almost perpen- dicularly upon his head. This position causes almost the whole quantity of intestines to hang or swing by the protruded parts, which frequently proves a means of effecting their re- duction. Placing the patient's feet over the shoulders of another person, while at the same time his body is allowed to hang downwards, and causing him in this posture to be a good deal jolted about, has on some occasions been known to answer when every other means has been tried in vain. For the same reason that in the inguinal and femor- al hernia the position now mentioned is more advisa- ble than any other, the usual erect posture of the body becomes most proper in cases of exomphalus or um- bilical rupture; and again, a horizontal posture is most likely to prove serviceable in cases of ventral hernia. While the patient thus remains in the most suitable posture according to the seat of the disorder, the sur- geon should at the same time endeavour to assist the return of the gut or other parts, by means of gentle pressure with his hands and fingers. In the inguinal or scrotal hernia, this pressure should be made ob- liquely upwards towards the os ileum, so as to corres- pond as nearly as possible with the opening in the ex- ternal oblique muscle. In the femoral hernia, the pressure ought to be made directly upwards; in the umbilical hernia, downwards and backwards; and in the ventral hernia, directly backwards. When tumors of this nature are of any considera- ble size, pressure, as we have here recommended, is most conveniently made, by grasping the swelling with one hand from the bottom upwards, while with the fingers of the other hand we endeavour to push forward Sect. I. Of Herniæ. 161 forward the contents at the superior part of the tu- mor. Some surgeons, in pushing forward the intes- tine, employ the fingers of both hands at the upper part of the tumor; but the same purpose is answered equally well with the index and middle finger of one hand, while the other hand is employed to great ad- vantage in pressing the under part of the tumor up- wards so as to cooperate in this manner in the reduc- tion of the parts. It is this operation which by au- thors is termed the taxis. No description, however, can convey an adequate idea of the manner of per- forming it properly: for, like many other circum- stances in the art of surgery, the knowledge of it can only be acquired by repeated experience and attentive observation: But this must always be had in view, that any pressure that is applied, must be of the most gentle kind; for every thing of this nature that cre- ates much pain, is very prejudicial, and ought by all means to be avoided. If a very moderate degree of pressure applied in the manner described, does not effect a reduction of the tumor, other means must be immediately em- ployed. Bloodletting is here a principal remedy. In no disorder is it either more indicated from appear- ances, or affords more relief in reality. The quantity to be taken away ought in a great measure to be de- termined by the strength of the patient: But if in any case we can with propriety venture upon abstract- ing large quantities of blood from weak people, it is here; and it is often astonishing to what length this evacuation is carried in cases of hernia without being productive of any prejudice to the system. A state of deliquium being known to produce a more effectual relaxation of the various muscular parts of the body, than can be obtained by any other means, it has sometimes been advised, in cases of hernia, to take off such large quantities of blood, and in such a sud- X den 162 Of Herniæ. Chap. V. den manner, as to produce fainting; and the practice has now and then been attended with advantage. As an obstinate costiveness is commonly one of the most alarming symptoms of hernia, it has been a com- mon practice to prescribe not only a variety of stim- ulating purgatives by the mouth, but injections com- posed of the most acrid materials. From all the ex- perience, however, which I have had in disorders of this nature, I am convinced that purgatives are very seldom productive of much good; and when they do not prove useful, they almost universally do mischief, by increasing not only the sickness at stomach which always prevails here, but even by adding to the pain and tension of the tumor. I am clear, therefore, that remedies of this kind should not be pushed so far as they commonly are; and when they are applied, in- stead of purgatives by the mouth, which always prove very nauseating, and in this state are usually rejected by the stomach, I would recommend tobacco smoke thrown up in the form of injections, as preferable to every other remedy. A variety of machines have been contrived for injecting smoke by the anus; but none of them I have met with answer the purpose ei- ther so easily or so effectually as the instruments rep- resented in Plates VI, and VII. They are easily pro- cured; and by means of either of them, smoke may be injected with any necessary degree of force. I would not have it supposed, however, that I rec- ommend tobacco smoke used in this manner as an infallible purgative, as many have done. For the contrary is certainly the case; I have known it used in a great number of cases both of hernia and ileus, and seldom with any advantage. I only advise it as the most effectual remedy of this kind with which I am acquainted; and I know that the method here recommended of injecting it, is the most effectual hitherto invented. It has been objected to these in- struments we have delineated, that we cannot when they Plate VI.   Plate VII. Sect. I. Of Herniæ. 163 they are employed ascertain the quantity of smoke in- jected. But this is a nicety of little importance; as the rule in all such cases should be, to continue to throw up the smoke, either till it has produced the wished for effect, till a considerable degree of sickness is induced, or till the abdomen is found to be some- what distended by it, as in some patients a third or even a half more may be necessary for this purpose than is found to answer in others. But although this remedy does not frequently an- swer as a purgative, it often, both in cafes of hernia and ileus, proves a very effectual anodyne. And as we are frequently in such cases deprived of the advan- tage of opium, by its being rejected by the stomach, in such instances, when the pain is very severe, it may be always employed as one of the best means of pro- curing ease. With the same view as the remedy last mentioned, acrid suppositories, composed of soap, aloes, and other stimulating materials, have been recommended; and when remedies of this class are to be used, these may be considered as a necessary addition to the other pur- gatives; but no great dependence ought ever to be placed upon them. I know, we are told that in some cases of hernia, the use of drastic purgatives has been of advantage; but I have so frequently known them do harm, by increasing the nausea, pain, and inflammation of the strangulated gut, that I am under no difficulty in say- ing that they ought seldom, if ever, to be used in any case of hernia. Opiates are here often of service, not only by re- lieving pain, but as tending to relax those parts which, by being preternaturally constricted, we consider as the principal cause of the disorder. We have already observed, however, that the constant retching which occurs in most cases of hernia, prevents the exhibition of opiates by the mouth; but in such instances they may 164 Of Herniæ. Chap. V. may be applied with some advantage in the form of injection, and their use may be alternated with that of tobacco smoke as we have above recommended. Warm bathing is another remedy from which much advantage has been received in disorders of this nature. It is not the local application of heat, how- ever, in the form of poultices and fomentations, &c. we mean to recommend, but the universal warm bath, in which the whole body is immersed, and which we know to be possessed of very relaxing powers. The latter, viz. the general warm bath, by tending to relax the constriction on the protruded intestines, has fre- quently had a considerable influence in promoting their replacement; but the former, viz. poultices and other means of applying local heat to the swelled parts, al- though commonly employed, are undoubtedly very prejudicial. On the constricted tendon they can have no influence, for it always lies so deep as to be out of the reach of every local application of this nature: And as the heat conveyed by such remedies, must for certain tend to rarefy the contents of such swellings, by their thus producing an increase of size in the tu- mors to which they are applied, instead of answering any good purpose, on this principle it is evident they must do harm; and accordingly, whoever will atten- tively observe their effects, will find this to be the case. When the external teguments are much in- flamed and painful, by their emollient properties they now and then afford some relief; but the ease so ob- tained is only momentary, as the pain commonly soon becomes more violent than before they were em- ployed. Whoever attentively considers the nature of these disorders, and the means generally found most effec- tual in relieving them, will probably coincide with us, in imputing the bad symptoms which occur in cases of hernia, to a stricture induced upon the protruded parts. By many, however, a contrary opinion has been Sect. I. Of Herniæ. 165 been inculcated; and the principal cause of the vari- ous symptoms which occur here, has been supposed to be, inflammation, or some spasmodic affection of the protruded parts, independent of any stricture of the parts through which these have passed. That inflammation of the prolapsed bowels, what- ever may originally have produced it, will in general terminate in all the symptoms of strangulated hernia, no person will deny; but that stricture of the surrounding tendons is by much the most frequent cause of them, we think is so very obvious, as to render it quite un- necessary here to adduce any arguments in support of the opinion: This, however, we must remark, that even on the supposition of the origin of all the mis- chief lying in the protruded parts themselves, and not in any stricture of those through which they pass, still the impropriety of warm applications must be equally obvious, as by the rarefaction they induce, they must always tend to produce an additional degree of swell- ing in the contents of the hernial tumor. Independent, however, of any theoretical reasoning, I can with certainty aver, that in practice, much more advantage is obtained in disorders of this kind, from cooling applications, than from those of an opposite nature. In different instances I have ventured on the application of ice and snow, sometimes with evident advantage, and I never saw them do harm*. But in general, the remedies I depend most on here, are, cold saturnine solutions, and cloths kept constantly moist with a mixture of cold water and vinegar. By a proper application of one or other of the rem- edies now mentioned, or by a due combination of all of them, many cases of hernia are relieved without any farther assistance: But it frequently happens, not- withstanding every endeavour, that the protruded parts * By some writers, this practice has been considered as hazard- ous; but I find it recommended by others to whom much credit is due, particularly by the late Dr. Monro. See his works, 4 to edition p. 559. 166 Of Herniæ. Chap. V. parts cannot be returned; the symptoms, instead of abating, become more violent; and the event of the disease is of course rendered more doubtful. In this situation, when no probability remains of success from the employment of the means already mentioned, the division of the parts producing the stricture is then our only resource. This, it may be remarked, is one of the nicest points in practice that a surgeon has ever to determine upon: I mean the exact period at which, in cases of hernia, the more gentle means should be laid aside, and the operation be put in practice. If a surgeon, without having given a full trial to all the usual remedies, should early in the disorder proceed to the operation, and if unfortunately it should not succeed, he would probably be blamed by the friends of the patient as the principal cause of his death; and again, even al- lowing a recovery to be obtained, he is apt to be blamed, not only by his brethren of the profession, but by the patient himself for having made him suf- fer an unnecessary degree of pain. In such a situation a practitioner often finds himself much embarrassed. But we ought to be directed here, as in every critical case we are employed in, by the result of experience only; and if this rule is ad- hered to, instead of tedious delays usual in every case of strangulated hernia, we will have recourse to the operation much earlier than is usually done. This operation, as is the case indeed with every other of equal importance, is no doubt attended with some hazard; but the danger accruing from it has by most practitioners been more magnified than it ought to be: For although no person of character can in any case of hernia be supposed to have recourse to it before other means have been tried; yet so far as from experience I am able to judge, the risk attending the disorder itself when the operation is long delayed, is infinitely Sect. I. Of Herniæ. 167 infinitely greater than is commonly experienced from the effects of the operation considered abstractedly. Were we able from the attending symptoms to de- termine the exact period at which the operation ought to be performed, no kind of difficulty would occur from it; but this is so far from being the case, that the most experienced practitioner cannot with any cer- tainty decide upon it. In some instances, herniæ with every symptom of strangulation, continue for six, eight, or ten days; and after all, the protruded parts are at length replaced, and the patient does well; and in many similar cases when the operation has been the means of relief, although the very worst symptoms have subsisted for several days, yet on laying the parts open, no appearances either of inflammation or gan- grene have been detected. On other occasions, again, the same set of symp- toms, with perhaps no greater degree of swelling or tension in the parts affected, end fatally in a very short space of time. In some such instances, the rapid progress of the disorder is very surprising; the space of eight and forty hours hardly intervening, from its first attack till the patient's death: I have even known the intestines become perfectly gangrenous in the course of one day from the time of their first ex- pulsion. Every practitioner must be sensible, that this is the real state of the question; and if it is so, it must at once become evident, that considerable delays must in such critical circumstances be always attended with great hazard; and as the real danger to be appre- hended from the operation itself, is trifling when com- pared to the risk which long delays usually produce, it ought therefore, I think, to be laid down as an estab- lished maxim, always to proceed to the operation, if in the space of a very few hours bloodletting and the other remedies pointed out, do not prove effectual. Two or three hours at farthest, even when the assist- ance 168 Of Herniæ. Chap. V. ance of practitioners is early applied for, is perhaps the greatest length of time that should ever be con- sumed in trials of this nature. In the treatment of herniæ, it is certain, that French surgeons are usually more successful than the generali- ty either of German or British practitioners; and so far as I know, no reason can be assigned for the differ- ence, but that the French in almost every instance proceed more early to the operation than the surgeons of almost any other nation. They will thereby, no doubt, perform it frequently on patients who might have recovered by more gentle means; but any in- convenience arising from this circumstance to a few, is fully compensated by the number of lives which must be saved by having recourse to the operation in due time, and which in all probability would other- wise have been lost. Although for very obvious reasons the reduction of every case of hernia ought to be attempted when that can be done with propriety, yet it frequently happens that particular circumstances occur which effectually debar us from every resource of this nature. When once a hernial swelling has been properly reduced, it is in general in the patient's power to pre- vent any return in future, by keeping a proper ban- dage constantly applied to the opening from whence the parts were protruded. But it often happens from inattention to this circumstance, that ruptures which might at first have been easily cured, come at last by repeated descents, and by the great quantity of parts that fall down, to form tumors of so great a magni- tude, in proportion to the opening through which they were protruded, that no art can replace them by the more simple means of reduction. Independently, too, of the great degree of bulk to which tumors of this kind sometimes arrive, such ad- hesions frequently take place, between the viscera forming the swelling and the surrounding parts, as render Sect. I. Of Herniæ. 169 render their return altogether impracticable by any other means than by the operation. By this last mode, indeed, almost every case of hernia may be reduced; but however necessary this operation may be when a patient's life is in danger, as it is always at- tended with some degree of risk, it ought never to be put in practice where symptoms of strangulation do not actually exist. In that chronic state of hernia we have been just describing, although by interested and ignorant prac- titioners the operation has been often proposed as a radical cure, yet no surgeon of character would in such circumstances ever think of advising it: He would rest satisfied with preventing any accumulation of feces in the intestines, by prescribing a proper diet and the occasional use of gentle laxatives; and with obviating any inconvenience which might arise from the weight of the tumor, by the application of a prop- er suspensory bandage. By these means alone, large tumors of this kind are often rendered very supportable for a great length of time; the circulation of the parts contained in the swelling goes freely and regularly on, as well as the peristaltic motion of such parts of the alimentary ca- nal as have been protruded; and hence it is that we have many instances of large portions of the gut fall- ing down even to the bottom of the scrotum, and continuing there for a great number of years without producing any interruption whatever to the usual dis- charge by stool. In this situation, therefore, of the disease, the opera- tion can never become admissible. But although people labouring under this state of the complaint, do frequently enjoy very good health, and sometimes feel little or no inconvenience from the swelling, yet it must not be supposed that their situation is altogether free from danger: On the contrary, it is very certain, that on many occasions, swellings of this kind which Y have 170 Of Herniæ. Chap. V. have subsisted for a great length of time without being productive of much trouble, do at last inflame and turn painful, so as to produce every bad symptom commonly observed from the real strangulation of a gut. As long, too, as a swelling of this nature re- mains, as the opening through which the parts have been protruded is thereby effectually prevented from closing, so the patient is always liable to descents of other portions of intestine which have not formerly been down, and which may be productive of the most fatal symptoms. But what we here wish to establish is, that till once these bad symptoms do actually occur, either from an affection of that part of the gut which has been long down, or of a portion more recently protruded, no such operation as the one in question ought to be employed. All that can be done with propriety in such cases, is, to fit the patients with proper suspensory bandages; to warn them of the risk they are constantly liable to; and to caution them against violent exercise, particularly leaping, and every sudden exertion. Although with regular practitioners this circum- stance cannot require much discussion, yet the public at large is much interested in it. The former know well, that the operation should not be performed in any case of hernia where violent symptoms do not render it necessary; but the latter, by not being able to judge of the various circumstances which ought to be taken into consideration, are too frequently imposed upon by that numerous set of Itinerants with which every country abounds. By these a variety of opera- tions are put in practice for performing what they call a radical cure of these disorders; by which they mean to say, a prevention of future descents. But as no remedy with which we are acquainted, a well adapted truss only excepted, can be depended on for this purpose; and as all the other means put in practice for it, are not only painful, but in general are Sect. I. Of Herniæ. 171 are productive of much danger; the magistracy of ev- ery community ought to interfere in suppressing them. The object in view by every attempt of this nature, is, either to effectuate the entire destruction of the her- nial sac, or at least to procure an accretion of its sides; which, by such as are ignorant of the anatomy of the parts concerned, has been considered as capable of preventing any returns of the disorder in suture; and for the production of which, various methods have been invented. In order to effect a total destruction of the sac, our forefathers employed not only the knife, but the po- tential and even actual cauteries; and with a view to produce a firm union of its sides, which was consider- ed as equally effectual, it was afterwards proposed by practitioners of more tender feelings, to employ the needle and ligature, or what was termed the Royal Stitch: And for the same purpose was invented the famous punctum aureum, which was performed in the following manner. After reducing the intestines into the abdomen, the sac was laid bare with a scalpel; and a piece of gold wire being passed round its up- per end, the wire being likewise made to include the spermatic cord, it was then ordered to be twisted with a pair of forceps to such a degree of tightness as to prevent the descent of the gut, but not to inter- rupt the circulation in the spermatic cord.* But none of these methods being found to answer, for even the actual cautery, when carried perhaps to the depth of the bone itself, did not secure the pa- tient against a return of the disorder, our modern pre- tenders have therefore ventured to improve upon the ignorance of ancient practitioners, and actually go the length of destroying not only the hernial sac, but even the testis also: Without any knowledge of the anatomy of * For a more particular account of these various modes of prac- tice in the different kinds of hernia as employed in former times, see the writings of Albucasis, Paulus Ægineta, Fab. ab Aquapendente, Hildanus, Parey, &c. 172 Of Herniæ. Chap. V. of the parts, and having no characters to suffer from whatever consequences may ensue, they proceed with- out fear; and, by promising all that patients can hope for, they are sure to be every where well received. In consequence of this, in every large town, many op- erations are performed by them; numbers according- ly are for certain mutilated, and many thereby even lose their lives. Their method of proceeding is shortly this: They lay bare the hernial sac, and hav- ing reduced the prolapsed parts, a strong ligature is passed round both the sac and spermatic cord, and is drawn so tight as to destroy effectually, not only the passage along the sac, but the cord itself, and of course the testicle. On some occasions matters go no far- ther; but on others, such a degree of inflammation has been induced, as to terminate in the patient's de- struction. If any of these means, however, was to be produc- tive of the effect proposed, viz. the prevention of eve- ry future descent of intestine, the risk incurred would be in some measure compensated by the advantage received: But the fact is much otherwise; for unless a truss be kept constantly applied, the patient contin- ues liable to a return of the disorder in nearly the same degree as if no operation had been performed. Even the operation for the hernia itself, does not, as has been supposed, fortify the parts against a return of the disorder, the continued use of a truss being just as necessary after that operation as if it had not taken place. I have dwelt longer on this circumstance than may be thought necessary by those who are much conver- sant in this part of practice; but as it is certain, that even of late years much mischief has been done by Itinerants in the various species of hernia, and as they still continue to impose upon the public, I thought it necessary to put the unwary on their guard against the effects of their knavery and ignorance. In  Plate VIII. Sect. I. Of Herniæ. 173 In plate VIII. are represented a variety of trusses for different species of hernia. Those here delineated are intended for the more usual kinds of hernia, viz. the inguinal, crural, and umbilical. When others are wanted for particular parts, some ingenious tradesman in that line of business should be applied to, with di- rections to fit the instrument with the nicest exactness to the parts for which it is intended. Indeed, the good effects of every bandage for this complaint, depend so much upon the exactness with which it is made to fit, that without the utmost nicety in this respect, it must always do more harm than good; for the sole purpose of a bandage in cases of hernia, is to prevent effec- tually the falling down of such parts as have been newly replaced: If therefore the pad or bolster of the bandage does not bear properly against the opening upon which it is placed, a portion of gut may slip out, and be thus materially injured by the pressure of the pad. I have met with different instances of this kind, where bandages by not being exactly fitted did much mischief; and every practitioner must have ob- served them: It is therefore a matter of the first im- portance, that tradesmen be ordered to pay much at- tention to this circumstance. Every bandage used for this purpose ought to be of the steel spring kind; for those composed of linen and other soft materials, can never be kept properly applied. Even in infancy the steel bandages, when properly made, are in general used with ease and safety: But at any rate, when they cannot be got to apply exactly, which in early child- hood is sometimes the case, no dependence ought to be placed upon any other; for they always fret and gall the parts to which they are applied, and I nev- er knew them in any one instance to answer the purpose. Having premised these general observations, which relate equally to every variety of the disorder, and by which frequent repetitions will be rendered unneces- sary, 174 Of Herniæ. Chap. V. sary, we shall now proceed to the more particular consideration of the different species of hernia; and first of the Bubonocele. SECTION II. Of the BUBONOCELE. TOGETHER with the general symptoms of strangulated hernia which we have lately enumerated, and to which we must here refer, the particular ap- pearances of the bubonocele, or inguinal hernia, are, a soft somewhat elastic swelling, beginning in the groin, and descending by degrees into the scrotum in men, and into the labia pudendi, in women. When a portion of gut forms the tumor, it commonly feels tense, and this always in proportion to the degree of stricture that occurs in the opening of the tendon; and when any inflammation takes place, the least de- gree of handling or pressure always gives pain. When the hernia contains omentum only, the swell- ing is both more soft, compressible, and more un- equal, than when gut alone is down; the scrotum be- comes more oblong, and of course less round, than in an intestinal hernia; and when the quantity of omen- tum is large, it is also much more weighty than a gut rupture of the same size: But in many cases, perhaps in the greatest proportion of all hernial swellings, the tumor is composed of both gut and omentum; and then the distinguishing symptoms of each can never be so clearly marked. In books, various symptoms are enumerated, for distinguishing the contents of ev- ery species of hernia; but whenever the case is any degree complicated, every candid practitioner must acknowledge, that no certainty as to this point can be obtained till the tumor is fairly laid open. As there are some disorders with which the ingui- nal and scrotal hernia may be confounded, practition- ers Sect. II. Of Herniæ. 175 ers ought to be as much acquainted with their charac- teristic marks as possible. These complaints are, glandular or other swellings in the groin, whether from the venereal disease or any other cause; that species of swelling termed Hernia Humoralis; and all the different kinds of hydrocele. The venereal bubo and other swellings in the groin, are readily distinguished from hernia, not only by the absence of all the general symptoms of hernia, but by that incompressible hardness with which all such swell- ings are at first attended, and by the fluctuation of matter which in their suppurated state is always ob- servable. In the hernia humoralis, or swelling of the testicle, the hardened and enlarged state of the testicle itself, as well as of the epididymis; their being exquisitely pain- ful to the touch; the tumor being remarkably heavy in proportion to its bulk; and the spermatic process being commonly very free from swelling; are in gen- eral pretty certain marks of distinction. In the her- nia humoralis, too, the intestines are free and unob- structed, and the other general symptoms of hernia as formerly pointed out are wanting. In the hydrocele of the tunica vaginalis testis, the tumor in general is more equal to the feel than in her- nia: In the former the swelling always begins in the under part of the scrotum, and proceeds upwards: Whereas the very reverse occurs in herniæ. Except in cases of very enlarged hydrocele, the spermatic process is always perfectly free and distinct; whereas in every case of hernia where the tumor descends to the scrotum, the spermatic cord cannot in any part of its course be distinguished. In a hydrocele, a fluc- tuation of a fluid is distinguishable; in a hernia it is otherwise. From the anasarcous swelling of the scrotum, or hydrocele of the dartos as it is termed, hernia is very readily distinguished; and indeed the means of distinc- tion 176 Of Herniæ. Chap. V. tion are so obvious, that they need not be here enu- merated ; but there is another species of hydrocele, viz. the hydrocele of the spermatic cord, which on some occasions it is no easy matter to distinguish from hernia, and which therefore requires particular atten- tion. The species of hydrocele, where the water is col- lected in one or more cells of the spermatic process, now and then begins in the under part of the cord, and proceeds upwards; and in such cases, this circumstance alone is a sufficient means of distinction between it and hernia, in which the swelling always proceeds from a- bove downwards; but it sometimes happens, that the swelling in this kind of hydrocele begins even within the opening in the abdominal muscle, and by degrees fells downwards. In such instances, it is altogether impossible from the state of the tumor merely, to say whether it is the one disease or the other. The gen- eral symptoms of hernia, such as pain and tension of the abdomen, obstructed intestines, &c. must be par- ticularly attended to: And as these do not occur in any species of hydrocele, when they happen to take place they will commonly throw much light on the real nature of the disease. In some cases, however, these and every other means of distinction are want- ing; but even in such circumstances a prudent prac- titioner will never run any risk, either of hurting his patient, or of affecting his own reputation; which the mistaking a Hernia for a Hydrocele, and treating it as such, must always do; and which, to the disgrace of Surgery, has on some occasions actually happened. In all such cases, where any degree of doubt occurs, as well as in every case of tumor in the testicle where the most perfect certainty is not obtained, and when it is necessary to have recourse to an operation, the surgeon ought to proceed as if the disorder was a real hernia: By doing so, every risk will be avoided; and on the tumor being laid cautiously open, the true nature Sect. II. Of Herniæ. 177 nature of the disease will be then rendered evident, and the practitioner accordingly will be at liberty to apply the means best suited for its removal. Whereas by adopting a contrary method, and by treating as a Hy- drocele what afterward turns out to be a true Hernia; independent of any injury to his own reputation, he runs a very great risk of destroying his patient. In the treatment of the Bubonocele, when the vari- ous means we have recommended when treating of hernia in general are employed without success, the surgeon is then under the necessity of proceeding to the operation; and the method of doing it is this. A table of a convenient height being placed in a proper light, the patient must be laid upon it with his head and body almost horizontal, whilst at the same time his buttocks are somewhat elevated by pillows laid beneath them. The legs hanging over the edge of the table ought to be separated so as to admit the operator between them; and should in that situation be firmly secured by an assistant on each side, who should take care to keep the thighs so far raised, as to relax all the abdominal muscles. In order to afford as much empty space as possible for the return of the protruded parts, the patient should be advised to empty his bladder entirely; and the parts having been previously shaved, an incision must now be made with a common round edged scalpel through the skin and part of the cellular substance, beginning at least an inch above the superior end of the tumor, and continuing it down to the most de- pending part of the scrotum. Even although the tu- mor does not extend to the bottom of the scrotum, the parts should be laid open in this manner. By a free external incision we are enabled to finish the ope- ration with more ease and freedom than when the first opening is not so large; it does not produce much more pain than a small incision; and by being contin- ued to the bottom of the scrotum, the matter produc- Z ed 178 Of Herniæ. Chap. V. ed in the upper part of the sore is prevented from col- lecting below, which it is otherwise ready to do. The operator now goes on to divide slowly the rest of the cellular substance, together with some tendinous kind of bands, which, unless the disorder is very re- cent, are universally met with, either loose upon the surface of the hernial sac, or, on some occasions, pass- ing as it were into its substance. Even this external incision of the teguments ought to be made with great caution: For although in by much the greatest pro- portion of hernial swellings, the spermatic vessels lie behind the protruded parts, yet on some occasions they have been found on the anterior part of the tu- mor; so that in order to avoid the risk of wounding them, as soon as the skin is divided the remainder of the operation ought to be done in the most cautious manner, care being taken to avoid every large blood vessel that makes its appearance. This circumstance of the prolapsed parts getting down behind the spermatic vessels, has never, so far as I know, been taken notice of in books; it must there- fore be a very rare occurrence. As I met with it, however, in one case, where the fact was exceedingly evident, the possibility of its happening I have there- fore no reason to doubt. If we attend only to the usual conformation of these parts, the hernial sac, we would say, ought never to get behind the spermatic cord: But we know well, that in no part of the hu- man body is nature more apt to desert her ordinary course, than in some circumstances relating to the tes- ticles and their blood vessels. We have already ob- served, that till near the period of delivery, the testicles continue in the abdomen; and about that time, fall down in a gradual manner to the scrotum. Many in- stances, however, occur, of both testes remaining in the abdomen through life: Sometimes one remains, and the other falls into the scrotum. On other occa- sions, one or both fall into the groin, and never pro- ceed Sect. II. Of Herniæ. 179 ceed farther; a circumstance which every young prac- titioner should be aware of, as instances have occurred of a testicle remaining in the groin being mistaken for a hernia, and of much pain and distress being pro- duced by different attempts made for their reduction. Now, if such varieties as these occur in the mechanism of these parts, why may not nature in some instances produce such a conformation as may, in the event of a hernial sac falling into the scrotum, bring the sper- matic cord, and even the testicle itself, into a situation anterior to the protruded parts? I shall not here enter into the discussion of the manner in which such a cir- cumstance may be produced; but, as I am certain that the fact has happened, and as it may therefore occur again, I consider it as an additional argument for the propriety of dividing the hernial sac in the cau- tious manner here directed*. In making this first incision of the skin, it is usual to do it by pinching up the teguments, and then di- viding them with a scalpel; but no surgeon of steadi- ness and dexterity will ever think it necessary to pro- ceed in this manner: For this incision of the skin is done with much more neatness, and with equal safety, by the operator grasping the tumor with his left hand, in such a manner as to render the teguments on the anterior part of it as tense as possible, while with the scalpel in his right hand he divides the skin from one end of the swelling to the other. The division of the skin and cellular substance be- ing continued in the manner directed till the sac is laid bare, an opening must be made in it so as to bring its contents into view; and the most safe place for such an opening is, not about the middle of the tumor, as is commonly directed, but as near to the under * Since this went to the press, I find that a similar instance is re- corded by Le Dran, in his Treatise on Ruptures of the spermatic ves- sels having been found on the anterior part of a bubonocele.--Such a situation, therefore, of these vessels, is perhaps more frequent than is commonly imagined. 180 Of Herniæ. Chap. V. under point of it as possible: It is here done with as much ease as in any other part; and besides, the gut is seldom if ever found just at the bottom of the sac, which is commonly occupied with a quantity of bloody serum; so that the risk of wounding it there is much less than in any other part of the swelling. In making this perforation into the sac consists the great- est nicety in the operation, the utmost caution being necessary to avoid wounding the parts protruded from the abdomen. Good eyes and a steady hand are in no operation more requisite than in this: With these, any practitioner acquainted with the anatomy of the parts may be sure of doing the operation properly, and without them the best anatomist must undoubt- edly go wrong. With the same scalpel that divided the skin and cel- lular substance, the operator must proceed slowly, di- viding one fibre of the sac after another, till there is reason to think that the whole substance of it is cut through. This may be always discovered by means of the blunt end of a probe: If it passes in easily, we may conclude with certainty that the sac is divided; and if it does not, the incision must be continued in the same gradual manner somewhat farther, when the same trial with the probe must be again made. In prosecuting this division of the sac, a good deal of assistance is obtained from the use of a small sharp pointed directory, open at the extremity, as is repre- sented in Plate IX, fig. 3. By pushing the end of this instrument below some of the fibres of the sac, they are thereby separated from the parts underneath, and may be thus divided with more safety than in any other manner; and in the same way the remaining parts of the sac must be divided, till this part of the operation is finished*. In * In the 4th Volume of Memoirs of the Paris Academy of Sur- gery, there is a very ingenious paper on Herniæ by Monsieur Louis. But although there are many useful observations communicated in this Sect. II. Of Herniæ. 181 In almost every case of hernia where the tumor is confined to the groin, and even where the swelling ex- tends to the scrotum if the parts are recently protrud- ed, the hernial sac is found very thin, and in such cases is always soon cut through; but it is necessary for the information of young practitioners, to observe, that in hernial swellings of long standing, the sac frequently becomes so very thick, as to require much more dis- section than beginners commonly expect: By going on, however, in the cautious manner we have directed, every risk of wounding any material part may be a- voided. . As soon as an opening is made quite through the sac, a circumstance of which we are made certain, as was already remarked, by a probe passing easily in, it ought then to be farther enlarged, till it is of such a size as to admit the fore finger of the operator's left hand. The finger being now introduced, is to be used as a director for entering the narrow blunt pointed bis- toury, represented in Plate VII, with which the sur- geon is to divide the hernial sac along its whole length from below up to the opening in the external oblique muscle. By means of the finger as a director for the bistoury, this part of the operation is performed with perfect safety; and the bistoury here delineated, ren- ders the many complex instruments formerly employ- ed this treatise, Mr. Louis in one point I think has gone far wrong, in ridiculing that degree of caution shown by some surgeons in dividing the hernial sac: The division of the sac, he says, is attended with so little difficulty, that he does not consider it as different in that re- spect from the first external incision of the skin. His words are: "Jamais le sac ne m'a donnè ni plus de peine, ni plus d'embarras que la peau; on divise, pour ainsi dire, celle-ci du premier trait, et le sac du second." In the hands of such an expert operator as Mr. Louis, the scalpel even in this manner may be so managed as to do no harm but with the general run of practitioners much mischief would be produced by proceeding in this part of the operation so rapidly as is here directed. And when we reflect that the difference of a few seconds in the course of the operation, is all that could be gained by the greatest dispatch we can employ, little doubt, I think, can remain as to the propriety of proceeding through every part of it in the most deliberate manner. 182 Of Herniæ. Chap. V. ed not only for this part of the operation, but for the subsequent division of the tendon, quite unnecessary. On laying the sac open at the bottom, a quantity of coloured fluid always rushes out, and the protruded parts now come fully into view: If a portion of gut is down, and is not much entangled with omentum, by being now set at liberty it pushes out immediately on the sac being opened; thereby giving the appearance of having been collected in a larger quantity, than the size of the tumor gave reason to expect. The portion of gut found in hernial swellings is very various, no part of the intestinal canal being en- tirely exempted from falling down. Hitherto the ile- um has been commonly supposed to form the sub- stance of the greatest proportion of such tumors; later and more accurate observation, however, renders it probable, that the cæcum, appendix vermiformis, and part of the colon, are perhaps as frequently contained in herniary sacs as any other portion of the gut. The sac being laid fully open, the parts contained in it ought now to be examined with the nicest atten- tion, in order to discover whether they are all sound or not; and if upon an attentive inspection they are found to be sound, that is, if they are not evidently in a gangrenous state, even although they do seem to be considerably inflamed, every endeavour should be used to get them immediately returned into the abdomen. In making the reduction, whether intestine or omen- tum, or a portion of each, have been found contained in the swelling, those parts of them which appear to have come last out, ought to be first pushed back; the difficulty and trouble of returning them being thereby much lessened: And in making the reduction, it both answers the purpose better, and is less likely to do mischief, to apply the fingers to that part of the in- testine connected with the mesentery than to the con- vex part of the gut. While the reduction is going on, the patient's thighs and loins, should be still more ele- vated Sect. II. Of Herniæ. 183 vated than they were during the preceding steps of the operation; as this posture of these parts tends much to facilitate the return of the protruded intestines to the abdomen. When the disease is recent, and the parts have not been frequently down, it sometimes happens, that by pulling out a little more of the gut than was former- ly in the sac, any obstruction which occurred to its be- ing replaced is thereby removed; and if the protruded parts are not of great bulk, they may thus be some- times reduced, without any necessity for enlarging the opening through which they have passed from the ab- domen: But when upon trial this cannot be done with great ease, it should never be attempted; much more danger being to be dreaded from any degree of force used for the reduction of the gut, than can ever occur from finishing the operation by an enlargement of the opening in the tendon of the external oblique muscle. As the tendon of this muscle runs in an oblique di- rection from above downwards, and as the opening through which the contents of a hernia protrude, is formed merely by a separation of the tendinous fibres from one another, the direction of this opening is of course the same with that of the tendon; that is, it runs somewhat obliquely from the spine of the ileum to the os pubis. In enlarging this passage, then, for the reduction of such parts as have passed through it, as a transverse section of the tendon is by no means necessary, the knife should be carried obliquely upwards, so as mere- ly to continue the natural separation of the tendinous fibres. The finger was recommended as the best director for the knife in opening the sac, and in dividing the tendon it is equally necessary. By insinuating the fin- ger into the aperture in the tendon immediately above the protruded parts, the point of the blunt bistoury is easily 184 Of Herniæ. Chap. V. easily introduced upon it; and in this manner, by keeping the end of the finger always a little before the bistoury, the opening may be enlarged to any neces- sary extent without any risk of wounding the con- tiguous parts. In general, a very small enlargement of the natural opening in the tendon is found sufficient for the reduc- tion of the gut and other parts: But the size of the opening ought by all means to be fully sufficient for the end proposed; for it is better to exceed in making it somewhat too large, than to run any risk of hurting the parts by forcing them through a very small aper- ture. If upon introducing the finger any adhesions of the gut to the contiguous parts are discovered, the in- cision in the tendon ought to be larger than might otherwise be necessary, in order that the finger may be freely admitted so as to destroy such adhesions as it can reach; for unless they are removed, complete success from the operation cannot be expected. Independently of such adhesions internally, it fre- quendy happens, by long confinement in the scrotum; pressure; and perhaps other causes; that strong ad- hesions are formed among the parts contained in the sac itself; and before they can be with propriety re- duced, it is always necessary to attempt to separate them. When adhesions of this kind occur, as they some- times do, between different parts of the protruded gut, the greatest caution is necessary in separating them: But connections of this nature between one portion of the intestinal canal and another, are seldom very firm, and are commonly easily separated by the fingers alone; and when the connection is formed by means of long filaments, which is sometimes the case, the easiest method of removing them is to cut them, either with a pair of scissors or the bistoury: But when it is found, that one part of a gut adheres so firmly to another Sect. II. Of Herniæ. 185 another as not to be separated but with difficulty, it is much better to return the whole even in that state in- to the abdomen, than to run the risk of hurting the intestine materially by using much force. When, again, adhesions occur between the gut and the hernial sac, or between the gut and omentum, if the filaments producing the connection cannot be oth- erwise removed, as there is no great hazard in wound- ing the omentum, and still less in hurting the sac, a very small portion of these may be dissected off, and returned with the gut into the abdomen; and in the same manner, when the omentum adheres so firmly to the sac as not to be separated in any other manner, no danger can ever accrue from the sac being some- what encroached upon. The risk and trouble attending the practice now recommended is nothing, at least it is very trifling, when compared to the inconveniences that would en- sue from leaving either the omentum or gut adhering externally to the hernial sac, as is advised by some writers when such adhesions cannot be very easily di- vided. The smallest portion of gut being left down, would run a great risk of suffering by exposure to an unusual degree of cold, and to the effects of the exter- nal air at the different dressings; and by leaving part of the omentum to protrude through the opening from the abdomen, one great advantage to be ex- pected from the operation would be lost, viz. the pre- vention in future of that risk which a patient with a portion of protruded omentum is always liable to, of a piece of gut slipping down, and perhaps of becom- ing strangulated. After returning the contents of the sac into the cavity of the abdomen, it has been proposed by some authors, to pass a ligature round the upper part of the sac just at its neck, with a view, as we are told, of procuring a reunion of its sides, in order that it may Aa serve 186 Of Herniæ. Chap. V. serve as a means of preventing future descents of the bowels. But as such a ligature cannot be applied without much risk of injuring, or even of destroying the sper- matic vessels, with which the posterior lamella of the sac is immediately connected, the practice from that consideration alone ought to be laid aside; but in re- ality it does not appear to be in any degree necessary, as this very union of the sides of the sac is universally produced merely by that degree of inflammation which always succeeds to the division of it by this operation. Hitherto we have recommended the immediate re- duction of the contents of hernial tumors upon the supposition that they have been only displaced; that they have been adhering to one another or to the neighbouring parts; or perhaps that they have been more or less in a state of inflammation. But when it appears that this inflammation has already termi- nated in gangrene, as the return of such mortified parts, whether of omentum or intestine, might be ex- ceedingly hazardous, a greater degree of caution be- comes necessary. When the omentum is found in a mortified state, as the excision of a portion of this membrane is not attended with much risk, it has been the common practice to cut away the diseased parts; and in order to obviate any inconvenience from the hemorrhagy which might ensue, we are advised to make a ligature on the sound parts previous to the removal of those that are mortified; whilst the ends of the ligature be- ing left hanging out of the wound, the surgeon has it in his power to remove them when circumstances ap- pear to render it proper. These ligatures on the omentum, however, having frequently been productive of bad consequences, such as nausea, vomiting, cough, fever, pains in the belly, and inability to sit erect; and it having been found by Sect. II. Of Herniæ. 187 by the experience of many individuals, that no hem- orrhagy of any importance ever occurs from a di- vision of this membrane even in a sound unmortified state; such parts as have become gangrenous may therefore be freely cut off, and the remaining sound parts be afterwards without the intervention of liga- tures introduced into the abdomen with no risk what- ever. This is now the opinion of different practi- tioners*: But if it should ever happen, on cutting off part of the omentum, that a vessel of any size is di- vided, a ligature may with great safety be passed a- bout the vessel itself, without including any of the membrane; and the ends of it being left long enough to hang out at the wound, the threads may be after- wards pulled away at pleasure. Another circumstance sometimes occurs, too, which renders the removal of part of the omentum necessary; when a rupture has been of long duration, and a considerable portion of caul has remained long down, from the pressure made by the usual suspensory bandage and other circumstances, it frequently hap- pens that considerable quantities of the protruded parts become much thickened, very hard, and col- lected into lumps. When these lumps are not very large, there is no necessity for removing them, as when small they may be returned into the abdomen without producing any inconvenience; but whenever it appears to the operator, that by their bulk and hardness they might probably do mischief if reduced into the belly, they ought as certainly to be cut off as if in a state of real mortification. When it is determined to remove any part of the omentum, the easiest and safest method of doing it is this. The membrane ought to be carefully expand- ed * A very accurate paper upon this subject may be seen in the 3d Vol. of Memoires de l'Academie Royale de Chirurgie of Paris, by Monsieur Pipelet, in which several cases are related of the bad ef- fects produced by ligatures on the omentum. Mr. Pott is also of this opinion.-—Vide Treatise on Ruptures. 188 Of Herniæ. Chap. V. ed at the part intended to be cut; and in this state it is very easily divided by a pair of thin edged scissors, much more so indeed than by any other instrument. When fully spread out, any turn of the intestine that happens to be enveloped in it, is at once brought into view, which without this precaution we would run a great risk of dividing by the scissors. When, again, a portion of gut is found to be mor- tified, if it should be returned in that state, a discharge of feces would certainly take place into the cavity of the abdomen, as soon as the mortified spot should sep- arate from the sound. In order to prevent such an occurrence, which would soon terminate in the pa- tient's death, if it is a small spot only that is diseased, we ought to endeavour by means of a needle and lig- ature, to connect the sound part of the gut immediate- ly above the mortified spot, to the wound in the ab- dominal parietes. By this means, when the mortified part separates, or on its being immediately cut out, which is perhaps better, the feces are discharged by the wound; and different instances have occurred, where the loss of substance produced by the mortifica- tion was not extensive, of the opening into the gut becoming gradually less, and at last healing entirely: But whether the event should prove so fortunate or not, whenever a portion of gut is observed to be com- pletely mortified, it ought by all means to be secured by a ligature to the parts most contiguous to the wound. And farther, when the mortified portion of gut is of great extent, and includes, so far as it goes, the whole circumference of the intestine, the gangrenous parts of it ought to be cut out at once; and if the quantity thus taken away is not so considerable as to prevent the ends of the gut from being brought into contact with one another, it ought to be immediately effected in the manner we shall direct in another chapter when treating of Gastroraphy. This at least affords a chance Sect. II. Of Herniæ. 189 chance of the ends of the gut being brought to re- unite; and if unfortunately that event should not take place, as the gut ought here also to be connected to the parts contiguous to the wound in the abdomen, a passage for the feces will still be secured by the groin. Although in cases of hernia, attended with a morti- fication of the intestines, many have recovered by the method we have recommended who otherwise must have died; yet it will be readily supposed, that the risk attending patients in such a state must be very great: But although a small proportion only of such as are unfortunately in this situation should recover, yet still no practitioner would be excusable for omit- ting those means which afford the greatest probable chance of a recovery. A patient of my own is now living, and in good health, voiding his feces by the anus, who lost at least one foot of the intestinal canal by mortification in a case of crural hernia; and we are told by different authors, of similar recoveries equally remarkable. It is to the moderns chiefly, we must remark, that this very material improvement in the treatment of hernials to be attributed. It is even recorded of Rau, who lived in a very late period, that on opening a hernial sac, where a gangrenous state of the parts was detected, as the case was considered as desperate, he laid down his knife and proceeded no farther in the operation. This patient, who died next day, would in modern practice have had at least some chance for life. When it is therefore discovered, that part of the contents of the sac are mortified, all such portions as are to be removed ought to be cut off; and the re- maining found intestine being retained till properly se- cured by a ligature, the opening in the external ob- lique muscle may then be dilated with safety: Where- as, if it should be enlarged before the diseased part of the gut is taken away, the gangrenous portion might very 190 Of Herniæ. Chap. V. very probably slip up together with the sound; but by the precaution now recommended, every risk of this nature is prevented. The parts forming a hernia being all completely replaced, when the sac in which they were contained is found thick, hard, and much enlarged, as in such a state no good suppuration can take place, and as its preservation cannot be in any degree useful, such parts of it as can be cut away with propriety ought to be removed: All the lateral and fore parts of the sac may be cut off with safety; but as it is commonly firmly connected with the spermatic vessels behind, this part of it ought not to be touched. The operation being now finished, by the protrud- ed, parts being replaced, and those intended to be re- moved being cut off in the manner directed, the re- maining sore must be dressed as lightly as possible with charpee of the softest kind; and the best bandage for retaining the dressings, is the usual suspensory bag properly stuffed with soft lint. The patient on being carried to bed should be so placed as to have his loins somewhat elevated above the rest of his body, and should in that situation be immediately laid to rest: Opiates are here particularly useful: To prevent, or at least to moderate, the fever which commonly succeeds, the patient should be kept cool; in plethoric habits, bloodletting should be pre- scribed, together with a rigid low diet; and lastly, a frequent use of gentle laxatives, so as to keep the belly moderately open, is particularly proper. When however the constitution has been previously much reduced, either by long sickness or any other cause, instead of bloodletting and a low diet, a nour- ishing regimen should be prescribed; for if a patient in such circumstances be not properly supported, he will not so readily recover from the effects of the disor- der: And it is proper to remark, that in ordinary practice, the indiscriminate use of bloodletting, and an Sect. II. Of Herniæ. 191 an abstemious regimen, in every case of hernia, ap- pears to be too rigidly adhered to; for although this practice proves always more effectual than any other means in every case of rupture attended with inflamma- tion, yet daily experience convinces us of its being highly pernicious where the system has been already much reduced by evacuations, and where no inflam- matory symptoms take place. The sore being regularly dressed as often as it ap- pears necessary in the same easy manner as at first, . and the same degree of caution being continued both with respect to diet and other circumstances, if the pa- tient survives the first three or four days he will in general recover: And as soon as the sore is firmly cicatrized, a truss ought to be properly fitted to the parts, and should never in any future period of life be laid aside. By many it has been recommended, and it is still a very common practice, to stitch up the wound with two or three sutures; but as no real advantage can be obtained from this, and as it has been on some occa- sions productive of mischief, it ought not to be at- tempted. No person will probably say, that such lig- atures ought to be carried so deep as the tendon of the oblique muscle; and if they are only made to pass through the external teguments, they can have no ef- fect in preventing a protrusion of intestines: On the contrary, it does now and then happen, during the cure of the wound after this operation, that small por- tions of gut pass out at the opening in the tendon, which are always readily seen and easily reduced when the external parts have not been drawn together; but on the skin being by ligatures made to cover the great- est part of the wound, I have known it more than once happen, that portions of intestines have passed out at the opening in the tendon, and remain protruded for a considerable time without being noticed; so that the practice ought not to be encouraged. After 192 Of Herniæ. Chap. V. After laying the sac bare, it was some time ago rec- ommended by Mr. Petit and other French practi- tioners, to endeavour to reduce the protruded intes- tine without dividing the sac. One great advantage expected from this, was, the prevention of those bad consequences which are supposed will most likely en- sue from the external air finding access to the contents of the abdomen. It ought to be remembered, however, that unless the hernial sac is laid open, we cannot possibly know in what state the protruded bowels are; so that parts might be returned into the abdomen in such a state of disease as would add greatly to the patient's risk. Not only the intestines are liable to mortification, but collections are apt to occur in the hernial sac, of a very fetid putrid serum, which, on being pushed into the abdomen, might be productive of much mischief. And besides, it has sometimes happened, that, on lay- ing open a hernial sac, the cause of strangulation has been detected, either in the entrance to the sac itself, or among the parts protruded along with it: For al- though, in a great proportion of all the instances of hernia that occur, a stricture of the passage in the ex- ternal oblique muscle is to be considered as the cause of all the bad symptoms, yet now and then instances of the contrary are observed; one of which I met with some years ago, and I have heard of others of the same kind.—In a case of scrotal hernia of long standing, symptoms of strangulation at last supervened; and on laying open the sac, the appendix vermiformis was found so tightly twisted round a portion of gut, as left no reason to doubt of that circumstance alone having been the cause of all the mischief. If the parts had here been returned into the abdomen without dividing the sac, no advantage whatever would have occurred from the operation; and, after death, the practitioner would have had the mortification to find, that, in all probability, Sect. II. Of Herniæ. 193 probability, the patient's life might have been saved, if this very necessary measure had not been omitted. Instances of the protruded parts being returned into the abdomen without opening the sac, are enumerated by different French authors; and in some of these which ended fatally, it was found on dissection, that strangulation of the gut had been occasioned by stric- ture formed by the parts contained within the sac, and not by the tendon of the external oblique muscles. Disasters of a nature similar to these we have men- tioned, having on different occasions occurred to Mr. Petit and others who had adopted the practice of re- turning the parts contained in the sac without divid- ing the sac itself, it has now accordingly been very generally laid aside. Even Mr. Petit himself was at last so convinced of the inconveniences resulting from it, that he is said to have joined keenly with those who had opposed it from the time of its being first introduced. By some authors again, it is advised, to reduce not only the protruded bowels, but even the hernial sac itself, without opening it; whilst, by others, it is al- leged, that the sac can never be reduced. Mr. Louis, in the paper we have already quoted, is clearly of this last opinion, as Mr. Pott also is. But we have the testimony of different authors of credit, and particu- larly of Mr. Le Dran, to the contrary; and I have myself met with one instance of this, where the appear- ances were so unequivocal as to leave no doubt with me respecting it. In cases of hernia where the parts have been long and repeatedly down, such firm adhesions are usually formed between the sac and the contiguous parts, as to reduce them apparently into one inseparable mass; so that, in such circumstances, reduction of the sac be- comes altogether impracticable. But although this is perhaps in every instance found to be the case in ruptures of long continuance, we are by no means warranted in supposing that it is so in every case of re- Bb cent 194 Of Herniæ. Chap. V. cent hernia. We know that the adhesion of one part of the body to another, cannot any where be instanta- neously produced. Even where recent division has taken place, and when the divided parts are kept in close contact, the space of several days is commonly required to effect a firm reunion. Now in the case of a portion of membrane being forced into a natural opening, where the parts are neither rendered raw by art, nor are as yet affected with inflammation, a still longer period we may suppose will be necessary for this effect; and in fact, although I suppose there is scarce an instance of a hernial sac of long duration being re- duced, yet there are sundry indisputable facts which show, that in recent ruptures the sac may be returned. The one above alluded to, which occurred in an ope- ration at which I was present several years ago had been down five or six days, and formed a tumor in the groin of the size of an egg: The sac did not in any point seem to adhere; the operator therefore found no difficulty in reducing it; and on dissection after death, which happened in about two days from the operation, the passage through the external oblique muscle was found dilated, but no existence of a sac could be traced into it. It is not, however, my own opinion, that this is a matter of much importance in practice, I mean the practicability of reducing the hernial sac or not; for, the various reasons we have al- ready given, against the propriety of returning the con- tents of a sac without opening it, occur with equal force against the proposed practice of returning the sac itself unopened. But as there is a possibility of su- ture experience deriving some advantage from this cir- cumstance, it is certainly right to have the fact as clearly established as possible. Hitherto we have been supposing the disorder to exist in a male subject only; as the same open- ings in the external oblique muscle are met with in females, Sect. III. Of Herniæ. 195 females, so they are also liable to the species of rup- ture we have just been describing. In males, however, the bubonocele is observed to occur more frequently than in women, and as in them too the cellular membrane surrounding the spermatic vessels is very lax and dilatable, so hernial swellings of this kind are commonly much larger in men than in women. But instances do now and then occur of such tumors even in women becoming very large; in such cases, the protruded parts fall down to the very bottom almost of the labia pudendi. As the openings in the external oblique muscles of females are exceedingly similar to those in male sub- jects, so the treatment of this species of hernia is in them very similar to what is found to answer in men. In cases of strangulated gut, when glysters, bloodlet- ting, and the other remedies formerly enumerated, happen to fail, the same operation of laying open the hernial sac, and of enlarging the opening in the ten- don of the oblique muscle, is here equally proper as in the other sex. With modest women, disorders of this kind often take place without the practitioner in attendance be- ing made acquainted with them; whenever therefore such symptoms of colic occur as give reason to sus- pect the existence of hernia, a particular examination ought always to be made, in order if possible to detect the cause of the mischief, from the removal of which a cure can alone be expected. SECTION III. Of the HERNIAL CONGENITA. BY attending to the anatomical description given in the first section, of the parts chiefly concerned in cases of hernia, it must evidently appear, that in the ordinary species of scrotal hernia, the parts protruded from 196 Of Herniæ. Chap. V. from the abdomen must of necessity be contained in a bag or sac perfectly distinct from the testicle; which in that kind of rupture is always found in its usual situation in the scrotum, unrounded by its own proper mem- brane the tunica vaginalis, and not in contact with any other part whatever. We then made it appear too, that if in early infan- cy a portion of gut should slip down by the same pas- sage with the testicle, that the parts so protruded must be in immediate contact with the testis, and must thus be surrounded with the tunica vaginalis; so that in this species of rupture, very properly by Haller term- ed Hernia Congenita, the tunica vaginalis testis forms the hernial sac. The discovery of this species of hernia, which was reserved for modern times, enables us to account for a number of cases recorded in books of surgery, of the contents of ruptures having been found in the same bag with the testicle: A circumstance which, till this discovery, was always considered as a clear proof of the peritonæum being frequently ruptured in those disor- ders; as there was not otherwise a possibility of ac- counting for the phenomenon. But we now know, that the peritonæum in these cases of hernia is never ruptured; and that the parts forming a hernial tumor being found in contact with the testicle, is a circum- stance easily explained from our more accurate ana- tomical knowledge of those parts. In the treatment of ruptures of the congenital kind, little difference occurs from the management of the bubonocele in its more ordinary form. When the parts can be replaced without any operation, it ought always to be done, a truss being at the same time rec- ommended as a preventative of suture descents; and when symptoms of strangulation take place, which can- not be otherwise removed than by the operation, it here becomes equally necessary as in any other species of rupture. When Sect. IV. Of Herniæ. 197 When from the circumstance of the parts having been protruded in early infancy, and from their having at times continued to fall into the scrotum from that period downwards, there is reason to suspect that the hernia to be operated upon is of the congenital kind, the surgeon in such a case, in laying open the contents of the tumor, must proceed with still more caution than in cases of ordinary rupture; for the tunica vag- inalis which here forms the sac, is commonly much thinner than the usual sac of herniæ. On the parts being returned, more attention is necessary too in dress- ing the wound than in other cases of hernia; for the testicle being here laid bare by its vaginal coat being cut open, if it is not treated with much delicacy it will very probably inflame, and may thereby be produc- tive of much distress. The testis therefore ought to be immediately enveloped with its own proper covering, the loose tunica vaginalis; and at every dressing, care should be taken to prevent as effectually as possible every access to the external air. In other respects the management of the hernia con- genita is perfectly similar to that of any other rupture. SECTION IV. Of the CRURAL or FEMORAL HERNIA. THE seat of this species of hernia, as we have else- where remarked, is on the upper and anterior part of the thigh; the protruded parts passing out at the same opening through which the large blood vessels of the thigh are transmitted from the abdomen. In the description given in a former section, of the external oblique muscles of the abdomen, the under edge of these muscles, it was remarked, by doubling backwards, forms a kind of ligament, which extends in an oblique direction from the spine of the ileum near to the symphisis pubis. It is this under border of 198 Of Herniæ. Chap. V. of these muscles which is commonly known by the name of Poupart's or Fallopius's ligament. Excepting at its two extremities where this liga- ment is attached to the pubes and ileum, it is not in any other part connected with bone. By the particu- lar shape of the ileum at this part, a kind of arch is formed by the ligament passing over a hollow in that bone through which the large artery and veins of the thigh find a passage, the rest of the cavity being filled up with cellular substance, glands, and fat; and all these parts again are covered and tied down by a firm tendinous aponeurosis of the fascia lata of the thigh. It is under the tendon or ligament just now describ- ed, that the parts composing a crural hernia descend. On some occasions they pass immediately over the femoral artery and vein; on others, they are found on the outside of these vessels; but more frequently they lie on the inside, between them and the os pubis. As the protrusion of any of the abdominal contents produces in this situation nearly the same set of symp- toms as occur in cases of inguinal hernia, the method of treatment recommended in that species of the dis- ease is also applicable here. When, therefore, in the femoral hernia, symptoms of strangulation occur, we must put all the remedies in practice already advised for the inguinal rupture: Only here, in attempting to reduce the parts by the hand, the pressure should be made directly up- wards, instead of obliquely outwards, as we directed in the other; and when these means are unfortunately found to fail, the operation itself must then be em- ployed. A free external incision was inculcated in cases of inguinal hernia; and it is here equally necessary, or even more so, from the parts concerned being more deeply seated than in the other. By too much timid- ity in making the external incision, the operator is frequently Sect. IV. Of Herniæ. 199 frequently much incommoded in all the subsequent steps of the operation. The external cut should ex- tend at least from an inch above the upper end of the tumor to the same space below the most depending part of it. The membrana adiposa, tendinous expansion of the fascia lata, and hernial sac, being all cautiously divided, if the protruded parts are found in a situation proper for reduction, we should immediately attempt to re- place them; and as the space below the ligament through which they have passed is considerable, this may frequently be done without dividing the ligament, merely by pressure properly applied with the hand, while the patient's body is placed in the posture we have already directed in the bubonocele as being best suited for favouring a return of the bowels. When in this manner the contents of the tumor can be reduced without the necessity of dividing the liga- ment, the patient is thereby saved from a great deal of hazard, as from the particular situation of the sper- matic vessels and epigastric artery with respect to this ligament, any cut made into the substance of the lat- ter, runs a very great risk of dividing one or other of them. The spermatic vessels as they go along to pass out at the opening in the external oblique muscle, run nearly upon the very edge or border of Poupart's lig- ament almost through its whole length, so that I con- sider it as impossible to make a free division of the ligament without cutting them across. We have been advised indeed by some, in order to avoid wounding the spermatic vessels, which they ac- knowledge would certainly happen if the incision should be carried directly upwards, to cut in an ob- lique direction outwards. In this method, they al- low, that the epigastric artery, from the course it usu- ally takes, may very probably be divided: But the risk attending the division of that artery they do not consider 200 Of Herniæ. Chap. V. consider as of much importance; and if the discharge of blood occasioned by any wound that may be made in it should happen to be considerable, they speak of it as a very easy matter to take it up by a needle and ligature, and needles of various shapes have been in- vented for this purpose. Even in emaciated people, however, it is a matter of much difficulty to reach the epigastric artery, and in corpulent patients it will be found altogether impossible to surround it with a lig- ature; so that the younger part of the profession ought to be very cautious in receiving the directions usually given on this subject. On reading the remarks of the late Mr. Sharpe upon this point*, to secure the epi- gastric artery by means of a ligature, one would ex- pect to be the easiest of all operations; but the diffi- culty which in reality attends it, is such as must con- vince every one who has tried it, that Mr. Sharpe himself had never put it in practice. But even although this accident of wounding the epigastric artery could be guarded against in the most easy and effectual manner, yet I will venture to say, when a femoral hernia is of any considerable size, the distention of the ligament thereby produced must bring the spermatic vessels so nearly on a line with the under border of the ligament, as to render it altogether im- possible to divide the one without the other; and whoever will examine these parts in the state we have now described, will see that this cannot be avoided, whether the incision be carried directly upwards, or even obliquely outwards or inwards. Some authors, from being sensible of the danger attending this part of the operation, have proposed merely to dilate the passage, instead of dividing the ligament; and Mr. Arnaud, a French writer on this subject, delineates a curved levator for the purpose of supporting the ligament till the protruded parts are re- duced: But as we are to suppose in every case of stran- gulated * Critical Inquiry into the present state of Surgery. Sect. IV. Of Herniæ. 201 gulated hernia, that the passage through which the parts have fallen down is already dilated to nearly its utmost possible extent, in such a situation to attempt a farther dilatation without the assistance of the knife, would seldom, it is probable, be productive of any ad- vantage. A considerable time ago it occurred to me, that in this part of the operation some assistance might be de- rived from performing it in the following manner; and having since had occasion to make trial of it in one case where it answered most effectually, I can now therefore recommend it with some certainty. Instead of dividing the ligament in the ordinary way, I only made an incision into part of its thickness: In order to protect the parts below, I first insinuated the fore- finger of my left hand between the gut and the liga- ment; and then with a common scalpel made a cut of about an inch in length, beginning above and pro- ceeding to the under border of the ligament. The first scratch with the scalpel was very flight; but by repeated touches, it was made to penetrate al- most through the whole thickness of the ligament, till at last a very thin lamella only of it remained: The finger being now withdrawn, the protruded parts were returned with great ease, the ligament at its weakened part yielding gradually as the necessary pressure was applied for the reduction of the intestines. As in this manner the opening may be enlarged to any necessary extent, and as the spermatic vessels and epigastric artery are thus effectually avoided, the ope- ration for this species of hernia may not only be done with equal certainty, but with the same degree of safe- ty, as for any other kind of rupture. For, by not penetrating with the scalpel through the whole thick- ness of the ligament under which these blood vessels lie, they are thereby kept free from all kind of danger during this part of the operation; and, the pressure to be afterwards used for the reduction of the protruded Cc parts, 202 Of Herniæ. Chap. V. parts, if done in an easy gradual manner, as it ought always to be, can never injure them materially; as blood vessels of the size and strength of which these are, easily admit of a degree of extension much more considerable than can be here required. The femoral hernia being in other respects perfect- ly similar to the inguinal, and the mode of treatment applicable to the one, being in every other circum- stance equally so to the other, it is not necessary to say any thing farther here concerning it: Only we may remark with respect to bandages for retaining the dressings, both in this and every other species of hernia, except in the bubonocele, as last described, in which the ordinary suspensory bandage of the scrotum an- swers the purpose in a very easy effectual manner, that in no other situation can a bandage be applied, without being productive of much inconvenience. For instance, the Spica, as it is termed, which after the operation of the crural hernia, used always to be employed, can never be applied but with much dif- ficulty; nor does it answer the purpose properly: Instead of this or any other bandage, a piece of thin leather spread with any plaster moderately adhesive, being applied over the dressings, retains them more effectually, and with much more ease. We have elsewhere remarked, that from the partic- ular conformation of the parts concerned in this dis- ease, which is found to take place in females, that women are more liable to it than men. In them the same means of relief, and the same mode of operating, ought to be employed as we have already advised for male subjects. For, as the same risk occurs here of wounding the epigastric artery, the same precautions are necessary for avoiding it; and by attending to the directions we have given upon this point, this may be always done with certainty. SECTION Sect. V. Of Herniæ. 203 SECTION V. Of the EXOMPHALOS, or UMBILICAL RUPTURE. IN this species of hernia, the parts protruded from the abdomen pass out at the umbilicus; and the con- tents of the hernial sac are here, as in every other kind of rupture, exceedingly various. On some occasions they consist of intestines only; sometimes of omentum only; and frequently of both. At other times, again, part of the stomach, the liver, and even the spleen, have been found in the sac of an umbilical rupture. As all the parts we have now mentioned, are, while in the abdomen, contained in the peritoneum, the her- nial sac, it is evident, must be here formed as well as in other ruptures, by that membrane being carried along with such parts as are protruded. Accordingly, in every recent instance of umbilical hernia, this sac is in general very evident; but when the tumor has become considerable in size, by a long continu- ance, and the great weight of its contents, the sac, by the pressure thus produced, becomes so connected with the neighbouring parts, that by many it has been doubted whether this species of hernia has a sac or not. In ruptures of this kind the swellings sometimes increase to such a degree, as actually to burst the sur- rounding parts; not only the sac, and cellular sub- stance, but even the skin itself. This disorder occurs most frequently in infancy, soon after birth; and corpulent people are more lia- ble to it than those of a contrary habit, from this evi- dent reason, that in the former, by the great bulk of contained parts, the surrounding muscles are kept con- stantly distended, and the opening at the umbilicus through which the parts are protruded, is thereby made more pervious: For the same reason too, wom- en 204 Of Herniæ. Chap. V. en in the last months of pregnancy are particularly lia- ble to umbilical rupture. If the disorder is attended to in due time, a bandage properly fitted to the parts will commonly effect a a cure; and, in such swellings as occur in pregnancy, a removal of the disorder, is, in general, a certain consequence of delivery. But even in cases of um- bilical hernia in pregnant women, by employing a bandage on the first appearance of the disease, and by persevering in the use of it for a proper length of time, although a cure may not be obtained till delivery, the disorder will at least be prevented from receiving any farther increase. Both in male and female patients, due attention to the use of a truss is absolutely neces- sary in every case of hernia; but as in this species of the disease the swelling and different symptoms are al- ways greatly aggravated by pregnancy, women in that state ought to be particularly attentive to the smallest appearance of every swelling of this nature. Although in some instances of umbilical ruptures, different portions of the alimentary canal are found to be protruded; yet by experience we know, that the omentum alone is much more frequently protruded than any of the other viscera: And hence umbilical herniæ in general, are not productive of such bad symptoms as usually occur in the other kinds of rup- ture. It happens, however, as we have already observed, that in some cases a portion of gut alone is pushed out, by which the usual symptoms of a strangulated hernia are apt to be induced. In which event, when the means usually employed for returning the gut in- to the abdomen do not succeed, as a stricture of the passage through which the gut has fallen, is to be considered as the cause of the disorder; so a cure, it is evident, must depend entirely on a thorough remov- al of that stricture. In performing this operation, a free external incision along the course of the tumor, is the Sect. V. Of Herniæ. 205 the first step to be taken; and on laying the protrud- ed parts bare by a cautious division of the sac, if they are found in a state proper to be returned, and if that cannot be effected without making an enlargement of the passage into the abdomen, this may be done with great safety by introducing the finger, and enlarging the opening as far as is necessary with the blunt point- ed bistoury. This incision, we may remark, may be made with almost equal safety in any direction; but left the ligament formed by the umbilical vessels should be wounded, which, however, would not prob- ably occasion much injury, yet if any person is ap- prehensive of danger from that circumstance, it may be always avoided by making the incision on the left side of the umbilicus, and carrying it a little obliquely upwards and outwards. When, again, the prolapsed parts, on being laid open, are found to be so far diseased as to render their reduction improper, the directions formerly given for the treatment of similar occurrences in other cases of hernia, apply with equal propriety here, so that they need not now be repeated. By Albucasis, Guido, Aquapendens, and other authors, it has been proposed, with a view to obtain a radical cure without having recourse to the operation, to lift up the skin covering the tumor, with the finger and thumb, so as to separate it from the gut under- neath; when a ligature is ordered to be applied round the parts so held up, and to be made of such a tight- ness as to induce a mortification of all the parts that lie anterior to it. In other instances again, when the form of the swelling did not admit of this, the same precaution be- ing taken as we have directed above for avoiding the gut, a needle containing a double ligature was intro- duced at the basis of the tumor, near to its centre, and the ligatures were afterwards tied one above and the other 206 Of Herniæ. Chap. V. other below, of such a degree of tightness as to induce the wished for effect. But as the practice thus recommended was not ad- equate to the design proposed, as it did not prevent a return of the disorder, and as the destruction of skin produced by it rendered every future descent more dangerous; so it is now, at least by regular practition- ers, very universally exploded. SECTION VI. Of VENTRAL HERNIÆ. IN this species of hernia the parts forming the swelling are protruded between the interstices of the abdominal muscles. No part of the abdomen is al- together exempted from the occurrence of such tu- mors, but they are most frequently observed in some of the parts most contiguous to the linea alba; and when the stomach alone happens to form the tumor, the swelling is situated just under, or immediately to one side of the xiphoid cartilage. The treatment of this kind of rupture corresponds exactly with that of exomphalos. When the parts are reducible by the hand merely, a cure may be fre- quently obtained by the constant use of a truss; and, again, when symptoms of strangulation occur, which cannot be otherwise removed than by an incision through the stricture, this must be done in the man- ner directed in the last Section, so as to admit of the parts being replaced. The after treatment of the parts concerned in the operation, is the same here as in other kinds of rupture. SECTION VII. Of the HERNIA of the FORAMEN OVALE. IN this variety of rupture, the viscera protrude through the foramen ovale of the pubis and ischium. It Sect. VII. Of Herniæ. 207 It is not by any means a frequent disorder; but, as it does sometimes occur, it is necessary here to describe it. The symptoms in this kind of hernia being very similar to those produced by the strangulation of in- stestines in other parts, it is not necessary to enume- rate them: Only it is proper to remark, that in this rupture the tumor is in men formed near to the up- per part of the perinæum; and in women, near to the under part of one of the labia pudendi. In both sexes it lies upon the obturator externus, between the spectinæus muscle and the first head of the triceps fem- oris. The foramen ovale being partly filled up by a membranous or ligamentous substance, and in part by the obturatores muscles, it was commonly supposed that this species of hernia arose from a relaxation of one or other of these; but as an opening is left in the foramen for the transmission of different blood vessels and nerves, it is now known, that in this disorder the viscera pass out at that opening, by gliding down in the course of these vessels. The general mode of treatment as we formerly rec- ommended for other species of hernia, must be here attended to; and when the parts are reduced, a truss properly adapted to the parts, must be trusted to for their retention. But as it will sometimes happen in this, as in every other case of hernia, that reduction cannot be effected by the hand alone, in that event the operation of dilating the passage through which the intestines protrude, is the only resource. The tumor, however, that occurs in this disorder, being in general so small as scarcely to be noticed but by the most minute examination, unless a local pain, with the usu- al symptoms of a strangulated gut lead to its detec- tion, it is seldom discovered from its size, until it is too late to expect much assistance from art. But whenever the operation becomes necessary, as it must always be when symptoms of strangulation are discovered 208 Of Herniæ. Chap. V. discovered to have arisen from a portion of gut being protruded, and which cannot by any other means be removed; in such an event, after carefully laying the prolapsed parts freely bare, if they cannot then be re- duced but by dilating the passage, and as death must be the certain consequence if that should not be effected; it ought at all events to be attempted: But as here it is almost impossible to enlarge the opening by means of any sharp instrument, without dividing some of the blood vessels which pass out at the foramen; and as such an occurrence, from these vessels being of a consid- erable size, would of itself, in all probability, end in the patient's death, the depth and situation of the parts rendering the application of a ligature impracticable; it is more advisable, by means of such a flat hook as is represented in Plate IX, fig. 2, to dilate the pas- sage to a sufficient size by gentle gradual stretching. By insinuating the end of the hook between the intes- tine and ligament, and pulling it gradually from with- out inwards, a degree of dilatation may be obtained sufficient for the reduction of the gut, without incur- ring that hazard which the division of the ligament with the knife or any sharp instrument must always occasion. SECTION VIII. Of the HERNIA CYSTICA, or HERNIA of the URINA- RY BLADDER. IN this species of rupture, the urinary bladder is the organ protruded; and the situations in which it occurs, either in the groin and scrotum, through the opening in the external oblique muscle of the abdo- men; in the fore part of the thigh, under Poupatt's ligament; or in the perinæum, through some of the muscular interstices of that part.* Instances have oc- curred, * An instance of this is recorded in Vol. IV. of Memoires de l'Academie Royale de Chirurgie, by Mons. Pipelet le Jeune, p. 181. Sect. VIII. Of Herniæ. 209 curred, too, of the bladder being pushed into the vag- ina, so as to form hernial tumors of no inconsiderable degrees of magnitude. As only a part of the bladder is covered with the peritonæum; and as the bladder, in order to get in- to the opening in the external oblique muscle, or un- der the ligament of Fallopius, must insinuate itself between that membrane and the abdominal muscles; it is evident; that the hernia cystica cannot be covered with a sac, as intestinal ruptures usually are. In the perinæum, again, that portion of the bladder most liable to fall into it, is in no way connected with the peritonæum. On some occasions, this species of rup- ture occurs by itself, without any complication; and on others it is found to be accompanied with intes- tines and omentum, both in inguinal and femoral herniæ: When complicated with a bubonocele, that portion of the bladder which is protruded lies between the hernial sac and spermatic cord; that is, the intes- tinal hernia lies anterior to it. The usual symptoms of this species of hernia are, A tumor, attended with fluctuation, either in the groin, in the fore part of the thigh, or perinæum, which gen- erally subsides when the patient voids urine. When the swelling is large, before water can be made with freedom, it is commonly necessary to have recourse to pressure, at the same time that the tumor, when in the groin or thigh, is as much elevated as possible; but when the swelling is small, and especially when no stricture is as yet produced, the patient generally makes water with great ease, and without any assist- ance from external pressure. When a hernia of the bladder occurs without any complication, it is commonly found to proceed from a suppression of urine. In the treatment, therefore, every cause of suppression ought as far as possible to be guarded against; and when no adhesions take place, and if the protruded portion of bladder can be Dd reduced 210 Of Herniæ. Chap. V. reduced, a truss properly fitted to the part, should be wore for a considerable length of time: And, again, when the parts cannot be reduced as long as no symp- toms occur to render the operation necessary, a sus- pensory bag, so fitted as effectually to support the pro- lapsed parts, while at the same time it does not pro- duce severe pressure; is the only probable means of relief. When, again, a portion of bladder happens to protrude into the vagina, after reducing the parts, which is done by laying the patient on her back with her loins somewhat elevated, and pressing with the fingers from the vagina, descents in suture may in general be effectually prevented by the use of the pessary represented in Plate IX, fig. I. And the same means, we may remark, are employed with suc- cess in preventing a falling down of part of the intes- tinal canal into the vagina; a species of rupture which now and then occurs. It may happen, however, that the prolapsed parts, by being attacked with inflammation and pain in con- sequence of stricture, may render the division of the parts producing these symptoms as necessary in this as in any other case of hernia; in which event, the directions given in the preceding sections for the treat- ment of intestinal herniæ, will be equally applicable here.-—Only it must be remembered, that as in the her- nia cystica without any complication, the protruded parts are not covered with a sac; so a still greater de- gree of caution is necessary in laying them bare, than in the ordinary kinds of rupture. It sometimes happens; that stones are produced in that portion of the bladder which remains protrud- ed; in which event, if it should ever become neces- sary to cut into them, if the bladder can be easily re- tained in its prolapsed state till the wound is healed, it ought always to be attempted, in order to prevent that extravasation of urine internally which would otherwise occur, and which in all probability would do mischief. Plate IX.  Sect. VIII. Of Herniæ. 211 mischief. The same precaution, too, becomes neces- sary, if, either by accident in the operation for the hernial cystica, the bladder should be cut into; or if any part of it has been found mortified, so as to ren- der it improper to return it into its usual situation*. CHAP. * The best accounts to be obtained of the various species of her- nia may be had in the works of Le Dran, Heister, and of Mauchart in a treatise De Hernia Incarcerata; in the different volumes of Memoires de l'Académie Royale de Chirurgie of Paris, in the Medical Essays of Edinburgh; in the works of the late Dr. Monro; in Haller De Hernia Congenita, in his Opuscula Pathologica; In Mr. John Hunter's very accurate account of the state of the Testis in the Fœtus in Dr. Hunter's Medical Commentaries; and in Mr. Pott's valuable Treatise on ruptures. These are the best modern authors on this subject; and very little satisfaction is to be got from any of the ancient writers upon it. 212 Of the Hydrocele. Chap. VI. CHAP. VI. OF THE HYDROCELE. SECTION I. GENERAL REMARKS on the HYDROCELE. EVERY tumor formed by a col- lection of water, might, from the import of the word, be with propriety denominated a Hydrocele; but the chirurgical acceptation of the term, implies a watery swelling situated in the scrotum or spermatic cord. Swellings of this kind, as well as every other species of tumor in the scrotum or groin not immediately produced by the protrusion of parts from the abdo- men, are by ancient writers termed False or Spurious Herniæ, in opposition to those described in the last Chapter, which they distinguished by the appellation of True Herniæ. No real utility, however, is derived from this dis- tinction; and as it arose from a very erroneous no- tion which prevailed of the origin of these disorders, we should not have thought it necessary to mention it here, but with a view to render intelligible the ideas of ancient writers upon this subject. Indeed, the opinions concerning these diseases, as handed down to us by all the older writers, by which I mean those of the last and former centuries, are in general so confused and perplexed, that few of them are worth much attention: For, as they were very ignorant Sect. I. Of the Hydrocele. 213 ignorant of the anatomy of the parts concerned, the ideas they formed of the situation of the diseases to which they are liable, were so erroneous, that the practice built upon them came to be very pernicious. So little were they acquainted with the structure of these parts, that they proceeded with much unnecessa- ry dread in the treatment of their disorders; for, by supposing an immediate connection to subsist between the coats of the testicle, the cavity of the abdomen, liver, kidneys, and other viscera, they were induced to consider the collections of water that occur in the hy- drocele, as depositions from these parts, and as tend- ing to free them, and perhaps the system at large, from some important disorders. Different passages in Hildanus, Lanfranc, Fabricius, ab Acquapendente, and even in Dionis's works, show this to have been the idea of practitioners in the times of these authors. In consequence of this, their practice became timid and undecided; so that every chirurgical operation, in which those parts were concerned, became a mat- ter of great importance to resolve upon, and very te- dious, painful, and uncertain in the execution. From the time of Celsus to the middle of the last century, very little progress seems to have been made in reducing the knowledge of these diseases to greater certainty. Indeed, from Celsus downwards, authors seem to have copied almost exactly from one another, till Wiseman, Le Dran, Garengeot, and Heister, grad- ually elucidated the subject: But they were never clearly and accurately described, till the discoveries of Monro, Haller, Hunter, and Pott, rendered the anat- omy of the parts concerned plain and intelligible. So much attention, however, is still given to the con- fused accounts of these parts handed down by ancient writers, that the real nature of the disorders of the tes- ticle and its appendages is less understood than it oth- erwise would be. There is no part, indeed, of chi- rurgical pathology, of which students in general are so ignorant 214 Of the Hydrocele. Chap. VI. ignorant as of this; and hence their notions of these diseases, and of the anatomy of the parts in which they are seated, are commonly very indistinct.-—Noth- ing but a strict attention to the discoveries of late an- atomists can convey clear and distinct ideas concern- ing them; and whoever will make himself thorough- ly acquainted with these, will find, that the hydrocele, send other disorders to which these parts are liable, are explained with as much clearness and simplicity as any other disease incident to the human body. We have already, in the beginning of the preced- ing Chapter on Herniæ, given a description of these parts, so far as related to that class of diseases. To what was then said, we must now beg leave to refer; but before proceeding to treat farther of the disorders now under consideration, we shall first enumerate such particulars relating to the structure of the parts con- cerned as were not formerly necessary to be men- tioned. In the anatomical description already given of these parts, we made it appear, that on the testes with their blood vessels descending to the groin and scrotum, as they were while in the abdomen surrounded by the peritonæum in the same manner with the other vis- cera, and as in their descent they bring a process of the peritonæum along with them, so when in the scro- tum, that they still remain in the cavity of that mem- brane. At the time of their falling down, and for a short while thereafter, a direct communication subsists along this process of the peritonæum between the testes and viscera in the abdomen; but soon after this, ex- cept, as we formerly observed, in the case of a con- genital hernia, the superior part of the passage begins to contract, and in a short time is entirely obliterated, from the opening in the external oblique muscle down along the spermatic cord, to the upper part of the ep- ididymis; the under part of the process continuing loose Sect. I. Of the Hydrocele. 215 loose and open. In this manner the inferior extrem- ity of the process is converted into a kind of bag, the tunica vaginalis testes. From the description formerly given of these parts it appears, that the testis while in the abdomen is at its back part firmly connected to the peritonæum, at which part the blood vessels, nerves, and vas deferens, communicate with it; so when in the scrotum, as the vaginal coat with which it is there surrounded is evi- dently a process or continuation of the peritonæum, it must of necessity be still connected with that mem- brane in the same manner as while it remained in the abdomen. And accordingly we find, that although the testicle lies loose in this sac or vaginal coat in every other part, yet all along its posterior part it is firmly attached to it. At this part the different vessels of the testis still enter; and at this part the peritonæum, or what is now the tunica vaginalis, is reflected over it, thereby forming the tunica albuginea, or immedi- ate covering of the testicle; so that the latter, viz. the tunica albuginea, is demonstrably a mere continuation of the former or vaginal coat. The inferior part of the peritonæal process being somewhat wider below than above, leaves the tunica vaginalis of a pyramidal form; and it is also some- what longer than the testis, reaching from the superi- or part of the epididymis, where it begins, to a little below the inferior point of the testicle where it ter- minates. It is altogether of such a size as to allow the testis to roll easily within it; its principal use ap- pearing to be, to retain a small quantity of a fine ex- halation, which is constantly secreting, either from its own surface, or from the surface of the testis itself, for the purpose of keeping the latter moist and easy. This vaginal coat which we have now described is the only loose covering belonging either to the sper- matic cord or to the testis: For although, by many writers on this subject, a vaginal coat of the cord is also 216 Of the Hydrocele. Chap VI. also described, together with a supposed septum be- tween it and the vaginal coat of the testis; yet no such covering is, on dissection, found to exist. The superi- or part of the peritonæal spermatic process, we have already seen, is entirely closed up very soon after the descent of the testicle; and a firm adhesion being pro- duced between the sides of the sac all along the course of the cord, no vestige whatever can be traced, either of a vaginal coat of the spermatic cord, or of any par- ticular septum between that and the testicle: This it is of some importance to attend to, as the diseases of these parts cannot otherwise be properly understood. As the diseases we are now to treat of are chiefly seated in the coverings of the testis, we have been more particular in rendering their structure clear and obvious, than is necessary in describing the testicle it- self; with respect to which we shall only observe, that it is evidently very vascular, being composed almost entirely of different convolutions of blood vessels. Besides the vaginal coat proper to each testicle, the two testes have for their farther protection a more ex- ternal covering, the scrotum: A bag formed almost entirely of skin and cellular substance; for that body the dartos, which has commonly been supposed to be muscular, is now clearly proved to be altogether cel- lular. Even the septum scroti, or that membrane which divides one testis from another, is composed of cellu- lar substance in a more condensed state. By air it is easily inflated, and it is equally pervious to water: So of course it partakes of all those watery effusions, to which the more external parts of the scrotum are liable. It is very necessary to be acquainted with this struc- ture of the scrotum, as from the descriptions which till of late have been given of it, young practitioners are induced to consider it as muscular, and to suppose the septum with its rapha to be ligamentous; and hence Sect. II. Of the Hydrocele. 217 hence they are led to be more cautious than they need be in performing operations upon it. We have thus entered with as much minuteness into the anatomy of these parts as is necessary for un- derstanding their diseases; and the nature of this un- dertaking not admitting of a more particular discussion, we shall now proceed to consider the different species of the hydrocele; the immediate object of this chapter. All the varieties of the hydrocele which have been mentioned by authors, may, I think, be comprehend- ed under the two following species, viz. the anasarcous, and encysted. In the former, the water is diffused over all the substance of the part in which it is seated; the swelling is not collected in any particular cavity, but occupies equally all the cells of the part: In the lat- ter, viz. the encysted; the water is collected in one distinct bag; and a fluctuation of a fluid is in general perceptible to the touch. . The scrotum, with its contents the testicle and its appendages, are liable to both species of the disorder; and the spermatic cord with its coverings are also liable to both. We shall first treat of the scrotal affections of this kind. SECTION II. Of the ANASARCOUS HYDROCELE of the SCROTUM. THE scrotum from being entirely cellular, and connected immediately with the trunk of the body, is rendered liable to partake of every diffusible swel- ling with which the general constitution is attacked: And accordingly we find, that anasarcous swellings of other parts of the body, seldom subsist for any length of time, without producing a similar affection of the scrotum. A local anasarcous fullness of the scrotum unattended with any general affection has on some occasions Ee 218 Of the Hydrocele. Chap. VI. occasions indeed been produced by a local cause; viz. by the accidental pressure of a tumor on the lym- phatics of the part; by external injury; and by an effusion of urine from a rupture of the urethra: But such occurrences are very rare, a general disease of the constitution being the usual forerunner of such tumors. As soon as water is collected in any considerable quantity in the scrotum, a soft, inelastic, colourless tumor, is observed over the whole of it; pressure of the finger or of any hard body is easily received, and the mark of such pressure is for some time retained by it: The skin at first preserves its natural appear- ance; and the rugæ of the scrotum, which in a state of health are always remarkable, are not for some time much altered; but as the swelling advances they gradually disappear, till at last they are totally obliter- ated: The swelling, from being at first soft and of a doughy feel, by degrees turns more firm; and the colour of the skin from being for some time very lit- tle altered, at last acquires an unnatural white, shining appearance. As the disorder increases, the tumor by degrees becomes larger; and from being originally confined to the usual boundaries of the scrotum, it at last spreads up the groin; and the penis being likewise affected, becomes so swelled and distort- ed, as to be productive of much inconvenience and distress: And although the scrotum is composed of parts which readily admit of extensive dilatation, yet in some instances the swelling here becomes so enor- mous as to burst the surrounding parts entirely. The various appearances we have enumerated are so characteristic of the disease as to render it almost impossible to confound this species of swelling with any other tumor to which the scrotum is liable. We have already observed, that instances now and then occur of the scrotal anasarca being produced by a local cause, but by much the greatest proportion of all Sect. II. Of the Hydrocele. 219 all such cases depend upon a general hydropic tenden- cy; so that the cure of this kind of hydrocele must depend almost entirely on the removal of that habit of body which originally produced it. The treatment of the general disorder of the con- stitution falls to the province of the physician, so we shall not here enter into the consideration of it; but the assistance of Surgery is frequently required for re- lieving that great distress which these tumors always produce when they arrive at any considerable degree of magnitude. In such circumstances, the object of Surgery is, by drawing off the water from the tumor, to diminish the size of it as much as possible; which not only af- fords much immediate relief, but is a means of the distended parts recovering their tone more readily than they otherwise would do. Different methods have been proposed for evacuat- ing the water, viz. by the introduction of a seton, by the trocar, by incisions, and by punctures. All these methods, that by the trocar excepted, serve very effectually to evacuate the diffused water; and therefore we are to adopt that mode which not only creates least pain, but which is least liable to be productive of troublesome consequences; and this unquestionably is the method by punctures. The seton and long scarifications may evacuate the water somewhat more quickly than punctures; but in dropsical constitutions, such as this species of hy- drocele is commonly connected with, they almost constantly go wrong. For the first twenty four hours or so, scarifications give the patient much satisfaction; the water is al- most entirely evacuated, the tumor is of course great- ly diminished, and much relief is thereby obtained. About this time, however the scarified parts com- monly begin to fret, their edges turn hard and in- flamed, 22O Of the Hydrocele. Chap. VI. flamed, and by degrees an erysipelatous kind of red- ness spreads over the neighbouring parts. That fretful uneasiness which was at first complain- ed of, by degrees turns into what the patient terms a burning kind of pain, which frequently becomes so tormenting as to destroy rest entirely; and it but too commonly happens, that all the applications employ- ed for relief, have no manner of influence in prevent- ing the accession of gangrene, by which the patient is at last in general carried off. I will not say that such symptoms are always in- duced by scarifications, but I have in many instances observed them; and on the contrary, although punc- tures do now and then terminate in the same manner, yet they are by no means so ready to do so.* As scarifications are so apt to produce mischief here, there is much reason to suspect that either the trocar or seton, which both give still more irritation, would commonly prove more hurtful. They are now accordingly in this species of the hydrocele very generally laid aside. When scarifications are to be employed, the meth- od of doing it is, with the shoulder of a lancet to make two or three incisions on the most depend- ing part of the scrotum, each of an inch in length, and extending no deeper than the cutis vera: And when punctures are to be depended on, they are like- wise to be made of this depth with the point of a spear pointed lancet; and five or six on the most prominent part of the tumor will commonly prove sufficient. This number will in general evacuate the water very quickly; but when they do not prove ful- ly adequate to the effect proposed, or when in the course of a day or two, these now made are found to heal, they may be renewed from time to time as often as is necessary. Preserving * Vide Le Dran's operations, with Cheselden's notes, p. 116; and Treatise on Hydrocele by Mr. Pott, p. 40. Sect. II. Of the Hydrocele. 221 Preserving the parts as dry as possible, by a fre- quent renewal of dry soft linen cloths, in order to im- bibe the moisture, is here a very necessary piece of attention; the want of it, I am convinced, is the cause of much of the mischief that frequently ensues from operations of this kind. When either scarifications or punctures go wrong, by beginning to inflame and turn painful in the man- ner we have described; instead of the warm emollient poultices and fomentations usually employed, a cold solution of saccharum saturni, applied upon soft linen, not only proves more effectual in putting a stop to the farther progress of the inflammation, but affords more immediate relief to the present distress. Aqua calcis employed in the same manner proves also a very useful application. When, however, the disorder proceeds to gain ground, by a real mortification coming on, we should immediately have recourse to bark and other reme- dies usually employed in such affections. But as we have elsewhere treated fully upon this subject, it is unnecessary to enter into a more particular considera- tion of it here.* It may only be proper to observe, that although in general, when the scrotum in this disease happens to mortify, the greatest danger is to be dreaded; yet now and then very unexpected cures are obtained, af- ter all the teguments have been destroyed by morti- fication. A remarkable case of this kind occurred some years ago in the Royal Infirmary here: The whole scrotum separated, and left the testicles quite bare. During the time that the sore remained open, all the water collected in other parts of the body was evacuated, and by the use of large quantities of bark and mild dressings to the sore, the patient got well. In the course of the cure, the testis became enveloped with a kind of cellular substance, which served as a very * Vide Treatise on Ulcers, &c. Section IV. On Mortification. 222 Of the Hydrocele. Chap. VI. very good means of protection. It must have been some production of this kind, I suppose which Hil- danus speaks of as a regenerated scrotum.* We have already observed, that although this spe- cies of hydrocele for the most part depends upon a general dropsical tendency, that some instances, how- ever, occur, of a local cause producing a mere local dropsy of the scrotum. Thus it has been known to happen, from swellings in the groin and in the abdo- men obstructing the passage of the refluent lymphat- ics. When this is the case, if the tumors producing such obstructions can be extirpated, no other means will afford such effectual relief; but when they are so deeply seated as to render any attempt for removing them improper, the practice we have already pointed out, of punctures in the most depending part of the tumor, must be employed with a view to palliate such symptoms as occur. It sometimes happens in cases of suppression of u- rine, either from caruncles in the urethra, from stones impacted in it, or from collections of matter, that the urethra bursts, and the urine in this manner finding a passage into the scrotum, an anasarcous swelling of it is thus suddenly produced, which still continues to increase till the cause giving rise to it is removed.† In order to prevent the formation of sinuses, which in such circumstances will otherwise be apt to occur, an incision should be made into the most depending part of the scrotum, and carried to such a depth as is sufficient for reaching the wound in the urethra. In this manner a free vent will not only be given to the urine already diffused, but the farther collection of it may very probably be prevented. If a stone impact- ed in the urethra is found to be the cause of this ef- fusion, it ought to be cut out; if a collection of mat- ter is discovered, the abscess should be opened; and if * Observat. Chirurg. cent 5. obs. 76. † The works of the late Dr. Alex. Monro, p. 569. Sect. II. Of the Hydrocele. 223 if the obstruction is produced by caruncles in the u- rethra, bougies should be employed for their removal. The cause being thus removed, if the patient's hab- it of body is good and untainted with any venereal or other general affection, by dressing the sore properly with soft easy applications, the opening into the urethra will probably be brought to heal, and a complete cure will be in this manner obtained. But when such ail- ments are complicated with any general disorder of the system, particularly with old venereal complaints, it frequently happens, that neither mercury nor any other medicine has much influence in removing them. Every practitioner must have met with instances of this kind. Both in the hospital and in private I have met with such cases, where, notwithstanding all the means employed for relief, the passage from the ure- thra remained open, and continued to discharge con- siderable quantities of urine. Instances of the scrotal anasarca of a local nature, have also occurred, from the rupture of a hydrocele of the tunica vaginallis testis: When this species of hy- drocele arrives at a great size, jumping from a height, or a violent blow or bruise of any kind, will readily burst it; and the water not finding a passage outward- ly, must necessarily diffuse itself over the whole scro- tum. Different instances of this kind have been met with; two of which are related by Douglass.* And the same kind of swelling has been produced by the water of a hydrocele of the vaginal coat being improp- erly drawn off by the operation of tapping. When the orifice in the skin is allowed to recede from the opening into the vaginal coat before the water is all discharged, the remainder of the collection is very apt to diffuse itself through all the cellular substance of the scrotum. In whichever of these ways the swelling is produc- ed, the cure ought to consist in laying the tumor suffi- ciently * Treatise on the Hydrocele, by John Douglass, p. 8. 224 Of the Hydrocele. Chap. VI. ciently open, not only for evacuating the diffused wa- ter, but for effecting a radical cure of the hydrocele of the tunica vaginalis. We have thus enumerated all the varieties of anasar- cous swellings to which the scrotum is liable, together with the modes of treatment adapted to each: For with respect to the hydrocele of the dartos, a disease particularly described by ancient writers, as that part of the scrotum is now known to be altogether cellular, so any water collected in it must tend to form that very disease we have now been describing, an anasar- cous swelling of the whole scrotum. We now proceed to the consideration of that species of the disorder, which, from its being seated within the cavity of the scrotum, we have termed the encysted hydrocele of the scrotum. Of this there are two varie- ties, viz. the hydrocele of the tunica vaginalis testis; and that species of tumor formed by water collected in the sac of a hernia. SECTION III. Of the HYDROCELE of the TUNICA VAGINALIS TESTIS. WHEN treating of the anatomy of these parts, we remarked, that in a state of health an aqueous secre- tion is always found in the tunica vaginalis; the prin- cipal use of which seems to be, to lubricate and keep the surface of the testicle soft and easy. In a healthy state, this fluid is absorbed by the lym- phatics of the part; its place being as constantly sup- plied by a fresh secretion: But in disease, it frequent- ly happens, either that the secretion of this fluid is morbidly increased, or that the powers of the absorb- ing vessels of the part are diminished. The effect of either of these causes must be, to induce a preternat- ural collection of water in the cavity of the vaginal coat; Sect. III. Of the Hydrocele. 225 coat; and by a gradual accumulation of this fluid, the species of hydrocele which we are now consider- ing will be at last produced. The symptoms and ap- pearances of the disorder are as follow. A fullness is at first observed about the inferior part of one of the testicles, which is at this time soft and compressible; but as the tumor increases in size, it also becomes more tense: No degree of pressure can make the swelling disappear either at this or any oth- er period of the disease: The teguments at first pre- serve their natural appearance, both as to colour and rugosity; but as the water accumulates, the skin grad- ually becomes more tense, although seldom or never to such a degree as to obliterate the rugæ of the scro- tum entirely. The shape of the tumor, which was at first nearly globular, becomes gradually more pyramidal, being larger below than above: In the first stages of the disorder, the swelling does not extend farther than the usual boundaries of the scrotum; but in process of time, it advances by degrees up to the abdominal muscles; so that although in the early period of the disease, if it be not combined with hernia, or with a hydrocele of the cord itself, the spermatic proc- ess may be always distinctly felt; in its more ad- vanced state it cannot possibly be distinguished.-— The weight of the tumor being now very great, the skin of the neighbouring parts is dragged so much along with it as to cause the penis to shrink consider- ably, and sometimes to disappear almost entirely: And in this advanced state of the disease, the testicle, which usually lies at the back part of the tumor, and which for some time after the commencement of the disorder could be distinctly felt, cannot now be evi- dently discovered. On a minute examination, how- ever, a hardness is always to be felt along that part of the scrotum where the testis is situated: And a fluc- tuation Ff 226 Of the Hydrocele. Chap. VI. tuation of a fluid may in general be distinguished through the whole course of the disease. It sometimes happens, however, in that very tense state of the tumor, which a long continuance of the disease usually occasions, that the fluid contained in it cannot be evidently distinguished: Nor in this situa- tion is the ordinary characteristic mask of hydrocele more to be depended on; I mean, the transparency of the tumor when exposed to the light of a candle or of the sun. In the early stages of the disease, when the contents of the tumor have not become discolour- ed, and when the vaginal coat has not yet acquired much thickness, the contained fluid, on being exposed to this trial, always appears transparent; and when it does so, it always affords a corroborating proof of the existence of water: Yet its absence is by no means a proof of the contrary; for as the transparency of the tumor depends entirely on the nature of its contents, and on the thickness of its coverings, whatever tends to render the one less clear, and the other of a more firm texture, must in proportion to this effect invali- date the certainty of the test. During the whole course of the disorder the patient does not complain of pain in the tumor itself; but some uneasiness is commonly produced in the back, by the weight of the swelling on the spermatic cord: This, however, is generally either prevented altogeth- er, or is at least much alleviated, by the use of a prop- er suspensory bandage. These are the usual appearances of a hydrocele when the disease is confined to one side of the scro- tum, which is generally the case. But on some oc- casions a double hydrocele is met with, in which both testicles are affected in the same manner; and in which the tumor, instead of being confined to one side of the scrotum, occupies the whole of it equally. As there are some disorders with which this species of hydrocele is apt to be confounded, it is particularly necessary Sect. III. Of the Hydrocele. 227 necessary to attend to such circumstances as most readily characterise it. These disorders are, All the variety of scrotal herniæ; the anasarcous hydrocele of the scrotum; the encysted hydrocele of the sper- matic cord; the sarcocele, or scirrhous testicle; and the hernia humoralis, or inflamed testis. When treating of herniæ, we enumerated such circumstances as, when properly considered, will al- most always serve to distinguish this species of hydro- cele from every variety of these disorders: To what was then said, we must here therefore refer.* It has on some occasions, we are told, been con- founded with the anasarcous tumor of the scrotum; but the means of distinguishing the two diseases are so evidently pointed out in the histories we have given of their appearances, as to render it quite un- necessary to enter farther into their consideration. In- deed it must be gross inattention only, which can ever render the anasarcous species of hydrocele liable to any degree of doubt. From the encysted hydrocele of the spermatic cord, it may commonly be easily distinguished, by the tes- ticle in the latter being plainly felt at the under part of the tumor; whereas in this disease, when the testis is perceptible, it is always at the back part of it: And in this species of hydrocele, the swelling begins in the under part of the scrotum, and proceeds upwards: Whereas in the encysted hydrocele of the cord, it makes its first appearance above the epididymis, and by degrees falls down to the inferior parts of the scro- tum. By this difference alone these two species of hydrocele may be always distinguished from one an- other. The circumstances which most clearly distinguish this kind of tumor from a scirrhous testicle are these: In the latter the swelling is hard and firm; it does not yield in any degree to pressure; the surface of the * See p. 313, 228 Of the Hydrocele. Chap. VI. the tumor is rough and unequal; it is in general at- tended with a good deal of pain, and is always heavy in proportion to its size. Whereas in the hydrocele, the swelling commonly yields to pressure; its surface is smooth; little or no pain takes place; and the tumor is light in proportion to its bulk. These differences will always serve as a sufficient means of distinction between this species of hydrocele and a pure unmixed sarcocele. But when a scirrhous testicle is combined with an effusion of water into the tunica vaginalis, forming what has very properly been termed a hydro sarcocele, the means of distinction are not so obvious. In the incipient state of such effu- sions, the difference between the two diseases is suffi- ciently apparent; but in the latter stages of it, the most attentive observer commonly finds it difficult, and sometimes impossible, to mark the distinction. In such doubtful cases, however, by proceeding in the cautious manner to be afterwards pointed out, no det- riment will occur to the patient from any uncertainty of this nature. From the hernia humoralis this species of hydro- cele is easily distinguished. In the former, the tumor succeeds either immediately to some external bruise; or it is evidently the consequence of a gonorrhœa, or of some other inflammatory affection of the urethra.* The skin is more or less affected with an imflamma- tory redness; it is attended with a considerable degree of pain, especially on handling, and the swelling is hard and firm; so of course no fluctuation can be distin- guished in it, unless in its more advanced state, when suppuration sometimes takes place, and when the usual symptoms of abscess, particularly the pointing of the * The operation of lithotomy is frequently attended with an in- flammation of one, and sometimes of both, of the testicles; proba- bly from the inflammation induced by the operation in the neigh- bourhood of the caput gallinaginis, being communicated along the vas differents to the testes. Sect. III. Of the Hydrocele. 229 the tumor, and its being much discoloured, serve to distinguish it sufficiently. In forming a prognosis of this disease, we must be directed almost entirely by the habit of body of the patient. In general, we are to consider it as a local affection; and in that state the most favourable ex- pectations may be formed of the event; for, whatever may have been alleged by some writers as to the haz- ard of every operation for a radical cure of the disor- der, in a simple unmixed hydrocele, and in a sound healthy constitution, it may at any time be advised with a very fair prospect of success. In the radical cure of the hydrocele, in whatever way it is attempted, some pain will be occasioned; the parts will inflame, and of course some degree of fever must be expected. In some instances, these symptoms have gone rather farther than was just nec- essary; but under the limitations I have already men- tioned, of an unmixed state of the disorder in a con- stitution otherwise healthy, whenever the operation has been properly performed, I can safely aver, that of a very considerable number I have operated upon my- self, as well as of many I have been connected with, I never knew one instance of any thing bad occurring. But on the contrary, in constitutions otherwise dis- eased; in old people; and in infirm habits of body; we are by no means to expect such certain success: Even in such circumstances, the operation very fre- quently succeeds; but it must be acknowledged that it now and then fails. The symptomatic fever is apt to run too high for the strength of the patient; and the suppuration produced by a high degree of inflam- mation tends afterwards to destroy entirely the remains of a constitution already much impaired. This, how- ever, ought not to be laid to the account of the opera- tion, but to the real diseased state of the patient. When, therefore, this disorder occurs in a healthy constitution, I would conclude, from all the experience I have 230 Of the Hydrocele. Chap. VI. I have had in it, that little or no danger is to be dreaded from any necessary operation: And on the contrary, in a diseased state of body, that some risk is always incurred by every operation that takes place; and the degree of risk we may suppose will be always in proportion to the nature and extent of that disease with which the constitution is affected. As long as a swelling of this nature keeps within moderate limits, patients in general rather submit to the inconvenience produced by it, than undergo the pain of an operation; at least this is commonly the case among people of better rank, who can more readily put up with any distress which it occasions, than the poorer set of patients, whole daily labour is frequently impeded by large tumors in the scrotum. Among those of the former class, instances occur of the disorder having existed for a great length of time without being productive of much inconvenience: But even among these is commonly happens that they become anxious; fatigued with uncertainty; and are at last induced to submit to the operation.-—In all such instances, when the constitution is otherwise sound, this may be undertaken, as we have already re- marked, with an almost certain prospect of success; but when the system is materially diseased, a patient had better submit to any inconvenience produced by the disorder, than undergo an operation for a radical cure: And this may be the more easily agreed to from the relief which people with tumors of this kind always experience from tapping, which is termed the Palliative Cure; and which when it is properly done, if the constitution is not greatly impaired indeed, may be always submitted to without any dread of its prov- ing hazardous. Various methods are proposed by authors for the treatment of this disorder. All of them, however, may be reduced to two general heads; viz. such as have in view only a temporary relief, and which, as we Sect. III. Of the Hydrocele. 231 we have just now observed, is termed the Palliative Cure; and such as are intended for effecting a Radi- cal Cure, or a final removal of the disorder. Whatever advantages may be experienced, from the use of internal medicines, in dropsical affections of the constitution, no practitioner, I believe, has so much confidence in remedies of this kind, as to ex- pect much benefit from them in any partial hydropic collections of the encysted kind: We have daily proofs of their general failure in almost every affection of this nature; and in no species of dropsy do they prove more ineffectual than in the hydrocele.-—We are told, in- deed, of cures having been performed by different medicines, particularly by the use of strong drastic purgatives: I have known them employed, but never with advantage; and when pushed to any extent, they are sure to hurt the constitution.-—As it is always nec- essary, however, to confine the patient to bed for some time after any operation that takes place, in order to prevent his being afterwards disturbed, it is proper to empty his bowels by a laxative immediately before the operation; but this is almost the only medicine that can be requisite. Internal medicines, therefore, being found ineffectual, as well as external applica- tions, we are to seek for that relief from Surgery which experience shows it is capable of affording. When the tumor in the scrotum has acquired such a size as to become inconvenient, if the patient either refuses to submit to the operation for the radical cure, or if his state of health renders that operation improp- er, in such circumstances, the palliative treatment, or a mere evacuation of the water by puncture, is the only means we can employ. There are two methods proposed for drawing off the water in this manner, viz. by the puncture of a lancet, or with a trocar-—It is alleged by some, that by the mere puncture of a lancet the water can nei- ther be so completely or so properly drawn off as when the 232 Of the Hydrocele. Chap. VI. the trocar is employed; for the orifice in the skin be- ing apt to recede from the opening in the vaginal coat, the water is thereby either stopt altogether, or is apt to insinuate itself into the surrounding parts. By others again it is said, that the difficulty of intro- ducing the trocar is such as to render it hazardous from the contiguity of the testicle; and instances are not wanting to show, that even in the hands of expert surgeons the testis has been very materially injured by a trocar reaching it in this operation. Indeed, the ordinary form of this instrument, which is triangular, renders its introduction both difficult and unsafe; but the trocar of a flat form which I proposed some years ago, enters with as much ease as a lancet.-—In Plate X, different instruments of this kind are represented, of a proper size for this operation.-—And as with a trocar of this kind an opening may be made into the tunica vaginalis with perfect safety, and the water with this instrument being much more freely evacuated than by a mere puncture with a lancet, which is apt to produce an effusion into the cellular substance of the scrotum, the mode of effecting it by the lancet ought therefore to be laid aside. The instrument being fixed upon, the next point of importance is the part of the tumor most proper for the operation. Even in this simple operation, an ac- quaintance with the anatomy of the parts will appear to be very necessary. We have already shown, that the testis does not hang altogether loose in the vagi- nal coat; but on the contrary, that its posterior part is firmly connected to the body of the testicle; so of consequence at this part there is no water to be met with between the scrotum and testis; and according- ly it would be highly improper to attempt an opening at this place: For if through ignorance the trocar should be inserted here, one instance of which I have seen, the instrument would for certain pierce the body of Plate X.  Sect. III. Of the Hydrocele. 233 of the testicle, and would not, after all, evacuate the water. The most proper part for introducing the instru- ment is the most anterior point of the under part of the tumor. The patient being seated on a chair, with the tumor hanging over the edge of it, the ope- rator with his left hand should grasp the tumor on its back part, so as to push the contained fluid as much as possible into the anterior and under part of the swelling. Having done so, he then makes an open- ing through the skin and cellular substance, of about half an inch in length, with the shoulder of a com- mon lancet, on that point where the trocar is to en- ter. This gives very little pain to the patient; it is done in the space of a second or two, and it ensures an easy passage to the point of the instrument; a cir- cumstance which divests this operation of all kind of hazard. The operator now takes the trocar in his right hand, and having fixed the head of the instrument in the palm of the hand, he places the fore finger along the course of it, leaving just as much of the point of the instrument uncovered as he thinks ought to penetrate the tunica vaginalis, and this being introduced in a gradual easy manner, the stilette is to be withdrawn immediately on the end of the canula having entered the cyst. The water will now run off; and if the tumor be not of a great size, it may be all evacuated at once: But when the swelling is large, as the sud- den discharge of the fluid, by taking away too quick- ly the support which it afforded to the vessels of the testes and vaginal coat, might endanger the rupture of some of them, it is better every now and then to stop the flow of it for a few seconds; and when the whole is thus evacuated, and the canula withdrawn, a piece of adhesive plaster should be immediately applied to the orifice, and a compress of soft linen being laid over Gg 234 Of the Hydrocele. Chap. VI. over the scrotum, the whole should be firmly sup- ported by a proper application of the T bandage.* The patient being in this state laid in bed, it com- monly happens, that in a few hours all manner of uneasiness is gone, and he goes about his ordinary business without farther interruption: Now and then, however, the sore produced by the trocar festers; and the inflammation thus produced, in some in- stances, has been known to terminate in a radical cure of the disorder. Such occurrences, however, are rare, and are by no means to be depended on. This operation, when done with attention, is easily performed, and is seldom productive of any mischief; but when not performed with caution, and especially when the patient is allowed to go about immediately after the water is evacuated, it sometimes terminates in very troublesome symptoms. Even when done with every possible attention, if the patient's habit of body is bad, it sometimes goes wrong. Of this eve- ry practitioner may have seen some instances more or less remarkable: And two cases are related by Mr. Pott; one of which terminated fatally; and in the other a mortification ensued, which in the space of a few days destroyed not only a good deal of the scrotum, but even a considerable portion of the tunica vag- inalis.† Both of these indeed occurred in very un- healthy constitutions; but it is proper to have it known, that this operation may in such habits of body be productive of these consequences. In sound healthy people, it seldom or never ends in any thing bad; but the event of these cases of Mr. Pott and others, ought to convince us that it should not be attempted where the system is evidently much diseased. Drawing the water off in this manner in order to relieve the patient from the bulk it produced, was the first * Some very judicious remarks on the importance of a due degree of compression in such cases may be met with in Dr. Monro's ob- servations on this subject, loco citato. † Cases xxi and xxii, Treatise on the Hydrocele. Sect. III. Of the Hydrocele. 235 first idea that occurred to practitioners in the treat- ment of the Hydrocele; but this being found inef- fectual for the complete removal of the disease, various other methods were afterwards introduced. The actual cautery and the ligature were both proposed as means of preventing farther descents of water from the abdomen, which in former times was considered as the origin of this disorder. Celsus orders a cyst of a hydrocele to be cut away, and many of his follow- ers do the same. Tents, both solid and hollow, were afterwards employed; as was likewise the use of the seton, which we find recommended by Fabricius ab Acquapendente, and other writers even of a more early period. The use of various applications of the caus- tic kind has at different times been in vogue: Inject- ing wine, diluted ardent spirits, and other irritating liquids, into an opening in the vaginal coat, has been proposed as a means of inducing a degree of inflamma- tion sufficient for effecting a radical cure; and a sim- ple incision of the cyst containing the water has been practised for the same purpose. These, I think, comprehend all the variety of means which at different periods, have been employed for the cure of the hydrocele. Ancient practitioners seem to have been acquainted with all of them; but having very inaccurate ideas of the anatomy of the parts concerned, they could not have any fixed or clear opinion of the manner in which any of their rem- edies operated in effecting a cure. In consequence of this they were applied very much at random; and no method proving at all times successful, the igno- rance they laboured under in the theory of the dis- order rendered changes of remedies very frequent in the treatment of it. One material advantage obtained by the moderns in this point is, that by knowing the water to be con- tained in a particular cyst with which no part of the body communicates, they are thereby left at liberty to 236 Of the Hydrocele. Chap. VI. to apply their remedies without any dread of injuring parts which were formerly supposed to be connected with the testicle; and by finding that the water col- lected in this disease, is in many respects in a similar situation to the contents of other tumors, with the means of curing which they are well acquainted, they have ventured from analogy to transfer the method of treatment found to succeed in these disorders, to this species of the hydrocele. Matter collected in a particular cavity or cyst, we suppose to be in circumstances very similar to water collected in the tunica vaginalis testis. In both situ- ations, the contents of the tumor are secluded from access to the external air; and neither of them have any communication with any other part of the body. And although the bag containing the matter of an en- cysted tumor is in some measure a new formation, yet in many instances it is found to be equally firm and elastic with the tunica vaginalis testis. In the treatment of encysted tumors, practitioners are now agreed, that, besides evacuating the matter, means must be employed for destroying the cavity which contained it, otherwise a return of the disorder may in general be expected. To accomplish this, different methods have been proposed; some with a view to destroy entirely the cyst which contained the matter; and others, as it is said, to fill up the cavity of the cyst with a formation of new parts. But we now know, that unless the coats of a cyst are much extended, and greatly thickened indeed, that there is no reason whatever for removing any part of it. It is also known, that to fill up the cavities of tumors with a creation of new parts, is a mere imag- inary matter, being what neither art or nature ever effects to any extent: And we likewise know, that the cavity of almost every tumor may be more effec- tually destroyed by producing an adhesion of its sides than by any other means. Parts Sect. III. Of the Hydrocele. 237 Parts of the human body in a state of inflammation very readily adhere to one another. Indeed so easily do they do so that some art is required to prevent the adhesion of contiguous inflamed parts. By attempt- ing the cure of abscesses and of encysted tumors, on principles analogous to this, the same phenomena were found to happen; for, after discharging their contents, it has been found, that cures are commonly obtained with more ease and certainty by inducing a sufficient degree of inflammation on their internal surfaces, than by any other means. And in like man- ner it is now known, that the hydrocele of the tunica vaginalis, may be treated upon the same principles, and with the same general effects. This is the most simple idea that can be given, of the present views of practitioners in the treatment of this disorder; and I hope it will serve to render their ideas respecting it sufficiently clear. The intention, then, of every means now in use for the radical cure of this species of the hydrocele, is, to induce such a degree of inflammation on the parts, as may tend to obliterate entirely the cavity of the tuni- ca vaginalis, by making it adhere firmly to the tunica albuginea or surface of the testicle. Some individuals, indeed, still proceed upon the supposition of a total destruction of the sac being nec- essary for a complete cure. But the extensive expe- rience of many of the best employed surgeons makes it appear very clear that this is never necessary. When the sac has become very thick, and has been distend- ed to such a degree as entirely to have lost its tone, removing a small part of it sometimes proves useful, by allowing the scrotum to contract more readily; but in no other point of view is it in any degree requisite. We know well, that in this, as in every species of encysted tumor, a cure may be, and frequent- ly is, obtained, by removing the sac entirely; for, the contiguous parts from whence the sacs have been 238 Of the Hydrocele. Chap. VI. been dissected, adhere very readily together, so as to destroy effectually the cavities in which the matter was contained.* But we also know that this is never necessary, as the same end may be always obtained by much more gentle means. We shall now proceed to the particular considera- tion of the several means at present employed by dif- ferent practitioners for effecting a cure, and shall treat with most minuteness those which are now in most general use. These are, xcision of the tunica vagi- nalis; the application of caustic; the use of a seton; and a simple incision of the sac. By Mr. Douglas it is recommended † to destroy the vaginal coat entirely; and his method of doing it, is, first to dissect out an oval piece of the scrotum, which he considers as always necessary; and having then laid the vaginal coat open, to cut it away by dif- ferent snips of a pair of scissors. But if there is any practitioner who still continues to prefer this excision of the sac, he will find that it may be more easily dis- sected away by the scalpel than with scissors, and it is rarely necessary to remove any portion of the scro- tum. The method of cure with caustic is commonly de- sired to be conducted in the following manner: The scrotum being shaved, a piece of common paste caus- tic properly secured with adhesive plaster is to be ap- plied, of about the breadth of a finger, the whole length of the tumor; and if, on removing the caustic, it has not penetrated the tunica vaginalis, this is or- dered to be done with a scalpel, so as to evacuate the contents, lay bare the testicle, and admit of proper dressings.‡ But * Mr. Else asserts, that in the method he recommends of curing this species of Hydrocele by caustic, the tunica vaginalis sloughs en- tirely off. † Loco citato. ‡ Douglas on the Hydrocele, pag. 3. Pott, loc, cit. pag. 155. Sect. III. Of the Hydrocele. 239 But Mr. Else, one of the latest writers in favour of the method by caustic, says, that there is no necessi- ty for such an extensive application of caustic as has been recommended by authors: That an eschar of the size of a shilling answers the purpose sufficiently; That this may be always fully obtained by the appli- cation of caustic paste of the size of a sixpence; which he directs to be laid upon the anteriour and under point of the scrotum, and to be properly secured by adhesive plaster in order to prevent it from spreading.† The caustic commonly produces all its effects in the space of five or six hours, and may then be re- moved. At this time digestives, or an emollient poultice, must be applied over the scrotum; and the whole properly suspended with a bandage. Inflammation, we are told, is soon induced over the whole tunica vaginalis; and the febrile symptoms which succeed, are directed to be kept moderate by bloodletting, injections, &c. In a few days the eschar of the scrotum separates and comes away; and in a gradual manner, in the course of four, five, or six weeks, the whole tunica vaginalis comes off, when the wound immediately cicatrizes, and a complete cure is obtained. When the seton is to be used, the following is the method of applying it, as is recommended by Mr. Pott, Who has wrote a very ingenious treatise on this subject: He uses a trocar; a silver canula, five inches in length, and of such a diameter as to pass easily through the canula of the trocar; and a probe, six inches and a half long, having at one end a fine steel trocar point, and at the other an eye which carries a cord of coarse white sewing silk, of such a thickness as will pass easily through the long canula. With the trocar, the inferior and anterior point of the tumor is to be pierced; and as soon as the perforator is with- drawn † Vid. An Essay on the cure of the Hydrocele of the tunica vagi- nalis testis, 2d edition, p. 33. 240 Of the Hydrocele. Chap. VI. drawn, and the water discharged, the seton canula is passed through that of the trocar, till it reaches the upper part of the tunica vaginalis, and can be felt in the very superior part of the scrotum. This being done, the probe armed with its seton is to be convey- ed through the latter canula, the vaginal coat and teg- uments to be pierced by its point, and the seton to be drawn through the canula till a sufficient quantity is brought out at the upper orifice, when both the canu- las are to be withdrawn, and the operation is finished. About the end of the third day, the parts begin to inflame; when fomentations, poultices, a suspensory bandage, a temperate regimen, and a lax belly, are or- dered, to keep the symptoms moderate: As soon as the parts become easy by the inflammation lessening, which is generally about the tenth or twelfth day, the seton is begun to be diminished, when six or eight threads are withdrawn at every dressing; the dressings consisting of nothing more than a superficial pledgit upon each orifice, and a discutient cerate, such as the seratum saturninum, to cover the scrotum. In using the seton, I should wish to follow the method here described, in every other point except in the mode of introducing it; an easier method or do- ing it being now discovered. In a former publica- tion, I have described the manner of opening abscesses by a seton; and the directions then given, prove equally applicable here. Let an opening be made, either with a scalpel or a lancet, in the superior part of the tumor, large enough to admit with ease a cord of white sewing silk of a proper size. The curved director with an eye at one end,* in which the cord is inserted, is to be introduced at this opening; and its farther extremity being carried down to the most depending part of the tumor, an opening is there to be made of about half an inch or so in length, by cut- ting * Delineated in the Treatise on the Theory and Management of Ulcers, &c. Sect. III. Of the Hydrocele. 241 ting upon the end of the director with a scalpel. The director being now drawn down till a sufficient quanti- ty of silk is left hanging out below, the operation is then finished. In every other respect the management of the seton ought to be the same with the method we have described from Mr. Pott. By making the first opening in the superior part of the tumor, the instrument conducting the seton is more easily introduced to the farther extremity of the swelling, than when the first opening is made below; for in this case, the tumor remains distended to the last: Whereas, when opened below, the water rushes cut immediately; and the vaginal coat collapses so much about the testicle, that I have seen a good deal of difficulty in getting the instrument insinuated be- tween them, by which I have been sensible of the tes- tis being considerably injured. Before entering farther into the consideration of this method of cure by the seton, we shall proceed to de- scribe the operation for a radical cure by incision. The patient being placed upon a table of a conve- nient height, and being properly secured by two assist- ants, with the scrotum lying nearly upon the edge of the table, the operator with one hand should grasp the tumor so as to hold it firm and make it somewhat tense on its anterior part; and with a common round edged scalpel in the other, he should now divide the ex- ternal teguments by one continued incision from the superior extremity of the tumor all along its anterior surface down to the most depending point of the swelling. By this means, as the divided scrotum retracts a little, the tunica vaginalis is laid perfectly bare, for the breadth of about half an inch from one extremity to the other. An opening is now to be made with a lancet into the vaginal coat, just at its upper extremi- ty where the first incision commenced. This opening should be of such a size as to receive the finger of the Hh operator; 242 Of the Hydrocele. Chap. VI. operator; which being inserted, the probe pointed bistoury is to be conducted upon it, and by means of it the sac is to be divided to the very bottom, all along the course of the first incision. By the previous divi- sion of the skin with the scalpel instead of the bistoury, the operation is done with much more accuracy, and with less pain; for the scalpel from its convexity ad- mits of a much finer edge than an instrument of any other form is capable of receiving, and hence it cuts with more ease. By making the first opening in the upper end of the sac, much trouble and inconvenience is prevented, which making the first orifice below is sure to occa- sion: For, as we have before remarked, when the tu- mor is first opened below, the water is instantly evac- uated; and as this produces an immediate collapse of the tunica vaginalis, the passage through it is not af- terwards easily discovered. Whereas, by making the first opening above, as the water is thereby evacuated gradually as the excision is extended downwards, the vaginal coat continues distended to the bottom till the incision is completely finished. We have not thought it necessary to say any thing here of the probe pointed scissors, an instrument which some time ago was very generally employed in this operation: For wherever the knife can with proprie- ty be used, no surgeon of these times will hesitate in preferring it. We have directed the incision into the vaginal coat to be carried from one extremity of the tumor to the other. Many surgeons, with a view to save some pain to the patient, advise the incision both of the scrotum and tunica vaginalis to be only two thirds of the length of the tumor. But the difference of pain thus produced is very little; being indeed nothing when compared with the uncertainty of a radical cure not being obtained by it. When the incision is car- ried the whole length of the tumor it is rarely found to Sect. III. Of the Hydrocele. 243 to fail; and I have known sundry instances of these partial openings being followed with a return of the disease.* The incision being completed in the manner we have directed, the testicle covered with its tunica al- buginea comes into view. Sometimes the testis pro- trudes from the wound altogether; in which case it should be replaced with great caution, and ought by all means to be covered as quickly as possible from the external air; and provided none of the tunica vaginalis is to be removed, this may be always done immediately by finishing the dressing directly on the sac being opened. When the sac is not much thickened, there is no necessity for removing any part of it; but when it is discovered to be otherwise; to be thick and very hard; the removal of a portion of it on each side of the incision, makes the cure of the remaining sore more easy and expeditious. As in this hardened state, the sac generally separates with great ease from the surrounding teguments, any quantity of it may be easily taken away with the scalpel without the least danger of wounding the scrotum. Some writers in- deed advise part of the scrotum itself to be cut away on every occasion;† but even in the most enlarged case of hydrocele I ever met with, no necessity ever appeared for removing any part of it. On examining the testicle after the division of the vaginal coat, it is generally found to be of a soft tex- ture, and of a more pale complexion than in a healthy state: On some occasions it is considerably enlarged; and on others, I have seen it reduced to a very small size, consisting of the tunica albuginea almost quite empty. As the cure of the sore, however, advances, the testicle in a gradual manner commonly regains its usual bulk; of this I have seen different instances, and a very * Mr. Pott is clearly of this opinion. Loc. cit. p. 163. † Vide Douglas on the Hydrocele, 136. 244 Of the Hydrocele. Chap. VI. a very remarkable case of the same kind is recorded by Douglas.* We have hitherto supposed that the disorder is con- fined to one side of the scrotum; but now and then, as we have elsewhere remarked, a double hydrocele is met with. The ordinary practice in such a case, is, to do the operation twice in all its parts, both in the scrotum and tunica vaginalis; to lay each collection open from top to bottom, by a double incision. Some- times both operations are done at the same time; but in general practitioners are afraid of too much inflam- mation being thus induced, so that one is commonly allowed to heal before the other is attempted. In this manner the patient is exposed to delay, uncertain- ty, and to the hazard of two complete operations. It may be done, however, in a much easier man- ner, with much less pain, and in less time, than in the ordinary method. After finishing the operation on one side, by mak- ing an opening into the vaginal coat of the opposite testicle at its upper extremity through the septum scroti, and continuing the incision down to the bottom of the tumor, the cyst is thus equally well laid open, the wa- ter is as completely evacuated, and the patient is liable to as little hazard of a return of the disorder, as if the operation had been done in the usual manner. From the account we gave of the anatomy of the scrotum, no danger, it is evident, can occur from any division of the septum, which we have shown to be entirely composed of cellular substance; and in fact I have twice had an opportunity of performing this op- eration in the manner here directed upon a double hy- drocele, and in both instances with most complete success. Whether the hydrocele be double or confined to one testicle, as soon as the water is all evacuated, and any part of the vaginal coat removed that may be nec- essary, * Loc, cit. p. 194, Case II. Sect. III. Of the Hydrocele. 245 essary, the wound ought then to be dressed; and on this it may observed, much of the success to be ex- pected from the operation depends. If the vaginal coat be just wrapped about the testi- cle without the interposition of any kind of dressings, partial adhesions are apt to occur, before a degree of inflammation is produced sufficient for rendering the cure complete. By this means cavities are left, which either fill with pus during the progress of the cure, or afterwards afford an opportunity for collections of wa- ter, and thus occasion a return of the disorder; differ- ent instances of which I have met with. And again, a desire for stuffing the cavity of the sore too much with dressings has also been a frequent cause of mischief. By their rubbing or pressing too much upon the surface of the tunica albuginea, a part which nature never intended to be much exposed, such a degree of inflammation is sometimes induced as to be productive of much pain, inflammation, and fever: But it is commonly the fault of the operator when this is the case; for in a sound healthy constitu- tion, it seldom happens that either of the occurrences we have mentioned take place when the dressings are properly managed. The method I have uniformly found to succeed, is this: The testicle, if it has pushed forwards, as it sometimes does, out of the scrotum entirely, being cautiously replaced, a piece of soft lint should be in- serted between it and the divided vaginal coat, first on one side of the divided sac, and then on the other, reaching from the superior part of the tumor to the most depending point of it. One end of each piece of lint ought to be left out of the sore, to fold over the edges of the wound; and the other ought to be gently pushed in between the testis and the vaginal coat, about halfway between the external incision and the bottom of the sac: If less is inserted, it does not with certainty answer the purpose; and I have com- monly 246 Of the Hydrocele. Chap. VI. monly found that a single ply of fine lint may be in- troduced this length without any difficulty, and ex- perience shows it to be sufficient. A compress of soft linen being now applied over the tumor, the whole should be properly suspended with a bandage; and for this purpose, either the T bandage, or the com- mon suspensory bag, may be employed. The patient is now to be carried to bed; an anodyne should be prescribed; and he ought to be enjoined to remain as much in the same posture as possible, for much mo- tion in this state of the sore certainly does mischief. The intention of this operation being to induce a moderate degree of inflammation in the parts chiefly affected, viz. the tunica vaginalis and tunica albugin- ea, if the pain, inflammation, and swelling, which in some degree always succeed to the operation, do not run to a great height, nothing is to be done for the first two or three days after the operation: But, when these symp- toms become violent, and especially when any consid- erable degree of fever is induced, it must then be the business of art to prevent their going too far. The remedies to be used for this purpose, are, bloodletting, according to the strength of the patient; gentle laxa- tives, so as to preserve an easy state of the bowels; a low cooling diet; and warm emollient poultices and fomentations to the part, in order to forward a plenti- ful suppuration, which commonly tends to moderate every bad symptom more effectually than any other remedy. By these means the inflammation may in almost every instance be kept within proper bounds: From all the experience, indeed, which I have had in this disorder, I might say that it may be done in every in- stance; for I never yet saw any thing to the contrary, where the operation was properly performed, in a sound healthy constitution. When, again, the pain, inflammation, and tumefac- tion of the parts, do not come to a great height, the cataplasms. Sect. III. Of the Hydrocele. 247 cataplasms and fomentations need never be employed before the fourth day: About this time, by foment- ing the parts, and applying a large emollient poultice over the whole, the external dressings are commonly easily removed about the fifth or sixth day. At this. time, on taking them away, the edges of the sore are observed to be hard, and considerably swelled; and the matter discharged is thin and discoloured: If the lint inserted between the testis and the vaginal coat can be easily taken out, it may at this time be remov- ed; but in general, it does not come away with free- dom till the third or fourth dressing, when the swell- ing of the parts is somewhat diminished. The sore ought to be dressed once every day or two, according to the quantity of matter produced; and the poultices should be continued till a plentiful suppuration is estab- lished. In twelve or fourteen days from the operation, the suppuration is in general very freely formed; and the swelling of the parts is now so much reduced as to give the whole a fine healing appearance: The only dressing necessary in this state of the sore, is a little soft lint, covered with a pledgit of any emollient oint- ment. The swelling of the scrotum now gradually subsides; and the sore continuing to lessen daily, a complete cure is commonly obtained in the space of four, five, or six weeks, according to the size of the wound and other circumstances. Having thus given an account of the manner of performing every operation at present in use for the radical cure of the hydrocele, we shall now make a few observations on the comparative advantages of the three last, viz. the caustic, seton, and the simple incision; these being almost the only means now practised for the removal of this disorder. From the testimony of many respectable authors concerning the efficacy of each of these, there is no reason to doubt, but that collections of this kind may in general be cured 248 Of the Hydrocele. Chap. VI. cured by any of them. That the caustic, when prop- erly managed, will seldom fail of producing a cure, we have every reason to believe; and the same may be safely asserted both of the seton and the simple in- cision. But, it commonly happens, that a practition- er, from being prejudiced in favour of a particular method, continues to practise that mode and no oth- er; and finding it in general succeed, he by degrees comes to persuade himself, that other methods of cure with which he has not had such opportunities of be- coming acquainted, are liable to objections, which those who have practised them do not find to be the case. I attended the hospitals in London about the time that Mr. Pott's publication on the Seton, and Mr. Else's Treatise on the Cure of the Hydrocele by Caustic, were published; when of course the various means of curing the disorder were frequently the sub- ject of medical conversation. I was thereby induced to pay particular attention to the subject; and having the advantage of seeing the practice of different hospi- tals, and not being particularly biassed in favour of any one method, I was thus furnished with an excel- lent opportunity of forming an opinion: And the re- sult of all the observation I was either at that time a- ble to make, or since that period, both in the hospi- tal here, and in private practice, is, That although all the three modes of operating, by caustic, the seton, and simple incision, are perhaps equally capable of producing a radical cure; yet that of the three, the lat- ter, viz. the simple incision, is liable to fewer objec- tions, and effects a cure both with less trouble to the operator, and with less risk to the patient: And of the other two, the treatment by caustic appears to me to be the most eligible. I have seen all the three methods produce trouble- some symptoms, such as great pain and tension of the abdomen, inflammation, and fever; but from much ob- servation, Sect. III. Of the Hydrocele. 249 servation, I can without hesitation say, that the seton is more frequently productive of these consequences than either of the others: And we need not wonder at this being the case; for the cord which is here introduced, lying in close contact with the body of the testis, must necessarily occasion a considerable and continued irri- tation, as long as it remains applied to it. The seton is likewise attended with other inconve- niences, to which neither of the others, when properly managed, are liable. When the inflammation which succeeds to the introduction of the cord runs very high, as it frequently does, it commonly terminates in such a plentiful suppuration, that the matter pro- duced by it cannot be readily discharged at the open- ing made for the seton: In consequence of this, it in- sinuates itself into the neighbouring parts; and differ- ent abscesses are accordingly formed, which must all be discharged by as many openings. Even when the operation has been done with much nicety and atten- tion, I have seen it terminate in this manner. Another objection to this operation, which I think of importance, is this: It does not admit of a free ex- amination, either of the state of the testicle, or of the fluid contained in the sac. I know, that in a simple uncomplicated hydrocele, there is no reason whatever for examining the testicle; nor would we think of re- moving it either on account of a mere enlargement or diminution of its size; provided it be not otherwise diseased. But we know well that cases do sometimes occur; which elude the utmost skill and penetration of the surgeon; no diagnostic symptoms with which we are yet acquainted being sufficient to direct us with absolute certainty. The most experienced practitioner must be sensi- ble, that at times he has been mistaken in his opinion respecting the nature of such tumors; a real sarcocele, or scirrhous testicle, attended with some effusion of a fluid, being now and then mistaken for a pure unmix- Ii ed 250 Of the Hydrocele. Chap. VI. ed hydrocele; and, vice versa, a simple uncomplicat- ed case of hydrocele has been frequently mistaken for, and treated as, a scirrhous testicle. Such occurrences every practitioner must have met with: And among other writers who confess their having been deceived in such cases, a very candid acknowledgment of this kind is made by Mr. Pott;* and Mr. Else takes no- tice of a similar occurrence in which he was con- cerned.† I have myself been concerned in different cases; where the most experienced surgeons were at a loss to determine the real nature of the disorder; that is, whether the swelling in the scrotum was a simple hy- drocele of the vaginal coat, or an effusion of a fluid into that bag produced by a scirrhous testicle. In all such cases where any doubt occurs, the surgeon ought to proceed as if the tumor was a real hydrocele. If, on laying open the swelling, the testicle should be found diseased, that is, if it should be in such a state as to require extirpation, it ought to be removed imme- diately; and on the contrary, if it should appear to be perfectly found, the case should undoubtedly be treat- ed altogether as a simple hydrocele. In several instances of this kind, where, by differ- ent practitioners, a mere collection of water was ex- pected without any other affection, the testicle has been found to be so much diseased with a real sarco- cele, as to render extirpation highly proper. Now, if in such circumstances a cure had been attempted by the seton, the testicle would have been allowed to re- main exposed to the irritation produced by the cord, which * Treatise on the Hydrocele, p. 288. In this case, which from every circumstance had been considered as a Sarcocele, the testis, after being removed, was found to be perfectly sound; the disease being a real Hydrocele of the tunica vaginalis. There being even a possibility only of such an occurrence with such an attentive observer as Mr. Pott, ought to serve as a most convinc- ing argument with practitioners in general, of the necessity of pro- ceeding with the utmost caution in all such cases where there is the least cause for doubt. † Loc, cit. p. 4. Sect. III. Of the Hydrocele. 251 which in all probability would have induced very troublesome and even alarming symptoms; for we know that every symptom of a scirrhous or cancerous tumor is uniformly rendered work by irritation. It has been alleged, that the real state of the testis may be always known, by drawing the water off from the tunica vaginalis by a trocar; and this has accord- ingly been recommended as a previous step to the in- troduction of the seton, with a view to ascertain the situation of the testicle. But it often happens, even after all the water is drawn off, that the thickness pro- duced by the vaginal coat and scrotum, collapsing in large folds about the testis, precludes effectually every accurate examination of this kind. We observed above too, that when the seton is us- ed, the contents of the vaginal coat cannot be proper- ly ascertained. It frequently happens, that the water of a hydrocele is contained in a number of hydatids; a circumstance which cannot be discovered previous to the opening of the tumor: And as it will be read- ily admitted that the method of cure by seton is ill suited for evacuating hydatids, this of itself is a very material objection to the practice. So that, upon the whole, although the seton in every other respect should be equally eligible with the simple incision, which for the reasons formerly given I think it is not, yet the two last objections we have adduced against it are sufficient reasons for setting it entirely aside. With respect to the mode of treatment by caustic, I have only to observe, in addition to what was al- ready laid upon this subject, that where patients are naturally timid, and do not incline to submit to the operation by the knife, this will in general be pref- erable. But the treatment by caustic is liable to one very material objection, which never attends the cure by incision, viz. that of being productive of sinuses, and collections of matter, in the scrotum and cellular sub- stance 252 Of the Hydrocele. Chap. VI. stance connecting that bag to the tunica vaginalis. One instance of this I have seen, where it was neces- sary to evacuate different collections of matter by dif- ferent openings; and a remarkable case of the same kind is related by Douglas, where an extensive incision was necessary for removing the collections which oc- curred.* For this reason, therefore, and as the mode by incision brings the state of the testicle more evi- dently into view; and especially as, from all the expe- rience I have had of the two different methods of cure, that by incision seems in general to be produc- tive of the least troublesome symptoms, I am clear that it ought to be preferred. In different publications, we read of many dreadful symptoms induced by this operation for the hydro- cele; but the same objections have been adduced a- gainst every mode of operating hitherto proposed, and the same will still be continued by such as judge from partial information. In old, infirm, or diseased con- stitutions, this and every other mode of operating will on some occasions be productive of troublesome and perhaps fatal consequences: On the contrary, all the three methods of cure of which we have been treating, viz. those by caustic, the seton, and simple incision, will in general be found to answer the pur- pose very effectually, of producing a radical cure of the disorder. What I have been here endeavouring to show, and what the importance of the subject makes me again repeat, is, that this end will com- monly be obtained with more ease both to the ope- rator and patient by the simple incision than by any other means. In a matter of this kind no person ought to form an opinion hastily. Nothing but a variety of oppor- tunities of putting the different operations in practice, can enable any practitioner to judge with propriety of the merits of each. In the writings of the late cele- brated * Loc. cit. p. 105. Sect. III. Of the Hydrocele. 253 brated Mr. Sharpe, we have a very remarkable in- stance of this. In his treatise on the Operations of Surgery,* he speaks of the treatment of the hydrocele by incision as a very dangerous operation, and thinks that it will probably be discarded altogether. At that time, it is evident, Mr. Sharpe's experience in this disorder had not been sufficient for warranting such a decisive opinion. It proved to be very con- trary to the direct experience of some of our best sur- geons; and Mr. Sharpe himself seems afterwards to be convinced that his first ideas respecting this operation had been very ill founded.† I will not positively say, that the experience of an- other practitioner will not lead him to make a differ- ent conclusion respecting the success of these three modes of operating, Consequences which I have not met with, may follow each of these methods. My opinion is chiefly founded on my own observa- tion; and as the opportunities I have had of treating this disorder, and of being concerned with others in the management of it, in all the variety of ways we have mentioned, have been frequent and ample, I have delivered it without reserve or difficulty. To those who are not thoroughly acquainted with the importance of the subject, it may perhaps appear that it has been here treated with more minuteness than is necessary; but I know I will not be considered as blamable in this particular by practitioners of ex- perience. . . We now proceed to consider the third species of scrotal hydrocele, viz. that variety of the disorder in which the water is collected in the cavity of a hernial sac. SECTION * Tenth Edition, Chap. IX. † Vide Critical Inquiry, First Edition, p. 86. 254 Of the Hydrocele. Chap. VI. SECTION IV. Of the HYDROCELE of a HERNIAL SAC. IN every species of hernia, when the parts have been long protruded, a quantity of a serous fluid col- lects in the bottom of the sac; and if any obstacle oc- curs to the absorption of this, if the disorder is seated in the scrotum, we can easily conceive the possibility of the tumor augmenting to such a size as to afford all the usual marks of a hydrocele: And accordingly, on consulting the various authors who have written upon hernia and hydrocele, I find a number of cases enumerated, which sufficiently warrant the insertion of this as a real, and perhaps not an infrequent, variety of the disorder. It was well known to the ancients, that a consider- able quantity of a fluid is frequently contained in the sac of a hernia, along with the parts protruded from the abdomen; but Saviard seems to have been the first who entered into a particular consideration of this occurrence. Le Dran relates different cases of it: Heister speaks of it under the title of Hydroentreo- cele: And the late Dr. Monro describes it with his usual accuracy, and mentions a case of this kind where six pounds of water were evacuated from the tumor by an opening made with the trocar.* A case of it is also related by Douglas,† and two cases of a similar nature are mentioned by Mr. Pott‡ The water is in this disorder confined in a cyst formed by a process of the peritonæum, and as it oc- cupies nearly the same situation in the scrotum with the hydrocele of the tunica vaginalis, so we cannot, by the feel alone, on every occasion, mark the differ- ence between them. For although the testicle in this species * Monro's Works, p. 579. † Loc. cit. p. 182. ‡ Treatise on the Hydrocele, p. 21. Sect. IV. Of the Hydrocele. 255 species of hydrocele is commonly distinguished more evidently at the lower and posterior part of the swell- ing than in the hydrocele of the vaginal coat, yet the difference in this particular between the two diseases is not always so evident as to prove a sufficient mark of distinction. When a portion of gut and other parts forming the hernia are down, the fullness they produce along the spermatic cord, serves in some measure to distinguish the disorder from a simple hydrocele. And when, along with this and other symptoms of hernia, we evidently discover in the tumor of the scrotum a fluctuation of a fluid, if this fluid can by pressure be made to dis- appear either entirely or in part, the nature of the dis- order is thus rendered obvious. This species of hydrocele may occur as readily in the hernia congenita as in any other variety of rup- ture, and in that event, the water must for certain be contained in the same sac both with testicle and protruded intestines. Indeed, as all the fluid naturally secreted for keeping the surface of the different ab- dominal viscera moist, must in the case of a congeni- tal rupture fall into the hernial sac, we would be in- duced to suppose that almost every case of this kind of hernia ought to be complicated with the disorder we are now describing. The two cases of this species of hydrocele related by Mr. Pott, we find to have been connected with a hernia congenita; and I have my- self seen two instances of the same kind. But whether this commonly happens or not, farther observation will discover. Whatever species of hernia this kind of hydrocele may be connected with, if the water can by pressure be made to pass into the abdomen, this will always prove a certain characteristic of the disease; for in no other species of encysted hydrocele is it possible to make the water disappear by pressure. It may hap- pen, however, in this kind of hydrocele, that this dis- tinguishing 256 Of the Hydrocele. Chap. VI. tinguishing symptom of the disease does not exist; for if by the pressure of a truss, or from any other cause, an adhesion is produced in the groin between the sides of the hernial sac, if the under part of the sac continues open with water collected in it, the tu- mor which it occasions will afford all the usual ap- pearances of a hydrocele, while no part of its contents can be made to pass into the abdomen by pressure: A case of this kind we find related by Le Dran, where the neck of the hernial sac was shut completely, and a hydrocele formed in the under part of it. In such a case, the only means of distinction will be, an acquaintance with the previous history of the disor- der. Whenever in an ambiguous case of this kind it is found, that, before the water began to collect in the scrotum, the patient had been liable to a hernia of the same side, this circumstance alone will tend much to determine the nature of the disease. But even although a mistake should occur here, and although this spe- cies of hydrocele should be considered by a practition- er as a simple hydrocele of the tunica vaginalis, noth- ing bad could ensue from it; for the treatment adapt- ed to one species of the disease, would apply with near- ly equal propriety to the other. But when the protruded parts still remain down, unless the operation for the bubonocele is at the same time submitted to, no other operation should be at- tempted than that of discharging the water by a punc- ture with a small trocar, when the size of the tumor renders such a step necessary. For unless it was in- tended to perform the operation for the hernia at the same time, much mischief might ensue from exposing the bowels to the external air, by laying the tumor open for a radical cure of the hydrocele. Whenever in this species of hydrocele it is resolv- ed to have recourse to the radical cure, the simple in- cision ought unquestionably to be employed; as from the risk of injuring the bowels or other parts protrud- ed Sect. IV. Of the Hydrocele. 257 ed from the abdomen, neither the seton nor caustic are here admissible. Indeed this consideration of itself af- fords a very strong argument in favour of the method of treating the hydrocele in every instance by incision, which lays all the parts concerned in the disorder open to view: The very possibility of a patient being kill- ed by a seton passing through a portion of intestine contained in a hydrocele, is a weighty objection against the seton being ever used; and every practitioner must acknowledge, that when the spermatic process along the groin is much distended, and when the vaginal coat of the testis is much thickened, such uncertainty often occurs as to render it impossible for the most skillful surgeons to determine with precision what the contents of such swellings really are. In the two in- stances above alluded to, of a hydrocele connected with a congenital hernia, and which I met with some years ago, there had not been previously in either of them any cause to suspect the real nature of the case. They were both by skillful practitioners taken to be collections of water in the tunica vaginalis without any complication whatever; and in each of them, on the tumor being laid open, together with water in contact with the testicle, a piece of intestine was found protrud- ed into the upper part of the scrotum: In one of the cases, too, a small portion of omentum accompanied the gut. In this last, it was proposed, at a consultation of different surgeons, to employ the seton. For some reason or other, this was fortunately rejected; for, on laying the tumor open by incision it evidently appear- ed, that if a cord had been introduced, it must in all probability have passed through the protruded gut. The mere possibility, therefore, of such an occurrence, I would consider as a very material objection to the method of treating any case of encysted hydrocele by the seton. Kk SECTION 258 Of the Hydrocele. Chap. VI. SECTION V. Of the ANASARCOUS HYDROCELE of the SPERMATIC CORD. IN the anatomical description we gave of these parts, it was observed, that, soon after the descent of the testis, the passage along the spermatic process of the peritonæum is completely obliterated, by the sides of the passage adhering to one another through the intervention of cellular substance. By external pressure, and perhaps from other caus- es, this adhesion of the sides of the peritonæal process in general is very firm in that part of it which passes along the groin; but the superior and more internal part of the process, is not only more loose in itself, but is connected with and enveloped in a very loose cel- lular substance. From this cellular structure of these parts we might à priori suppose them to be liable to œdematous swellings, which other parts of the body of a similar structure are frequently attacked with: And accord- ingly we find this process of the peritonæum liable to partake of every anasarcous swelling with which the rest of the body is attacked: It sometimes accompa- nies ascites; and it now and then appears as a local disorder, without being combined with either of these. The causes of this disorder in general are, obstruc- tions produced in the lymphatics of the part, by scir- rhous affections of the liver, spleen, and other abdom- inal viscera: I have likewise known it induced by the pressure of a truss applied for the cure of a hernia.* When a swelling of this kind is connected with a general anasarcous affection, the nature of the disorder is so distinctly marked as to render a particular de- scription * An instance of this kind is also mentioned by Douglas, Treatise on the Hydrocele. Sect. V. Of the Hydrocele. 259 scription of it unnecessary. When it occurs as a local disease its appearances are these: A colourless tumor in the course of the spermatic cord; soft and inelastic to the feel, and not attended with fluctuation. In an erect posture, it is of an oblong figure; but in a re- cumbent posture of the body, it becomes more flat, and somewhat round. It does not commonly occupy more than the usual stretch of the cord along the groin; but on some occasions, it extends down the length of the testicle, and even stretches the scrotum to an enormous size.* By pressure the swelling can be always made to recede, if not entirely, at least in great part, into the cavity of the abdomen; but it in- stantly returns to occupy its former situation on the pressure being withdrawn. When a tumor of this kind depends upon a general anasarcous swelling of the body, unless the cause which gave rise to the original disease of the constitution be removed, it would be a vain attempt to endeavour to cure this particular symptom: And it commonly hap- pens, that these swellings in the groin which occur in the anasarca disappear, when the disease of the system at large is carried off. But when a swelling of this nature occurs as an original disorder; produced perhaps by some local cause; a local remedy is then the only means necessary to be employed. In such a case, as we have not the general bad habit of body to encounter, which com- monly occurs in cases of scrotal anasarca, we need not be so much afraid of making a free large incision into the tumor; and accordingly all that is necessary to be done here, is this: As soon as the swelling has ac- quired such a size as to become inconvenient, an in- cision should be made with a scalpel from one end of it to the other, taking care to go so deep as effectually to evacuate all the water contained in the cells of the part; * A remarkable instance of this is related by Mr. Pott, who from a swelling of this kind discharged eleven English pints at once. Treatise on the Hydrocele, Case X. 260 Of the Hydrocele. Chap. VI. part; and as the water is now and then found to have acquired a viscid consistence, this circumstance ren- ders a deep incision more necessary than it otherwise would be. The contents of the swelling being all removed, some soft lint should be inserted between, the lips of the sore, which must afterwards be treated in every respect as a simple wound from any other cause; by poultices and fomentations, if much pain and a scanty suppuration render these remedies necessary; and by a due attention to dressing so as to induce the forma- tion of firm granulations from the bottom. SECTION VI. Of the ENCYSTED HYDROCELE of the SPERMATIC CORD. THE surrounding substance of the spermatic cord being altogether cellular, the formation of encysted tumors, we may conclude, ought here to be as fre- quent as in other parts of the body; and accordingly we find in some instances, that water, instead of dif- fusing itself over the whole spermatic process, is col- lected in one or more distinct cells or cysts. This kind of hydrocele being on its first appear- ance very small, gives little or no trouble, and is therefore seldom much noticed till it has acquired a larger size. On some occasions, the swelling begins in the superior part of the process; but in general, it is first observed towards its lower extremity a little above the epididymis. By degrees, however, it stretches upwards, and on some occasions so far down- wards as to reach from the abdominal muscles to the very bottom of the scrotum; in which case, a person not versant in disorders of this nature, may very prob- ably mistake this species of hydrocele for a collection in the tunica vaginalis testis: But we have here a very characteristic Sect. VI. Of the Hydrocele. 261 characteristic distinction between the two diseases. In the commencement of this species of swelling, the tumor is always above the testicle, which is distinctly felt below it; and even in the most advanced stages of the disorder, the testis is found lying at the back part of it, perfectly unconnected with the swelling: Whereas, in the advanced state of a hydrocele of the tunica vaginalis, although some degree of hardness is always discovered at that part where the vaginal coat adheres to the testicle; yet in the latter period of that disorder, when the swelling is considerable, the testis itself can never be distinctly felt. In the species of hydrocele we are now describing, the figure and size of the penis is not commonly so much altered, as when the water is collected in the tunica vaginalis, when the penis is frequently made to disappear almost entirely. In other particulars, the encysted dropsy of the spermatic cord is very similar to the hydrocele of the tunica vaginalis testis. A fluctuation of a fluid is ev- idently discovered on pressure: The tumor is com- monly of a pyramidal form, as is generally too the case with the other, with its base or largest extremity downwards:* And no pressure has any influence in making it disappear either altogether or in part. This is the appearance of the disorder when the water is contained in one cyst; when it is separated into two distinct cells, the line of division is common- ly evident, by the tumor being at that part somewhat puckered, or sometimes a little diminished in its di- ameter. A similar appearance, we may observe too, takes place when this species of swelling is combined with a real hydrocele of the tunica vaginalis testis, which * A Hydrocele of the tunica vaginalis testis is so frequently of a pyramidal form, with its base downwards, that this shape may be considered as one of the characteristic appearances of the disease; every other tumor to which the testis and its coats are liable, being either more round, or of a more irregular shape. 262 Of the Hydrocele. Chap. VI. which on some occasions it is: And in that case a line of separation is observed at that part where the upper extremity of the tunica vaginalis terminates. We have already mentioned the means of distinc- tion between this species of hydrocele and that of the vaginal coat of the testis. The only other affections with which it is in danger of being confounded, are the anasarcous hydrocele of the spermatic cord; and a real hernia, either of the omentum, or of a portion of gut. From the former, however, as also from an omental hernia, it may in general be distinguished by the feel. In neither of these can the fluctuation of a fluid be in the least perceived, and to the touch they are both soft and inelastic; whereas, in this spe- cies of hydrocele, the tumor has a springy kind of feel, and a fluctuation is evidently found in it. And in both the other, the swelling recedes more or less upon pressure, which it never does in this species of encysted hydrocele. From a gut rupture it is chiefly distinguished by the tumor beginning, not at the ring in the external ob- lique muscle, as is the case in hernia, but farther down the cord: In the latter, too, the swelling commonly turns less on the patient getting into a horizontal pos- ture; and it is always considerably affected both by coughing and sneezing; but no posture, no pressure, nor any accident whatever, alters the size of this va- riety of hydrocele. The absence of other symptoms of hernia, too, is here material in the distinction: For there is neither pain in the tumor, nor in the abdo- men; nor sickness, vomiting, nor any interruption to the passage by stool, as there very commonly are in hernia. Although all the ancient writers were quite unac- quainted with the anatomy of the parts concerned in this disorder, it is evident they were well aware of its existence. We find it particularly described by Ægin- eta, Sect. VI. Of the Hydrocele. 263 eta, Albucasis, and afterwards by Fallopius, Wiseman, &c. Arnaud, in his treatise on hernia, also takes notice of it, though not with much accuracy; and we find it more lately described with exactness, by the late Doc- tor Monro, by Douglas, and by Mr. Pott. This species of hydrocele, as also the anasarcous swelling of the cord, and the œdematous tumor of the scrotum, are all very frequent in infancy. In that ten- der age, however, they generally soon dissipate, and in this they are much assisted by the application of cloths dipped in spirit of wine; and I have seen much ad- vantage produced by an application of a strong infu- sion of red rose leaves, combined with a considerable proportion of alum. The late Doctor Monro advises the application of cloths warmed with the fumes of burning benzoin. But in adults, the cyst confining the water gener- ally becomes so firm as not to be affected by any of these remedies. So that when it arrives at any consid- erable size, which it frequently does, either the means for the palliative or radical cure may be employed, as was recommended in the hydrocele of the tunica vag- inalis testis. When it is intended merely to evacuate the water by puncture, it ought to be done with a trocar, in the same manner as was directed for a hydrocele of the tunica vaginalis; taking care to introduce the instru- ment at the most depending part of the tumor. And again, when it is intended to effect a radical cure, the same means are to be employed which we formerly recommended in the other species of the disease. There do not here, indeed, occur the same objections to the use of the seton, as in the hydrocele of the tunica vag- inalis from the presence of the testicle: And if we could in every species of hydrocele ascertain with cer- tainty the exact contents of the tumor, the seton might no doubt be employed here with safety and advantage: But as it is clear from what we have already said upon this 264 Of the Hydrocele. Chap. VI. this point, that no certainty of this kind can be obtain- ed; and as a hydrocele of a hernial sac in which a portion of gut is contained, may be as readily con- founded with this as with any other species of the dis- ease; I would therefore without hesitation lay this method of cure entirely aside. A material objection occurs to the method of cure by Caustic in this species of hydrocele, which is not ap- plicable in the hydrocele of the tunica vaginalis, viz. the water being in some instances of this disorder col- lected in two or more distinct cysts; different cases of which I have met with, and similar occurrences are related both by Garengeot and Douglas.-—Now in such an event, if caustic should be applied in the meth- od recommended by Mr. Else, upon a small spot on- ly, all the water would not be evacuated; and in or- der to obtain a complete removal of the disorder, it would be necessary to repeat the application of the caustic. This, I think, is an additional reason for employing in all such instances the method of cure by incision; which by laying the tumor open from one end to the other, divides at once all the different cysts of which it may be composed, and saves the patient from that distress and disappointment which must always be ex- perienced, on a complete cure not being obtained when good reasons had been previously given for ex- pecting it. We would therefore advise the treatment by incision in this species of hydrocele, in the same manner as was recommended in the hydrocele of the tunica vaginalis; the mode of performing the opera- tion, and the after treatment of the patient, being near- ly the same in each. We have thus enumerated all the kinds of hydro- cele which can properly be considered as forming dis- tinct varieties of the disorder. In doing so, as no dis- ease is described but such as every practitioner of ex- perience must have met with, and of which the symp- toms Sect. VI. Of the Hydrocele. 265 toms are clearly and distinctly marked; so it will not, I hope, be considered as an unnecessary degree of mi- nuteness that I have particularly taken notice of them all. I can by no means agree with some authors, par- ticularly with Mr. Sharpe* and Mr. Else, † who think it might be better to confine the description of this disorder to two species. We need not indeed wonder at Mr. Sharpe speaking in this manner: For even at the late period in which he wrote, although the exist- ence of all the varieties of the disease we have men- tioned had been described by different authors, yet they were not till of late years understood with much accuracy; and it is very evident from Mr. Sharpe's writings on this subject, that his ideas of these disorders were in many respects more confused than could have been expected in one of his usual accuracy and pene- tration. But whatever was the case with Mr. Sharpe, it is truly surprising, that those who are unquestion- ably well informed in every circumstance relating to this disorder, and who must be convinced, from their acquaintance with dissection, of the existence of all the varieties of the disease that have been mentioned, should object to their being retained. Where no evi- dent or marked distinction occurs between one tumor and another, an attempt to establish a difference would be useless, and therefore improper; but where ap- pearances point out an obvious variety, it would sure- ly be considered as an unpardonable neglect in an au- thor to omit the detail of them. In our description of the five different species of hydrocele, viz. the anasarcous swelling of the scrotum; the hydrocele of the tunica vaginalis testis; the hy- drocele of the hernial sac; the anasarcous swelling of the spermatic cord; and the encysted collection in that part; it was necessary in going along to enume- Ll rate * Treatise on the Operations of Surgery. † Loco citato. 266 Of the Hydrocele. Chap. Vl. rate the symptoms of each as they occur separately and uncombined. It sometimes happens, however, that one, two, or more of the different species occur at the same time in the same patient: On some occasions I have met with three, and not unfrequently with two, varieties in the same person: The late Doctor Monro mentions an instance of four species of hydrocele being all combined in one case.* In such occurrences some difficulty and confusion is, no doubt, to be expected; but practitioners in form- ing a judgment of their nature, must be entirely di- rected by a due attention to the various symptoms which usually occur in a separate state in each variety of the disease. We now proceed to the consideration of the other varieties of false hernia; and first of the Hæmatocele. * See his works, p. 576. CHAP. Chap. VII. Of the Hæmatocele. 267 CHAP. VII. OF THE HÆMATOCELE. THE Hæmatocele is a tumor in the scrotum or spermatic cord, produced by extrav- asated blood. The usual seat of such tumors is in the tunica vag- inalis of the testis; but on some occasions they are seated in the spermatic process, and now and then they are met with in the dartos. Tumors of this kind are in general produced by the rupture of one or more blood vessels, in conse- quence of external violence. Blows upon the scrotum have produced ruptures of veins, not only in the cel- lular substance of the scrotum, but in the vaginal coat of the testicle; and accidents of a similar nature have produced similar affections in the course of the sper- matic cord: And as the parts in this situation are very lax and cellular, the rupture either of an artery, or of a vein of any considerable size, will always be attended with a plentiful extravasation of their contents. In the tunica vaginalis testis, this disorder is fre- quently induced by the point of a trocar or of a lancet in tapping for a hydrocele, wounding some of the blood vessels of the sac, which in such cases are always much enlarged. In such an occurrence, we are com- monly rendered certain of what has happened, by the water drawn off being suddenly tinged with blood; but on other occasions it does not appear till the water is all evacuated, and then a tumor of a consid- erable 268 Of the Hæmatocele. Chap. VII. erable size is frequently produced in the course of a very short space of time. In some of these cases where the bulk of water has been remarkable, the sudden discharge of it, by tak- ing away the support which the vessels of the part have been for some time accustomed to receive from it, has undoubtedly been the cause of the rupture of some of them; and from repeated observation I think it may be considered as a certainty, whenever a tumor is produced either in the scrotum or spermatic cord, suddenly after the water of a hydrocele has been evacu- ated by tapping, that it is entirely the consequence of an extravasation of blood; for collections of water are never known to arrive so quickly at a considerable size. In the spermatic process, injuries of the same kind will be attended with a similar effect upon the smaller veins of the sac containing the water; and more con- siderable violence has on some occasions produced a rupture of the spermatic artery and vein. But, in whatever way the tumor has been produc- ed, the appearances are nearly similar to those of wa- tery collections in the same parts, so that we do not consider it as necessary to repeat them here: Only it may be observed, that when blood is extravasated in the scrotum, it is easily discovered from a collection of water by the colour, it being in every respect a real Ecchymosis. When the swelling is seated in the tu- nica vaginalis, the means of distinguishing between blood and water, is, that a tumor produced by the former, feels to be more heavy than water in propor- tion to its bulk; and they who are much accustomed to handle such disorders, are on many occasions sensi- ble of a difference of consistence. The treatment here is nearly the same that we have already recommended in cases of hydrocele. In the commencement of the anasarcous or diffused species of hæmatocele, when produced by a slight external vio- lence, Chap. VII. Of the Hæmatocele. 269 lence, whether in the scrotum or spermatic process, the application of ardent spirits, or of a solution of alum, will on some occasions effect its discussion: But when this, upon trial, is not found to succeed, the tumor is to be laid open, and in every respect treated in the same manner as was directed for the hydrocele; only, if a ruptured blood vessel is discovered, the only ef- fectual means of preventing a return of the disorder is to secure it by ligature. In the same manner, all collections of blood, either in the vaginal coat, of the testis, or in the cyst of a former hydrocele of the spermatic cord, are to be laid open by an incision extending the whole length of the tumor, and are to be treated as we formerly directed for hydrocele. And, as we have already advised in the diffused species of hæmatocele, if any ruptured vessel comes into view in the course of the operation, it ought to be immediately secured by ligature. It some- times happens, however, in affections of this kind, both of the spermatic process and tunica vaginalis tes- tis, that the vessels from whence the blood is discharg- ed cannot be detected; a very considerable oozing continuing from day to day, notwithstanding the use of bark, vitriolic acid, and every other means com- monly employed in such cases. If, after a proper trial of all the ordinary remedies used in cases of hæmorrhagies, the vessels from whence the blood is discharged cannot be otherwise secured, the end in view may frequently be obtained by extir- pation of the testicle; which, in such occurrences, is the only remedy from which any advantage is to be expected. Another species of hæmatocele is taken notice of by Mr. Pott, in which the blood is contained within the tunica albuginea of the testis. It proceeds, he thinks, from a relaxation or dissolution of part of the vascular structure of the testicle; and when the quan- tity of blood collected is considerable, it produces, Mr. 270 Of the Hæmatocele. Chap. VII. Mr. Pott remarks, a fluctuation somewhat like to that of an hydrocele of the tunica vaginalis. When this happens to be mistaken for a hydrocele, as it has sometimes been, and an opening with a trocar is made into it, a discharge is produced, of a dark dusky coloured blood, nearly of the consistence of thin chocolate; but although some diminution may be made in the size of the tumor, by the evacuation thus obtained, yet no considerable alteration is effected by it. Any perforation that is made into it, accordingly does no good; and as the testicle is commonly so far spoiled by the disease as to be rendered quite useless, castration is advised as the only effectual remedy.* I have different times met with a disease very sim- ilar to this described by Mr. Pott: But as the blood in such instances did not appear to be extravasated, but to be still contained in the vessels of the testis in an enlarged varicose state, I would not incline, there- fore, to refer this kind of tumor to any species of hæ- matocele. I have even seen this disorder mistaken for a hydrocele, and treated as such, by a trocar being plunged into it, when the effects were just such as are described by Mr. Pott. But, if the blood had been extravasated, a more copious discharge ought to have taken place, in consequence of the operation, than was procured by it in any of the cases I have met with: Even where the tumor has been of a considerable size, I never found it possible to evacuate in this man- ner more than a spoonful or two of blood; and al- though in such cases the blood appears evidently to be thicker than it ought to be, yet it is by no means so much so as should prevent it from being freely dis- charged by the cannula of a trocar if it was lodged in a state of extravasation. But in all the instances I have ever seen of this disorder, the blood appeared to he still contained within its proper vessels in an enlarged varicose * Mr. Pott's Treatise on the Hydrocele. Chap. VII. Of the Hæmatocele. 271 varicose state; so that, instead of considering such a tumor as a variety of hæmatocele, I would rather re- fer it to a species of Varix. In any cases of this kind that have occurred to me, when the tumors were not opened, but were entirely trusted to the support afforded by a suspensory, they have in some instances remained for many years with- out being productive of any mischief: And they are commonly attended with this peculiarity, that when effectually supported by a bandage, they remain sta- tionary for a great length of time, without acquiring any additional size; a circumstance which no support will prevent either in a hydrocele or in the real hæ- matocele. But as soon as the tumor, by being mis- taken for a hydrocele, is touched with an instrument with a view to evacuate its contents, it is from that moment fore to go wrong. The patient, from being previously liable to little or no pain, immediately on the tumor being opened becomes very much distress- ed; the swelling then begins to increase, and in a gradual manner to prove so troublesome by frequent discharges of blood, as to render castration absolutely necessary. Even this disagreeable resource does not always prove a certain relief; for it sometimes happens, that such a spongy relaxed state of the vessels occurs along the whole course of the cord, that although they are secured by ligature today, the blood bursts out from different parts of the sore tomorrow. I happened once to be concerned in a very melancholy instance of this kind: After the usual operation of castration, fresh hæmorrhagies occurred at every dressing; the vessels were at different times secured by ligature, but to no purpose; the blood burst out again and again; and the patient, after suffering much distress, at last died. The only difference which, before laying the parts open, can be observed between this species of tumor and 272 Of the Hæmatocele. Chap. VII. and a real hydrocele of the tunica vaginalis, is, that in this, the fluctuation in the swelling is never so evident as in the other; the tumor is heavy in proportion to its size; and if properly supported by a bandage, it does not receive any additional increase. Whenever these circumstances, therefore, occur in the same case, it ought to afford much reason to suspect that the swelling is of this nature, and that accordingly it ought not to be meddled with. As I consider this disorder to be entirely of the varicose kind, I would not have thought of introduc- ing the consideration of it here; but as it was proper to mention its having been taken notice of by others as a species of hæmatocele, I thought it better to fin- ish the discussion of it at once, than to be under the necessity of bringing it in again in a subsequent chapter. CHAP. Chap. VIII. Of the Varicocele, &c. 273 CHAP. VIII. OF THE VARICOCELE, CIRSOCELE, SPER MATOCELE, AND PNEUMATOCELE. BY the first of these terms is meant, a varicose distention of the veins of scrotum; which in this state form a tumor of hard knotty in- equalities, seldom attended with pain, and in general productive of no inconvenience except what arises from its bulk. The Cirsocele is a tumor of a nature similar to the former, in the course of the spermatic cord, extending from the superior part of the scrotum to the abdom- inal muscles, and produced by a varicose distention of the spermatic vein. Both these affections are now and then produced, by obstruction of one kind or another in the veins of these parts: But most frequently they depend on a de- bilitated relaxed state of the veins. When tumors in the course of the veins are detect- ed as the cause of such swellings, or when the pressure of a hernial truss upon the spermatic process is dis- covered to be their origin; the removal of this evi- dent cause of the disease ought to be the first attempt towards a cure. If the pressure of a truss has been the cause of the swelling, an alteration in the bandage may probably remove it. If tumors of a hard scirrhous nature have produced it, their extirpation, when that is found to Mm be 274 Spermatocele, &c. Chap. VIII. be practicable, will be the most effectual means that can be employed; and if the tumors have any ten- dency to suppurate, warm emollient applications will be more useful than any other remedy. But when a general relaxed state of the veins is sus- pected to give rise to the complaint, such remedies ought to be employed as will most effectually recover that tone, of which they have been deprived by being long overdistended. For this purpose nothing com- monly answers so well as the use of a proper suspen- sory bandage; a horizontal posture; the cold bath; and the application of a solution of alum and other astringents, to the parts affected. By a due continuation of these means every affec- tion of this kind may be always prevented from in- creasing, and will commonly be so far relieved as to render the harsh means by the knife, the cautery, and ligature, recommended by ancient writers for the re- moval of such tumors, unnecessary. By the term Spermatocele, is meant, a morbid distention of the epididymis and vas deferens, produc- ed by a stagnation of semen. This may be produced by tumors, stricture, or inflammation, about the caput gallinaginis, or in the course of the vas deferens; but there is reason to think, that it is more frequently in- duced by the last, viz. by inflammation, than by either of the other two. When an inflammatory affection of the parts is discovered to be the cause of the disease, general and topical bloodletting, gentle laxatives, a low cooling diet, and rest of body, will commonly be found the most effectual remedies. And again, when tumors are discovered to press upon the vas deferens, they ought either to be brought to suppurate, or their ex- tirpation should be attempted when that can be done with propriety. At other times, these tumors are found to depend on a venereal cause; and in such in- stances Chap. VIII. Of the Pneumatocele. 275 stances a well directed course of mercury has been known to remove them. On some occasions we are told, that all the other means having failed, castration has at last been found requisite. This, however, we cannot supposed to be ever a very necessary measure. The term Pneumatocele, is applied to signify a dis- tention of the scrotum by a collection of air. This has been described by most of the ancient writers as a very frequent occurrence; but there is much reason to think, that a great proportion of all the tu- mors they take notice of as containing air, were either formed by collections of water, or by a protrusion of some of the bowels. That species of hernia to which young children are liable, is to this day by our com- mon people termed a Wind Rupture; as are all those collections of water in the scrotum with which new born infants are affected: But we know well, that none of these tumors are formed merely by wind; their contents being of a very different nature. In wounds of the lungs, air is sometimes thrown into the surrounding cellular substance, and in that way passes into the scrotum, as it does in particular instances over the whole body; and in high degrees of putrid diseases, so much air may be separated from the blood, as to distend the cellular substance of the scrotum, as well as of other parts: But a real pneu- matocele has never, probably, existed as a mere lo- cal affection of the scrotum; at least I have never seen it. In the case of air diffused into the cellular substance of these parts, in consequence of a wound or any other affection of the lungs producing an extravasation of it, the same method of cure will answer for its removal that we recommended for anasarcous swellings formed by water, viz. small punctures with the point of a lan- cet, which are found to be fully sufficient for evacuat- ing great quantities of air. But whenever the disease is 276 Of the Pneumatocele. Chap. VIII. is induced by such a great degree of putrescency in the system as is necessary for effecting a separation of air from the blood, there can be little reason to expect any advantage to result from whatever means may be employed for relief. CHAP. Chap. IX. Of the Sarcocele. 277 CHAP. IX. OF THE SARCOCELE, or SCIRRHOUS TES- TICLE. BY the term Sarcocele, is under- stood, a firm fleshy kind of enlargement of the testi- cle: A simple inflammatory affection of the testis af- fords a tumor of some degree of firmness; but the true sarcocele, or scirrhous testicle, is attended with a hard- ness never to be met with in the real hernia humoralis or inflamed testicle. A scirrhous testicle, in the course of its progress, puts on such a variety of appearances, as renders it difficult by description to give an adequate idea of it: In general, however, the accession and progress of the disease is as follows. An unusual degree of hardness, attended with a trifling enlargement of the whole testis, proves in gen- eral to be the first indication of the disease: In the beginning no discolouration is observed, nor is there any material pain: In a gradual manner the tumor acquires a larger size: As yet it remains smooth and equal on its surface; but with the size of the swelling, the hardness also becomes more remarkable: Slight pains are at times felt through the substance of the tumor; and if it be not suspended the patient com- plains of some uneasiness in his back. When there is nothing particularly bad in the con- stitution, the disorder will on some occasions remain in this situation for a great length of time; and in a few instances, by a moderate diet, keeping an open belly, suspending the tumor properly, and avoiding violent 278 Of the Sarcocele. Chap. IX. violent exercise, the disorder has not only been pre- vented from increasing, but has in a gradual manner dissipated: Such favourable occurrences, however, it must be owned, are exceedingly rare; for the swelling, instead of discussing, or remaining stationary, in gen- eral proceeds with more or less rapidity to turn worse. The tumor acquires a larger size; becomes ragged and unequal on its surface; and the pain, which at first was trifling, becomes more severe, darting, in smart stings, through the substance of the tumor. The inequalities on the surface of the tumor by de- grees increase, and continue to retain the same kind of hardness with the swelling from which they originate: On some occasions, a considerable quantity of serum is extravasated into the tunica vaginalis, which, to those not acquainted with the nature of such disorders, gives the tumor the appearance of a common hydrocele: And at other times, instead of such depositions into the vaginal coat, partial collections of matter are formed through the whole body of the tumor: These by degrees increase; and the scrotum, which has hith- erto been gradually distending, at last bursts, and a discharge takes place from the various collections in the body of the tumor, of a thin, fetid, bloody matter. On some occasions, the spermatic cord becomes hard and enlarged soon after the commencement of the disease; but in general the cord does not become affected till the tumor has acquired a considerable size, and most frequently, I have observed, not till matter has formed in some part or other of the swelling. As the disorder of the testicle advances, this affec- tion of the cord also becomes worse: From being at first only slightly tumefied, it gradually turns more hard and swelled; it becomes very painful, and knot- ty or unequal through the whole extent of it. The discharge from the openings in the scrotum still continues: But although the matter increases in quan- tity, the size of the tumor is not thereby diminished; on Chap. IX. Of the Sarcocele. 279 on the contrary, it still continues to increase: The edges of the sore become hard, livid, and retorted; and fungous excrescences push out from different parts of it. Whatever was the state of the patient's constitution on the first attack of the disease, in this advanced state of it, it is always greatly impaired: He now becomes emaciated; of a pale, wan complexion; and the dis- order, which in this stage of it is a real cancer of the most malignant nature, turning still more virulent, by the pain becoming more tormenting, the patient is at last carried off in very great misery. Such, in general, is the progress and event of this dreadful disorder, if it be not interrupted by extirpa- tion of the testicle before the swelling has proceeded too far. We have already said that it exhibits a great variety of symptoms: Those here enumerated occur most frequently; but no description can convey a clear idea of all the appearances it assumes. On some occasions, we have already observed, it remains ap- parently in an indolent, inactive state, for a great length of time, even for years; and in others, it proceeds so rapidly, that in the space of a few months it has been known to pass through all the various changes we have enumerated. In by much the greatest proportion of such affec- tions the disorder begins in the body of the testis, af- fecting the whole of it equally; but now and then it makes its first appearance in the epididymis, and some- times even in the spermatic cord. It has been a pre- vailing opinion, indeed, that a scirrhous hardness tend- ing to cancer, never does begin in the epididymis; but that the testicle is always first affected. This is cer- tainly the case in general; but every practitioner must at times have met with cases of a real cancerous na- ture beginning in the epididymis, and sometimes even in the spermatic cord, and spreading from thence to the neighbouring parts.-—I might here insert different cases 280 Of the Sarcocele. Chap. IX. cases of this nature, which have fallen within my own observation; but Mr. Pott's collection furnishes a suf- ficient number of well marked examples of the fact.* In almost every case of a swelled testicle from a gonorrhœa, the epididymis is not only affected before the testicle, by the inflammation in such cases spread- ing from the urethra along the vas deferens, when of course it must first reach the epididymis; but the dis- order in such cases, when it begins to yield, always first removes from the testicle, leaving in general a scirrhous hardness in the epididymis, which on some occasions in the course of time dissipates entirely, and in others remains of the same degree of hardness for a considerable time, and now and then even for life. But as the hardness produced in this manner is mere- ly the consequence of inflammation upon a membran- ous or vascular part; so here as in other parts of the body of a similar texture, we seldom find, that hard- ness thus induced terminates in any thing bad. The contrary, however, of this has been too much inculcated. It has been said, that the hernia humora- lis produced by a venereal infection, is a frequent cause of the worst kind of scirrhous testicle; which, as the fact is very much otherwise, has this improper ten- dency, that it prevents the use of, and a proper persever- ance in, such courses of medicine, as might, without the necessity of extirpation, have removed it: There have even been instances of this idea being so improp- erly applied, as to be the means of different testes be- ing extirpated, which were evidently diseased from a venereal cause, and which by proper courses of mer- cury might in all probability have been removed. But although I have said that affections of this na- ture, I mean a swelling of the testis from a venereal cause, are very seldom known to end in any thing bad; yet I will not go so far as to say that they never do so: For I know, that a hardened state of the testis and * Treatise on the Hydrocele, Cases 42. 48. and 49. Chap. IX. Of the Sarcocele. 281 and epididymis, produced originally by a venereal taint, does in some instances degenerate into the worst species of sarcocele; that is, that though affections of this kind do most frequently terminate easily, yet that now and then in particular constitutions, whose pecu- liarities, however, we are not acquainted with, they do certainly produce scirrhosities of the very worst kind, when such ailments would never probably have ap- peared if the original venereal taint had not occurred as an exciting cause of the disorder. We know well, that a predisposition to different disorders will remain long in a latent state in the system, without being pro- ductive of any evident affection, till the application of some particular stimulus brings it into action: In the same manner, a venereal inflammatory affection of the testis, will in some constitutions terminate in much mischief, although in general its effects in this way are by no means to be dreaded. I have dwelt longer upon this point than I other- wise should have done, from a contrary doctrine hav- ing been strenuously inculcated by one whose authori- ty is deservedly great, and whose observation in this disease has led to the conclusion he endeavours to es- tablish:* But as all the experience I have had in these matters, has led me to form the opinion here delivered, I could not avoid stating it in the manner I have done. In the treatise alluded to, we are told, that a hernia humoralis is never, in any one instance, productive of this disease. If on this subject Mr. Pott's idea is just, it ought undoubtedly to be received: But if it is not, it may very certainly do mischief, by rendering both patients and practitioners more remiss in cases of sar- cocele proceeding from this cause than they otherwise would be; as, by continuing still in hopes of a mercu- rial course being able to effect a cure, they may there- by allow the disease to go too far even for extirpation to be advisable. Nn In * Mr. Pott, Treatise on the Hydrocele, &c. p. 232. 282 Of the Sarcocele. Chap. IX. In every doubtful case of this kind, when a venereal infection is suspected as the cause of the disease, blood- letting when the pulse is full; an open belly; a cool- ing diet; a horizontal posture; with a proper sus- pensory bandage; and a well directed mercurial course, will very commonly remove it. But when in such instances the means recommended are put in practice without any evident advantage; and especial- ly if, during their application, the disorder, instead of mending, turns gradually worse; as soon as from its increase in size there appears to be any risk of its ad- vancing beyond the reach of operation, it ought then at all events to be extirpated, whatever the cause which originally produced it may have been. Among other causes mentioned by authors as being productive of a scirrhous state of the testicles, is the hydrocele of the tunica vaginalis. From quantities of a watery fluid being frequently found in the vaginal coat of a scirrhous testicle, it has been supposed, that the water in such cases was the original cause of the disease in the testis, and not the consequence of it. There is every reason, however, to think, that in these collections of water in the vaginal coat, in which the testis is found diseased, that the hardened state of that organ ought to be considered as the original disorder, and not the quantity of water which surrounds it. Collections of water are no doubt often met with, even in the real sarcocele; but this ought to be con- sidered only as a different stage of the same disease: For although the true scirrhous testicle is never at first attended with any collection of this nature, it is natur- al to suppose, that a hard diseased state of that viscus must have some influence in producing an alteration in the quantity of fluid with which the tunica vaginalis is always provided in a sound healthy state. If it ei- ther produces an augmented secretion, or a diminish- ed absorption of that fluid, a dropsical swelling must be the certain consequence; and every such collection, combined Chap. IX. Of the Sarcocele. 283 combined with a scirrhous testicle, has been very properly termed a hydrosarcocele. That the testis, by remaining long immersed in the water even of a true hydrocele, does frequently be- come somewhat altered in its texture, there is no reason to doubt. Thus, as we have elsewhere observ- ed, on laying open the tunica vaginalis, the testis in that disorder is always found to be of a more pale ap- pearance than it naturally ought to be: On some oc- casions it is very much diminished, and on others con- siderably enlarged; but all such enlargements, when connected with a real hydrocele, are of a soft harmless nature, such as never give any pain; and in this state the testis ought never to be extirpated. This is a point, we may remark, which it is of some importance to ascertain: For on the idea of these en- largements of the testes, frequently connected with, and perhaps produced by, their immersion in the wa- ter of a hydrocele, being of a real scirrhous nature, their extirpation has been often advised, and unfortu- nately too often practised. In circumstances of this kind the means of distinc- tion between the mild and malignant species of en- larged testicle, by which we should in general be di- rected, are the following. When the body of the testis becomes hard and en- larged, previous to any collection of water in the tu- nica vaginalis, such collections as afterwards occur ought not to be considered as constituting a simple hydrocele; and if, upon evacuating the water by in- cision, the testis, besides being enlarged, is found in a hardened state, and especially if it is attended with pain, and is ulcerated on the surface, extirpation ought undoubtedly to be advised immediately: And, on the contrary, when the water of a hydrocele is known to have been collected while the testicle remained sound and of its natural size, whatever enlargement it may be found to have acquired on laying the sac open, if the 284 Of the Sarcocele. Chap. IX. the testis is neither of a scirrhous hardness, nor affect- ed with pain or ulceration, we ought unquestionably to proceed as in a case of simple hydrocele; for any enlargement of this kind will be rarely found to oc- casion future uneasiness, and consequently will seldom or never render extirpation necessary. In forming a prognosis of this disorder, different circumstances are to be attended to; the age, and habit of body, of the patient; the duration of the dis- ease, and the state it is in at the time. Thus, whatever treatment is to be adopted, more success may be reasonably expected in a young healthy constitution than in the reverse; particularly if extir- pation of the testis is to be advised. In the former, the chance of success from the operation is commonly considerable, provided the disorder be not too far ad- vanced; whereas in old, infirm people; and in habits attended with pale, wan complexions; with indiges- tion; and other symptoms of obstructed viscera whatever state the disease may be in, little or no ad- vantage can be expected to accrue from any operation. With respect to the duration of the disease, if it has already subsisted for a considerable time without mak- ing much progress, there will be great reason to think that it is of a mild nature; and that the system, in general, is not so much affected by it as if its progress had been great and rapid; and lastly, the state of the disorder for the time is of much importance in form- ing an opinion of its final event. As long as the tes- ticle is only somewhat hard and enlarged, without the formation of matter, and without any disease of the cord, if the constitution is otherwise healthy, there will be much reason to expect a favourable event from any operation that ought to take place. But on the contrary, when the disorder is so far ad- vanced that collections of matter have formed, either upon the surface of the testicle, or in its more internal parts, as in that state the constitution will probably have Chap. IX. Of the Sarcocele. 285 have suffered from absorption, so there is less chance of the operation in these circumstances proving so successful as in the more early period of the disease: And this is still more remarkably the case when the tumor has become ulcerated externally; for we know well, that in all such cases, the system is much more apt to suffer from absorbed matter on the parts being laid open, than while they remained excluded from the external air. In whatever state, however, the tumor may be, there is always reason to expect more success from the operation while the spermatic cord is yet found, than when it has become much diseased; for, as soon as the cord is materially affected, the chance of success from any means to be attempted is always propor- tionably lessened. The cord, indeed, may towards its under extremity be diseased, even in the same manner with the testis itself, without lessening the chance of benefit from the operation; but whenever the disorder has spread so far up the spermatic process as to render it doubtful whether the parts affected can be all re- moved by the knife or not, and especially when it is once rendered clear that the cord is diseased within the boundaries of the abdomen, instead of there being in such circumstances any advantage to be expected from the operation, every attempt towards the remov- al of the parts below, will for certain tend to aggra- vate every symptom, and will be a means therefore of forwarding the patient's death. Whenever a scirrhous or cancerous tumor is so sit- uated as to render its total removal by the knife quite practicable, it ought always to be advised; but when the disease has advanced so far as to render this im- possible, in whatever part of the body it may be situ- ated, no attempt of this kind ought to be made, the fact being now clearly ascertained, that cancerous af- fections are always rendered worse by extirpation, when all the diseased parts cannot be removed. It 286 Of the Sarcocele. Chap. IX. It is of much importance, however, to observe, that the spermatic cord is in this disorder frequently affected with a fullness and thickness of its parts, pro- duced merely by the weight of the tumor, without being in any other respect diseased. A fullness of this kind, when no pain occurs in the cord itself, and when there are no knots or inequalities upon its surface, ought never to prevent the operation, when in other respects it appears to be necessary; as a mere enlarge- ment of it very frequently occurs, either from a vari- cose state of the vessels, or from a watery deposition in the cellular substance of the part, when the process is not in any other manner diseased.* But on the contrary, when the cord, at the same time that it has become considerably enlarged, hard, and knotty, ad- heres to the neighbouring parts, is painful to the touch, and especially if it is already ulcerated; these, if the disorder extends over the whole process up to the ab- dominal muscles, are circumstances which, with every prudent practitioner, will at all times forbid the ope- ration of castration. It has indeed been proposed, in such a state of the cord, to enlarge the opening in the external oblique muscle, so as by dissection to trace the diseased parts even into the cavity of the abdomen, with a view to extirpate them entirely. But although theoretical writers may attempt to amuse their readers with such proposals, they will never be seriously thought of by practitioners whose opportunities for observation ena- ble them to think and act for themselves. We do not think it necessary to say any thing, either of the effect of internal medicines, or of external ap- plications, in the removal of this disease; for in the real sarcocele, or scirrhous testicle, no remedy with which we are acquainted has any kind of influence. Even * Of what is here inculcated we have some singular proofs in Mr. Pott's Collection of Cases, which we have so often referred to as a depository of useful facts. See Cases xxxix. xl, xlix. and l. Trea- tise on the Hydrocele. Chap. IX. Of the Sarcocele. 287 Even cicuta, the powers of which are so much extol- led, does not appear to be in any degree useful, either in carrying off the disorder entirely, or in mitigating any of its symptoms. The only remedy, therefore, from which we at present reasonably expect any ad- vantage, is the removal of the diseased parts by extir- pation; so that the most important matter to be here determined, is that period of the disease in which the operation is most advisable. We have already observed, that cases of scirrhous testicle do now and then occur with which patients go about for a great length of time with little or no in- convenience: Such instances, however, are exceeding- ly rare; for, by much the greatest proportion of all such affections, prove to be of a dangerous malignant nature. With respect to this point, therefore, we may short- ly determine, that, whenever a scirrhous or hardened state of the testicle does not yield to the means com- monly employed, such as moderate evacuations of blood when these are indicated; a soft easy diet; a lax belly; the use of a suspensory bandage; and espec- ially when mercury, which, on the chance of the dis- order being venereal, is very commonly tried, all are used without any effect; we may in such circum- stances always have great cause to suspect that the dis- ease is of a truly bad nature. When more inveterate symptoms appear; when the tumor, which till now was in a hard indolent state, becomes painful, and is evidently going on to acquire an additional bulk; no farther delay ought then to be advised: For however improper it would be to remove a hardened testis, which for a considerable time had remained indolent, without pain or any increase in bulk, yet it would be equally unpardonable in any practitioner to recom- mend a delay of the operation when matters are so far changed that the tumor is become painful, and is daily becoming larger. In such circumstances, the sooner 288 Of the Sarcocele. Chap. IX. sooner the diseased parts are removed, the greater will be the chance of a recovery, and not a day therefore should be lost. For whatever may have been the opinion of a few individuals on this point, it has long been a fixed maxim with the most experienced sur- geons, that, in all scirrhous or cancerous affections, the risk of a relapse after the operation is commonly in proportion to the duration of the original disease.* The extirpation of the testicle being at last deter- mined upon, the method of performing the operation is this; The patient must be placed in a horizontal posture on a table of a convenient height, with his legs hanging down, to be firmly secured by an assistant on each side. The parts being previously shaved, if the tumor is very large, an assistant must be employed to secure it properly; if only, however, of a moderate size, it is better for the surgeon to do it himself. With one hand, therefore, he ought to grasp the swelling so as to keep it firm; and with a scalpel in the other should make an incision along the whole course of it; beginning at least an inch above the part where the cord is to be cut, and continuing it through the skin and cellular substance to the inferior point of the scro- tum. The easiest method of doing this, we may ob- serve, both for the surgeon and patient, is by one con- tinued stroke of the knife; as it is both more quickly and more neatly performed in this manner, than in the usual way of pinching up the skin between the finger and thumb before cutting it; and there is no kind of difficulty or risk in doing it in the manner we have here directed. The spermatic cord being thus laid bare, the sur- geon is now with the finger and thumb of one hand to endeavour to separate the spermatic arteries and veins * The opinion of the late Mr. Sharpe on this point was singular in a man of such extensive experience. He considered the risk of a re- lapse after extirpation in cancerous tumors to be greater in the more early periods of these diseases than in their more advanced states. Critical Inquiry, 4th edit. p. 108. Chap. IX. Of the Sarcocele. 289 veins from the vas deferens; which is for the most part easily done, and which ought never to be omit- ted, for it is in no degree necessary to include the nerve in the ligature: And this being done, a firm, waxed, flat cord, composed of a number of small threads, is by means of the curved needle, Plate V, fig. 4, to be carried round the blood vessels, which are thus to be secured by a running knot about a quarter of an inch above that part of the cord which is to be divided. The cord being at this part cut across, the testicle is then to be entirely removed by dissecting the cord and it from above downwards, so as to separate them as easily as possible from the surrounding parts. Dif- ferent contrivances have been proposed for facilitating the separation of the testis from the contiguous parts; but no invention with which we are acquainted an- swers this purpose so well as a scalpel. When the diseased parts are all removed, the knot upon the cord should be united, in order to discover the spermatic artery and vein, which by means of the tenaculum may generally be separated from the nerve with which they are in contact; and whenever this can be done, they ought unquestionably to be secured in this manner; for, by including the nerve, no ad- vantage whatever is obtained, and it always renders this a very painful part of the operation. I have seen more pain, indeed, complained of in tying the sper- matic cord in the usual way, than I was ever witness to in any part of almost any operation; so that when- ever the nerve can be separated from the other parts, as it very commonly with a little attention may be, it ought always to be left out of the ligature.* When it so happens, however, that this cannot be done, the ligature must then be applied in the ordinary manner, and be made to surround the blood vessels and nerves indiscriminately; care being taken to make no more Oo pressure * Vide Chirurgical Cases and Observations, by Mr. Bromfield, Vol. I. p. 336. 290 Of the Sarcocele. Chap. IX. pressure with the knot than is just necessary for the preventing any discharge of blood. We have desired, that in securing the divided blood vessels, both the artery and veins, ought to be tied; for if the veins are not included in the ligature, a good deal of blood may be discharged from them, as they are not furnished with so many valves as the veins of other parts of the body. The cord passed at the upper part of the process is to be left entirely loose, and to serve only as a tour- niquet for securing the blood vessels more readily in case the ligatures passed upon them should accidentally slip. There is in fact no more necessity for allowing this ligature to remain tied, than there is for leav- ing a tourniquet firmly applied upon any of the ex- tremities after the operation of amputation; and yet, instead of one ligature of this kind, it has been the practice with many, to apply two, about half an inch distant from one another, by way of very great secu- rity; and these they leave firmly tied upon the whole substance of the cord during the cure of the sore.* There is, however, no kind of necessity for this precaution, as all manner of risk may be entirely pre- vented by securing the blood vessels in the manner we have here directed. I have often done the opera- tion in this way, and I never saw any inconvenience produced by it. By leaving the ligature at the up- per part of the wound untied, it may be made use of to compress the cord in the event of the blood vessels bursting out again: But when the operation it prop- erly done, this is an occurrence that will be very sel- dom met with; and at any rate, when it does unfor- tunately happen, it may be always prevented from producing much mischief by the ligature left for that purpose, and which may with safety be removed at the second or third dressing of the sore. In * Even the late Mr. Sharpe gives these directions. Treatise on the Operation of Surgery, 10th edit. p. 55. Chap. IX. Of the Sarcocele. 291 In making the ligature of the blood vessels at the extremity of the cord, if it is necessary to divide the process near to the abdominal muscles, as there is a possibility, of its retracting for a small space so as to get it within the ring, the ligature ought to be cut of such a length as to admit of this; a few inches of it, therefore, should be always left hanging over the sore, so that it may be pulled away at a proper time, in the event of any retraction taking place. But we may here observe, that this retraction never happens, when the cord has not been too much separated from the surrounding parts in endeavouring to introduce the ligature below it. Indeed, no farther separation should be attempted than merely to raise the cord so far as to get the point of the needle introduced be- tween it and the bone. In prosecuting the removal of the testicle, the scro- tal artery is necessarily divided, and it is sometimes of such a size as to discharge a great deal of blood; in which case it should always, before going farther, be secured by a ligature. The parts being all removed, and the different blood vessels all secured as we have here directed, a quantity of soft lint should be gently laid into the bot- tom of the fore; and a compress of linen being ap- plied over it, the whole should be secured either with the T bandage, or with the suspensory bag usually em- ployed in affections of the scrotum. The patient be- ing now laid to rest, and an opiate administered, the sore ought not to be touched till a free suppuration takes place, which will commonly be about the fifth or sixth day; and then the dressings should be re- moved, and renewed from time to time, once every two days or oftener, according as the quantity of mat- ter renders it necessary. Now and then, after this operation, the patient complains of much pain in the sore, and of tension and uneasiness in the belly; in which event, warm fomentations should be applied to 292 Of the Sarcocele. Chap. IX. to the abdomen, and the sore itself should be covered with an emollient poultice, to be repeated as often as may be necessary. In describing the manner of performing this opera- tion, we suppose it to be done in a case where the testicle has not arrived at any great bulk: In such a situation there is never any good reason for removing any part of the scrotum, as has been commonly ad- vised; * for if the teguments are not diseased, or ren- dered very thin by being much overstretched, they al- ways recover their tone very soon, and should not therefore be removed. But, when the skin has become very thin and in- flamed, and especially if any of it is actually in a state of ulceration, all such parts of it ought to be removed along with the testicle. In such circumstances the best method of doing it is this: Instead of a longitu- dinal incision along the course of the testicle, the first incision ought to be carried in a straight line to the under extremity of the spermatic cord; from whence two semilunar incisions ought to be continued to the under part of the scrotum, and should be made to in- clude all the parts of the skin that are in any degree diseased. In this situation the remainder of the operation ought to be exactly the same as we have already de- scribed: The skin included by the two semilunar cuts is not to be dissected off, but ought to be remov- ed at once with the diseased testicle. CHAP. * Mr. Sharpe in such cases advises a portion of the scrotum al- ways to be removed, p. 55. Loc. cit. Sect. I. Of the Phymosis. 293 CHAP. X. OF THE DISEASES OF THE PENIS. SECTION I. Of the PHYMOSIS. THE glans penis is naturally pro- vided with a covering termed the præputium; formed by an elongation and doubling of the skin. This in a healthy state is in general of such dimensions as to pass easily over the glans, but by disease it is frequent- ly prevented from doing so; and when the prepuce has got forward, and cannot be drawn back over the glans, the disease thereby produced is termed a Phymosis. This complaint is induced by whatever tends to swell the glans, or to excite inflammation and stric- ture in the preputium; and in some people, the pre- puce is so tight, as to render them liable to com- plaints of this nature from very trifling causes. An exsudation of a whitish, viscid matter between the prepuce and glans is natural to many; and the dis- ease now under consideration, is frequently the conse- quence of want of cleanliness, by which this matter is allowed to rest till it becomes acrid: But the most frequent cause of it undoubtedly is the application of the venereal virus to these parts, by venereal inter- course with diseased women. In 294 Of the Phymosis. Chap. X. In flight affections of this kind, especially when the disorder has not been of long continuance, fomenting the parts frequently in any warm emollient decoction, commonly gives relief; or what answers perhaps bet- ter for such purposes than any decoction, is warm milk; this, together with the use of emollient poul- tices with a view to relax the constricted preputium, will often answer so effectually as to render any other application unnecessary. At the same that fomentations and poultices are applying in this manner externally, part of the fo- mentation ought to be injected from time to time by means of a syringe between the prepuce and glans, in order to wash away any matter, either of concealed chancres, or that may be produced merely by the in- flammatory affection of the part. When the parts are much inflamed, bloodletting often proves serviceable: When the superficial veins of the penis can be opened, any blood to be discharg- ed should be taken from one of them by the lancet; but when they do not appear conspicuous, discharging it from the arm will answer as well as from any other part: Local bloodletting by means of leeches would be here particularly indicated; but when the disorder has originated from a venereal taint, the bites produc- ed by these animals almost constantly terminate in troublesome sores. Together with a discharge of blood proportioned to the strength of the patient, gen- tle laxatives should be prescribed, a low diet, and ab- stinence from exercise. When, however, it is found that even a due perse- verance in these means has no influence in removing the disorder, and especially if chancres are confined un- der the prepuce, which might injure the glans by the matter discharged from them not getting a proper vent, in that case it becomes necessary to remove the stricture by an incision carried along the whole course of the preputium. As  Plate XI. Sect. I. Of the Phymosis. 295 As the skin of the prepuce is exceedingly lax, it is almost impossible to cut it with neatness and accuracy in the ordinary way, either by a scalpel or bistoury; and when done in this manner, the skin yields so much before the instrument, as always to render it a very tedious and painful operation: Neither are the probe scissors well calculated for doing it properly, as the parts are commonly so thick as to be much bruised by the blades of the instrument. These inconveniences in this operation being ex- ceedingly obvious, many inventions have been pro- posed for effecting it more easily. In Plate XI, is represented an instrument which I had made for this purpose several years ago, and it answers the intention very effectually and with much ease. It consists of a director with a small curve at its extremity, to which a sharp pointed bistoury with a very narrow blade, is so exactly adapted, as to have the cutting part of it entirely concealed in the groove of the director, which ought to be about a quarter of an inch longer than the blade of the knife. The knife being inserted into the director so as to be concealed by it entirely, the instrument in this state is to be insinuated between the prepuce and glans on one side of the penis, till the director is found by the finger to have reached the upper end of the preputium. The operator is now to keep the director firm with one hand, and with the other is to push the knife for- ward, so as to make its point pass through the pre- puce; and the director being withdrawn, the opera- tion is finished by drawing the knife forward so as to make it divide the prepuce through its whole length along the side of the penis. In this manner the preputium is preserved in a tense state while the division is going on, by which means the operation is very easily accomplished: And by making the division on the side of the penis, the large veins of the part are avoided, which they could 296 Of the Phymosis. Chap. X. could scarcely be if the operation was done in the back part of it. The prepuce being thus divided, the parts below ought to be bathed with warm water so as to wash off effectually any acrid matter with which they may be covered; and this being done, the sore should be covered with a bit of soft lint; and a compress of old linen being laid over it, the whole may be very effec- tually retained by a small linen bag adapted to the size of the penis, to be secured by two straps pinned to a circular bandage made to surround the body. This bag must indeed be always removed when the patient makes water; but this is easily done; and it retains the dressings, not only more effectually, but with more ease to the patient, than is ever done either with ad- hesive plasters or any other form of bandage. In the after dressings of the sore, care should be taken to insert a piece of soft lint between the divided prepuce and glans, otherwise troublesome adhesions are apt to occur between them; I have met with sev- eral instances of this, which gave much distress to the patients, and which by a little nicety and attention in dressing the sores might very easily have been pre- vented. It is scarcely necessary to observe, that when any venereal infection subsists in the constitution, the sore produced by this operation will not readily heal, if the patient be not put under a proper mercurial course. In such circumstances therefore, if mercury has not been previously administered, it ought always to be prescribed immediately on the operation taking place. In some cases of phymosis, the preputium is found to be so very long, that instead of dividing it longi- tudinally, the operation of circumcision answers the purpose better; and it is very easily effected, by tak- ing away such a portion as may appear requisite, of the whole circumference of the prepuce. In such circumstances, when the prepuce is naturally too long, Sect. II. Of the Paraphymosis. 297 long, the removal of a quarter or half an inch of it often frees the patient from what even before the ap- proach of this disease he had found to be inconveni- ent; and as the removal of the extremity of the pre- puce in general allows the remainder to retract easily, the operation is accordingly now and then performed in this manner. SECTION II. Of the PARAPHYMOSIS. BY the term Paraphymosis is meant a morbid re- traction of the preputium, producing stricture be- hind the glans penis. This disease, like the former, is induced most frequently by a venereal taint: But it will arise from whatever tends to produce, either a preternatural fullness in the glans, or a constriction of the prepuce; and more especially from such causes as affect a complication of both. In the incipient state of this disorder, by a little at- tention and dexterity, the prepuce may be sometimes brought over the glans, by the surgeon pushing the nut gently back with both his thumbs, while his fin- gers are at the same time employed in moving the prepuce easily forward. In the more advanced state of the disease, however, no attempt of this kind ought to be made, as it is in the commencement of it only that it is ever known to succeed; and when it does not prove useful, it is apt to do harm, by inducing an increased degree of irritation in the parts to which the pressure is applied. As the paraphymosis seems evidently to be more frequently induced by an enlargement of the glans than by any original affection of the prepuce, so the stricture in the latter is not here so effectually relieved by warm fomentations, as it commonly is in the phy- mosis, where the disorder is most frequently produced Pp by 298 Of the Paraphymosis. Chap. X. by an affection of the prepuce itself. In the paraphy- mosis, indeed, I have often seen much harm done by applications of this kind; as they evidently tend to produce an increase in the swelling of the glans, by which the stricture in the prepuce is always propor- tionally increased. Nothing in general answers so well here as the sat- urnine applications. Such swellings, indeed, will often subside by being frequently immersed in a cold solution of saccharum saturni, when no other remedy has any influence. But, when the penis is evidently much swelled and inflamed, together with this appli- cation to the part, the patient ought to be kept cool, gentle laxatives should be prescribed, and discharg- ing blood from one of the superficial veins of the pe- nis is sometimes of use. By a due continuation of these means, and by keep- ing the patient on a low diet, this disorder will most frequently be removed: But when, notwithstanding the use of these remedies, the disease proceeds to in- crease, by the swelling in the glans becoming more considerable, and the stricture of the prepuce increas- ing, an œdematous swelling begins to appear in the latter, which on some occasions acquires a considera- ble degree of magnitude; and unless relief be now obtained by a complete removal of the stricture, mor- tification of the glans itself is very apt to occur. When, therefore, none of the remedies we have recommended prove effectual in preventing this stage of the disorder, we are now to attempt to remove the stricture by an operation; and the easiest method of performing this, is, with the shoulder of a lancet to make a deep scarification on each side of the penis, directly behind the glans; taking care to make each cut of about half an inch in length, and of such a depth as effectually to divide the prepuce just at its termination. The Sect. III. Amputation of the Penis, &c. 299 The parts ought now to be allowed to bleed freely, as this circumstance of itself in general affords imme- diate relief; and as soon as the hemorrhagy stops, a pledgit of any emollient ointment being applied to the sores, and a soft well made poultice being laid over the whole, if the scarifications have been carried en- tirely through the stricture, nothing farther will in general be necessary than dressing the parts daily with the same ointment with which they were at first cov- ered: But, if they have not been made of a proper depth, it will be afterwards necessary to renew them; when care must be taken to do the business effectually. In the phymosis, it was recommended to put the patient under a mercurial course whenever there is the least reason to suspect that any venereal taint sub- sists in the constitution; and the same precaution, it is evident, must be equally proper in cases of para- phymosis. SECTION III. Of AMPUTATION of the PENIS, &C. THE penis, like other parts of the body, is liable to disorders, which sometimes renders it necessary to remove the parts affected by amputation. Thus we know, that on some occasions the penis is seized with mortification, and it is frequently at- tacked with sores of the cancerous kind: And when mortification has been induced, either by a neglected paraphymosis or by any other cause, it becomes nec- essary to remove the diseased parts; as is likewise the case when any part of the penis is seized with a can- cerous sore, which, instead of healing by the means regularly employed for its removal, proceeds to turn worse. We have elsewhere entered fully into the consid- eration both of cancerous disorder and of mortifica- tion. 300 Amputation of the Penis, &c. Chap. X. tion.* To what was then said respecting the treatment of these affections we must now refer, and shall at pres- ent attend only to the operation of amputating the penis whenever it has become so diseased as to render this necessary. A circular incision ought to be first made through the sound skin at the farthest extremity of the sore, and the skin should be then drawn back by an assist- ant; when the body of the penis should be cut through by one stroke of the scalpel, care being taken to re- move every part that appears to be in any degree diseased. This being done, such arteries as bleed freely should be carefully searched for, and ought by all means to be secured by ligature. In general, two, and some- times three branches, of an artery will be met with; and they should all be secured in this manner. But even after the principal arteries have been tied, a con- siderable oozing of blood usually occurs from the sur- face of the sore, which the sprinkling with starch or gum arabic in fine powder will sometimes command; but when this does not answer, a small silver cannula being introduced into the urethra, and retained there by a proper bandage, any farther discharge of blood may be very easily stopt by a slight compression made with a narrow roller upon the remaining parts. A very slight compression answers the purpose, such a degree of it indeed as has no influence in hurting the parts on which it is made; and as there is no necessity for the tube inserted into the urethra being of a great length, it is easily retained during the whole cure without being productive of much inconvenience. In Plate IX, fig. 4, is represented a tube which I have on different occasions used for this purpose. A. the tube itself; B. B. two ligatures for connecting it to a bandage passed round the patient's body. Heister * Vide Treatise on the Theory and Management of Ulcers, &c. Sect. III. Amputation of the Penis, &c. 301 Heister and some other authors, being afraid of the hemorrhagy produced by amputation of the penis, advise it to be done by means of a ligature. A lig- ature being applied, with sufficient firmness a little above the diseased parts, they are thereby made to fall off in the course of six or eight days; but when- ever a part can be removed by the scalpel, it is done with much more ease and certainty than by ligature. Others, again, have said, that there is little or no danger to be apprehended from any discharge of blood that can ever occur here; but this I know from ex- perience is far from being the case. In the course of one season, I had occasion to perform this operation three different times in the Royal Infirmary here; and in the first I was persuaded by a gentlemen who had found it in one case to succeed, not to secure the arteries by ligatures, but to trust entirely to compres- sion. This was accordingly done; but unfortunate- ly, in the course of an hour or two after the opera- tion, such a profuse hemorrhagy supervened as ter- minated in the patient's death. In the next that occurred I was resolved to secure every branch of an artery that could be laid hold of. Three different arteries were accordingly tied, and no hemorrhagy ensued. In the third operation two branches of an artery were secured; but a plentiful oozing still continuing from the sore, the silver tube abovementioned was introduced into the urethra, and a slight compression being made upon it, the hemor- rhagy was thereby effectually stopt. When any arteries that appear have been secured in the manner directed, the parts ought to be covered with pieces of soft lint sprinkled with starch or gum arabic in powder; and a compress of linen, with a hole in it large enough to pass over the canula in the urethra, being laid over the whole, and the T band- age being employed to retain it, all the dressings may in this manner be effectually secured. And the after treatment 302 Amputation of the Penis. Chap. X. treatment of the sore should be similar to that of wounds in any other part. In proceeding to this operation it ought to be kept in view, that the prepuce is frequently so much enlarged and ulcerated, as to give cause to suspect the glans and other parts below to be much diseased, when in reality they are perfectly found. I once saw an in- stance of this, where the appearances previous to the operation were such as gave no reason to doubt of the glans being affected; and the prepuce with part of the penis were accordingly taken off, when it afterwards appeared that the glans might have been saved, as the disease was found to be entirely confined to the prepuce. In every case, therefore, where there is not an ab- solute certainty of the glans being affected, all the dis- eased prepuce should be first removed; and the state of the parts below being examined, if they are found to be so much affected as to render amputation nec- essary, this can be then done with as much ease as if they had been taken off along with the prepuce; and on the contrary, if they are discovered to be found, both the surgeon and patient will have much cause to rejoice. It sometimes happens, that the frenum of the penis is so short as to create good deal of uneasiness to the parts when in a state of erection. But as there is no danger to be dreaded from a division of this ligament, whenever it proves troublesome it may with great safety be cut across; and it is very easily done with a pair of probe pointed scissors: After the frenum is fairly divided, a bit of soft lint ought to be inserted between the lips of the wound, otherwise the parts newly separated will be apt to reunite immediately. On some occasions, the urethra in male children is found to be incomplete, by terminating before it reaches the extremity of the yard. Now and then it does so without any external opening, and at other times Sect. III. Amputation of the Penis. 303 times it terminates by a small orifice at some distance from the end of the penis. When no opening is discovered outwardly, if the urine is found to stop at any particular part, the intro- duction of a small trocar from the point of the yard along the course that the urethra ought to take, and carrying it forward till it meets with the urine, will always afford immediate relief; and by the use of small bougies the sides of the passage may be render- ed callous, and a clear opening be thus preserved, But when any opening is discovered, although it should not be properly placed, yet if it affords a tem- porary passage to the urine, it is better to delay the operation till the patient is somewhat advanced in life; and on an opening being then made with a tro- car in the manner we have mentioned, a piece of flex- ible catheter may be introduced, not only for preserv- ing the passage free and pervious, but for carrying off the water till a cure is obtained. In the earlier peri- ods of childhood, the smallness of parts through which it ought to pass, renders the flexible catheter altogeth- er inadmissible. Independently of these affections of the penis which we have been just considering, fistulous openings fre- quently occur in the urethra, and they are always pro- ductive of much distress. These we shall attend to when we come to treat of the Fistula in Ano and Perinæo; and the treatment of Stones impacted in the Urethra, will fall to be considered under the opera- tion of Lithotomy. CHAP. 304 Of the Stone. Chap. XI. CHAP. XI. OF THE STONE. SECTION I. GENERAL REMARKS on URINARY CALCULI. PARTICLES of stone have been known to form in almost every cavity of the body, but they are more frequently met with in the organs of urine than in other parts. It is the effects which calculi produce in the urinary passages, with the means which have been found the safest and most effectual for removing them, that we are now to consider. The blood, as well as the various secretions which it affords, are, by experiment, found to contain a con- siderable proportion of earth: When this earthy part of our fluids is in a proper or natural quantity, and when no cause occurs to effect a separation of it, it continues to circulate along with the other parts of which these fluids are composed; and in such a state it is never productive of any inconvenience. A vari- ety of causes, however, may concur to produce a dep- osition of this earthy matter from the blood and its secretions. 1. We know, that every liquid can dissolve and keep suspended a certain quantity, and no more, of those substances of which it is the proper menstruum; and it is likewise known, when a greater proportion than Sect. I. Of the Stone. 305 than this is added, that a separation and consequent deposition takes place of all the additional quantity. In like manner, we may suppose, if the lacteal ves- sels ever become so diseased as to absorb a greater proportion of earthy matter from the contents of the intestines than the quantity of fluids in the circulating system can keep suspended, that this superabundance of earth must necessarily separate from the rest: And the depositions thus produced, are much more likely to occur in the bladder and kidneys, than in other parts, from the urine being known to contain a great- er proportion of earth than any of the other secretions. 2. Independent of other causes which may tend to induce a superabundant quantity of earthy matter in the blood, such articles of diet as contain a large pro- portion of any kind of earth have been supposed to be more productive of it than others: But unless such quantities of earth as are contained in food, be conveyed in a state of the most perfect fluidity, any effect which this may produce on the general mass of blood cannot probably be of much importance. There is much reason, however, to think, that a long continued use, either of water, or of wines, abounding with earth in a dissolved state, has a considerable ten- dency to produce such a state of the blood as we are now describing. 3. People who are much accustomed to live upon solid food, will be more liable to the effects of a large proportion of earthy matter in the blood, than those who by a free use of liquids are in the habit of pre- serving a more plentiful and more diluted state of the different secretions. And, accordingly, in such pa- tients as are frequently voiding particles of sand, and even of real calculi, I have known more advantages derived from a continued and plentiful use of diluent drinks, than from any other remedy. A liberal use of watery fluids may, no doubt, operate to much ad- vantage, by washing away particles of sand and of Qq stone 306 Of the Stone. Chap. XI. stone already formed and lodged in some of the uri- nary passages; but they seem likewise to prove ser- viceable, merely by their diluent properties. 4. A superabundance of earthy matter being once produced in the blood, various circumstances will concur to form depositions of it in the different cavi- ties: Of these a sedentary life is, perhaps, one of the most remarkable; and hence it is, that such people are found to be most liable to calculous complaints, whose occupations require the least bodily exertion. It must, indeed, be acknowledged, that stone in the bladder is frequently met with among indigent and industrious labourers; whose necessities, at all times, prevent their indulging in indolence. In such instances, however, it may be supposed, that the very coarse articles of food, with which people in this line of life are chiefly nourished, will tend to impregnate the blood with such a large proportion of earth, as must necessarily produce effects not to be obviated even by the beneficial influence of a continued and reg- ular course of exercise. 5. Whatever influence a predisposition in the sys- tem may have in the formation of calculus and in its subsequent increase of bulk, the introduction of any substance that can serve as a nucleus, will almost cer- tainly produce a stone, in whatever cavity it is lodged. Thus, a particle of sand, of blood, or coagulable lymph, may, in consequence of spasm or inflamma- tion, be confined in the pelvis of one of the kidneys, or in the cavity of the bladder, and may soon acquire such a size, from the constant addition of earthy mat- ter it is receiving, as to make it impossible for the u- rine to carry it off: And urinary calculi, thus begun to be formed, will acquire, sooner or later, a consid- erable bulk, according to the quantity of earth with which the urine is impregnated. Thus instances have occurred of stones becoming very large, in the space of a few months from the first obvious symptoms produced Sect. I. Of the Stone. 307 produced by them; while, on other occasions, they have been known to remain in the bladder for a great many years without arriving at any size of impor- tance. When speaking of nuclei, it is necessary to remark, that their effect in the formation of calculi, in the urinary passages especially, appears to be so great, that it may be doubted whether a stone is ever known to form in these parts without the intervention of this cause; for, however large the quantity of earth con- tained in urine may be, it would probably all flow off by the urethra, if it was not detained by the accidental introduction or formation of a nucleus. Nuclei of different kinds, such as hairs, needles, musket and pistol bullets, pieces of bougies, and a variety of other articles, have been met with in the centre of urinary calculi; but particles of blood, or of coagulable lymph, are most frequently found to produce them. By the difference of food used at different periods of the disorder; by the stone being formed slowly or more quickly; and, perhaps, by the intervention of other causes which are not always known, and which, when known, cannot be easily explained; it com- monly happens, that the different lamellæ of which human calculi are composed, vary considerably both in colour and consistence; a crust of a soft friable na- ture being frequently known to cover one of a tex- ture equal in hardness to the most solid marble; while this again is found to surround a stratum not firmer than a piece of dough. Whatever may be the immediate cause of this dif- ference of consistence in stones, and even of different parts of the same stone, is of little importance in prac- tice: But we know from experience, that the symp- toms produced by calculi formed of hard compact materials, are in general more severe than such as arise from those of a softer texture; and we likewise know 308 Of the Stone. Chap. XI. know, that the surface of stones being smooth or rag- ged, has much more influence than any other circum- stance in the violence of the symptoms which they produce: Much variety too, it may be remarked, is met with in human calculi with respect to the smooth- ness of their surfaces; some of them being perfectly polished, while others are altogether covered with hard sharp spicula. The violence of symptoms in affections of this na- ture, is frequently found to be in a great measure in proportion to the size of stones; stones of the great- est bulk being commonly attended with the most se- vere pain. This, however, is not universally the case: For instances sometimes occur of the most se- vere symptoms being induced by stones of no great bulk; whilst in others, stones of considerable mag- nitude have been known to subsist for a great length of time without being productive of much pain: But in general it is otherwise, and the symptoms which take place are most frequently mild or severe accord- ing as the stone by which they are produced is of a small or large size. When a stone in the bladder has acquired such a size as prevents it from passing off by the urethra, the patient becomes liable to a set of symptoms which from their commencement are productive of much uneasiness; and which, in the event, commonly ter- minate in the most afflicting scenes of distress to which the human frame is liable. One of the first symp- toms in this disorder, is an uneasy sensation at the extremity of the urethra, which for some time is only discovered on the patient taking violent and jolting exercise, or immediately after voiding urine. This pain by degrees becomes more frequent and more severe. The patient has a strong propensity to pass urine frequently; and commonly voids it in small quantities, perhaps even drop by drop. When Sect. I. Of the Stone. 309 When flowing in a full stream, it often stops sud- denly; and this it is most apt to do when there is a considerable quantity of urine collected, and when of course the patient's desire of voiding it is strongest. Nor does the pressure usually employed on such oc- casions answer any good purpose: For, as the inter- ruption to the flow of urine proceeds from the weight of the stone bearing against the neck of the bladder and orifice of the urethra, nothing will produce a free return of it but an alteration in the site of the stone; which will be most readily affected by the patient changing the posture of his body, and particularly by the pelvis being more or less elevated. The urine of calculous patients is sometimes per- fectly clear: But most frequently it is thick, and de- posits a mucous sediment; and on some occasions, when the disorder is violent, and when the paroxysms return frequently, it is tinged with blood. When the stone is large, a dull uneasy sensation is at all times experienced about the neck of the bladder; and the irritation produced by it frequently induces a very troublesome tenesmus, or a constant desire to evacuate the contents of the rectum. All these symptoms are uniformly aggravated by exercise, particularly by riding on horseback; and from a long continuance of pain, and from that want of rest which frequent returns of the paroxysms are sure to induce, the patient's state of health by degrees becomes much impaired; and unless some effectual means are now employed for removing the cause of the disorder, it commonly happens that his misery is only terminated by death. When all or most of the symptoms we have enu- merated occur in the same patient, there can be no great reason to doubt of the nature of the disorder; and we are rendered particularly certain of the exist- ence of calculous, when fragments of stone, or per- haps when sundry small stones, continue to be pass- ed 310 Of the Stone. Chap. XI. ed from time to time along with the urine: But when this last circumstance does not occur, we can never know with certainty whether the attending symptoms originate from a stone or not; for instances frequently happen of all the symptoms usually pro- duced by stone in the bladder, arising from an ulcer or tumor either in the body of that organ or in its neck, or even from tumors on the contiguous parts which press upon the neck of the bladder. A person much accustomed to this part of prac- tice, will in general be able to determine from the symptoms which occur, whether a stone actually ex- ists in the bladder or not; but the only certain means we have of judging of this matter is through the in- tervention of a sound, or curved probe; different sizes of which are represented in Plate XII. By in- troducing this instrument into the bladder, in the manner we shall afterwards direct, if it touches a stone, such a sensation is thereby communicated to the operator, as renders the nature of the disease alto- gether certain; a circumstance of which we can nev- er be clearly convinced by any other means. Among other causes which concur to prevent any certainty from being obtained on this point, except from the test of sounding, is, that the very same set of symptoms with those produced by a stone in the bladder, frequently occur from a stone impacted in one of the ureters, or perhaps even in the pelvis of one of the kidneys. A stone in the kidney is com- monly indeed attended with symptoms which do not often proceed from a stone in the bladder; particu- larly with pain in the back, with frequent nausea, retching, and vomiting: But these do not always oc- cur from calculi in these parts; and when they do not, the other symptoms produced by them are frequently so similar to those which originate from a stone in the bladder, as to render it impossible to judge with cer- tainty Sect. II. Of the Stone. 311 tainty of the true nature of the disorder by any other means than by sounding. SECTION II. Of SOUNDING or SEARCHING for the STONE. IT will be proper, before describing the operation of sounding, to give an anatomical description of such parts as are concerned in it; and at the same time we shall exhibit an account of those parts that are most immediately affected by the various operations of lithotomy: These are, the kidneys, ureters, urinary bladder, pelvis, vesiculæ seminales and their ducts, prostate gland, urethra, penis, some of the muscles of the penis, and part of the abdominal muscles. A minute description of these parts would lead to an extensive discussion inconsistent with the nature of this undertaking; and as such a description is by no means essentially necessary, we will only endeavour to give such an idea of the situation of the parts, as will serve to render intelligible what may be said upon any of the operations of which we shall afterwards have occasion to treat. The kidneys are two glandular bodies lying in the back part of the abdomen, on the upper part of the psoæ muscles; the right being situated immediately below the great lobe of the liver, and the left under the spleen; and they are both, we may remark, al- most completely covered by the slight curvatures of the inferior false ribs. They are supplied with blood vessels, termed the Emulgent Arteries and Veins, di- rectly from the trunks of the aorta and vena cava. The use of these organs is to separate the urine from the blood, which, as soon as it is secreted, is carried by means of two canals or tubes, one from each kid- ney, termed the Ureters, directly to the vesica urina- ria. The ureters, after leaving the kidneys, proceed obliquely 312 Of the Stone. Chap. XI. obliquely downwards behind the spermatic vessels over the os sacrum; and passing in between the bladder and rectum, they are inserted into the former near to its neck, at a small distance from one another; and after piercing the external coat of the bladder, they run obliquely for a short space between it and the more internal covering of that organ before penetrat- ing its cavity: A construction well calculated for pre- venting a reflux of urine to the kidneys. The pelvis is a kind of box or basin, formed by a conjunction of the os sacrum, os coccyx, and ossa in- nominata. The cavity formed by a particular com- bination of these parts, being intended for the protec- tion of the bladder, and some other organs, is every where surrounded with bone, or with very strong liga- ments, except at its upper and inferiour parts, where alone the cavity of the pelvis is accessible, being here covered with soft parts only. The greatest part of the cavity of the pelvis is occupied by the bladder; which, when distended with urine, fills it almost en- tirely and on many occasions even ascends considera- bly above its brim. The bladder, or receptacle of the urine, is a mem- branous bag composed of different coats, one of which is evidently muscular, with its fibres running in differ- ent directions. The human bladder is of an irregu- lar oblong figure. The superior part of it has com- monly been termed its Fundus, or Bottom: The op- posite extremity lying at the bottom of the pelvis, is termed the Cervix or Neck; and the intermediate space, its Middle or Body. The bladder is every where nearly, though not exactly, of the same diame- ter, except at its fundus, where it is somewhat con- tracted; and again near to its neck, where it dilates considerably, extending back towards the coccyx. The superior part of the bladder is covered with the peritonæum; and it therefore lies, along with the other abdominal viscera, within the abdominal cavity; but Sect. II. Of the Stone. 313 but the under part of it is not covered with that mem- brane. The anterior under part of the bladder is connected by cellular substance to the pubes; lateral- ly, it is fixed by productions of its external covering to the other bones of the pelvis; and posteriorly, it is in male subjects firmly connected with the rectum, from the entrance of that gut into the pelvis, till with- in a little of its termination in the anus, when the neck of the bladder and commencement of the urethra sep- arate a little from the gut, leaving a space which is occupied with fat and cellular substance. In females, the uterus, in an unimpregnated state, lies altogether in the cavity of the pelvis immediately behind the bladder; and the vagina, in which the os tincæ terminates, lies directly behind the urethra, and before or upon the intestinum rectum, to which it is firmly attached. The heck of the bladder terminates in the com- mencement of a cylindrical membranous canal, the urethra, which comes off at nearly a right angle from the anterior part of it. The urethra, at its com- mencement, is surrounded by the prostate, a gland of a flat pyramidal shape, with its base towards the blad- der, and its apex pointing to the perinæum; its su- perior lamella being connected with the pubes, and its inferior part with the anterior and under part of the rectum. The urethra continues to be entirely membranous for a short space after it leaves the apex of the pros- tate gland; and this part of it keeps in close contact with the ossa pubis, till it passes out from below the arch formed by these bones, which it does by making a pretty sharp curve in its progress to the perinæum. This curvature in the urethra it is material to be well acquainted with, for in the operation of Sounding a good deal depends upon this circumstance. A good anatomist in general finds the introduction of a staff very easily accomplished, while those who are not ver- Rr sant 314 Of the Stone. Chap. XI. sant in the anatomy of the parts concerned, are not only apt to fail entirely in attempts of this kind, but are sure to put their patients to a great deal of unnec- essary pain. The commencement of the urethra, which we have just described, is termed the Membranous part of it; which, before it has proceeded an inch from the ex- tremity of the prostate gland, is surrounded by a cel- lular kind of body termed the Corpus Spongiosum Urethræ, which here forms a kind of protuberance termed the Bulb of the Urethra; and which after- wards proceeds along in a more diffused state to the extremity of the penis, where, by expanding again, it terminates in the formation of the glans penis. The rest of the penis is formed of the preputium, which, as we have elsewhere said,* is merely a doub- ling of the skin, and of two round cavernous bodies, termed the Corpora Cavernosa Penis, which origin- ate by two crura or legs from part of the os ischium and posterior part of the pubes on each side; and having united near the symphysis pubis, they thus form the principal part of the body of the penis, and are continued to the glans, with which they are con- nected, but with which the cellular or cavernous parts of these bodies have no direct communication. By the junction of the two cavernous parts of the penis, which are nearly round, a kind of hollow is formed both above and below. In the former of these, or in that vacuity which runs along the back part of the penis, the principal veins of the penis run; and the urethra is protected by the latter. The ob- vious use of the urethra is to serve as a passage for the urine and semen; the receptacle of the former we have already described, and we shall now mention those of the latter. The semen, after being secreted by the testes, is, by two very small tubes termed Vasa Deferentia, lodged in the vesiculæ seminales, which are * Chap. X, Section I. Sect. II. Of the Stone. 315 are found to be two cellular kind of canals, contorted in such a manner as when distended to resemble the intestines of a small fowl. They are seated on the posterior part of the neck of the bladder, below the entrance of the ureters, and lie in close contact with the rectum; and the semen is again discharged from these receptacles by two excretaory ducts, which ter- minate in two points, at a part which, from its figure, has been termed the Caput Gallinaginis, situated in the inferior side of the urethra, nearly about the mid- dle of the prostate gland; and a little below the en- trance of these canals from the vesiculæ seminales, the two excretory ducts of the prostate gland empty themselves into the urethra. The muscles we have to mention here, as being liable to be injured by the operation of lithotomy, are the erectores penis, accelerators urinæ, transver- sales perinæi, and levator ani. The erector penis arises from the tuberosity of the ischium; and after covering almost completely the crus penis of the same side, it is inserted by a tendinous expansion into the superior part of the penis, near to where it joins with its fellow of the opposite side. The accelerator urinæ arises by fleshy fibres from the sphincter ani and contiguous soft parts; and after covering the membranous part of the urethra it is in- serted into the middle of the bulb, where it joins with a similar muscle of the opposite side: Part of these muscles, too, run along the crura penis, and are after- wards lost in the ligamentous covering of the corpora cavernosa. The transversales perinæi, are two thin nar- row muscles which originate from the firm membranous covering of the tuberosity of the ischium, and, after stretching directly inwards, are inserted into the bulb of the urethra. Besides these muscles, which all suffer more or less in the lateral operation of lithotomy, a few fibres of the levator ani are necessarily cut in the same opera- tion; 316 Of the Stone. Chap. XI. tion; and in the high operation for the stone, part of the musculus transversalis abdominis, of the rectus, and pyramidalis, are also cut. Almost all the parts we have described are fur- nished with blood by branches from the internal il- iac artery; and those vessels which run most hazard of being cut in the lateral operation for the stone, are, the arteria pudica interna, and the pudica exter- na: For the former supplies not only the parts about the anus, but the bulb of the urethra and the corpora cavernosa; and the latter, viz. the pudica externa, sup- plies a great part of the bladder, the prostate gland, and vesiculæ seminales. Having thus premised all that is necessary for our purpose, of the anatomy of these parts, we shall now proceed to the operation of founding. For the purpose of discharging water collected in the bladder, a curved silver tube is made use of, nam- ed a catheter; different forms of which are delineated in Plates XIV and XV: But for detecting a stone in the bladder, a solid instrument made of steel is preferable, as the sensation communicated through the intervention of a firm substance is much more distinct than when an instrument of silver or of any other softer materials is employed. In females, the urethra runs almost in a straight line; so that an in- strument either altogether straight or nearly so, is more easily introduced than one with a large curva- ture: But in male subjects, the turn made by the u- rethra, when it passes up between the rectum and pubes, is so considerable as to preclude entirely the introdudion of a straight instrument, unless much vi- olence is used. By preserving the penis at an acute angle with the body, the course of the urethra may indeed be rendered so straight, that a straight probe may be easily introduced till it reaches this turn to- wards the farther extremity of the perinæum; but the curvature made by the urethra at this place, ren- ders  Plate XII. Sect. II. Of the Stone. 317 ders it necessary to employ an instrument with a cor- responding degree of convexity. The curvatures commonly given to these instru- ments are either too great, or not considerable enough. Either extreme renders it difficult to obtain a passage into the bladder: For when the staff is made with more convexity than is necessary, besides being more difficult to introduce, it gives a great deal of unneces- sary pain, by stretching the urethra very considerably; nor can such an instrument, with a large convexity, be so easily managed, when in the bladder, as when the curvature given to it is less. In Plate I, founds of various sizes are represented, and of such degrees of curvature as by experience have been found to an- swer better than any other. They are taken exactly from the natural curvature of the urethra, the instru- ments from whence these are delineated having been exactly adapted to that passage, after the surrounding parts were dissected off. The patient to be sounded should be laid upon a bed, with his thighs somewhat elevated, and separated from one another; and the surgeon being placed up- on his left side, ought to take a sound of a size pro- portioned to the passage intended to receive it: Hav- ing previously brought it to the heat of the patient's body by immersion in warm water, and having rub- bed it over with fine oil, he is now to grasp the penis with his left hand; and, having introduced the point of the sound into the urethra, with its concave side towards the abdomen of the patient, he must push it easily forwards with his right hand, while at the same time he continues with his left hand to draw the penis gently forward upon the instrument. The sound being in this manner carried a suffi- cient length, it will commonly slip into the bladder; but, occasionally, some difficulty is experi- enced in passing it through that part of the urethra where it is surrounded by the prostate gland, the instru- ment 318 Of the Stone. Chap. XI. ment being apt to stop when it comes to this part of the passage; and whenever it does so, practitioners ought to be extremely cautious in the force they employ for carrying it on. That part of the urethra, immedi- ately anterior to the prostate gland, being entirely membranous and unsupported, if the sound at this part meets with any obstruction, and if it is still con- tinued to be pushed forward with any considerable force, much mischief will for certain be produced, by the point of the instrument being forced entirely through the urethra; by which, instead of getting in- to the bladder, it will form an artificial passage, ei- ther between the bladder and pubes, or between the bladder and rectum: An occurrence which is sure to be productive of much distress; and which, there is reason to fear, is, either from ignorance or inattention in practitioners, much more frequent than it ought to be. In order to guard against the very dreadful conse- quences of such an occurrence, as soon as any obstruc- tion is discovered to the passage of the instrument, the fore finger of the left hand, after being well oiled, ought to be introduced into the rectum, which by elevating the point of the staff, while at the same time it is pushed gently forward, will commonly procure its ready entrance to the bladder when no other means have any effect. By depressing the handle of the sound we may also elevate the point of it, and in this manner its entrance into the bladder may be sometimes effected; but in general the introduction of the finger into the rectum answers this purpose with much more certainty. This passage of the staff into the bladder, it may be observed, is a very nice operation; and a dexteri- ty in performing it can be acquired by no other means than by a great deal of practice. Every stu- dent, therefore, ought to embrace all opportunities that occur of practising it, first on the dead subject, and Sect. II. Of the Stone. 319 and afterwards on the living. For every candid practitioner must acknowledge, that he has, on differ- ent occasions, found the introduction of a catheter, or of a sound, to be a matter of much difficulty. But when the parts concerned are not materially affected with inflammation, swelling, or ulceration, the opera- tion does not frequently misgive in the hands of an expert surgeon. The staff being thus introduced into the bladder, the operator must now take hold of the handle of the instrument with one hand; and if any part of it falls immediately upon the stone, the business of sounding is at once accomplished, as a certainty is thus obtain- ed of the nature of the disease: But if the stone is not soon discovered, it may commonly be found by mov- ing the instrument so as to make its point pass easily from one side of the bladder to the other. When the stone, however, is small, and has fallen into that part of the bladder which lies below the entrance of the urethra, the staff is very apt to pass over it entirely. With a view to obviate this difficulty, the finger of the left hand may be again introduced into the rec- tum, so as to elevate that part of the bladder in which the stone most probably lies concealed. If, again, even this attempt should be found to fail, the patient's body should be put into a different posture; and no situation will, in general, answer so effectually as low- ering the head and upper part of the body, while at the same time the pelvis is considerably raised. By this means a stone, if it be not contained in a particu- lar cyst, which it rarely is, may be moved from the projection at the neck of the bladder towards its fun- dus, where it will be more readily struck with the sound. But when even by this posture of the body we fail in obtaining a certainty with respect to the ex- istence of a stone, every variety of position ought to be tried: The patient's head may be elevated, and the pelvis depressed; he may be made to stand erect; or, what 320 Of the Stone. Chap. XI. what I have sometimes known to succeed after other attempts had failed, he may be made to stand upon his feet, with his body as much bended forward as possible. It sometimes, however, happens, when the stone is very small, and the capacity of the bladder is large, that our first attempt in sounding fails altogether; but when the symptoms of stone are strongly marked, and when scirrhosity and ulceration of the parts which might give rise to these symptoms are not found to exist, we ought not to rest satisfied with one or even with two trials. I have known a stone discovered on the third or fourth sounding, which had escaped the instrument in all the preceding trials. When a stone is struck by the staff, the sensation it communicates to the operator is of such a particular nature, as to render it impossible for any person ver- sant in matters of this kind to be deceived by it if he attends sufficiently to the business he is about: But, to those not much accustomed to this part of practice, a hardened state of the bladder itself communicates such a sensation through the staff, as frequently proves the cause of most unfortunate deceptions. Occur- rences of this kind have even happened to practition- ers of much experience: It is reported of the most celebrated lithotomist of this, or perhaps any other country, that in the course of his practice, which in- deed was very extensive three patients were cut by him in whom no stones were discovered, and where a scirrhous, or hardened state of the bladder, had given rise to the mistake.* With practitioners of experi- ence, however, this can never happen but from gross inattention; for I will venture to affirm, that a person who is once accustomed to know the nature of that sensation communicated by a stone, can never, if he attends properly to what he is doing, be deceived by the * The late Mr. Cheselden, Sect. III. Of the Stone. 321 the application of the sound to a scirrhous or any other tumor. There being the least hazard, however, of such a misfortune occurring as the one we have mentioned, namely, that of a patient being made to undergo all the pain and risk attending the operation of lithotomy, when no stone has existed, is a matter of such a seri- ous nature, as ought to render every practitioner ex- ceedingly attentive to this part of the operation. SECTION III. GENERAL REMARKS on the OPERATION of LITHOT- OMY. THE presence of a stone in the bladder being as- certained in the manner we have mentioned, the means to be employed for the patient's relief is the next object of consideration. At a certain period, the publick were much amus- ed with high encomiums on the lithontriptic powers of different articles, particularly of lime water, and of caustic alkali in a diluted state. But although some human calculi are soluble in either of these liquids, particularly in the latter when directly immersed in it, yet neither of them can be conveyed in such a state to the bladder as to be much depended on. Many patients, indeed, have experienced some relief from the use of these remedies: The pain has, by their means, been rendered somewhat less severe, and the paroxysms have apparently been rendered less frequent; but we have not one authenticated instance of a stone in the bladder being dissolved by the use of these, or of any remedy whatever. As the constituent principles of these and other li- thontriptic medicines, render them liable to very ma- terial changes in their passage through the circulation from the stomach to the bladder, it has been propos- Ss ed 322 Of the Stone. Chap. XLI. ed to convey remedies of this class directly into the bladder itself, in order to bring them into immediate contact with the stone; and machines have, accord- ingly, been invented for injecting with facility such medicines of this kind as are supposed to prove most effectual: But, after a great many trials have been made of remedies of this nature, it seems now to be universally allowed among practitioners, that no sol- vent, powerful enough to have any effect upon a stone can be injected into the bladder, but with the greatest hazard of injuring that organ in a very material man- ner. But as some practitioners still continue to think favorably of this practice, we have given a delineation, in Plate XX, of a machine by which liquids may with great ease be injected into the bladder. Every attempt, however, of this kind is now in general laid aside; and as no dependence is to be placed upon the lithontriptic powers of any medicine taken by the mouth, the only resource we have, is, the removal of the stone by a chirurgical operation. By this means, if the patient's constitution is not much impaired, he may again enjoy as good health as he did previous to the appearance of the disorder. And unless the ope- ration be submitted to, it is almost certain that the re- mainder of a miserable life will be cut short by the frequent returns of pain and fever to which people in this situation are constantly liable. It is to be remembered, however, that although a great proportion of those who are cut for the stone recover and do well, yet a considerable degree of dan- ger always attends the operation; so that, before ad- vising any person to submit to it, such circumstances ought to be considered with attention as can best en- able us to form a just prognosis of the event. By experience it is found, that children more read- ily recover from this operation than adults; and it is likewise observed, that old people, from the fifty fifth to the seventieth year, whose, constitutions have not been Sect. III. Of the Stone. 323 been much broke, run less risk from it than men in the full vigour of life. This difference may possibly arise from the inflammatory symptoms, which usually suc- ceed to this operation, being more apt to proceed to a dangerous length in young plethoric people than in older patients; and we know from experience, that more danger is to be dreaded from the effects of in- flammation after this operation, than from any other cause. But at whatever period of life the patient may be, if he is otherwise in good health, more success is to be expected from the operation, than if his consti- tution had been previously impaired by frequent re- turns of the disorder; and this especially if the dis- ease should have continued so long as to produce ul- ceration in any part of the bladder. In such a diseased state of the bladder as ulceration commonly induces, if the patient is far advanced in years, he could not expect much enjoyment of life, even although he should recover from the operation: In these circumstances, therefore, a prudent practi- tioner would rather decline to operate; and instead of this, he would advise a plentiful use of mucilagi- nous drinks; the use of the warm bath; together with doses of opiates proportioned to the degree of pain. By these means the violence of the disorder is sometimes mitigated, and the patient is thereby saved from the distress of a severe operation, the effects of which, in a constitution such as we have mentioned, are frequently sound to prove fatal. But, even in these circumstances, if the patient is at an early period of life; if he is suffering much from the disorder; and if he is not so weak as to render it probable that the quantity of blood usually lost in the operation may prove destructive to him; I would be clear and decided in advising the operation. His chance of recovery will, undoubtedly, be less than if his health had been otherwise unimpaired; but, if he is 324 Of the Stone. Chap. XI. is lucky enough to survive the operation, he may en- joy life with comfort and ease. When it is once determined to have recourse to the operation of extracting the stone, the next point of importance is the best method of effecting it. From the anatomical description we have given of the parts with which the human bladder is surrounded, it is evident, that there are only two parts of it which can with any propriety be laid open for this purpose. A considerable part of the fundus of the bladder we have shown to be covered with the peritonæum; so that to open it here would be attended with immi- nent danger, from the certainty of exposing the ab- dominal viscera, not only to the effects of the exter- nal atmosphere, but to the irritation of the urine evac- uated into the cavity of the peritonæum from the wound in the bladder. The posterior part of the bladder we have shown to be either immediately cov- ered with bone, or internally connected with parts which it would be highly improper to injure; and these particularly are, the rectum, the vesiculæ sem- inales, with the vasa deferentia and ureters. The only parts of the bladder, therefore, which we tin with propriety cut into, are, that portion of the an- terior part of it, which lies immediately below the peritonæum, and which, when in a state of distention, is raised somewhat above the pubes; where an inci- sion directly above the brim of the pelvis will lay that part of it bare where it is not covered by the perito- næum, and where accordingly an opening into it is commonly practicable: And, again, that portion of the bladder we have termed its neck, which may be opened laterally an incision in the perinæum, with- out any danger of wounding other parts of importance. It is in one or other of these parts that any opening into the bladder can be made with safety. Some practitioners, indeed, have attempted to cut into it at the posterior part of its neck, or even into the body of Sect. IV. Of the Stone. 325 of it at once; but the hazard of wounding parts of much importance is here so great, that for this and other reasons which we shall afterwards mention, ev- ery operation of this kind is now laid aside. We shall presently, however, enter more fully into the dis- cussion of this point, by giving a detail of the various means which have been proposed from the time of Celsus downwards, for the purpose of extracting stones from the bladder; and this we shall do in the order of time these different operations were introduced in- to practice. The distress and misery occasioned by urinary cal- culi were probably experienced in the early ages of the world. Relief, we may therefore suppose, would be sought for by the removal of the stones, as soon as such a sufficient knowledge of anatomy was obtained as could render attempts of this kind practicable. Accordingly we find, from the writings of Hippoc- rates, that, even at this early period, the operation for the stone was frequently performed; but as this branch of business was then solely practised by a particular set of men termed Lithotomists, no account is trans- mitted to us by this author of their method of per- forming it. Celsus is the first who describes the method of operating at the time when he lived; and it consisted in an opening being made in the body of the bladder, directly upon the stone itself. From the small number of instruments used in this method of cutting, it has been termed the operation by the Lesser Apparatus. SECTION IV. Of the OPERATION of LITHOTOMY by the LESSER APPARATUS. THE person to be cut being properly secured, the easiest and best method of effecting which we shall 326 Of the Stone. Chap. XI. shall describe when speaking of the lateral operation, the surgeon is then to dip the sore and middle fingers of his left hand in oil; and having introduced them into the anus of the patient, he is to search for the stone, and to push it forward towards the perinæum, directly below the pubes. In order to facilitate this part of the operation so as to get the stone properly fixed, the surgeon ought to press with his right hand upon the under part of the abdomen, at the same time that he is pushing the stone forward by his fin- gers in the rectum. By this means the stone is to be pressed forward below the pubes, and is to be secured upon one side of the perinæum, between these bones and the anus. This being done, we are directed by Celsus to make a semilunar cut through the skin, cel- lular substance, and muscles; beginning on one side of the anus, and carrying the cut directly over the centre of the tumor formed by the projection of the stone. The bladder being thus laid bare, a transverse incision is ordered to be made through the coats of it directly upon the stone; when the stone, if it is a small one, may probably be turned out by the fingers in the rectum pressing upon it from behind; but if it is large, and if it does not come away easily, we are desired by Celsus to take the assistance of a hook for scooping it out. This operation, with a few variations, continued, so far as we know, to be the only method of cutting for the stone, till the beginning of the fifteenth cen- tury, when another method of operating was intro- duced, which we shall afterwards relate particularly. Long after this period, however, this operation of Celsus was still continued by many regular practi- tioner; and the ease with which it is accomplished, essary for doing it, but from little or no anatomical knowledge being absolutely requisite, preserved it in constant use with Itinerants, who continued, even to a very Sect. IV. Of the Stone. 327 very late period, to practise it in different parts of Eu- rope, under the name of the operation upon the Gripe. This method of cutting for the stone is indeed so easily effected, particularly in young subjects, that, even in these times, many of our well informed prac- titioners have a strong partiality towards it. At so late a period as the time of Heister we find it was much in repute, that practitioner himself having been in the habit of performing it frequently. But sur- geons in general have been much deceived with re- spect to the parts injured by this operation: For it has been commonly supposed, that by cutting directly upon the stone, the bladder itself must alone be wound- ed, while all the neighbouring parts of importance are imagined to escape unhurt; a circumstance which would undoubtedly prove a strong recommendation of it, if on experience this was found to be the case: This, however, is far from being so, as any person who will make the experiment will readily perceive. A strict attention to the anatomy of the parts might at once indeed convince us of the difficulty, if not of the absolute impossibility, of cutting from the perinæum directly upon a stone of the bladder, without destroy- ing either the vasa deferentia, the vesiculæ seminales, or the excretory ducts of those receptacles; the de- struction of any of which would accomplish the effects of castration with as much certainty as a total extir- pation of the testes themselves. These parts we have shown to be all placed upon the under and back part of the bladder; and as they, as well as the ureters, are immediately connected with that part of it which is cut in this operation, it is perhaps impossible to per- form it without dividing one or other of them. As I had once a favorable opinion of this operation, I thought that on many occasions it might be usefully employed, if on experience it should be found that these pasts could be avoided by the scalpel. I accord- ingly put it frequently in practice on dead subjects; but 328 Of the Stone. Chap. XI. but although in all of them it was done with every pos- sible attention, it was constantly found either that the vesiculæ seminales were divided, or that their excre- tory ducts were cut across. This, however, was not all; for although in some instances the urethra was not touched, yet in others it was found to be com- pletely laid open before the scalpel reached the blad- der. In every instance where the operation is per- formed in the manner directed by Celsus, this circum- stance of injuring the urethra before opening the blad- der, is what must unavoidably happen: For it is al- together impracticable to make a transverse incision here into the bladder, as is advised by that author, without previously passing through part of the urethra; that canal at its farther extremity being always pushed forward by the fingers in the rectum, in such a man- ner as to render it impossible to avoid it in this meth- od of performing the operation. But in most of the trials of this kind which I had occasion to make upon dead subjects, I attempted what I should consider as a very material improve- ment of Celsus's method. A transverse or semilunar incision through the teguments and muscles I believe to be better adapted than any other for giving a free passage to the stone; but as the bladder is composed of a very dilatable membranous substance, there is no necessity for a transverse incision being made into it. After laying the bladder bare, therefore, by a semicir- cular cut along the course of the stone, instead of con- tinuing the same kind of incision with which the operation commenced, a longitudinal wound was made directly on the centre of the stone, in order to avoid with as much certainty as possible all those parts which ought not to be injured. Even with this precaution, however, although the urethra was avoid- ed, some of the other parts we have mentioned were always found to be divided; so that although they may by accident, perhaps, be avoided once in a great number Sect. IV. Of the Stone. 329 number of instances; I am confident that even the most expert anatomist would very seldom be able to make an opening into, this part of the bladder suffi- cient for extracting a stone even of a very moderate size, without dividing either the vesiculæ seminales, the vasa deferentia, or their excretory ducts. In some instances, too, the entrance of the ureters into the blad- der is so low down as to render them liable to be injured by this operation: This, however, is a rare occurrence; but it has on some occasions been known to happen. Another very material objection to this operation is, that the bladder when cut, being pushed forward and divided at a part which must afterwards recede from the external wound in the teguments, considera- ble risk must be thereby incurred of sinuses forming, by the urine insinuating itself into the neighbour- ing parts; and we have to add to all this, that in general this operation must be confined to the early periods of infancy. The readings of Celsus with which we are furnished, limits the performance of this operation to the age of ten, or from that to the four- teenth year; but this must surely be considered as an error in the late editions of that work, as the opera- tion of which we are now speaking is unquestionably better calculated for the earliest periods of infancy than for the more advanced stages of it, insomuch that it is always practicable with more or less ease, in proportion to the thickness of parts about the rectum and bladder; and this, again, we know depends in a great measure upon the age of the patient. We are told, indeed, of some practitioners who performed this operation on people of every age, of every habit of body, and whether corpulent or not: Such ac- counts, however, have never been well authenticated. Among other improvements of this operation of Celsus, the use of the forceps for extracting the stone was none of the most inconsiderable; but neither this, nor any other advantage it can receive, is capable of Tt obviating 330 Of the Stone. Chap. XI. obviating the difficulties we have mentioned. We find accordingly, that, about the beginning of the 16th century, some time between the year 1500 and 1520, a new method of operating for the stone was propos- ed at Rome, by Johannes de Romanis, as we are af- terwards informed by one of his pupils, Marianus, and whose name has been commonly given to it; this being termed the Methodus Mariana, or Lithot- omy by the Greater Apparatus, from the great number of instruments which on its first introduction were employed in it. SECTION V. Of LITHOTOMY by the GREATER APPARATUS. BY this operation a passage is made into the blad- der, by cutting into the urethra immediately at the bulb; and at this opening a variety of instruments were by ancient writers proposed to be introduced, for the purpose of dilating the passage to such a size as might easily admit of the extraction of the stone. From the period at which this operation was in- troduced, a number of inventions were proposed at different times, for the sole purpose of rendering the dilatation of the urethra and adjacent parts more easy. These it is unnecessary to enumerate, as an account of the operation as it was last practised in its most improved state, will serve to communicate all that is necessary to be known concerning it. The patient being properly secured, and placed up- on a table in the manner we shall describe more par- ticularly when treating of the lateral operation, a groov- ed staff was then introduced through the urethra into the bladder; the handle of the instrument being car- ried over the right groin, while its convex part was made to push out the urethra on the left side of the perinæum. In this position the staff was preserved by an Sect. V. Of the Stone. 331 an assistant, who likewise suspended the scrotum; while the operator, with a scalpel in his right hand, made an incision from the very bottom of the scrotum to within a finger's breadth of the anus, carrying it all along the left side of the perinæum, within a very lit- tle of the rapha. The skin, cellular substance, and muscles, being thus divided, the urethra itself was now opened at its bulb, by turning the back part of the knife towards the rectum, and cutting with the edge of it directly into the groove of the staff; and the incision was then completed by carrying it along to the extremity of the urethra, at the commencement of the prostate gland. Various instruments were at one period in use, termed Dilators, Male and Female Conductors, &c. &c. for the purpose of finishing the operation, by di- lating such parts as we have not here directed to be cut; and the timidity of some operators was even so great as to cause them to dilate almost all that part of the urethra which lies between the bulb and the prostate gland: A degree of caution by no means necessary, and which, by the violence done to the parts, was sure to be productive of many disagreeable con- sequences. Other practitioners, however, performing the operation so far in the manner we have mentioned, finished the remainder of it, first, by introducing a blunt gorget into the bladder by running its beak a- long the groove of the staff, and afterwards pushing it forward so as to force a passage through the prostate gland; and this being accomplished, the fore finger of the left hand was introduced along the gorget, and with it the passage was farther dilated, till the opera- tor thought the opening was sufficiently large for the stone to pass through it. The opening being in this manner finished, the stone was extracted in the manner we shall afterwards direct when treating of the lateral operation, by the use of different forceps adapted to the size of the parts: And 332 Of the Stone. Chap. XI. And in the extraction of the stone, all those parts which were not cut in the previous steps of the ope- ration, were of necessity very much lacerated. Although this operation was long practised, it is li- able to many objections. The number of instru- ments used in it is mentioned as one of these: But in the improved state of the operation we have described, this objection is entirely removed, no more instru- ments being used in it than are necessary in the most simple method of performing the lateral operation; namely, a scalpel, gorget, and forceps for extracting the stone. But the material objections to which it is liable, are, that by beginning the incision so near to the scrotum, much more of the urethra is cut than is necessary: By not dividing the prostate gland with a cutting instrument, such laceration is produced, first by the forcible introduction of the blunt gorget, and then by the extraction of the stone, as must be the cause of much irreparable mischief: And lastly, by the parts not being so freely divided as they ought to be, it must frequently be impossible to extract large stones by this operation, which, in the lateral method as it is now practised, would pass with tolerable ease. In other respects, however, this operation was possessed of much merit, and it required only to be improved in a few circumstances to become the real lateral op- eration of modern practitioners. These, however, it is unnecessary to dwell longer upon at present, as they will be afterwards particularly taken notice of when we come to treat of that operation. After this operation had been practised for thirty or forty years, some of the inconveniences attending it suggested the idea of what was afterwards termed the High Operation; an appellation it received from the bladder in it being cut into above the ossa pubis. About the year 1561, Franco, a French surgeon of this name, published a treatise on herniæ*; and here * Traité tres ample des Hernies, par Pierre Franco. Sect. VI. Of the Stone. 333 here we find the first account of the high operation that is to be met with in books. It was accident which suggested it to Franco; for having, as he in- forms us, met with a large stone in a child of two years of age, which he could not possibly extract by the operation as then practised in the perinæum, he was induced to open the bladder above the pubes: But although the stone was extracted and the child recovered, Franco never performed the operation a- gain himself; and he even advises it never to be at- tempted by others, from the great danger which he thinks will attend it. The next account which we find given of it is by Rosset, in a publication on this and some other sub- jects, published at Paris in the year 1590. But it does not appear that he ever performed the operation himself; nor was it any where much practised till some time after the commencement of the present century, when it was adopted and keenly patronized at London by Mr. Cheselden and Mr. Douglas. During the twelve or fifteen years immediately sub- sequent to the year 1720, the high operation was fre- quently performed both in London, Edinburgh, and other parts of Europe: But the lateral operation, with the improvements upon it by Rau, being then more generally known, the superior advantages it was found to possess very quickly procured it a preference; and since this period the high operation has never been generally practised, either in this or in any other country. But we shall now proceed to describe the method of performing it. SECTION VI. Of the HIGH OPERATION for the STONE. WE have already shown, that the bladder, at its fundus, or that part of it which lies highest in the pel- vis. 334 Of the Stone. Chap. XI. vis, is covered with the peritonæum; so that at this part no opening, it is evident, can be made into i with safety, as the operator would not only run the risk of wounding the intestines, but the urine would be apt to escape into the cavity of the abdomen. It is the anterior part of the bladder, viz. that space ly- ing between the middle of this viscus and its neck, which ought to be opened in this operation: But this part of the bladder is seldom sufficiently elevated for this purpose, unless when it is considerably distend- ed; and as one common effect of the stone in the bladder is to produce a diminished contracted state of it, this circumstance of itself is not an unfrequent ob- jection to this operation; for unless the bladder is capable of containing a considerable quantity, at least a pound and a half in an adult, it ought seldom, if ever, to be attempted. Various methods have been contrived for the pur- pose of distending the bladder. It has been proposed to effect it by means of air thrown into it from a pair of bellows; and others have recommended a quanti- ty of water to be injected into it immediately before the operation, and to retain it there by making a lig- ature upon the penis. Both of these methods, how- ever, will incur some risk of hurting the bladder by too sudden distention; and we are even told by some writers, that the bladder has been burst by attempts of this kind. Means, therefore, of a more harmless nature should be attempted; and it may be done, I think, without running any risk of injuring the blad- der, merely by desiring the patient to accustom him- self for a considerable time before the operation, to retain his urine as long as possible; and as soon as it is found that he can retain the quantity that is thought necessary, viz. a pound and an half in an adult, and so in proportion according to the age, by passing a ligature upon the penis ten or twelve hours before the operation, and ordering him to drink plentifully of any Sect. VI. Of the Stone. 335 any diluent drink, we may be almost certain of pro- ducing a sufficient degree of distention. This being done, the patient must be laid upon a firm table about three feet four inches in height; at the same time that his legs and arms must be proper- ly secured, not by ligatures, but by the hands of as- sistants. In order to guard as much as possible against any injury being done to the bowels, the patient ought to be laid with his head considerably lower than his body, and his thighs and buttocks a good deal elevat- ed. By this situation, too, the stone, which would otherwise fall into the neck of the bladder, where it could not be very accessible, will be brought more contiguous to the intended opening, and will hence be more easily laid hold of, either by a pair of forceps or by the fingers. The patient being thus properly secured, an incision is to be made with a roundedged scalpel, directly up- on one side of the linea alba, beginning about four inches above the ossa pubis, and continuing it down to the symphysis of these bones: Even the linea alba itself may be divided with perfect safety; but it is bet- ter to avoid it, as the incision is much more easily made in soft parts than in tendinous ligamentous sub- stances. The skin and cellular substance being freely divided, the recti and pyramid ales muscles come suc- cessively into view: In general, the incision may be carried on merely by separating these muscles from one another; but no detriment could ensue from some of their fibres being cut by the scalpel. A sufficient opening of the external parts being thus obtained, the operator is now to search with his fingers for the bladder; which he will commonly be sure to discover immediately above the pubes. With the fingers of his left hand he ought now to press back the peritonæum, with the intestines contained in it, and with the same scalpel with which the preceding steps of the operation were effected, he is to penetrate the 336 Of the Stone. Chap. XI. the bladder itself at its most prominent part. This opening into the bladder ought at once to be made so large as to receive the two fore fingers of the opera- tor's left hand; which being introduced, the incision is to be enlarged to the length of about three inches, by running a probe pointed bistoury along one of the fingers down towards one side of the neck of the bladder. The instant that the fingers are introduced into the bladder, the ligature upon the penis should be taken off; so as to admit of the water contained in it being evacuated by the urethra, otherwise the whole of it will be immediately discharged by the wound. The incision being completed in the manner we have directed, the operator ought to search with his fingers for the stone, and, if possible, he should extract it without the assistance of any instrument: But if this is found to be impracticable, the forceps must, no doubt, be employed. One great advantage at- tending this operation is, that as very little force is necessary for extracting the stone, so it is here rarely known to break: But when this misfortune occurs, the pieces will be more easily removed by the fingers alone, than with any of the scoops commonly employ- ed. The stones being removed, the superior part of the wound in the teguments ought to be drawn to- gether, either by the means of strong adhesive plasters, or by the twisted suture, care being taken to leave at least an inch and half in the under part of it open, in order to evacuate any urine that may be thrown out from the wound in the bladder into the contiguous parts. It might even be proper to keep the whole external incision open till the wound in the bladder is reunited; but as the bowels, supported now by the peritonæum only, would be apt to protrude at this opening, and as such an occurrence would prove not only troublesome, but even dangerous, it ought to be guarded against as much as possible. With Sect. VI. Of the Stone. 337 With this view the bowels should be kept open by the use of gentle laxatives, and the patient during the whole cure ought to be kept with his head and upper part of the body considerably lower than the pelvis. The parts cut in this operation are hot any where nearly surrounded by bone; on this account large stones can be extracted with more ease by this than by any other method: And as the wound in the bladder is made at a distance from its neck, fistulous openings are not so apt to ensue from it as from incisions made in the perinæum. These are two advantages which attend this mode of operating; but the objections to it are various. 1. When it is found that the bladder cannot admit of such distention as to be elevated above the ossa pu- bis, it is almost impossible to make an opening into it without dividing the peritonæum. Much danger must undoubtedly be the consequence of this, from the protrusion of the bowels which will probably oc- cur, from the access which is given to the external air, and from the urine escaping into the cavity of the abdomen. We are informed, indeed; by writers on this sub- ject; of a protrusion of part of the bowels having sometimes happened in the high operation, without any bad consequences being induced by it; the wounds being found to cure, and the patients after- wards to do as well as if no such occurrence had hap- pened. Such favorable terminations, however, of accidents of this kind could not probably be frequent; and this is, accordingly a very strong objection to the high operation. 2. After the high operation, and during the whole course of the cure, the urine, in many instances, passes readily by the urethra; but it happens not unfre- quently, in consequence of inflammation about the neck of the bladder or some other cause, that the nat- ural course of the urine is obstructed. In these in- Uu stances, 338 Of the Stone. Chap. XI. stances, from the wound in this operation being made in the anterior part of the bladder, the urine is very apt to be diffused in the cellular substance between the peritonæum and abdominal muscles, and between the bladder and pubes; and as no proper vent can be procured for it, sinuses are frequently produced, which always terminate in much distress. 3. It has been observed, whenever the patient's habit of body is not altogether good, that it is almost impossible to obtain a cure either of the wound of the bladder, or of the external teguments. This, it will be said, may be alleged as an objection to every op- eration of importance: But although, in every other method of performing the operation of lithotomy, the wound both of the bladder and of the more ex- ternal parts heals more easily in some constitutions than in others; yet from all the writings we have on this subject it is clear, that any depravity of con- stitution is, in this respect, always productive of much more distress after the high operation than what com- monly occurs from the same cause in the usual meth- od of operating in perinœo. 4. This operation is confined almost solely to pa- tients below thirty years of age: For although it was frequently practised on older people, and although no particular reason can be given why it ought not to succeed in more advanced ages; yet we learn from almost every author who has wrote upon it, particu- larly from Middleton, Smith, Douglas, and Heister, that a very small proportion only recovered of such as were above their thirtieth year. It is perhaps for one or other of these reasons that the high operation has fallen so generally into disuse, and that it has not been much practised for a great length of time in almost any part of Europe. But although this method of operating is attended with hazard, and is frequently followed with inconveni- ences; Sect. VI. Of the Stone. 339 ences; yet there is reason to think, that, on some oc- casions, it might be practised with advantage. The most material objection to the modern, or lateral method of cutting for the stone, arises from the bruising of the soft parts against the contiguous bones in the extraction of a large stone; which is so much the case, that we may consider the risk from the lat- eral operation to be almost in proportion to the size of the stone. When a stone is small and is easily ex- tracted, the proportion of deaths in the lateral opera- tion is very small: But whenever a stone is of such a size as to weigh seven, eight, or ten ounces, this ope- ration perhaps is one of the most dangerous to which a patient can submit. Different instances have occur- red, too, where the stone has been so very large, as to render its extraction by the lateral operation impracti- cable, by all the force that could be applied; and some cases are on record in which there was a neces- sity of having recourse to the high operation, after the operator had failed in extracting the stone by the usu- al method of cutting in the perinæum.* When, therefore, from the long continuance of the disease; from the sense of weight about the neck of the bladder; and particularly from the touch by the finger in ano, we have reason to suspect the stone to be of a large size, it ought to be an object of consid- eration, how far it may be proper to avoid the lateral, and, in certain circumstances, to employ the high op- eration. The circumstances we allude to respect the age of the patient, the soundness of his constitution, and the possibility of distending the bladder so as to raise it above the brim of the pelvis. These circum- stances may be favorable where the stone is of a large size; and when it is found to be so, the high opera- tion, although perhaps less advantageous in the gen- eral run of calculous cases than the lateral method of cutting, * This disagreeable occurrence, we find, happened to Heister. Vid. Heister's Surgery, P. II. Sect. V. chap. cxlii. 340 Of the Stone. Chap. XI. cutting, may be practised with greater probability of success than any other with which we are acquainted. Having how said all that is necessary respecting the Apparatus Altus, we shall proceed to the considera- tion of what has usually been termed the Lateral Op- eration. SECTION VII. Of the LATERAL OPERATION. IN the operation of lithotomy, as it was formerly practised by the great apparatus, the external incision was made in nearly the same part that it is now in the lateral operation; but the two methods of operating differ materially in every other circumstance. The original invention of the lateral operation is due to a French Ecclesiastic commonly known by the name of Frere Jacques. This operator first appeared at Paris in the year 1697, when, by the successful event of a few cases, he was allowed to operate upon a great number. But it soon appeared to practition- ers of discernment, that the same he had acquired would not probably be of long duration. For, with a very imperfect knowledge of the anatomy of the parts concerned in the operation, a bad assortment of instruments, and a total neglect of his patients after the operation, it was almost impossible that much success could result from his method. His manner of operating was as follows. The patient being properly secured either upon a table or on a bed, a common solid staff was introduc- ed into the bladder by the urethra, and the handle of it being carried over the right groin, the convex part of it was made to elevate the teguments and other parts on the left side of the perinæum. With a straight bistoury he now made an incision through the skin and cellular substance, beginning be- tween Sect. VII. Of the Stone. 341 tween the anus and the tuberosity of the ischium, and continuing it upwards along the left side of the perin- æum, at a small distance from the rapha, till it ex- tended at least one half of the course of the perinæum. With the same knife he now went on along the di- rection of the staff, to divide the parts between the external incision and the bladder; which he also opened with the point of this very knife with which the other steps of the operation had been executed. At this opening in the bladder he first introduced the index of his left hand, in order to discover the situa- tion of the stone; and having withdrawn the staff, he laid hold of the stone with a pair of forceps, and ex- tracted it in the usual manner. The patient was now carried to bed; and no farther attention was paid to him by the operator, who never applied any dressings, as he trusted the subsequent management of every case to the nurse or other attendants. In consequence of this unpardonable negligence, and by his frequently cutting parts in the course of the operation which ought to have been avoided, a great proportion of those he operated upon died; no less, we are informed, than twenty five of sixty.* Hence Jacques soon fell into disrepute; and although he afterwards introduced considerable improvements in his method of proceeding, particularly in being more attentive to the subsequent management of his patients, and in using a grooved staff instead of a sol- id one, yet his reputation in Paris never again gained ground; nor do we find that his method was ever attended with much success, either in Holland, or in the various parts of Germany where he afterwards practised. For with so much inattention did he proceed, that although he professed to cut directly into the body of the bladder, without injuring either the urethra or prostate gland; yet in the dissection of such bodies as * Vide Morand Opuscules de Chirurgie, part ii. p. 54. 342 Of the Stone. Chap. XI. as died of the operation, it was found that on many occasions the prostate gland was divided, together with the vesiculæ seminales. In some instances, the bladder was cut in two or three different parts; in others the rectum was divided; and it frequently happened that the bladder was found to be entirety separated from the urethra.* We need not wonder, therefore, that this practitioner, as well as his method of operating, soon fell into discredit. But although this was a consequence which necessarily ensued from the ill success that attended his practice; yet the world, it must be acknowledged, is much indebted to Jacques, for having laid the foundation of the lateral method of cutting for the stone, which, in its present improved state, is practised with so much success over all Europe. The famous Rau was the first who endeavoured to improve this operation of Frere Jacques, which he did by using a staff with a very deep groove, which enabled him to continue his incision into the bladder with more certainty than it was possible to do without this assistance. But Rau, afraid of wounding the prostate gland, introduced a refinement into his meth- od of cutting, which, in the event, proved extremely prejudicial, and was probably the cause of its being afterwards laid aside. For, instead of dividing the urethra and prostate gland, by which means the ex- traction of the stone would have been much facilitat- ed, he dissected with much caution by the side of the prostate, till the convex extremity of the staff was dis- covered in the bladder itself. At this part an incis- ion was made into it, and the stone was afterwards extracted, in the manner then practised for cutting with the great apparatus. By this method of operating, the rectum and vesic- ulæ seminales were in great danger of being injured; the * For a particular account of Frere Jacques's method of operat- ing, see Dr. Lister's journey to Paris; the works of Dionis, Meri, Collet, Saviard, and Morand. Sect. VII. Of the Stone. 343 the stone was extracted with difficulty; and from the depth of the incision the urine did not pass easily off by the wound, so that troublesome sinuses were very frequently forming.* These inconveniences prevented this operation of Rau's from ever being generally received, and sug- gested to the celebrated Cheselden the lateral method of cutting, as it is now, with a few alterations, very universally practised. As this operation of Mr. Cheselden's is described by many writers in Surgery, it is not here necessary to enter into a detail of it: We shall, therefore, now proceed to describe the lateral operation in its present improved state. In order to prevent the patient from being under the necessity of going soon to stool after the operation, the bowels ought to be thoroughly emptied by a laxa- tive given on the preceding day; and with a view to evacuate the contents of the rectum entirely, an in- jection should be given a few hours before the opera- tion is performed. When the bladder is in a collapsed state, it is lia- ble in this operation to be cut in different parts; the patient ought therefore to be desired to drink plenti- fully of some diluent liquor, and to retain his urine for several hours before he is laid upon the table: And when the irritation produced by the disease is found to render a voluntary retention of the urine im- practicable, it ought to be effected by a slight com- pression upon the penis. These circumstances being attended to, and the perinæum and parts about the anus being shaved, the patient is now to be laid upon a table for the op- eration. The most convenient height for this ta- ble * Rau himself kept his method of operating as much concealed as possible. But an account of it was published after his death by Albi- nus; who, by assisting frequently at his operations, became perfectly master of his manner of performing. Vide Index suppellectilis anatomicæ, &c,Lug. Batavorum. 344 Of the Stone. Chap. XI. ble is three feet two inches. It ought to be made perfectly firm: And in order to afford sufficient space for the patient to lie upon, it ought to be about three feet eight inches long, and at least two feet and a half wide. As it is of much importance to have the patient properly secured, it becomes necessary to attend par- ticularly to this circumstance. The most certain method of effecting it is as follows: Let a noose be formed in the double of a piece of broad firm tape about three feet in length; the patient's wrists being introduced at this noose, he ought then to take a firm hold of the outside of the ankle of the same side, when, by different turns of the tape round the hand, ankle, and foot, his hand is to be effectually secured in this position; and this being done on one side, the hand and foot of the opposite side are to be firmly tied to- gether in a similar manner. The operator ought now to introduce a grooved staff, of a size proportioned to the parts through which it is to pass. These staffs are represented in Plate XII; the artist who makes them ought to be very attentive in rounding off the edges of the grooves, otherwise they are apt to injure the urethra; and the further extremity of the groove ought to be perfectly free and open, otherwise it is difficult to disengage the gorget from it after it has been introduced into the bladder. As the groove is only necessary in the con- vex part of the staff, and from that to its point, the handle of the instrument down to the commencement of the convexity, ought to be entirely solid, so as to ad- mit of the penis being pressed upon it, without being hurt either by the hand of the assistant, or by a piece of tape, which may be sometimes necessary, as we have already advised, for preserving the urine from being evacuated. It is necessary to remark, that more attention ought to be paid to the length of the staff than is common- ly Sect. VII. Of the Stone. 345 ly done. These instruments are generally shorter than they should be; so that when, in the course of the operation, the handle of the staff happens to be pressed down upon the groin by the assistant, the point of it is very apt to slip out of the bladder alto- gether; a circumstance which must always be pro- ductive of much hazard and inconvenience. Care, therefore, should be taken to have the staff always of a sufficient length. The stone being again distinctly felt, not only by the surgeon himself, but by his assistants, the patient must be then put into that posture in which he ought to be kept during the remainder of the operation. The table intended to be used ought to be perfectly level; but, that the patient may lie with as much ease as possible during the operation, a pillow may be put under his head, and, in order to raise the pelvis considerably higher than the abdomen, two pillows at least ought to be laid under the buttocks, which should be made to project an inch or two over the end of the table. This direction we have given for elevating the but- tocks, is a matter of much importance, although it is seldom attended to by operators; indeed, the very reverse is commonly practised, the head and upper part of the body being generally kept a good deal higher than the pelvis. This, however, must pro- ceed entirely from inattention on the part of the sur- geon: For the least reflection may convince us, that the more erect the body is kept, the greater pressure must be produced by the intestines upon the bladder; and if by such pressure the fundus of the bladder is pressed down upon its neck, the risk of its being wounded must be very great. Of such patients as have died of this operation, I have in two different instances sound on dissection, that the bladder was wounded in three different parts: In its cervix, as is always the case when the gorget is Xx of 346 Of the Stone. Chap. XI. of a sufficient length; in its side considerably above the cervix; and, again, very near to its most superior part. Now this is an accident which can never hap- pen, if the directions we have given are attended to; for when the bowels are prevented from falling upon the bladder, by keeping the buttocks elevated above the rest of the body, and if at the same time the blad- der is properly distended with urine, it must be alto- gether impossible, in the usual lateral operation, to in- jure it in an improper part. But if this precaution of having the bladder distended during the operation is neglected, at the same time that the bowels are, by an elevated posture of the upper part of the body, allowed to fall into the pelvis, the bladder must be so completely collapsed, and its fundus pushed so much down upon its neck, as must frequently be the cause of much unnecessary hazard. Besides these two cases I have mentioned, in which the bladder was after death found to be wounded in different parts, we find a very candid acknowledg- ment made by a celebrated lithotomist, of his being once so unfortunate in the lateral operation, as to have an immediate protrusion of a considerable portion of the small guts at the wound.* Such an occurrence would have disconcerted many operators: But, fortunately for the patient, the ope- ration was in this cafe completely finished; the bow- els were reduced, and a perfect cure was obtained. Mr. Bromfield attempts to account for this protru- sion of the bowels in a different manner: But we are much inclined to think, that it must have been owing to the pelvis not having been sufficiently raised above the rest of the body, and to the bladder having been in a collapsed state at the time the incision was made into it. For this author, it must be remarked, instead of ordering the bladder to be distended at the time * Vid. Mr. Bromfield' Chirurgical Observations and Casesi Vol. II. p. 264. Sect. VII. Of the Stone. 347 time of operating, desires expressly that it may be emp- tied immediately before the operation.* Matters being adjusted in the manner we have di- rected with respect to the patient, an assistant on each side is to secure his legs and arms: One must pre- vent him from moving the upper part of his body; another must lay hold of the staff; and a fifth will be required to hand the necessary instruments to the op- erator. The surgeon, after having again felt the stone with the staff, is now to make the hand of it pass over the right groin of the patient, so as that the convex part of the instrument may be distinguished on the left side of the perinæum: And in this position it ought to be preserved by the assistant, who with his right hand should lay hold of the handle of the staff, while with his left he elevates and supports the scrotum. The thighs of the patient being sufficiently separat- ed by the assistants, and the surgeon being seated be- tween the patient and the window, in such a manner as to make the light fall directly upon the parts to be cut, an incision is now to be made through the skin and cellular substance, at least four inches in length in a full grown person, and so in proportion in small- er sized people; beginning a little to the left side of the rapha, about an inch from the termination of the scrotum, and proceeding in an oblique direction along the perinæum, till it is made to run at an equal dis- tance between the tuberosity of the ischium and the anus, which last it ought to pass at least an inch. As the success of the operation depends in a great measure on this part of it being properly executed, the attention of beginners ought to be particularly fixed upon it. From timidity or inattention, which always proves prejudicial to the patient, this external incision is frequently made much shorter than it should be; in many instances, instead of four inches, I have seen * Page 228, Vol. II. 348 Of the Stone. Chap. XI. seen it, even in the largest adult, scarcely two. The consequence of this is, that the muscles, and other parts below, cannot be properly divided; the opera- tor has no freedom in prosecuting the other steps of the operation; and if the stone is large, the parts through which it has to pass must be much more bruised and lacerated than if they had been freely di- vided by the knife; and as there is no risk whatever in making the external incision free and ample, it ought, in every instance, to be done. Much hazard may occur from a small incision of the teguments and muscles; but no detriment can ensue from their being largely laid open. By this first stroke of the scalpel, the skin and cel- lular substance should be freely divided, so as to bring the subjacent muscles completely into view; when, by a continuation of the incision, the erector penis, accelerator urinæ, and transversalis perinæi, are also to be divided; and as some part of the levator ani is in- termixed with these muscles, it will likewise be cut. As there is no danger found to occur from a free division of these parts, and as a large opening not on- ly facilitates the extraction of the stone, but admits of any blood vessel that happens to be cut being easily secured by a ligature, which can never be done when the incision is small, every operator, as we have said, ought to be particularly attentive to this circumstance. In general, the arteries with which these muscles are supplied are not so large as to render this precaution necessary; but whenever it is found to be otherwise, and that a considerable vessel has been cut, and es- pecially if the patient is weak and emaciated, a liga- ture ought to be immediately applied before the sur- geon proceeds to the other steps of the operation. In the ordinary method of performing this opera- tion, the surgeon now proceeds to lay open the ure- thra, and enters the point of the knife into the sub- stance of the bulb itself. But this adds greatly to the hazard Sect. VII. Of the Stone. 349 hazard of the operation: For, independently of the blood vessels of the bulb being frequently pretty large, but which indeed may, when the external incision is extensive, be secured, sinuses are much more apt to form; and the cure of the wound is therefore much more tedious when this part is divided, than when no injury is done to it; and as a division of the bulb is not by any means necessary, it ought on every occa- sion to be avoided. When, therefore, the incision of the muscles is completed, the operator ought to search for the staff with the index of his left hand; and hav- ing found it, he is now to push the point of his finger along the course of it till he passes the bulb, when, with the edge of his knife turned towards the groove of the staff, he is to divide the membranous part of the ure- thra in its whole course, from the bulb to the prostate gland; and as the finger is made use of as a director, and as by means of it the rectum is effectually preserved from being injured, this incision of the urethra may be made with perfect safety. Indeed, there is in gen- eral such a quantity of cellular substance between the urethra and rectum, as renders it impossible, in this part of the operation, to cut into the gut, if the sur- geon is not either very unsteady or inattentive : And by means of the precaution we have recommended, of keeping the fore finger of the left hand always be- tween the knife and the intestine, it may in this man- ner be on every occasion very certainly avoided. The incision of the urethra being now completed, the prostate gland, which may be evidently discover- ed by the finger, is next to be divided. In the hands of an expert surgeon, a patient would be equally safe by having the operation finished with the scalpel as with any other instrument: For, by continuing the incision of the urethra, and carrying on the scalpel so as to divide the prostate gland laterally, if the finger is still continued between the knife and the rectum, no risk whatever could occur from it: But as this part of 350 Of the Stone. Chap. XI. of the operation is performed entirely by feeling, with- out the assistance of the eye sight; and as many ope- rators are not so much accustomed to this kind of bus- iness as, in such circumstances, to have a sufficient de- gree of steadiness, it is probable the rectum would be frequently wounded if the scalpel was usually employ- ed for finishing the operation. This inconvenience, however, of wounding the rectum, may be effectually avoided by using a cut- ting director, or Gorget, as it is termed, instead of a scalpel: This instrument was originally the invention of Mr. Hawkins at London. It is represented in Plate XIV; and in Plate XIII different views of an instrument are delineated, which I consider as a very material improvement of Mr. Hawkins's gor- get. The gorget of Mr. Hawkins is contracted too much at the cutting part of it, which prevents it from dividing the prostate gland sufficiently. If we were to use a gorget much wider in the cutting part of it than is usually done, the opening through the prostate gland might indeed be made extensive enough: But the gorget in common use will by no means effect this; the division of this gland being in general quite too small, either for the extraction of a stone, or even for the introduction of the forceps, without much lac- eration; a circumstance which we ought to guard against as much as possible. The gorget in ordinary use is made to expand greatly behind; the diameter of the blunt part of it being at least twice the extent of that of the cutting point. This will appear to be very unnecessary, when we consider, that the only use of the gorget, af- ter it has cut through the prostate gland, is to serve as a conductor to the forceps; and as this purpose may be answered equally well by a director that does not expand to near the extent that the gorget does, it is obviously improper to have this instrument so wide as it is commonly made. But farther, the impropri- ety Plate XIII.  Sect. VII. Of the Stone. 351 ety of this construction is still more evident, when we compare the size of the common gorget with the parts through which it has to pass: For it is perfect- ly evident, that the latter, and particularly the ure- thra, must be greatly injured by the forcible introduc- tion of the former; the back part of the gorget being so wide and deep, as to render its passage through the urethra quite impracticable, without much laceration. The cutting director we have mentioned above, will be found to possess all the advantages of the gor- get, without any of its inconveniences: The cutting part of it expands more than that of the gorget, it therefore divides the prostate gland more freely; and as the blunt part of it is much contracted, no injury is done to the urethra on its being pushed into it. To those who have never used this instrument, and who thereby may have a partiality for the gorget, it may perhaps appear that it is not sufficiently wide for serving as a director to the forceps: This, however, is not the case; and it will soon be found, that it is not only more easily introduced than the gorget, but that it answers equally well for conducting either the finger or the forceps. It has been objected to this instrument, that it will not probably make such a free division of the mus- cles as is obtained by the gorget. This observation, however, proceeds solely from prejudice in favour of an instrument with which practitioners are as yet bet- ter acquainted, and which has indeed been deservedly much employed; but it is thrown out without due reflection on its import. We have already endeav- oured to inculcate the necessity of a free division of the teguments and muscles in this operation; but whoever considers this point with attention will see, that this ought to be effected by the scalpel alone, and that it should not depend in any degree upon the gor- get. All that should be left for the gorget or cutting director to do, is to divide the prostate gland with a small 352 Of the Stone. Chap. XI. small portion of the neck of the bladder. Some prac- titioners have indeed recommended instruments for carrying the incision into the body of the bladder; but this is a very hazardous attempt, and it is not in any respect necessary: For as soon as the prostate and neck of the bladder are divided, the forceps are admitted with much ease; and the bladder itself is so easily dilated, that it very readily yields to the passage of the stone, however large it may be. We would wish to have it understood, that it is not the size of the wound in the bladder which renders the extraction of stones easy or difficult; and that it is the previous free incision of the muscles and prostate gland upon which this entirely depends. The membranous part of the urethra being divid- ed by the scalpel in the manner we have directed, the nail of the index of the left hand ought to be intro- duced into the groove of the staff, in order to serve as a conductor to the point or beak of the cutting direct- or. And the surgeon having no further occasion for the scalpel, must now lay it aside; and having introduc- ed the point of the director into the groove of the staff, he is now to take the handle of that instrument from the assistant; and having raised it considerably from the groin of the patient in which it lay, he must with his left hand preserve it firm in this situation, while with his right he pushes on the director till it has passed freely into the bladder, a circumstance which is rendered evident at once by the urine rushing plentifully out at the wound. In executing the first part of the operation, the surgeon ought by all means to be seated; but in passing the gorget or director into the bladder, as likewise in the extraction of the stone, he ought to stand immediately before the pa- tient, as in this posture these steps of it are more easi- ly performed. Much attention is necessary, in this part of the op- eration, in raising the staff to a proper height before pushing Sect. VII. Of the Stone. 353 pushing on the gorget. The staff ought to form nearly a right angle with the body of the patient; and if it be kept sufficiently firm in this position, the gorget or director may be pushed on with great safety, as the beak of the instrument, if this direction is attended to, can scarcely escape from the groove of the staff. But if the elevation of the staff is either much greater or much less than this when the gorget is pushed forward, its point instead of getting into the bladder must be forced out of the groove, and pass- ing between the rectum and bladder, or between the bladder and pubes, it must here run the risk of doing much mischief. I have known even expert sur- geons, from an unpardonable degree of inattention, fall into this error with regard to the height of the staff. Younger practitioners, therefore, cannot be too much on their guard against it. While attention is thus given to the elevation of the staff, care ought also to be had that the beak of the director or gorget be exactly fitted to the groove intended to receive it; for if these are not properly a- dapted to one another, the gorget cannot run so easily as it ought to do. Besides, if the beak of the instru- ment is turned a little inwards, as is represented in Plates XIII and XIV, it is pushed forward with more safety than when the point of it is either in a direct line with the instrument, or, perhaps, somewhat turned back, as is too frequently the case. In order to render this part of the operation per- fectly safe, different inventions have been proposed for fixing the beak of the cutting gorget so effectual- ly in the groove of the staff, as to prevent it from getting out of it till it has passed into the bladder: But every contrivance of this kind produces some difficulty in passing the instrument; and besides, there is not the least necessity for it, as no operator can possibly go wrong if he attends sufficiently to the di- rections we have given. Yy As 354 Of the Stone. Chap. XI. As soon as the gorget has freely entered the blad- der, the staff ought to be withdrawn; and this being done, the next step in ordinary practice is, to intro- duce the forceps immediately; but as the stone may be frequently felt by the finger, and as no other meth- od serves so effectually to discover its real situation, this precaution of introducing the finger into the bladder ought never to be omitted. If the stone cannot be felt by the finger, the pain of the patient is not increased by its introduction; and if the opera- tor is lucky enough to discover it, he is thereby in- structed with some certainty of the best direction for the forceps. The situation of the stone being in this manner discovered, or if, upon trial, it is found that the finger cannot reach it, a pair of forceps, proportioned to the size of the patient, are to be introduced along the course of the director or gorget, while the latter is to be immediately withdrawn. In an operation of such importance as this, the most trifling circumstance is worthy of attention; for the more obvious and leading parts of it may be per- formed in the most masterly manner, and the whole be rendered unsuccessful by the operator not attending so accurately as he ought to do to the more minute steps of it. Even the method of withdrawing the cutting director or gorget, is a matter which requires attention, much more, indeed, than is commonly giv- en to it. After the forceps are introduced, the gorget ought to be slowly withdrawn in the very exact di- rection by which it is entered: For if it be turned in any degree either to one side or another, it must of necessity make another incision, not only in the pros- tate gland, but in all the other parts through which it is made to pass; the impropriety of which is too ob- vious to require any further animadversion. If the stone has been previously discovered by the finger, it is commonly easily laid hold of with the forceps; Plate XV.  Plate. XIV.   Plate XVI. Sect. VII. Of the Stone. 355 forceps; but when the finger has not been able to reach it, it is on some occasions with much difficulty met with. The forceps must necessarily be introduc- ed shut, that is, with their blades as near to one an- other as their form admits of; for, with a view to pre- vent them from laying hold of the bladder, they should be so constructed as not to meet at any part except at their axis, by at least the tenth part of an inch. But as soon as they have entered the bladder, they should be gradually opened; and in this expanded state ought to be easily moved about, with their handles sometimes depressed and sometimes elevated, till the stone is discovered, when it is to be immediately laid hold of. It frequently happens, however, even with very expert surgeons, especially when the stone is small, that it is not readily discovered by the forceps. In such instances it is sometimes met with near to the fundus of the bladder; but it is most frequently found concealed in the under and back part of it, near to its neck, in that bag which we have mentioned as be- ing formed by the natural pressure of the urine. When it is found to be in this situation, nothing will bring it so readily into contact with the forceps, as elevating this part of the bladder by introducing the finger into the rectum. In general, straight forceps, such as are represent- ed in Plate XVI, fig. 1. and 2. are preferable to those that are much crooked, delineated in fig. 3. For they not only prove more effectual for extracting the stone, but serve equally well with the others for discovering it. Every operator, however, ought to be provided with all the varieties of forceps that are now in ordi- nary use. When much difficulty occurs in discovering the stone, it is frequently alleged by operators, that this proceeds from its being contained in some preternat- ural bag or cyst; and when it is laid hold of by the forceps, and requires an unusual degree of strength to extract 356 Of the Stone. Chap. XI. extract it, this is commonly said to arise from the stone adhering to the coats of the bladder. That the weight of a stone will sometimes form a partial cavity for it- self, by pressing that part of the bladder on which it lies into the neighbouring soft parts, there is no rea- son to doubt; and in some instances the bladder is found to have been so much contracted round a stone, as to form almost two distinct bags. Such occurrences, however, are exceedingly rare: And the adhesion of stones to the bladder, we believe to be still more so, if it ever takes place. Stones have indeed been fre- quently found covered with the coagulable part of the blood, which on some occasions becomes so firm and tough, as to have the appearance of an organised membrane; but we are perfectly unacquainted with any process of nature by which an adhesion can be produced between the bladder and a stone contained in it. It is very improbable that it can take place in conse- quence of a communication of blood vessels betwixt the bladder and stone: And it is equally improbable that it can be produced merely by agglutination; for, by the intervention of the urine, with which the blad- der is constantly moistened, such an effect must be very certainly prevented. But it is not reasoning alone that militates against this opinion. For although such an occurrence has been frequently mentioned by authors, yet we do not meet with one authenticated instance of any firm adhe- sions betwixt the bladder and stones contained in it be- ing discovered after death: We are therefore led to conclude, that this idea is entirely void of foundation; and that it has probably originated from the mis- conduct of operators, who, by making the external incision too small, or by not dividing the muscles and prostate gland sufficiently, have experienced much difficulty in extracting a stone of even a mod- erate size, and who, to escape censure, have suggest- ed Sect. VII. Of the Stone. 357 ed the possibility of stones adhering to the internal coat of the bladder. When the stone is laid hold of by the forceps, the operator, before he proceeds to extract it, ought to introduce his finger into the bladder, in order to dis- cover whether it is properly fixed in the forceps or not. In many instances, this is of much advantage; for, when it is discovered that a stone of any consider- able length is laid hold of in such a manner as to have its longest diameter made to press in a transverse di- rection with respect to the opening in the bladder, much pain and laceration, which would undoubtedly occur from extracting it in this direction, may be ea- sily prevented, either by turning the stone with the point of the finger when this is found to be practica- ble, or by letting it slip altogether out of the forceps, and again endeavouring to lay hold of it in a more favourable position. When the operator is certain that this is properly accomplished, he is then to pro- ceed to the extraction of the stone, which ought to be done in a very slow and gradual manner: He ought to hold the forceps firmly in both hands, his right be- ing applied towards the extremity of the handles, and his left near to the common axis. In ordinary practice, if the stone does not come readily away, the force made use of is commonly ap- plied so as to dilate the parts equally in every direc- tion. The stone is made to move not only upwards and downwards, but laterally; and, on some occa- sions, even a rotatory motion is given to it. Noth- ing, however, can be more destructive to the parts through which the stone must pass than such a prac- tice, while at the same time it is evidently ill calculat- ed for facilitating the extraction of it. Instead of moving the stone in this manner, the pressure ought to be made almost entirely downwards; not directly from the symphysis of the pubes towards the anus, but in the course of the external wound, which 358 Of the Stone. Chap. XI. which ought, as we have already said, to run between the anus and the tuberosity of the ischium. As it will be readily admitted, that the force employed in ex- trading a stone will prove more useful when exerted upon soft yielding parts, than when applied immedi- ately upon a bone; so, whoever attentively considers the anatomy of the parts concerned in this operation, will see the propriety of the advice we have now giv- en. The opening into the pelvis is at this place so extremely narrow, that a very slight examination must convince any one, that in the extraction of a stone no advantage can be derived from lateral pressure. If a- gain the stone is pressed upwards, it must press against the bones of the pubes; for in this direction nothing intervenes between these bones and it, except the ure- thra, and a small quantity of cellular substance: And if it be directed towards the anus, it must press the rectum against the point of the coccyx; a circum- stance which must not only produce much immedi- ate distress to the patient, but which must even add to the hazard of the operation. The rotatory motion which in this operation is sometimes given to a stone unites all these disadvan- tages; but by carrying the pressure downwards in the course of the wound so as to fall between the anus and ischium, every inconvenience of this kind is avoided, and a more extensive dilatation is obtained than can possibly be procured in any other direction. By a proper and gradual application of pressure in this direction, the stone, if it is not very large, will be at last extracted: In the course of the extraction, how- ever, if the operator finds considerable resistance to the passage of the stone, he ought to examine the state of the divided parts; and if any part of the muscles which ought to have been cut are still found to be en- tire, they should be immediately laid freely open; and the easiest method of doing this, is, to secure the stone in Sect. VII. Of the Stone. 359 in the forceps with the left hand, while a scalpel is em- ployed in the other for effecting what is necessary. In order to prevent the forceps from pressing so much upon the stone as to be in danger of breaking it, some inventions have been proposed for rendering the degree of pressure employed by them steady and certain. Of those the best seems to be what is repre- sented in Plate XVIII, fig. 3. in which, as soon as a stone is laid hold of, it is preserved in the same posi- tion by means of a screw which passes from one of the handles into the other. During an operation, howev- er, every incumbrance of this kind proves trouble- some, and there is not in fact the least occasion for such an improvement: For, when a stone is small, no surgeon of experience will apply great force in the extraction of it; and when it is very large, it will be more for the patient's advantage that it should be broke than extracted entire. We have already had occasion to speak of the great risk which occurs from the extraction of stones of a large size: Indeed, this, as we have said, is so consid- erable, as to warrant this conclusion, that cæteris par- ibus, the hazard attending the operation of lithotomy may be considered as corresponding to the size of the stone to be extracted. In healthy subjects, when the stone is small, and when the operation is properly per- formed, there does not above one die in twenty: But, although a few instances have occurred of patients re- covering from whom stones have been extracted of a large size, yet whenever the stone exceeds seven or eight ounces in weight, so far as I am able to judge, not above one in ten recovers. This, therefore, is a most material circumstance, and worthy of our most serious attention; and although the breaking of a stone, in the course of extraction, is in other respects rather disagreeable, yet, with a view to obviate the dreadful consequences which com- monly ensue from tearing out a very large stone, when in 360 Of the Stone. Chap. XI. in the course of an operation it is found that the stone is of an uncommon magnitude, and that it cannot be extracted but with great hazard to the patient, Might it not be more eligible, either to endeavour to break the stone with the forceps already introduced, or to withdraw these and to introduce an instrument repre- sented in Plate XVII, fig. 1. originally invented for this purpose by Andreas à Cruce, and since improved by Le Cat and others? By means of the long and strong teeth with which these forceps are furnished, and especially by the intervention of the screw for compressing their handles, almost any stone may be broken into very small pieces; and as soon as this is effected, the different pieces may be extracted with the common forceps. In such circumstances, however, or when a stone has broke by accident in the course of any operation, the utmost care is necessary in order to extract every fragment of it; for, if the smallest particle be left, if it be not afterwards washed off with the urine, it may prove very prejudicial, by serving as a nucleus for the formation of another stone. After all the lar- ger pieces have been extracted by the forceps, a scoop, such as is represented in Plate XVII, fig. 2. is some- times found serviceable for taking out the smaller par- ticles; but for this last purpose nothing ever proves so effectual as injecting, either with a syringe or a bag and pipe, large quantities of warm water, which, when a proper heat and a due degree of force are attend- ed to, may be thrown in without injury, and it com- monly proves very effectual for the purpose for which it is employed. When a stone is extracted with a smooth polished surface, it is commonly supposed that there will be others remaining in the bladder, as this smoothness is imagined to be owing to the friction produced by other stones; and, on the contrary, a rough unequal surface is supposed to denote the existence of one stone only. Plate XVII.  Sect. VII. Of the Stone. 361 only. No dependence, however, ought to be placed upon these circumstances; for every practitioner must have met with instances of a single stone with a smooth surface; and, on the contrary, a stone of a rough un- equal surface has been found where there have been more than one in the bladder. As soon, therefore, as one stone is extracted, the operator, instead of trusting to any appearances of the stone, ought first to search with his finger, and then, either with the forceps, or with the thick curved instrument represented in Plate XV, fig. 3. which may be termed a searcher, and which answers the purpose better; and as long as any stones are discovered, the forceps are to be repeatedly introduced till the whole are entirely extracted. In the course of this operation, some blood vessels are unavoidably divided; but when the incision is kept as low down in the perinæum as we have direct- ed, and when therefore the bulb of the urethra is a- voided, there is seldom much risk to be apprehended from any hemorrhagy that ensues. It now and then happens, however, that those branches of the internal iliac artery which supply the parts lying anterior to the prostate gland, are so considerable as, when divid- ed, to pour out a good deal of blood: But as a free discharge during the operation has a considerable in- fluence in preventing inflammation, a symptom which is more to be dreaded than any other occurrence sub- sequent to lithotomy, nothing in general should be done to put a stop to the hemorrhagy till the stones are all extracted; when, if the discharge still contin- ues, any divided artery that appears ought to be se- cured by ligatures; and if the external incision has been made large and free in the manner we have di- rected, this is a part of the operation by no means so difficult as is commonly imagined. On different oc- casions, I have passed a ligature upon an artery almost as deep as the prostate gland; and when a large ves- sel has been cut, the advantage derived from this ef- Zz fectual 362 Of the Stone. Chap. XI. fectual method of securing it, is of itself a very im- portant argument for making the external incision in every instance very free and extensive. When, however, the divided, vessel cannot be se- cured by ligature, we are then to endeavour to stop the hemorrhagy by pressure; and for this purpose a firm roller introduced at the wound would answer very ef- fectually: But in order to avoid any stoppage to the flow of urine, instead of a solid roller a silver cannula covered with soft linen may be employed with advan- tage; a figure of such an instrument is represented in Plate XVIII, fig. 3. Notwithstanding, however, ev- ery precaution, some of the deep seated arteries, which have been divided by the operation, continue some- times to pour out a great deal of blood, and which, instead of passing off by the wound, is, on some occa- sions, collected in great quantities in the cavity of the bladder. As soon as this is perceived, some means ought to be attempted for its removal; and the most effectual of these are, to extract as much of the coag- ulated blood as possible, by a proper use of the scoop already mentioned, and afterwards by the fre- quent injecting of warm water by the wound, to wash off the remainder. In this manner very large collec- tions of blood have been evacuated; and when, as has sometimes happened, means of this kind have not been employed, the coagulum in the bladder has at last become so firm, and has filled up the cavity of that viscus so effectually, as to prevent entirely all further deposition of urine. In such instances the abdomen becomes pained and much tumefied; the fever gradually increases; and death itself very com- monly succeeds. With a view to prevent such an unfortunate occur- rence with as much certainty as possible, every pa- tient should, immediately after the operation of li- thotomy, be placed in such a posture as most effectu- ally to evacuate any blood that may be discharged: Instead Sect. VII. Of the Stone. 363 Instead of laying the head low, and the buttocks high, as is commonly done, the pelvis should be considera- bly lower than the rest of the body; by which means the wound is kept in a depending posture, which serves to assist the evacuation of any blood that the divided arteries may throw out. As soon as any flow of blood that has occurred is stopt, the patient should be untied, and a piece of soft lint being inserted be- tween the lips of the wound, the thighs should be laid together, and in this position he should be carried to bed; and a considerable dose of laudanum being ad- ministered, he ought for some time to be left entirely to the charge of the nurse in attendance. No dress- ing whatever answers so well as a piece of dry soft lint: For as the urine is constantly running off by the wound, and as the parts are thereby kept very wet and are apt to fret, it becomes necessary to renew the dressings very frequently; and nothing is either more easily applied or removed than a piece of dry lint. When the stone has not been difficult to extract, the patient generally remains easy, and free from much pain; and he frequently falls into rest, and procures some sleep during the first three or four hours after the operation: But when the stone is large, and when much violence has been done to the parts in extract- ing it, a severe pain in the under part of the abdo- men often supervenes in the space of an hour or two from the operation; and this, we must observe, when it does not soon yield, is one of the most alarming symptoms which occur. If it is merely of a spas- modic nature, however, which in some instances it appears to be, it is commonly soon removed by the use of warm fomentations to the belly, or by emolli- ent and especially by anodyne injections thrown up by the rectum. When by a continuation of these remedies the pain is found to abate, little or no anxiety need be enter- tained on account of it; but when, instead of becom- ing 364 Of the Stone. Chap. XI. ing less violent, it proceeds to increase, and especially when the abdomen becomes hard and tumefied, and the pulse full and quick, and when these symptoms continue to be aggravated, much danger is to be dreaded. As they almost constantly originate from inflammation, blood ought to be taken in quantities proportioned to the violence of the disorder; emolli- ent injections ought to be continued; and if the local application of heat to the abdomen, either by warm flannels, or by warm water contained in a bladder, is not found to answer, the patient should be immedi- ately put into the semicupium. Indeed, in such cir- cumstances, I have experienced more advantages from this than from any other remedy; for the heat is not only applied with more effect directly to the parts affected, but a free discharge of urine by the wound is also more commonly procured by this than by any other means, and accordingly much relief is often obtained from it. A due continuation of these means, with a proper use of opiates, a low diet, and a free use of diluent drinks, will frequently remove very alarming symp- toms. But, in some instances, all our efforts prove ineffectual; the pain and tension of the abdomen continue to increase; the wound, instead of putting on a kindly healthy appearance, remains sloughy and ill conditioned; the quickness of pulse, and other symptoms of fever, increase; and death closes the scene. But, when matters terminate happily; the wound by degrees acquires a healthy aspect: The urine, in some instances, passes by the urethra from the beginning; but in most cases it comes away by the wound for the first two or three weeks: The pain in the abdomen gradually abates; and any symptoms of fever which at first prevailed, are in a short time entirely removed. The period at which a complete cure of the wound is effected, is exceedingly various, and depends much on Sect. VII. Of the Stone. 365 on the state of health the patient is in: In some few cases of young healthy boys, I have known the wound completely cicatrised in less than three weeks; but in others this is not accomplished till the sixth, seventh, or eighth week. Unfortunately, in some instances, a- gain, although a great part of the sore heals perhaps quickly enough, yet a small opening is left at which the urine continues to be discharged, and, the edges of the passage becoming callous, a real fistulous open- ing is produced, which cannot be cured but by anoth- er operation; the manner of performing which we shall presently have occasion to mention. Indeed the prevention of fistulous openings depends much on proper attention in dressing the wound. If care be taken to introduce the lint sufficiently within the lips of the wound till granulations fill up the bottom of the sore, there will seldom be any risk of fistulous sores: At the same time, however, the wound ought not to be much crammed, either with lint or with any other dressing; for in this case the edges must either in- flame, or acquire a morbid degree of hardness. In other respects the treatment here ought to be nearly such as is known to answer in similar wounds in other parts. It is proper, however, to observe, that noth- ing removes so effectually that excoriation of the but- tocks, which sometimes proves very troublesome af- ter the operation, from their being kept constantly wet with the urine, as their being frequently washed either with brandy or any other ardent spirit, or with lime water. In patients of a weak, feeble constitution, an incon- tinence of urine frequently occurs after the operation of lithotomy. In general, however, this is removed upon the patient recovering, his former degree of strength; and the use of the cold bath, Peruvian bark, and a nourishing diet, contribute much to this effect. But, in order to obviate the immediate disagreeable effects of a constant discharge of urine, different in- struments 366 Of the Stone. Chap. XI. struments have been contrived: Some of these have in view the compression of the penis, in order to pre- vent the urine from being discharged; and others are intended to be concealed within the patient's breeches, and to serve as receptacles for the urine on its passing from the urethra. In Plate XIX, fig. 1. is represented the most con- venient form of the former of these; and in fig. 2, is delineated a receiver, which by experience has been found to answer the purpose of the latter both easily and effectually. And these instruments, it is obvi- ous, may be used in all cases of incontinence of urine, whether originating from this operation or from any other cause. Hitherto we have been supposing the operation to take place in a male subject only; but although the shortness and width of the urethra in women renders them much less liable to stone in the bladder than men, yet instances frequently occur of this disorder in females; and whenever it does so, and when the symp- toms produced by it are violent, some means must be employed for relief. While from the shortness of the urethra women are less liable to the stone than men, the operation of lithotomy with respect to them, is, on the same ac- count, much more simple, and of course more easily performed. It cannot be done by cutting from the perinæum, in the same manner as in male subjects; for, as the urethra and bladder lie immediately above the vagina, any opening made into them from the perinæum must of necessity pass through the vagina, so as to wound it both above and below: And this was considered as a very material objection to the lat- eral method of cutting, upon its first introduction. There is not here, however, the least necessity for do- ing any injury to the vagina, as the urethra may be di- vided from one extremity to the other, without any risk of touching it. The Sect. VII. Of the Stone. 367 The patient being placed upon a table, and secured in the manner we have already directed, a grooved staff, such as is represented in Plate XIV, fig. 3. is to be introduced into the bladder, by passing it through the urethra which lies between the nymphæ immedi- ately below the clitoris; and the operator, keeping it firm with his left hand, is with his right to introduce the beak of the cutting director into the groove, and to run it easily along till it has fairly entered the bladder. He ought now, as in male subjects, to in- troduce his finger along the director; and having dis- covered the stone, should proceed to extract it in the manner we have already recommended. By the old method of cutting in females with the greater apparatus, no incision was made into the ure- thra, but different instruments were used for the pur- pose of dilating it; and when this was supposed to be sufficiently effected, the forceps were employed for extracting the stone. In this manner, however, much laceration was produced; the patient suffered a great deal of unnecessary pain, and the bladder was com- monly deprived of all power of retention. We have no difficulty, therefore, when operating on female sub- jects, in preferring the method we have recommend- ed, of laying the urethra open through its whole length. As the bladder in females lies immediately above, and quite contiguous to, the vagina, it has been pro- posed, that, instead of laying open the urethra, as we have directed, an opening should be made directly in- to the bladder from the vagina, at which the forceps are to be introduced for extracting the stone. One case of this kind we find recorded by Bussiere*; and, more lately, other three are related by the ingenious Mr. Gooch, in which this method of extraction was successfully employed†. It has never, however, been generally * Philosophical Transactions for the year 1669, p. 106. † Vide Cases and Remarks in Surgery, vol. ii. p. 182. by Benja- min Gooch. 368 Of the Stone. Chap. XI. generally adopted; and as various objections occur to it, we do not think it will ever be frequently put in practice. By cutting into the bladder through the vagina, parts are injured, which by the other method may be avoided: The stone, when it does not lie directly up- on the vagina, is with difficulty laid hold of; it can- not be so easily extracted as when drawn along in the course of the urethra; fistulous openings must in all probability occur more frequently after this than after the other method of operating; and if the woman should afterwards become pregnant, the cicatrix form- ed in the vagina would produce pain, obstruction, and perhaps laceration in the time of delivery. One great advantage which the lateral operation, in its improved present state, possesses over the others, both in males and females, is, that no laceration whatever is produced by it unless the stone is remarkably large; in which case, no precaution with which we are ac- quainted has any influence in preventing it: But, in ordinary cases, where the stone is not large, if the parts are divided in the free manner we have recom- mended, all the risk attending laceration, and which we have endeavoured to point out as the most haz- ardous part of this operation, is very effectually avoided. We have thus described the various means, hither- to employed by practitioners, for extracting stones from the bladder; and from what has been said, it must readily appear, that the lateral operation is, in ordinary cases, greatly preferable to every other. In- deed it stands so eminently superior to the others for general use, that we do not consider it as necessary to draw any farther comparison between them; but, as we have already observed, particular cases do some- times occur in which the high operation may with great propriety be employed instead of it. We have already in strong terms pointed out the risk which oc- curs Sect. VII. Of the Stone. 369 curs from extracting a large stone by the lateral meth- od of cutting; and we have shown, that stones of any magnitude which the bladder can contain may be ex- tracted by the high operation. Whenever, therefore, it is known with any tolerable certainty, that a stone is of an uncommon size, and when the high operation is in other respects admissible, it ought certainly in every such instance to be preferred: For although in cases of large stones it may be better to break them into small pieces in the manner we have directed, than to lacerate the parts by extracting them entire; yet this practice is only advisable when the operator unexpectedly meets with a large stone after the bladder has been cut into: And whenever it happens other- wise, and the stone is previously known to be very large, much advantage may accrue to the patient from a judicious choice, on the part of the operator, of his method of operating. In the directions here laid down for performing the lateral operation, the dictates of experience are strictly adhered to, and nothing is recommended that is not either at present very generally adopted, or that I have not myself put in practice. Many ingenious proposals have been made by in- dividuals for the improvement of the operation of lithotomy, particularly of the lateral method of cut- ting: But a minute detail of all that has been sug- gested upon this subject, is incompatible with the na- ture of this work; nor could it serve any purpose, but to bring into view some particular modes of prac- tice, which were either never generally followed, or which, if adopted, have fallen again into disuse. The most remarkable of these proposed improve- ments of the lateral operation are, those of three French surgeons, Monsieur Foubert, Monsieur Thomas, and Frere Cosme. The two first of these gentlemen in- vented instruments for penetrating the body of the bladder without interfering with the urethra. The Aaa bladder 370 Of the Stone. Chap. XI. bladder being distended with urine, and an incision be- ing made through the skin and cellular substance, a cutting instrument of a particular construction is then directed to be pushed past the urethra into the side of the bladder; and an opening being made of a suffi- cient size, the stone is to be extracted in the usual manner. One material advantage proposed from this improvement is, that by the urethra and prostate gland being avoided, that inability to retain the urine and other troublesome consequences, which some- times ensue from injuries done to these parts, are not so apt to occur when the body of the bladder alone is wounded. But, independent of any other objection to which this method of operating is liable, this of it- self must serve effectually to prevent it from being ever very generally received, namely, the wound in the bladder being sure to recede from the wound in the teguments as soon as all the water contained in it is evacuated: And the consequences resulting from such an occurrence must frequently, it is obvious, prove very distressing; as the urine, by not finding a free passage by the wound, will readily insinuate it- self into the contiguous parts, where it must of conse- quence be productive of very troublesome fistulous openings. So that although this method of cutting directly into the neck or body of the bladder, is, at first view, extremely plausible, yet the least reflection on these consequences which frequently result from it, must at once convince every practitioner of the risk attending it being considerable. The operation of Frere Cosme, is, in effect, the same with the real lateral operation, as it is now common- ly practised. The parts cut in it are exactly the same, only they are divided in a different manner. After the staff is laid bare in the usual manner, the beak of the instrument, fig. I. Plate XVIII, is introduced in- to the groove; and being pushed forward till it reach- es Plate XVIII.  Sect. VII. Of the Stone. 371 es the bladder, the spring C is then to be pressed down, so as to raise the knife from its sheath, when the ope- ration is to be finished by withdrawing the instrument in such a direction as may divide the neck of the blad- der and prostate gland in the same manner as is done by the common gorget: After this, the other steps of the operation are to be completed in the manner we have already directed, by the forceps alone. Most of the other deviations from the established mode of practice, hitherto proposed by surgeons, con- sist, either in some improvement of the cutting gor- get of Mr. Hawkins, or in a preference which some practitioners still continue to give to the knife. We have already observed, that Mr. Hawkins's gorget does not spread sufficiently at the cutting part of it; and that it is much wider and deeper backwards than it ought to be, by which it is liable to tear and otherwise injure the urethra more than is necessary: This in- convenience, however, we think is effectually remov- ed, by the cutting director we have ventured to rec- ommend. With respect to the scalpel being preferred by some operators both to the cutting gorget and direct- or, we have only to observe, that an expert surgeon of steadiness, and possessing a minute knowledge of the anatomy of the parts, may with ease and safety perform the operation of lithotomy with the knife a- lone; but we must also remark, that, with the gener- ality of surgeons, the danger of wounding the rectum is so great when the scalpel is employed, that the use of the gorget or cutting director, by either of which the intestine is effectually defended, ought to be com- monly preferred. In the course of this Section we have endeavoured to deliver all that is worth recording, of modern prac- tice in the operation of lithotomy: We are not con- scious of having omitted any improvements of im- portance; and some, we hope, are proposed, which are not 372 Of the Stone. Chap. XI. not generally known, or which, if known, are not commonly practised. As the subject we are treating of is one of the most material in the department of Surgery, we have been induced to extend the consideration of it to a very considerable length: It may therefore prove servicea- ble, to students especially, to have such circumstances enumerated in a more concise manner as particularly merit their attention. 1. We have already in strong terms pointed out the propriety of an absolute certainty being attained, of a stone existing in the bladder, before the operation of lithotomy is proposed: And we have endeavour- ed to show, that no symptoms, however strongly marked, afford sufficient evidence of the presence of calculus; the operation of sounding, or touching the stone with a staff, being the only certain means we have of judging of this matter. 2. In performing this operation, a considerable quantity of urine ought to be previously allowed to collect in the bladder; the rectum should be emptied by an injection; the buttocks ought to be considerably elevated above the rest of the body; and the external incision ought to be more extensive than is commonly advised. In full grown adults, instead of an inch and a half, or two inches, as it is generally made, it should be at least three inches and a half long; care being taken to commence the cut at the inferior edge of the pubes, and to continue it in an oblique direction till it has passed the anus, at an equal distance be- tween the extremity of the rectum and the tuberosity of the ischium. 3. As the great resistance frequently experienced in this operation to the extraction of the stone, pro- ceeds most commonly from the muscles covering the urethra, these ought to be freely divided: No danger can ensue from this, and much advantage may be de- rived from it. 4. But Sect. VII. Of the Stone. 373 4. But although a free division of the muscles is of much importance, there is no necessity for cutting so much of the urethra as is very commonly done: It does not render the extraction of the stone in any de- gree easier; and it makes the operation more hazard- ous than when the membranous part of the urethra only is divided. When the incision is carried through the teguments and muscles so as to leave the staff covered by the urethra only, the operator ought to in- sert the index and middle finger of his left hand into the bottom of the wound, by which means the rectum will be effectually protected; and this being done, an opening should be made into the urethra by piercing it with the point of the scalpel very near to the pros- tate gland, and extending the incision to the bulb, but no farther. This, we may remark, should be done by one stroke of the knife; and not by repeated ap- plications of it as is the common practice, for by this means a rugged unequal wound must for certain be produced. In the first part of the operation, the point and edge of the knife ought to be so applied as to cut from above downwards, as in this manner the incision is very easily and safely accomplished; but in dividing the urethra, the back of the knife ought for certain to be turned down, while the edge of it is made to penetrate the urethra, and to run along the sulcus of the staff. By this means the rectum cannot possi- bly be injured; an occurrence, which, in the usual method of operating, is too frequently met with. 5. The next step in this operation is to divide the prostate gland, with a very small portion of the neck of the bladder. This, we have observed, may be done with much safety and ease with the scalpel alone, by a good anatomist, whose hand is perfectly steady; but as there is a necessity for dividing the prostate gland in such a direction as to avoid the rectum, with which it is posteriorly connected, and likewise the ex- cretory ducts of the vesiculæ seminales which termin- ate 374 Of the Stone. Chap. XI. ate here, much exactness is required to get this ac- complished, and it can only be done with safety to these parts by a lateral cut through this gland. A very small variation, it is evident, in the direction of the scalpel, might here be productive of much danger; and few practitioners being possessed of such equal steadiness as at all times to be able to avoid this, for ordinary practice, a knife, constructed in such a man- ner as to protect the rectum and other parts behind, at the same time that it effects a lateral division of the gland, ought certainly to be preferred. The gor- get of Mr. Hawkins is attended with all these advan- tages; but we have formerly shown, that it is likewise attended with a very material inconvenience. This, we think, is effectually obviated by the cutting direct- or we have already described, which makes a more clean and ample cut than the gorget, at the same time that it does not tear the urethra, as the gorget always does by being made to expand more behind than is necessary. 6. After the stone is laid hold of by the forceps, it ought to be extracted in a very flow and gradual manner; not by a rotatory motion, or by pressure applied equally in all directions; but by endeavouring to dilate the parts along the course of the wound in a line directly between the anus and the tuberosity of the ischium. Moderate pressure laterally, may likewise have some influence: But no force ought ever to be appli- ed towards the upper part of the wound; for nothing can be gained by doing so, and it must for certain do mischief by pressing the urethra with violence against the pubes. When in the course of extraction it is found, that the passage of the stone is impeded by some of the muscles not having been sufficiently di- vided, this ought still to be done, by the operator keeping the stone firm in the forceps with one hand, while with a scalpel in the other he effects what is necessary. 7. The Sect. VIII. Of the Stone. 375 7. The stone being extracted, soft easy dressings should be applied to the wound: And the patient should be laid in bed with his head and upper part of the body elevated, in order to facilitate the evacu- ation of any blood that may be discharged from any arteries that have been cut; and which, by a contrary posture, with the buttocks raised above the rest of the body, is often made to lodge in the bladder, to the great detriment and even hazard of the patient. Having thus enumerated those points in this ope- ration which deserve most attention, we shall now proceed to consider the operation of Nephrotomy. SECTION VIII. Of NEPHROTOMY. WHEN one or more stones are impacted in the kidneys, in such a manner as to be prevented from passing off with the urine, they give rise to a train of symptoms which occasion the most complete misery during the life of the patient, and which at last almost constantly terminate in his death. The severity of the pain produced by stones in the kidney, is frequently so great, as to have induced practitioners to suggest an operation for extracting them. This consists in a cut being made through the common teguments and muscles immediately a- bove the kidney, with an opening into the kidney it- self of a sufficient size to afford a free passage for the stone. But we are to remember, that, however marked the symptoms of a stone in the kidney may appear to be, it is impossible to obtain an absolute certainty on this point. We know that a stone in the kidney oc- casions pain in the region of the kidney; together with sickness and vomiting, and a discharge of urine sometimes mixed with blood, and on other occasions with 376 Of the Stone. Chap. XI. with mucus, and even with purulent matter. We also know, however, that the same symptoms are not unfrequently induced by other causes, particularly by inflammation and consequent suppuration of the kid- ney. Many instances have occurred of the most vi- olent nephritic complaints subsisting for a great length of time, where stones were suspected as the cause of them; but where, upon dissection, instead of this the kidney has been found to be completely suppurated, and as it were entirely dissolved, a quantity of purulent matter being contained within its external covering. Even in the case of calculus of the bladder, a dis- order less ambiguous than the nephritis calculosa, the symptoms are never so distinct and characteristic as to render the operation of lithotomy advisable, unless a stone is discovered upon the introduction of a sound. But in affections of the kidney, suspected to originate from stone, we are deprived of this means of ascertain- ing its presence; so that it might not unfrequently happen, that, after laying open the kidney, no stone would be discovered. This is, therefore, an objec- tion, and a very important one to the operation in question. But it is to be farther observed, that the kidneys do not lie near the surface of the body; that although they are not altogether covered by the inferior false ribs, yet these ribs project so much over them, as to prove a considerable obstacle to an operation; and that, in people who are corpulent, the kidneys are very thickly covered indeed. For these reasons, it is impossible to make an o- pening into the kidney with so much accuracy and precision, as the near contiguity of the neighbouring large blood vessels would require; and whoever at- tempts the operation of nephrotomy, even on the dead body, will find it a difficult matter to cut into the pelvis of the kidney without opening some of the large blood vessels belonging to it: The very great and Sect. VIII. Of the Stone. 377 and immediate danger from such an accident is too manifest to require to be farther mentioned. When, indeed, the inflammation, frequently induc- ed by a stone in the kidney, terminates in an abscess, and when the matter thus collected forms a tumor in which a fluctuation is distinguished, little or no dan- ger can ensue from opening it: And in such an event the stone which produced the tumor will either be dis- charged along with the matter t may, if it can be laid hold of, be afterwards extracted with safety. The stone being thus taken out, the opening through which it passed, will either heal by the usual means employed in the treatment of abscesses in other parts; or the most unfavourable termination that can proba- bly happen, will be a fistulous sore, through which a mixture of pus and urine will continue to be discharg- ed. Upon the whole we may conclude, that when we are not directed by the appearance of a tumor to the part which ought to be opened, the uncertainty of the ground upon which we proceed when we un- dertake this operation-—the difficulty of performing it-—and the very imminent danger which attends it, will more than counterbalance any advantage which can ever be expected to be derived from it; and that for this reason the operation of nephrotomy will nev- er probably be received into general practice, howev- er much it may be recommended by some writers, and warmly supported by others, who, in order to raise a reputation which they might not otherwise obtain, will sometimes step forward and propose with confidence what no practitioner of character would think right to attempt*. Bbb SECTION * For farther information on the subject of Nephrotomy, see Rosretus de partu Cæsareo, cap. vii. sect. 4. Philosophical Transac- tions for the year 1696. Schenkius Observat. Med. lib. iii. Junck- er's Conspect. Chirurg. tab. 93. Edinburgh Medical Essays. Me- moires de l'Academie Royalle de Chirurgie of Paris,-—And Mery's Observations sur la Maniere de Tailler. 378 Of the Stone. Chap. XI. SECTION IX. Of STONES in the URETHRA. IT is not an unfrequent occurrence for patients li- able to calculus complaints, to pass small stones along with their urine. When the stones, in such instances, are smooth and not very large, they usually come off with little or no difficulty; and in some cases stones of a very considerable size have been passed without being productive of much pain. But when an an- gular or rough stone is pushed into the urethra, if it is not so small as to pass easily off with the first flow of urine, it is sure to create a great deal of distress. Pain is the first symptom produced by a stone lodg- ed in the urethra; and to this succeed inflammation, tumefaction of the parts, and always a partial and fre- quently a total suppression of urine. In some instan- ces, when the disorder is long neglected, this suppres- sion and consequent tumefaction terminate in a rup- ture of the urethra; in consequence of which, the u- rine escapes into the contiguous cellular substance, and very troublesome swellings are produced not only in the body of the penis, but frequently in the scrotum, and through the whole course of the perinæum. The treatment suited to such tumors will be pointed out when we come to treat of fistulous sores in these parts; we have now only to relate the easiest and most effectual means of discharging the stones which are lodged in the urethra. As soon as it is known that an obstruction is formed in the urethra by the stoppage of a stone, the nicest attention be- comes requisite in order to procure its removal. When a stone has been long fixed at one particu- lar part without yielding in any degree, and when the pain and inflammation produced by it are considera- ble, a chirurgical operation ought to be immediately employed Sect. IX. Of the Stone. 379 employed for removing it; but in the incipient stag- es of this disorder, other means of a more gentle na- ture should be first put in practice. Whether or not the urethra itself is possessed of any contractile power, is a point not easily to be deter- mined: But the muscles with which it is immediately connected, are in common with other muscular parts subject to the influence of stimuli; and as nothing with which we are acquainted, can be supposed to give a more powerful stimulus to a sensible part than the irritation of a rough or angular stone, so we may fairly conclude, that when once a stone is impacted in the urethra, its farther passage along that canal may very possibly be impeded by a spasmodic contraction of some of the contiguous muscles. One very im- portant indication, therefore, in the treatment of this malady, is, the removal of spasm; and when we keep this idea in view, and continue to persist in the use of proper remedies, we seldom fail to bring off such stones as have been lodged in the urethra, without the aid of any chirurgical operation. But, instead of the application of means calculated for the removal of spasm, the ordinary practice of surgeons is the direct reverse of this, and must frequently be attended with a very opposite effect. An attempt is commonly made to push the stone forward at once with the fingers. It is obvious, how- ever, that until the spasm which in part produces the obstruction, is removed, every trial of this kind will rather tend to increase the complaint. For this rea- son, therefore, no pressure ought to be used till the most effectual means have been employed for remov- ing the spasm produced by the stone. With this view, the patient, if he is plethoric, ought to lose a considerable quantity of blood by the lancet; or if he is thin and emaciated, a proportionable quantity should be discharged by leeches, directly from the part affected. A quantity of warm oil should be re- peatedly 380 Of the Stone. Chap. XI. peatedly injected into the urethra, in order to lubri- cate the passage as much as possible.-—The patient should be immersed in a warm bath-—and a full dose of laudanum should be at the same time exhibited. Together with these remedies, a plentiful use of diuretic medicines, and of diluent drinks, is common- ly prescribed; but, instead of being productive of any advantages, they almost constantly do harm. For, when the urine rushes out with violence, if it does not carry the stone freely out of the urethra, it will tend to fix it more firmly than before; and the pain thus produced, will always increase the inflam- mation, tension and spasm of the parts affected: So that whatever has much effect in increasing the quan- tity of urine should be carefully avoided. A proper quantity of blood having been discharg- ed; the patient having remained for a sufficient length of time in the warm bath; and the opiate having be- gun to operate; the parts will thus be as completely relaxed as possible: And this is the period when some attempt should be made for extracting the stone. Various instruments have been contrived for this pur- pose, particularly long small pliers or forceps con- cealed in a cannula of a size corresponding to that of the urethra; but as none of these have ever proved in any degree useful, and as they often do much harm by producing an increased irritation in the urethra, we do not think it necessary to delineate them. In place of using instruments of this kind, a surgeon ought at first to eadeavour by very gentle pressure to push the stone forward along the course of the ure- thra. In this manner large stones may be brought off, for the removal of which a very painful operation might otherwise be necessary. Indeed, stones of so very considerable a size have been sometimes passed by the urethra, as ought always to induce practition- ers to persevere for a considerable time in the employ- ment Sect. IX. Of the Stone. 381 ment of the more gentle remedies we have recom- mended, before advising any other means of relief. It frequently happens, however, that stones of such a size and figure get into the urethra, as cannot by any means be made to pass to the extremity of that canal. When a stone, thus fixed in the passage, is of such a form as to admit of the discharge of the urine, a pa- tient, rather than submit to an operation, is sometimes induced to allow it to remain; and when he does so, the stone, in a short time, commonly obtains an in- crease of size by a deposition of earthy matter from the urine: I have known different instances of this in which the stones have become very large, and in which the urethra was so dilated as to form an extensive pouch or cavity corresponding to the size and figure of the stone. But when the stone, instead of allowing any of the urine to pass, fills up the urethra entirely, it then becomes necessary to have immediate recourse to an operation as soon as the means we have already recommended are found to prove ineffectual. This operation consists in cutting directly upon the stone, and extracting it either with a scoop or with a pair of small forceps; but the methods of effecting this vary according to, and depend upon, the part of the urethra in which the stone is fixed. When a stone is situated near to the beginning of the urethra, and very contiguous to the bladder, it has been advis- ed to push it again into the bladder by means of a staff: But as it might there probably acquire a much larger size, and would consequently render the patient liable to all the distress usually produced by a stone in the bladder, this is a practice which ought by no means to be admitted, as the stone may be extracted with much more ease from any part of the urethra, and with much less hazard to the patient, than is commonly incurred by the more formidable operation of cutting into the bladder. When 382 Of the Stone. Chap. XI. When therefore, an operation is necessary for ex- tracting a stone fixed in the urethra near the neck of the bladder, the method of performing it is this. The patient ought to be laid upon a table, and se- cured in the manner we have directed for the opera- tion of lithotomy: And an assistant suspending the scrotum and penis, the surgeon, after oiling the first and second fingers of his left hand, should introduce them into the anus, and by means of them ought to press firmly upon the parts immediately behind the stone; which will not only enable him to lay it bare with more ease, but will be the surest method of pre- venting it from being pushed into the bladder by the necessary pressure of the knife. This being done, an incision should be made through the common tegu- ments and urethra, so as to lay the stone completely bare; which may now be either turned out by a due degree of pressure applied with the fingers in the rec- turn; or, if this is not found to be sufficient, it may be taken out either with a scoop or with a pair of for- ceps. The after treatment is the same here as we have directed in the operation of lithotomy. When, again, a stone has passed farther into the urethra, in order to extract it the skin ought to be drawn as much as possible past it, either in a back- ward or forward direction; and the stone being now secured in its situation by pressure, a longitudinal cut is to be made directly upon it through the urethra, of a sufficient size to admit of its easy extraction either with the scoop or forceps. The edges of the wound are now to be completely cleared of fabulous particles, and the skin allowed to regain its natural situation; by which means, if the operation has been properly done, the wound in the urethra will be entirely cov- ered by skin that has not been injured: A circum- stance which tends to render this operation much less formidable than it otherwise would be; for the wound in Sect. IX. Of the Stone. 383 in the urethra is thus so well protected, that it com- monly heals by the first intention. It sometimes indeed happens, that in voiding urine, part of it escapes at the wound, and insinuates itself in- to the contiguous cellular substance. This is, how- ever, a rare occurrence, and the inconveniences aris- ing from it are easily obviated by laying open any collection of urine which may take place during the cure. When a stone fixes near to the point of the yard, as it sometimes does; if it is so near as to be observ- ed by the eye, it may frequently be taken out with a pair of small dissecting forceps: And in order to fa- cilitate the extraction, when it cannot be otherwise ef- fected, the urethra may be somewhat dilated from its extremity with the point of a scalpel. But when we fail of success in this way, an incision must be made upon the stone in the manner we have directed where the urethra is covered with skin. Soft dressings should be applied to the wound; and when the cure is near- ly completed, a hollow bougie, a short silver tube, or a small catheter of the elastic gum, should be intro- duced into the urethra, in order to preserve it of a proper size. The most perplexing situation in which a stone can be fixed in the urethra, is just below the scrotum; for if the stone either makes its way into the scrotum, or if it is necessary to make an opening into it with a scalpel, such large collections of urine are apt to oc- cur, as commonly occasion much distress. In order, therefore, to obviate this inconvenience, as soon as a stone is discovered in this situation, the greatest attention ought to be given, either to get it carried farther into the urethra, or, if this cannot be ef- fected, to push it back into the perinæum by means of a staff. By a due perseverance in the means we have recommended, this will very commonly be ef- fected: But when it is found to be impracticable, and that 384 Of the Stone. Chap. XI. that there is a necessity for extracting the stone, an in- cision must be made into the urethra, by beginning the cut at the under part of the scrotum immediately to one side of the septum, and continuing it upwards till the stone is distinctly felt, when it is to be laid bare and extracted in the manner we have already directed. By making the incision from below upwards, any urine that escapes from the urethra finds a very free passage; and if the opening is made sufficiently large, the stone may be in this manner easily extracted. During the operation, care must be taken to have the testis of that side on which the cut is made, as much protected as possible, by an assistant pulling it away from the knife; and when this is properly done, there is no danger of the testicle being injured. Some at- tention is necessary after the operation in applying the dressings in such a manner, that the sore may heal first at the bottom; for if this circumstance be not kept in view, and if the teguments are allowed to heal before every vacancy in the parts beneath is filled up, purulent matter, and perhaps urine, will very proba- bly be collected, and may thus give rise to trouble- some sinuses. When urine continues to be discharged for any length of time at a preternatural opening of the ure- thra, whether the consequence of the operation of li- thotomy or of any other cause, if the calculous dia- thesis prevails, stones of a large size will frequently form in the cellular substance contiguous to the open- ing. I have met with several instances of this: In some of them, the stones were small and easily ex- tracted; but in others they were found to occupy a considerable portion of the cellular membrane, and to occasion a good deal of trouble in taking them entire- ly out*. The treatment here consists solely in mak- ing * A very remarkable case of this nature is recorded by Gooch. See Cases and practical Remarks in Surgery, Vol. ii, p. 174, by Benjamin Gooch. Sect. IX. Of the Stone. 385 ing a free incision along the course of the calculous concretions; in turning them out, either with a scoop or a pair of forceps; and in dressing the wound prop- erly, so as to induce a firm adhesion of the parts be- neath, before the external teguments are allowed to heal. In females, the urethra is so short, and dilates so readily, that small stones seldom stop in it: They are most commonly carried off by the flow of urine which brings them into it; but when they happen to fix in it, they are commonly turned out with much ease, merely by the end of a blunt probe being insinu- ated behind them, and then pulled forward: Or, when this does not succeed, it may always be effected with safety, by cutting open the extremity of the ure- thra so far as to admit of the introduction of a pair of small forceps by which the stones may be extracted. Ccc CHAP. 386 Incontinence of Urine. Chap. XII. CHAP. XII. OF INCONTINENCE of URINE. INCONTINENCE of urine may be produced by various causes; but as it is frequently connected with calculous complaints, and is in some instances the consequence of the operation of lithoto- my, we are hence induced to take the subject under consideration in this place. The ordinary causes of this malady may be re- duced to the following heads. 1. Irritation about the neck of the bladder, pro- duced by the friction of stones contained in it. Thus we know, that inability to retain urine, is a very fre- quent symptom of stone in the bladder; and we can- not suppose this to proceed from any other cause than the constant stimulus communicated by the stone to the coats of the bladder. For, if it always originated, as has been supposed, from a total loss of power in the sphincter visicæ, the disease would seldom or nev- er admit of a cure. But we know well, that an in- continence of urine, depending upon a stone in the bladder, is very commonly removed entirely by the operation of lithotomy: And we likewise know, that it is very frequently much relieved, even when the stone remains in the bladder, by the use of those rem- edies which most effectually remove irritability; par- ticularly by a plentiful use of mucilaginous drinks, and by a free use of opiates. Indeed, by a continued use of these remedies, this variety of the disease is com- monly more effectually removed than by any other means, Chap. XII. Incontinence of Urine. 387 means, extraction of the stone excepted; which, when these fail, is to be kept in view as the only resource upon which we are to depend. 2. A constant stillicidium, or incontinence of urine, is a frequent consequence of paralytic affections; and it would appear, that the sphincter of the bladder now and then loses its contractile power, while the natural tone of its body, or of the muscle termed Detrusor Urinæ, remains entire. In this variety of the disorder, the obstinacy of the paralytic affection with which the constitution in general may be attack- ed, commonly renders fruitless every attempt to re- move it. But the most obvious remedies to be em- ployed for it, are, tonics, particularly Peruvian bark, chalybeates, and especially the cold bath general and local. In every affection of this kind, the local ap- plication of cold to the perinæum has more influence than any other remedy. Cloths wet with vinegar and cold water, or with a strong solution of saccharum sa- turni in vinegar, are sometimes of use; but the most effectual method of applying cold, is by dashing water directly from the fountain upon the perinæum and fundament. 3. An incontinence of urine is not an unfrequent consequence of laceration produced in the operation of lithotomy in male subjects; and in the same ope- ration, and by violence done to the parts in delivery, in females. It ought to be remembered, however, when in the lateral operation of lithotomy much laceration is produced, that in general it proceeds from the muscles and other parts not having been freely enough divided by the knife: And accordingly, except in cases of exceeding large stones, this incon- venience of an incontinence of urine seldom succeeds to this operation, when it is properly performed. As the disease in this case depends upon nearly the same cause as the one last mentioned, namely, on a loss of power in the retaining parts, the same remedies be- come 388 Incontinence of Urine. Chap. XII. come necessary; and by a due perseverance in the use of these, particularly of cold bathing, many are at last very effectually relieved from this species of the disorder. But it does frequently happen, in every variety of the disease, that no relief is obtained from any remedy whatever; in which case it becomes an object of im- portance to prevent the urine from incommoding the patient, which it does in a very distressing manner, if some effectual means are not employed to guard against it. When the disorder proceeds from either of the two last mentioned causes, namely, from a paralysis of the sphincter of the bladder, or from laceration, compression of the urethra answers very effectually for preventing any inconvenience produced by it, as the pressure can be so modified as to be applied and removed at pleasure. Nuck invented the first instru- ment for this purpose that we find any description of. The Jugum, or Yoke, as it is termed, in Plate XIX, fig. I. is an improvement upon this; and, when prop- erly fitted, it answers the purpose exceedingly well. When lined with quilted silk or velvet, it sits easily on the penis, and by means of the screw the pressure can be made of any degree of tightness. For women an- other invention becomes necessary, as the pressure here must be applied through the vagina. Pessaries of sponge have been invented for this purpose; but, when the parts are not so irritable as to prevent the application of them, nothing answers so well as the ordinary pessaries of ivory, or of any solid timber, such as lignum vitæ. In Plate XX, are represented pessaries of different sizes. In the introduction of these instruments, care should be taken to have them very finely polished, and they should likewise be well covered with oil. After being fairly passed into the vagina, the pessary should be placed directly across, so as to press with as much effect as possible against the urethra. This Plate XIX. Plate XX. Chap. XII. Incontinence of Urine. 389 This method of obviating the inconveniences pro- duced by an incontinence of urine, by pressure, is not, however, applicable when the disorder proceeds from irritation about the neck of the bladder; for the con- tinual desire to pass water, with which patients in such circumstances are constantly tormented, renders every attempt to suppress a complete evacuation of it total- ly inadmissible. It is therefore a matter of import- ance, for practitioners to attend to the different causes by which the disorder is produced; for here it is ev- ident, that a remedy well calculated for one variety of the disease may prove very prejudicial in the others. In all such instances where pressure upon the ure- thra is found to be improper, much relief may be ob- tained by having a machine properly fitted to serve as a reservoir for the urine. The instrument formerly referred to, represented in Plate XIX, has been used by different people, and with much advantage. It ought to be made so as to apply as closely as possible to one of the thighs; and, when properly fixed to a circular bandage round the body, it commonly re- mains sufficiently firm, and at the same time admits of a change of posture in any ordinary exertion of the body. Instruments of this kind, however, prove use- ful only in men. In women, all that can be done, is, to apply sponge and soft linen in such quantities as will effectually absorb the urine as it passes off. By one or other of the methods here pointed out, most of the inconveniences induced by this disorder may be much obviated; and in course of time it fre- quently happens, that when the original causes which produced it are removed, the disease itself is at last completely cured. CHAP. 390 Suppression of Urine. Chap. XIII. CHAP. XIII. OF A SUPPRESSION OF URINE. THE disorder treated of in the last chapter, namely, an Incontinence of Urine, is always attended with some inconvenience; but the disease now under consideration, proves, in every instance, very alarming, and on many occasions is productive of more real misery than almost any other to which the human body is liable*. Various causes tend to the production of this dis- order; and in the treatment of it, a nice discrimina- tion of them is necessary. I. In the preceding chapter we have seen, that an incontinence of urine is often produced by the sphinc- ter of the bladder becoming paralytic, while the de- trusor urinæ still retains its power of contraction. In a similar manner, a suppression of urine frequently oc- curs in paralytic disorders, and seems to originate from loss of power in the body of the bladder, while the sphincter still preserves its usual power of retention. Although this species of the disease is often con- nected with a paralytic affection of all the under part of the body, yet it is frequently induced by the perni- cious custom of people remaining too long, especially when drinking freely of diuretic liquors, without void- ing * It is that species of the disease we here mean to consider in which the urine is collected in the bladder, but which by some impediment or other is prevented from being evacuated. When this discharge is suppressed by any affection of the kidneys, a variety of the disease is produced, which it is not in the power of any chirurgical opera- tion to relieve; so that the consideration of it does not belong to our department. Chap. XIII. Suppression of Urine. 391 ing urine; by which means the bladder is sometimes so over distended, as to lose entirely all power of con- traction. In this variety of the disease the catheter is commonly found to be a very certain remedy; and as in cases of this kind it is generally easily introduced, it ought always to be employed as soon as the sup- pression is evidently formed; and as a complete cure of the disorder will be more readily obtained by a- voiding the cause which produced it, namely, an over distention of the bladder, than by any other means, this circumstance ought to be very particularly at- tended to. When, therefore, the least inclination to void urine is felt while the inability to discharge it continues, the catheter should be immediately em- ployed. For although the introduction of the cathe- ter is always disagreeable, and should never be at- tempted but when necessity points it out, yet in such circumstances as we are now considering, much delay or caution on this point might frequently prove very detrimental. The method of introducing the cathe- ter, both in male and female subjects, is the same with the operation of sounding for the stone, which we have already described. 2. A suppression of urine frequently occurs in the last months of pregnancy, from the uterus, during that period, pressing much upon the neck of the bladder. So effectually indeed does this pressure of the womb obstruct the passage of the urine, as on many occasions to prevent the evacuation of a single drop, unless the catheter is used: And as the instru- ment is in females commonly introduced with much ease, it ought always to be employed when any diffi- culty in voiding urine is perceived. By delaying the use of the catheter too long, much distress is fre- quently incurred. In different instances, the bladder has from this cause been distended to such a degree as to lose entirely its power of contraction; and in a few 392 Suppression of Urine. Chap. XIII. few cases, even a complete rupture of its coats has been produced. As soon, therefore, as any necessity occurs for the use of the catheter, by the bladder being much dis- tended, it ought to be regularly employed. Tumors in the vagina and neighbouring parts, when they happen to arrive at any considerable mag- nitude, have frequently the effect of compressing the urethra so much as to induce a total suppression of urine; and it is not an unfrequent consequence of a prolapsus uteri. The method of treatment best calculated for a complete removal of a prolapsus uteri, as likewise the means of cure commonly employed in cases of tu- mors in the vagina, will be the subjects of different chapters; only it must be remembered, that till these views are accomplished, the urine should in the mean time be regularly drawn off by means of the catheter, whenever it is found to be collected in any consider- able quantity. The very irritable state of the parts about the neck of the bladder, which often prevails in cases of sup- pression of urine, renders it necessary in some instances to employ the catheter often. Instead of this, some practitioners have advised the common catheter to be allowed to remain in the bladder a considerable time at once, so as to admit of the urine being evacuated as quickly as it is secreted: But this is a practice which ought by no means to be admitted; for the ir- ritation produced from a long continuance of this in- strument in the bladder, commonly does more harm than is ever experienced from a frequent introduction of it. When it is wished, however, to allow a cathe- ter to remain in the bladder, either for this purpose, or in cases of wounds in the urethra, the hard silver tubes in common use ought not to be employed; a flexible instrument of this kind, prepared with the Resina Elastica, Chap. XIII. Suppression of Urine. 393 Elastica, is found to answer this intention better than any other. 3. A stoppage to the flow of urine is not an un- frequent consequence of scirrhosities of the prostate gland, and of obstructions formed in the urethra in cases of virulent gonorrhœa. The treatment best suited to these affections will also be the subject of a different chapter. That species of suppression of urine induced by stones impacted in the urethra, has been already treat- ed of, and the remedy pointed out. 4. But the most alarming variety of the disease is that which proceeds from inflammation about the neck of the bladder, inducing pain and such a degree of swelling in the parts as renders the introduction of the catheter inadmissible. Suppression of urine from an inflammatory affec- tion of the neck of the bladder, is not unfrequently found to originate from inflammation in cases of gon- orrhœa proceeding backwards along the course of the urethra: An improper use, too, of astringent injec- tions has frequently induced this species of the disease; and as the bladder is equally liable with other parts of the body to the influence of those causes which induce inflammation, whatever has any effect of this kind in other parts will be productive of the same consequen- ces here. The method of treatment is nearly the same, by whatever cause the inflammation may have original- ly been induced. Blood should be discharged in a considerable quantity from some of the larger vessels, and leeches ought to be applied upon the perinæum as near as possible to the seat of the disease. Opiates should be prescribed in large doses; injections of warm water or milk should be repeatedly thrown up by the rectum; and the whole body should be immersed in the warm bath. By these means, when the cause in- ducing the disorder is not of an obstinate nature, the Ddd inflammation 394 Suppression of Urine. Chap. XIII. inflammation producing the suppression of urine will sometimes be removed before any troublesome symp- toms supervene. But when they do not prove effectual: when the bladder becomes painfully distended; and when every attempt to introduce the catheter has fail- ed, some other means ought to be immediately em- ployed for relief. With this view, nothing in such cir- cumstances is to be depended on, but puncturing the bladder in order to discharge the urine collected in it. Various methods have been proposed for effecting this operation.-—By some it has been advised to puncture the bladder a little above the pubes; oth- ers have proposed to cut the membranous part of the urethra, prostate gland, and neck of the bladder: And an opening from the perinæum directly into the body of the bladder, has been likewise recommend- ed*. It is not necessary, however, in order to reach the body of the bladder, to lay the urethra open, and to divide the prostate gland: This method, there- fore, of removing a suppression of urine, is now very deservedly laid aside. Puncturing the bladder above the pubes, has been recommended by many respectable authors, particu- larly by the late Mr. Samuel Sharp; and as it is still practised by many in preference to every other method, we shall here describe the method of doing it. There is no difficulty in perforating the bladder in this place; for if an opening be made any where with- in two or three inches of the upper part of the pubes, if it be carried deep enough, it must of necessity, in this distended state of the bladder, be sure to reach it: But the best situation for entering the perforating in- strument, is about an inch or an inch and a half above the symphises of the pubes. We are directed by writers upon this subject, first to make an incision of about two inches in length through the common teguments and muscles, and then * Vid. the works of Saviard, Tolet, and Cojet. Chap. XIII. Suppression of Urine. 395 then to perforate the bladder with a trocar. But there is no necessity whatever for this extensive division of the teguments and muscles; for the operation may be done with equal safety, and with much less pain to the patient, by merely pushing a trocar at once through the skin, muscles, and bladder. As soon as the tro- car has fairly entered the bladder, the stilette should be withdrawn, and the canula secured in its situation by pieces of ribbon or tape connected with it and made fast round the body of the patient; and a piece of cork ought to be fitted to the canula, that the urine may pass off at proper intervals only, by which means alone the patient can be kept dry and comfortable. In corpulent people, a trocar with a canula two inches long, is found to be necessary; but in others the instrument need not be longer than an inch and a half. This circumstance, it may be remarked, is of some importance, and ought to be attended to; for when a long canula is used, and more especially when the puncture is made very contiguous to the pubes, there is always some risk, upon the evacuation of the urine, of pain and distress being produced by the pressure of the canula upon the back part of the blad- der. Of this we have an instance on record, in which the extremity of the instrument was found, af- ter death, to have penetrated not only the back part of the bladder, but even the rectum*. The canula, it must be remembered, is to be retain- ed in its situation till the cause which produced the ob- struction is so far removed that the patient can void his urine in the usual manner; but it has been very properly remarked †, that a canula cannot be kept a- bove ten or fourteen days in the bladder, without con- tracting such a calculous crust, as renders its extraction exceedingly difficult, and, in some instances, even im- practicable. The canula, therefore, should be taken out * Vid Sharpe's Operations of Surgery, chap. xv. † Vid. Critical Inquiry, &c. by Mr. Sharpe, ch. iv. 396 Suppression of Urine. Chap. XIII. out and cleaned every two or three days; but, pre- vious to withdrawing it, a firm probe of a sufficient length ought to be passed through it into the bladder, upon which it may be again returned with ease and safety as soon as it is properly cleared of the incrustation. To this mode of operating, however, some objec- tions occur. From the situation of the canula above the pubes, the bladder is suspended by it for a consid- erable length of time, and is thereby liable to suffer. Besides, if the bladder slips off from the extremity of the canula, the operation must either be repeated, as we are told by Daran, was once done, or the patient must be left in nearly the same state in which he was previous to the puncture being made. If, on the other hand, we consider the advantages attending the mode of puncturing the bladder from the perinæum, namely, that it is done with great ease; that the urine contained in the bladder is more readi- ly evacuated than by puncturing above the pubes; and that it is likewise less liable to escape into the neighbouring parts; we will have no hesitation in giving it the preference, in perhaps every instance of suppression of urine. With a view to puncture the bladder from the pe- rinæum, the patient ought to be laid upon his back; and his thighs being properly separated and secured by assistants, an incision should be made of about an inch and a half in length, beginning at the commence- ment of the membranous part of the urethra, and continuing it towards the anus, in a line parallel to, but at least half an inch distant from, the rapha pe- rinæi. In this manner the skin and cellular substance ought to be freely divided; which puts it in the pow- er of the operator not only to introduce the trocar with more ease, but to avoid the urethra with much more certainty than he otherwise could do. This being done, as the bladder is always much distended when this operation is necessary, it will be very  Plate XXI. Chap. XIII. Suppression of Urine. 397 very easily distinguished by pressure at the bottom of the wound: But, whether it should be felt by the finger or not, there need be no hesitation in pushing in the trocar a little above and to the left of the pros- tate gland, which, if the parts have been freely divid- ed, may be always discovered; and if the point of the instrument be directed a very little upwards, there can be no danger of wounding either the ureters or vasa deferentia, which some have been afraid of in this op- eration; and at the same time there must be an abso- lute certainty, if the trocar is carried deep enough, of its reaching the bladder. It has been alleged, and with some reason, that in this part of the operation the surgeon must be at some loss to know when the instrument has reached the bladder; and several inventions have been proposed to obviate this inconvenience. In Plate XXI, fig. 4. is represented a very simple contrivance for this pur- pose: It consists of a trocar, with a canula of the usu- al form, and a deep groove in the stilette, so that u- rine begins to flow along the groove, immediately on the instrument having entered the bladder. As soon, therefore, as by this circumstance it is known that the trocar is properly introduced, the stilette should be withdrawn; and the canula should be secured in its situation by two pieces of tape, connected with two rings upon its brim, being firmly tied to a circular bandage round the patient's body: And if one of these tapes be tied behind immediately above the sacrum, and the other directly above the pubes, the canula will not be easily displaced. It is equally necessary here as when the operation is done above the pubes, to change the canula, or at least to clean it every now and then; and in this situ- ation too, so long as the canula is found to be neces- sary, the urine may be retained and drawn off at pleas- ure, by a plug of cork properly adapted to the canula. In 398 Suppression of Urine. Chap. XIII. In treating of this operation we have not mentioned a method that has been proposed of perforating the bladder by means of a curved trocar entered from the rectum. Indeed it scarcely deserves to be noticed, as no advantages can probably occur from it that may not with more certainty be obtained from perforating in the perinæum; and it is attended with this very ma- terial inconvenience, that by passing the instrument in at the back part of the bladder, much risk must be incurred of wounding either the ureters, vasa deferen- tia, or vesiculæ seminales; while at the same time a passage will be formed by which the fæces may find access to the cavity of the bladder, and by which much misery may be induced: Without further con- sideration, therefore, we can with freedom venture to say, that this method of operating ought never to be employed. In the operation of lithotomy in females, we assign- ed reasons, which appear to be sufficiently conclusive against the method of cutting into the bladder from the vagina; but these reasons do not apply with equal force against the propriety of puncturing in this part. On the contrary, whenever there is any necessity for performing this operation in women, it cannot possibly be done in any other way either with so much ease or certainty, as from the vagina. When the bladder is much distended with urine, it is readily discovered by the finger from the vagina; and from this circumstance it may with great safety be perforated with a trocar. The fore finger of the left hand being introduced into the vagina, the point of the instrument ought to be conducted upon it, and should at once be pushed through the vagina into that part of the bladder which is first discovered by the finger; for here the ureters run no risk of being wounded, which farther back they certainly would do. After the trocar is fairly intro- duced into the bladder, and when the urine is all e- vacuated, the canula ought to be left in its place, and should Chap. XIII. Suppression of Urine. 399 should be continued there as long as the cause subsists which produced the suppression. That the canula may be firmly secured, it ought to be of a sufficient length for passing out at the vagina, and to admit of its being tied to the T bandage by means of tapes properly connected with it. CHAP. 400 Obstructions in Chap. XIV. CHAP. XIV. OBSTRUCTIONS IN THE URETHRA. IN the preceding section, when treat- ing of the causes of suppression of urine, obstructions produced by claps, of which caruncles are supposed to be the most common, were mentioned as the most frequent and most remarkable. But although we have particularly mentioned the term Caruncle, by which is meant, a fleshy excrescence arising from the membrane of the urethra, we are by no means convinced that it is a frequent occurrence. That such excrescences are sometimes met with, par- ticularly towards the extremity of the yard, there is no reason to doubt; but as I have had many opportuni- ties of dissecting these parts, in patients who had long laboured under symptoms supposed to proceed from caruncles in the back part of the urethra, and as caruncles were not in any of these found to be the cause of the disorder, I am therefore clearly of opinion that their existence in the more remote parts of the ure- thra is a very uncommon occurrence. I have often observed productions of this kind, within half or a quarter of an inch of the extremity of the urethra, es- pecially in cases where the glans and prepuce have been covered with watery excrescences of a similar na- ture: But from having never, even in cases of this kind, found them spread farther up the canal, although it is not a proof that they never occur in other parts of it, yet this, together with some observations of a similar nature by Dionis, Saviard, Mr. Petit, and others, Chap. XIV. the Urethra. 401 others, is sufficient authority for the opinion we have advanced, that caruncles in the more remote parts of the urethra is a circumstance rarely met with. Daran indeed speaks much of this species of obstruction; and he no doubt had more practice in disorders of this nature than perhaps ever fell to the share of any other individual: But if he is properly attended to, it will be found, that his ideas on this subject are by no means accurate; for he evidently confounds other causes of obstruction, particularly callous strictures and cicatrices of old ulcers, with, and mistakes them for, caruncles. Practitioners in former times, as well as many in more late periods, have doubted so little of the fre- quent occurrence of caruncles, that almost every in- stance of obstructed urethra succeeding to a clap has been attributed to this cause. What we have here advanced, however, will have some influence in set- ting this matter in a different point of view; and we shall now proceed to enumerate the different causes by which obstructions in the urethra may be produced. 1. Although we have said that caruncles are rare- ly if ever met with in the superiour part of the ure- thra, yet as they sometimes occur towards the ex- tremity of this canal, we cannot avoid mentioning this as one cause of these obstructions. We must a- gain observe however, that in every instance we have met with of caruncles, or carnosities as they are sometimes termed, they have always been of the same nature with those warty excrescences so frequently ob- served upon the prepuce and glans as a consequence of gonorrhœa: Most frequently, too, they have been connected with external affections of this kind. 2. Ulcers in different parts of the urethra have on some occasions been known to produce very complete obstructions. On opening the bodies of patients who have at the time of death laboured under gonorrhœa, it has frequent- Eee ly 402 Obstructions in Chap. XIV. ly been found that no ulceration could be discovered; and this gave rise to the idea that ulcers in such cases never take place. We now know indeed that very great quantities of matter, even of a purulent kind, may be furnished by parts merely inflamed, and that are not in any degree ulcerated: But we also know, that parts remaining for any considerable length of time in such a high degree of inflammation as to furnish a great supply of pus, are very apt to become ulcerated; and if this happens in other parts of the body, we may conclude that the same cause will be productive of the same effects in the urethra. Accordingly, there is no reason to doubt of the existence of ulcers merely as the consequence of an inflamed state of the urethra; but it is likewise certain, that ulcers are sometimes met with in the urethra from the same cause by which sores or chancres are produced in the glans, namely, from the mechanical effects of the venereal poison, independent of the intervention of any degree of inflammation. The excretory ducts of the different glands in the urethra, particularly of the prostate gland, as also the ducts of the vesiculæ seminales, and the other parts a- bout the verumontanum, have commonly been con- sidered as being particularly obnoxious to the effects of the venereal virus; and ulcerations are according- ly said to be more frequently met with in these parts than in any other. Whatever may have occurred to others for the foundation of this opinion, I will not pretend to say; but, from all I have been able to learn of this subject from my own experience, I would say, that ulcers occur much more frequently towards the extremity of the urethra than in other parts of it, and that they are very rarely found far- ther back than an inch or two from the point of the yard. 3. Dissection has shown that a mere contracted state of the urethra is to be considered as a frequent cause Chap. XIV. the Urethra. 403 cause pf obstruction. In some instances the stricture has been confined to one point, and in others the pas- sage has been found contracted in different parts. A real contracted state of the urethra is probably more frequently produced by the cicatrices of old ulcers, than by any other cause; but as parts which have continued long in a state of inflammation, are very apt to become thickened, and even harder than they are ever found to be in a state of health, a gonorrhœa, attended with much inflammation, may frequently, it is probable, be productive of this effect. Astringent injections are supposed by those who consider them to be pernicious, as apt to produce a contracted state of the urethra more frequently than any other cause. Injections of this kind, when im- properly applied to parts already in a state of high in- flammation, will no doubt often do much mischief; and, by increasing the inflammatory state of the ure- thra, may in this manner tend to produce strictures: But this is evidently not the fault of the remedy, but of the improper use of it. Similar objections might with equal reason be adduced against the use of every medicine with which we are acquainted; for no rem- edy ever proves more effectual, or more safe in its operation, than astringent injections in cases of gonor- rhœa. When properly applied, indeed, many cases occur of obstinate claps being safely cured by injec- tions which cannot be removed by any other means. 4. Tumors in the cellular substance surrounding the urethra, or in any of the glands connected with it, very frequently produce most complete obstructions in the course of this canal. And inflammation, whether originally induced by a gonorrhœa or by any other cause, if it terminates in suppuration, is often at- tended with this effect. In such cases, indeed, as soon as the matter collected in the abscess is discharged, the obstruction produced by it is in general removed: In some instances, however, it happens otherwise; for, in different 404 Obstructions in Chap. XIV. different cases of this nature, I have found, that the compression produced by the tumor has induced such a firm adhesion between the sides of the urethra as to obliterate the canal entirely. This, however, can on- ly occur from a long continuance of the pressure pro- duced by the tumor; and which, again, can never be continued for any considerable length of time in such a degree as completely to obstruct the passage, unless the urine has forced some other opening for itself: And accordingly, in all such cases, one or more open- ings, communicating with the urethra, are found be- tween the seat of the disease and the prostate gland. 5. Of all the causes productive of obstruction to the passage of the urine, which I have ever been able to discover, none are so frequent as a particular kind of fullness or enlargement of the corpus spongiosum u- rethræ. On dissecting the penis of such as have labour- ed long under obstructions of this kind, an enlargement or thickening of the substance of the urethra as now described, has been very often met with; and this en- largement has, in many instances, proceeded so far as totally to obstruct the passage of the urine. In some of these this affection of the urethra was confined to a particular spot. In others it extended a considerable length; while in some it was found to have attacked different parts of the canal, leaving in- termediate spaces of it perfectly sound. We have thus enumerated the causes which appear most frequently to be productive of obstructions in the urethra. We shall now proceed to the method of treatment best calculated for their removal. When obstruction of the urethra arises from causes enumerated under the fourth head, our practice must be directed by the nature of the tumor by which the disorder is produced. Accordingly, when tumors of an indolent or scirrhous nature are found to induce such obstructions, extirpation of the diseased parts, when this is found to be practicable, is the only means Chap. XIV. the Urethra. 405 means of relief which will probably prove useful: But although tumors of this kind which appear externally, and which do not penetrate deep, may be extirpated with safety; yet when the prostate gland, or any of the parts about the neck of the bladder, are found to be the seat of the disease, the removal of them cannot possibly be attempted. In such desperate cases, cicuta has been often used; but seldom, I believe, with much advantage. In an ulcerated state of the parts, a plen- tiful use of uva ursi has been known to give relief; but nothing with which we are acquainted, affords such a probable chance of relief, as long continued, though very gentle, courses of mercury. In the mean time, a plentiful use of mucilaginous drinks is found to prove serviceable, and the violence of the pain must be obviated by adequate doses of opiates. When, again, such tumors are evidently of an in- flammatory nature, if they are not soon removed by discussion, the most effectual means should be employ- ed for promoting their suppuration. These we have already in a former publication pointed out*. As soon as by these, or similar means, the formation of matter is accomplished, the abscess in which it is collected should be immediately open- ed. In some other parts of the body, whenever an inflammatory tumor is probably to terminate in sup- puration, it is considered as good practice to delay giving vent to the matter till pus is thoroughly form- ed; but in this situation, as much distress would for certain be produced by any considerable delay, the ab- scess ought undoubtedly to be opened as soon as there is the least reason to suppose that the pressure upon the urethra would be diminished by doing so; and this must always be the case whenever any collection of matter is evidently discovered. In every abscess therefore, of this kind, the cure of the suppression of urine * Vid. Treatise on Inflammation and if consequences. 406 Obstructions in Chap. XIV. urine produced by it will be accomplished with more certainty by discharging the matter contained in it than by any other means. If, on laying the collec- tion open, however, it shall be found that the stoppage in the urethra, is not removed, recourse must be had immediately either to a bougie or a catheter: By in- troducing a bougie of a proper size and consistence, and passing it easily along the urethra, any obstruc- tion produced by the pressure of the abscess may in general be effectually removed; and by continuing to insert either a bougie or a flexible catheter, and allow- ing it to remain for several hours daily, every effect which such obstructions might otherwise produce, will be very certainly obviated. In some instances, again, when abscesses of this kind are allowed to press too long upon the urethra before they are opened, the urine bursts into the cel- lular membrane of the perinæum and other contigu- ous parts, and from thence forms one or more exter- nal openings; and in this manner induces a disorder which always proves very distressing to the patient, and extremely perplexing to practitioners. This, however, will be afterwards more particularly consid- ered, when we come to speak of the fistula inperinæo. In the other cases of obstructions in the urethra, pro- ceeding from caruncles when they happen to occur; from ulcers, and the cicatrices produced by them; from stricture and contraction of the urethra; and from an enlarged and thickened state of the corpus spongiosum urethræ; when these arise from a venereal cause, the disorder of the general constitution must be particularly attended to; and we know that it can be effectually removed by a proper use of mercury only. At the same time, we must attend to the local affec- tion of the urethra; and here a little consideration will render it evident, that the several causes of the disor- der must operate in the same manner with tumors mentioned above, namely, by inducing a diminished or Chap. XIV. the Urethra. 407 or contracted state of the urethra: And this accord- ingly accounts for the universal utility of the bougie in obstructions of this passage; a remedy which, in every affection of this nature, proves chiefly servicea- ble by its mechanical action on the obstructed part. It has been alleged indeed by many, particularly by Mr. Daran and Mr. Sharpe, that, in removing ca- runcles and other causes of obstruction, bougies prove more useful by what they term their Suppurative quality, than by any other property: By which they mean to say, that bougies may be composed of such materials as will induce a suppuration upon the ca- runcles to which they are applied; and that this sup- puration, if continued for a sufficient length of time, will ultimately destroy all such diseased parts*. This idea, although founded on inaccuracy, con- tinues still to prevail: But a very little attention must set the matter in a more distinct point of view; and will make it appear, that the effect in general expe- rienced from bougies, is obtained more from the me- chanical pressure produced by them, than from any other property. Among other reasons which might be mentioned as a refutation of the opinion respecting the advantages to be obtained from the suppurative effects of bougies, the following seem to be sufficient for our purpose. 1. Those who allege that bougies prove common- ly useful by inducing suppuration, have always affirm- ed * For Mr. Daran's account of this matter, see his Treatise on Diseases of the Urethra: And Mr. Sharpe's account of it may be seen in his Critical Inquiry, chap. vi. Although Mr. Sharpe is clearly of opinion, that the principal advantage derived from bou- gies proceeds from their influence in inducing suppuration; yet, whenever he attempts to investigate the matter with accuracy, he is obliged to acknowledge, that the pressure produced by them has no inconsiderable effect: For he says, "That though I have a great opinion of the good effects produced by the suppuration, yet I be- lieve also, that bougies operate by distending the urethra ; and I will go so far as to give it as my judgment, that even the cures done by Mr. Daran are wrought partly by distention, and partly by sup- puration; though he himself ascribes them to suppuration only." Vide p. 171, fourth edition, loc. cit. 408 Obstructions in Chap XIV. ed that such cases of suppression of urine as are re- lieved by this remedy, originate most frequently from caruncles in the urethra; and that the suppuration produced by the bougies, tends to destroy, or as it were to dissolve, them. Although excrescences of this nature may sometimes prove the cause of obstruc- tions in the urethra; yet, as we have already endeav- oured to show, they are by no means a frequent one. From all the experience, indeed, which I have had in affections of this kind, I would say, that there does not one tenth of the whole depend upon the existence of this cause. It must therefore follow, if this idea respecting the cause of the disorder be ill founded, that the supposed modus operandi of the remedies em- ployed in it must likewise be erroneous; for every practitioner who has attended much to this branch of business, must acknowledge, that bougies in every complaint of this nature, prove much more frequently useful than the cause upon which they have been sup- posed chiefly to operate is found to exist. Indeed the general utility of bougies in cases of obstructed urethra, must be acknowledged by all who have used them, while scarcely any advantage is derived from the use of any other remedy. 2. But although we should allow that caruncles are frequently formed in the urethra, we cannot ad- mit that a suppuration induced upon them would have much influence in removing them. We know, that, in other parts of the body, warts or other hard excrescences cannot be carried off merely by a suppuration being formed upon them; and we cannot suppose that there is much difference in this respect between the same disorder in the ure- thra, and in other parts of the body. 3. It has been said, that these bougies, at the same time that they act by inducing suppuration, have like- wise some influence as an application of a caustic na- ture; and; that many of Mr. Daran's bougies, the composition Chap. XIV. the Urethra. 409 composition of which was kept secret, were evidently possessed of this property.-—Mr. Daran, in order to render the operation of his remedy as mysterious as possible, did indeed allege, that his bougies were endowed with many virtues: But no candid practi- tioner will say, that any application of this kind, pos- sessed of a degree of causticity sufficient to destroy warts, can with propriety be introduced into the ure- thra; for, if made of such a strength as to corrode these excrescences, they would surely be in great dan- ger of injuring the whole course of the urethra to which they are applied.-—Indeed, the mildest materi- als we can employ, frequently produce inconveniences by their stimulating power. For upon withdrawing any bougie that has remained long in the urethra, it is almost always found covered with matter or pus. It is this circumstance, we imagine, that first suggest- ed the idea of bougies acting by inducing suppura- tion; which, however, is to be considered only as a necessary effect of a stimulus applied to a delicate sen- sible membrane, and in no respect essential to the cure of the disorder for which the bougie was used. 4. But without having recourse to the suppurative or escharotic effects of bougies, the advantages fre- quently derived from them, in obstructions of the ure- thra, may, as we have already endeavoured to show, be easily and simply accounted for upon the principle of mechanical pressure alone. We have thus thought it proper to consider the action of bougies with minuteness; for till once the idea is thoroughly exploded of medicated bougies, as they are termed, being necessary, much mischief may be done, by forming them of irritating or even of es- charotic materials, as is sometimes the case, instead of rendering their composition perfectly mild and inof- fensive, as in every instance it ought to be. The opinion we have endeavoured to establish be- ing admitted, namely, that bougies ought to operate Fff solely 410 Obstructions in Chap. XIV. solely by mechanical pressure, it must necessarily fol- low, that, in the formation of bougies, much will de- pend on their being made of a proper consistence, neither too hard nor too soft. When too soft and compressible, they cannot act with advantage against the obstructing cause, and against which pressure is intended to be applied; and when too hard, they are apt to crack, and are neither introduced into nor re- tained in the urethra with so much ease as when made of a proper consistence: Bougies ought likewise to have a smooth polished surface, to facilitate their introduc- tion; and lastly, they ought, as we have already re- marked, to be composed of very mild materials, so that when introduced they may give as little irritation as possible. Bougies may be made of a great variety of mate- rials; but, so far as my experience enables me to judge, no composition answers the several purposes we have mentioned so well as a plaster of which sim- ple diachylon forms the basis.-—The following form I have had much experience of. ꝶ. Emplast. Diachyl. simpl. ℥iv. Ceræ puriss. ℥iβ. Ol. Oliv. opt. ʒiij. The bees wax and oil give a degree of softness to the diachylon which prevents it from cracking, which it is otherwise apt to do upon being long kept; be- sides, a better polish can be given to bougies prepar- ed from a plaster composed partly of wax, than can be given to those made of any other materials. Bur- gundy pitch, rosin, and even some of the turpentines, have been advised as proper additions to these materi- als: But all of them tend to render the composition too irritating; and as wax communicates a sufficient degree of tenacity to it, these ought never to be em- ployed. The diachylon should be slowly melted, and the wax being also melted in the oil in a different vessel, let Chap. XIV. the Urethra. 411 let the two be mixed properly together; and while the liquid continues still tolerably warm, let pieces of fine firm old linen be dipt in it, care being taken, by means of a spatula, to cover the whole linen as equal- ly as possible.-—If the liquid is of a proper heat, no more of the plaster will adhere to the linen than is just necessary; but as air bubbles are apt to occasion inequalities on the surface of the cloth, the spatula made use of ought to be somewhat warmer than the plaster, and by means of it the whole should be ren- dered perfectly smooth. Some indeed have desired the plaster to be spread entirely by the spatula, rath- er than to dip it: This, however, is attended with much more trouble, and does not cover the cloth with that equality which the formation of bougies re- quires. As soon as the dipt cloth is sufficiently cold, it may be formed into bougies; and the manner of do- ing it is this: The number intended to be formed ought all to be cut; and the easiest and most exact method of doing this is by means of a sharp pointed knife directed by a ruler. The pieces ought to be from nine to ten and eleven inches in length; and as they should always be smaller at the point which enters the urethra than at the other, this circumstance should be attended to in the cutting of it into slips, The thickness of the linen, and of the plaster with which it is spread, must in some measure determine the breadth of these slips for the different bougies: But when the linen is of a proper degree of fineness, and is rightly spread, a bougie of a middle size, may be formed of a slip of about five eighths of an inch broad at its largest end; and the point of it may be made of a proper size, and may be thus adapted to a- ny particular case, by making the piece of linen taper more or less from about two or three inches from its smaller extremity. These slips of spread linen are now to be rolled up as neatly as possible by the fin- gers; 412 Obstructions in Chap. XIV. gers; and in order to give them a smooth polished sur- face, they should be smartly rolled between a piece of smooth hard timber and a plate of fine polished mar- ble. This being continued till the whole are render- ed perfectly smooth and firm, and their points being rounded properly in order to facilitate their introduc- tion, they are in this state to be preserved for use. The directions we have now given will convey an idea of the method of preparing bougies; but no surgeon can ever become so expert in forming them, as those artists who are daily accustomed to prepare them in very considerable quantities. We come now to the application of the bougie.-— When that kind of obstruction occurs which points out the bougie as the most proper remedy, the fol- lowing is the method of using it: A bougie, adapted to the size of the passage through which it is to go, is to be well covered with fine oil, in order to facilitate its introduction; and the penis being firmly grasped and extended with one hand, the point of the instru- ment is to be inserted into the urethra with the oth- er; and being pushed forward with caution, it is in this manner to be carried on till it meets with the cause of obstruction; when, if a moderate force makes it pass, our object is so far accomplished; but if, af- ter different attempts, it cannot be easily carried through, it should be immediately withdrawn; and at next trial, which in order to avoid any risk of in- flammation, should not be made till the following day at soonest, a bougie with a smaller point should be employed. A great deal of nicety is requisite in this part of the operation; for, by proceeding gradually and with due caution, every risk may be avoided of injuring the urethra, at the same time that the object in view may be often accomplished with more certainty than if much force was made use of. As soon as we reach the cause of obstruction, if a bougie of the smallest Chap. XIV. the Urethra. 413 smallest size is employed, instead of pushing it on with force, as to a certain degree may be done with a catheter, it answers the purpose much more cer- tainly to twirl it between the finger and thumb, so as to make it press very moderately upon the part which it ought to pass. But, on the other hand, al- though mischief has often accrued from too much violence being used in inserting bougies, and although every practitioner ought therefore to be warned of the danger occurring from it; yet, when much re- sistance is met with, there is a necessity for pushing them on with some degree of firmness. If this, however, is done with due caution and in a proper direction, which experience alone can teach, it may frequently be accomplished without any risk, and with much advantage to the patient. In many cases, indeed, unless a tolerable degree of force be used, the bougies will not pass through the obstruction, and no benefit will therefore be derived from them; for un- less a bougie be made to pass the point of obstruction, it cannot operate to any advantage. This, I must observe, is a point of much impor- tance, and ought to be kept in view. For although no unnecessary force should be ever employed, yet in cases of this kind we commonly meet with too much timidity: For, in ordinary practice, if the bougie meets with any unusual resistance, and if it cannot, on the first or second attempt, be introduced, the case is commonly considered as desperate, and no further trials are made. I can from much experience, how- ever, say, that scarcely any case ever occurs in which the bougie, by a frequent repetition of cautious tri- als, may not be introduced. Even where I have been convinced that the passage of the urethra has at a particular point been entirely obliterated by the sides of it adhering to one another, and where the u- rine has been voided by openings in the perinæum, the 414 Obstructions in Chap. XIV. the bougie, with a due degree of force properly ap- plied, has at last effected a cure. In some instances, bougies with very small points will enter, when others of a larger size will not pen- etrate; but, in general, when the obstruction is found to be unusually firm, those of a middling size are preferable to such as have very small points: For bougies of this form are very apt to bend if they do not pass forward at once; and as soon as the point yields in any degree, the bougie should be withdrawn, as it cannot afterwards be pushed forward; for if more force is now employed, instead of being carried far- ther into the urethra, it becomes twisted, and is sure to produce a good deal of pain in the extraction.* By different cautious trials, the bougie will at last be made to pass the different points of obstruction, for in some instances they are met with in more points than one; and as instances have occurred of bougies slipping into the urethra altogether, and even into the bladder itself, this accident ought to be care- fully guarded against by a piece of narrow tape or soft thread, connected with the extremity of the bou- gie, and either tied round the penis behind the glans, or to a circular belt passed round the body. Certain regulations have been mentioned by au- thors for the length of time a bougie ought to be kept in the urethra: But with some patients they oc- casion a good deal of pain, while with others they produce little or no uneasiness; and as it is the de- gree of pain induced by them which ought to regu- late the time they remain in the urethra, nothing de- cisive, * With a view to give more firmness to bougies, Mr. Dease, an ingenious surgeon of Dublin, recommends their being formed up- on catgut.—Vid. Observations on the different Methods of treating the Venereal Disease, by William Dease, Dublin. We may likewise mention, that, for purposes of this kind, catgut alone answers exceedingly well.-—When cut into the length of bou- gies, and on being properly polished by rubbing on a plate of marble, they become sufficiently firm for forcing almost any obstruction that can occur. Chap. XIV. the Urethra. 415 cisive, it is evident, can be said upon this subject. When their introduction is attended with much pain, they ought neither to be allowed to remain long at once, nor should they be used above once in the two or three days: But when they can not only be intro- duced but be retained in the urethra without produc- ing much uneasiness, they ought to be kept almost constantly employed; for as it is by pressure almost solely that they produce any advantage, and as this pressure must be continued for a certain length of time according to the nature of the obstruction, the more constantly the bougie can be used, the more quickly a cure will probably be accomplished. And with the same view the size of the bougie should be gradually increased, till one of such a thickness can be easily introduced as the urethra could probably receive, were we certain that no obstruction existed. When much uneasiness is incurred by the use of bougies, the patient should never employ them but when he can confine himself either to bed, or at least to his apartment; but with many the distress produced by them is so trifling, that they can walk easily with bougies of the largest size inserted along the whole course of the urethra. Nothing certain can be said with respect to the length of time that bougies should be used, as this must be always regulated by their effects; which, a- gain, will in a great measure depend on the nature of the obstruction. This, however, we can with free- dom propose, that the bougies ought to be continu- ed, not only while any difficulty in passing water re- mains, but for a considerable time thereafter. In the use of bougies, care should be taken never to push them altogether into the bladder: For, even when prepared of the very best materials, a portion of the composition may crack and fall off; and if this should happen to be too large to pass off with the urine, it may be a means of creating much dis- tress. 416 Obstructions in Chap XIV. tress, by serving as a nucleus for a stone. When it is necessary to pass any instrument of this kind so far as the bladder, a catheter ought undoubtedly to be employed; for the risk attending the introduction of a bougie to such a length must be always considera- ble. Several kinds of flexible catheters have been in- vented for the purpose of remaining in the urethra with ease, and for answering both the intention of a catheter and of a bougie. Various methods have been proposed for preparing these instruments; but the most convenient form of any I have met with consists in a tube formed of flexible silver wire, wrapped spirally round a steel probe of a proper length and thickness; and this being neatly covered with a piece of fine linen spread with a bougie plaster, and the probe upon which it was formed being withdrawn, the in- strument is thus completed; only it must be after- wards furnished with a silver wire or cleanser, in a similar manner with other catheters.-—These instru- ments, however, do not prove so serviceable as was once expected; but when it is ever necessary to al- low a catheter to remain long in the urethra, one of this flexible form answers the purpose exceedingly well. It must be remembered, however, that as these catheters are covered with plaster, they ought not to be allowed to remain long in the bladder, for the same reason that we have desired bougies not to be inserted into it. When it is necessary to leave a flexible catheter in the bladder, those composed of the resina elastica should be employed, as the adhe- sive property of this substance prevents it from crack- ing and falling off, as every kind of plaster is apt to do. When speaking of the formation of bougies, we have said, that as it is chiefly by mechanical pressure they prove useful; so a proper consistence is the principal circumstance to be kept in view in their composition. Chap. XIV. the Urethra. 417 composition. This, we must still say, ought to be the leading object in the employment of bougies: But when any tolerable certainty occurs of a chan- cre or internal ulceration existing in the urethra, as nothing would probably prove so useful in cicatrising the ulcer as a local application of mercury, a consid- erable quantity of quicksilver extinguished in honey may with advantage be added to the composition we formerly mentioned.-—If two ounces of mercury, properly extinguished in this manner, be added to every six ounces of plaster in a melted state, a pretty strong mercurial preparation will thus be obtained; and as mercury in this state produces little or no ir- ritation, it may be employed with perfect safety.-— Red precipitate in fine powder has been sometimes advised to be sprinkled upon bougies, not only to be applied in this manner to ulcers in the urethra, but with a view to corrode other causes of obstruction: This, however, is a practice which we hope is now generally laid aside, as in many instances the pre- cipitate would surely prove too violent a stimulus for the internal surface of the urethra. Whatever may, in disorders of this kind, be the immediate cause of obstruction to the free passage of the urine, a venereal taint will for the most part be found to be the original cause of the whole: We have therefore desired, that at the same time the use of bougies is persisted in, the patient ought to be put upon a very complete course of mercury, in order to destroy every possibility of his suffering again from the same cause; for we need scarcely observe, that as long as any venereal infection continues to prevail, little or no permanent advantage can be expected, either from the use of bougies or any other remedy. We have thus entered fully into the consideration of the use of bougies. Indeed, too much attention cannot be given to a practice from which such mate- rial advantages may be derived: For by a proper Ggg use 418 Obstructions in Chap. XIV. use of this remedy, almost every case of obstructed urethra proceeding from any of the causes we have enumerated, may be either altogether cured, or at least greatly relieved; and was it not for the advan- tages derived from bougies, almost every instance of such obstructions would terminate in the most com- plete degree of misery. Before concluding the subject now under consid- eration, we must not omit to mention the effects of bougies in some cases of troublesome gleets.-—When- ever a discharge of this kind is kept up by an exco- riation or slight ulceration of the urethra, as is some- times the case, no remedy whatever proves more ef- fectual than bougies of the mercurial kind, such as we have recommended; and even in the ordinary kind of gleet proceeding merely from a relaxed state of the excretory ducts opening into the urethra, noth- ing will more certainly effect a cure than the com- pression induced by the common bougies.-—Whether they operate by affording a proper support to the re- laxed membrane of the urethra, or by inducing some degree of inflammation upon the affected parts, I know not; but in many instances of those obstinate gleets which have resisted the most powerful injec- tions, bougies have been found to prove effectual. We have hitherto considered obstructions of the urethra in male subjects: But the same affections oc- cur in women; and when they do so, they demand an equal share of attention. As bougies afford the easiest means of removing such obstructions, this method of cure should always be first attempted: But in women it sometimes happens, that tumours of such a size form in the urethra as cannot possibly be cured by this remedy; and as the urethra in females is not only very short, but much wider than in men, swell- ings of this kind may often be removed either by lig- ature or with the scalpel.-—Nay, we know from ex- perience, that a tumor adhering, even to the bladder itself, Chap. XIV. the Urethra. 419 itself, may, in women, be taken off, not only with ease, but with safety. In such cases, there is a ne- cessity for laying the urethra open; which, at either of the sides, may be done with great safety, and with- out any risk of wounding the vagina: And if an in- cision be made here with freedom, any tumor situat- ed near to the neck of the bladder, may be so far pulled down as to admit of the application of a liga- ture; and whenever it can be laid hold of, this may be done without any danger. A remarkable case is related of this kind by Mr. Warner, where a tumor of the size of a turkey's egg, produced from the internal membrane of the blad- der, was extirpated by ligature, and with most com- plete success*. When such tumors are not so large as totally to obstruct the passage of the urine, or to be productive of much distress, a prudent practition- er would no doubt rather wish to avoid touching them: But when the reverse of this is the case, and when the urine is voided with much difficulty, neces- sity in such circumstances points out the propriety of the operation we have recommended; but it must be comfortable for a patient, in a situation which would otherwise be desperate indeed, to know that a reme- dy can be employed from which a cure may be ex- pected. It has been advised even by practitioners of repu- tation, when obstructions of the urethra proceed from caruncles or carnosities, as they are termed, to des- troy them by the use of lunar caustic; and instru- ments have been invented for applying the caustic with as much safety as possible to the diseased parts: But the risk of injuring the contiguous parts by ap- plications of this nature, even when guarded in the most cautious manner, is evidently so great, as must forever prevent the practice from being generally received. CHAP. * Vid. Cases and Remarks in Surgery, by Joseph Warner 420 Of the Fistula. Chap. XV. CHAP. XV. OF THE FISTULA IN PERINÆO. BY the term Fistula in Perinæo is meant, a sinuous ulcer of this part, communicating most frequently with the urethra only, but in some instances directly with the body of the bladder. The term however, is not strictly confined to ulcers of this kind in the perinæum; it is also applied to sores of a similar nature opening into the scrotum, or terminating in any part of the penis. The word Fistula ought with propriety to be re- stricted to that species of sinus in which the edges of the sore have become hard and callous; but custom now applies it indiscriminately to every ulcer that is not superficial, but which lies deep, and discharges its contents by one or more narrow openings in the external teguments. In consequence of the latitude given to the mean- ing of the term Fistula, a great variety of appearan- ces are exhibited under this general denomination of Fistula in Perinæo. In some instances a single open- ing is met with in one part or other of the perinæum or penis, discharging matter mixed with urine; and this without any hardness or inflammation of the con- tiguous parts. But in others, instead of this simple form of the disease, along with one or more external openings communicating with the urethra, at which all, or at least the greatest part, of the urine is passed, the parts contiguous to these openings are very much diseased Chap. XV. in Perinæo. 421 diseased. In some instances they are found merely in a hard callous state, without much enlargement; but in others they are not only exceedingly hard, but much swelled, inflamed, and very painful. In a few cases, this hardness and enlargement is confined to a small space; but most frequently, when the disorder has been of long continuance, it extends nearly from the anus to the scrotum, reducing the whole perinæ- um to a state of callosity. In many, too, the mala- dy does not stop here; but the scrotum, and even the fore part of the penis, are liable to be affected by it; and when the urine unfortunately escapes into the cellular substance of these parts, particularly when it lodges in any part of the scrotum, it is apt to termi- nate in a great deal of mischief. As a considerable part of the urine, and sometimes the whole of it, is evacuated by sores of this nature, they are, on every occasion, productive of much dis- tress; and merit therefore the greatest attention from practitioners. In treating of this disorder, the causes which give rife to it are to be first considered. They are in gen- eral as follow. 1. Wounds and other injuries of the urethra and bladder, from external violence, in whatever manner they may be produced. In the old method of performing lithotomy by the apparatus major, the parts were so much bruised and lacerated, that the wound seldom healed kindly, and frequently terminated in fistulous sores of the perinæ- um; but when the operation is well performed ac- cording to the present improved method, this is sel- dom the case. From some cause or other, however, it happens in a few instances, that the urine does not flow freely by the yard; and as it finds a ready pas- sage by the wound, it continues to come off in this manner, till the edges of the sore becoming callous, the disorder in question is produced. In some cases of 422 Of the Fistula Chap XV. of this nature, a direct communication is kept up be- tween the neck of the bladder and the sore; but in others, the urine passes first into the urethra, and from thence is discharged by the wound in the peri- næum. This disease is sometimes the consequence of incisions made into the urethra, for the purpose of extracting stones lodged in it, when the wounds do not heal, but continue open and give vent to the urine which they sometimes do for a considerable length of time. 2. Inflammation in any part of the urethra, by whatever cause it may be induced, if it terminates in an abscess, is very apt to corrode the membrane of this canal, and to produce a sinuous opening, at which the urine is discharged along with pus. This species of the disorder, we may remark, is not an un- frequent consequence of virulent gonorrhœa: For when the inflammation spreads along the perinæum towards the anus, if it be not quickly removed by bloodletting and such other means as are employed, it will be very apt to terminate in suppuration. Abscesses which form originally in the soft parts about the anus, are also known to give rise to it by communicating inflammation and stricture, termi- nating in suppuration, to the cellular substance con- nected with the urethra. 3. The several causes enumerated in the last Chap- ter, inducing obstruction of the urethra, by impeding the free discharge of the urine, frequently give rise to the disease now under consideration: And according- ly we find that fistulous sores in the perinæum are very commonly connected with an obstructed state of the urethra. As the disorder may be thus induced by a variety of causes, it is necessary to have these in view when we endeavour to accomplish a cure. In order, how- ever, to render this very perplexing branch of practice as Chap. XV. in Perinæo. 423 as obvious and simple as possible, it is necessary to re- mark, that the different causes we have enumerated tend to the production of the disease by two general effects only: I. By the formation of a passage directly into the urethra or bladder, either by external violence or by the destruction of part of the urethra as a consequence of ulcers seated in it, or of matter collected in abscess- es tending to abrade its substance; this, we suppose, may occur, independently of any obstruction to the passage of the urine. 2. By the sole influence of obstructions in the ure- thra: These, by putting a stop to the free evacuation of the urine, at first induce a fullness and tension of the urethra, which, if it be not suddenly removed by such means as are employed, it very commonly terminates in a complete rupture of this canal. In the treatment, therefore, of this disorder, we are to be directed by one or other of these general ef- fects; and it is to be remarked, that in no disease is it of more importance to distinguish accurately be- tween the causes tending to induce it. When the opening into the urethra has been produced by a previous obstruction, no external application, nor any remedy directed to the system in general, will have any effect; while a proper and long continued use of the bougies, by removing the obstruction, will very commonly accomplish a cure: And on the oth- er hand, when the disorder has not originated from any obstruction, but has been induced by a simple opening in the urethra, bougies are not only very unnecessary, but frequently do a great deal of mis- chief.-—This, we must observe, is a distinction which is not so much attended to in practice as it ought to be. Affections of this kind are commonly treated with bougies only, whatever may have been the cause which at first induced them: But we shall soon make it appear that this must frequently prove prejudicial. In 424 Of the Fistula Chap. XV. In the cure of these disorders, too, it is a matter of the first importance to distinguish between such af- fections as are merely local, and those that are evi- dently connected with some general disorder of the system. For however well our means of cure might be directed towards the topical management of the sores, if the patient at the same time laboured under lues venerea, scrophula, or scurvy, no permanent cure could be expected, unless proper remedies were employed for the removal of these affections. We shall now proceed upon the supposition, that the sores are merely local, or that any general affec- tion with which they may have been connected, is as much as possible removed; and we shall likewise suppose that the disorder has been originally induced by some obstruction in the urethra.-—In such circum- stances, if the disorder has not been of long continu- ance, and if the parts, through which the opening runs that communicates with the urethra, are not much diseased, the bougie is almost the only remedy that is necessary: By a proper and long continued use of bougies in the manner we have described in the last chapter, the obstruction will in all probability be removed; at least, I have as yet met with very few instances of the contrary: And as soon as this is ef- fected, which will be known by the instrument passing in without any impediment, and by the urine flowing in a full stream when the orifice at the sore is com- pressed, if this preternatural opening does not now in the course of a short time heal of itself, it will be found to be prevented by its edges having become hard, and by their being covered as it were with a morbid production of the surrounding cuticle. Till this obstacle to the progress of the cure is re- moved, no advantage, it is evident, can be derived from any means to be employed. We are therefore to attempt the destruction of these callous edges of the sore, as soon as it is found that the bougies, after removing Chap. XV. in Perinæo. 425 removing the obstruction in the urethra, have not proved altogether effectual; and the method of doing it is this: The patient must be laid down upon a table, in nearly the same posture as is used in the op- eration of the stone; and a staff being introduced into the urethra, so as to pass the opening at which the urine is discharged, it is in this situation to be held firm by an assistant; while the surgeon, introducing a small probe at the external opening of the sore, and cutting upon it in the direction of the sinus, is thus to lay it open through its whole length, till it termi- nates either in the urethra, or, if necessary, in the blad- der itself. When more openings than one are discovered, they must all be laid open in the same manner. In some instances, there are two or three sinuses in the cellular membrane, leading from one opening in the urethra; but in others, there are as many openings in the urethra as there are sinuses or sores outwardly. This, however, is not a frequent occurrence: But it is a matter of little importance, as the same method of treatment answers equally well in both cases; for whether the different sinuses originate from one com- mon opening in the urethra, or not, they ought all to be laid completely open from one extremity to the other. In general, this simple division of the sinuses would prove sufficient; but when any of the parts through which they run have become uncommonly hard, a small portion of such diseased parts as lie most contiguous to the sores may be removed by the scalpel. This, it may be observed, however, is not often necessary, as the inflammation and consequent suppuration, induced by the division of the parts af- fected, very commonly removes any slight degree of callosity; but when the hardened parts are extensive, and appear too considerable to be removed in the course of the subsequent suppuration, such a propor- Hhh tion 426 Of the Fistula Chap. XV. tion of them should be taken off by the scalpel as will not probably be removed in this manner. This, however, is a circumstance upon which nothing deci- sive can be said; for the necessity of removing a por- tion of such diseased parts or not, and the quantity to be removed, must, in all such cases, be left to the judgment of the operator. After all the sinuses have thus been freely divided, the staff should be withdrawn, and the divided parts ought to be gently separated by the introduction of soft lint spread with any emollient ointment, in order to prevent their immediate reunion. But although it is necessary for this purpose to inert some soft easy application between the lips of the wound, yet this ought to be done with much caution; for stuffing or cramming the sores, as is sometimes done, always does mischief, and in some instances even renders all the other steps of the operation ineffectual. The sores are now to be covered with a pledget of emollient oint- ment; and proper compresses being applied over it, the T bandage should be employed to sustain the whole. About twenty four hours after the operation, an emollient poultice should be applied over the dress- ings; and as soon as a free suppuration is formed, the whole should be removed, and light easy dressings should be continued till the different sores are healed by a proper adhesion of the parts at the bottom of each. A very material part of the cure is found to con- sist in the dressings being duly attended to. Indeed, regular and proper dressing is of so much importance, that without it all the previous steps of the operation will avail nothing in effecting a cure: And it is to this circumstance chiefly, we are to attribute the su- perior success, which occurs in cases of this kind, in private practice, over what is commonly observed in hospitals, where such care and attention can seldom be Chap. XV. in Perimæo. 427 be obtained. Even in private there is much differ- ence met with in the cure of sores of this nature: I have known instances of fistulous openings in the pe- rinæum of a very bad appearance, completely cured by one practitioner, when several others had failed entirely, owing in a great measure to the difference of attention with which they were treated. I have not yet mentioned the use of the bougie, nor of the catheter, as a necessary part of the treat- ment subsequent to the operation: And in this I shall possibly appear to be singular; for, in all cases of this kind, we are commonly directed to keep a bou- gie constantly inserted from the time of the operation, excepting at the time of voiding urine, when a cathe- ter is advised to be employed; and in order to avoid the trouble of withdrawing the one and inserting the other, some practitioners have advised a flexible ca- theter to be kept in the urethra from the first. The advantages supposed to accrue from the use of the bougie, is the prevention of any undue contrac- tion of the urethra; and by the catheter it is intended to prevent the urine from passing out at the sore dur- ing the cure.-—These motives, for the use of both the one and the other, are plausible; and they have ac- cordingly been very generally adopted.-—I am free to confess, too, that, following the example of others, I have often, in cases of this kind, employed both the catheter and bougie; but I cannot say that I ever did so with any advantage, and in many instances I think I have seen them do much harm. For, in every case in which they are used, they keep the urethra too much distended for admitting of an easy cure of the sores; and if the catheter be not inserted so far as to pass fully into the bladder, part of the urine, in coming off, almost constantly passes between it and the ure- thra so as to get access to the wound, and in this manner has the same influence upon the sore as if no catheter was used: And again, if a catheter is passed entirely 428 Of the Fistula Chap XV. entirely into the bladder, and is preserved in this sit- uation for any considerable time, it almost constantly does harm, by inducing pain, inflammation, and swelling about the neck of the bladder. But whoever will attempt a contrary practice, and will endeavour to cure affections of this nature with- out any aid from these instruments, will soon find that they are not necessary; and that the wound in the urethra from the operation we have described, is in general much more easily cured, without the assist- ance either of bougies or of the catheter, than when they are employed; for, instead of forwarding the cicatrization of the sores, they uniformly tend to retard it, by frequently tearing open such adhesions, as na- ture, if left to herself, would have made altogether complete. This, we must again remark, is a point of much im- portance, and merits the utmost attention of practi- tioners. The use of the bougie, in all such cases, is at present so universal, that the cure of a fistula in peri- næo by an operation, is almost never attempted but where bougies are at the same time employed; but, from much experience in this branch, I am now per- fectly satisfied, that many more cures would be ac- complished if the bougie and catheter were both laid aside. In real obstructions of the urethra, bougies, as we have said, are almost the only remedy to be depended on; but, so far as I have seen, they are of no farther use after these obstructions are removed; when, there- fore, a fistulous opening remains after the removal of the obstructions, the operation we have described ought alone to be depended on; and in this part of the cure bougies ought never to be employed. But it is said by those who patronise the use of the bougie and of the catheter, that if the urine be allowed to pass out by the sore, the cure will be thereby, if not altogether interrupted, at least much retarded. To Chap. XV. in Perinæo. 429 To this it may be answered, That after the operation of lithotomy, we do not find the cure retarded, al- though the urine comes at all times into immediate contact with, and during the first days after the ope- ration passes constantly off by, the wound. In what manner this is effected, I shall not at present deter- mine; but that the fact is so, no practitioner will de- ny: And from all the experience I have had in these matters, openings in any other part of the urethra re- quire as little assistance from the catheter, as they do in that part of it which is divided by the operation of lithotomy; and every lithotomist, I believe, would spurn at the idea of keeping a catheter constantly in the bladder after this operation, in order to prevent the urine from passing off by the wound. After the operation of lithotomy, it happens, in- deed, in a few cases, that a contraction of the urethra is produced by the cicatrix of the sore, and in such in- stances, after the parts are firmly united, bougies are sometimes of use, by effecting a distention of the stricture: And in a few cases, too, where the sore is prevented from healing, by the urine continuing to pass off by the wound in consequence of the forma- tion of strictures or adhesions in the urethra, the bou- gie is employed with advantage even during the progress of the cure. But these are rare occurrences, and no practitioner of experience ever thinks it right to have recourse to bougies, till the presence of some obstruction renders them altogether necessary; and in the same manner they ought never to be employed in the operation we have been describing, till the propriety of using them is pointed out by the forma- tion of some degree of obstruction. When the parts composing the perinæum have be- come hard and otherwise diseased, before any operation such as we have described is put in practice, we are com- monly directed to a long and continued use of poul- tices; of mercurial frictions; and the use of resolvent gum 430 Of the Fistula Chap. XV. gum plasters. So far, however, as I have ever seen, little or no advantage is derived from these remedies; for any suppuration expected from their use, is, in general, very partial, and has seldom much effect in removing, or even in relieving, the disorder for which it is induced. And, again, when the hardened parts are extensive, and when no relief is obtained from the discutient remedies we have mentioned, we are in general di- rected to cut them entirely away with a scalpel. There is not, however, the least necessity for such a measure, for although it may be proper to remove the edges of the sores when they have become callous, there is never any good cause for extirpating every part that is become hard. This would frequently be a very cruel operation; and as it could seldom be productive of any advantage, it ought rarely, if ever, to be put in practice. When, again, a preternatural opening is found in the urethra, either by external violence or by the abrasion of its substance by abscesses seated in it, a dif- ferent kind of practice becomes necessary.-—When an abscess in the perinæum, or in any part of the urethra, has been the cause of the disorder, much attention should be given to a free discharge of the matter; ev- ery part of the cellular substance in which it is found to lodge, ought to be laid open; and any inflamma- tory tumor that has not suppurated freely should be treated with warm fomentations and poultices.-—In this manner many such affections, which if neglected would terminate in much distress, may be brought to heal; but when even by these means the sores do not unite, but continue to discharge matter, and especially when they become fistulous, the method of treatment we have formerly pointed out must be likewise em- ployed here. Disorders of this kind induced by wounds of the urethra, require a similar method of cure.-—By the removal Chap. XV. in Perinæo. 431 removal of extraneous matter, and by the use of poul- tices to abate inflammation, a cure will frequently be effected without any other assistance; but, when the state of the sores requires it, they ought to be laid open, and treated in every respect in the manner we have already directed. The most distressing variety of this disorder is that in which the urine passes off directly from the body of the bladder without communicating with the ure- thra. This species of the disease, we may remark, is readily distinguished from the other by the urine drilling off insensibly and at all times; whereas, when the external opening does not communicate directly with the bladder, and when the urine passes first through part of the urethra, the patient has common- ly the power of retention in full perfection; a circum- stance which renders his situation much more com- fortable than when the urine is constantly passing off. -—But although this variety of the disorder is easily distinguished from the other, it cannot be so readily cured; for in such cases, the sinuses from whence the urine is discharged communicate directly with the bladder, and nothing has any effect in removing them but laying them open to the very bottom. When, therefore, a patient labouring under this disorder finds his situation to be so distressing as to render the pain and risk of such an operation an eligi- ble alternative, it ought undoubtedly to be employed as the only means from which any probable chance of relief is to be expected. As the intention and principle of this operation are the same as of that in which the urethra only is con- cerned, all that need be said with respect to the mode of performing it, is, that a staff should be introduced into the bladder; the different sinuses should be laid freely open to the bottom; any callosities of their edges should be removed to such a depth as can be done with safety; and the wounds thus produced ought 432 Of the Fistula, &c. Chap. XV. ought to be treated with light easy dressings, such as we have already advised. In this manner, a great proportion of all who are afflicted with such disorders may be effectually cured, provided the means we have recommended are em- ployed in due time, and are properly persisted in: But in long continued fistulous sores of these parts, where the surrounding cellular membrane has become much hardened, and otherwise diseased; and especially, when the system is tainted either with scurvy, scroph- ula, or lues venerea; it must be acknowledged that no means with which we are acquainted will prove at all times successful. ERRATA. [From the British copy.] PAGE 100. 6th line from bottom, read Plate V. 317. line 12. For Plate I. read Plate XII. 362. line 12. For Plate XVIII. read Plate XVII. EXPLANATION 433 EXPLANATION OF THE PLATES. PLATE I. [Opposite to page 20.] Fig. 1. A FORM of hook, commonly termed a tenaculum, for the purpose of pulling out bleeding vessels to be tied by ligatures. Fig. 2, and 3. Two needles of a different curve from those in ordinary use. The curvatures being altogether on their fore parts, and the handles perfect- ly straight, they are thereby more easily managed than the others, particularly in deep wounds. Fig. 5, and 6, represent two needles of the usual form; but neither these nor the other two have an edge on their concave parts. They are made somewhat round like a lancet, both on their convex and concave sides; which adds to their strength, and makes them enter with more ease than the others. I have long made use of those needles, and whoever employs them will find them preferable in every respect to the others. Figs. 4, and 7. Two straight needles for sutures of the intestines and other delicate membranous parts. All these needles are represented of the full size. A number of instruments have been contrived for holding the needles when they are to be employed in deep wounds. The Porteaiguille represented in Plate II, will answer this purpose as well as any other; but instruments of this kind cannot be often needed. PLATE II. [Opposite to page 25.] Fig. 1. A Porteaiguille mentioned in p. 25. A. A. The handles of the instrument. Iii B.A 434 Explanation of the Plates. B. A groove for receiving the pins used in the twisted future. This instrument is commonly made with a slider for fixing the handles after the pins are inserted into the groove; but as this always proves troublesome to the operator, and is not in any degree necessary, it is here purposely omitted. Fig. 2, 3, and 4, are different sizes of pins used in the twisted suture described p. 23. And fig. 5, is a flat needle sometimes found useful in stitching blood vessels that lie between contiguous bones. All the instruments in this plate are represented of their full size. PLATE III. [Opposite to page 31.] Fig. 1. A screw tourniquet described, p. 30. Every part of the instrument is here represented of the full size: It may be made either of brass or steel; and the strap connected with it ought to be of very firm materials, at least an inch broad, and of a length sufficient to pass fully round the largest circumference of any of the extremities. Fig. 2. A spring phlegm described, p. 56. This instrument is also represented of the full size. PLATE IV. [Opposite to page 56.] Fig. 1, and 2, Two Scalpels of the best form, ei- ther for the anatomist or surgeon. Fig. 1, is of a size large enough for any operation; and fig. 2, is of a very useful size for operations about the eyes, mouth, and other parts where a larger instrument proves incon- venient. Fig. 3, and 4. The best form of lancet for the operation of bloodletting, described p. 57, fig. 3, is of Explanation of the Plates. 435 of a full size for any purpose of this kind; and fig. 4, is for the small veins of infants. Fig. 5, represents the broad shouldered lancet in ordinary use; but which, from its figure, is evidently ill suited for the nice operation of venæsection. PLATE V. [Opposite to page 100.] Fig. 1. A scarificator with sixteen lancets, A, a cu- bical brass box, in which the blades of the lancets firmly fixed on an axis are included. B, a lever for bending a spring with which the axis and its lancets are connected. C, a button or head of a screw nail connected with a catch for securing the spring in a bent state: On the spring being bent by means of the lever B, and the flat part of the instrument D D being placed upon the part to be scarified, the button C is then to be pressed upon till the spring is unbent, which forces the lancets into the parts they are placed upon, to the depth at which they have been previously set; and the flat, covering of the box D D being moveable, serves to regulate the length of the lancets which pass through it. Fig. 3. A cupping glass with a mouth of an oval form; and fig. 4, represents one of the ordinary round kind. Fig. 2. A strong curved needle, with a round though somewhat sharp point. This instrument an- swers the purpose better than any yet contrived, for introducing ligatures below the artery, in the opera- tion for the aneurism; and below the spermatic cord, in the operation of castration. All the instruments of this plate are represented of a proper size for use. PLATE VI. [Opposite to page 162.] Fig. 1, 2. and 3, represent different parts of a ma- chine for injecting tobacco smoke by the anus. Fig. 1. 436 Explanation of the Plates. Fig. 1. A brass box for containing the burning to- bacco. The mark A is a bottom or division in the inside of the box, perforated with small holes to admit the passage of the smoke to the extremity of the box B; which, by a male screw, is adapted to a brass tube, fig. 3, at D, which is again fitted to an elastic leather pipe E, terminated by a common glyster pipe F. The pipe E is made of waxed leather, protected by brass wire rolled spirally round it from one extremity to the other. Fig. 2, represents the covering of the box, fig. 1, to which it must be exactly fitted. G, a division of thin brass, perforated with a number of small holes for admitting the passage of the air from a pair of bellows fitted to the opening H. Fig. 3. The instrument completely fitted up on a small scale. I a pair of double bellows, whose tube K is fitted by a screw to an opening in the cover of the box L, which again is terminated by the brass tube M, the leather pipe N, and the ordinary glyster pipe O. The box L being filled with burning tobacco, and the glyster pipe O being inserted into the anus, by working the bellows I, any necessary quantity of smoke may be very quickly thrown up. It is scarcely necessary to observe, that all the parts of this machine ought to be exactly fitted to one anoth- er, with a view to prevent effectually the escape of smoke at any of the joints. Bellows of the ordinary size answer very well for this purpose; and are preferable to those of a smaller size, as being better calculated for injecting the smoke quickly. The brass box for the tobacco should be about an inch and half in diameter, by three inches in length from the brim to the bottom; the brass tube connected with the box should be six inches in length, by a quarter of an inch in diameter. The leather pipe ought to be of nearly the same diameter with Explanation of the Plates. 437 with the tube, and about two feet and an half in length. When of this length, it is easier managed than when shorter; and it serves more effectually to cool the smoke before it is thrown into the bowels. The glyster pipe at the end of the leather pipe ought to be somewhat larger and wider than those in ordinary use. PLATE VII. [Opposite to page 163.] Fig. 1. Another instrument for the purpose of injecting tobacco smoke, originally invented by the celebrated professor Gaubius. The principal differ- ence between this and the instrument represented in Plate VI, is, that in this the tobacco box A, is fitted to the air hole of the bellows; so that in working the bellows, the air with which they are supplied en- tering in at the openings B, the smoke of the burn- ing tobacco must accordingly pass through them; and from the bellows it is thrown into the other parts of the instrument, and in that manner is transmitted to the intestines. The other instrument represented in Plate VI, is wrought with more ease than the one here delineated. Fig. 2. A crooked bistoury, with a blunt or probe point. The curve here represented is much less than is usually given to this instrument, and the blade is also much narrower: It ought, indeed, to be alto- gether straight, excepting a very slight curvature to- wards its point. This bistoury is well calculated for dividing the stricture in cases of hernia; for opening sinuses in ev- ery situation; and particularly for dividing the rec- tum in the operation of the fistula in ano. Fig. 3. A bandage for compressing the temporal artery, either after the operation of Arteriotomy, or in accidental divisions of that artery. It is made of well tempered spring steel, covered with soft leather, and 438 Explanation of the Plates. and of the same strength as is used for the truss of a hernia. The wound being dressed, and a small com- press of linen being applied over it, the limbs of the instrument are to be opened, and applied over the back part of the head, so that their extremities B D may rest upon the temples, and one of them be made to rest exactly upon a compress covering the wound. If the instrument is made of proper metal, and of sufficient strength, it will remain exactly upon the part on which it is first placed without any assist- ance; but, to prevent its being rubbed off by acci- dent, it is here furnished with a buckle and strap A C, by which it may be firmly fixed by drawing them tight upon the forehead. This instrument should be about three quarters of an inch broad; and from twelve to fourteen inches in length will answer for the dimensions of any head. I once had a screw with a button adapted to this bandage, the button being made to press upon the divided artery; but the compress of linen here rec- ommended, answers the purpose better, and is easier to the patient: Bandages made of linen or of other materials of a yielding nature, do not answer so well as those of spring steel, which always remain with more certainty on the spot they are first placed upon. PLATE VIII. [Opposite to page 173.] Fig. 1. A spring truss for an inguinal or femoral hernia of the right side. A, the bolster or pad for pressing upon the opening at which the parts have been accustomed to protrude. B, a strap with holes in it for fixing upon the knobs on the back part of the pad. C, a strap hanging down from the back part of the bandage, to be passed between the legs of the patient, and to be also fixed upon the knobs of the pad by the holes in its extremity. This Explanation of the Plates. 439 This strap is intended to fix the bandage firmly in its situation; but if the bandage is properly fitted to the parts, and if the steel spring of which it is com- posed is sufficiently elastic, there is no necessity for the intervention of this strap, which always frets and galls the parts upon which it is made to pass. Fig. 2, represents a bandage of this kind for the left side with no back strap. Fig. 4, represents a double bandage of the same kind for a hernia on each side, with two back straps connected with it. The steel of which these bandages are made should be covered with thin soft leather, properly stuffed with wool or flannel, in order to prevent the parts from fretting by the pressure necessarily produc- ed upon them. The pads ought to be broader than they are generally made, with a prominence or slight elevation in the middle, while their sides are made perfectly flat. Of this construction they apply with much more exactness, and sit more firmly on the parts than when altogether round as they are com- monly made, without any flatness on their sides. Fig. 3, represents a bandage for umbilical rup- tures. A, a steel spring to be applied upon the um- bilicus after the hernia has been reduced, and to be retained in that situation by the bandage B; which, by means of the strap CCC and the buckles DDD, may be kept at any degree of tightness. EE, two straps for passing over the patient's shoulders; and F a strap for passing between the legs, the whole to be fixed upon knobs on the back part of the bandage opposite to the spring A. By means of these buckles and straps the bandage may be preserved very firmly in its situation. The belt B should be five or six inches broad, and the steel spring A should be of a size propor- tioned to the opening it is intended to press upon. All 440 Explanation of the Plates. All the parts of the bandage should be made of soft leather, lined with flannel or cotton.* PLATE IX. [Opposite to page 210.] Fig. 1. A pessary for the prevention of herniæ in the vagina. This pessary consists of a conical tube of ivory, silver, or gold, with a cord at its extremity, for the purpose of withdrawing it when necessary. The protruded parts being reduced, and this cone being rubbed over with oil, is to be introduced into the vagina, by which any farther descents may in general be prevented. Pessaries for this purpose have been formed of spring steel; but the rust which instruments of that metal are apt to contract renders them very unfit for such uses. Fig. 2. A hook described p. 208, for enlarging the opening in the foramen ovale in cases of hernia of that part. This hook was originally proposed by Mr. Arnaud, a French author, for dilating the pas- sage at which the parts protrude in cases of crural hernia. Fig. 3. A director open at the extremity, describ- ed p. 180, for the purpose of laying open the sac in the operation of the bubonocele. Fig. 4. A silver canula for introducing into the urethra after the operation of amputating the penis. The strings with which it is furnished are intended to fix it to a circular bandage which ought to pass round the patient's body. PLATE X. [Opposite to page 232.] Fig. 1. A trocar of a proper size for evacuating the contents of an encysted hydrocele. By the flat- ness * The spring here represented is taken from a figure represented by the late Dr. Munro, in his Treatise on that subject. See his works in 4 to. Explanation of the Plates.441 of its form, and its point being of the lancet kind, this instrument penetrates the cyst with great ease; and can thereby be used with more safety than the ordinary form of this instrument. The point of the perforator is commonly made much longer than is necessary. It ought not to pass more than the fifth or sixth part of an inch from the extremity of the canula; of this length it answers equally well as when the point is longer; and it is not so apt to wound the testis on being introduced into the cavity of the tunica vaginalis. Fig. 2. A trocar, the invention of Mr. André. Fig. 3. The canula of this instrument, formed of two hollow plates of elastic steel, firmly united to- gether at their larger extremities by two screw nails. The tube formed, by these two hollow plates is of such a size as to allow the perforator, fig. 4, to be pushed into it with very little force; and the elastici- ty of the plates, which admits of their yielding to this passage of the perforator, enables them to return instantly to form the same size of tube, as soon as the large extremity of the instrument A has fairly passed the extremity of the plates. The point of the perforator with a small portion of the extremity of the tube being pushed into the vaginal coat, the perforator is to be then withdrawn, which when the instrument is properly made may be done without much force. The advantage which this instrument is supposed to have over any trocar of a different form; is, that the point of the perforator making a larger opening than is just necessary for the passage of the canula, the latter is thereby made to enter with more ease than it does in the usual form of the instrument. But although this invention of Mr. André's is neat and ingenious, it does not appear to be very nec- essary; for, when the other form of instrument is well finished, and the silver at the extremity of the Kkk canula 442 Explanation of the Plates. canula is made very thin and properly fitted to the perforator, it enters with a great deal of ease. The canula of Mr. André's instrument has this disadvan- tage too, that being made of fine polished steel, it is almost impossible to render it so dry after every time it is used, as to prevent it from suffering with rust, at the part where the two plates are fixed together by the screw nails. PLATE XI. [Opposite to page 295.] Fig. 1, and 2. Different parts of an instrument described p. 295 for performing the operation of phymosis. Fig. 3. The two parts of the instrument connect- ed and ready for use. Fig. 4. A large imposthume lancet. PLATE XII. [Opposite to page 317.] Fig. 1. Represents a common staff for the pur- pose of sounding. Fig. 2. A grooved staff for the operation of lithot- omy, with the groove on one side. This improve- ment was suggested for the purpose of passing the gorget more easily into the bladder than when the groove is on the convex part of the instrument: But the usual form of the staff is found to conduct the gorget with much ease; so that this alteration of it has not been generally adopted. Fig. 3. A common staff of the usual form, with the groove on the convex part of it. The curvature we have here given to the staff has by experience been found to be more proper than any other: There is no necessity for that degree of convexity which is generally given to it; the form here represented is introduced with more ease; and Explanation of the Plates. 443 and it does not injure the urethra, which those with a greater degree of curvature always do. A staff for a full grown male subject should be twelve inches long, besides the handle; and for children of seven years and under, they should be from seven to nine inches long. PLATE XIII. [Opposite to page 350.] Fig. 1. A side view of the cutting director de- scribed in page 350. This instrument is here repre- sented of a full size for the largest adult, viz. five inches from A to B, and three inches from B to C. Fig. 2, represents a front view of the same instru- ment. Fig. 3, affords a back view of it; and fig. 4, a transverse section of it. This director, in the grooved part of it, should be exactly three eighths of an inch broad, viz. from D to E; and the cutting part of it, from F to G, should measure nearly an inch. The beak of the in- strument should be exactly fitted to the groove of the staff with which it is to be used. In order to obtain a free passage for the stone, it has been proposed to increase the breadth of the cut- ting part of Mr. Hawkins's gorget to a great extent: By some, it has even been said that a couple of inch- es may be added to it. This, however, proceeds from inattention to the anatomy of the parts concern- ed in the operation; for that part of the urethra through which the gorget passes to the bladder, is so much confined by the contiguous bones, that it is absolutely impossible to introduce a gorget of this size into it in a proper direction. The prostate gland ought, in the operation of lithotomy, to be di- vided in a horizontal lateral direction. Now, this can- not be done by an instrument of the breadth we have mentioned. But, even although it were easily practicable, there 444 Explanation of the Plates. there is no necessity for such an extensive wound as this instrument would make. We have formerly said, that nothing should be left for the director or gorget to divide but the prostate gland, together with a very small portion of the neck of the bladder; and as an instrument such as we have here delineated effects this in the most complete manner, there is no necessity whatever for one of a greater breadth. The back part of the cutting director being con- siderably narrower than the common gorget, it ought to be made of a sufficient thickness, in order to over- come any resistance it may meet with in passing into the bladder. The transverse section, fig. 4, shows the strength of it. For children from three to seven years of age, this instrument should not exceed three inches in length; and one of four inches will answer for every age a- bove this to the twentieth year. The cutting edge of this director, as well as the cutting part of the gorget in Plate XIV, is here rep- resented upon the right side of the instrument, by which the wound in the operation of lithotomy is made in the left side of the patient: But for a sur- geon who operates with his left hand this must be reversed, so as to have the cut made in the right side of the perinæum. As this director has never been before mentioned to the publick, I have given a more particular de- scription of it than would otherwise be necessary. PLATE XIV. [Opposite to page 353.] Fig. 1. The cutting gorget of Mr. Hawkins, with the edge of it made to expand more than the usual form of it, by which it divides the prostate gland more freely. The figure is of full size for the largest adults: From A to B should measure five inches and a half, and Explanation of the Plates. 445 and from B to C nearly three inches. This instru- ment at the widest part of it measures one inch, and contracts in a gradual manner to the point: The beak should be exactly adapted to the grooves of the staffs with which it is used; and should be turned a little forward, instead of being perfectly straight or turned back as is sometimes the case: By this means it is carried with more steadiness along the groove of the staff than can otherwise be done. In page 350, we have mentioned at full length the objections which occur to the use of the gorget, and the reasons which induce us to consider the cutting director in Plate XIII, as a preferable instrument. Fig. 2. A female catheter. This instrument is represented straight, as being more easily introduced when of this form than when much crooked: A sound for females, however, should have a small cur- vature, as being better adapted for discovering a stone in the bladder than a straight staff. A grooved staff of this form is represented in fig. 3. PLATE XV. [Opposite to page 354.] Fig. 1. Is an improvement of the gorget by Dr. Munro. It consists of a common gorget A B, with a blunt gorget C D fitted to it: The nail E fixed in the cutting gorget being made to pass through the slit in the blunt gorget F, the latter is thus made to run easily upon it. In using this instrument, the blunt gorget must be pulled back, so as to admit of all the cutting part of the other to project before it: And as soon as it has reached the bladder, the blunt gorget should be pushed forward; by which means the contiguous parts are effectually protected from farther injury, as the sides of the blunt gorget should be made considerably deeper, so as to project over the cutting edges of the other. This 446 Explanation of the Plates. This is an ingenious contrivance; and it will an- swer the purpose effectually, of protecting the sur- rounding parts while the instrument is withdrawing; a circumstance of much importance, and not always duly attended to. Fig. 2. A male catheter of silver. The small holes near the extremity of this instrument answer better than a slit on each side of it, as with these it does not so readily become entangled with the urethra. Ca- theters have likewise been made of other materials, namely, of leather, and of flexible twine rolled into the form of a tube and covered with bougie plaster; and of late a very neat invention of this kind has appear- ed, prepared of the resina elastica. These last are particularly recommended for remaining in the ure- thra in cases where bougies were formerly employed; but, from the trials we have made of them, they do not seem to answer when long inserted at once, as they turn soft and lose their elasticity entirely. Fig. 3. An instrument I have named a Searcher, mentioned page 361.-—In the operation of lithotomy it frequently happens, that the stone is not readily felt by the forceps. When it is discovered by the other means we have advised, it may frequently be found by introducing this instrument at the wound: Which being of a considerable thickness, answers bet- ter for this purpose than a common sound; and when once the stone is discovered, the searcher ought to be preserved in close contact with it with one hand, while the forceps is conducted to the stone by means of it with the other. In this manner, stones may be discovered, which otherwise might escape the ordinary means of searching.-—This instrument should be made of steel, and should be nine or ten inches in length. PLATE XVI. [Opposite to page 355.] Fig. 1, and 2. Forceps of different sizes for ex- tracting stones from the bladder.-—For a full grown adult Explanation of the Plates. 447 adult they should be ten inches long and proportion- ally strong. Every operator ought to be furnished with three or four sizes from those of ten inches to such as are not more than seven. We have already desired, that the blades of the forceps may not meet when they are shut; for by doing so, they would be apt to lay hold of the bladder; and for the same rea- son, their teeth ought not to be very long. If they have merely a roughness, it answers the purpose suf- ficiently of fixing the stone; and this is all the advan- tage to be derived from it. Even this roughness should be confined to within an inch of the point of the forceps; for when it is made to reach nearer the joint, small stones are apt to fix in this part, and to dilate the blades of the instrument much more than otherwise it would do. Fig. 3. Forceps with a small degree of curvature. When the forceps of the usual form do not easily lay hold of a stone, such as are somewhat crooked will sometimes meet with it: In general, however, the straight forceps answers all the purposes of the other; and as stones, when laid hold of, are always more easily extracted with the straight forceps, they should commonly be preferred. PLATE XVII. [Opposite to page 360.] In the chapter on Lithotomy, we have taken dif- ferent opportunities of mentioning the risk attending the extraction of a large stone; and when a stone is found to be so very large as to give cause to suspect that it cannot be extracted but with much difficulty, we have given it as our opinion that it should rather be broke into different pieces: For this purpose va- rious instruments have been proposed.-—Fig. 1, rep- resents forceps with long teeth, by which almost any stone may be broke.-—By the screw and lever connected with it, a much greater force may indeed be 448 Explanation of the Plates. be employed than will commonly be necessary.-— These forceps should be about twelve inches in length, and of a sufficient firmness in every part, particularly in the joint, for bearing any force that may be needed. Fig. 2. A scoop for extracting such small pieces of stone as cannot be taken out with the common forceps. Fig. 3. A silver canula for introducing into the wound after the operation of lithotomy, for compress- ing such arteries as lie too deep to be tied by ligatures. This tube should be of a flat form: For a full grown adult, an inch broad and four inches in length; and before being introduced, it should be covered with several plies of soft old linen. There should be two holes in the brim of the instrument for connecting it by means of two pieces of tape to a circular bandage round the body. PLATE XVIII. [Opposite to page 370.] Fig. 1, and 2. Different views of Frere Cosme's instrument for the operation of lithotomy. Fig. 1, represents the instrument shut; and fig. 2, gives a view of it open.-—The handle A with which the nitches B are connected, being kept in the situation represented in fig. 1, by the spring C being fixed in one of the nitches, the knife is thus preserved shut. But when the spring C is pressed upon, so as to raise it out of the notch, as the handle A is made to move upon a pivot, it may now be turned; and the project- ing part of it D being turned fully round, if pressure be now applied to E, it will raise the knife F, with which it is connected, to the elevation here represent- ed.-—The point G should be made blunt and round, so as to run with ease and freedom in the groove of a staff. The length of this instrument, including the handle, should be ten inches. The method of using it is as follows: All the previous steps of the operation being finished, and the 449 Explanation of the Plates. the urethra being cut in the manner we have directed, the beak of the instrument C is to be conveyed into the groove of the staff, and while shut is to be pushed into the bladder. The staff is now to be withdrawn; and pressure being applied to E, so as to elevate the knife F, it is now to be drawn out in such a direction as to divide the prostate gland laterally, when the forceps may be either introduced by running them in upon the fore finger of the left hand, or upon a blunt gorget employed for the purpose. Various instruments of this kind have been invent- ed; but the one here delineated is the most simple, and in every respect, indeed, the best of any we have met with. As the operation is still performed with it in different parts of Europe, particularly in France, we think it right to give a representation of it, but we do not by any means recommend it.-—The objections which occur to it are these: Although by the form of the handle the blade or cutting part of the instru- ment may be elevated to any necessary degree, yet this does not ensure the formation of a wound of a fixed and determined size. It has indeed been asserted by those who think favourably of this instrument, that a wound of any determined size may be made with it: But this is by no means the case; and whoever will give it a trial will find, that the wound produced by it varies in size in every two that are cut with it; and this, even with the blade at the same degree of elevation; for the cutting part of it is at such a distance from the handle, that it is impossi- ble for a surgeon to withdraw it always with such steadiness as to cut uniformly in the same direction; and if in one case it is made to press in any degree more to one side than in another, the wound formed by it may not only be of a different size, but very dif- ferent parts may be cut by it. But the most material objection to this instrument is, that it is very apt to injure more of the bladder Lll than 450 Explanation of the Plates. than ought to be cut. It is the prostate gland and a small portion of the neck of the bladder only which should be divided by this knife; but as it is always necessary to insert the point of it far into the bladder before this can be done, the sides and even fundus of it are in this manner very apt to suffer. The only advantage which this instrument is sup- posed to possess over the cutting gorget or director is, that being inserted shut, and withdrawn open, only one cut is made in the parts through which it is made to pass; whereas, it is alleged, that, in the usual meth- od of employing the gorget or director, one incision is formed by the introduction of the instrument, and another when it is withdrawn. But, by attending to the directions we have given in the chapter on Lithot- omy, this inconvenience commonly attributed to the gorget, and consequently to the director, may be al- ways avoided; and as these instruments form a more free cut than the lithotome cachée, and as they do not so readily injure any part of the bladder which ought not to be cut, they should therefore be preferred. Fig. 3. Forceps with a screw H passing through their handles.-—When a stone is properly fixed in the forceps, various inventions have been proposed for preserving them in the same state; but the one we have here represented is the best and the most simple of any that has been mentioned. PLATE XIX. [Opposite to page 388.] Fig. 1. A jugum which answers the purpose of compressing the penis very completely, and it sits up- on the parts without producing any pain or uneasi- ness. It consists of a piece of elastic steel lined with velvet or soft flannel. By means of the screw A, it can be made wide or strait at pleasure; and the cush- ion B being placed upon the urethra, any necessary degree of pressure may be produced upon it, by turn- ing Explanation of the Plates. 451 ing the screw with which the cushion is connected. By means of this cushion and screw, the pressure is chiefly confined to the urethra; so that the circulation is scarcely interrupted through the rest of the penis. Fig. 2. A receptacle for the urine mentioned in page 389. It may be made either of tin or silver, or any other metal. It is somewhat convex on one side, with a concavity on the opposite side, by which it applies easily to the inside of the patient's thigh. C D, Two tubes for fixing two pieces of tape, by which, when the penis is put into the neck of the in- strument, it may be tied to a circular bandage round the body; and the tube F serves to fix a piece of tape for tying the instrument round the thigh of the pa- tient. This instrument, when properly fitted, sits very easily, and has frequently proved very useful to pa- tients who could not retain their urine, and with whom the jugum, for the reasons we have formerly enumerated, could not be employed. A receptacle of this kind, of a size sufficient to con- tain three or four gills, may be so adapted to the thigh as to admit of every necessary exercise. Fig. 3. A bandage, originally invented by Mr. Gooch, for retaining the rectum in cases of prolapsus ani. F, a plate of elastic steel covered with soft leath- er, which ought to be exactly fitted to the parts on which it rests; and the cushion T should be stuffed in such a manner as to produce an equal and easy pressure on being applied to the end of the gut after it is replaced. G, a strap to be fixed with a buckle on the fore part of the body above the pubes; and H H, two straps connected with the upper part of the in- strument, which, by passing over the shoulders, and being fixed by small knobs on each side of the buckle, serve to retain it exactly in its place. PLATE 452 Explanation of the Plates. PLATE XX. [Opposite to page 389.] Fig. 1. An instrument mentioned in page 322, originally invented by Dr. Butter, for injecting liquids into the bladder. A A, the handles of two thin plates of timber, which serve to compress a bladder placed between them, in which the liquor to be in- jected is contained. B, a stopcock of a pipe with which the bladder must be connected; and to the ex- tremity of this short pipe a longer tube C is adapted, to be inserted into the urethra when the liquid is to be injected. Fig. 4, is a funnel for conveying the liquid into the bladder, by inserting the small extremity of it into the short pipe near to B, on the tube C being removed. Fig. 2, and 3. Two pessaries for the purpose of supporting the prolapsed parts in cases of a prolapsus uteri, and for compressing the urethra in cases of an incontinence of urine. Before being introduced, they should be well covered with any emollient ointment, or with sweet oil; and they should be made to lie directly across the diameter of the vagina, so as to support the prolapsed parts as much as possible. These instruments may be made of any timber capable of receiving a fine polish: But much attention, we may remark, is necessa- ry to this circumstance; for unless they be made per- fectly smooth, they cannot possibly be used. These pessaries, when a patient can admit of them, tend to support the relaxed parts better than any other; but even with the utmost attention to their being thor- oughly polished, they frequently produce so much ir- ritation as to become altogether inadmissible. When pessaries of this kind cannot be employ- ed, other inventions have been proposed. Pessaries composed of the resina elastica, are in general found to sit easily; and they commonly answer, for some time, the purpose of supporting the relaxed parts; but as they become soft and glutinous by long im- mersion Explanation of the Plates. 453 mersion in the natural mucus of the vagina, they soon lose that elasticity which a continued support of these parts requires. A piece of soft sponge being immersed in common glue, or in melted bees wax, and being kept in a compressed state till cold, and being then cut into a proper form, and inserted into the vagina, commonly expands so much on the wax or glue melting, as to afford in most cases a very ef- fectual and easy support to the relaxed parts: And in order to render the application of the sponge still more easy, it should be previously covered with a small bag of soft waxed linen, which prevents the sponge when it expands from fretting the sides of the vagina, which it is otherwise ready to do. Pessaries of every kind, before being introduced, ought to have a piece of firm packthread or catgut tied to them, which by hanging out from the vagina, admits of their being more easily removed than they otherwise can be. A great variety of instruments have been proposed by different authors for the purpose of preventing a prolapsus uteri; but these in general have been of a very complicated nature, and have never answered the purpose so easily as one or other of those we have now mentioned. PLATE XXI. [Opposite to page 397.] Fig. 1. A trocar of a flat form, which may be in- troduced into the abdomen or scrotum with much ease, and with no risk to the contained parts. This instrument consists of a stiletto or perforator, fig. 3, exactly adapted to the silver canula, fig. 2. The can- ula is left open on one side, which admits of the per- forator being broader through its whole length, as is represented in fig. 1. By this means an opening is made by the perforator, of a sufficient size for ad- mitting the canula with much ease; and as the sides of the canula do not fall close together on the perfo- rator 454 Explanation of the Plates. rator being withdrawn, this instrument is not liable to an objection which has been adduced against the tro- car of Mr. André, represented in Plate X, Vol. I. viz. there being some risk of the steel plates of which the canula of that instrument is composed doing some injury to the contents of the abdomen, on their fall- ing together, which they do with some force on the perforator being withdrawn. The instrument of which I now give a representation, is the invention of Mr. Wallace surgeon in Glasgow. Fig. 4. A trocar of a common triangular form, for the purpose of puncturing the bladder where this operation is necessary in cases of suppression of urine. The round or triangular form of this instrument ren- ders it more proper for this operation than the tro- cars with lancet points, as the fine points of these are not so well adapted for the different steps of the op- eration. And the groove in the perforator, by com- mencing at the point, and being continued through the whole of it, serves to point out with much cer- tainty its entrance into the bladder; for the urine is observed to flow along this groove immediately on the point of it having entered the bladder. Fig. 5. A flat silver canula, with a small degree of curvature for leaving in the opening after the opera- tion for the empyema. END OF VOLUME I. PRINTED AT WORCESTER, BY ISAIAH THOMAS, MDCCXCI. DIRECTIONS to the BOOKBINDER, for placing the PLATES in VOL. I. Plate I. to face page 20 II. to face page 25 III. to face page 31 IV. to face page 56 V. to face page 100 VI. to face page 162 VII. to face page 163 VIII. to face page 173 IX. to face page 210 X. to face page 232 XI. to face page 295 Plate XII. to face page 317 XIII. to face page 350 XIV. to face page 354 XV. to face page 354 XVI. to face page 355 XVII. to face page 360 XVIII. to face page 370 XIX. to face page 388 XX. to face page 389 XXI. to face page 397