15
James Barlow
J Barlow, the well-known surgeon of Blackburn, Lane.
J.W.





Monro's Surgery
Edinburgh
May 20th: 1787




1
We have now fully considered
the general & particular structure of all
the parts of the human body, excepting
its basis viz: the bones & parts connected
with them, & from the particular structure
of these, they make a detached inquiry;
we are therefore sufficiently prepared to proceed
to the Operations in Surgery.
In treating these, I shall not think it sufficient
merely to show you the Instruments
proposed by others, or the method of using
them, but I shall further endeavour to explain
the changes produced by disease
where an Operation can be of use, with
the

2
the symptoms & manner of distinguishing
it; then I shall show the various Instruments,
and methods of others, & endeavour
to point out that which is fittest for us.
I have said, that an Operation or Surgery
being nothing more than a piece of Dissection
performed on the living body, we
are at liberty to reduce it to Anatomical rule.
The Operations are so various that it wou'd
be difficult to reduce them to distinct
Genera & Species, or perhaps, woud such
an attempt be very useful, at the same
time it is evident, that we may avoid
much of the tediousness of Repetition that
is to be found in Surgical writers. It is
not necessary, first to treat of all the diseases
of the head, then of these of the trunk,
then to finish at the extremities, since many
diseases are common to all the parts. Look
into

3
into Heister, and you find the manner of
operating in Amputating the different parts,
not connected together, but detached. In like
manner, under Humors, were treated the
different operations for Dropsy, the manner
of letting blood from the vessels, whether
Veins or Arteries &c._ Now it is evidently
better, that we consider at once, all the
different kinds of Amputation; the [?pe?cha]
in consequence of Humors, wherever seated
&c: - dividing these into Classes, Species &c. _
The particular place of the body where
we shou'd begin, is by no means mechanic,
it signifys little whether we begin with the
head, and to proceed to the thorax, & finish
with the extremities; or whether we study
conveniency, imitating the demonstrations
on the subject, beginning with the most
putrescent parts. Upon the whole, following
the

4
the Method I formerly did, I shall endeavour
to explain the operations in that part of
the body which is most apt to be changed
by keeping for some length of time, so shall
begin with the Cataract, then I shall
follow the most common & constant plan,
beginning with the Abdomen, proceeding
to the Thorax, then to the Head, and
finishing with the extremities, but always
taking in one general view those
Operations that are closely connected.
Cataract

5
Cataract. By this you all know is
understood an Opacity on the Crystalline
Lens. - If we were merely to reason concerning
the seat from the structure, we woud
be more apt to place it in the Capsule than
in the body of the Lens, for in young
subjects, we demonstrate the vessels of the
former, while at no time of life are we
able to do so in the latter; but in 99
cases of 100, the body of the Lens is affected.
I examined in the possession of Baron Wenzel,
3 or 400 Lenses in a diseased state. That
however the Capsule is sometimes the seat of the
disease, is evident from the appearance the
eye has, and after the body of the Lens
has been detracted, perhaps in the space
of a month, a new darkness forms about
the

6
the pupil, and probably the vessels of the Capsule
have been irritated by the operation
and contracted this opacity.
In some few instances, the Cataract is occasioned
by External violence, but for the
most part it comes on in the decline of
life in a very gradual manner, and
generally there is the appearance of it in
both eyes, at the same time; the whole body
of the Lens is not uniformly changed, but
it begins in points, that gradually enlarge;
in others, we find a general cloud increasing
in the most equable manner.
Attempts have been made to cure the disease
by Internal Medicines, & when it is from
external violence, time, assisted by Medicines,
sometimes have an effect beyond
our expectations. I saw a remarkable instance
of that sort, where from a violent
blow

7
blow, the Capsules had been burst; it being
in the Aqueous humour, & the body of the
Lens was of a milky whiteness, which
continued for two months time, but in
two months, it was almost entirely gone,
and the person now observes no defect in
that eye. But where the disease forms in
a gradual manner, I am inclined to suspect
that we shall very seldom succeed
by Medicines. [??ork] alledges that he performed
cures partly with the Pulsatilla
Nigricans, which we find to affect the eye
of a person in health; but in all old
animals, the Lens becomes more & more
opaque, & when the Cataract happens, its Origins
in both eyes at the same time; so we
may consider the disease as an early change
in the constitution of the person, therefore,
unless

8
unless we can totally change that, there is no
room for a Cure; without adding, that
it is placed in the most distant extremities
of our Circulating System. - By what I say,
I am far from meaning to disuade against
an attempt to Cure, but to put you on
your guard in forming a Prognostic, for
as the disease is not dangerous to life,
and as there is no necessity for having
immediate recourse to an operation, I wou'd
make a trial, taking care not to go so far
as to hurt the Constitution of the patient.
Supposing then that Medicines have failed
in their effects, before the Surgeon undertakes
the Operation, there are several circumstances
to be attended to.
1st. That the bottom of the eye, that the Retina
be not likewise affected, that the patient
has only a Cataract, and not combined
with

9
with a Gutta Serena or Amaurosis, & in order
to judge of that, you must recollect a
circumstance that I took care to demonstrate,
that the Choroid coat is joined to the whole
circumference of the Lens, and that there is no
space according to Sharp and others between
these processes, giving passage to the Light;
for you see a plain consequence, that if
Cataract is very opaque, we might, trusting
to the common notion, be led to judge the
is insensible, whilst perhaps the bottom
of the eye possessed its full degree of Sensibility,
& therefore if we observe that the patient
has had no complaints till a darkness
was seen about the pupil, that he
has not formerly been subject to headack,
which generally precedes the Gutta Serena,
& that there is any tolerable degree of
motion in the Iris on exposing the eye to
a

10
a very strong light, we may take it for
granted that the bottom of the eye is
not diseased; or you'll observe two persons
labouring under the Cataract, that
the motions in the pupil of the one,
may be much more evident than in the
other, and the bottom of the eyes in both
be equally sound; so we are to attend
to the colour & opacity of the Cataract,
in forming our judgement, & generally
speaking, the milky or white coloured
Cataracts are the most opaque, & at the
same time softest; whilst then Mr. Sharp
compares to burnished steel. (but which
are rather of a yellowish brown colour,
resembling the Amber in the [illegible]) are
less opaque, but much harder, the light
passes easier thro' them, but they have
a greater firmness.
The next circumstance that you will
attend

11
attend to, is, that the Crystalline Lens has
no Adhesions with the neighbouring parts,
and particularly with the Iris, which must
play upon the Lens with tolerable freedom,
and I have seldom seen an adhesion of
this kind without an alteration in the figure
of the pupil, it becoming irregular,
tho' this is by no means a certain proof
of it, only in such a case, let us be more
careful in our Observation.
I wou'd mention a Caution, which is generally
neglected by Itinerant Operators, i.e.
Not to perform the Operation unless both
eyes are diseased, for if one eye is tolerably
good, we endanger it by do so, the Inflammation
that is occasioned by every operation,
is in danger of producing the
Cataract, and suppose we cou'd remove
it by a wish, without any operation,
the

12
the deformity of the Eye wou'd be somewhat
lessened, but they cou'd not well be filled
to the same object, the one having the other
wanting the Lens; by means of Glasses, we
might bring them to be nearly equal, but
the advantage to the part wou'd be nearly
inconsiderable.
Suppose then that we shou'd have found that
the bottom of the eye possesses its power,
that there is no adhesion, & that both eyes
are affected; before we undertake the Operation,
we ought to confine the patient for some
time, to a strict Antiphlogistic regimen, for
the consequences of the operation are sometimes
greater than one wou'd expect, & the inflammation
often defeats the purpose of the Operation.
We next attend to the Methods of Operating,
and this consists in mechanically removing
the Cataract from the Pupil or Axis of the Eye,
which

13
which may be done in two ways. The most
antient & most common is to thrust a
Needle into the Eye, to push the body of the
Crystalline Lens away from the Axis, and
to lodge it at the bottom, entangled in the
vitreous humor, & this is called Depressing
or Couching of the Cataract. But as the Lens
frequently starts up again from its place,
& the operation needs to be repeated, while
every other attempt is attended with more
difficulty than the first; of late years, instead
of depressing it, it has been proposed
to extract the Lens, to take it out of the Eye.
Perhaps accident more than reasoning led to
the attempt, but the first person who pointed
out distinctly the method of doing it was
Monsr. Daviel about 20 years ago, & I shall
begin with showing you this method.
Of


14
Of Extraction - With the fingers, the Eye-lids
were drawn asunder, and the Ball fixed
a little, an Assistant supporting the Upper
eye-lid. The Surgeon places himself before the
patient, & the Assistant behind him, then
he takes a Lancet fixed in a handle, & the
stalk of it bent a little, & makes an opening
into the lower part of the Cornea; then he
introduces a blunt pointed, double edged
knife, with what he enlarges the opening,
cutting side ways, first with the one side,
then with the other, then he introduces a
pair of Crooked Scissars, having their curvature
adapted to that of the Cornea, &
with these he continues his incision, in
order to seperate the lower half of the Cornea
from the Sclerotis, then he lifts the flap
of the Cornea with a blunt spoon, & makes
a moderate pressure on the ball of the eye,
bursting the Capsule of the Lens, or he
introduces

15
introduces a Needle thro' the pupil & cuts the
Capsule, then making a moderate pressure,
he pushes out the Lens. _ Now this method,
it is evident, requires that the Instruments
be very directly put in & taken out from
the Eyes; it appears complex, & altho' it may
be executed with tolerable safety, I apprehend
we have other methods that are
more simple, & preferable.
Soon after, this method was published in
the French Memoirs by some of the French
Surgeons, & soon after, Mr. Sharp showed
the possiblity of doing the operation with
one knife. With this, he seperated the lower
half of the Cornea, introducing the point
of the knife at the middle of the Cornea
on the outside, & passing it between the
Cornea & Iris, bringing it out at the other
side, then downwards, seperating the Cornea.
Still

16
Still later, a most excellent Oculist, Baron Wenzel,
has practised the Operation, with a Lancet blunt
on the back, & he makes his incision exactly
in the manner just described, without
using any particular Instrument to
confine the motion of the eye. Now for the
want of such an Instrument, the Operation
is not to be executed with tolerable
ease, & I apprehend that a very great improvement
has been made by Mr. Miller.
We had formerly contrivances for opening
the Eye-lids, see one printed by Mr Sharp
with a Spring, but this may open with
too much or too little force, so we prefer
that which is invented by Mr. Miller,
which consists of a circular piece for taking
in more than the Cornea, & we have them
of different sizes. We apply such a circle then
to the fore part of the eye, it has a bent
stalk coming from it which keeps down
the

17
the under lid, whilst the upper eye lid is received
into a groove. After fixing the eye
by means of it, we make an incision with
such a Lancet as Wenzel and, but matter
on the outer side of the Sclerotis, & a part
of the Circle of Speculum may be left incomplete,
that we may remove it if we
chuse, before we bring out the Lancet.
I observed in Wenzels operations, that he
made it a general rule after making the
incision, to introduce a piece of steel, rough
at the point, thro' the pupil, & with that
tore the membrane of the Lens; after which
he made a slight pressure upon the Ball of
the eye, and I have no doubt but the success
of this operation depended upon this,
for if without this, we make our pressure
in any unguarded way, we burst the
posterior Capsula as well as the Anterior,
and

18
and a part of the Vitrious humor will be
discharged. Nay in one case, where there was
a considerable resistance, owing to the the thickness
of the Capsule, he introduced a
small Lancet lodged in a Canula, which
reached the Lens, & he allowed it by the
spring to fall back. _ Now these are
the Instruments we need, & we shall next try them
Before we begin, we must take care
to put the patient & ourselves in a
proper posture; Wenzel was particularly
attentive to this. The Patient was seated on
a chair of the common height, or upon
the side of a bed, then he seated himself
before the patient, or a little to one side,
according to the eye upon which he was
going to operate; he then put his foot
upon a stool of such a height, that when
he rested his elbow on his knee, his hand
was


19
was on a level with the eye. Now we ought
to have some better rest than one knee,
we may set the patient on a low chair
or stool, at the side of a table, that the
Surgeons elbow may rest on the table; we
then fit the Speculum to the eye, pulling
the upper lid into the Groove that is
made for it, & it is impossible for the
eye to move, nay the rude touch of the
Speculum, instead of making the eye move,
fixes it, clinging on a contraction of the
whole muscles; just as when we irritate
the nose slightly, a person sneezes, but
if we irritate it more rudely, as wt: Sp: C.C.,
that effect is not produced. Either the
parts are not disposed to move in that
manner, or there is such a motion of the
whole at once, that the eye remains
more in its place. But the Surgeon
trusts

20
trusts to the pressure it makes. I then take
the Lancet in my hand, between the Thumb
and two fore fingers, & rest my hand on
the patients Cheek; I enter the knife near
to the edge of the Cornea, keeping the clear
part that I may save the Iris, & prevent
an effusion of blood, otherwise, the
nearer the better, because we throw the
Cicatrix more to the side of the Cornea.
I have made the Lancet so like a wedge
that it may fill up the whole, & prevent
the Aqueous humor from running
out quickly; then carrying the knife
across, I bring it out at the other side,
when I immediately lessen the pressure,
but still keep the Speculum there. Wenzel
now turned the patients back to the light,
but it is better that an Assistant shou'd
hold his hand before the eye. I can,
now

21
now by pressure on the eye, bring out the
Lens, but a skillful Operator wou'd do better
in first introducing a blunt probe to [illegible]
the Capsule, at the same time, this is a
dangerous instrument in the hands of most
Operators, and may considerably injure the
Iris or other sightbauring parts, so that
perhaps such Operators as have not much
experience in this operation, had better
just content themselves with making an
equable pressure of both sides of the ball of
the eye at the same time. While bringing
the Lens out, we cover the eye from the
Light, that the iris may not contract, &
more room therefore be given. _ After
Extraction, we apply dressings merely wt:
a view of excluding the Air, which has a
remarkable bad effect upon the eye, so
instead of changing the Dressings in order
to

22
to pour something of a healing Antiphlogistic
nature into the eye, we put a piece of oiled
substance over the whole; perhaps keeping
the cloth wet in rose water may be of
service, and we may pour a little on the
cloth from time to time. We keep the patient
in absolute darkness, covering both
eyes, till all pain & inflammation is
gone, & the wound compleatly healed, that
is for several weeks, for tho' the operation
has been properly done, yet in some little
time a darkness is formed on the eye,
probably in consequence of inflammation,
and you know that the Iris is an organ
of great sensibility, has red blood circulating
thro' it, and there are sometimes
Fungi produced from it.
We next attend to the way of Coutching
a person. 
Of

23
Of Couching. This has been long practised,
and yet no Operation in Surgery is worse
performed or less understood. It ought to be
executed by striking a Needle into the eye
thro' the Sclerotic coat, one 10th: of an inch
behind the edge of the Cornea, when the Opening
of the eye lids have sufficient room;
it is directed thro' the vitrious humour
to the side of the Crystalline Lens, which
the Surgeon endeavours to push down to
the bottom of the eye. The Needle commonly
employed is shaped like a Lancet in the
point, & is somewhat thicker than a
common sewing Needle. It is difficult
to know whether we are to get above the
Lens & press it down with the blunt
side of the Needle, or if we are to lay hold
of it. Some of these Needles are made with
a blunt one to be conducted along with it,
and

24
and by touching a Spring, the sharp needle
flies back, & leaves the blunt one in the
eye, so in this case, the Operator means
to get the Needle above the Lens, & merely
to press it down. _ But an eminant
Oculist, Kilmore, uses a Needle of the common
shape, quite round like a sewing
needle, this he strikes into the body of
the Lens, spitting it as it were [upon]
the Needle. Dr: Taylor sometimes used it
in the one way, sometimes in the other;
he used a sharp Needle, & seems to have
struck it into the Lens, tho' he means 
only to depress it; but sometimes he
used a sharp needle with a blunt one
of gold; he made the hole in the
Sclerotic coat with the sharp one, and
sought for the hole with the blunt one,
tho' in private, he only used one. Now
I

25
I am convinced, not only from the success
of Kilmore, but from the reason of the
thing, that it is best to strike the Needle
into the Lens. We do not need a Speculum
for this Operation, at least we
may do it without one, for the Needle
fixes the eye tolerably well. The Surgeon
rests his hand on the cheek, brings the
Needle opposite to that part of the eye to
be wounded, pulling down the under
eye-lid, whilst the Assistant raises the upper,
& he strikes it at once into the eye;
he then directs the Instrument so as to
get between the Lens & Iris, which shou'd
be the next step, till he sees the point
of his Needle looking thro' the Cornea,
he then turns it back & stabs it into
the Lens; after this, he makes a turn to the 
bottom


26
bottom of the eye, and brings his hand forwards,
in order to push the Lens under
the vitrious humours, keeping it there for
a few seconds till the humour settles,
when he pulls the needle straight out
of the eye; he immediately closes the
eye, and observes the directions I have
already given.
Now which method ought we to prefer?
If both Operations were to be executed
with all possible dexterity, we shou'd be
much at a loss to determine. There is
less inflammation, provided the operation
be done properly, after Coutching,
but the one is a Radical Cure, & the
other may only prove palliative. - Then,
if the Lens is very soft, there is no possibility
of Couching it, but you may
extract it with a spoon, or by injecting
a

27
a little water. I wou'd propose to prefer the
Extraction to the Couching, to prevent Surgeons
from pretending to do an operation which
they are not qualified for, but wound &
has the parts; so that when we take the
same number of patients on which the
operation has been done, more recover after
Extraction than Couching. The parts are seen
in Extraction, but they are concealed in
Couching; to that I wou'd [pro?erate] the
Extraction till the effects of it are better known.
Let us next suppose that from any
cause, after Couching or Extraction, a membrane
has grown across the Pupil, or
that the Iris has been inflamed, & that
the sides of it have united together
during the Cure; we are [surely] in such
a Case to make an attempt to restore
the sight of the patient, however small
the

28
the prospect may be of our succeeding, or
we are with Cheselden, to attempt to form
an artificial pupil. He cut & brought the
point of his knife forewards, till it appeared
in the Aqueous humour. Now
instead of this, I wou'd make the cut
from before, backwards, as we know that
wounds of the Cornea heal readily; so
a couching Needle may be passed at the
side of the Cornea, lower than the Axis,
and we form one opening either straight
or Circular. We must avoid wounding
the other Coats, perhaps tearing the Retina
itself, or the Iris, as well as the Choroid Coat.
Let us next consider the manner of
treating accidents which happen to workmen,
as when bits of Iron or sharp substances
stick in the Cornea, & produce the
most violent Inflammation, with excessive
pain

29
pain. We remove those by Cutting the Cornea
with a Lancet, which we use in Bloodletting,
introducing the point, & cutting directly
upon the substance.
At our last meeting, I showed you the
manner of performing the Operation of
the Cataract upon the left Eye, supposing
the Surgeon to be right handed; but
if the disease is in the right eye, he
must change his posture, placing himself
behind the patient; to prevent any
change of posture, he must use another
instrument, also the invention of Mr. Miller;
it is nothing more than the Lancet fixed
to the handle, nearly at a Right Angle,
and the Lancet is made somewhat
larger than the Diameter of the Cornea,
but the patient may be directed to Cock
a little sideways, then having fixed
the

30
the Cornea, we enter the lancet at the
inner side of it, and in that way, we
can execute the operation as easily upon
the right Eye as the Left.
Next suppose that the Ball of the eye turns
Dropsical, & that the disease does not yield
to the common remedies, we let out the
humours by making a puncture. Instead
of a general increase of all the parts,
the vessels secreting the Aqueous humour
may be chiefly in fault, so we first wou'd
make a puncture in the Cornea with a
couching Needle. If the disease shall return
& increase to a great size, we,
wou'd then make a large incision &
push out the humour, thus the Ball
may shrink; & what will more effectually
empty the Ball entirely, we wou'd make
a large puncture of the Ball with a Lancet
behind

31
behind the joining of the Cornea with the
Sclerotic coat. Now there is one caution
which I wou'd observe here, that sometimes
where water seems to be the Cause,
of the distention, it is merely owing to
a Cancerous substance, so we shou'd be cautious
in the way of treating such. - In one case
which I saw of this kind, there was a
clearness in the fore part of the eye, but
there was a large & hard swelling under
the Ear, upon the neck, on the same side;
so that from there, & the pain the patient
had, who was a Child that suffered,
I concluded that the disease was of a
Cancerous nature. Mr. Millar, who attended
the patient with me, made a small
puncture into it, & the Instrument went
thro' into a substance not thicker than
a cloat of blood; upon this, we desisted
from the puncture, & it healed up, but
it

32
it afterwards broke out into an open Cancer
& killed the patient. By the bye, such cases
as this show that there are Lymphatic vessels
in the eye. If therefore it appears
that the eye is in this state, & that
swellings are not formed in consequence
of it, these may be removed.
The Next Step is the Extirpation of
the Eye from the Socket. Now this appears
to be a very dreadful operation from the
quantity of blood that must flow out,
and the number of nerves which are divided;
yet experience has shown that
the operation may be done easily. It
has been done twice in this place, &
no very troublesome symptoms followed.
We open the Eye-lids, cut out the membranes
making the connection with the
Ball, & stop the blooding vessels with
Spunge, or dry lint. In like manner
it

33
it may be necessary to perform this operation
when the Lachrymal Gland is affected with
Cancer, & if we can't get at it, we must
bring the eye Along with it.
Next let us consider the complaints in
which the Ball of The Eye is concerned.
First you know that the Tunica Adnata
or Conjunctiva is full of vessels conveying
red blood, it is therefore a frequent seat
of Inflammation, which sometimes increases
so much, that the Membrane is pressed
out double between the Eyelids & the Ball;
in such cases, when the common method
for lessening the Inflammation fails, Surgeons
do service, especially if the disease
is not Scrophulous, by scarifying the
membrane, or shou'd the inflammation
still continue, by calling off considerable
portions of it, & Dr. Taylor acquired great
reputation

34
reputation by this Practice. His method was
to lay hold of the Membrane thus doubled
and pass a needle, either straight or crooked
thro' it, to extend it, whilst with the
point of a Lancet, knife, or pair of Scissars,
we take off considerable portions of it. But
we are not to torture the patient with
the application of caustic as he did,
we need only apply some gentle Astringent,
& defend the eye. This operation not only
gives a discharge to the vessels gorged
with blood, but greatly [illegible] the pain,
which is increased by the tears running
along it, the part naturally depended
by the Slime or the tebacious glands,
being no longer the Ducts that convey
them, but the inner & more tender part
of the Eye-lid.
Next suppose a contrary complaint,
that the edge of the eye lid, from the 
laxity


35
laxity of the skin is turned inwards, by
which the hairs upon the edges are directed
upon the Ball, which proves a cause of
very great uneasiness & inflammation,
and for which, Surgeons are at a loss to
find a proper remedy. Now I have seen
a good deal of relief obtained by drawing
the under eye lid downwards, then laying
a large piece of sticking plaster, first
upon the eye lid, then fixing it below,
to the Cheek, which hinders the eye lid from
taking again that situation. But if still
the disease occurs, we either cut out a
part of the Skin, to shorten it; we draw
it out double till the eye lid has got a
proper situation, pass a needle thro' it,
& cut out what is superfluous; or we
may get rid of the hairs upon the edge
of the Eye lid; we cut them in vain, for
they

36
they grow again harder & sharper than before.
Surgeons endeavour to pull them out
by the root, but generally as much remains
of Ball as grows again. Now
I have thought of cutting upon the Ball
with a point of a Lancet, & turning it
out.
Next, in consequence of Inflammation
of the Eye, & more particularly of the Tunica
Adnata, Specks form upon the cornea,
which sometimes appear like a Cloud,
semitransparent, while in other cases, there
is a greater opacity or whiteness, & in
many cases, if you look narrowly,
you perceive distinctly a number of red
vessels, which in 99 cases of 100 are not
produced by the natural vessels of the
part being enlarged by an Error loci as
Boerhaave speaks. I wou'd be willing to
admit the Error loci of Boerhaave, but
in

37
in this case it does not take place; from
the Tunica Adnata there is a growth of
vessels, which creep upon the surface of the
Cornea; now this leads to a ready method
of cure. If the speck be slight, & the Inflammation
in the rest of the eye has
subsided, I have repeatedly seen it disappear,
where little else was done but the
defending the eye from the light, Cold & Heat &c.,
giving perhaps a slight Purgative from
time to time, & washing the eye with Cold
water, or with a small proportion of Sacch:
h: dissolved in it; But in other cases more
powerful remedies are necessary, & I have
known certainly that Mercury given in
a slow manner to touch the mouth gently,
for a length of time has a very great effect.
I have seen the whole Cornea as red as
the Tunica Conjunctiva, & that often two
months

38
months every vessel disappeared. But suppose
that these remedies have failed, from the disease
being on the surface, we are led to a
method of Cure what has long been practised
by Different Oculists, the dividing
the vessels with a knife or Lancet, & in this
way, Mr. Millar has done more service
than in any other of his operations.
His method is this. He applies the Speculum
Oculi, by which he secures the eye, & lays
the Cornea in view; he then takes a knife
or sharp convex edged Scalpel, & with this
he first makes the Circular cut round
the edge of the Cornea, making [hinder]
a cross incision, dividing the trunke of
the vessels, which he examines from time
to time with a magnifying glass; Nor
is this all, for after making these Incisions,
which give a good deal of pain,
and repeating them perhaps once every 2d
or

39
or 3d. day at farthest; he next uses a Practice,
which we cannot see without feeling for the
patient, yet I do not observe that the pain
is considerable, he takes a piece of Plaster
spread, which appears to be the Diachyles [of]
[Gammis], but this is one of his secrets, on
linnen, & lays between the eye lids, forming
eye-lid pieces over the eye lids; he then presses
together the sides & fixes it on by a bandage,
and he freely applies from time to time
a water with Camphere in it. Now without
giving any Medicines inwardly that cou'd
have effect, unless perhaps Antimonial vomits,
which seem to have some singular efficacy,
I have seen very great abatement in the Inflammation.
The Ducts conveying the sebaceous
matter are somewhat obstructed, & knots, from
which generally Inflammation & Suppuration
take place.
Next

40
Next suppose that in consequence of the operation
I have mentioned, the Ball of the eye
shrinks; some endeavours to conceal the
deformity by an artificial eye, a piece of
glass, on which there is a representation
of the Cornea, Iris & Pupil. These are admirably
well executed at Paris. The person sits for
the picture of the eye. We introduce,
such substances within the eye lids, & unless
the Ball is altogether shrunk, it carries the
plate of glass with it. But the advantages
which arise from this use do not
ballance the uneasiness they occasion, putting
the eye lids at first very considerably;
so that the patient perhaps had better
be contented with concealing the eye entirely
Next suppose that the eye is weak, and
we mean to defend it from the light; instead
of doing that by a dark rooming,
it is better to use an instrument that applies
to

41
to the part readily, & is supported with a Circular
round the head, & a strap over it, & we
cover the opening with a piece of Gauze.
The next complaint which I mean to discuss
has been treated of at great length by Surgeons,
and many Volumes have been wrote upon
the subject, I mean the treatment of the
Fistula Lachrymalis. By this term, Surgeons
mean any Ulcer which may affect the Lachrymal
passages, whether it is fistulous or not.
It is necessary to put you in mind of the
passages of the tears. They are secreted by a 
Gland above the ball of the eye, & are poured
out under the upper eye-lid, by a number
of Ducts, falling down by their gravity,
and are conducted by the edge of the under
eye-lid to the Internal Confines of the eye, &
are there sucked in at two open orifices
at

42
at the Puncta Lachrymalia, from which, Ducts
lead to the Sac, which is placed under the edge
of the Orbicularis Palpebrarum, & which is before
membranous, but behind, the Sac &
Duct leading downwards from it, are supported
by bones & when the Duct reaches the
superior Maxillary bone, it is quite surrounded
by bone, & enters the Nose under
the Anterior Os Spongiosum, between it &
the Septum, which seperates the mouth
from the Nose. Now it is evident that the
passage of the tears will be subject to disease,
because the tears want the Vis a
tergo, & it requires a nice operation, &
a sound state of the parts to suck them
in & convey them to the Nose. Next
we must suppose that the acrid nature of the
fluids disposes to Inflammation. It is in
vain to imagine that natural liquors cannot
possess

43
possess any such bad qualities, for we find
that the passages are carefully defended
with slime, there are mucous orifices in
considerable number in the Sac, & the end
of the Duct terminates in the membrane of the
Nose, which is subject to thickening & swelling,
and this may mechanically affect the end
of the Lachrymal Duct, by pressing upon it,
without supposing that the thickening extends
into the Duct; & in the common Cold or
Coryza, the eyes water, not from the tears
being increased in quantity, but from their
not going thro' the natural Duct, but
falling over the face.
The Causes that expose this part to disease,
makes the disease difficult to cure, after
the tear advanced to a certain degree, especially
that the membranes are confined
within the bones, so that the imitation
is

44
is not easily taken off, by allowing the parts
to swell & expand, by applying Emollient
Ointments &c. as in other cases. -
The common appearance where a Fistula
Lachrymalis forms, are these - First the
person is sensible that the tears pass over
the face, the inner corner of the eye comes
to be scalded, is of a red colour; soon after
this, he feels an uneasiness at the inner
corner where the eye lids meet, & if he is
attentive, he discovers a small degree of
swelling there, viz: the enlargement of the
top of the Lachrymal Duct; if he presses
on the swelling, the tears which fill the Sac,
instead of going into the Nose, run back
into the Eye, & then he observes a quantity
of mucus or slimy matter mixed with
them, which by degrees comes to be more &
more discoloured, till after a certain
space,

45
space, according to the Constitution & Cause of the
complaint, we find purulent matter mixed
with the Mucus & with the tears. Now the
Teguments come to be affected, & to grow
red, at length a hole is eroded, the tears
are discharged from the orifice, & if the
disease is neglected, & the inflammation
does not subside, the bones come to be carious,
& sometimes, tho' rarely, spongy flesh
grows out, which bleeds very readily on
the slightest touch. _ But we are not to
imagine that a swelling does not happen
at the inner Canthus, without affecting
the Lachrymal passages; in one or two instances
I have seen the inflammation
quite external & particularly in Venereal
Cases; after the throat has suffered swellings,
Inflammations are apt to form here, and
this part of the body some way or other
is

46
is disposed to Cancer, of which, I have seen
two or three instances begin about the external
Canthus, higher than the Lachrymal
passages. - Now in what manner are
we to treat this complaint in its different
stages? To do this, I shall shew in
a general way the methods that have been
contrived by Surgeons, and all of which
are at present in practice.
First, if the common [depressing] applications
do not answer, it has been advised that we
shou'd inject healing liquors, water & Balsam
of different kinds in at the Puncta, for it
seldom happens that the Puncta are obstructed,
it is a possible case, & shou'd it occur,
we may make an artificial Duct, by means
of drawing a Needle with a Cord in it through,
& keeping it until the passage grows callous;
But as far as accounts go, the obstruction
does


47
does not force between the Puncta Lachrymalia
& the Lachrymal Sac, so Injections
are thrown in by the Puncta by means of
a very minute tube, the point to be entered
at the Puncta. Some, instead of watery liquors,
have proposed that we shou'd inject the
smoke of different plants.
Suppose next that the Injections fail, we
have been advised to make use of probes,
made so small, that they may be introduced
at the Puncta, & pass into the Lachrymal
Sac, & with these, the obstructing matter is
to be broken down, the little cloats & ther matter
preventing the passage of the tears to the
Nose from the sac. With these few years,
in a French Memoir, a supposed improvement
upon the method, is proposed, a
probe with an Eye like a needle, is to be
introduced at the Superior Puncture into
the Nose, & a piece of thread by way of
Seton

48
Seton is to be passed thro' the eye of the probe
and pulled downwards; this is allowed to
remain till the Inflammation & Obstruction
are dissolved.
Others again propose that we shou'd introduce 
probes from the Nose, or hollow tubes
for throwing in Injections, & I showed
you the possibility of doing it.
But suppose all these methods ineffectual,
in the farther progress of the disease, what
farther are we to do? - it remains to Any
open the Sac with a common knife or
Lancet, then we endeavour to pass a probe
into the Nose, properly bent; but if this
be found impracticable, that we can't enter
it into the Nose, or introduce a Tent,
we are advised immediately to have recourse
to an Artificial opening, to endeavour to give
a discharge from the Lachrymal Sac into
the Nose, by perforating the back parts of
the

49
the Sac, & breaking the bone on which it is supported;
and an Instrument for the purpose is
painted by Mr. Sharp. It is not necessary to
mention the Actual Cautery that was formerly
proposed, but is rejected on good grounds
by Sharp. Why use Cautery when we can
make an opening in a much easier way?
It is a practice which has been imitated
from the Antients, who were not acquainted
with the Anatomy of the parts.
Let us now see how far these various processes
may be necessary.
The Injections are an universal practice, &
I find no where any objections made to
them; but they are superfluous, & are not
to be executed; we can't introduce a small
probe into the Puncta without great trouble
to ourselves, & pain to the patient, & every
time we do so, we render the Puncta more
unfit

50
unfit for the office of Absorption; nay we
overlook the very action of the Puncta, these
still continue to absorb the tears, so may absorb
any proper Injection; therefore if we
have any faith in these, as in a weak
Solution of Sacch: t., we need only drop it
into the Eye, after emptying the Sac of the
tears; the patient lays himself on his back,
& with a tea spoon, or a quill filled with
the liquor, & stopped at one end with the
finger, which prevents the liquor from running
out, it is poured into the eye, which serves
every purpose of an Injection in a more
gentle manner. - Supposing them of no
avail, may we not in some cases attempt
to exclude the tears, prevent their
entering the Sac, at the same time assisting
with Medicines for the detumifying of the
membrane of the Duct, that the Inflammation
and

51
and thickening may subside, which is to be considered
as the common Cause of stoppage
I two or three persons I made some little
attempt of this kind, but it was not conducted
properly; however I know two or three
persons who have had a stoppage for these
10 or 12 years, the tears running backwards,
without the disease coming forwards to the
last stage, & they have found relief from
the Injections dropt in, in the manner
I have mentioned.
But next let us suppose that the obstruction
continues, & that the disorder seems to increase,
are we to introduce these Probes? - What are
we to expect? Surely the proposal succeeded
from a wrong idea of the nature of the
complaint; how do we know that there is
muccus stuck by squeezing it out from the
Puncta? why then bring the matter down
with

52
with probes, & no relief is to be expected from
it? the Ducts & membranes must be more
irritated, & the disease increased. These are
beyond all doubt to be laid aside.
Are we next to Attempt to introduce a Syringe
thro' the Lachrymal passages in a living person
without any considerable pain? This is a
most difficult operation, I believe scarcely
possible in many subjects to execute, considering
the turns the passage forms. I
take it for granted that the passage from
the Sac into the Nose will allow the probe
to pass; but I have known several instances
where after the Sac was opened; the Surgeon
had it not in his power to make
the probe pass from the Sac into the Nose,
the disease renders the introduction so
impracticable, & by bringing the probe forwards,
we are in danger of tearing the
end

53
end of the Duct, & after all, the removal of
the substance within the Ducts, wou'd not
give the expected relief; this therefore I wou'd
evidently lay aside. Nor do I find any reason
to imagine that Smoke can have more
effect than other Injections, nor have we any
Analogy to suppose it, we can only have the
idea of a thickened wet membrane
which we mean to dry, but the Inflammation
will do this more effectually. -
I need say as little of the Injection from
beneath upwards, for I take it for granted
that the Ducts are free, but what advantage
do we find from it? can't we fill the
Lachrymal Duct as well by pouring the
liquor into the eye; & suppose the sides of
it are applied so close to one another by the
swelling, that the tears are not able to force
their way, I can fill the Lachrymal Sac with
an Injection, then press upon the Duct with
the

54
the forefingers of one hand, whilst with the
forefingers of the other I press upon the Sac,
so that if any passage is to be gained
by forcible means, I can do it in this
manner, without the pain & trouble of introducing
tubes. -
If therefore we find that the common Antiphlogistic
Courses or Medicines against the
disease, Simple Liquors pressed into the Ducts,
gentle compression upon the Sac so as to
prevent the tears from lodging in it, or
keeping these from getting into it for some
days; if no relief can be obtained from
these measures, & at length a suppuration
forms, the next step is to make an Opening
into it, & if the natural Duct
can't be made pervious, to form an
artificial one.
There is one thing only I wou'd venture
to

55
to suggest, If the Lachrymal Sac is gradually
distended, & comes to enlarge, but on pressure,
the tears & mucus appear pretty much of the
same colour, without any marks of considerable
erosion, & that by pressure we cannot
force the liquor down into the Nose; perhaps
to save the part the inconvenience of a
Scar, from the incision, we might enter
a very small Trocar into the Sac, & then
with it perforating the back of the Sac, make
a passage into the Nose to give vent to the
tears, and thus may be found sufficient for
the Cure, & perhaps the flow of the tears
will prevent the orifice from closing, or for
that purpose, we can introduce a leaden paste.
But if there is any evident Suppuration,
we make a sufficient opening with a small
knife, & we may be provided with another
with a concave edge in order to dilate
the

56
the Sac, and with this we are to open the
Sac its full length. _ The next step is to
take a common probe & to pass it down
into the Nose, & if the Surgeon fails in this,
it is usual to proceed immediately to the
perforation; but we are not to think of this
without giving further time; I have seen
several instances where no passage cou'd
be found with a probe, & where it was impossible 
to make any Injection to go immediately,
and yet in 8 or 10 days, when
the inflammation of the parts has subsided,
the probe entered, or Injections passed very
well. - So having laid the Sac open, we
may make a trial with the probe, & if it
enters, we are pretty sure of curing the Patient;
but let us not fret the membrane by making
the trial, we may bring on a concretion,
that without this wou'd not have happened,
so I wou'd immediately put on a
Dossil

57
Dossil of lint to fill the Sac, to prevent the
teguments from healing, with a thread about
it, & confined with a stripe of sticking plaster,
which dossil may be renewed once a day,
as the dressings soon becomes wet, partly
with the matter & partly with the tears. When
the Inflammation has subsided, we renew
our attempt to introduce the probe, & we
attend to the turns which the duct makes
downwards, making a bend in the passage
to the Nose. In one or two instances where
I attended, & where the Surgeon thought there
was no passage; upon holding the probe
slack, & allowing it to fall down by
its own weight, it entered readily
But suppose we fail in gaining a passage,
we are to make an Artificial one;
but this is not to be done according to
Sharps method, who not only perforates,
but turns the Instrument sideways to break
the

58
the bones, whereby a much larger hole is
made than that made by nature, and
after all, there were no pains taken to preserve
the opening he had made. Instead
of this, a small opening is to be made with
a perforating Instrument, such as that proposed
by my father in the Medical Essays,
viz: a Trocar made for the purpose, adapted
to the size of the Duct in a healthy
state; but it can't without some difficulty
be passed down. Having made the Perforation,
we may preserve it by a bit of
leaden probe, catgut, or Bougee; but the
leaden probe answers very well for rendering
the passage Callous. Some propose
to take it out now & then, & to throw in
an Injection to harden the passage, but
this is scarcely necessary. I know one case,
where the Surgeon by neglecting the directions
that

59
that were given, allowed the probe to remain
nine months, and the passage was perfectly
Callous, without any inconvenience following.
I shall now shew the operation, & endeavour
to bring it to a very great simplicity; &
tho' we are working upon minute parts, we
shall not find that this is so difficult
an Operation, as at first we might apprehend,
and it is much easier to operate
where the disease is formed, than in a
sound subject, because the Sac is so much
enlarged that we cannot readily miss it,
and we may take pains to prevent the
liquor from running out in the time of
the operation, by pressing upon the Ducts that
lead from the Puncta; then we make an
Incision over the Sac, & the incision in the
teguments may be somewhat larger than
in the Sac, in order to have free room for
introducing the dressings to keep the wound
open

60
open till the Inflammation subsides. I begin
the Incision over the edge of the Orbicular
Muscle, & continue it downwards for the
breadth of a finger, or there abouts; but the
length must very much depend on the state
of the teguments & of the parts underneath;
I continue to go deeper with the Incision;
now, if I was at a loss to find the Sac,
I might do what some Surgeons have proposed
to be done, introduce a probe into
the Punctum, & make it enter the Sac,
then, if we see the probe appearing, we
have gone deep enough; but in a diseased
state, this is not necessary, we know upon
the discharge of tears that we have made the
Incision properly. I have preserved the Tendon
of the Orbicular muscle, but instead of
finding any occasion to preserve it, I find
that it straitens the Operator, therefore, I next
cut thro' it, & dilate the Sac its whole length
thro

61
thro' the Muscles, sufficiently to the Nose; I next
attempt to introduce a probe into the Nose,
and I shall suppose that with all proper
delay, I failed in doing that; I am now
to make the necessary perforation, & I use a 
common probe for conducting the Trocar.
The probe I introduce into the Sac, & you'll
recollect what I demonstrated with regard to
the situation of it, that the inner side of the
Sac rests upon the Nasal process of the outside
of the Os Unguis; and we are to keep
within the ridge of the Os Unquis, otherwise
the tears may insinuate between the Ball of
the eye & its Socket, & occasion troublesome
symptoms. Then taking the Perforator, with
the slightest touch, I pass it into the Nose;
I next take the leaden probe, which passes
thro' the Canula, & can readily introduce
it within the Nose; but to prevent the point
from

62
from pressing against any part of the nose,
and hurting it, I do not allow it to descend
so far, but confine it, by bending it, &
cutting off what may be unnecessary; we
then incline the patients head forwards, &
observe whether the blood passes out at the
Nose, if this is the case, we are sure we
have made the perforation; we then apply
the dressings, & trust to a bit of sticking
plaster; but if we are to make a gentle
compression upon the Lachrymal Sac, here
is an Instrument that has been used & found
convenient for that purpose, it is an
improvement of the Instrument represented
by Mr. Sharp; his instrument is a bit of
Iron than binds to the forehead, it cannot
however be changed in the situation, but
here it is made so that we can draw it
out and in, & with a Screw can make
what

63
what pressure we please upon it, & it is
fitted for both eyes.
Generally the disease will need a treatment
of a month or six weeks to render
the passage Callous, & to remove the inflammations;
we then draw away the probe,
bring the skin together, & keep the opposite
sides adhering by means of a patch, & shou'd
the skin not unite, we need only touch
the sides with a bit of Caustic.
After several cases of this kind that I have seen,
I wou'd alledge that the inconveniences attending
it is not so great as might be
imagined; we are told that now wants
its long leg, & no doubt it turns the
worse for it, but there is a degree
of contraction in the Lachrymal Ducts,
which prevents the tears from passing backwards,
& the motion pushes on the part, so
that

64
that they get into the Nose, tho the opening
be not much lower than the opening to the
Puncta; neither are we to imagine that the sides
of the sac grow together, the flow continues
for a great length of time, there is such a
continual attraction of tears as prevents the
ready adhesion of the Sac, tho' after a violent
inflammation & swelling of the internal membrane,
we may suppose this to happen.
Next, it frequently happens to tradesmen,
especially those that work in Metals, that particles
of the Metal stick in the Eye, & particularly
in the Cornea, & the most minute substances
sticking there I know beyond all doubt is the
Cause of a high degree of Inflammation,
which at last affects the whole ball of the Eye.
We are not with Haller to believe that the
Cornea possesses very little Sensibility, let any
one make the experiment of touching his own
eye

65
Eye with the head of a pin, and the sensibility
is much increased if the eye at the same
time is in a state of Inflammation. Mr:
Angelo, Master of the Riding School here, had
a most violent Inflammation of his eye for
the span of six months, & it was treated by
different Physicians & Surgeons in Town without
effect, till it was discovered by Mr. Millar
that the Inflammation was owing to an exceeding
minute particle of Iron sticking
in the Cornea. If the substance is near the
surface, a common writing pen is by no
means a bad instrument for removing
it; but suppose that the substance is struck
deeper, & it comes, by a degree of thickening
in the Cornea, to be sunk within it, there
is a necessity of making an incision, as was
done in the case of Mr. Angelo, to remove
it. Now in making the Incision, Operators
generally

66
generally blunder. Of late, they have been in
use, to extract the Crystalline Lens, with a
Lancet, the sides of which are turned to
the eye; so they do the same here, by which
means, a larger wound than is at all
necessary, is made, cutting the Cornea in two
places. Therefore, I wou'd do it, by holding the
Lancet in the common manner, making
the Incision, as when we let blood, whereby,
we cut upon the substance itself, & if
possible, we avoid cutting thro' the Cornea
altogether; but if we must penetrate it, it
heals very soon, & the Aqueous humour
will collect in the Space of one day. -
Sutures

67
Sutures in General. If Dressing or Compresses,
with Bandages & Plasters, are not sufficient
for the purpose, of retaining divided
parts, Surgeons have recourse to the sewing
of the parts. Thus suppose that a Cord of
vessels, such as the Spermatic, is laid in
view, & that the whole or any of the parts
need to be tied up, we take hold of the
Cord with one hand, the Needle & thread
in the other, & comprehending the whole, or
a part, as occasion may require, we make
the most simple Ligature, & if it is to remain, 
we form the most simple knot, but if it is
to serve the purpose of a Tornequet only, for
compressing the vessels, we make a running
knot, which we can undo at pleasure.
Next suppose that the mouth of a vessel
presents, as after a leg or arm is cut off,
and

68
and we may suppose that the Umbilicus
represents the mouth of the vessel, how are
we to stop the blood? - Perhaps the method
that wou'd most readily occur to an ignorant
person is the best, that is, to take
hold of it with a pair of forceps or common
hook, by which we can pull it out, when
we tie a thread about it in the most
common manner. But instead of this
method, the most common practice is
to surround the mouth of the bleeding vessel
with a thread, without drawing it out,
taking in some of the flesh as Cellular
substance; & many cases may occur,
where from necessity, we are obliged to operate
in this manner; thus, a vessel may pour
out blood, where we see the place nearly,
but not perfectly, or the extremity of this
vessel may be in a putrid state, or sunk
in the flesh. Out of choice then, or from
necessity

69
necessity, Surgeons employ the Crooked needles,
& the thread should be about the size of the
Needle, & the two ends brought to be equal;
we begin in one side; as the needle is semicircular,
we can describe the semicircle with
it, & entering it a second time nearly where
we brought it out, we compleat the circle,
and there is no reason, with Sharp, only
to describe 1/3 of the circle, surely the nearer
the circle the better. Then we tie the thread,
and the force here necessary is much less
than the Surgeons generally suppose, they take
it to be so great, that they include with
the Artery a good deal of flesh. Now
suppose the coats of the Artery to be alone
drawn out, I can make a ligature so
light, that I can't rarely burst open
the Artery with the Syringe, the rest of the
coat will as readily give way. In
tying

70
tying an Artery, we make the most common
knot, & it is scarcely necessary to add
a second to prevent the first from slipping,
but it may be done if you choose. If
you are to have a Ligature round a firm
& hard substance, you wou'd employ
what Surgeons call their knot, i.e. you
woud pass the thread twice; this does not
so readily apply round the Artery as a
single one, but often it is drawn to resist
more.
Next suppose a Membranous part, as the
Alimentary Canal, is cut, & we are to join
the sides of it, we wou'd not use the round
or crooked needle, but rather a common
sewing needle, & we wou'd join the parts
in this way as two bit of cloth are joined
together; we bring the wound closs, pass the
needle thro' both sides, & repeat these turns
in

71
in the most suitable way. But if we suspect,
or suppose with Le Dram, that the
Intestines are so thin, that the Cicatrix
will not resist sufficiently the expansion
of the Air within the Gut, nor confine the
food; we may Attempt to heal the wound
in the following manner - We pass
a number of threads with the straight needle
at half an inch distant from each other,
then take hold of them on each side, draw
them together & twist them, by which the
Intestine is straitened & thereby made a thicker
Cicatrix. But in wounds of the Intestines,
I believe the former is the best, for while
the thickness is increased, the cavity of the
Intestines is straitened, whereby the fæces
are in danger of being accumulated, and
bursting the Intestines. But we wou'd not
employ in such a case what has commonly
been

72
been done, the method recommended by Cullen
for sewing of wounds in General.
Next suppose that a part of moderate thickness
is [formed] wounded, as a fissure formed
in the Lip; we join these parts by a pin
or round needle, without a thread, then
draw the Lips together by passing a thread
over the pin, repeating the turns at pleasure;
and we employ in a long wound more
than one pin, or as many as the length
may render necessary.
Next suppose a very deep wound, that
the parts wounded are of very great thickness,
& with a retraction partly owing to
the Inflammation which succeeds the wound,
partly to a muscle being divided transversely;
thus suppose a wound in the
fore part of the thigh, & I shall make
it slanting, which is the most difficult to
manage

73
manage. Now you must always have in
view, that we first try what bandages
and proper Plasters can do, attending at
the same time to the posture. If the Flexors
are wounded, bending the part, if the Extensors,
extending the part. But I must suppose
that the bandage is not sufficient, & we
need a stitch to retain the parts, how is it to
be performed? Sharp, L. Dran & others direct
to bring with your hands the lips of the
wound contiguous, then to enter the
Crooked Needles followed with threads at
the distance of an inch from each other,
so if the wound is 4 inches in length,
we are to make 3 stitches; next we are
to enter them at a sufficient distance
from the sides of the wound; Sharp reduces 
the distance to measure, but it must
vary according to the depth, as the attraction
will

74
will bear a proportion to it. Le Dran proposes
that the distance shou'd be nearly equall
to the depth of the wound; but in a deep
wound, we are to follow neither of them,
for how can we make a needle to enter
at a distance equal to the depth of the
wound, & bring it out at the opposite side
unless the needle be very long, & how do
we know that the Needle has passed at
the very bottom of the wound; if it passes
deeper, it must wound the parts underneath,
if more superficial, a part of the Lips will
retract, & a bag of matter form; so the
best measure is, if a part is not very
thick, as the skin of the head, nor a large
portion cut off, the stitching of it is of
advantage, at proper distances, to keep the
Skin in its place, while the rest is secured
by Plaster & bandage; and we
shoud

75
shou'd follow the method of neither of these Authors,
at once passing the Needle thro' both sides of
the wound & teguments, but in a deep wound
the best way is to lay the lips of the wound
together, then to consider the depth, the number of
Stitches, the distance necessary from the sides
of the wound, & if it slants, as it must come
out farther where the slant is formed; the
Surgeon takes pen & Ink, & marks the places
where the stitches are to come out; we then
open the wound, & employ two needles, one
at each end of the thread, we enter the one
from the bottom, & bring it out on the one
side, then do the same thing with the other
on the other side; after this, putting the member
in the posture in which it is to remain,
Assistants push the Lips together, & the
Surgeon ties the knot, throwing it upon
the sound skin, not upon the lips of the wound,
and

76
and after one, he makes a second, with the
view of not unloosening it again, for the
matter that comes out, entangles the threads
so much, that if they are to be changed,
the Ligature must be cut. If however there
is a probability that in a short time some
alteration will be necessary, you may form
it so that you can loose it again. As
to the Practice of pulling bits of linnen rolled
together, between the first & second knots, &
adding a third to them, it is a mere incumberance,
for the pain is from the retraction
of the lips of the wound, & not from the
knot laid on the sound skin
Now the only remaining Suture is where
a wound penetrates into a large cavity, as
into the Abdomen; in that case it has been
thought that a more equal support to the sides
of the wound is necessary, to prevent
Hernia from happening. The Lips of the wound
being

77
being drawn in, & openings left, so a contrivance
has been proposed to make the Lips
of the wound perfectly equal, viz: you
pass the threads, & then draw the Lips together
by Pegs, or rolls of Plasters with a bit of
wood, which is called The Quilled & Peg Suture;
the thread is doubled to let in the Peg at
one side, then taking hold of the other two
ends, you bring it down, & then dividing the
thread, & putting in the other Peg, the Assistant
presses the Lips together, whilst the Surgeon
ties the threads, making the Knot to fall
upon the Peg; & here we make a running
knot, because the Peg being between the wound
& knot, we can loosen & change it.
Now I am not sure whether this be preferable
to the Interrupted Suture, providing only
you employ more threads than is commonly
done, as it is very material that the wound
be closed accurately closed so as to exclude the Air.
Lithotomy

78
Lithotomy. I now come to explain the Operations
which are practiced on the Organs
of Generation in both Sexes, beginning with
a very principle one, for the stone in the
Bladder, for I need add nothing to the objections
that I made to Nephrotomy
or the cutting a stone from the cavity of the
kidney. I shall hand round again the
different kinds of Calculi; with regard
to which there are a number of things which
require attention. They differ very much
in colour & consistence from each other,
some are vastly harder than others; next the
shape is various, but upon the whole, where
the stones are within the cavity of the
bladder, they resemble generally an Egg
pressed flat, or they have three different
Diameters, length, breadth & thickness and
it

79
and it very material to know this when you
are about to extract them, as much depends
on catching the stone in a favourable way.
Next, attending to the surface, you find
that many of them are unequal, & the irregularities
are often very regular, resembling
the Crystals of Salts, or there is a crystalization
in the Calculi. Next we find
that they have concentric Lamellæ, &
that these are seldom the same throughout,
which points to an useful enquiry, for the
Lamellæ depend upon an unequal [growth?????]
and are occasioned by a variety
in the manner of Life, the constitution remaining
the same. Next, where there are
more than one stone in the bladder, we
can determine that upon the appearance
of any of the Stones, for one makes an
impression upon the others, as such stones
as

80
as are polished in certain places, & want the
round figure which they otherwise readily
take. In some stones, the pressure is very
remarkable, & a great number can' be put
together, so as to form a figure perfectly
regular, thus I shew you thirteen, the whole
forming two, quite regular, like the brass
handle of a door. Many have been divided
as to the manner of the appearance,
some have supposed the large stone broke
down into so many pieces, while others
imagined that a number of small stones
by pressure had assumed that shape. Now
the latter is certainly true, for I have
since got three stones since, two of which
make a regular figure, & I can perceive
that two such stones have formed the
third, we see the Rim where they are joined,
& in cutting the stone, we find a stricture
where the two surfaces meet & are
connected

81
connected, each having its concentrated Lamella
I formerly suggested that the formation of
Calculi might depend upon a variety of
Causes, a number of which might be very
easily conceived, so we are not to imagine
that we can always explain it from the
Diet, or that it depends upon the kidney entirely,
there may be many other circumstances,
the Absorbent vessels of the Animal may have
a great affect, the intimate structures of the
kidney, the nature of the general excretories
of the body, allowing the useless parts to escape
thro' the pores of the Skin; the Fluids
stagnating in the Receptacles; the posture of the
body, the habit of retaining the water, the
negligent manner of making it; in the
mean time, particles of blood falling into the
bladder, & attracting the stony matter, as
threads put into a Solution of Sugar, give
the

82
the appearance of Crystals as in Sugar Candy;
and viewing the variety of these Causes them,
we wou'd conclude that the stone may have
its first beginning in the bladder of Urine,
and we are not always to look for the descent
of it from the Pelvis of the Kidney, tho' that
is very common, and we can frequently
trace it by the symptoms, which are very
easily distinguished, & generally well described.
When it had fallen into the Bladder, we
endeavour to discharge it by a proper posture
of the body, by relaxing fomentations &
Injections, by the use of Opium to take of
the Contraction of the Sphincter, & by a proper
posture in discharging the Urine, as sitting
on the knees, leaning forwards, to throw
the stone immediately over the passage;
Next suppose that a stone has formed in
the Bladder, or got into it, how are we to
distinguish

83
distinguish it? There are a great variety of
marks that enable us to do this with a
probability approaching to certainty. The
patient finds always an uneasiness on
motion, he is perhaps tolerably easy when
sitting or lying, but on getting up to walk,
he feels an uneasiness; he has generally
a frequent desire of passing his water, from
the irritation, in consequence of which, he
passes it in small quantities; there is a
difference in the colour of the urine, it is
generally of a paler colour in calculous
cases, which may depend upon the stone,
attracting the earthy particles, but likewise
the affection being communicated back to
the kidnies, just as the colour of urine
varies in feverish cases; next, the uneasiness 
is increased if the motion is of a jolting
nature, as riding on horseback, or walking
down stairs; on passing his water, tho' he
has

84
has a strong desire, he finds a great difficulty,
the Irritation making the Sphincter contract,
or the flowing may be mechanically stopt,
by the stone falling on the neck of the bladder;
when he has nearly emtied the bladder, he
relaxes all the parts, the knees are set at a
distance to prevent the pressure, & the
trunk bends forwards, not from particular
muscles being irritated, but because the parts
are then most relaxed; still however on
passing the last drop, the pain is greatly
increased, the stone being brought near to the
Neck of the bladder, which is the most sensible
part of it, & he feels a pain extending
to the Glans Penis, just as a person
after Amputation feels a pain referred to
the toes, being to the termination of the Nerves,
not to the middle parts which are irritated
by the Calculus. Blood passes after voluntary
motion being made, & sometimes Sand.
These

85
These & a few other circumstances render it
probable that a person labours under a Calculus.
But a Cancer, or Ulceration, or small
sand may produce nearly the same kind
of feeling, so before any operation be performed,
it is necessary to sound the patient, by introducing
a probe into the Bladder.
Suppose in consequence of sounding, I am
certain of the disease, that I feel a stone,
am I to trust to Internal Medicines for the
Cure, or to Injections into the Bladder? I
apprehend we are to trust to neither, nor
have we clear proof that any has great
effect, at least not such as many Physicians
seem to conceive; I wou'd alledge that it is
far from being certain that by Caustic
Alkali; Lime water, Soap, &c., we can prevent
the generation of Calculus; that is,
suppose a person cut for the stone, & giving
proof

86
proof of Calculous disposition, & especially if there
has been more than one stone, we cannot
promise that we can prevent the return
of the disease, & the reasoning upon this subject
is to be set aside entirely. - It is
not worth mentioning the effect of the
Caustic Alkali, it is soon changed in the
Stomach & Intestines, where acid or asescent
matter is always contained, so it can have
no more effect than a Neutral Salt; but
I appeal to experiments, & there is not a single
proof to lead us to believe that we possess
a medicine of such power, far less
that we can by any medicine - dissolve
a stone that is already confirmed. This
is alledged, and one case of this kind
in particular was published, but I know
there was a mistake, the Stone was supposed
to be dissolved, as it cou'd not be felt,
but

87
but afterwards, another person turning the
patient into different postures, the stone was
discovered; but Surgeons frequently do not
discover a stone by the Sound, tho' it be
present. - Neither wou'd I trust to Injections
made into the Bladder; it was proper
that these shou'd be continued, & Dr:
Butter has contrived an Apparatus for
the purpose; it consists of a bladder
intended to be filled with Lime water,
& Soap &c., & it is put between two boards,
by which the patient can press out the
Liquor. The Bladder has two pipes fitted
to it, one for the Male, another for the
female; it is introduced into the Urethra,
& in the female, it may reach the 
bladder, so here there is more room for
trusting the Experiments, but in the Male
it is attended with pain, which at last
becomes

88
becomes quite intolerable, so that this Practice
cames to be laid aside. In the female
however, if we cou'd find a proper Solvent,
we might try it, as it has a better
chance than in the former way, where
the Stomach & constitution are at the same
time much injured; and I will venture
to alledge that if you were to take any
given number of Calculus patients, suppose
100, & trust the one half of them
to Lithontriptic Medicines, and on the
other half perform the operation, more
wou'd die of the Medicines, than in consequence
of the Operation, while perhaps
not one of the 50 had received a compleat
cure; many of them might grow
easier, but that might have happened
without the use of any medicines at all
owing perhaps to the bladder growing Callous, the Coats
becoming thicker & feeling less pain.
At

89
At our last meeting, I alledged, that whether
we can tell the reason of things, or appeal to
experience, we are so far from knowing
any remedy which possesses the power of
dissolving stones already formed, in the
Bladder, that we can't clearly shew that
our remedies possess the power, of preventing
the generation of Calculus; & therefore
as the remedies commonly employed
hurt the Constitution, I alledge that the
Operation is the best resource, & this ought
to be done early, for the stone in the 
bladder affects it in a way that comes
to be dangerous, occasioning a contraction
& thickening of its coats; the Prostate Gland
may also come to be affected, & the health
suffers greatly, so the danger of the Operation
is increased where the Calculus
has lodged long, & the Inflammation from
the

90
the Operation, & exposure to the Air, comes to
be more dangerous. I next mentioned the
particular circumstances by which we judge
with a degree of probability that stones are
lodged in the bladder; but none of the
Symptoms are absolutely certain, so the
Surgeon ought first to feel the stone by
a Probe of a proper shape, introduced
within the cavity of the Bladder; this probe
or Sound ought to be of the hardest materials,
as Steel; Surgeons use a common
instrument for drawing off water, made
of Silver, for this purpose, but it is better
to use a harder metal, which communicates
the Tremor more sensibly to the hand.
We make the Instrument not only smooth,
but we accomodate the Shape to the passage
of the Male. _ Now the method of employing
this Instrument is perfectly simple - The
patient

91
patient is to be laid on a table nearly of the
usual height with his shoulders raised
a little with Pillows, to slacken the parts,
& to bring the Stone forwards towards the
neck of the bladder, then the Surgeon places
himself before the patient, betwixt his knees,
or he may stand on the left side if he be
right handed. Now if you never had
seen this Operation done, you might probably 
introduce the Instrument right,
that is, as the Sound is adapted to the
passage, by keeping it in that direction;
but Surgeons have got into the Absurd
practice of entering the Instrument in the
reverse way, till they can get no further,
when they make a turn; now this is attended
with no advantage, the patient
suffers in turning the Sound round, & the
Surgeon may in that manner twist the
passage, especially if he does it with an [illegible]
of

92
of dexterity, turning it quickly round. _ The
Instrument ought to be made warm by
laying it warm water, then wiping it,
& rubbing it over with a Oily substance,
as Butter or [Axunge]; for the thin Oil
runs off before it gets into the Bladder.
In introducing it, the two hands ought to
cooperate, we press in the probe with the
one hand, & drawing the penis upon
it with the other; there is always a contraction
at the neck of the bladder, owing
to the bulk of the Prostate gland, & the Muscular
fibres collected into the Sphincter,
& here if the Surgeon feels a resistence,
he generally introducted the fore fingers of
the left hand into the Rectum, as is said,
to raise the point of the Instrument,
but this is better done by depressing the
handle; so that the only use of the practice
is that after we are within the Rectum,
we

93
we draw the Sphincter of the Anus to us, strech
the Urethra, & make it straight; but the
effect is not equal to what Surgeons expect,
and the principal rule is to work gently,
& to keep the point in the very axis of
the passage, for the end of the probe may
be resting against a fold after it is within
the cavity of the Bladder. In the Adult body,
the mouth of the Urethra is not the lowest
part of the bladder, so that by turning the
Instrument backward, we may strike the
stone; but if we still miss finding, we introduce
the finger into the Anus, that
with the point of it, we may press up
the stone, & you can generally reatch with
the finger above the Prostate Gland. If
still the stone is not felt, let the patient
alter the posture of the body, stand up,
lean forwards, or rest upon his knees, leaning
forwards, which brings the Urethra to be the lowest
part

94
part of the Bladder & throws the Stone upon it.
After the Surgeon comes to rub upon a hard
substance, & feels a tremor, he concludes that there
is a stone, but let him be cautious, for a
few grains of Sand may give the same
sensation, so he shou'd shift the point of the
probe, & if the stone is of considerable size,
he feels it after making some motion, nay
one may be able to guess the size of a stone
from Sounding. I suppose then he is satisfied
of the presence of a stone; before he
proceeds to operate, especially if the patient has
been subject to Nephritic complaints, & the
stone seems to have begun in the kidney,
and to have descended to the Bladder, he ought
to put the patient on a course of Diluent
Medicines, or some of these called Lithontriptics,
in order to wash off Sand or small gravel
Stones from the cavities of the kidney,
and he shou'd attend to the season of the
year

95
year, avoiding the Extremes of Heat & Cold.
The propriety of the Operation being determined
upon, Let us now consider the various methods
which Surgeons have attempted or proposed.
I shall give you a general description of
them first, & after that, choosing what shall be
the most fit, shall perform it, & without
attending to the order of time, shall explain
them in a way that may very easily be
understood.
Celsus's method
Before Anatomy was much cultivated, in
the days of Celsus, they attempted to extract
the stone from Children, by introducing one
or two fingers of the left hand into the
Intestinum Rectum, & pressing the stone forwards,
(the patient being put in a proper
posture for the purpose, set on the knees
of another person, & the knees raised;) to the
space between the Urethra & the bones of
the Os Ischium; the Surgeon next made
a

96
a Crucial Incision upon it & brought it in
view, then it was turned out with the
finger, or a Scoop. - Now surely, as we
are cutting in this manner at random,
we cannot see what parts may fall
between the stones & the teguments; therefore
this method is not at all to be thought of.
Afterwards, a safer method was proposed.
The patient being put in a proper posture
and secured, a furrowed probe, bent like
a sound, was introduced into the cavity
of the bladder, then the Surgeon entered the edged
point of a double edged knife or Lancet into
the Urethra, where it makes the [?ust] from
the Perineum to run up into the Bladder, or
where we lose it; he then laid aside his
Lancet or knife, & run a Conductor upon
the furrowed Probe into the Cavity of the
Bladder; & having now no further use for
the furrowed probe, he took it out, and
introduced

97
introduced another Conductor upon the first
into the Bladder, which was forked at
the point in order to run upon it; the
one was called the Male, the other the female
Conductor. The Next step in the Operation
was to tear open the passage, to
make it big enough to allow the Instrument
to enter, & that now is the meaning
of having two Conductors, the Surgeon by
opening these; tears open the parts as far
as the Neck of the bladder, then introducing
a pair of forceps along the Conductors,
& withdrawing the Conductors, you search
for the stone & extract it. This is called
the Operation with the Greater Apparatus,
and it is no doubt an improvement upon
the former method, because we are led
certainly to the Cavity of the Bladder. But
we wou'd not think of following it,
for

98
for first we tear the parts instead of cutting
them, and a laceration must make a more
dangerous wound than an incision, & we
tear open more of the Urethra than is necessary,
for the opening wou'd be equally
large supposing half an inch has been tore
as when 3 or 4 inches of the Urethra is
tore open. Hence the method, & every improvement
of it, as cutting upon the Urethra
with a knife, (for still the several blood
vessels entering the Ball of the Urethra
are cut,) must be discarded.
Lateral Operation
In the end of the last Century, a very material
improvement was made on the Operation
of the Great Apparatus by Frère
[Calme] Jacques an Ecclesiastic; he proposed
& practised an incision made into the
side of the Urethra very near to the Bladder,
or he introduced what is call, on that
account, The Lateral Operation; he continued
the

99
the Incision thro the neck of the Bladder,
and then dilated it with the proper Instruments,
& this method with various
improvements is now commonly practised.
But of late years, from our tearing or
cutting the Prostate Gland, & on being
in danger of tearing the Ducts of the Vesiculi
Seminalis, while at the same time,
the opening is confined to the Cervix of the
bladder itself, between the Urethra & membrane
of the Ureter, avoiding the neck of
the bladder entirely. I show you Instruments
proposed for the purpose by Foubere
a French Surgeon, as they have been joined
by Monsr. Thomas. We make an incision
into the Skin with a common Scalpel,
then we make the opening between the
Crus of the Penis & the Bulb of the Urethra,
in the very place I shewed as proper for
puncturing the Bladder of the male, or
nearly

100
nearly in the place where we perform the common
operation of Lithotomy. We then take
this compound instrument, consisting of a
Lancet at the point, & in a groove, a knife
which we regulate by the handle; the third
piece is a wedge-like instrument, which we
call a Gorget, & which supplies the place
of the Old Conductor; now that is fixed
to the other two Instruments or pieces, & the
Lancet is supposed large enough to carry
with it the Knife & Gorget. Suppose the Lancet
within the Bladder, I take hold of the
Gorget with my left hand, & with the right,
I withdraw the knife, by which I cut a sufficient
hole in the body of the Bladder,
ready for conducting the Forceps; & this
method Foubere practised with success.
But with all the precautions we can take,
this method will never come into practice,
for it requires a considerable degree of
distension

101
distension of the bladder, whereas in Calculous
cases of some continuance, the Bladder is
very much contracted. But next suppose, a
sufficient distension of it, which may be known
by the quantity of Urine the patient can contain
in it, & pass at one time; the operation
is rather too nice for most Surgeons, who
may hit the bladder perhaps in the wrong
place; but supposing an Incision made,
in a proper place, the moment the Surgeon
draws out the Instrument, it collapses, the
wound of the bladder slips away from
the wound in the teguments, & the Urine
insinuates itself into the Cellular membrane,
& spreads round the bowels in the cavity of
the Pelvis, and we ought not to add to
the danger of making incisions of considerable
size in the body of the Bladder,
for the admission of the Air; besides, there
is soon enough in most cases for the
extraction

102
Extraction of Stones of very great size by the
Lateral Operation, and we do not find in fact
that the Ducts of the Vesiculæ Seminalis ever
are divided, & wounds in the Prostate Glands
are not dangerous.
High Operation
One more method only remains that I think
needs to be mentioned, for I put out of the
question a project of some, of cutting into
the bladder at the side of the Intestinum Rectum
from behind, which is attended with danger,
and no advantage; so the only other, &
that which I shall show, is what is called the
High Operation, where the Incision is made
above the Os Pubis. First the Bladder must
be distended; some have proposed to do this
by throwing in Injections with force by
means of a Syringe, but is better to do it
by tying up the Penis, & letting the Urine collect,
nay the patient ought to accustom himself
for many weeks before, to retain the Urine as
long

103
long as possible, that he may dilate the
Bladder considerably, & we judge whether the
dilatation be sufficient by observing the quantity
of Urine discharged, & by feeling the
fore part of the bladder, for we may distinctly
press it all round, provided we relax the
Abdomen properly. _ As throwing in water
wou'd [incom????] us a little, I shall blow
in Air. The patient is laid on a table with
the shoulders low, that the parts may be
fully on the stretch; & the Surgeon begins his
Incision in the very middle, cutting from the Os
Pubis up towards the Umbilicus, & his first
Incision ought to be of considerable length,
perhaps 3 or 4 inches, to give abundance of room.
After dividing the skin, I next cautiously cut
thro' the Cellular substance, then I seperate
the Recti & Pryamidales Muscles. You know the
Pyramidales are sometimes wanting. I next
meet with the Cellular substance that is on
the

104
the outside of the Bladder, after this, I am absolutely
certain of going into the Bladder; for
that purpose, I use a sharp-pointed concave
edged knife, directing the edge of it upwards,
and putting the fore finger of my left hand
on the back of it, which is the safest Conductor,
& I can at pleasure dilate the incision
upwards or downwards. I then introduce
the forceps, & feeling for the stone with my
finger, I readily direct the forceps to lay
hold of it & extract it. - Now this will
appear so very practicable, that at first sight,
one is really prejudiced in its favour; yet,
it has from Practice been almost entirely
laid aside, & I have a strong suspicion that
Surgeons have been right in doing so;
It has perhaps been done 100 times in
Britain, & I have a most distinct account
of the Operation done in this way by the
late Mr. Smith of Perth who cut more
than

105
than usually falls to the share of one man;
he had practised the Lateral Operation, seldom
under 4 years, & seldom above 40, & one
in ten only died, & at one time he had
cut 22 without loosing one. In the High
Operation, he had performed 18 times & of
that number, 8 died. He had the opportunity
of examining the bodies after death,
& he found the Bladder & whole bowels in
a high state of inflammation; and there is
more danger than Surgeons are aware of
from incisions of the body of the Bladder,
where the Air gets freely in; besides that,
the Bladder instantly collapses, & the wound
slips below the Os Pubis, and where the Inflammation
is considerable, there is even
a necessity of getting the Urine out this way
be means of a Canula, so that it is right
that the Surgeon shou'd know this very
way

106
way of doing the Operation, but as far as
experience yet goes, we return to the
Lateral Method in all its steps & improvements,
and first I shall give you a
notion of the Instruments employed.
We begin with tying the patient, tho' some
do not tie the hands till after the Sounding
is over, which is sometimes the most tedious
part of the Operation, & generally when the
sound is fairly into the Bladder, the Operation
is half done - So suppose the body
properly secured, & the Sounding performed,
the Surgeon next introduces a furrowed
probe, & endeavours to adapt not only the
Curvature, but the size of the probe, as
nearly as possible to that of the Urethra;
and we are not to imagine that it is more
difficult to introduce a large probe than a
small one, which is more apt to catch the
Rugæ

107
Rugæ, whereas the other stretches the Membrane,
and prevents Rugæ from forming. - As
the probe is to be withdrawn before the Operation
is quite finished, certainly we do
better than the French, in leaving the furrow
quite open at the end; for when it is stopped
at the end, it is not so readily withdrawn,
when the Gorget is introduced. _ After we
have introduced the Instrument, we give it
to the management of an Assistant, who
turns it over, if the Surgeon is right
handed, to the left side, or vice versa.
We then begin the External Incision, which
is to run betwixt the Crus of the Penis &
bulb of the Urethra, where they meet, & continue
in a slanting direction downwards,
to the Space between the Os Ischium and
Anus; and the convex-edged, or commence
Dissecting Scalpel is the best Instrument.
With this, we divide the Skin & fat, then
the

108
the Transversalis Penis, then the Levator Ani
with the Cellular substance within; after
that, the Surgeon introduces his finger at
the wound, & he can distinctly feel the
staff thro' the Membranous cavernous
substance of the Urethra, but he pushes
down to the part of the Urethra that is
membranous only, when he feels the probe
quite thin, for that is the part we ought
to cut; the cut is to be made with the
same instrument, or generally we take
a small knife. Sharps instrument is one
with Tow wrapped round it, which is
always troublesome, & we can make a
knife sharp at the point only; with this
I am to open the Urethra, by turning the
edge towards the furrow, & the back
toward the Intestinum Rectum, directing
it with the fore finger of the left hand,
so that we are in no danger of wounding
the

109
the Rectum, & when that is done, the Operation
has been performed in a most bungling
manner; nay I am so far from apprehending 
any danger, that I wou'd prefer
one double edged at the point, in order
to make a sufficient opening in the membrane.
We next, instead of tearing the
passage with a blunt Gorget, cut open the
passage, & for that purpose, there have
been various contrivances; some do it with
the knife, & we may do it very well with
the very knife with which we open the
Urethra, with the back turned to the furrow.
But we ought to accomodate our Instruments
to all Surgeons, for if the Surgeon is
harried, & turns the knife wrong, he may
cut down upon the Intestinum Rectum; so
we shou'd endeavour to put this out of their
power. An Ingenious French Surgeon, Lewis, has
attempted

110
attempted this; he introduces an Instrument
quite horizontally into the whole of the
Urethra, which has a grove in it, but
surely there is no need for the level that
is here added; then he takes a knife, and
entering it into the slit, pushes it into
the Bladder; the Incision is made always
in one direction. This is by no means a
contemptible instrument, but Lewis has
made his cut too much backwards. We
have known better contrivances than these
still. Here is an instrument of Frère Colmes;
we enter a [illegible] knife, which we can
regulate by turning the handle; it is introduced
into the furrow, and we thrust
it into the Bladder, then withdrawing
the staff, we open the knife, pull it back
again, & so make the incision, and in
reality Frère Colmes has cut several hundreds
in

111
in this way with great success, and it must
answer tolerably well. But we have still
a better Instrument, the invention of Mr:
Hawkins an ingenious Surgeon in London,
which is the sharpening about an inch
of the side of the Gorget, so that it cuts
as we push it in. The advantage of this
over Frère Colmes is that it makes way
for itself, while his only cuts as it comes
out, so may tear the Vesiculæ Seminales;
and the only objection I see to it is that
as the Gorget has to remain a considerable
time in the Bladder, in order to introduce
the forceps upon it perhaps a
second & third time, without any want
of Care; the Bladder collapses, the Bowels
fall down, or the patient by his cries
pushes them down, & the Bladder is cut
upon the Gorget. Now that can be remedied
with the greatest ease, by fixing
a

112
a blunt Gorget to the Sharp one, or making
a double Gorget with a nail to keep
them together; now we take the blunt Gorget
back about an inch, & holding them as
one Instrument, I enter the sharp one into
the Bladder, making the cutting side always
a little upwards, whereby I avoid altogether
the Seminal Ducts, as well as the Rectum,
and when the neck of the bladder is split,
I push down the blunt Gorget, & allow the
Sharp one to remain in safety.
I need not detain you with another instrument
of Le Cat, who makes a Gorget
with a knife fixed to it; but this shape
is more unfavourable than the former.
After we have got in, we lay hold of the
stone by the Forceps, & the very best kind
is the most simple; the blades do not
meet altogether lest they catch the coats
of the bladder; they are made a little hollow'd,
and

113
and teeth at the point. We make the forceps
for common use straight; it is alledged
that we need Crooked forceps, where the
stone is lodged in that portion of the
Bladder that is behind its neck, but
they are never to be used without absolute
necessity, and I hardly think that a case
will occur, where with an Assistant putting
his finger into the Anus, we cannot
lay hold of it; it is true, the inner coat
of the bladder may push out between the
fasciculi of the muscular fibres, & the
stone become encysted. Here is another
contrivance, which too is unnecessary,
it is a pair of Forceps, with a plate
of iron riveted into one of the handles,
the plate is perforated with several holes,
and a screw is made to answer them,
so that by turning the screw in any of
the different holes, you adapt them to any
wideness

114
wideness you please; after grasping the stone,
you turn the screw, & fix the Instrument, to prevent
the stone from being broke in extracting;
but it is better that the Surgeon regulate the
pressure upon the Stone with his hands; he
takes hold of the blades of the forceps wt: both
hands, & by introducing his fingers between
them, he prevents them from pressing too much.
Now after discribing this operation, you will
readily understand the method of doing it.
I begin with tying the Ligature. I make a
running knot about the Wrist, then I desire
the patient to put his hand upon his sole,
then I bring one of the turns over the foot,
and the other under it, & cross again at the
other side, then make a running knot.
I next bring the body over the edge of the
table, raising the Shoulders. I then introduce
the staff, which I give to an Assistant,
who takes it with his right hand, & turns
the

115
the grooved side towards the Os Ischium, whilst
with the left hand he supports the Scrotum,
and the other Assistants manage the knees
& feet. - I now begin the incision, the place
of which is easily found, and this Operation
is really so easy, that I cou'd do it in
the dark as well as in day light, because
I am guided by the feel, where the Crus of
the Penis joins with the Urethra, & I am
sure that the inner incisions cannot go
higher; but I may make the outer a little
higher, tho' I have heard of one case, where
the Operation was begun so high, that the
Testicle dropt out of the Scrotum. It is
of advantage however that the incision
be 3 or 4 inches long, even where the stone
is small, and in doing the Operation,
the Surgeon is to study his own case, he
is to place himself so that his hand does
not shake; the French put their knee to ye. ground.
We

116
We make the next incision thro' the Tranversalis
Penis, and dividing the Muscles,
the Crus of the Penis presents. I then cut
thro' the Levator Ani. Often some small
blood vessels pour out blood, and I
have seen a necessity in some cases of taking
these up with the Needle. We now feel for
the staff, & turning the knife towards it,
make the incision thro' the membrane of
the Urethra, & it is material that we
shou'd divide the Membranous part fully,
(least our instrument shou'd slip on the
outside of it) till we can feel the staff
perfectly bare, & there is room to admit
the point of the finger. We now take Hawkin's
Gorget, & introduce the ballon of it into
the furrow of the probe. Now Surgeons
commonly take the staff from the Assistant,
that their two hands may co-operate,
but it wou'd be better to let it alone,
and

117
and to guide the Gorget with the forefinger
of the other hand into the Grooves, only
the Assistant must draw the staff towards
him till the concave part presses against
the Os Pubis, whereby all the parts
are made slack on the outside. Having
thus introduced the Gorget into ye. Bladder,
we have no farther occasion for the Staff,
so we draw it out, and enter the Forceps
upon the Gorget, with which we search
for the Stone; if you feel the stone at the
neck of the forceps, you move the Leg
that is uppermost, and if the stone is
not raised sufficiently, you introduce the
finger into the Anus; you are to remember
the three Diameters of the stone, & not
to grasp it fast, but to take a moderate
hold of it, that is may turn round, &
the end present, we even assist by
introducing

118
introducing the finger; after you have got
it into the proper direction, you turn the
blades towards the Os pubis & Rectum,
to defend these, & pulling down, we work
very gradually, as in the delivery of a Child,
pulling downwards & backwards, because
there is most space that way. - Next
suppose that the stone has broke, or that there
are a number of small stones; Surgeons
generally only repeat the introduction
of the forceps, till they are all extracted,
which is attended with great pain, &
the patient in such cases generally dies;
if therefore the stone has broke, after the
Surgeon has brought away the larger pieces
with the forceps, for the smaller, we
use a spoon, or if they are numerous, &
very small, we wou'd set the patient
on his feet, introducing a large pipe of
a

119
a Syringe, throw up water & Oil to Stifle
the Bladder, stopping the wound till, the
small stones have time to fall to the bottom,
whereby we may wash them all [out?h???].
We then lay the patients Legs together,
put some dry lint upon the wound, & cover
all with a Poultice, to lessen the Inflammation;
thus keeps out the Air, & sucks up
the Urine, so is attended with manifest
advantage. To prevent the cloths from being
wet, you roll a sheet, & put below the patients
body; and some tough griezy
substance may be rubbed on the skin
round the edges of the wound to prevent
excoriation.
In the present way of performing the
Lateral Operation of Lithotomy, we trust
a good deal to the Assistant in directing
the Convexity of the Staff towards the
Os

120
Os Ischium, the Groove being in the back
of the Instrument, so I wou'd rather make
the groove on the side of it, when the Assistant
has merely to hold the staff quite
straight. I wou'd next cut off the left or
blunt side of the Gorget, which is in danger
of tearing the parts, as the Vesiculæ
Seminales, on pulling it back. Next, in
order to be certain of going into the Bladder,
I wou'd make a large button to
enter the furrow, which instead of being
round, may be made flat. _
If the stone has made its way into
the beginning of the Urethra, & has remained
there for some time, & increased
in size, we cut directly upon it, & if
we feel it distinctly, we scarcely need
the direction of the staff; but if the stone
be very small, tho' it be too large to be
pushed farther forwards, we take the
Assistance

121
Assistance of a Staff. If by touching it, we
cou'd throw it back into the Bladder,
perhaps it may be better, as it may be
difficult to lay hold of it in that place,
after making the Incision; but we are
never to use force here, for if it has remained
any length of time, we cannot
push it back, without doing material
injury to the neck of the bladder.
Suppose next that a small stone, after
beginning to form in the Bladder,
but got forwards a certain way into the
Urethra, & then stops; if we can't bring it
the whole length by pressing gently with
the hand, (the patient at the same time
making the effort of emptying the urine,
& having previously thrown in some
oily matter into the Urethra) it has
been proposed by Sanctorius & Wales
that we might introduce a hollow tube
into

122
tube into the Urethra till we touch the Stone,
then pass thro' it a pair of forceps
which open with a Spring, so that by drawing
back the Canula, the forceps expand,
& you endeavour to slip the blades between
the membrane & the surface of the
stone, then you push down the Canula
to grasp it, & endeavour to extract. Now
I am doubtful if you will be able often
to succeed with this Instrument, & you
can assist nearly as much by pressure
on the outside with the hand; in neither
way are you to use much force,
as the patient will receive more material
injury, than by the only remaining
way, the Incision. In making this,
reasoning merely upon it, we wou'd
think it best to cut directly upon it,
making the opening in the Skin, and
Membrane of the Urethra at the same place,
least

123
least when the Skin retracted, the Urine
shou'd get out under the Skin & be diffused;
yet experience shews that the last is a safe,
and as evidently the best method of Operation;
so we draw the skin strongly forwards, then
cut directly upon the stone & turn it out
directly by a probe, then we allow the skin
to slide back again, which confines the
Urine, or shou'd it get out, we next try
the pressure of the hand; if that still
is insufficient, you may introduce a
bit of flexible Catheter, & if all fail, the
last remedy is making the Incision of
the skin directly opposite to the incision
of the Urethra, & the patient is in no
worse a situation than at first.
We shall next suppose there is an
Incontinance of Urine in either fix, and
that the Medicines we have given have
failed

124
failed, and the relaxation of the Sphincter
of the Bladder seems to be the reason,
we are under the Necessity of mechanically
stopping the discharge, and in the Male,
instead of a bandage round the Penis,
we use an Instrument called the Jugum Penis;
I have caused this to be made of one
piece, which opens by its elasticity, and
I use a Screw to bring it to its proper
situation. I once thought of another Screw
to press directly upon the Urethra, but
I find that it is unnecessary.
If the same complaint occurs in women,
one of the best contrivances is recommended
to us by Heister, I mean a Ring,
such as is employed for the Prolapsus
Uteri, only we must bring it lower, so
as to press upon the Urethra; we stretch
the part by it, & if we wish to give
a pressure at a particular part, we
fasten

125
fasten to the ring a bit of Sponge,
which we introduce dry.
Next suppose the contrary complaint,
that the patient can't discharge her Urine;
After attempting relief by Bloodletting,
fomentation, Warm Bath &c., the Surgeon
endeavours to draw it off by a Catheter,
the use of which in the Male is already
known to you, we do it in the same
manner as the sound or staff. In the
female, we introduce A Catheter streight.
or nearly so, for it will be better to
use them gently bent, for when the
bladder is empty, the Urethra can be
brought to a streight line, yet when
it is distended, the Urethra is somewhat
crooked. I shewed you formerly
the method of sounding or of introducing
the Catheter in Women.
The

126
The Catheter is generally made with a
number of small holes, as being least
in danger of hurting the person; but you
shou'd be provided with others which
have a large opening at one side, for
I have repeatedly seen, in Calculous cases
in particular, such a great quantity of
slime in the bladder, that it cou'd
not pass thro' the small holes. _ Suppose
next that the Surgeon finds it
impracticable to introduce the Instrument,
he is next under the necessity
of puncturing the Bladder, and the only
difficulty is to determine the proper place.
I formerly shew'd you that it was possible,
& easy, to make a puncture into
the Bladder at the very place where
we begin to make the incision for the
Lateral Operation, & where in Fouberes
method we finish the [Operation] Incision, that
is

127
is near to the neck of the Bladder, or
at the lower part of it. I prefer this to
other Methods that have been proposed.
The most common method was to
introduce the Staff as far as possible
into the Urethra, suppose near to the
neck of the bladder, then the Surgeon
cut in upon the staff, as if he was
going to perform the Lateral operation.
But now, instead of using the Gorget,
Heister & others advise to take a Trocar,
& to follow as well as we can the
natural passage; now in this attempt we
cant follow the Urethra exactly, but cut
and tear it, and with it, the Prostate
Gland & Vesicula Seminales, and we
thus cut & tear the parts which are
in a diseased state, so that this method
has been laid aside by Sharp
and

128
and others. Sharp makes an incision above
the Os Pubis thro' the Skin, then the Trocar
is passed; but when you have drawn
off the water, the bladder slips away
from the Instruments, and if we keep
the Canula within the Bladder, we may
by pushing it too far, press against
the Rectum, and Sharp gives us a Case
where it was pushed thro' the Rectum.
If on the other hand it is too short,
the bladder slips off from the end of it;
or if no Canula is used, the Urine
gets in to the Cellular substance.
But instead of this, if we make the
Puncture of the Outside of the Prostate
Gland, we are sure of hitting the Bladder
with as much safety as above the Os Pubis,
and we have the advantage that the
Urine does not distill into the Cellular substance,
and

129
And if we have a Canula, we readily fix
it in its place, and the Urine runs
as fast thro' it as it gets into the
Bladder, & we may preserve it here;
for several days together till the Inflammation
at the neck of the bladder,
by the continued use of remedies, has
subsided. We need a common Lancet
or Scalpel to cut a hole in the skin,
an the Trocar with its Canula, and
a flexible Catheter, which is an improvement
on the former one; it is made
by twisting a bit of wire, & covering
it with a bit of linnen spread with
Plaster, as if you were going to make
a common Bougee, and this can remain
in the Bladder with much
greater safety to the patient. In entering
the Trocar, to prevent any mistake,
we

130
we may introduce a Catheter into the
Urethra as far as the neck of the Bladder,
and we pass the Trocar at the breadth
of a finger of so from the side of it,
pushing upwards, and a little forewards,
till we are sensible from the want
of resistance, that we are within the
cavity of the bladder, and taking away
the Canula, we leave the soft flexible
Catheter, & support it with a bandage
and a Circular round the waist. We
allow this to remain, till, by stopping
the end of it, and allowing the water
to collect within the bladder, we find
it can pass the natural way.
Next suppose the same complaint in
women, & that we can't even in them
draw off the water by the Catheter,
which you are sensible will happen
less

131
less frequently, from the greater wideness
and shortness of the passage, and the
want of the Prostate Gland, which
mechanically presses upon the neck
of the bladder. You recollect the manner
of introducing the Catheter in the
female, under the Clitoris, between the
Nymphæ; and if you are not allowed
to see the Urethra, you prevent the Instrument 
from entering the Vagina, by
applying the forefinger. _ There are the
same reasons as in the male for
avoiding the puncture above the Os
Pubis, & here the reasons are still stronger
for puncturing it in another place,
as we can not only do the Lateral puncture
here by passing the Instrument
at the side of the Vagina, & within the
Crus of the Clitoris, but there is still
a better method to puncture it from
the

132
the Vagina, for not only the whole Urethra,
but a large share of the bottom of the
bladder is immediately connected to the
Vagina; so we can cut or puncture
from it into the cavity of the Bladder
with certainty. _ We take a Trocar of the
common length, or we may have one
for the purpose; we make the perforation
in a slanting direction, puncturing
the membrane of the Vagina
first, & running the Instrument up
between it & the membranes of the bladder,
& having got into the Bladder, we can
as before, withdrawing the Trocar, enter
a flexible Bougee thro' the Canula, &
leave it within the bladder.
Now after having shown you that the
Bladder pushes down in females, you
will observe that the same thing happens
in the Male, only you do not
see

133
see it for the situation of the parts. This
is to be well attended to, because from
it, we determine the seat of the disease.
When the Bladder is distended, I find
that in a full grown person, I can pass
the finger higher than the Prostate Gland,
which I have repeatedly found more
irregular & harder upon the one side, than
on the other, or in a schirrous state;
and therefore if a tumor forms about
the bottom of the Abdomen, with regard
to which Surgeons may be divided, we
can determine the part, by placing
one hand above the Os Pubis, & the other
within the Rectum, where we will find
the general pyramidal form of the bladder
& be able to make the pressure of one
hand affect the other. Where the Urine
is passed with difficulty, and retained
in

134
in the bladder, the coats are apt to grow
thick, and contract adhæsions to the
neighbouring parts, hence the patient
is only able to discharge a few ounces
of water, yet the tumor appears very
large; from the top of its tone, the
emptying comes to be at last nearly
a running over. I know that in such
cases, the Operation of Sounding shou'd
be performed more early & frequently
than common, as it gives a great
relief, especially in the beginning.
Calculi in Women. Next suppose there
is a stone in women, and we are under
a necessity of taking it out by Operation.
If in Man, notwithstanding of the neck of the
bladder being surrounded by the Prostate
Gland, & the Ducts of the Vesicula Seminales
enter

135
enter thro' it into the Urethra, we prefer
the Lateral to the high Operation, we wou'd
do so still more readily in women, as we
wou'd prefer the Opening the bladder
where the Urethra comes out of it, to the
incision above the Os Pubis, & the only
point to be settled is with respect to the
making the incision, about what place;
we may do the Lateral operation as a
man, within the Crus of the Penis, avoiding
the Vagina; but tho' this is
practicable, yet it is easie for Surgeons;
& nearly the same thing for the patient,
to begin the Incision at the very extremity
of the Urethra, when the Surgeon sees the
direction of the cutting instrument, and
the only danger is in cutting the neck of
the bladder, the wound in the urethra
healing up very readily, nor will cutting
the

136
the interior part occasion an incontinence
of urine. The end of the Urethra in Men
has a true muscular power, but in
women, the urine is chiefly confined
by the neck of the bladder, so we wou'd
still open the Urethra, which in women
is not more than two inches in length.
The only other method is the making an Incision
from the Vagina, to which Surgeons
seem rather to be led by accident, as we
find in [illegible] that a stone worked
its way from the bladder into the Vagina,
and Gouch taking the first made such
an incision, & the patient was cured in
three weeks; yet I wou'd not recommend
this operation, for the Urine may keep
the part fistulous on account of the thinness
of the membranes, & distill into the Vagina,
which wou'd be a terrible accident; whereas
at

138
at the sides, there is a thickness of fleshy
parts that unite readily. - I wou'd
say nothing of the very cruel methods
that have been practised, the forcing
open the Urethra with a blunt Gorget,
or the old Conductors, the making a
cut being much better, so we wou'd
confine ourselves to the division of the Urethra.
We are directed to introduce a straight
probe into the Urethra, made nearly the
length of the Urethra in women, then
push down a double edged knife or Lancet,
to open both sides of the Urethra, and
drawing back the Lancet, pass along the
probe the forceps into the bladder. Now
why cut both sides of the Urethra, it opens
wide enough in men when only one side
is cut, so one cutting blade is sufficient,
but I imagine the sharp Gorget is a
better

139
better Instrument, it makes the incision
with equal care, & by means of the Gorget
we readily conduct the forceps into the
cavity of the bladder; so with this instrument,
conducted by any common staff,
or with the instrument for making incisions
in Abcesses, or with a larger one,
that the hand may be out of the way,
and holding the staff laterally, we are in
no danger of cutting the Vagina. I may
use the blunt Gorget alongst with the Sharp
one, that I may do no mischeif with
the Sharp one; and we may put out of
the question altogether the instruments of
Frère Colme, the sharp Gorget answering,
cutting as it enters, & with it, the Surgeon
knows when the neck of the bladder is divided,
& immediately stops when he is sensible
of the want of resistance.
Cæsarian

140
Cæsarian Operation. To finish the
Operations proper for the female sex, I
shall offer a few things with regard to
this. _ You recollect the situation of the
Uterus with respect to the Bladder
& the Rectum, that it is between them;
and you remember that the whole body of
the Uterus is covered by the Peritoneum,
and in pregnancy the same thing still
holds true, the peritoneum remains still
over it, the Ligament opening, & allowing
of the gradual extension of the Uterus, so
that they come to be much narrower in
the last months of pregnancy. - If then
it be necessary to cut into the Uterus for
the extraction of a Child, as to perform the
Cæsarian Operation, the first step is to
make an opening into the cavity of the
Abdomen

141 
Abdomen, and the second is to go into the
Cavity of the Uterus. Now, if a woman
dies suddenly in an accidental way, we
endeavour to save the child by making
an incision as quickly as possible. But
suppose that the Child cannot be delivered,
and that from some straitness of the
natural passage; before you undertake
the Operation, you must carefully attend
to the cause; if ever the women had a
child at full time, the operation is
unnecessary, unless some accident renders it necessary because, tho' the delivery be
necessary to save his life, it is better
to force the Os Uteri than to undertake
this operation, which is highly dangerous,
and we have been misled with respect
to it, by single successful cases. - It has
been performed here five times, & in some
of the cases, the patients were in their
ordinary state of health, yet every one
of

142
of them died. So we are not to undertake
it without the most absolute necessity,
and it is necessary to observe, if you find
the person of a moderate size & tollerably
well made, that sometimes the deformity is
confined to the Pelvis, but yet it is very
rare, and the presumption is that the
fault is in the softer parts, & the operation
has been done when the last was really
the case, so we ought to examine the
[illegible] a general shape of the Pelvis, introducing
the finger into the Vagina &
Rectum. - Now suppose this matter
ascertained, & that we are about to perform
the operation; Surgeons are not aware of
the whole danger, they conceive it to be
in the nature of the parts divided, whereas
it is very much owing to the admission
of air into the Cavity of the Abdomen,
and

143
and especially if blood remains in the
cavity, so we shou'd go on with the Operation
very cautiously. The place is tolerably well
chosen, it may be between the Recti Muscles,
tho' perhaps it is rather better to go on
the outside of the Rectus. We do not cut
thro' the Rectus, on account of the trunk
of the Epigastric artery. We choose the left
side if the patient is right handed;
having emptied the Bladder & Rectum;
we make out first incision thro' the integuments
& Muscles, & lay the Peritoneum
in view, then we stop till the blooding
ceases, & if a large artery springs, we
take it up, then we cut the Peritoneum,
which is to be done with caution, for
tho' the Uterus is contiguous,
yet some turn of the Intestines may have
got between, so we shou'd make a small
hole

144
hole, and slit it up very cautiously, then we
wou'd press close the Peritoneum to the Uterus
to prevent the air from getting into the
Abdomen; for cutting into the Uterus, we
keep the middle of it, where the vessels are
smallest, and tho' the vessels of the Gravid
Uterus are very large, they do not pour
out so much blood as might be expected.
We then divide the membranes of the
Child & take it out with the Placenta.
There is one step more to be taken, to introduce
the hand into the wound of the
Uterus, & with the finger to open the Os
Uteri, to allow the blood to be naturally discharged,
as well as that which comes by
the wound, & to pass downwards by
the Vagina. We next endeavour to close
the wound; I am not certain whether we
ought to make a slight stitch in the
Uterus

145
Uterus itself, drawing the sides moderately
together, & bringing the threads out at the
teguments. Having let all run out that
comes readily, we shut the wound in the
Abdomen, making the stitches near to each
other, which we find of effect in saving the
lives of Animals; but if we apprehend
that blood will be discharged, we leave
the bottom of the wound open, only covered with
a thick compress to exclude the Air, & we continue
the Antiphlogistic method during the
Cure.
Injections into the Urethra have been
practised by many in Gonorrhœa with a
light Ivory Syringe, with a conical shaped
point that shuts the Urethra entirely. Of
late, a machine has been used, made of
the Elastic Gum. The effect is this, that is it [I]
resists moderately to pressure; I can bring
the opposite sides to touch, but as soon as
I

146
I let it go, it swells to its former bulk;
if then I dip the pipe fixed to it in water
whilst it is compressed, & then remove the
pressure, it is filled quite full of liquor,
and we can shut it, by screwing on a bit of
Ivory, so that the materials of the Injection
may be carried in it in ones pocket.
Water does not affect it, nay we hardly
know of any substance that corrodes it,
we may carry the Oil of Vitriol in it.
Supposing the bottle larger, it wou'd answer
for giving a Clyster, and it may be made
so large as to contain two pints, or only two
ounces; but it has no material advantage
over the common Syringe.
I wou'd however be far from recommending
any of these Injections as necessary or useful
in the common case of Gonorrhœa, they by
no means answer expectation in what has
been

147
been alleged by many, of their effects; I am
to give a probable argument against them,
tho' it is not altogether conclusive; no two
Surgeons agree in their composition, some
use weak Solutions of Copper, others Calomel
suspended in Gum Arabic, & others Volatile Alkali;
and one evident disadvantage attending their
use is that the Venereal poison is conveyed
deeper into the Urethra notwithstanding all
the pains we can take to the contrary. If
a person is to use an Injection, he wou'd empty
the Urethra by passing his urine first,
but still some of the matter is carried deeper,
and it is the natural progress of the disease to
go deeper & deeper, & when the matter reaches
the bottom of the Urethra, the Gonorrhœa is
generally attended with a swelling of the Testicle,
and I wou'd observe that of late this is much
more frequent, merely because Injections
have

148
have been much more employed, even the most
innocent substances do harm, Oil has
been spoken oft, but it does not give releif,
it does not adhere to the wet Urethra.
A Solution of Gum Arabic will be found
to have a better effect, tho' still inconsiderable.
But shou'd the Injections succeed to our wish,
that by some Astringent power it stops
the running, we risque the tainting of the
Constitution, the matter goes more readily
into the mass of blood, for it is a
mistake to suppose that the Gonorrhœa is
not capable of producing Lues.
Next, there is often a doubling of ye. Skin
of the Penis, the Prepuce often suffers, as in
Venereal cases. &c. There is a sebaceous
matter secreted around the circumference of
the Glans, which becomes acrid & inflamed
the parts; & a wash of Sacch: Saturn; is
of effect in removing the complaint, but
especially

149
especially from the Venereal disease, the prepuce
grows thick & is lightened on the Glans.
If the straitening is before, the Glans with
it swells, & hinders the urine to be passed
with ease, the complaint is called Phymosci,
but if the Skin is straitened behind the Glans,
the complaint is called Paraphymosis, & here
the only difference is in the situation of the
Skin. Sometimes at birth the skin is found
straitened in this manner, especially before
the Glans; now take the most simple
Case, suppose the straitening natural, what
kind of Operation is necessary? You find
the practice recommended which religion,
or superstition introduced, from the false idea
that any part cou'd be hurtful to us.
We are directed to draw forewards the doubled
skin, & to cut off a circular portion of it;
but it is difficult to perceive the necessity
of it almost in any case, as it is evident
slitting

150
slitting open the side will answer all the
purpose, the skin is only tightened at the
anterior part, there is the tightness of a
circle at one place, & cutting the circle,
the whole becomes loose, so that a want
of reflection has led to advise the compleat
circumcision; after dividing the
side, you may draw back the skin, & keep
the straiten'd portion assunder that the void
may be filled with new flesh, which
soon gets looseness, so as to be moved at 
pleasure. - Next suppose a Venereal Cause,
the same thing applies, the skin was
formerly wide enough, & is now grown
strait by the disease, & suppose the usual
remedies to fail, I have sometimes run
the vien of the Penis opened in imitation
of Coupes, but this is dangerous, on account
of the Nerves, & has been proposed
more

151
more from Theory than experience of its effects,
so we wou'd use Leeches, taking care that the
Venereal matter does not touch them,
lest chancres be produced. But suppose
the common method, bleeding at the arm,
the general antiphlogistic method, & the
injecting Ung: ☿ale under the prepuce,
as there are generally Chancres, & this seems
to have some effect, perhaps any greesy
substance wou'd have the same; suppose
I say that these fail, we slit open the side;
Some use a pair of scissars that create great
pain & torture, but at any rate, the Skin
is too thick there to be easily cut with
scissars, it is better to take a very small
furrowed probe, & to introduce it between
the Glans & the prepuce, & cut upon it, or
there may be other ways proposed, we May
introduce a small tube between the Glans 
and

152
and skin, then pass thro' it a knife, which
we push thro' the skin, and drawing it
forewards, we make the incision, & we ought
first to draw back the skin till we find
a resistence, only putting it forewards
when we have hold of the straitened
part; we make the cut on the side, avoiding
the under part for the frænum, &
the upper on account of the large vessels.
If the Pressure is Cancerous, we cut it
off, we slip in a thin Spatula between the
prepuce & Glans to stretch, & make the incision
on the Spatula. _
If there is a Paraphymosis, the best way
is to cut the double skin with a Lancet,
making a number of incisions where the
structure is greatest, for the ring straitening
the Glans, may even occasion a mortification
or Gangrane in the body of its -
We

153
We shall next suppose that the Penis is
affected with Cancer, and to save the life
of the Patient, there is a necessity of Amputating
the member. My father used long
ago to alledge that the method of Ruysh & of
Surgeons following him was cruel and improper,
the making the diseased part
drop off by Ligature instead of making
an incision, from the idea that as the blood
is discharged into the Cells, every Cell
wou'd pour out its blood in considerable
quantity. Now this idea was
that we ought to make the amputation
in the most ordinary way; we first
cut the skin, & drawing it back, we divide
the cavernous substance of the Penis, &
the blooding is so inconsiderable that
there is no necessity of stitching the trunks
of the Arterys supplying the Corpora Cavernosa;
we may use a bit of knitting
with

154
with a stick like a Tournequet in the time
of the operation, and if the principal Artery
springs, we bring it out & tie it up,
and if the Urethra is in danger of contracting
too much, we introduce a bit
of silver pipe, or softer kind of Canula
during the Cure.
The treatment of one complaint of the Urethra
still remains, which is commonly the consequence 
of Gonorrhœa. I have endeavoured
to prove formerly that sometimes ulcers form
within the Urethra. When they form on the
outside of the Glans, a chancre is produced,
& that is sometimes followed by a fungus
or wart. If then Ulcers form on the inner
side, the consequence may be the same.
Several Authors have denied this, & yet I
have not only seen the Ulcers within the
Urethra, but in consequence of them, the warty
substance

155
substance produced. But much more frequently
the Gonorrhœa gives rise to a straitness of
the Urethra in particular places, & thus will
happen frequently where there is chordee,
which is common in Gonorrhœa; the penis
is then distended & erected with pain, & sometimes
the hardness extends a considerable
length, but at other times it is confined
to a small spot, & if we can feel the swelling
outwardly, a small swelling on the inner
side will straiten the Urethra.
With regard to the Cure of [b?????d] or Stricture,
the both plainly prove, but especially the
Veneræ, that the Lues venerea had preceded,
but they are no proof that the disease is
present; we can cure them certainly by a
course of Mercury long continued; or suppose
that the patient in the beginning of
the disease, has taken the ordinary quantity
of Mercury, but the Veruca remains, he
may

156
he may allow them to remain without
dreading a Venereal Taint, at the same 
time, we shou'd endeavour to get rid of
them by cutting them off, or by destroying
them with Caustic or Pulsis Sabina, which
without particular pain, has a remarkable
effect in destroying them. _ Suppose next
that there is merely a hardness & stricture;
nearly the same thing may be observed,
and a principal remedy is in a milk &
vegetable Diet; at the same time, we may
rub on the part Ung: ☿iale, or apply an
Emollient Poultice, & we endeavour to open
the passage by the use of the Bougee,
which, I believe with Mr. Sharp, acts here
mechanically, & provided with give it a
proper consistence with a Conical Shape,
it is all that is necessary; it acts by mechanically
dilating the Urethra in a gradual
manner, without fretting it so much as to
inflame

157
inflame it, so that one made by the Receipt
Sharp has proposed, will be found to answer
as well as those prepared by Darran. I
refer you to an excellent Chapter on this
subject in the Cutical Enquiry; I am persuaded
that the observations there are just,
that a long continuance is generally necessary.
In introducing them, we are to work
our way slowly, not to push the instrument
with considerable force; we begin with
small Bougies, then with a large one,
wearing it at first a few hours, then lengthening
the space, to be guided by the feelings
of the patient, nor are we too soon to give
them ours, after 2 or 3 weeks wearing, we
may have made but little progress, yet
in some months, the Cure may be compleated,
Supposing that the Materials are not of any
consequence, Bougies may be made of
Leather varnished, which enters more
readily

158
readily, and will swell a little when heated
and moistened.
I shall next suppose that there is not only
some part of the Urethra that is constricted,
but behind the Contraction, that a
Fistula has formed, & that there is a burrow
made thro' the Membranous & Spongy parts
of the Penis into the Subcutaneous Cellular
Substance, & thro' the Skin, so that the Urine
comes to be passed in considerable quantity
thro' it; & generally passages of this kind
are primed behind the Scrotum, about the
Perineum, so that its most common term is
Fistula in Perineo. Now in what manner
ought this to be treated? In Practice it
is one of the most troublesom disorders,
and proper rules, either for examining it,
or further management of it, are not laid
down. We must take a view of it; And
first

159
first, it is very material to determine the
beginning of the fistula. Almost always you
will find that it is a single opening in
the Urethra, but that may be followed by
many openings in the External parts, & with
immense swellings; in several cases, I have
seen the Scrotum swelled so more than
the bulk of my two hands, & almost as
hard in some cases as a piece of Cartilage,
from the Urine diffused under the teguments.
Now in what manner are we to trace the
several passages, so as to reach all the rest?
Surgeons commonly attempt this with a probe,
but for the most part in vain, for like the
holes a rabbit burrows in the ground, they
are crooked & irregular, & the probe stops
at every turn; so that we find it more convenient
to trace the passages by injections
& by blowing in Air, passing at the same time
a

160
a flexible Catheter into the Urethra, & observing
where the Air gets into it, or we inject
Milk & Water, & that brings us to the communication
with the Urethra.
This is the first thing we are to look for,
for after we find it, we are to make a free
passage from that outwards, to prevent the urine
from stagnating & spreading in the Cellular
substance. We divide the Teguments by an
Incision, & cut into the passage that comes
directly from the Urethra. The patient now
in making water, discharges part by the
Penis, & part by the wound, the proportion
varying according to the degree of stricture
in the Urethra, & we shall be able to judge
of that by the stream; tho', when a great
part of the membrane is eroded, the Urine
may gush out at the wound, when perhaps
the stricture is in a great measure gone,
and perhaps the discharge made by the rupture
of

161
of the Urethra has removed the Inflamry: hardness.
Having made this free passage, we are immediately
to have recourse to a further incision,
but we have recourse to Bougies, which
we push past the communication between
the Urethra & fistula, whereby we have a better
chance of healing the fistula, & in this
way, it will often heal itself. But supposing
it not disposed to heal, we take care to preserve
the opening made in the skin, (which
is more disposed to contract than the internal
part,) [by?] a bit of Sponge Tent;
and whenever the patient finds an inclination
to make water, he draws it out, letting
the water pass freely, otherwise it gorges up
in the Cellular substance, & produces new Fistula;
or we may introduce a small pipe,
& fix it to the side by a bit of Plaster, thro'
which, the Urine may run freely, & when
we come to find that pressure is made
on

162
one the fistula, the Urine runs thro' the Urethra
in a considerable stream. We glue
together the fistula, by making an incision,
following it into the Urethra, & we may
perhaps hasten the healing of the fistula
by keeping a flexible Catheter introduced
within the Urethra, & the patient might
press upon the further end of it in time
of making his water; or at least, let him
endeavour by the pressure of his hand
to prevent the urine from passing thro'
the wound, which might dispose the passage
to become again Callous, or the fistula
to remain notwithstanding the Operation.
I have endeavoured to explain the treatment
of Fistula communicating with the Urethra,
here I shew you a preparation of one that
is very singular, for in the common Fistula,
the Urine spreads in the Cellular
substance, inflames every part it touches,
&

163
and occasions considerable hardness, but without
any remarkable degree of distension made
by the Urine, whereas here, we find a new
& Artificial Vesica Urinaria. The history
of the Case is shortly this; After a Gonorrhœa,
the patient had a difficulty in passing
his water, & began to observe swelling
with pain in the Perineum; the pain by
degrees abated, but the swelling continued to
increase, & in making water, by pressure
with his hand upon the tumor, he cou'd
discharge ℥viii or x; & by making the effort
in the common way, he again filled the
Sac. He continued in this miserable way
for 7 or 8 years without mentioning his Case;
at length Mr. Wood & I were called, when
he had all the Symptoms of what we wou'd
call a slow Nervous fever with a retention
of his water, nor cou'd any be discharged
by

164
by pressing on the tumor. Mr. Wood endeavoured
to pass a Catheter within the
Bladder, but in vain, the urine had squeezed
the sides together. We made an incision into
the Sac, & the urine ran freely out by
the fistula, but the symptoms of the fever continuing,
he died five or six days after the operation.
The bladder was much enlarged & thickened
in its coats, & there was a large hole in the
Urethra leading into the Sac. Had he recovered
of the fever, we proposed to introduce a
flexible Catheter into the Urethra beyond
the fistula, which we saw distinctly, & to
have endeavoured to heal up the wound,
& there was a sufficient thickness of the teguments
to have closed it firmly
Hydrocele

165
Hydrocele. We now come to speak of the
various sorts of this disease with the method
of Cure.
The first sort is a diffused Dropsy under
the skin of the Scrotum communicating
with the whole Cellular substance of the
body. In this case, an operation is only
needed in the part for its dependent
situation, for if we raise the Scrotum, &
make an opening in the foot, we can discharge
the water, & the manner of doing
this will be considered when speaking
of Anasarca in general.
Next there is a diffused Dropsy in the
Spermatic Cord, or water may be confined
by the covering of the Cord, without spreading
at first into the neighbouring Cellular
substance. Of this kind of Dropsy
however

166
however there are scarcely above a dozen of
examples in late writers of credit. We distinguish
the complaint by the size & softness of the
Cord, the want of a free fluctuation, & that
it keeps nearly the same size & shape in
different postures of the body, whereby it is
distinguished from the Varix of the Spermatic
Cord veins. - This too requires that the
water be let out by puncture & Incisions.
Next, the water may be confined in natural
Cyste, formed by disease, in every part of
these organs, even within the Tunica Albuginea,
tho' this is a rare case
Next, there is a Hydrocele depending upon
the original situation of the Testicle the process
remaining open, so that if the patient
labours under Ascites, this will produce
Hydrocele, or suppose that the Hydrocele
shou'd throw out a vast quantity of water,
it

167
it may be the Cause of Ascites; but this too
is a very rare complaint. We distinguish
it from the passing to & fro, according to
the situation of the body.
Next, you may suppose Cysts to form, shut
bags, without any communication, depending
perhaps on an irregular union of parts
soon after birth, as if the process remained
open in particular parts, shutting perhaps
below, & then again at the rising; or a Hernia
may happen, the peritoneum be pushed
downwards, & the Sac remain straitened
at the ring, & shut & leave a bag beneath,
which may come to fill with water, tho'
I cant produce an instance of either of these.
There is another kind which does happen,
a Bag grows from the Tunica Albuginea
or Epididymis, quite shut, & containing
water, or the water may come to fill the
cavity of the Tunica Vaginales, & yet on
opening

168
opening the tumor, we do not find the Testicle
within the Bag
Two Species still remain, & one of these by
far the most common, occurring in 99 cases
of 100; it is the distension of the Vaginal
coat, where the water collects in it. - The other
has been denied by some Authors, as Sharp,
but without reason, for I have seen more
than six examples of it; it is a preternatural
Encysted Dropsy of the Spermatic Cord, a large
bag, perfectly shut, filled with water, & requiring
the same kind of treatment as when the
water is contained in the Vaginal coat;
so we wou'd chiefly attend to these two species,
or if any of the others occur, if we know the
treatment in these two, we apply it to them.
Now by what marks do we distinguish the
most common kinds of Hydrocele, that of
the Vaginal coat -
First, it almost always begins to increase
very


169
very slowly, tho' sometimes an accident gives
occasion to a more sudden dilatation. It is
filled with pure water, & does not give pain
to the patient. After it acquires such a bulk
as to produce uneasiness, we find that the
Testicle is concealed by the water every where,
excepting when the Spermatic Cord enters it.
We next know the disease by the pellucidity
which is generally to be observed, tho' this
mark is not to be depended upon, as the
water may be bloody; besides, Hernia,
if the Intestines be concerned, are transparent;
but we here feel the fluctuation
of the fluid, & we perceive the Spermatic
Cord unchanged between the Testicles; and
the use of the muscles, & the posture & situation
of the body, do not alter the tumor,
whereas, in whatever manner the Hernia
may have begun, the tumor alters its situation
according to the posture, & we can
in

170
in general replace it in some measure wt:
the hand; we are sensible of air, & we
fill the tumor running up into the Belly;
& besides, the Hernial tumor is formed all
on a sudden, & begins at the rings of the
Abdominal Muscles, & goes downwards,
whereas in the Hydrocele, the swellings
begins from below, & proceeds gradually
upwards.
The other kind is distinguished by our feeling
the Testicle distinctly quite round, generally
under the tumor, not always, for in some
cases the swelling pushes down lower than
the Testicle. This distinguishes it from the
Hydrocele of the Vaginal coat, & we distinguish
it from Hernia by the marks I
have mentioned.
Supposing then the nature of the disease understood;
here, as in other cases of Encysted
Dropsy, we can do little towards a Cure
by

171
by Medicines, or External Applications; yet
sometimes from lucky circumstances these
succeed, or nature without their assistance
here performs a Cure; thus I have known
three instances, where the operation was
intended to be performed, but the patients
insisted for a delay, & tho' the tumors were
as big as a goose egg in a few months
they went away; but this happens so
very rarely, that there is little encouragement
for making trial of such remedies
as may hurt the constitution; we may apply
a weak solution of Sacch: Saturn:
mixed with spirits or Vinegar, & if this does
not succeed, we have recourse to Surgery if
the Constitution will admit of it, & at any
rate if the Tumor has grown to a great size
we must of necessity do the operation.
The Cure is either Palliative or Radical;
In the first, we have it in view merely to
draw

172
draw off the water, and the method of doing
this is very simple; we need a common
Lancet, & a round Trocar, or rather a Lancet
shaped Trocar, which enters with the utmost
ease, & by the narrowness you readily avoid
the vessels; we are also provided with
a probe, & the patient is laid upon his back,
with his feet over the edge of a bed, & a
pillow placed beneath the Scrotum. The
next step is to streatch the tumor; with my
left hand upon it, I make it as long as
I can to increase the distance between the
lower parts & the body of the Testicle,
that we may be in no danger of wounding
it in the operation. Next I examine the
course of the Vessels of the Scrotum that
I my avoid the accident of blood getting into
the Sac. With the Lancet, I only make
a Cut in the Skin, not bigger than if I was
letting blood. If I do not use the Lancet,
the

173
the Skin is pressed in with the Trocar, & plays
in all at once. I now look within the
orifice to see that no blood vessels present,
and taking the Trocar, & making a reasonable
allowance for the thickness of the skin
and Sac, I lay the Instrument in the hollow
of my hand, regulate the depth by my forefinger,
& enter the Instrument in a slanting
direction, making the hole upwards, at a
different place from the puncture of the Skin,
that from the oblique passage acting as a
Valve, there may be no oozing of the
water, nor air get in; then turning it inwards,
I know by the want of resistance
when I am within the Cavity, when I draw
back the perforator, pushing in the Canula.
During the discharge, it is material to make
pressure with the hand on the Sac, for in a
common Abcess, the matter comes out pure,
but towards the end bloody, the blood
pushing

174
pushing out from the vessels when relaxed;
so blood may follow water here, as in the
other case it follows matter, we therefore
support the part. If we feel that the whole
of the water is not discharged, [or] that it
does not run thro' the pipe, it may be
owing to the end of the pipe pressing
against the side of the Sac or body of
the Testicle; so we enter a probe & push
away the matter, that the whole may be
discharged, then putting the finger on the
part, we withdraw the Canula, & immediately
apply a proper bandage; as a Compress,
flannel dipt in a Solution of Sacch: tr:
with Spirits & Vinegar, & we support the whole
with the T bandage, & confine the patient
to bed 3 or 4 days at least, keeping him
on a cooling Diet, whereby the collection
will be found to return not so soon as
usual, the Coat contracting, so as to resist
greatly

175
greatly to the farther distension, whereas by
neglecting the posture & compresses, it readily
fills again with water & blood, & Inflammation
coming on, may prevent the
Radical Cure from being done with tolerable
safety.
But suppose next that our patient is willing
to submit to a Radical Cure, that is to
such an Operation, as by its consequence
produces an inflammation, & an adhesion
of the Vaginal Coat to the body of the
Testicle. What shou'd by the general means
Surgeons employ, or manner of doing it?
There are various projects for this purpose,
some of which it may be sufficient
to mention in a very slight way. Some
propose to throw in irritating liquors, as
Wine, or Spirit of Wine to produce an
inflammation; or to introduce a hard body
as the Canula of the Trocar which is to be
left

176
left there, or a Bougie; but the objection
to these is, that the Surgeon has not the
management of the Inflammation afterwards
in his power. - The other method
proposed are - The Application of Caustic,
the making an Incision, & the introducing a Seton.
First with respect to the application of
the Caustic, there are two methods in
which it is done, the one is with the view
of supplying the place of an incision
in a tumorous person, hence it was applied
nearly the whole length of the tumor
to make a free opening. Of late, Mr.
Else advises to apply it to the lower part
of the tumor, of the breadth of a sixpence,
which makes an Eschar double the Diameter,
and it lays on for a certain number of
hours. Now, tho' beyond doubt, several
cures have been performed in this way,
I wou'd prefer the other methods of Incision
&

177
and Seton as being more certain; for in a
Case which occured in our Infirmary,
where the method has been practised, &
yet at the place where the coat had
been destroyed, there was a compleat
adhesion of the External skin to the Tunica
Albuginea of the Testicle.
It only remains then to compare the
method by Incision, & that by Seton.
I must acknowledge that I have not had
a sufficient opportunity of seeing the Seton
tried in a proper way, that is merely
a Seton, where we first make an Incision,
& afterwards pass a Cord. With respect
to the Incision, the consequences of it
have been extremely exagerated; Mr. Sharp
gives the history of a few unsuccessful
cases which were treated in this manner
40 years ago, & which are rather to be put
down as uncommon Cases, than as Rule
by

178
by which we are to be guided. My father did
this Operation 30 times, & I have directed
it in 20 cases more. My father alledged
that none of his patients ever seemed
to be in eminent danger, & the Cure did
not fail in a single instance. In every
one Case where I had the direction of the
patient, there was no degree of danger
nor of fever. Nay I am convinced, that taking
the most favourable representation
of the Seton by Mr: Pott, I am doubtful
whether in case of the Incision, the symptoms
be as violent, and the Cure is more to
be depended on; besides, we see exactly
the state of the Testicle; we are in danger
of running into a mistake, where we may
pass a Seton, where there is water indeed
in the Vaginal Coat, but the Testicle at the
same time, may be in a Schirrous or
Cancerous state. -
The

179
The Method by Incision is this. If the Hydrocele
is small, & from the feel we can
judge that the Testicle is sound, we do
the Radical Cure at once, providing the
patient be convinced of the small chance
in any other way; but if the patient
thinks the letting out of the water will
do, we wou'd do this, & by the feel, examine
the state of the Testicle. In 2 or 3
months, the water collects again. Or if the
swelling is larger, I wou'd not do the
Radical Cure immediately, but wou'd draw
of the water, & do the radical Cure
before it is collected again in the same
quantity, the danger being in proportion to
the size of the Sac. In this way we satisfy
the Patient that there is no other
method of Cure, & we know the state of the
Testicle. - In performing the Operation,
we examine carefully the veins under
the

180
the skin, or the vessels in general, avoiding
any large one. We make an Incision,
not the full length of the tumor, leaving
a certain pouch or bag at the bottom for
the Testicle. We begin with a common
Scalpel at the top of the tumor, & carry
it down, then with the same instrument
we divide the Cellular substance, avoiding
the vessels. I next suppose that the Cyst
presents, I divide it with the same, instrument,
or what will answer as well,
I take a common or an Abcess Lancet, &
I have ready a furrowed probe to be
introduced, but if I can easily cut on
my finger, it is the best Conductor. Now,
suppose this is done; whilst the water
is running out, I introduce the probe,
& lay open the rest of the Sac with the
knife made straight with a probe point,
that I may not hurt the Epididymus at the
top.

181
top of the Testicle. If any large vessel bleeds,
I take it up, I then apply common dressings
lightly between the lips of the wound.
The operation is generally done the fore
part of the day, & if there is no bleeding
in the evening, I cause a poultice made
of bread & Oil to be applied; but if the
vessels ooze, relaxing them may promote
the discharge, so I delay the poultice till
next morning, & continue a poultice
during the Cure, confining the patient, &
I cause him to observe the Antiphlogistic
course, & if he is Plethoric, to be blooded.
Now a strict attention to these circumstances
renders the Cure much more safe & easy
than it has been generally represented.
But suppose that with Pott we employ
the Seton, there is an easier method of introducing
it than what he discribes. We
use Heisters bent Trocar, or a flat Canula
with

182
with a long Lancet-pointed Perforator, &
we make the puncture of the Skin with the
Lancet. If the tumor projects considerably,
a Cautious Surgeon may begin in
the upper part, but to avoid the Testicle,
we wou'd rather puncture the lower part.
Having entered the Canula within the
Sac, we withdraw the Perforator, & allow
the water to be discharged, then we bring
the Instrument to the upper end of the
Tumor, or where we are to perforate the
Skin, & holding it in that situation, we
cut in upon it & bring it out. Now
in Heisters way, we tie the Seton to the
end of the Perforator, & draw it back
again, but it is just as easy to have
a common probe with the proper Seton.
Pott makes his of silk sewing threads,
but being an Animal substance, it rots
sooner

183
sooner than linnen. We wax it well, then
Oil it, & enter it without farther pain
to the patient, & taking hold of the Seton,
we withdraw the Canula, leaving it in the
Sac. I woud apply here as in the former
case, a Poultice, & confine the patient
to a horizontal posture & absolute rest.
Pott proposes after 10 or 12 days, to pull
out the threads, but I wou'd rather allow
the Seton to remain till there is a concretion
in every place, except where the Cord
passes, then we withdraw it.
After shewing the method of operating
in general in Hydrocele, the only circumstance
further that needs to be added is,
that where the water is collected in a
large bag or bags, in the Spermatic
Cord, or in the Case of præternatural
encysted Dropsy of the Cord, there is more
caution to be used in passing the Instrument

184
Instrument, or in making the Incisions,
for the Cyst may be as readily behind
as before the principal Spermatic vessels,
or the Vas Deferens; so that we must
take particular pains to discover the Course
of the Cord by feeling with the hand, &
examining the part with the clear light
of the Sun, or a Candle in a dark room;
but as the light renders the blood vessels
as well as the Cyst, in a great measure
transparent, we only get a kind of
assurance from examining in that way.
Having determined as nearly as possible
the situation of the Cord, we make the
incision, first thro' the skin, then thro'
the Cyst, avoiding especially the Vas
Deferens.
Schirrous

185
Schirrous Testicle, or the swelling
of it which is generally named so. If the
disease is supposed to be of that nature
which degenerates into Cancer, it is called
Sarrocele; but if it swells, & be occasioned
from a Gonorrhœa, the absurd name
of Hernia Humoralis has been introduced.
The Cause & Manner of the Testicle swelling
from Gonorrhæa were formerly explained.
Blows may produce a hardness, which
will begin in the part injured, whether
it be the Epididymis or Testicle. The
Swelling may begin from Internal Causes,
in which case, it begins in the part making
the Secretion, in the proper Glandular
parts, or body of the Testicle, tho' I have
seen a true Schirrus begin in the Epididymus.
- Now when the swelling is
produced

186
produced from the Venereal disease, even tho'
it does not subside in the ordinary time,
yet the long continued use of Mercury
generally compleats a Cure, & it seldom
terminates in Cancer; but if the disease
proceeds from a blow, the Cure is much
more uncertain, tho' I have seen cases
of considerable swelling, attended with
pain, discussed by the long use of Mercury,
even where the Cicuta had been tried for
some months without any visible effect. -
If it proceeds from an unknown cause,
i.e. that the disease is of that kind
which naturally runs into Cancer from Schirrus;
if the Constitution be tolerably sound & the
swelling moderate, with little pain, and
not very unequal in its surface, we make
the trial for some time of such medicines
as have the effect of discussing Schirri,
and

187
and many will try the Cicuta, for the most
part perhaps to little purpose. But if
the swelling be considerable, or after making
a moderate trial, we ought to have recourse
to Surgical Operation, the Testes
ought to be extirpated. But before proceeding
to the Operation, I wou'd observe that there is
a danger in some cases of mistaking a
Hydrocele for a Schirrus, & water contained in
the Vaginal coat is a very common consequence
of it, water collects after the schirrus
has continued for some time. For the
most part, we distinguish the Hydrocele
by the symptoms mentioned at our last
meeting, but in a few cases, the Sac & Teguments
become very thick & unequal to the
feel. - I may here mention a very instructive
Case, which occured three years ago, &
in which Dr: Cullen, Mr. Wood & myself
were consulted. - A patient came from a
distant

188
distant part of the Country with a large swelling
of the Scrotum; the Testicle on one side was
supposed to be Schirrous, it was as large
as the fist, hard & unequal; there was evidently
a collection of water, but at the under
& posterior part of the tumor, there was an
ulceration, which was supposed to be cancerous,
& which affected the body of the Testicle
itself. On examining the Case with
all possible care, we were not able to draw
a certain conclusion with respect to the
nature of it, but we agreed to treat it in
this manner, that as the Ulcer might be
owing to the very great size of the swelling,
& the little care the patient had taken of
the complaint, we shou'd draw off the water
by puncture with the small Trocar, 
& examining the state of the Testicle, we
found that it remained sound within
the Sac, & that the Ulcerated part was at
some

189
some distance from it, & by taking off the
pressure, & confining the patient very much
to bed, the Ulcer healed up of itself in ten
days; we then proceeded to treat the
other side, we hoped to find it likewise
a Hydrocele, & agreed to proceed as it were,
& that if the Testicle was Schirrous, we
wou'd extirpate it; we found an unusual
thickness of parts, & an appearance of dark
brown matter like Coffee, & extravasated blood
mixed with water, the testicle sound, &
the Cure was compleated without any bad
accident in the space of three weeks, when
the Incision was made on the other side,
& that compleated in about the same time.
So we see the danger of mistaking Hydrocele
for Schirrus of the Testicle. - Now
on the other hand, Surgeons are apt to
trust to the first appearance & feel of the
parts, they suppose a Hydrocele, & examine
no

190
no farther, whereas there may be a complication,
which may be discovered by a more
accurate examination; we distinguish the
bulk of the Testicle enlarged, hard & unequal,
and a much greater quantity of water is necessary
to conceal the Schirrus of the Testicle than
in its sound state; so joining these marks
to the manner in which the disease was
produced, the pain attending, the weight of
the part, weighing the part in the hand, we
may be pretty certain with respect to the
state of the case, but the safest practice in
such cases is to proceed as if we were to
treat a Hydrocele, which is attended with
very little disadvantage, as the incisions in
both cases are to be made in the same manner,
only instead of at once compleating
your incision, you make it half the length,
examine the Vaginal coat, making a puncture
in it, & finding a schirrus, you compleat
the

191
the Incision. - Now as to the steps of the
Operation, they are really so simple, that
I do not think there ought to be any dispute
about the manner of doing it; we make
an Incision the whole length of the diseased
part, & pretty high, that we may be at
freedom to take up the Cord, & vessels that
bleed after the removal of the Schirrus;
I need not say that the Operation is not
to be undertaken if the Spermatic Cord partakes
of the schirrus beyound our reach, but
I wou'd not be averse to performing the
operation, merely because the Spermatic
Cord was considerably enlarged, for in
every enlargement of the Testicle, there is a 
proportional enlargement of the Cord; tho'
therefore the hard schirrous state of the Cord
attended with pain, forbids the Operation,
yet if it is soft, & there is merely an appearance
of enlargement of its vessels, or
perhaps

192
perhaps only a slight diffusion of water into the
Cells; in the interstices of the vessels we wou'd
perform the Operation. - I suppose then that
I am certain of the disease, I make an incision
into the Testicle & I find it diseased,
I make my incision from the ring downwards
to the bottom, & in doing so, there is
no occasion to pinch up the skin, which
is very commonly done; I make the incision
as easily with this, & more exactly in
the proper place, & there is not the smallest
danger of cutting the Spermatic Cord. Now
it is unnecessary, having done this, to fall
to work dissecting the skin from the Spermatic
Cord, all we want, is to be able to
pass a Ligature round the Cord, which we
do with a large thread & Needle, as we mean
with it to make a Tournequet in the time
of the Operation, or if the Cord is not enlarged,
we mean to confine the blood after
the

193
after the Operation, & to render it unnecessary
to take up the vessels singly with Needles,
and a large Ligature does not cut & injure
the vessels so much. In making the Ligature,
Heister speaks of leaving out the Nerves,
meaning the Vas Deferens, but I woud
propose that you shou'd on purpose take
it in, as there are considerable branches
of the Spermatic Arteries running along it,
& it is not more sensible than any other
part of the Cord. Having tied the Ligature
with a running knot, I divide the Cord
transversally without seperating the sides,
first from the Cord & from the Testicle, for
the seperation is perfectly easy afterwards, besides
it renders the Operation tedious, & the blooding
vessels are not distinctly seen; we make
the Cut about half an inch below the Ligature
& by pushing the finger behind the
Cord & Testicle we turn it out of the Sac;
the

194
the Cellular substance is so loose that the Surgeon
with his fingers might tear out the
Testicle with his fingers, but Laceration
& Contusion ought to be avoided, as producing
more violent symptoms than follow the
cutting the Cellular substance; so we dissect
the Testicle from the skin, & here the Surgeon
is much the better of his Assistant holding
the skin with his one hand, while he holds
it with the other, tho' even without such help
there is no particular difficulty in doing it.
Immediately after making the Separation, the
Surgeon looks for bleeding vessels, & takes them
up as quick as possible, taking hold of them
with a common forceps, he pulls them out, &
ties a Ligature round them, for if he delays
doing this, the patient faints, the blood clouts
in the orifices, & in a few hours after the
dressing are applied, breaks out again. [illegible]
with respect to the Cord, if it be small, the
Ligature

195
Ligature is to be left, & a running knot will keep
it well enough, so that we need not even
alter the knot; where patients have suffered pain,
it was owing to the knot being drawn with
too much anxiety, & bruising the Nerves, or
the Ligature has been applied when the Spermatic
Cord was remarkably enlarged, when the Ligature
may be improper, & it may be better to loosen
it & give the patient some Cordial to make the
vessels bleed, & observing the bleeding orifices,
we draw them out seperately & tie them, & in a
large schirrus every branch comes to be enlarged;
you still however leave the Ligature for two or
three days, that if any artery shall not have
been tied, or if any Ligature slip, we may use
it again as a Tournequet; but is by no means
necessary with some to have recourse to a
machine for pressing the Spermatic Cord against
the Os Pubis in the operation. - I
have taken no notice of removing any part
of

196
of the Skin either in this complaint or in the
Hydrocele, for however large the swelling be,
if the skin is sound, it is unnecessary to remove
it, but if diseased, we remove the diseased
portion, beginning & ending in an angle,
& cutting out a section like an orange. Then
the Surgeons lays aside the lips of the wound,
& puts in Lint to prevent the joining; we
take less pains in laying in the Lint, & as soon
as the blooding is stopt, we shou'd cover
the lint with an Emollient poultice,
that is in the evening or next morning.
Fistula

197
Fistula in Ano. By this is understood
not exactly a Fistula, but any considerable
Abcess about the extremity of the Rectum.
It is very evident that the Cellular substance
surrounding the Rectum, & the Rectum itself,
are particularly exposed to diseases, from the
nature of the contents, & from the unequal
distension to which the parts are exposed
from costiveness &c. - Next you'll recollect
that the skin about this place is remarkably
hard, the Cellular substance within loose, &
the quantity of fat very considerable, & hence
matter formed, spreads far from the looseness
of the skin, & from the hardness getting out
with difficulty; so if the matter is allowed
to stagnate from the errect position of the body,
it falls down upon the side of the Rectum, &
the skin resisting more than the Gut, it may
form

198
form a passage into the Gut, so that part
of the matter, or whole, may be discharged
by stool. The matter most readily forming
on the outerside, falls in along the Gut, till
it is stopped by the close connection the
sphincter of the Anus has with the teguments,
so that it resists about the top of the Sphincter;
but where acrid matter is contained
within the Gut, it falls down till stoped by the
Sphincter, & hence where eronous are formed
you will generally find them in 9 cases
of 10 about one & a half inch from the verge
of the Rectum, just a little above the inner
or higher part of the Sphincter Ani.
As soon as Suppuration can be discovered
in the Buttock, at the side of the Anus, by the
pain, hardness of the part, & increase of pain
on going to stool, the Surgeon ought carefully
to examine the situation within, & to introduce
a finger into the Rectum, & being satisfied of
the

199
the place, he ought to make an incision upon
it, tho' at a considerable distance from the
surface, & tho' no fluctuation can be discovered,
& he is not to wait for a fluctuation,
otherwise it may become too late, & the
Coats of the Gut be destroyed. - If any
known disease has been the occasion of the
Abcess, whilst the Surgeon begins his Incision,
he applies the proper remedy, if from
a Venereal complaint, he must use Mercury.
Next let us suppose that on examining
such an Abcess, we find that the matter has
been lodged upon the coats of the Rectum,
that the outer part of it is bare; are we,
to comply with a general direction to make
the Abcess or fistula compleat, by perforating
the Rectum, the cutting down the side
of it & laying the whole cavity open in that
manner? We are by no means to do so,
but be guided by circumstances. I suppose
that

200
that this rule has crept in from a particular
circumstance, that if the matter has actually
made its way into the Rectum, & a fistula is
already formed, you will not easily cure without
such an Operation. Now I apprehend that
Surgeons have even tried to heal the Abcesses,
supposing that there was no communication,
when in reality there was one, from the difficulty
of finding out the diseased part, &
we must seek very carefully, sometimes the
hole perhaps is not so large as a Crow quill,
but generally round it we can discover a
hardness, & the fleshy part of the finger sinks
in at the middle of the hardness. - Now we
are not rashly to open the Gut, & we may
compleat the Cure without doing so, thus
putting the finger into the Abscess, & another
[crossed out] into the Anus, I have found
nothing between them but the Coats, & yet
Cures were absolutely well compleated.
Next

201
Next let us suppose that there is a hole in the 
side of the Intestinum Rectum, that there is
a real fistula, in what manner are we to
perform the Cure. We first determine the place
of the hole, & we ought to make it a rule,
that whilst a probe is introduced into the
Abcess, we introduce the finger of the other
hand into the Rectum, otherwise we may be
led into the mistake of imagining that the
fistula is of great length, when the probe
has passed thro' a very short one into the
cavity of the Gut. If the Sinus extends a
great length, as 4, 5, or 6 inches upwards
to the Os Coccygis, it will be difficult to
make the Cure, the vessels come to be of considerable
size, yet if you make a free incision
below, and give discharge, provided the bad
habit [be] corrected by a Milk & Vegetable
Diet, with the Cortex taken largely, & very
deep sinus will heal up. If the Sinus is short
& the habit tolerably good, the Cure may be
made

202
made with great safety to the patient, & great
ease to the Surgeon. The method of Operating
ought to be very simple, nay you'll often be
called to cases that appear very complex,
& which yet are very trifling, thus you will
find holes half round the Rectum, yet all
coming from a single orifice. We search
for the bend of the cavities, by injecting
into them Water or Oil, & we ought not
only to make the Injections from the Sinuses
into the Rectum, but the reverse way, especially
as the passages are oblique, & act
as valves. - Suppose next that we have
determined the nature of the complaint
& that we have found it to be simple; the
reputation which Wards Paste acquired is
a proof that such will cure of themselves
where there is a free discharge; but suppose
that the complaint continues, & there is a
necessity for an Operation, are we to imitate
Le

203
Le Dran and other Surgeons in cutting out
the diseased piece. They introduce a furrowed
probe into the fistula, & from it into the
Gut, then they take a piece of silver on
account of its being flexible, & making it
sharp at the point, they run it into the
furrow of the probe, till they get it as
high as the fistula, there they push up the
end of the Sharp probe higher than the furrowed
one, & bending the point they bring
it out at the Anus receiving it upon the
finger, & having now hold of all the diseased
portion, they cut out the piece with
the knife, proceeding on the supposition that
the fistula has become callous, & will not
granulate & heal. But experience has exploded
this operation & has shewn that there
is no necessity for cutting out the diseased
portion, nor is it in many cases practicable,
as

204
as where there are holes on both sides of the
buttocks, and an Injection thrown into
one, runs into the other; the whole circumference
in this case must be cut away;
so we must only think of a method of
sliting the fistula open, & of throwing the
wound into the [sa???] cavity with the Abcess
fistula, as when exposed to the air, &
dressings, the Callous substance granulates
& fills up. Surgeons speak of such substances
sloughing off, but there is a granulation
from the surface, without any observable
seperation of parts, so that membranes which
have not many vessels, when exposed to
the air, are affected so as to produce
granulations of flesh freely. You must
have seen this operation frequently done by
a simple Incision, which is recommended
by Pott in a very good Pamphlet on
the subject, & he recommends a concave edged
Bistory

205
Bistory with a blunt point. This is to be introduced
into the fistula, then into the Rectum,
defending the part with the hand, then the
Surgeon endeavours to turn it out, & cut
thro' the part with it. - But there is another
& perhaps a better instrument recommend
by Heister, for this very purpose, the Probe
Razor; you introduce it with less pain to
the patient, & you have firm hold of it; you
can introduce the blunt point much better
than a knife thro' a fistula, as the probe
is made flexible so you readily pull it down
& bring it out at the Anus before you have
brought in the knife, & then you have a
firm hold of it, & before the patient is well
aware that the Operation is begun, it is finished.
If the disease runs high, here is a method
I have caused to be practised; you take a
common Gorget, make it quite smooth &
even, like a tube, & introduce it into the Rectum,
you

206
you then take Frère Colmes knife, introduce
it into the fistula, & you cut with safety
& certaintly, & the side of the Gut is put on
the stretch; or we might introduce a bit of
wood & cut upon it; but we shou'd not
act higher up than we can reach with the
finger, i.e. three inches or so -
After having done such an Operation, a good
deal depends on the dressings applied, they must
neither be applied too hard so as to irritate &
inflame the parts, nor must they be laid
on so loose as to allow the fæculent matter
to get between the dressings & the fistula,
which wou'd prevent the granulation &
filling up of the part; so they must reach
the bottom of the wound. The patient ought
to be kept loose in the Belly with a little
Elect: Lenetive, & the extremes of Costiveness &
too great looseness are to be avoided, by giving
Laxatives

207
Laxatives in the former, & Opiates in the latter,
and if the Stomach will bear it, & the constitution
relaxed, we give the Bark freely, which
disposes the parts to heal. A Cure may be
compleated in four or five weeks, but if
the fistula runs high, we are not able always
to promise success, the patient may die of the
discharge, at the same time, even where
the discharge is very considerable, if there is
a free opening beneath, the patient may
recover. -
(Dods Probe Bistory here shewn, which is very
like the Probe razor)
We next consider the management where
the natural passages are shut, or improperly
directed. There have been some few instances
where the lips have been found joined together,
by the bye, a proof that the fætus can
be nourished without swallowing. The Operation
here is very simple, requiring merely
an

208
an incision, & the Saliva may keep the lips
from joining again.
Next, at the beginning of the mouth of the
Vagina, naturally there is a membrane
called the Hymen, the appearance of it however
varying much. Now in some few cases
that membrane is compleat, so that when
the woman comes to menstruate, the Menses
are retained. If the Cause is known, the Cure
is perfectly simple; we cut out a circular
piece, or it may be sufficient to divide it
by Crucial Incision. Some have lost their lives
by concealing this, where from four to eight
pounds of blood have been retained from
that Cause.
Next the Nostrils either are shut, or the Small
pox sometimes in Children occasions the closing
of them, when the Child is obliged to breath thro'
the Mouth; Here we first cut the Opening,
then introduce a bit of Bougee to keep
the

209
the sides from uniting again.
Next, suppose the Anus shut, but the place
evidently marked; here the Cure is perfectly
simple. But in a few cases, the Rectum
terminates in the Bladder, or in a blind
Sac, & there is no vestige of the Anus. Here
we make an incision as near to the place
as we can judge, exactly in the middle, &
passing a Trocar upwards within the Os
Coccygis, we work it like a drill, & withdrawing
the Canula from time to time to observe
if there is any Meconium on the point
of it, & as soon as we see this, we withdraw
the Trocar, introduce a probe, & continue
the incision upon it till the Meconium
is discharged freely, & with a Sponge tent
we may keep the part open. I was called
to a case of this kind by Mr. Walkes, where
there was no Vestige of Perineum to be seen;
he had cut thro' the skin & Cellular substance
before

210
before I was called, but was affraid to proceed
without further advise. We agreed that the
Incision shou'd be continued, & at times to put
in a probe, to see if any Mæconium came
upon the point of it; after making the Incision
pretty deep, there appeared some Meconium
on the point of the probe, & the opening
of the Intestine was evidently by the Incision;
there was a plentiful discharge of Meconium,
& the child lived for three months, passing
its fæces in a tolerable way, when it died.
Next, the Urethra in either sex may be stopped.
If the orifice is only covered with skin, & has
no other fault, we cut it, & introduce a
Bougee; but if there is a wrong termination,
a fistula, a high degree of inflammation,
and mortification, after delivery, may be induced,
and a part of the Urethra fall out; or
suppose that in the Male, the Urethra terminates
with the opening on the side of the Glans,
behind

211
behind it, at the under part, & the urine is
discharged with difficulty; here by enlarging
the opening, the Urine might be discharged
very well, but such a direction is improper
for the Semen, so in a grown person, we
might perforate the Glans with a Trocar,
beginning at the extremity, then introduce
a piece of flexible Canula, or hollow flexible
Catheter thro' the Glans into the Urethra, stitching
the skin & Cellular substance upon the Canula,
in order to promote a growth of flesh,
& keeping the Canula in during the
Cure. -
Treatment

212
Treatment of Hernia. You all know the
meaning of a Hernia; we may conceive it
to be a protrusion of the bowels from the
natural Cavities, but still remaining covered
with the common teguments, & even
for the most part with the teguments
they had when in the natural cavity. You
likewise know that the bowels of the Abdomen
are cheifly, tho' not solely; subject to the disease,
& you can determine the place where the Hernia
will most readily happen, viz; where teguments
resist least, generally owing to the passage
of a Cord of vessels, or of nerves, which necessarily
carry out along with them a loose Cellular
substance, to allow of their easy motion.
They may therefore happen at the upper
part of the Abdomen, the Abdominal Viscera
may be pushed into the Thorax with the
Œsophagus


213
Œsophagus, the Vena Cava, or Aorta, or into
the Interstices of the containing Muscles,
or at the back part, where the vessels
go out; but the most common species are
The Hernia of the Ring of the External Oblique
which ought to be called ye. Annular Integumental Muscle
Next, that where the large vessels of the thigh
pass out at the opening behind the Tendon
or Ligament of Fallopius, & over which the
Inguinal glands are situated. The third
species is the Umbilical. Now of these three,
the Annular is the most common, the next
most frequent is the Crural or Fæmoral,
for the Umbilical is seldom observed in
men, or in women who have not had
Children, but it sometimes forms during
pregnancy, the distended Uterus pushing
up the bowels, & straitening them at the top of
the Abdomen. - Comparing the two sexes,
Women are more subject to the Crural or fæmoral
on

214
on account of the size of the round Ligament
of the Uterus &c. the length & looseness of the
Tendon of the External Oblique, from the
breadth of their Pelvis. Perhaps these three
kinds, but especially the Inguinal & fæmoral,
happen the more readily, from the looseness
of the Peritoneum at the bottom of the Abdomen,
where it is not covered closely by
tendinous matter, perhaps to allow the free
motion of the Vesica Urinaria, from which
circumstance, as also from the depending
situation here, the Peritoneum yields more
readily.
We distinguish Hernia from other complaints,
& particularly from Hydrocele, by attending
to the Cause, the suddenness of the appearance,
the pain, the feel of the parts, which, if
the Intestine is included, is different from
that from water contained in a Hydrocele;
nay we feel the motion of the Air, & often can
hear

215
hear it. If the Omentum is included, we distinguish
it from its inequalities & softness;
the tumor too is continued from the openings
in the Belly, & it is affected by change
of posture, & the Surgeon perhaps may have
it in his power to reduce it, but if he cannot
do so, & the part inflames, the Bowels
come to be affected, vomiting is brought on,
& the patient is at the same time bound
in his belly, the passage of the fæces being
interrupted. We can next readily conjecture
that particular part of the bowels that will
naturally form such tumors; the most of
the Abdominal Viscera are free from the
disease, as they are well supported by [illegible]
of the Peritoneum, which yield suddenly
or are drawn out gradually; for the
most part, the under parts of the small 
Intestines, the Intestinum Ilium will be
the subject of the disease, not only being
the

216
the lowermost, but also having the longest
Mesentery. Next we wou'd suppose that the
Omentum may be very easily included, &
if it shou'd, it may very probably carry
along with it the large arch of the Colon; &
these parts from experience are found to form
the tumor in the Herniary Sacs. - Next suppose
the disease to happen suddenly, & that the Surgeon
is called, he ought to attempt the reduction
without even waiting till he has let
blood, or performed any other kind of Operation,
for a delay of hours, or even minutes,
may bring on inflammation, & render the
reduction very difficult; so the first attempt
is to put the bowels back, after laying the
patient in a proper posture; but if we
find a difficulty in doing so, we are to let
blood freely; if the Alimentary Canal is inflamed,
it requires Venesection more perhaps
than

217
than the other organs of the body; the necessity
of this will be still more evident, where
it is not only inflamed, but mechanically
draged out of its place, & pressed upon, so
we ought to let blood with very great
freedom, at the same time, we put the body
so as to bring on faintness, to take off the
tension of the parts, i.e. we make the
patient sit erect, or stand; We open a large
orifice in the Vein, draw off the blood as
quick as possible, & loosen the Ligature instantly,
& when the patient remains in the
fainting fit, we attempt the reduction; if
still we fail, besides repeated Venesection,
we assist by pressure, fomentations, and
Injections thrown into the body. When the
[patient] Surgeon is about to attempt the reduction,
the posture of the body ought to be horizontal,
the shoulders & Pelvis raised a little, so as to 
slacken the Belly as much as possible, the
Surgeon

218
Surgeon then applies his hands to the tumor
and instead of making a general pressure,
he attempts to reduce first what may have
fallen out last. If still he fails, he ought
next to try the effect of proper agitation,
& the opening of the ring shou'd be made
the highest part of the Abdomen, a pretty
strong man should hold the patient with
his two Legs over his shoulders, & thereby
agitate him, when the weight of the bowels
will have a considerable effect, & may
pull the protruded parts into the Abdomen,
when it is not in the power of the Surgeon
by pressure to do this. Suppose that
we still fail, we next, before proceeding
to the Operation, try the further effect of
Purgative Medicines, & of Injections, or of any
means that will produce Intestine motion,
which have been found to succeed when all
other

219
other attempts were unsuccessful; so we wou'd give
a brisk Purgative of Calomel & Jallap, & we assist
Purgatives by Injections, particularly of
Tobacco Smoke, which has been recommended
for this purpose; I have used it, yet I must
confess that I am not convinced that its effects
are much greater than an Injection of
Senna with a few grains of Tartar Emetic
dissolved in it; but as some are of a different
opinion; I shall an easy method of
throwing it in. I take the common Anatomical
Syringe, with a double stop-cock,
& have caused to be made a box of Iron to
hold the Tobacco, & a plate of Iron perforated
to allow the smoke to pass thro' it; now joining
these, if I draw the sucker of the Syringe,
I fill the Syringe with smoke, then turning
the stop-cock, & pushing down the Piston, the
Air goes out at the side, & it is conveyed
by a flexible tube into the Intestines, or if
we

220
we wish to heat the smoke still farther, &
to make it stronger, we need only change the
situation of the places, fitting the Syringe to
the box, I put a head upon it, then put
the double stop-cock to the top of the box, & now
if I draw the Syringe, the Air passes thro' the
Tobacco again before it gets to the pipe; I
can at pleasure throw it in in any quantity;
one person manages the stop-cock, &
another the Syringe, while a third confines the
smoke within the Gut by a wet cloth put
round the pipe. - An ingenious Gentleman,
instead of the syringe, has made an
Apparatus with bellows, meaning these
both to give Injections for blowing up the
Lungs for recovering drowned persons; now
the Syringe wou'd answer very well likewise
for that purpose, & in giving the Injection,
you work in a more equal manner
with it. - It may be worth while
to.

221
to shew another Instrument, viz: a method
by which we can ourselves manage an Injection,
& the patient seats himself upon
the pipe, or we may do the same with the
flexible pipe.
I shall next suppose that these methods have
likewise failed; we ought to have recourse
to an Operation, by which we mean to take
of the mechanical pressure or stricture upon
the bowels, made chiefly at the outlet from
the Abdomen, & next after doing so, to
replace them, and the operation ought no
doubt not to be delayed so long as is frequently
done, it is impossible however to
determine the time that ought to intervene
between the disease forming & the operation,
for that must vary according to the nature
of the accident producing the disease, the quantity
& kind of bowel that is protruded. If the
Omentum comes down, that may serve as a
mechanical

222
mechanical protection, tho' in a few instances
it may enlarge the Intestine. Next
much depends on the natural size of the
rings & openings, upon the age & constitution
of the patient, & the management of the
case, but upon the whole, if the attempt fail,
& there is no symptom of Mortification, we
ought to operate, & I suspect independant
of the immediate effect of the part out of the
body, the distension of the bowels within
has very dangerous effects, as they lose their
tone, & a mortification may begin higher
up than the place strangulated.
Next suppose that we are to proceed to the
operation. I shew you a case of Hernia, with
the mouth of the Sac open & the Spermatic
Cord passes down behind the sac, which is
its common situation, the Peritoneum is
pushed out, & our name of Rupture is improper,
as

223
as if we meant to express a bursting of the Peritoneum,
tho' that is a possible case. Next
the Sac is a good deal thicker than the Peritoneum
within, & in this Sack you see the [illegible]
included in the Vaginal; but if the process receiving
the Testicle has not shut the bowels are in
contact with the Testicle; this has led some
to imagine that the cause was rather a consequence
of the Testicle than of the bowels.
Let us now suppose the operation necessary
& proceed to consider the several steps, & I
shall take the Inguinal Hernia for an example
being by much the most common
species. We place the patient horizontally
on a table with under his shoulders a pillow,
& the thighs are raised by an Assistant, so slacking
the parts, the Surgeon places himself between
the patients knees, he begins his incision
with the common Scalpel, above an inch
above the ring to bring it clearly into
view

224
view, & continue the incision to the bottom of
the Hernia, cutting the Skin only; now in
doing that, there is no occasion to take up the
skin double, which looses time, & does not
lessen the pain, & the incision is not so exactly
in the place as you wou'd wish it;
after we divide the skin, we proceed with the
utmost caution, for tho' it often happens
that water is contained or lodged in the Herniary
Sac, & gets between the Sac & bowels,
yet this is not a common event, & where
there is water, it is frequently at the lowest
part of the sac, so behind the bowels, which
being full of Air, push forwards; so that
by cautious strokes, I have divided the Cellular
substance, shunning any vessel
that might present. We are next directed
by Surgeons to open the Sac, in order to examine
the state of the bowels; now if the
Omentum is down with the Intestine, & there
is

225
is a suspicion of its entangling it, or if there
is water in the Sac that needs to be discharged,
this step is necessary; but if the case
is recent, & there is not room to suspect
this circumstance, we ought to take of the
stricture about the ring, if possible without
opening the Sac, for the letting in Air on the
bowels is a circumstances of the great danger
in the operation, & the cutting the tendon
is in comparison to that, of no consequence;
& besides the Tendon, we cut another thing
which is the cheif hinderance, the constriction
of the neck of the sac, which strangulates
the bowels more than the Tendon does, &
is 1/4 of an inch thick perhaps, & the opening
not so large as to allow us to thrust in the
point of the finger, so we are to attend to
this, & by slow scratches cut thro' the stricture,
we then reduce the bowels thro' the sac, pushing
them back with the fingers alternately, & thus
we

226
we save the patient a great deal of trouble. But
suppose that we find it necessary to open
the Sac, we do it with the same knife, & taking
a pair of common dissecting forceps, we pull
out the membrane a little, so as to get a hole
made in it with safety, looking carefully that
no part of the bowels is drawn out; we
thus make a very small hole, which will
receive a common furrowed probe or Director,
we then raise the Sac upon the probe, &
by pressing it against the Sac, we are absolutely
certain that none of the bowels is included, &
thus we enlarge the opening till we can thrust
in the point of the finger, with which as a
Conductor, I open it with safety, the knife
having a straight edge & a blunt point, which
is better than a concave edge, which is in danger
of allowing part of the Gut to slide over it;
we thus open the sac its whole length, & lay the
Intestines fully in view. The next step is to
examine

227
examine the state of the Intestine & of the Omentum,
& we ought not to cut the neck of the sac or
ring, least the Intestines shou'd fall back into
the cavity of the Abdomen, so we turn them over
gently, anointing the finger with Oil, & see
that the Intestine Omentum be not twisted
round the Gut, & that the several parts are
in a proper state for being reduced.
Next we are directed to divide the neck of the
Sac & ring; now I consider the cutting of the
Tendon as a matter of no consequence, & I
wou'd make the division; but the stricture
is such, that by a general pressure, we can't
reduce the bowels, yet taking piece-meal,
it is possible; but least soon after the Operation,
the bowels may tumble again into the Sac, I
wou'd divide it, & after the Cure is compleated,
the firmness is much the same, whether we cut
it or not, as from every part which is exposed
to the Air, there is a granulation of flesh; so
we

228
we wou'd next dilate the ring, pressing in the
finger, & along with it the knife, & we divide
the Sac & ring freely, & it is of no consequence
whether you cut the tendinous fibres transversly
or humour the slant; at the same time we
examine the ring, as one side of it may have
grown to the other, & there may be two passages
in the place of one; in the Memoirs of the
Accademy of Sciences, we are told of a case,
where the Gut had descended on one side of the
Membrane, & was returned on the other.
Having replaced the bowels, we make loose
stitches, in the skin only, but so thick as to
exclude the Air from the top of the Sac where
it is contiguous with the Abdomen; yet the Inflammation
may not run so high. I have seen
several instances, & many are discribed, where
the Sac adhered to the turns of the Intestines; Now
where we suspect this to be the case, we ought
not to cut directly in under, but upon the
Peritoneum

229
Peritoneum, above the stricture, & having got into the
cavity of the Abdomen, we bend a probe, & pass
it down thro' the ring, so as to get in between
the Sac & Intestines, but sometimes the bowels
not only adhere to the Sac, but to one another,
& here if the Adhesion be compleat, we only take
of the stricture, when we have done all that
prudence will admit of. But when the adhesion
is slight, we may make free with the
Sac, & seperate the Guts from it, you may encroach
upon the Sac, but you can carefully
avoid the Intestine. We next return the adhering
bowels into the Abdomen, as they are surely better
within than without.
Next suppose a Mortification occurs, how are
we to treat it? If we are dubious with respect
to it, have no sure symptoms of it, as the colour
of the matter, want of pain in the part &c., we
shou'd return the Intestines, tho' they look somewhat
darker than natural, for when in their
proper

230
proper place, they may recover unexpectedly,
whereas if they remain out, it is almost certain
death, but if there are clear signs of mortification,
we give the patient the very little chance that
remains; we have instances, where a portion of
the Intestines has seperated, & yet the patients lived,
nay where the two pieces joined & performed
their function; in one case of this kind, the
Surgeon only endeavoured to retain one end in
the wound, to discharge the fæces by this way,
but he afterwards found that he passed them
in the natural way; the other end had been
stitched to the ring, & the two had grown together.
But suppose the Gut mortified in a small part,
we join the ends together by a stitch, or we
do what is called Gastroraphia; to shew it, I
shall take out a part of the Intestine, or we may
suppose a bowel to have fallen out in consequence
of a wound, in this case, we examine
it carefully, & see that there is a hole
in it, or that the parts are entangled, and
we

231
we endeavour to reduce it, pressing the parts that
fill out last, first into the Belly. But next
suppose that there is a wound in the Intestines,
if that wound is length ways, Le Dran passes
a number of needles with threeds thro', twists
them together, & keeps the wounded part, & the
wound of the Abdomen; but this straitens
the Cavity of the Gut, so that I wou'd prefer
the Glovers Suture. Suppose next that the
Intestine is wounded transversly; several
Surgeons have tortured their brains to very
little purpose; some propose to put the
Trachea of an animal within the Gut, & to
sew it in; but the manner ought to be this -
you take a common needle & thread, enter
it from the outerside of the under end, & bring
it out at the upper end, we enter it in lithe
manner thro' the upper end of the cut & bring
it out again, then we pass it within the under
end again, & bring it out, & making a few
such

232
such stitches, we do all that is in our power.
If a discharge of matter is expected, let us see
the upper end, & introduce a bitt of Sponge
tent into the under, which keeps out the air.
I shall add a few words about the
Hernia Congenita; we avoid wounding
the Testicle or Spermatic Cord at the back of
the Sac, as it is more in danger of coming
in the way than in the common case.
Next suppose that there is a Crural Hernia,
the situation of which is just where the fæmoral
Artery is to be found, & where the Inguinal
Glands are placed; we are in danger of mistaking
the disease for a Buboe, tho' if we
attend to all the circumstances, there can be little
or no risk of such a mistake. Here we make
the Incision as in the former Case, an inch
above the place that makes the strangulation, or
the Tendon; The Steps are all the same here, except
the Peritoneum is covered with a thin
tendinous

233
tendinous Apaneurosis, from the Tendon of the
External Oblique over the thigh; & the same of the
Inguinal Glands, which are placed here; so we
divide the thin tendon, avoiding these Glands.
If the Sac is open, the Incision is to be made
as I have already directed, & if we use the knife
with proper caution, there is not the least danger
of wounding the spermatic Cord or Epigastric
Artery; Sharp advises us from cutting inwards,
that we may avoid the Spermatic Cord, &
says that by cutting outwards, we divide the
Epigastric Artery, we can lay hold of it with
a needle, but the artery is very large, & from
the principal trunk of the body. Le Dran again
apprehending most danger from cutting the
Artery, advises to cut inwards. Now from the
situation of the part, there is not the smallest
danger of cutting either, if instead of going inward
or outwards, we cut upwards, towards the Umbilicus,
dividing the Tendon transversly, and
using

234
using the knife like a Saw.
If we are to operate upon the Umbilicus, we
make the opening where we best can, only we
must use caution, as the bowels more frequently
adhere, from the disease forming slowly. Now
there is no occasion in a case of such importance,
to mind the situation of the Umbilical vessels
turned into Ligaments, but we cut where we
have most room.
At last meeting, in treating of Hernia, I mentioned
the agitation of the body, that the patients body
shou'd be inverted, with the head turned undermost;
the patient may be put on another mans
back, the Legs over the shoulders with the face
towards the back, & the body is not only to be
kept in that situation, but any agitation may
be used.
We now proceed to consider the Surgical
treatment of
Dropsy

235
Dropsy. Here we must first determine the
seat of the Water. When found diffused in the
Cellular substance, the complaint is called
Leucophlegmasia or a white swelling to dis-
distinguish it from Inflammatory tumors, or
attending merely to its seat, it is properly called
Anasarca, & the name explains more than
Surgeons generally conceive of the complaint,
they imagine that the water is merely confined
to the Cellular substance under the skin, whereas
it has got in between all the muscles, nay into
the Cellular substance tying together the fibres
of each muscle, & we can even trace it to the
membranes of the bowels, so in the Abdomen,
it gets between the Muscles & their fibres, from
that to the back of the Peritoneum, from that to the
doubling of the Mesentery. In like manner in the
Thorax, it passes into the Interstices of the Muscular
fibres

236
fibres of the Intercostal, & then into the Cellular
substance at the side of the Pleura, & from
that into the Mediastinum. It is generally imagined
that the water likewise fills the cavities which
naturally confine the fat, but this is a mistake,
at least we can't prove it; I formerly
shewed that the Cellular substance & adipose
Cells or folicles are totally distinct, that they
have no communication, however, Physicians
in their practice, have been led into this opinion
from the circumstance of the fat being generally
consumed in Dropsical persons, where the
disease had continued for some time. - I
have found the Adipose follicles filled with
their natural contents, nor cou'd I discover
Bags, as the fatty Cells are filled with water,
nor have I been able to find that the place
of the fat comes afterwards to be occupied by
water, tho' that is a very possible case, that
is, if you make an opening into the Cellular
substance

237
substance, as far as it is yet known, you may
discharge all the water in such cases collected
together. - This kind may be called Diffused.
You next know that the water may be confind
in many shut sacs found in the body, & on
a collection you readily determine the seat of this;
the principal ones are but few in number;
There is a shut Cyst between the Dura & Pia
Mater of the brain, the same cavity is continued
to the Spinal marrow & its sheath, so there
is one Cyst over the whole surface of the brain
& Spinal marrow, & water collected in the
head may fall down into the Spinal marrow,
& form tumors at the bottom of it, or the
Disease called Spina Bifida may arise in
this way, tho' we in general observe a connection
of the parts whereby this communication
is interrupted.
Next I have shewn that all the Ventricles of
the Brain communicate with each other, making
one

238
one Cavity, but not with the first Cyst discribed,
or there may be two Species of Dropsy of the
Brain, the External & Internal Hydrocephalus.
Next the Coats of the eye form a Cyst, containing
naturally the Aqueous humour, which sometimes
enlarges so as to [for] require an Operation.
Then going lower, into the Thorax, we find the
Pericardium & two Pleura; & in the Abdomen,
one large Sac called Peritoneum, & we may add
to it the Sac afterwards formed out of the one
which encloses the Testicle, the Vaginal coat,
& in the female, the Ovaria are full of Cysts,
& there may be a Dropsy in every one of the
natural Ova. But besides these Cysts,
which we observe by Dissection, diseases produce
others, so that there may be præternatural
Cysts in every part of the body, as in the
Spermatic Cord, Kidney, under the skin &c.;
Or we see that there is the Diffused &
Encysted Dropsy, & the latter is divided into
the


239
the Natural Encysted, & the Præternatural, which
is the effect of other diseases.
Let us now view the general cause of Dropsy, why
it is produced. We wou'd first say that there
may be three Causes forming it, the first
& most obvious is the bursting of the Absorbing
vessels which naturally convey watery
humours, and as we find in Lower, examples
of the Thoracic Duct having burst, &
collections of Chyle made within the Thorax,
so the small branches may be subject to the
same accident, tho' this will happen very rarely,
& I know that wounded Lymphatic vessels
will heal very readily; I have known in
letting blood, Lymphatic vessels opened, which
discharged their liquor for some time, & afterwards
healed up, nay I have known the Receptacle
of the Chyle, tho' cut transversly, shut
again, & the communication came to be compleat.
He may hold this in view as a possible
cause

240
Cause of Dropsy. Next if we are to speak in general
terms, the Accumulation is either from
an increase of Exhalation, or diminution of
Inhalation. Now let us reduce under general
heads what can induce either of these Causes,
and we shall find that they depend partly on
the fluids, partly on the Solids, & that very often
both are in fault, thus we find several instances
well attested, where the flow of the Urine
has been interrupted, & Dropsy has succeeded,
and in this case we conceive that one Mass
of blood is overloaded with the watery vehicle
of the food, which gets thro' the Exhalents, into
the several Cavities, & on Dissection, I have found
the several interstices of the vessels of the kidnies
filled with a sebaceous matter, where the
pressure on the vessels must have prevented
a free secretion of the Urine; now if we can
prove that Dropsy begins sometimes in that
way, & as the quantity of watery vehicle
passing

241
passing by the skin is in this Island nearly
equal to what passes by the kidney. A want
of free Perspiration may in other cases end in
the same complaint; or take it in another view,
we have instances of Dropsies following large
Hæmorrhagies, where some of the principal branches
were divided. To this we may join an experiment
of Lower; he draws off the blood
in large quantities, & furnishes the animal
freely with thin broths; the vessels came to be
filled with the liquor, & swellings were produced.
Or where there is a want of a sufficient
quantity of the aglutinating part of
the blood to entangle the thinner parts, there
comes to be an effusion, or Dropsy may depend
on the fluids, & many circumstances
may be supposed to introduce such a state
of the mass of blood. - Next, we can give
a clear proof, that Relaxation may be the
Cause of Dropsy, because we find it succeeds
the

242
the weakness of the Solids however brought on;
If a person is struck with a Palsy in one
of the Arms, it in a few hours becomes Dropsical,
while the state of the fluids remains
unchanged in the rest of the body, so we
account for this from the Relaxation, & this is
no proof that Exhalation is performed by
inorganic pores, but by a regular organization
of vessels possessing living & muscular powers.
Next the Exhalation may be increased by a
mechanical pressures, which affects the viens
more than the Arteries. If I tie a Ligature
around my Arm, so that the blood forces into
it by the Arteries, but its free return is prevented,
the vessels swell, & even the whole arm.
Let us go a step farther, that the swelling
happens, tho' you confine the pressure to the
red viens only, which does not prevent the
Absorption, for this is performed by the Lymphatic
system, but the Exhalation is increased,
the

243
the blood returning with greater difficulty, the thinner
parts are pushed off by the Lateral exhalent
branches. In like way we explain how a
Schirrus liver produces Dropsy of the belly.
Pressure every where will cut in that manner,
affecting the viens in the way a Ligature does,
applied in imitation of Lowers experiments.
Some have rashly denied this effect of the
Ligature, because on tying a single vien,
such swellings do not appear, but on account
of the free communication subsisting between
the Viens, in order to get the experiment to succeed,
we must take up the whole of them. Thus
an increase of Exhalation may produce
the disease. This may proceed from a fault
of the blood, or of the Arteries circulating the
blood, or from mechanical pressure, &
I wou'd include here even where the Schirrus
of a bowel has effect.
Next, Dropsy frequently depends on a want of the
proper

244
proper Inhalation, and you readily conceive this
if you reflect a moment on the way the
Inhalent system operates to convey its fluids; they
may enter by the Attraction of Capillary tubes,
but this does not serve to continue the motion,
but the Muscular power of the Inhalents becomes
necessary, which may be weakened by a
variety of Causes, thus in Paralytic cases, whilst
the water passes off more readily by the Exhalents,
it may be taken in more slowly by the Inhalents.
Next, if there is a mechanical obstacle to the
return of the liquor thro' the Absorbents, Swellings
will happen very readily, and on this principle
we in some measure explain the swellings that
happen in weakly persons, beginng.: in ye. feet.
The obstruction of a few Lymphatics does not
produce the swelling on account of the
numerous communications, but I have repeatedy
seen large swellings of the Limbs from tumors
of the Lymphatic Glands, I have known the 
whole

245
whole arm swelled, & yet it was not more diseased
than the other in any other respect.
Next, neighbouring parts may swell & press on
the Lymphatics in their course; thus in the
Ascites produced by Schirrous Liver, which
first occasions a swelling of the Belly, but not
of the lower extremities; when the water is accumulated
to a certain degree in the Peritoneum,
and the Absorbent vessels are pressed against
the back bone, the liquor returning thro'
them with difficulty, then the swelling of the feet
takes place, tho' there is no material communication
between the cavity of the Peritoneum
& the Cellular substance of the feet.
Now under these few general heads, it is
possible to reduce the Causes of Dropsy. The necessity
of attending to them is evident, it shews
that there is no general cure for the disease,
but that we must vary the medicine according
to the Cause, whether Relaxation,
Schirrus &c. - Next let us apply this in
the

246
the Cure - I beleive you will generally find that
the effects of emptying the Dropsical Cysts is more attended
to by Physicians than removing the Causes, & yet
they proceed by general rules too much without
proper attention or exceptions; thus in the first
case of Dropsy, the Encysted, as in the Ascites,
where the feet swell, we are not to imagine
that we have occasioned this by the posture
of the body, but only that it is occasioned
by the Causes of Ascites, & shews itself in the
feet in consequence of the posture. It is evident
therefore that [patients] Surgeons are in the wrong
when they are affraid to indulge patients
in exercise, which is necessary to give the
parts the chance of recovering their tone,
for the disease shews itself where the patient
is inert, yet by counteracting the Cause using
exercise with freedom, & assisting by mechanical
support to prevent the great distension
of the skin at one particular place,
we may perhaps remove the Disease.
Next

247
Next, in all the kinds of it, & almost without
exception, Physicians prescribe too dry Diet. How
tho' in many instances drink may be hurtful,
and that in every instance the tumors increase
more slowly, yet when it depends upon obstruction
of any of the different viscera, & a swelling
of these ails mechanically on the Circulating
system, that Rule is not to be adhered to & we
understand how persons drinking largely of Mineral
waters have been cured of Dropsy, the
water adding to the swelling, at the same
time acting on the Cause, so that with time the
swelling gradually disappeared.
There is a third circumstances in which Practitioners
likewise err, they endeavour to find
out that kind of discharge which will the
most speedily evacuate the Dropsical Cysts,
& Purgatives perhaps do this the most readily;
Now we are often under a necessity of having
recourse to Purgatives, yet I apprehend we
wou'd

248
wou'd use them in the last place, for suppose that
you free a person from Dropsical humours,
by this course, upon desisting from them, the disease
returns, this not being a natural opening
for ye. fluids in Dropsy, so we wou'd open the skin
or Kidnies, or Diuretic & Sudorific medicines
ought to be more insisted on. -
But suppose next that every circumstances
attended to, not only the effect but the Cause of
the disease, & that our medicines have failed,
we are under the necessity of having recourse
to a Surgical operation for letting off the water,
so I now proceed to the manner of doing that,
and we shall begin with the Diffused Dropsy
where the water is contained in the Cellular
substance. - Generally Surgeons defer doing
any operation till the skin is so distended
as to be ready to burst; now I am persuaded
that we will stand a better chance of curing
the patient, if we draw of the water more early,
because

249
because the whole parts of the body by their distension,
loose their tone. The Operation itself
is perfectly simple; some use a knife, & with
it make a large Incision about the foot or
ankle; I have seen them made about 3 or 4
inches long, but it is not very easy for the
Operators to account for their Practice, they
seem without any reflection to have transferred
the operation for the Cure of the Hydrocele, without
considering the total difference of the effect,
but we are merely to let out the water, so the
effect is the same whether the incision is large
or small, & besides the pain, large incisions
are particularly dangerous, as from the drilling
of the water, the parts inflame, & very readily
mortify, & I have even seen a great deal of
trouble where the biggest kind of Lancet was
used, so that the Surgeon was well pleased to
patch up the wound he had made; we shou'd
therefore proceed with great caution in such
cases

250
cases, & if the distension is very considerable, we
do not begin to make the incision in the
most depending part, that is in the foot or ankle,
but we first perhaps begin in the Trunk itself,
or near the top of the thigh, emptying what is
above, & then going lower, as there is real
danger from the water all drilling thro' one
wound, & the Surgeon is apt to get much
blame, & as the prospect of Cure is but small,
he ought not to run [illegible] hazard, especially
as no advantage attends [such] free openings,
for if the first opening is too small, it is easy
to make new ones, & the common lancet makes
an opening sufficiently large; we enter it under
the skin, & cut the Cellular substance freely round,
otherwise it stops the wound; having thus
made punctures, we next endeavour to direct
the water to them by proper pressure & friction
of the body, & this also assists in making the
Skin recover its Tone, & serves to enable
the

251
the Absorbent vessels to do their office of taking in
the fluids more freely, & with the same view we
support the skin with proper bandages, & instead
of Linnen, we use rollers of flannel, which
by their elasticity support the parts, & take
in more moisture, so that the skin is not
nearly so much galled, & when the water runs
immediately out from the puncture you defend
the skin by some greasy substance, at the same
time, after the first tension is taken off, we
give the medicines on which we place our confidence;
but along with these, in the case of Anasarca,
we give Vomits frequently, by which we
give a general Stimulus to the parts, & enable
them to recover their Tone, & mechanically push
the water from the Cellular substance of the
bowels in which it is apt to stagnate, & we
ought not to confine the bandages to the extremities,
but also take in the trunk, a considerable
quantity of water being lodged so deep, we
cannot

252
cannot distinguish the swelling by the feel.
Let us next suppose the water is confin'd in
shut Sacs, & I shall begin with Præternaturaly
shut Cysts, as these are for the most part small,
& the most easily managed; in this case, the
very same operation is nearly necessary as in
the Hydrocele, & a seton passed thro' is particularly
proper, & I wou'd prefer it here, tho' I
preferred the Incision in the case of Hydrocele,
because the Cord can have a bad effect by acting
upon the Testicle & putting it, so in the Hydrocele
of the Spermatic Cord, the Seton is preferable
to the Incision, providing only we can discover
the situation of the larger vessels, without making
such an opening as is necessary to bring them
in view; we pass thro' the Cord, & it occasions
a concretion of the sides; where that is not
practicable, & the tumor is large, we endeavour
to palliate the complaint by making a
puncture, but we shall seldom make a Cure
by

253
by this or by Medicines, it being particularly difficult
to Cure præternatural encysted Dropsy,
as the inflammation may form new exhalents,
yet Inhalents are probably not formed in the
same proportion, as the chance of Cure is less
where the water is confined in the natural Cysts.
Next suppose that the water is confined in
the natural Cysts, so take the water in the
Peritoneum, or Ascites, where the Belly swells
like a bladder full of water. Now first it
is very material that you determine not
only the presence of the water, but the exact place
of it; we know water by the swelling & fluctuation,
with the want of circumstances to
produce an Abcess, & the manner of feeling is
this - you lay a hand on one side, & strike
with the other, either with a single finger, or
with two fingers together, & you can make
the water undulate, so that if you are used
to the feel, you know it certainly, at the same
time

254
time, I have seen persons who we supposed to
have a Dropsy, & where without touching them,
I knew there was a mistake. When fat is collected,
there is somewhat of the general appearance,
but the Umbilicus is drawn inward,
whereas if water is collected, it is pushed outwards.
If the quantity is small, the Surgeon places 
[himself] the patient in a sitting posture, &
bending forewards, so as to press the skin inwards,
when he feels it, but if there is a great distension,
& the skin does not yield sufficiently, he
will feel it better when the patient is laid in
bed, with the shoulders raised & the Pelvis relaxed,
when the water is moved with greater freedom.
Next we distinguish the water in the open cavity
from the collection in particular cases, by attending
to the posture; if the tumor forms above or below,
extends gradually, while in the Ascites the water
alters its situation according to the posture
of the body; thus we distinguish it from Dropsy
of

255
of the Ovarium &c - But there is one kind of
Dropsy, when there is more difficulty, & very
great danger, if the water is contained in the
Sac to which the foramen of Winslow leads;
suppose it to begin in the Liver, which is Schirrous
perhaps, & that an inflammation coming on,
shuts the passage, if the Surgeon performs the
operation, he may wound the Stomach or Colon
before he gets to the water, so he shou'd have the
possibility of this in his view; & see it be the
erect posture, the water falls to the bottom of
the Belly.
Next suppose that there is no doubt with regard
to the existence of the disease, & that we are under
a necessity of making the Perforation, or suppose
that the patient is convinced that he has a
better chance of being cured by submitting to
the operation early, than by delaying it long,
which is a general rule in Dropsy, but particularly
in Ascites, where the urine is in
danger

256
danger of not being secreted so readily, but the pressure
of the Ascites against the Back bone. The
Antients performed this operation under many disadvantages,
as they wanted the proper instruments,
instead of the Trocar, they used the double
edged knife, then thrust in a knife which did
not well fill the hole, nor did they attend to the
proper posture of the body, & they wanted means
for making pressure in the time of the operation.
Now we first employ the Trocar, an instrument
which fills the hole we make, so that we can
stop the discharge at pleasure, if in any case
that shou'd be necessary. Next we attend to the
posture; Mr. Sharp directs that the patient shou'd
be placed in a sitting posture, where certainly
he ought to be laid horizontally; we all know,
that in common cases of faintness, the horizontal
posture recovers persons, & it is especially
necessary to attend to this in Ascites, as on
taking off the pressure from the lower part,
the

257
the blood rushes in there, & a small quantity
goes to the head; besides, there is not a single
advantage attends the sitting posture, below the
part where the instrument is entered, remains
full of water, whereas, if the orifice is made
at the side, in the horizontal posture, it
can be made the lowest part of the belly, &
we can draw off every drop of water; the last
advantage was first pointed out by Dr Venney
& more particularly by Mead, the making a
pressure in the time of, & after the operation.
It is generally directed to be done by means of
a roller of flannel, which at first may answer
tolerably well, but we need to shift it,
so it is more convenient to have a belt; here is
one which was proposed by my father in the
Medical Essays, it is made of flannel to lie
next the skin, but strong linnen is joined to
it, by which it does not yield so readily; it
is put on before the operation, & there is a sufficient
opening

258
opening where the orifice is intended; we draw it with
buckles, & to prevent it from slipping, a strap goes
round each thigh. Now instead of that, I have caused
to be made, a more convenient bandage, a cloath
waist-coat, with 10 or 12 buckles, & a strap for
going round the thigh; there is an opening
in the side of it, or without attending to that circumstance,
we may turn back the waist coat, till
the water is all discharged. For the operation,
we ought to be provided with Trocars of different
sizes; for common use, one of the size I shew
you, will answer very well, but sometimes
the water grows glutenous, nay we have a
few examples where Hydatides were found in
that cavity, & an incision was necessary to let
them out. The patient is laid upon the very edge
of the bed, with the side over the edge of it, &
you put round a piece of flannel, the ends of
which may be taken up on a bit of wood,
but the wood must not be very long,
otherwise

259
otherwise at the end of the operation it presses
against the parts; so you take a short bit,
such as you can easily twist. Next you determine
the place where you are to puncture, which
ought to be half way between the anterior
spinal process of the Os Ilium, & Umbilicus,
where the bowels are not immediately applied
to the Peritoneum, but when the water has got
between the fore part & the bowels; generally
we prefer the left side, because the Liver is
most frequently diseased; but the Spleen may
fall down by its weight, & we ought to examine
this as we can. That the trocar may enter
readily, it is proper first to make an Incision
in the Skin with a Lancet, & making a regular
allowance for the thickness of the teguments, which
are much thinner in Dropsy, the Surgeon puts
his finger on the Trocar, that it may go no
deeper, & works the Trocar like a drill, till
he finds the want of resistance, then taking
hold

260
hold of the Canula with one hand, he pulls out
the Perforator with the other, & putting the patient
in a proper posture, he keeps up the pressure
the whole time the water is running out;
this is of the utmost consequence, otherwise
Mortification or Gangrene may be brought on,
from the faintness, & the blood stagnating in the
Lungs, in consequence of the lax state of the
Abdominal Muscles. I had once occasion to
see the remarkable effect of pressure, when
120 pounds of water were drawn off in 2 hours;
by the time the water was half drawn off,
the patient herself discovered the effects of
the pressure, & on growing faint, called out
to pull the belts, & by applying the pressure
properly, she was not more faint at the end
than at the beginning, but a stop was made
at every bason-full, to give her a little time,
which is always necessary. - If a turn of
the Gut &c. Stop the flow of the water, we
put

261
put in a probe, but it must be bended, least
it fall into the cavity of the Abdomen, &
if in any case the patient grows so faint, that
it might appear improper or unsafe to draw
off the whole at once, there is no occasion to
intertain the notion of the water putrifying,
tho' we wait a day; I have known the one
half drawn off with relief, & the other half
not drawn off till 8 to 10 days after. - After
it is all taken away, we withdraw the Canula,
& put on a patch. In introducing the Trocar,
we may push it beneath the skin a little
way, & then slip it in, which prevents an
oozing that might excoriate the parts.
As the disease generally returns, substances
have been thrown in to heal the mouths of
the vessels, & one or two lucky cases have
occured where a compleat cure was obtained
in this way, one of the patient was siezed
with an Inflammation of the bowels, I suppose
from

262
from mismanagement in the operation. In
the Philosophical transactions, you will
find such attempts made with irritating &
Astringent liquors; in one case they produced
a Cure, in others they were the Cause
of Death. They did not try the experiments
first on the Quadruped; they used Tar water,
& trying the same experiment on a sound
Dog, he died in the same time, & I know
that several substances which can be introduced
into the stomach & Rectum, without
any fatal effects, kill quickly when poured
into the Cavity of the Peritoneum, thus Opium
has a much greater effect when poured
into the Peritoneum than when taken into
the stomach. - But suppose next that these
fail, some have proposed to introduce
a Seton, & Dr: Young tells us that he has
seen this tried, but that they were obliged
to withdraw it. I might have added
when

263
when speaking of Injections, that perhaps we might
inject Air, which might bring on inflammation
sufficient to produce an adhesion of the parts, &
on dissection, we cannot often discover the smallest
disease in any of the bowels, nothing but
a general state of Relaxation. But suppose the
Seton necessary, you introduce it with Heisters
Trocar, you enter it into the cavity of the Abdomen
till you feel a want of resistance, then
draw back the Perforator till you bring the
Canula to a proper distance, when you bring
out the Trocar, then withdrawing the Perforator
and entering a Seton, the water runs along it.
There is one other account on which the [crossed out]
Paracentesis shou'd be performed, where air
is effused. I told you the signs of this, & the
manner of doing the operation is evident.
I avoid saying any thing of Dropsy in the
Thorax at present. - With respect to the Head,
I have only to observe that in some few instances,
an

264
an external Hydrocephalus happens in a shut Sac,
particularly in Children at birth, & if these continue,
a long Cord may be passed thro' them
but for the most part they gradually disappear.
The water besides may be collected both without
& within the brain, & there is a dilatation of the
head, where the water is within oftener than
Dr: Whyte is aware of; he in other respects has
wrote better upon that complaint than any other.
When there is any probability of its being
on the outside, we may cut the skin, then scratch
the Dura Mater at the sides of the Bregma, where
the bones are most open, & if there is no water
we shou'd stop, but if there is any, we shou'd
let it out, by making proper compression.
I think it unnecessary to mention any reason
to disuade you from letting out the water
from the Ventricles of the brain, which must
prove fatal, in consequence of the wound
thro' the Medullary part of the brain; nay if
you

265
you cou'd suppose it in our power by a wish
to remove the water; the parts of the brain falling
together wou'd unquestionably produce fatal symptoms,
supposing the quantity considerable, such as by
the distension we cou'd discover.
We now proceed to the Paracentesis
of the Thorax, which requires to be considered
a part, as we want the evident fluctuation
of fluids to discover the disease, & in consequence
of the difference of structure, the Method
of operation requires to be varied.
It may be necessary to perforate the Thorax
in consequence of Air effused, of Water, of
Pus, & of blood. You recollect what I proved
with regard to the means of Respiration, that
the Lungs with respect to their Dilatation, are
merely passive, that they are kept contiguous
to the containing parts, & follow their motion,
only because the Air by its weight acts against
their inner side, having no other outlet but
the

266
the Trachea Arteria. This being understood, you
foresee the danger that must attend openings
made thro' the containing parts, in a sound
Animal, that if such be large, the Air comes
to be applied to the out as well as to the inner
side, so that the Lungs remain nearly immoveable.
Suppose the Operation done at both sides at
the same time, If the operation be done, on one
side, a large opening made, the Lung of that
side receives its motion in a great measure
from the other side, is that the Animal by
an instinct of nature, when about to expire,
contracts the Glottis, that while the sound
Lung is performing Expiration, the side
with the opening is performing Inspiration,
or rather is distended, life is continued, &
that imperfect. If however the opening is very
small, the Air, whilst the Animal makes an
attempt of inspiring, raises the containing
parts suddenly; entering however in smaller
quantity

267
quantity by the narrow wound than by the
Trachea, there may be some imperfect degree
of Dilatation; so there is danger attending
even small wounds in a sound animal.
How comes it then that Surgeons, in cases of
disease, perform the Paracentesis, or make an
incision without any danger following? The
fact is, the Lungs are not more oppressed
by the Air let in than they were by the [illegible]
matter between them, & we may add, that
whilst the matter collected gets a discharge,
for the most part, particular adhesions support
them mechanically, so that they are dragged
along with the containing parts, or by the
adhesions, they are prevented from collapsing.
Next let us attend to the different circumstances
that may render Operation necessary.
I begin with Air effused. This may happen
first from the tender thin membrane covering
the Lungs, even with the continuation of the Pleura
added

268
added to it, bursting by a violent effort; nay
you wou'd rather wonder that this does not
happen oftener; the cheif reason why it is so
seldom, is that the membrane of the Lungs swell
beyond the containing parts, just as a thin
bladder covered with leather, receives additional
strength from the leather, so that it is not
in our power by a blow to make it burst.
Sometimes this does happen, one instance of which
I saw when I was at Berlin in 1757; on
opening the Abdomen of a subject, we were
surprised that the Diaphragm was convex
towards the Abdomen, we supposed that water
had been accumulated within the [Crossed Out]
Thorax, but on cutting the Diaphragm, there
was a vast blast of air, & on examining
farther, the Lungs of that side where we observed
the convexity, we squeezed into a small bulk
at the top of the Thorax, & there bed down; no
hole cou'd be perceived, nor did air escape from
the

269
the Trachea Arteria when blown into the Lungs.
Dr: Meckel who has published this case, supposes
Mucus to have gathered into the trachea
so as in some measure to have obstructed the
passage, & that the Air in the Lungs, heated
by the body, occasioned the rupture, but it
is more probably that it was occasioned by
some violent effort, & the passage being oblique,
it might not be able to return, so that gradually
more had been accumulated, till the Air
was condensed, so as to squeeze the Lungs together,
& then an inflammation was excited,
which probably soldered the original hole.
Next we may suppose, that when the Membrane
of the Lungs gives way, the Pleura [illegible]
the ribs shall likewise give way; of this I
have met with two examples - A man of 55
years of age, not liable to Pulmonic complaints
further, than that he had a Cough in the
morning, as many at his time of life commonly
have; during his ordinary Cough, he
was

270
was struck with a violent pain, and in the
space of a few hours, he observed his sides
to swell; the swelling extended over the Thorax
and face, & on touching the skin, there was
heard a crackling like a dried bladder
stuffed with Air. On mentioning the Case to
Dr: Alexr. Hamilton, it put him in mind of another
of a Girl, who in Child-bed, tried to stifle
her cries, least she shou'd be discovered; 
she observed a swelling behind in her body
which extended a considerable way, with
Oppression & sickness, but it went off of itself.
Now next suppose that a rib is broken, &
the end beat inwards, you may conceive that
the Lungs may be wounded, & the Air getting
out, may be confined within the Pleura, getting
out thro' the oblique wound of the Lungs, when
the Pleura is pressed against the Intercostal
Muscles, which acts as a Valve, but generally
if the wound in the Pleura be considerable,
the

271
the Air will spread from the Cavity of the Thorax
into the common Cellular substance, & so get
out between the fibres of the Intercostal Muscles
under the skin, & be diffused universally.
There is one other probable method in which
an effusion of Air may take place, the Lungs
may be corroded by an Abcess of the Membranes
destroying Pleura & all, so that the matter
gets outwards, & the air will escape with the
matter, & will get into the subcutaneous
Cellular substance; or if the adhesion be compleat,
a portion of the Air may escape into the cavity
of the Thorax, & in fact, in some cases, where
matter was collected in the cavities of the Pleura,
it was found mixed with air, there were
bubbles of Air burst out with the matter
as soon as the incision was made. He
might form other suppositions about that
of the proper membrane of the Lungs, by an
effort in the interstices of the Lobes, yet the
air

272
air escapes into the intermediate Cellular substance
which ties the Pleura to the Lungs, &
so on to the skin; but in the adult, these
parts are so close connected, that this will
not readily happen.
Let us next see by what marks we know, &
remove these complaints. In discribing the
several possible cases, the symptoms were in
a great measure pointed out. - A person
after meeting with some accident, is siezed
with a very sudden oppression, when there
is no reason to suppose that pus is collected,
or blood or water effused, or there is not
that paleness that attends Hæmorrhagy,
& no blood is thrown out from the Trachea
Arteria. Some are led to ascribe the oppression
to air contained between the Lungs & Pleura,
& this may be so condensed as to press on them
more than if a wound was made in the
side, & they were exposed to the Atmosphere;
there

273
there may be an actual condensation; the
patient feeling a difficulty of Respiration,
by an instinct of nature, the Glottis is more
contracted than in health, & in pushing
out the air with violence, it passes thro'
the oblique wound, & can't return, so it is
condensed to a great degree. - Now in
such cases we may releive or cure the
patient by Paracentesis, & certainly there
is great room for proposing such an operation,
where the Lungs & Pleura burst together.
I caused it to be done, & with great advantage,
I have given the history of the Case, the patient
was exceedingly oppressed, not able
to lie horizontally, but was panting for
breath, & felt the greatest degree of weakness
at the same time, the face was flushed,
& the pulse small, weak & quick. I made
him discribe the place where he was struck
with the pain, it was on the right side,
about

274
about the middle, so I caused the Surgeon to
make an incision at the very place, as the
air had got out into the subcutaneous Cellular
substance, I thought that the person
might be relieved by that incision, & the
further effusion of the Air prevented; this however
proved ineffectual, we had no certain
guid to lead to the opening, it did not
take off the pressure of the Lungs, so I next
caused a Perforation to be made with the
Trocar, which was introduced slanting
under the Skin & Cellular substance, &
then the point turned downwards, & worked
like a drill, till from the want of resistance
we found that it had entered, & then withdrawing
the Perforator, we kept in the
Canula, & there was such a blast of air,
that we lighted a Candle three or four times
that was put out by it, & it was as evident
as from air condensed in a large machine;
we

275
we then observed the motion inwards & outwards
accompanying Respiration, & when the air ceased
from blowing, the patient found releif, lay
back in bed, cou'd keep the body in any posture,
& the pulse fell remarkably; as we
were not provided with any better instruments,
we left the Canula of the Trocar in a slanting
way, & confined it with bandage. Next
afternoon, I found that the patient cou'd
breath with ease, & that no accumulation
was made, tho' the Canula of the Trocar
was altogether stoped, the hole had shut
up, the inflammation had closed it, so that
now the Canula was withdrawn, & the patient
was restored to his former health; but
about 12 months after, he was siezed with
the common symptoms of inflammation
of the Lungs, & died of a suppuration within
them. - Now upon the whole, in such a case,
I am clear there may be the utmost relief
from

276
from the Operation I have just now mentioned,
and that cases requiring the Operation will
occur very frequently, but the case has not
been understood, nor properly attended to,
such cases especially following broken ribs,
have happened often, & the patient has lost
his life from the Surgeon being ignorant
of the true Cause & the manner of curing it.
Next, the Trocar is the proper instrument,
and we are not to think of incisions, for
tho' we are mistaken, if we use the small
Trocar, the patient will not suffer any
material injury, & we take one that has
a blunt point, & enter it into the skin,
then obliquely into the Thorax, working it
like a drill, so we enter it without wounding
the Lungs, & unless we are very wrong in
our conjectures, the Air will support the
Lungs. But suppose we do not find Air
come out, that is no material injury,
whereas

277
whereas the incision is very dangerous, producing
violent inflammation, from the air getting
freely in. If we mean to keep any thing in
we prefer to the Canula of the Trocar a
hollow Catheter, or Hollow Bougie; nay with
such an instrument, we can do somewhat more,
a person can apply his mouth or a Syringe
to the tube, & suck every particle of air out
of the Thorax.
I shall next put the case of water being
collected, & let us see how we are to distinguish
it, which I apprehend we can do for
ordinary with a higher degree of probability.
The general marks are very well laid down
by accurate writers, as by Dr: Cullen in his
Nosology. What I have seen are these -
The patient is of a dropsical habit, or some
complaints preceded that almost always induced
this; when there has been a slight inflammation,
& that seems to be discussed, often a
disposition

278
disposition to Dropsy succeeds, as in the Scarlatina,
which occured last year, a dropsical disposition
shewed itself after the disease, or where
other complaints about the Thorax of pain, which
were not followed by marks of suppuration,
in some time after a Dropsy has formed within it,
or this disease will come on, without the patient
being sensible of any Cause. The urine
is often, tho' not always scanty, for in this small
cavity, the difference of the urine is less remarkable
than in Ascites; but still it may
be observed to be scanty & high coloured. Next
the patient feels an oppression about the breast,
has a difficulty in breathing, particularly in
attempting to walk up a hill; he has a Cough,
without any spilling from the Trachea, it is
belchy & dry; his feet are apt to swell at
night; after the disease has made some progress,
the sleep is much disturbed, the weight of the
water pressing upon the organs so very
material,

279
material to life, affecting the vessels of the heart
as well as of the Lungs, so he weaks frequently,
has disturbed dreams, and we distinguish that
the water is not within the Pericardium,
which produces all the symptoms I have
mentioned, by our feeling the stroke of the
heart, whereas, when the water is within
the Pericardium, the heart is buried in it.
Then we ought to attend to the posture of the
patient, that he is much easier in an erect
posture, & on lying down, he feels an oppression,
for when he is erect, the water pushes
down the Diaphragm, whereas when lying, the
Thorax is straitened by the weight of the Abdominal
Viscera. The undulation of the water
may be perceived in several cases. I have
observed that where water is collected, it does
not always float freely, but there is surrounding
the Bag an universal adhesion;
but if the disease comes on slowly, without
any

280
any inflammation to produce a concretion of
the parts, the gliding of the water can be
felt & heard.
Now from all these circumstances concurring,
suppose we are certain of the presence of the
disease, shou'd we not attempt to releive the
patient by an operation? It has been done
but seldom, because till of late years, the
marks of water were not clearly known;
next, as the disease often proves fatal, & the
making a hole in the Thorax is looked
upon with dread, Surgeons did not attempt
any operation, least they shou'd be blamed
for the after death of the patient; but there
is not doubt but that the operation cou'd be
more successful here than in Ascites, tho'
in either case, the disease is desperate, as
where the cause of the collection is rooted
in the diseased Lungs, a schirrous or hard
state produces it, as the hard state of
the

281
the Liver produces it in the Abdomen. In other
cases I have observed the water, & with it an
ossification in the mouth of the Aorta, for as an
obstruction in the smaller circulation produces
Dropsy in the Aortic system; so a general obstruction
in the Aortic system will produce
Dropsy in the Pulmonary, & in such cases there
is very little hope of a Cure, but is just
as possible to cure a patient of a Dropsy of the
Pleura as of the original coat of the vessels;
it may depend upon an unknown disease
in the extremities of the minute vessels, & we
obtain a Cure by producing an adhesion
between the Lungs & Pleura, & yet Respiration
may be carried on tolerably well, Nay
we generally find a partial, & often a total
adhesion of the Lungs to the Pleura; so we not
only obtain a Palliative Cure, but we may
make a radical cure of this disease, we may
occasion a concretion of the parts by the
Inflammation

282
Inflammation of the parts without killing the
Animal, so we wou'd try to determine the proper
method of doing the Operation. - I wou'd
lay aside incisions, which have been proposed
in all cases, & wou'd begin with the Trocar,
& I wou'd first try the effects of letting off
the water, when the access of the Air may occasion
such an irritation of the Pleura, as to
bring on the necessary degree of Inflammation.
We wou'd do the operation early, before the
Lungs are contracted by the water, which in
time presses them to the top of the Thorax, when
they contract adhesions; but suppose that the
water collects again, we wou'd think of an
incision, or rather I wou'd propose a better
method, the introducing a Seton; I wou'd take
a bended instrument, & instead of being the
Circular shape, it shou'd be flat to enter
between the Ribs.
Next I shall suppose a Suppuration within
the Thorax, how are we to distinguish it? that
is

283
is the great difficulty. I might refer you to
the most common books, for knowing when
matter is formed. When previous Inflammation
is succeeded by symptoms of Suppuration, the
patient feels an oppression of the Lungs, has
some degree of fever, clammy colligative
sweats, shivering &c., & a difficulty of lying
in a particular posture; by these we distinguish
the suppuration, but we do not learn
where the matter is seated, but we judge of this
by the seat of the pain, & the manner in
which the patient lies, who for ordinary, sleeps
easiest on the sound side, the weight of the
body straitens that side in the motion of the
Lungs, & the weight of the diseased side also
straitens it by the pressure of the Mediastinum,
whereas, if you lay the patient on the diseased
side, you no doubt straiten that side
still more, but you leave the other free, so
that he maintains life the easier.
Next

284
Next it is necessary to know whether the disease
is within the Lungs. If water is in the Cyst,
we know that it is without the Lungs, but in
the case of matter it may be within the substance
of the Lungs, & not in the cavity of
the Pleura. To judge of this, we enquire if the
patient coughs up matter, if he does, we know
that is within, but tho' he does not, it may
still be within the Lungs. - We next observe
the surface of the side, the teguments, for tho'
the disease has not affected them, yet when
the matter is near to the surface, the teguments
often are thickened. - We wou'd next have
recourse to the stroke of the side, & last of
all to the fluctuation & feeling the undulation,
& hearing the Noise it makes; there is a
possibility of distinguishing both, I knew three
cases where I was so certain of it, that I
caused the side to be opened, in one case,
℔iv of matter were evacuated, in the second
two

285
two pounds, & in the third, ℔vi, & the two
last patients were brothers. Now let us be on
our guard not to fall into a mistake here;
when the patient bends the body quickly or
turns sideways, or when a person is placed
behind him on a low chair, takes hold
of the shoulder, & makes these motions, the
noise of the matter can be distinguished, as
we hear the clacking of water in a bottle
half full of water; but some years ago, I
had a clear proof that we cannot trust
altogether to the Noise; - When I was upon
this subject, a Young Gentleman attending
the Lectures, took a fancy that he had a
Dropsy & was dying, & wrote so to his friend;
I was called, & was suprised to find a
fat well coloured fellow dying of a Dropsy,
but he told me that the thing was beyond
doubt, for not nearly a motion could
be felt, but it was heard, & I heard it
most

286
most distinctly, by making a particular motion
there was a very loud noise, but I found
that before, he had drunk pretty freely of water,
nay he had done so on purpose, for his idea
was that the stomach needed to be distended
before he cou'd press against the water in the
Pleura. - Now here, is a clear proof, that by
such an action, the noise of the liquor in ones
stomach may be felt, so we shou'd feel the
liquor strike the Thorax, that it dashes against
part of the side, & we shou'd mark the middle
of the place with Ink. - Now suppose that we
have discovered the Complaint, & even where the
matter is within the Lungs themselves, if it
appears in the form of an Abcess, & we have
Symptoms of Suppuration, that the patient discharges
some ounces of matter, I wou'd be
in'clined to try some opening lower in the
Thorax, for every Abcess heals with difficulty
if the Opening is at the top; so if there is a
fixed

287
fixed pain & perhaps a swelling of the teguments,
the patient will have a much better chance
by our making an incision there in the common
way. Suppose the Operation be determined to
be done, the place is pointed out from the
Undulation, but if the motion is general,
it is left to the Surgeons Choice, he makes
it half way between the top & the bottom,
as also between the fore & back parts, for if
we go low, the Diaphragm may come in the
way, it being near to the side, & it may
have contracted adhesions. - Having determined
the place, instead of the erect posture,
we may lay the patient horizontally,
whereby he is less in danger of fainting,
& we can make the opening the lowermost
part. As to the Operation, it is so simple,
that it is hardly necessary to shew it; in
a case of this consequence, we are not to mind
the fibres of a few muscles, which are said
to

288
to come in our way, as the Latissimus Dorsi, but
we are to make the Incision which is most
favourable for the purpose between the 2 ribs,
& we dont make one incision humouring the
external, & another the Internal Muscles; we
use a common Scalpel, & we make the incision
farther from the upper than the under edge of
the rib, on account of the furrow for the
vessels & Nerves; in order to give the matter
free discharge, I make the external opening
large & free, then I proceed to slow incisions,
dividing the Internal Muscles till I have the
Pleura in view, I then have ready a small
furrowed probe, & I scratch a hole in the
Pleura with my knife, making it very small,
I then introduce an instrument for directing
it, & use the knife with a blunt point, making
a hole big enough for the discharge of the
matter. - Now this is the common method;
but I am very doubtful whether we had not
better

289
better use a Cord, which answers in common Abscesses,
when the size is very considerable, & the irritation
maybe too violent from the incision, which
perhaps lets in Air too freely; but whether we
use the one method or the other, we may be
under the necessity of trying to prevent all the
matter from getting out at once, as the Lungs
come to be too loose, so we take it off gradually,
but we need not stop it so often as has
been directed, for in the cases where 4 & 6 pounds
came off, every drop of it was discharged in
two minutes, & the patients greatly releived,
by the matter having oppressed them more than
the access of the air. We dress in the plainest
way, & we are not to think of a Canula here,
there being no necessity for using any thing
to keep the wound open; the best dressing is
to lay a piece of cloath as broad as the wound,
over it, & on the outside of it Lint, which you
press against the side of the wound, then you
apply

290
apply the common bandage. -
When Blood gets into the Cavity of the Thorax from
a wound, Sharp advises you not to medle with
it at all, for he says we are not to make an
incision the time the blood is running, because
if a persons Nose bleed, there is no better way
of stopping it than by pressing the Nose & letting
it fill; & next, tho' a great quantity is discharged,
the Absorbent vessels will take it up again. - Now
we are by no means to follow Sharp here, for
if a person receives a wound in the Lungs, I
wou'd alledge that the wounded vessels will
more readily close if the air gets to them pretty
freely, than by keeping it out, so that it will
not alter the Case much whether we make a
wound on the one side or not; if therefore
from evident symptoms, as the paleness of the
patient, the oppression of his breathing, & the
weakness of the pulse, there appears to be a
good

291
good deal of blood pouring out, I wou'd be very
much tempted to dilate the External wound,
so that the blood may get out from the Thorax
as fast as it comes from the Lungs, as it will
be mixed with a certain proportion of air,
it will readily clott in the cavity, so that it
is in vain to throw in Injections to dissolve it,
nor can Sharp prove that a great quantity, 
suppose ℔ii. can be absorbed with any degree
of safety, as mixed with the air from the Lungs,
it wou'd putrify, corrupt, & destroy Life.
Next, if a Surgeon is called where there has been
a collection of blood within the Pleura, is he to
trust to Nature? certainly not; but rather to make
an incision into the side, & let it out.
T

292
Tumors.
I now proceed to explain the management of
different kinds of Tumors, which admit of Cure, by
Operation, vizt. Abcesses, Hydatides; the tumors
which have named by Authors. Atherometa,
Meliceris, Talpa, with the treatment of
Steatoma, of Sarcoma, & the degenerating
into Cancer; & we begin with the kind
of Tumor that is most manageable, & where
the method of proceeding is most determined,
& the execution easy. . Let us first then determine
the way in which a common Abcess is to be
treated, for Authors disagree very much about
that. It is a common practice in France to
cut off a large portion of the teguments, on a
supposition that if these be loose after the
matter gets out, it confines the matter, & produces
dangerous consequences. Others propose that,
a trail of Caustic, nearly equal to the length
of

293
of the tumor shou'd be applied; whilst others in
place of the Caustic, cut the Abcess from end to end.
A few imitating nature, satisfy themselves with
small openings, which they preserve by means
of a Cord or Seton. Now upon the whole, if a
collection is made; & that we clearly perceive
a Scrophulous taint, let the Surgeon be cautious
how he attempts any operation, for he ensures
blame, without the prospect of doing much
service; if the tumor is small, tho' there is
an evident fluctuation, he leaves the Cure
to nature, or he applies a common Supp[orting]urating
plaster to the most dependent part of the tumor;
but if the matter is yet to be spread under
the Teguments, the danger being in proportion
to the Cavity, as soon as the fluctuation is evident,
he ought to let the matter out. This leads to
the general point with regard to the treatment
of an Abcess, & I am satisfied, on comparing
the different methods, that the near we
imitate

294
imitate the method of Nature, so much the better;
the cutting out large portions of the skin is unnecessary,
& the making large incisions admits
the Air too freely, which proves hurtful, & a
great degree of inflammation & suppuration succeeds,
whereby the Constitution receives a violent
shock; - So the best method is to use the Seton.
We introduce a Cord, giving a favourable discharge,
by introducing the end of it at the
very bottom, & the other, as the situation of the
tumor best allows; for passing it, we use the
Crooked Trocar of Heister, only having the Perforator
of the sharp lancet shape, or if we
want such an instrument, the place of it
can be very easily supplied with a common
probe & Lancet. It will answer best to make
the opening at the top first, that the matter
may not run out till we have passed our
Cord, I then enter a large probe thro' the
Abcess, till I bring the point of it to strike
the


295
the skin below, when I cut upon the point of it,
& bring thro' the Cord; we draw the Cord every
day, bandaging the Abcess properly so as to
prevent the matter from lodging in Cysts
& forming Sinuses, & to assist the skin in recovering
its Tone. If we observe that the
matter is too much confined, we either enlarge 
the opening or cut upon the Cord as
far as it is necessary.
Next suppose in the Abcess, Hydatides,
or that a Bag is filled with; the method
of Cure differs in no other shape, but a large
opening is necessary, & we cannot attempt
the Cure by a Seton. - As to the nature of
these Hydatides, I am at a loss to determine;
they are not changed Lymphatic vessels as
some have imagined, nor are they parts of
the Cellular membrane joined to the parts of
the body, for there is no connection by means
of

296
of Solids, neither do we find vessels running
upon them. You know that the Hydatides, at
least such as are taken from the Liver, are
supposed to be worms; Now I examined these
I shew you, which were discharged from an
Abcess of the Loins, the very moment they came
out, but I cou'd not observe any thing of life
in them, there was not the smallest spontaneous
motion, nor by bruising or tearing them,
cou'd any contraction be seen; but they are different
from many of the Hydatides, they want a double
kind of skin; vessels upon the inner side, which
I take to be a kind of Ovarium; here there are
no smaller ones within larger, but a number
of different sizes floating in the same cavity,
& as to the point, that the smaller are found
within the larger, I have not seen an absolute
proof of it. Now whether can we imagine
that the Cellular substance becomes diseased,
& a number of Cysts containing water formed
in

297
in it, as in the Præternatural Encysted Hydrocele,
and that in consequence of a Suppuration the
bags are loosened. I leave the nature of them to
be enquired into by future observation, but as
to the Method of Cure, it is to give them free discharge,
& from the case I have mentioned, it wou'd
appear that a bag formed by them, is more
disposed to heal up than common Abcesses.
Next let us suppose the case of the Atheroma
or Melicotis, or of Talpa, which is such a
tumor in the head. The treatment of these was
explained in treating of the præternatural
encysted Dropsy; we wou'd then remove the
Cyst altogether, or we dispose it to slough
off or granulate, making an incision thro'
them, exposing them to the Cold air, or we
pass a Cord thro' them. Generally speaking
the first is the best method, & in the Talpa
in

298
in particular, it can be executed with great ease;
before I knew the connection of the tumor to
the teguments & to the Cranium, I caused the
Surgeon to make a crucial incision of the teguments,
& to dissect out the bag entire which was
tedious & painful, but on examination I found
the real Cyst, the Bag containing matter had
little adhesion to the common teguments, so that
I cou'd seperate it with the top of my finger,
& that it was not necessary to use the knife;
so the next I met with, I caused to be made, a
longitudinal incision upon the large bag, then
sliting open to pull away the Cyst, which
was done with ease, & coming to other small
Cysts, instead of cutting into them, with the
point of the finger the Surgeon turned them
quite out. By these easy separations it wou'd
dispose us to think that these may form
Hydatides, but in general, in other places
of

299
of the body, such Cysts are firmly connected.
The method of Operating upon them than these
is plainly this - to save the teguments as
much as possible; if the tumor does not exceed
the size of an orange, we scarcely need
to cut off any of the skin, provided it is not
diseased, but we merely make a longitudinal
incision, then instead of following Authors
in attempting to take out the bag entire,
having dilated it a little, so that we can
get hold of it readily, we on purpose cut
into it, when we can seperate it with the
knife more readily, if no large vessel or
nerve is contiguous, but if there is, one is
in hazard of cutting these, so we leave it, &
the succeeding Suppuration will make the
Bag granulate & throw off, so there is no
danger of a return, provided you [leave] expose that
part of the Bag Ast. freely to the dressings
&

300
and to the Air.
What I have said applies to the Atheroma &
Meliciris, but there remains one more
kind of Cyst, what is called Ganglion,
which is the liquor collected in the Burræ
Mucosa, but Anatomists have overloaded
these Burræ around every ones of the Tendons.
As to the Cure, many have done it, by giving
a violent blow & bursting the Sac, but it
is better to puncture the Sac with a small
Needle, & to draw thro' it, whereby you
make the Cure with great safety. Tho' I am
much persuaded that Tendons have less
sensibility than is common believed,
yet I dont recommend the slitting open the
Sac because of the inflammation which
might follow, so a small Cord run thro'
such a Sac will be the best method of
Cure.
Let us next consider the treatment of the
Steatoma

301
Steatoma. Authors have spoke of this as Encysted,
they speak of a Cyst that incloses it,
& next they conceive that a single particle
of fat; these, as far as can observed by
the Microscope, are but bags collected
into Lobes, & the these are joined together
by the common articular Cellular substance.
Next there is no general Cyst containing
the whole mass, but the utmost Cyst is merely
the Cellular substance condensed, as by blowing
into it we can change it into a Reticular
matter. Upon the whole, the more one thinks
upon the manner in which it may be produced,
the more he is puzzled to account
for the Cause of it. It is not the extension
of original, but a vast collection of new
parts added to a particular state of the body,
having the same structure as the sound. The
degree of consistence varies much, we sometimes
find it not firmer than the ,
&

302
and in other cases it approaches to the hardness of
the Sarcoma, or we find a mixture of a reddish
fleshy like substance.
Many, as Heister, advise to discuss the Steatom,
& restrain its growth  by applications or
pressure, & Surgeons will lay plates of Lead
over them; but all such attempts are not
only fruitless, but hurtful, for instead of succeeding
in restraining the growth, we cannot
do any thing that will more promote it,
whatever irritates the parts, makes it swell,
so we wou'd lay aside all thoughts of that kind.
With respect to Medicine, we have no instance
of a Steatom being put away by any course,
patients have undergone long courses of Cicuta
or Mercury, but to no purpose; so, if the
Steatom is so situated that it can be removed,
one wou'd never attempt to put
the patient under a Course of Medicine
that can affect the constitution, or use any
application

303
application that is irritating; if we are forced
to humour the patient, let us apply some inocent
substance, but if he will submit to the
proper treatment, it shou'd be cut out as soon
as the nature of the disease is clearly marked,
because it is the nature of it to increase in
so gradual a manner as becomes dangerous,
& as it increases in size, it alters in its nature,
so that a blow wou'd produce a new
working within it, which may end in Cancer,
or after extirpation, a Cancer may come on
in the place of it.
With respect to the manner of Extirpating it,
if the Skin slides on the tumor, we make a
straight incision, draw it back, & dissect out
the Steatom, & tho' it is of great size, the
skin in a few days will recover its Tone.
The Next kind of Tumor is called
Sarcoma, which term has been applied in
a very vague way; the schirrus of the Testicle
has

304
has been called Sarcocele, or Sarcoma of the Testes.
But besides the Schirrus of Glands, substances
form in different parts of the body of a red colour,
nearly to that of the Muscles entering
them, but without any regular fibrous structure;
they grow from the throat, or within the Rectum.
Now with regard to these, many are not apt
to return if cut early, & even where they
do return, it is in their first state, they do
not put on the Cancerous appearance, but if
such a tumor has remained long, it becomes
unequal in its shape, & from irritation, is
more apt to degenerate into Cancer than
the Steatoma; we ought therefore to be more
attentive in making an early seperation of it,
& it is a piece of plain Dissection.
The Last tumor is the Schirrus, by which
we understand such a swelling as with time,
or from irritation, or when broke, or exposed
to the air, or from any cause, degenerating
into

305
into Cancer; if the tumor has ulcerated, we call
the disease Cancer, to which we before applied
the name of schirrus, & as no part is more
frequently subject to this complaint; or more frequently
requires an Operation on that account
than the Mamma, I shall consider it as a
general example. - We find then that a
Schirrus can be produced in the Mamma,
from external violence, as a blow given to a person
in perfect health, & generally if a hard lump
forms in the breast after a blow, & remains
some weeks, shou'd it break, the probability is
that the Ulcer will not heal, but turn into
a Cancer, & I wou'd make a general observation,
that Schirrus degenerate[ng] in that manner
most readily in the Conglomerate Glands,
for the Conglobate, tho' they swell in consequence
of blows, the swelling does not end in
the same dangerous manner, & this is likewise
true when the disease breeds spontaneously,
in

306
in so much, that I never saw an example of Schirrus
& Cancer beginning in the Conglobate Gland,
tho' it is probable that this may happen, as
the acrid humours from all parts of the body
pass thro' them. Next the Mamma is subject
to hardness & swelling from its office of persisting
Mick; we find often large tumors produced in
the Mamma from Nursing, but tho' these
give the same feel as tumors forming from
blows, yet they seldom degenerate into Cancer;
my father used to alledge that he had never
seen a single instance, I may say I have
seen one or two instances of real schirrus &
Cancer from nursing, but trusting to his opinion,
I have seen repeatedly very great hardness
continue for weeks & months, & yet I
have ventured to apply a common discussing
Plaster, or Poultice with a weak solution of Sacch
Saturn, & if this brings it to a suppuration,
the wound heals rapidly. - Lastly, Schirrus
begins

307
begins in the breasts in a very insensible way,
& without any evident Cause, particularly about
the decline of Life, when the Menstrual flux
becomes irregular, or ceases entirely, & it often
[illegible] on so suddenly, without any previous
marks of inflammation, that the tumor is the
size of a walnut before the patient is aware
of it, & it remains several weeks & months,
without giving much pain. - Next suppose that
a Schirrus shou'd come on in that insensible
manner, so far as I have observed, the common
progress is thus, that from five or six months from
the time of observing it, when perhaps it was
not the bigness of a Nutmeg or Walnut, it increases
to the size of an Egg; in as many months
more, perhaps the size is double. In some very
lucky cases, the tumor remains without any
sensible increase for a number of years, but
this is not observed perhaps in one of twenty Cases.
After the tumor acquires nearly the size of
the

308
the fist, sooner or later, according to the situation,
the pains of the patient increase considerably,
he feels a gnawing pain in the part, shooting to
the Axilla & shoulder; & now examining the
Lymphatic vessels & the Glands, you will often,
tho' not always, feel some of the Glands just behind
the edge of the Pectoral muscles, between
that and the Axilla, hard, tho' not much enlarged,
Nor bigger perhaps than a horse bean,
& unless a person is used to the feel, & knows
pretty exactly where to feel, he might not discover
the swelling of them, a Surgeon not attentive
to the Course of the Lymphatics, wou'd
pass the hand over the part, & imagine that
all was sound. - These continue gradually increasing,
& are succeeded by others deeper & nearer
to the large vessels in the Axilla, & are felt
by relaxing the Arm, & by pressing the point of
the fingers deeper into the Axilla. - In two
or three months more, there is a discolouration
of

309
of the skin, & it clings to the tumor, grows rather
thinner, very often unequal in its surface, & often
the Nipple is drawn inwards; at last an erosion
begins, & spreads very fast; in the mean time
the tumor increases, & in some cases, before the
Ulcer has enlarged much, it bleeds violently,
tho' it is not perhaps 1/4th: of an inch deep, [illegible]
ounces or more will be thrown out; it is restrained
with difficulty after the breaking of ye. Ulcer.
In 12 months, the patient generally dies, & during
this time, she is very miserable, suffering the
Symptoms that are discribed in every book, & that
whether Medicines are given or not. - The disease
will take this progress in 49 of 50 cases, so
that I wou'd propose, in place of putting our dependance
on Medicines, to attempt to prevent
the effects of the disease upon the Constitution
by an Operation; but I find myself at a difficulty
in coming to a conclusion, because several
eminent writers have discouraged the attempt
of

310
of operation, as Le Dran, & Sharp, & my father has
mentioned 60 cases where he has had the operation
performed, & not above five remained
free of the disorder some years after the operation.
Now as there is no doubt that this is a fact,
yet I find that the success of the Operation is much
greater than has been supposed; I must alledge
that the far greater part were of the worst kind;
the practice of Surgery was then at a low ebb
in this Island, they did not venture to perform
Operations in capital cases, but tampered
with their patients as long as they could,
& then sent them to town, where the Cancer was
extirpated, after the mass of blood was thoroughly
tainted. - But let us consider the matter;
A person has contracted a Schirrus from a
blow, surely it will not be said that the
whole mass will be tainted at the first appearance,
it takes a certain time before the
matter breeds in it, & the Lymphatic glands do
swell

311
swell not for a long time, so there can be no objections
to the taking it out previous to the swelling.
But suppose next the Schirrus breeds spontaneously,
you will say that this evidently shows a Cancerous
disposition in the body, so that an operation
cannot be expected to be attended with success.
Now I do not see that this conclusion follows,
for if the general mass of fluids are so disposed,
how comes it that the schirrus appears in this
single point, & not in both Mammæ at the
same time; but if the worst kind can be produced
by a blow, the constitution tainted, the
tumor may begin without any Cancerous taint,
& the taint may be communicated to all the
other parts, so let us remove the local affection,
& the patient is cured, & we can never pretend
to say that removing the diseased mass
can add to the taint of the blood, & the only
injury sustained is the pain & danger of
the operation, which is in comparison slight.
But

312
But next suppose the Case cancerous, or an Ulcer
to have formed; it is admitted that the Ulcer
very soon destroys the patient, & whilst living,
she is in the utmost misery; so suppose by
an Operation I cannot cure her, & that the
blood is inoculated by the Cancerous taint, I
am doubtfull whether a patient submitting to the
operation, & the disease returning, suffers much
more than by allowing the Cancer to continue,
& I know that many escape in such circumstances
& situations. I have kept a pretty exact list of all
the patients that I have attended, taking an account
of those cases where I have seen the operation
done in the Hospital, & I find that I have
attended 47 patients where the operation for
schirrus & Cancer was performed, & many of
them much later than I cou'd have wished,
in several, there were not only schirrous swellings
of the Conglobate Glands, but Ulcer in the
breast; & of these sixteen still remain, so that
I

313
I am much inclined to be of the opinion that we
ought to attempt the Cure by an operation.
It remains to shew the steps of the operation, which
are very simple. We first examine if we can
remove the whole of the disease, we see that
the breast has no adhesion to the parts beneath,
& that there is no swelling of the Axillary
glands, or if there shou'd be any, that it is
such that we can remove it; we determine with
regard to these glands as well as we can,
streaching the arm, slackening it, & trying every
posture; but if the patient is fat, there is often
a swelling in these glands which you cannot
discover with the hand, this shews the necessity
after the operation, of feeling with the fingers put
into the Axilla. Next, with regard to the
Mamma itself, we determine whether it adheres
by moving it upon the ribs, whereby, we
know that it is impossible to do the operation;
we will still be more satisfied, if we find
on

314
on stretching the arm backward, to stretch the
Pectoral Muscle, the motion continues, which
shews that the Cellular substance is loose behind,
& that there is no adhesion to the muscle.
Having determined these points, I next propose,
that altho' a very small part of the breast
only be diseased, & unless it be of very great
size, we shou'd take out the whole, for the
danger is increased, the pain not much greater,
& the wound, if the skin be properly managed,
will heal in a reasonable share of time,
generally it requires 2 months, tho' some require
three. In doing the Operation, we do not use large
knives, we do it quicker with a common
Scalpel. The patient is seated on a low chair,
& the Surgeon sits before, while an Assistant
places himself behind, with an arm over each
shoulder, to stretch the skin, & take care of the
bleeding vessels; generally he puts his finger
on them to stop them till the operation is
over

315
over, but they shou'd be tied up as soon as
the bleeding is observed, for from want of
attention to this, a great quantity of blood may
be lost, the patient never fails to grow faint,
when the bleeding stops, but after the Dressings
are applied, the vessels bleed again, & they may
burst out a second or third time. It is the business
of the Assistant to have a pair of forceps
in his hand, to take hold of a bleeding Artery,
& draw it out till the Surgeon ties it. The
Surgeon cuts in a Circular manner as much
of the skin as he proposes to remove before he
detaches the Gland, & the circle shou'd be
somewhat less than the tumor, otherwise, by
the skin retracting, a much larger wound
may be made than is necessary. He meets
with the External Thoracic artery coming
out from the Axilla, & this will be enlarged
in proportion to the tumor; on the other side,
he will generally meet with small branches
from

316
from the Internal Mammary. Having seperated
the skin all round, he cuts in till he is behind
the Gland, & detaches it from the Pectoral
Muscle, & suppose there is an adhesion of it
to the Muscle, that is not to hinder us to
do the operation; Albinus thought that the Incision
of it was attended with locked jaw and
other dangerous symptoms, but he was mistaken.
The Surgeon examines from time to time with
his finger that he leaves no diseased portion,
he then looks for the bleeding vessels which
he cou'd not conveniently take hold of, draws
them out & ties them. Next he is to look for
swelled Lymphatic glands, he puts his finger
under the skin & examines them, & removes such
as are diseased. The management of the wound
is perfectly simple, & will be explained afterwards.
Now tho' we have thus removed the complaint,
there is danger of the disease returning,
so

317
so we ought to do two things, the first, to keep
in an Issue for ever, without entering into
any reasoning upon the effects of Issues; I
wou'd observe a plain fact, that the disease
never returns while the wound continues
open to discharge freely, yet soon after the
wound heals, it may begin to appear again;
so my father made it a practice to direct
an Issue to be kept in the part, you allow
it all to heal but a small piece, which
you dress with Issue Ointment. - If the
breast is very large, & a portion only taken
away, we ought not to make the Issue in the
breast, but if the whole is taken away, it
answers best in the part; but in doing this
the Surgeon exposes himself, for if the disease
returns, it will be in the part, & it may
be said that the Surgeon kept it from
healing; but yet the discharge from the part
is best, as it will probably have the best
effects

318
effects. By the time the patient has recovered
the shock of the operation, she ought to be
put on the Bark with Milk & light Diet,
& she may try a course of Mercury
or Cicuta.
I shall next explain the method of recovering
Drowned persons, but I am here only
to speak of the Operative part, referring you
to an excellent paper by Dr. Cullen on this subject.
We cover the body with some warm substance,
& draw a small quantity of blood, cheifly
from the Jugular viens, as the vessels of the
head are much gorged by the stoppage of
Respiration. The general view we have is to
restore the Circulation of the blood. You recollect
the experiment of cutting the heart out of an
Animal, after which it cou'd move its body -
for

319
for an hour; life does not immediately depend
upon the Circulation, but it cannot
long exist without it, in some animals
much shorter than in others; there is an
action & reaction of the Nervous & Circulating
systems upon each other; now Where a person
appears to be drowned, often the Circulation
has almost entirely ceased, yet the vital
principal remains, but wou'd soon be extinguished,
unless we restore the Circulation;
so besides keeping the body warm, & endeavouring
to ease the vessels of their blood,
we mechanically propel the blood by proper
friction, & as soon as possible, we
endeavour to restore the Respiration by
inflating the Lungs; so the stoppage of this,
the stoppage of Circulation has in a great
measure been owing. Now as the most
simple means of doing this, I wou'd propose,
that instead of clapping a tube to
our

320
our mouth, & to the mouth of the drowned person,
we shou'd blow the air thro' a tube put into
the Nostrils, which is the natural passage
for it; the tube is made to fill one Nostril
accurately, & you press upon the other Nostril,
as they communicate to the throat, & the
mouth is kept shut by covering it with any
[illegible] substance, & to prevent the air from
passing into the stomach, another person takes
hold of the fore part of the Larynx, & particularly
the Cricoid Cartilage, & push back against
the Œsophagus, & in a dead body stiff with
Cold, I can make the whole thorax move,
so I cou'd do it certainly when the Vital
principal or warmth remains; but if we need
greater force, we either use the Syringe or
Bellows, & we may enterpose a double
stop Cock between the pipe & the bellows & Syringe,
& throw in heated air, or warming the syringe
it retains its heat for some time.
Next

321
Next it is proper to stimulate the stomach, &
Intestinal Canal, & to fill the stomach with
warm liquor poured into the mouth, or we can
with a tube, having nearly the bend of the
male Catheter, force the liquor over the Trachæa
into the Œsophagus; & we must throw
substances into the Anus, as the smoke of Tobacco,
for which I have shewn you an Apparatus;
but it is likewise of use to throw
in warm liquors, as wine & water, as a
Stimulus to the system, & we may try
to bring on a vomiting with the Emetic Wine,
for if it can bring on a spontaneous motion
of the Diaphragm & Abdominal Muscles,
it will have more effect than any thing
we can do by art. For injecting Liquors
into the Intestines we use a Syringe.
Going

322
Going upwards, I find myself obliged to
say something of the cutting of the Sterno-Mastoid
muscle in the Neck. Now altho' Sharp
speaks of this as an operation that may be
frequently necessary, yet I apprehend very few
cases will occur where it can be proper, because
there is generally a complication, it does not
depend upon a single muscle, but a number
of parts are concerned; or if the complaint
shou'd depend upon the action of a single muscle,
the patient at first probably wou'd not allow
the operation, nor the Surgeon think of it, & after
it has remained a length of time, it is difficult
to alter the posture; but shou'd such a case
occur, instead of imitating Sharp, by thrusting
in a Sharp-pointed instrument, as the Probe
Razor, cutting & dividing the muscle at one
stroke, as the Internal jugular vien is immediately
behind the Mastoid Muscle, with
the

323
with the other vessels & Nerves, we wou'd open
the skin with the first stroke, then cutting
the Muscle thro' gradually with the knife,
we raise the last fibres of it upon a furrowed
probe. - But tho' upon this account such
an operation will seldom be needed, yet sometimes
the skin of the Neck is contracted by
burns, & if we find that this affects the
situation of the head, it will be proper to
divide the skin & in the time of the Cure
to turn the head the other way, leaving an opening
in the wound, which will fill up
with granulated flesh.
Bronchotomy

324
Bronchotomy or Tracheotomy, by which we
understand an Incision in the Trachea Arterea.
From what you know of the parts covering it,
& of the manner of Respiration, it will be
obvious that this operation may be performed
without any considerable degree of danger;
the principal danger is from the bleeding
of the vessels that enter the middle of the Thyroid
Gland, which is situated cross the Trachæa, over
the first ring, not over the Thyroid Cartilage,
& the Respiration may be continued nearly as
well as thro' the Glottis, as in both cases they
are passive, or supposing that they are in
any measure active, this activity is not injured
by the Operation.
Let us next consider the different cases in
which the Operation may be adviseable or necessary.
If in Deglutition, a substance slips under the
Epiglottis, it may stop in the passage, and
not

325
not merely from the straitness of the passage,
& particular shape from the projection of the
Ligaments of the Larynx, but an involuntary
contraction will be produced in the Muscles,
& if, as I have proved, we have power to
shut the Glottis by a Muscular action entirely,
so as to stop either inspiration or expiration,
it must be evident, that if any small body
falls into the Glottis, the muscles may be applied
so closely as to intercept the passage of the Air,
& Cases of this kind have occured in this
place, as one of a Child suffocated by a pea,
& another of a patient in the Infirmary choaked
by a bit of meat.
Next we find in Authors examples where large
bodies put into the mouth, have sliped back
into the Pharynx, & by pressing on the back
of the Larynx have produced Suffocation.
Next we wou'd suppose ourselves much
exposed to danger, (which experience proves
to

326
to happen very seldom) of suffocation in consequence
of a thickening of the Membrane of the Larynx.
The membrane of the Nose, tho' it is closely
glued to the Bones, in Coryza swells so as almost
to interupt the passage of the air; &
the membrane of the trachea is a continuation
of this, or of the same nature, so we wou'd imagine
that it wou'd be exposed to the same
swelling, & in a few cases this no doubt take place;
I shewed formerly when considering the diseases
of the Lungs, a preparation where the
Larynx had been much swelled & inflamed
& the patient was supposed to have died
of Peripneumony, but on dissecting the body,
the disease was found confined to the Larynx;
& several other cases have occured where
the Cause cou'd be more evidently braced,
as where there was a necessity of making the
perforation in consequence of swelling from
Lues Venerea, & I have seen an Ulcer
of

327
of a corroding nature spreading from the top of
the Sternum up to the throat, & which at length
threatened a suffocation, & occasioned the operation
to be done, & the patient lived for six or eight
months, tho' there was a discharge of matter,
& he died Hectic after the space of a year.
Next we wou'd suppose that we are in danger
of suffocation from a swelling of the neighbouring
parts, particularly of the Tonsils from
catching Cold; I have seen the swelling such,
that the Surgeon was under the necessity of
making an incision into the Tonsils to let
out matter, & supposing we are not able
to lessen them by incision, we may be under
the necessity of making an opening below.
We see the necessity of this still more clearly
if an excresance grows on the throat, as a
Polypus; I shewed you one the size of an
Egg, taken from behind the Velum Pendulum
Palati; & in the German Transactions,
we

328
we have examples, where from the complaint;
the patient has been suffocated. I shew you
a case where an immense Polypus grew from
the top of the Œsophagus, of which you have an
account in the last Volume of the Medical
Essays. It was thrown from the Œsophagus & Pharynx
into the mouth, & it hung out of the mouth
on the Chin; the Respiration was stopped, so
before the Surgeon wou'd medle with it, I
advised that he shou'd make a small hole
in the Trachea. This case plainly shews the
advantage there may be in extirpating such
tumors deep seated in the Throat.
One further supposition remains, that the
Trachea may be compressed by tumors situated
at the back of it, particularly in the
Bronchocele, by which Surgeons understand
a swelling in The Thyroid Gland, & Mr. Sharp
supposes that this is the only case in which
Bronchotomy can be of use, but from what
we

329
we have said, he is evidently mistaken, nay it will
seldom be proper here, & from the small tube
he recommends, he probably never performed,
because it is not long enough to enter in a
sound state, far less in this disease where the
distance is considerable.
The Operation may be performed with ease &
safety; the patient is placed on a low seat
leaning backwards; if any substance has stuck
in the Trachea, we are not to mind the several
steps, but cut in as speedily as
possible without any instrument at hand, for
a person cannot be without breathing much
more than the space of [a] half a minute.
But supposing the Surgeon had time, he
begins the Operation with the common Scalpel,
making a Longitudinal Incision thro' the
teguments, for if we make it across, the
Trachea being very moveable, the incision
into it wou'd get above or below the
transverse

330
transverse incision of the Teguments. We begin it
over the Cricoid Cartilage, & from that go downward
for the length of an inch & a half, or
two inches; we are under no necessity of cutting
thro' the Sterno-Hyoidic muscles, we only
seperate them; we now bring into view the Thyroid
gland, the most part of it is thus saved,
as it consists of two large lobes joined together
by a middle thin portion; now we scarcely can
avoid this gland; where the neck is very long
we may get beneath it, but in general, a
part of it will be cut, & as we are unacquainted
with the use of it altogether, we are apt to suppose
that no other danger arises from the
division of it, than the blooding, as it is Vascular,
the superior & inferior Laryngial Arteries
uniting here. We next bring into view
the coats of the Trachea, & we ought with the
knife to dissect away the Cellular substance,
or any other parts that adhere to the Trachea
where

331
where we intend to cut it, that nothing may remain
in finishing the Operation but the thin
coat of the Trachea, for if after we open the
Trachea, there is any considerable blooding,
it occasions great inconvenience to the patient
by exciting a Convulsive Cough, therefore we shou'd
wait till the blood has entirely stoped.
If there is any internal Inflammation, we allow
the Arteries to bleed freely, & that may save
the patient from the Operation, i.e. from opening
the Trachea; but if there is no suspicion of this
kind, we take up the large arteries with the Needle,
& by gentle Styptic substances, & Lint, we stop
the matter. - We now proceed to make an
incision into the Trachea, which we do transversely,
on account of the Cartilages, & we
ought to finish the operation with the same
knife, but it is easier with a large sharp
Lancet; the orifice flies open, so that it
readily receives the point of my finger,
&

332
and it is wider than the Glottis, & there is no
difficulty of the space filling up afterwards.
Dr: Haller wou'd persuade us that an irritation
of the Trachea does not produce any considerable
uneasiness, nor excit Coughing, & he supposes
that the Coughing proceeds from an Irritation
of the Larynx; but I have observed, that any
thing droping into the Trachea, occasions
Coughing, & I have tried the experiment with
a probe, & immediately on touching the back
or sides of the Trachea, the patient was thrown
into Coughing.
Perhaps immediately after the operation, it
will not be necessary to introduce a tube to
preserve the opening, but in the space of a
few days, when the parts inflame, there is a
danger of its shutting up, hence in time of the
Cure, there is a necessity for being provided
with a proper pipe, so large, that the patient
may draw a sufficient quantity of Air thro' it,
and

333
and that will not readily stop by the slime &
matter of the Trachea, & to prevent one taking
it out, frequently it is made double, & the inner
one draws out easily, so that leaving the outer
one always in the Trachea, we take out the
inner one, clean it, & replace it. To secure
this pipe, & to prevent it from rubbing against
the Trachea, I have caused a machine to be
made which answers exceedingly well, it
consists of a semicircle thrown over the Trachea, so
as not to press upon it, & it is fixed to the
neck like a common stock; if the patient feels
an inclination to Cough, he can draw back the
pipe with the hand till the Cough ceases, &
the opening being opposite, he replaces it readily;
the teguments in a few days close round the
pipe, & so the passage becomes almost fistulous,
but when the pipe is no longer necessary, when
the opening closes with difficulty, it is only requisite
to touch the sides wt. Caustic to make them raw
Bronchocele

334
Bronchocele, or the Extirpation of the Thyroid
Gland. - From looking into the works of Surgeons,
one wou'd imagine that this operation
might be done with tolerable safety, but we
are not to undertake it without a great many
Cautions. The Inhabitants of Mountainous
Countries, as the Alps, seem particularly disposed
to this disease, & least the swellings
they are subject to are very frequently in
this Gland; even in this Island it is not uncommon,
I may have seen ten or twelve
examples of it.
It is pretended that Burnt Sponge has a considerable
effect in discussing the Bronchocele,
but I have known it tried without the smallest
advantage, nay the swelling of this gland
resists the most powerful medicines, I have
given Cicuta for several Months, & afterwards
a course of Mercury till the Gums
were

334
were sore, but with very little change, only it
did not seem to increase for the space of five
or six years. Sometimes it increases suddenly,
& there are instances of persons being suffocated
by it. The Late Dr: Gregory met with one
case of this kind in his Practice, & Dr: Cullen another.
As we find the growth is so uncertain, we
shou'd not propose the extirpation when small,
but when large, some operation may be necessary
on account of the pressure made on the
Trachea, but even in this extremity, I wou'd
not extirpate the whole gland, because by this
time, the lobes are pushed back on the Carotid
Artery, & the swelling has enlarged
the 8th: pair of Nerves, & the Intercostals; so if
the Gland notwithstanding the use of Medicines
is disposed to increase, but is not so large
as to push back to the place of the Carotid Artery
or Nerves, it may be possible to extirpate it,
but if it is of a considerable bulk, we
shou'd

335
shou'd only take off as much as strangulates the
Trachea, & we may use freedom with it, without
being affraid of its degenerating into Cancer;
I have seen Suppuration in it, & the sore had
an [a] ugly look, but resembling Scrophula more
than Cancer; so we may extirpate the middle,
& this will occasion the rest to subside.
The Operation is a plain piece of Dissection,
only you will find a good deal of blooding,
& as soon as any vessel springs, it is proper to
secure it, otherwise the effusion of blood will be
considerable
Hare Lip

336
Hare-Lip; by which you are to understand
a fissure in the Lips, whether Natural, or made
by accident. The Division is almost always
in the Upper Lip, I never saw a child born with
the disease in the Under Lip, & yet it is no
easy matter to explain this. We find two
bones in the upper jaw, which seldom grow
together; in the under jaw we find two original
pieces, but there is no division originally
in the softer parts. In some cases the
Velum Pendulum Palati is affected in the
same manner; in a few cases there is an
opening thro' the Lip, thro' the Velum, & [thro']
between the two Maxillary bones, but the
most common is the fissure of the upper
Lip. Sometimes there is a single fissure, sometimes
two, & then it is called Labium Leoninum.
The Complaint can only be cured by an Operation.
If

337
If a Child be born with this Complaint, we are
disired to operate immediately, but if the Child
can suck, we shou'd delay the Operation, if
not, perform it immediately. It is plain that
for ordinary, the Child will not be able to
suck, because the lips cannot be drawn closs
to make the void within the mouth; but
in a few cases the lips are glued down by
Cellular substance, which is so loose, that they
can bring the opposite sides to meet, so as to
suck.
We place the patient in a low chair before
us; we first seperate the Lips from any unnatural
adhesion with the Gum, with a crooked
Bistory having a sharp point, & we carry
this incision a little higher than the angle
where the two sides meet, because the next
step of the Operation is the rendering the whole
edges raw, that they may grow together,
& to be sure of this, we ought to cut out
the

338
the skin lining the two sides joined at the angle.
To do that, some make the incision with the
knife, sliding in a bit of probe & cutting upon
it; but tho' I wou'd discard Scissars from this
operation, especially where any considerable thickness
is to be divided, here I know that the
Scissars do the operation more exactly than the
knife, only they shou'd be made stronger than
usual, & the blades short.
The Surgeon in cutting the right side, places
his thumb within, & his finger on the outer
side, wiping the Lips dry; to cut away the
left side, he stands at the right side a little
behind the patient, & puts the forefinger
into the mouth, & I wou'd prefer the hand
to the Assistance of any Forceps, which pinch
the lip & give pain; thus we make the
Incision up to to the corner, & dividing the
angle, we have a state of the wound
fit for growing together, & if the sides can
be

339
be brought together to unite, we are sure of a
Cure.
If there are two natural openings, & the piece
between small, we may cut it out altogether,
as if there was one opening only; but if the
piece is large, we do the operation on each
side, & if the lip is not very loose, we ought
to finish one Cure before we begin the other,
as we cannot stretch the parts on both sides
together.
For uniting the lips, some have used only the
Uniting bandage, & it has succeeded in a
few cases; but it is with risque, & we fail in
as many as we succeed, & from the loss of substance,
we do not succeed so well a second time.
I wou'd trust to Plaster laid on the Cheeks &
tied together more than to bandage; but the
Suture is certainly the best manner of Cure.
Some propose the common Interrupted Suture,
but it has no evident advantage, it is a
mistake

340
mistake that a thread will give less pain than
a needle, which being round, is not so liable to
cut the lip; & having tied the thread, there is not
space to draw the sides closser together without
new substance. We have therefore Needles of
Silver or Gold, but with steel points, to pass
readily thro'; after they are passed thro', Sharp
directs to cut of the points, but it is much
better to have them fixed in with the turn
of a screw; I have made them thicker than
a common pin, as giving less pain, & not
cutting the lip so much. The putting them in
requires particular nicety; we lay the sides
together accurately, & particularly the red parts
of the lips, as the smallest deformity is distinguishable
by the eye, & beginning with placing
the lowers parts, we pass our needle at the
very edge of the red part of the lip that there
may be no fissure left; the second is to be
passed very near the upper end, that you
may

341
may not leave a fistula, & two in many cases
will be sufficient, but we had better make
one too many than one too few, & therefore
in general three needles will make the best
Cure, & we introduce the third exactly halfway
between the other two, & then take off the points.
We next draw the lips of the wound together
by a thread, & we may either have a thread
for each pin, or we may make one serve for
all, but I wou'd rather apply a thread to each,
that we may alter any part at pleasure, &
we are to begin drawing the threads in the
same order that we apply the Needles; by crossing
the threads, I press together the sides of the lips
filling up the space exactly, & having made
a sufficient number of turns, I tie these, &
cut off what may be superfluous, & thus we
have formed what is called the Twisted Suture.
Where there is a considerable retraction, we
make an additional security by applying two
broad

342
broad pieces of plaster, one to each cheek, with a
small bit that comes over the lip, & making
holes in these we tie them together.
Le Dran advises to take out the pins in two
or three days, but we leave them till the
lips are sufficiently united, which may perhaps
require the space of a week.
Now these directions will apply to a fissure
in any other part of the body. I have seen a
division of the upper eye-lid, & I directed a few
threads to be passed thro' it, as pins woud
have hurt the ball of the eye.
In the same way we operate for a Cancer of
the lip, & complaint very incident to old people
We

343
We next proceed to the treatment of tumors
growing in the different cavities, in the Rectum,
Nose &c., & to save time, we shall treat of them
altogether, not only because the method of extirpating
them is similar, but because the texture they
resemble each other much, as the several parts
in which they are produced, are covered with
nearly the same kind of Vascular & Mucous
Membrane. There are some few things however
special, & others supposed to be so, we must mention
them singly, & I shall begin with the
Hæmorrhoidal tumors. You will find the
reasoning with respect to the frequency of these
by no means well founded, neither have Authors
conceived just ideas of their texture,
1st: They imagine we are subject to Hæmorrhoids
from the particular course of the blood
here, which is supposed to ascend to the Liver
from

344
from the Vena Portarum, so is more apt to
stagnate. But the common seat of the Hæmorrhoids
is beyond the system of the Vena Portarum;
the vessels at the extremity of the Rectum are
particularly affected, which receives its blood
from the Internal Iliac Artery, & returns it to
the Internal Iliac Vein; so we must explain
its frequency from the situation of the part,
nature of the contents &c.
Next they speak of these tumors as if the Veins
were swelled out & become varicose, but we
are by no means to suppose that the large
swellings depend on any considerable Varix;
from the suddeness of the swelling we must
imagine that there is an effusion or extravation
of the blood into the Cellular membrane,
& on cutting into several tumors of this sort
I have seen clotted blood in the Cellular substance,
but we cannot trace any large vessel
into it, so we are not to suppose that
the

345
the danger of an incision here bears any
exact proportion to the size of the tumor, the
vessels communicating with it are larger,
but we are not to beleive that we are cutting
into a blood vessel.
It is alledged that this discharge removes diseases,
& that the stopping it brings them
on, but this only proves that the discharge
becomes habitual.
An Operation in consequence of Hæmorrhoids
shou'd be much more frequent than it is,
& a great deal of pain & after danger might
be saved; as soon as we have observed that
it is fairly formed, let us try its situation
& attempt to get it out by an Operation, &
the operation is not painful & dangerous
as has been supposed, it is soon over, &
it does not occasion a fever that is dangerous
to life.
Next you have seen Polypi, Sarcomata, or
fleshy

346
fleshy-like excrescences, for the name of Polypus
is improper, as it supposes that there a number
of feet or roots. Surgeons have taken the name
from the Analogy of Polypi within the heart,
where the cloat sticking to the different Muscular
fibres has this appearance, or they may
have taken the top of the Sarcoma, which branches
out into different fangs, for the root.
In the Rectum & Vagina the tumors are for
the most part red coloured, tolerably smooth
on the surface, particularly those which grow
within the Vagina, which are softer than the
tumors which grow within the Rectum. But
both when irritated, especially in the Rectum
in old people, are in danger of degenerating
into Cancer, & opening a communication
between the Rectum & Vagina in women,
& Bladder in Men.
We find in the Nose several different appearances.
First I shew within the Antrum Maxillare
a

347
a bag containing slime, very much resembling that
which is naturally secreted, so it is probably
one of the natural follicles, the orifice of which
is shut, & the Mucous bag afterwards dilated,
but this is a singula occurence.
In the throat the tumors never have that softness,
the Membrane is similar, from the first beginning
it resists the finger more, & resembles the impregnated
Uterus in the colour & feel, & when we
cut into it; & what I alledge of the back part of
the throat applies to the lower part of the Pharynx
& Œsophagus only the membrane of the Œsophagus
is more dilatable, soft & spongy than the membrane
of the Pharynx, so the tumors are of a more
spongy nature.
These tumors are little changed by Medicine,
Bark, Saline Purgatives, Cicuta, Mercury &c: have
no effects, so we must heal them surely by
Operation, we must destroy them with the Caustic,
Knife, or Ligature according to their seat.
First

348
First, it is common to apply Astringent substances,
& these failing, to have recourse to
Caustic; but from the former I have great
doubts if in Practice we shall derive great
advantage, I have known the softer kind of
Polypi washed several months with strong solutions
of White Vitriol, Sacch: [illegible]:, Alum,
[illegible] &c Sal Ammoniac &c., without any remarkable
effect, & the tumor remaining nearly the same.
Next, Caustics are for the most part very injudiciously
applied, perhaps it is better
to reject them altogether, for the Caustic is
only made to touch the lower part of the
tumor, & before the [illegible] we form throws
off, the tumor is as big as before; besides,
the Irritation of the Caustic in broken constitutions
may be dangerous, it may introduce a Canus.
Applied to tender Polypi of the Nose, it has
had the disired effect, but supposing it to be
so large that we can only touch the lower
part

349
part, we shall make very little progress.
Let us therefore endeavour to exterpate the whole
tumor, & then destroy the root whether by Caustic
or any other means. With regard to the extirpation,
it is evident that the Ligature, where
it can be applied, is to be preferred to the knife
or Scissars, nay where we can use these, we
will generally be able to apply the Ligature,
but it is right to be acquainted with the various
kinds of knives or Scissars which may
be employed. We use a knife with a blunt
point & gentle Curvature, or we are provided
with Scissars of different shapes, straight, & bent
different ways. But I have seen a Hæmorrhagy
produced by the use of these Instruments, which
cou'd not be restrained by any Astringent
substance, not even by the Lunar Caustic or
Actual Cautery, & this shoud be another reason
to deter us from their use. In some cases
it may be impracticable to apply the Ligature,
thus

350
thus suppose the Polypus is rooted deep in the
cavity of the Nose, & that the bulk of it beneath
fills the Nostril, & perhaps some of the turns
of the Spongy Bones come in the way, in this
way, we must pull away the Polypus by
force by the Forceps, & we have them of very
different kinds; What the workmen generally
give you is the most useful, but they are
generally made too weak. - Some have
proposed to cut the Ala Nasi, but not much
is gained by that, because the straitness is
occasioned by the bone. Where the Polypus hangs
down behind the Velum Pendulum Palati
some recommend that we shoud cut it, but
that may be avoided by having the forceps
crooked; or I shall shew you another way of
treating these; so we may confine our views
to this common instrument. We guide it as
far as we can towards its root, at the same
time taking hold of the Polypus with a pair
of

351
of small forceps that it may not be pushed
back so as to straiten the passage, we then
grasp it firmly, & give it a twist at the same
time. If it breaks about the middle, perhaps the
Surgeon applies the forceps a second time, & he
shou'd do the Operation with the Sun shining
into the Nose, as with the light of the sun, we
can see thro' the whole cavity of the Nose, & observe
the place & manner in which the Polypus
is rooted. After it is broke away, we restrain
the bleeding & destroy the root; we shall shew
this afterwards.
Next suppose there is room to use the Ligature in
a Hæmorrhoidal tumor; suppose, as it sometimes
happens, the root is smaller than the body, in this
case, we tie the thread around the root, only taking
care not to include more of the coat of
the Rectum; we pass a needle thro' the middle of
the tumor, & tie it upon the two sides, nearly
in the way recommended by Chesleden for
Schirrus

352
Schirrous Amygdala, & the Surgeon may have
two threads of different colours that he may
divide them with certainty, & to prevent the
thread from sliding, it will be proper to make
the Surgeons knot by passing the thread twice.
Trepan

353
Trepan. When I formerly demonstrated
the vessels & nerves of the Teguments of the Cranium,
I mentioned the danger attending wounds here;
we are now to confine our attention to disorders
affecting the Cranium, the Encephalon, the Brain,
or Cerebellum; & in order to distinguish when
the Operation may be necessary, we ought to understand
the various ways in which these parts
may be disordered -
1st. The Brain & Cerebellum may suffer in such
a manner from Concussion, as to kill the patient,
& yet upon the most accurate examination
of the head after Death, we are not able
to discover any læsion of the Cranium or of
its contents, without finding any breaking of
the bones, any bursting of the vessels, or laceration
of the Medullary substance. - Next, we find
Animals killed by a shock of Electricity or
thunder

354
thunder, & yet there is no sensible læsion. We
find ourselves at a loss to understand the
possibility of this, because we do not know in what
life consists; but if we add to what I mention,
that persons by a fall from a height with
the feet undermost, have remained disordered in
their sense for many years; or a person knocked
down with a stick remains insensible
for a few minutes, but afterwards recover perfectly
& this is more inexplicable than the Insensibility
without the recovery, so that we cannot doubt
of the possibility of Death from Concussion without
any sensible læsion. - But in other cases,
the concussion or stroke bursts the vessels & occasions
an Extravasation. Eleven years ago I examined
the head of a French Prisoner who was
killed in trying to make his escape from
the Castle; he pitched upon his feet, & there
was no laceration of the Teguments, but I
found blood not only extravasated not only
upon

355
upon the surface of the brain, but within the Ventricles;
& we are informed by a Physician
in Holland, who has examined the appearance of
the brain in Sheep, which in that country
are usually killed by a stroke on the head;
the Skull is not broke by the stroke, yet he
found blood extravasated within the Ventricles.
It is evident that it wou'd be of consequence
to be able by proper signs, to distinguish whether
the Concussion has produced Extravasation or
not, because when there is no extravasation,
the Trepan woud be of no use, whereas in the
Case of Extravasation it must be of great service.
This has led some of the French Surgeons to attempt
the distinction, & they conclude upon the
whole, that if the Encephalon be affected in the
manner I first mentioned, it will be instantaneous,
but if from extravasation, the symptoms
will come on slowly, so they conclude where
a person is immediately insensible from
a

356
a fall, & no wound without, or breaking of the
skull, there is no use for trepanning, & on the
contrary, they expect benefit from it if the symptoms
of oppressed brain come on slowly. But there is
reason to doubt whether such distinction can be
made. My Father met with a case, where a person
received a blow three miles from town,
& was not insensible, but became so by degrees;
the Operation was proposed, but not agreed
to, & he died; the head was very accurately
examined, but no extravasation or læsion was
discoverable, so that mere concussion may
act slowly.
Next, it is beyond a doubt, that if by Concussion
any large vessel give way suddenly, we
will not be able to distinguish Extravasation
from Concussion -
But farther, there is an insuperable difficulty,
that both may be complicated, there may be
such a Concussion as to render the person
insensible

357
insensible, but not such as to destroy life; the
mere effect of the Concussion may go off, & the
insensibility from that cause alone may be
momentary, but some of the small vessels
may be broke, the blood poured out slowly,
& a considerable quantity collected in time. So
Surgeons are to be guided by the symptoms, &
by these only. If the patient is not releived by
letting blood freely & frequently, & by pursuing
the Antiphlogistic method strictly, the Surgeon
ought, if he has any thing to guide him
to the place of the blow, to proceed to the Operation.
Next, the Operation is not necessary merely in
consequence of blood effused, it may be of
equal use where matter is collected, & the matter
may proceed from an accident, & that in a
way we wou'd not perhaps with examples,
have suspected, i.e. if the patient receives a
blow, & seems to recover for several weeks,
but after some months, begins to have symptoms
of

358
of an Oppressed brain, & on dissecting the head
purulent matter is found to be collected; & in one
case that I have met with, there was no reason
to doubt but that a blow had given occasion to
a collection of matter which appeared 20 years
after the accident, i.e. the patient from the time
of the accident had constantly felt uneasiness
within the head, a dull pain, which was sometimes
considerably increased, shooting down from
the head, along the Spine, occasioning weakness
of the extremities; Epileptic fits followed, & these
increasing in frequency & violence, were attended 
with Mania. Matter was found collected
at the basis of the brain, & it was evidently
in a diseased state an inch deep. Sharp
gives instances where the operation was done
3 or 4 months after the accident, with advantage.
So we ought to have this in view, that if [any]
in some cases the large vessels throw out such
quantity of blood, as by its immediate pressure
to

359
to produce Insensibility, in other cases, the small
vessels may be so injured, as to run into a
state of suppuration, & I apprehend it is only in
this way that we are to explain an observation
made by Mr. Pott, that if we perceive after a blow,
that any part of the teguments of the head is odematous,
we shall generally find that the Dura Mater beneath
is in a diseased state, that where the teguments,
as he expresses it, are puffy, the Dura Mater is in
a sloughing state; this is not however from the communication
of vessels as he imagines, but from the
blow being communicated, for I have seen the Pericranium 
seperated without the Dura Mater being
affected, but such a stroke as disorders the External
teguments, is communicated to the Internal, which
are more delicate, & the vessels of which have thinner
coats than the External have.
Next we proceed to accidents which more evidently
require the Trepan.
In a Young subject it is supposed that a portion
of

360
of the Skull may be depressed without fracture, & I
will admit that this is a possible case, tho' it by
no means happens so frequently as many seem
to imagine; there is even at that age seldom a
depression without a fracture; any effusion into
the Cellular Membrane between the skin & bone
gives the feel of a depression. - It has been
further supposed that the skull may be depressed
in young Children without any great injury,
but this is a rare occurence, for tho' the brain
may suffer that pressure, as in Hydrocephalus,
yet where the pressure is made suddenly, the case
is otherwise.
Next, in the Adult, it is evident, that if a portion
of the skull be depressed, & the symptoms of oppression
follow, it is necessary for the Surgeon to raise
the depressed portion, by making a hole, & introducing
a proper instrument. It is ridiculous to
suppose that we can do it by applying Plaster,
or fixing a Screw, they have no firm hold,
nor

361
nor can we raise the whole by means of a single
point; we must make a hole, & use a Levator -
If the blow is given by a Sharp pointed instrument,
in an adult there will be a rent fissure, & where
the skull is so hurt, it will be proper to apply the
Trepan, if there are any symptoms to shew the brain
to be affected, for generally there is a degree of
extravasation, & if the Operation is done cautiously
& the extravasation between the Dura Mater & Bone,
there is no more danger from taking out a circular
piece, than there is from a rent, the
air gets in at both, & a bit of skull may be cut
out, the Dura Mater being entire, without any
dangerous symptoms following.
Next suppose that beside merely a rent, a piece of
the bone is quite loose, & may be readily taken
out, where all around is sound. Here there is
no occasion for the Trepan, as we have as free a
discharge as can be required; but if another
piece is depressed beneath the level of the skull,
&

362
and we cannot raise the depressed portion at the hole
that is made, we make a hole on the opposite
side; where there is any corner that fixes it.
Now there are the several views the Surgeon is
to have in the operation, therefore let us next proceed
to consider the steps of it.
You know from the Anatomy that there are several
places of the Cranium on which the operation cannot
be so conveniently done, but if a case is urgent,
& we have no choice, by proper caution, the general
degree of danger may be much lessened.
We first examine the nature of the fracture. Suppose
we learn that the patient has got a stroke about
the temple; Most Surgeons, as Sharp, tell us that
we are to begin with a circular or oval incision,
but in this way we seperate more of the teguments
than is necessary; so we wou'd begin to search
for the fracture by a plain incision in the place
that is most suspicious from the account of the
accident, the appearance on the teguments, &c. & we
shou'd

363
shou'd have the whole of the accident in view before
we proceed to further violence, & supposing that
the fracture branches different ways, we are led
to the centre, where the stroke was given; if the
fracture is in this place, we need not be affraid
of wounding the temporal muscle, I have seen considerable
portions of that removed, without any
material bad symptoms. It has been observed
that a blow on the temples is often fatal, which
is thought to be owing to the tendon having been
hurt, & the External Nerves injured that are spread
over the skull here may contribute, but the danger
cheifly arises from the thinness & flatness of the
skull, & the concussion being more readily communicated
to the brain within.
We next make particular room for applying the
Instrument, by an Incision somewhat of a circular
kind, & we ought to lay the parts bare with freedom,
that the Circular saw may not run on the
teguments in the time of the operation. I dissect
off

364
off all the soft parts & take up any vessel that
may be found to bleed with violence, otherwise
the blooding may insinuate under the dressings,
& occasion danger as well as trouble. - If a
portion of the skull is depressed, a bit of the
sound bone is removed, that we may introduce
the Levator under the depressed portion; we mark
the place with the Circular Saw, (which was known
to Hipprocrates.) we then scrape the bone bare, for
which I am provided with the instrument.
I am next to apply the Saw. Formerly this was
Cylindrical; about Parre's time a conical shape
was introduced, as they supposed the circle was
in danger of plunging into the brain. Of late,
Sharp & others mention the circular form as an
improvement, & it is abundantly safle, while
the Conical shape is entered with more difficulty
That it may discribe its circle, a centre pin is
necessary, till we have sunk the saw some little
way in the bone, when we take it out with a 
key

365
key for the purpose, & to prevent the pin from being
too much blunted, we first make a small hole
in the skull, but not wide, otherwise the saw
vaccillates.
Now whether are we to use the Trepan or the
Trephine? the latter is recommended by Sharp &
other Surgeons of this Island, but the former is generally
used in other countries, & I am perfectly
convinced that nothing but prepossession & want
of experience has led to the use of the Trephine;
1/4 of a circle is all I can discribe with the
Trephine, whereas with the other I can discribe the
whole circle, & we can work with it in the
most equal manner, & make the pressure at
pleasure. But if any person shall from timidity
prefer the Trephine, let him at least begin
with the Trepan, for ease to himself, & to
save time to the patient; with the Trepan we
shake the head less, which in the case of extravasation,
is of great consequence. - We are
not

366
not to trust to the blooding of the Diploe & the want
of resistence, for this is not remarkable, as we
are never entirely cutting Diploe, some part of
the saw is rubbing on the solid, while the rest is
in the Cancelli; as the blood coming out prevents
us from seeing the depth, we shou'd have
a bit of spunge to take it up. We shou'd have
a bit of quill for taking out the sawings, wc:
catch the saw, & a hard brush for wiping the
Trepan, & we shou'd have two heads of the same
size that the Assistant may clean the one while
the Surgeon is using the other. These saws now
upon the whole are made larger than formerly,
but the size is to be determined by the view, if
it is to raise a depressed portion, the larger
size is best, but for giving a discharge to -
extravasated blood, a small one is sufficient.
Some make the pressure by the head, but it is
better by the hand. - Supposing the Surgeon
finds the saw sticks, he is not by force to 
overcome the resistence, but to draw it back
again

367
again, & disengage some particles of the bone that
may have stuck between the Saw & side of the bone.
At the end of the Operation, we are to be particularly
cautious that we have not cut the bone unequally,
& you will remember that the bone is unequal
in some persons, in some persons there is a growth 
of fungus that makes pits, & in every person
there are arteries that make marks; now if
we come upon an Artery quickly, we readily open
it, but by working slowly it yields, & we go thro'
the bone without opening it, so that the Arteries
may run upon the surface of the Dura Mater
without being wounded. - We from time
to time try whether the bone is moveable, by
the Lever, & when we find that it moves easily,
instead of attempting to cut it entirely thro' with
the saw, I wou'd advise to break it off; I
see no objections, as soon as it vacillates, to
snap it off, for in experience, I find that the
broken piece will be as soon smooth, as if
we

368
we attempt to cut it, for we cannot cut the whole round,
and we avoid opening the Dura Mater, which is a
material circumstance; I have tried the danger
of the Trepan on different Animals, in some I opened
the Dura Mater, in others I did not; they were
all thirsty & hot, some of them dangerously ill,
& upon the whole these were in most danger who
had the Dura Mater cut. - We bring out
the bone by employing two Levators, for with
one, while the one side starts out, the other
is plunged in; if we observe any particular
roughness, we break it off with an Instrument
made for the purpose, which has a cup on the
end of it for receiving the sawings, but as
this requires to be pressed a good way in, instead
of a Cup, we shou'd only have a thin
plate of metal, however these sharp edges
are not of much moment, as they merely
make a part of the hole.
Next suppose we distinguish blood or Pus within
the

369
the Dura Mater, we are advised to make the
opening with a Lancet concealed in a bit of
common cloth, but we shou'd never conceal any
of our instruments, we shou'd use the lancet
avowedly, but with the utmost caution; to give
a peer outlet we may make a conical incision,
avoiding any considerable.
Suppose next that the depressed portion of the bone
is to be raised, we introduce the instrument
best upon the opposite side, but the Surgeon
is merely to pull it up, because tho' the part
he wou'd rest the Elevator upon may appear
sound, it may be cracked round, & thus he may
push in another piece, whilst we raise one edge,
the other may sink in. - Petit recommends
another kind of levator, which is by no means
a bad instrument, it has a rest at a distance
from the hole. - If we meet with great
resistance we must examine the depressed
portion, & perhaps we will find [it] that it is
by

370
by means of some corner that it resists, so we disengage
this, if this cannot be done, it will
be necessary to make another hole.
Next, is it to be a rule to raise the Depressed
portion to a level with the rest of the skull,
& there to sustain it. I apprehend we ought to
make many exceptions to this, & that we cannot
lay down any general rule; in Children
it may be cracked all around, & in an adult
no larger piece is uniformly depressed, without
a fracture, so the root gives way & the whole
bone is loose with respect to the hard parts.
If there is a considerable adhesion inward or
outward, we wou'd let it remain, but if it
is removed from its place, so as to loosen
the connection, we ought to take it out.
We apply simple dressings, & are not to use Spirituous
medicines with [illegible] &c.; we apply
dry dressings, & we are not to imitate Mr.
Gouch in making considerable pressure
with

371
with the view of keeping down fungous excressences
that may grow up, let us take our chance of
these, & if they grow, we ought to be well afraid
of their root, if they come from the Dura Mater,
we may use freedom with them, we may venture
as Mr. Hill directs, to cut them off, or to
touch them with Caustic; but if they are from
the substance of the brain, this may be dangerous,
so we wou'd try the effect of gentle pressure,
first slightly with the finger, we may next
irritate some part of it with a slight touch
of Caustic, & thus we go on till with safety
we get out the whole.
We

372
We shall next speak of the different methods
of drawing of the Circulating fluids, & first
of Issues; these are of three kinds, the Blister
Issue, the Pea Issues, & the Seton or Chord.
Now what effects may we suppose to attend the
use of these different kind of Issues, they are
certainly all similar in this operation; some
imagine that the Pea Issue & the seton are more
powerful than the Blister Issue, but in the
latter, the discharge is equally free, & the matter
discharged is the same, it is purulent, the
fungus produced spues out pus in very
great quantity, of the same  nature as that adhering
to the Cord. - The effects of these remedies are by
no means tolerably ascertained by Authors,
because it requires very great experience to pronounce
with certainty. My father, who had used
Issues & Setons very much, observed a remarkable
effect

373
effect from them in cases of inveterate headach,
even in Epilepsy, in Scrophulous, Ophthalmia,
in Phthisical complaints, in Asthma, & in general
in Internal Suppurations; he used to mention two
cases, where after using an Issue for some time
the persons were cured of the Asthma, & upon taking
out the Issues, the Asthma returned, tho' we are not
to imagine that this will be a common effect.
If we are to be allowed at all to reason upon them,
we may expect releif in a variety of instances; I
wou'd suppose first, where there is an Internal
Suppuration, & where of course the matter, by being
confined, is absorbed in considerable quantity,
& is generally thin, acrid, & therefore hurtful
to the constitution, that by forming an Issue, we
give a more ready outlet from the general system
of the Circulation than it has by the natural
excretions; not but that pus passes thro' the kidnies, 
nay we will be able by inspecting the
Urine, to determine whether a suppuration has
formed

374
formed in any large Sac within the body. Next
we may presume that an Issue will be of service 
where a disease proceeds from a redundancy
of the serous or thinner parts of the blood. It
is admitted on the best authority from Dissections,
that there is a distinction of Apoplexy into Languineous
& Serous, & where a person is disposed
to the latter, we might expect advantage from
Issues; or suppose a Child in danger of Hydrocephalus,
perhaps that others of the family have
died of the complaint; by giving a free outlet
by Issues, we may prevent its happening. In
like manner, in cases of Catarrh, as in the Peripneumonia
Notha, an Issue wou'd be of particular
service. -
Nay further, it is evident that the whole constitution,
the whole system of the body, is affected by Issues,
for after a person is habituated to one, he takes it
out not without danger. - Next I wou'd observe
that wherever you form an Issue, the
part shrinks in its bulk, that there is a wasting
in

375
in the whole circumference of it, when in the right
arm, which is naturally the largest, it grows
the smallest, tho' the use is litte interrupted.
It is evident therefore as a topical remedy that
we must value them highly, & we may suppose 
that they operate not only on the Hydraulic system,
but likewise in many cases upon the Lenient.
Future accurate experiments can alone point
out the particular cases in which they may
be of service. -
We shall next consider the drawing off
the red part of the blood from the vessels, & first
from the smaller ones. That is done by cutting
them with a Lancet, making a number of orifices
in any place by repeated strokes; [or] by fixing
a number of Lancets in the same instrument;
we determine the depth of the incision, by the lid
which is moveable; they are struck in by the
force of a spring, by pressing down the handle
we

376
we throw the lancets in a slanting direction, & by touching
the catch the spring throws them back again;
with this instrument I can venture almost to cut any
place, for the lancets are scarcely so long as to
cut thro' the true skin & Cellular substance so as
to hurt the subcutaneous viens & nerves, but where
these are large, we wou'd keep off their course. We
promote the flow of blood by washing with warm
water, & by taking off the pressure of the air from
the parts, as this disposes to coagulation; we have
a glass syringe intended for that purpose, or a
glass cup by itself, in which case, the air is rarified
by some burning substance, as Spirit of wine.
When the blood has filled the glass a little way,
tho' a great part of the air is drawn out, it coagulates,
& therefore it shou'd be a practice to change
the glass frequently, for there is a coagulation at
the same time taking place at the mouth of the
vessels, & every time we shou'd wipe the part
roughly with a wet sponge. Instead of the Scarifator

377
Instead of the Scarificator many use Leeches,
& I do upon the whole imagine that these will
upon the whole will be found more frequently
to answer the purpose; the Cupping frequently fails,
& does not draw off the blood freely, this I believe
is much owing to the want of practice, the
Surgeon does not apply the Instrument properly;
but Leeches blood freely. I do not remember
to have seen Surgeons think of using glasses after
Leeches, but why not, as well as in cupping, & that
we may be able to use the cup with advantage
we put the Leeches into a drinking glass, & confine
them to a particular part. When Leeches get
into the body, as when applied to the mouth
or Rectum, we give the patient a vomit or an
Injection of Sea Salt.
Now what use are we to expect from these
that we prefer them to the opening of the larger
vessels by the Lancet? First it will often happen
in practice that in Children you cannot
find

378
find a proper vien, not even the External Jugular,
which is sometimes remarkably small. Next,
even in grown persons, the vessels frequently divide
into a number of branches, & if there is a quantity
of fat under the Skin, it may be difficult
to find the vien; or the patient may have a degree
of timidity, & will allow himself to be cupped
or Leeched, tho' he cannot bear the thoughts
of the Lancet. But besides their cases from
necessity, we apply leeches out of necessity in topical
complaints, they draw blood from the
seat of the disease, & perhaps from the arteries as
well as the viens.
Next we consider the way of drawing blood
from the larger vessels, & first from the viens.
It is done with the common lancet, or the
Phleme, which is much used in Germany,
while the Lancet is almost only used in this Island.
Now I think it pretty evident which of these we
ought to prefer in different cases; the Phleme
is struck in perpendicularly, & the lancet is entered
in

379
in a slanting direction, therefore we may make
the point of the Lancet longer & Sharper than
the point of the Phleme, or it will cut easier without
pressing the foreside of the vien against the back
of it; therefore in all cases where viens are small,
or situated behind parts of consequence, as Arteries
or Nerves, the Lancet is preferable to the Phleme;
but on the other hand, if a vien is large, &
there is no such danger, the Phleme does the business
in an instant, with a small stroke, & the
patient cannot start, or if he does, he is not
in danger of being much hurt, & the opening of
the skin is directly over the opening in the vien,
hence if we are to operate on a large vien as
the Jugular, this instrument answers very well.
Now this much being determined in general,
let us suppose that we are to blood in the arm,
which I take for the principal example, & that I
prefer the lancet, we are next to consider the different
steps necessary in the operation, in which more
things

380
things are to be attended to than we are generally
aware of -
1st., We are to study the posture of the patient,
if we mean to prevent his fainting, we lay
the body horizontal, the head low, without
a pillow; - Next, we make a small orifice
in the vien, to allow the blood to run slowly,
lastly, in loosing the Ligature, we take care
not to do it too suddenly. - If again we
mean to bring on faintness, which is of real
use in many cases, as when we want to
reduce a fracture, Luxation or Hernia, nay
perhaps in all cases of Inflammation, it
may be of service, in time of the languor,
the vessels may adapt themselves to the contents,
& if the patient recovers he is not so much
exhausted of blood.
The safest [part] vien in the arm is the Median Basilic,
avoiding the part that is crossed by the
Artery. In the shape of the Lancet Surgeons
differ

381
differ greatly, the most common is too broad, & makes
too large a wound; on the other hand of late
some Surgeons have them too narrow, what
they call Spear pointed, which is a dangerous
weapon in the hands of the generality of Surgeons,
generally we woud prefer a middle kind of shape.
We ought to hold the Lancet so as to have a
full command of it, & at the same time so as
to see the wound we are making. The Surgeons
next places his thumb upon the vien, so as to
hold it in its place, & for the right arm we
employ the right hand, & rather use the left
hand for the left arm, but many people operate
awkwardly with the left, there is no great
fault in letting blood always with the right hand,
& turning the patients arm a little outwardly
I can make it face the right hand tolerably
well; in like manner, if we are doing the
operation in the Neck, we can constantly use
it. We enter the Lancet not altogether in a
transverse direction, nor quite perpendicularly,
but

382
but we make the incision oblique, & we push it
in till we see the blood run along the side
of it, then we dilate the opening a little, but
not by raising the point, instead of this, we 
make the point the centre of motion, & open
the skin a little more than we do the vien,
so that the blood is in no danger of getting
between the skin & vien: If we wish to draw
off the blood suddenly, we make the patient work
with the Muscles, by the Anastomosing branches
to determine the blood to the orifice. When
a sufficient quantity is drawn we slacken the
Ligature, & place the thumb on the orifice,
& cleaning away the blood, we apply the 
sides together, & make a slight compression
by means of a compress & bandage, & when
we apply this, [to] the arm [,] is to be put in the
position it is afterwards to lye in. Surgeons
generally apply the bandage too tight;
Sticking plaster in general frets the orifice
& produces some degree of suppuration. If

383
If the Operation is in the neck, we cannot, as the
French propose, use a Ligature, especially when
it is done to releive the head, & it will be
sufficient to make the vien swell by the Surgeon
making pressure upon it with his thumb,
below the part he intends to open, but the skin
(which is thicker here than in the Arm,) not only
covers the vien, but also the Platysma Hyoidis
Muscles, so we do the operation at two strokes,
which, if they are made, the one after the other,
without taking away the hand, will not be
perceived by the patient.
We Next consider the manner of drawing
blood from Arteries. Some have proposed opening
them not only in topical cases, but where the
whole constitution is affected, but opening the
Viens, in such a case will probably have nearly
the same effect, & Arteriotomy is to be confined
to topical affections. We cannot reach the 
Arteries

384
Arteries in the trunk, & there will be little advantage
in opening those of the extremitys, & I
imagine we may, so far as experience goes, confines
the operation of the Temporal Artery. It
may be even unnecessary to show the method
of opening Arteries in certain experiments, as proposed
by Mr. Butter; he uses lancets in the shape
of wedges, of different sizes, & after the artery
is laid bare with a common lancet, we take
one of these, & plunge it perpendicularly into
the artery, & make in it a longitudinal puncture;
if the blood cloats, we take one of the second
size to enlarge the orifice, & we may have one
blunt to serve as a Conductor. - But if
we are to confine the operation to the temporal
Artery, we are then to use the common Lancet,
or one that has the convex point rubbed off
that we may not cut the back of the Artery.
You are directed to the Artery by its strokes,
& you cannot begin lower than the Zygomatic
process

385
process, & generally Surgeons take the Artery after
it has made its division, & we prefer the anterior
branch, because the teguments are thinner
& there are scarcely any considerable nerves sticking
to it, whereas a nerve is closs on the other
branch. The Artery is not to be opened with
one stroke, we first cut the skin, & lay the Artery
in view, dissecting the Cellular substance,
then opening the Artery longitudinally; with a
sponge we wipe of the blood from time to time
if it is in danger of stopping. After the Operation,
we apply any common compress, or a bit
of Agaric, or of very closs Sponge with a compress
over it, & here is a very neat instrument
invented by Dr. Butter, it is tied over the head
& under the chin, & we have it in our
power to adapt it more closely by turning
a Screw, which presses down a compress
upon the orifice.
Having

386
Having explained the way of drawing blood from
the vessels, we proceed to consider the accidents that
attend such operations, & the manner of remedying
or curing them.
1st: You remember that I have proved that the
dangerous symptoms which are said to follow
the wounds of Tendons, depends upon wounds
of the subcutaneous [viens] nerves, & I have
pointed out the proper method of treatment.
Next we suppose that in opening a vien, the
blood has insinuated between the vien &
skin, & is diffused in the Cellular substance
so as to form a tumor, which Surgeons call
Thrombus, either from the Surgeon unnecessarily
shifting his Ligature, or instead of considering
the point of the Lancet as the
centre of motion, from his raising the
point of it, & cutting [nearly] of the [skin] than
of the vien. - If you observe the skin beginning
to insinuate, instead of attempting
to

387
to draw up the skin or to dilate the wound in it,
so as to bring it opposite to the wound of the
vien, you are to take of the Ligature, & make
pressure on the vien, & if necessary, perform the
operation on the other arm. - If a small
quantity is effused, that is absorbed in a short
space of time, but if the quantity is considerable,
we must make an incision, otherwise the blood
corrupts, & produces a great many bad consequences.
Sometimes a thrombus gives the appearance of
an Aneurism, & may be mistaken for it, when
the blood is pressed in upon the artery, & has
the stroke of an artery communicated to it; but
will generally be able to make the distinction.
In the case of Aneurism, if the tumor is cirscumscribed,
it is small at first, for if the opening
of the artery is so free as to allow a large
quantity to escape suddenly, that comes to be
more diffused. Further, in the case of Thrombus,
upon bending the patients arm, the blood effused
from

388
from the Vien, receives the stroke of the Artery but
slightly, & the stroke becomes feeble. In the
Aneurism again, the stroke of the Artery is nearly
equal whether the arm be straight or bended
Next suppose in letting Blood, the Artery
has been wounded. I formerly observed that
if the wound is directly thro' the skin & vien
into the Artery, there may be a considerable
discharge of blood without any insinuating,
& the wound of the Artery can be readily discovered.-
Next we suppose that the wound
in the Artery is large, & that the blood flows
freely, & getting thro' the Apaneurosis, comes
to be diffused, & may spread very far in
the Cellular substance, like water in Anasarca,
& unless means are taken to prevent a large
quantity from getting out, the Cure is very
painful & dangerous, for we must open
the skin perhaps the whole length of the Arm.
Next, we suppose that the wound of the 
Artery 

389
Artery is small, whether all the Coats are wounded,
or the External only, & the blood is lodged near
the orifice; & forms a round tumor, that it is
confined partly by its coagulating, & partly by
the pressure of the Apaneurosis, & that it puts
on somewhat of the same shape that the Artery
does when all its coats are dilated, in the true
Aneurism, the appearance at first is nearly
the same. - Lastly, the wound perhaps is
not made in the Artery by the Surgeon having
missed the vien, but the lancet passes thro
the Vien into the Artery, & besides, that the
communication is made so directly in both
that it comes to be maintained between them,
or that the blood, instead of escaping into the
Cellular substance, passes directly into one of
the larger viens. We readily distinguish
this from a circumscribed Aneurism; in the
latter, from the nature of the complaint, the
hole is generally small, & the blood clots,
not

390
not being kept in constant motion, especially if
the tumor is large, so by pressure we cannot
make the tumor disappear; whereas in the
Aneurismal Varix, the blood passes freely into
the vien, & is in a fluid state, so the tumor
will disappear by pressure, & even by posture;
by pressing on the viens & stopping the hole,
by which the Artery communicates, we remove
it entirely.
These are the different kinds of Aneurism. We
next consider the way of managing them
by operation. - Their treatment includes that
of Arteries opened in living animals on purpose,
the only difference is, that in the one case
we treat recent wounds, in the other, one
that has continued in the artery for some time
Now notwithstanding that we find a number
of detached histories of Aneurism, yet the number
is not so considerable, nor the experiments
so accurate, that I can speak with the precision
I

391
I cou'd wish; instead of saying what is the
best method of treatment, I am to give a
history of the methods that have been taken,
& leave to future experience to determine the best.
First, there are a few histories, not above
4 or 5, where an artery was wounded considerably,
& the wound cured by a pressure made
on the sound skin, which was pressed in
upon the opening in the Artery; but in other
cases this has been found impracticable,
& it is evidently so wherever we cannot
make the tumor disappear by pressure.
In such cases there is a necessity for cutting
the skin, & discharging the clotted blood, or
bringing the orifice of the artery into view,
& then applying proper compression; we
have also a few instances where this has
succeeded, we have two by Fouberre, two by
Dr. De Haen, & one or two by other Authors.
After taking off the clotted blood, a compress
was

392
was applied, & the substance chosen by Fouberre
& De Haen is Agaric; in one case, a broad
piece was applied to the orifice, then the powder
thrown over it; in another, the powder was
first applied, & then the solid piece. Now
this substance has softness with a degree of Elasticity,
is extemely closs, & gently Astringent,
for if a Solution of steel is thrown over it,
it becomes black & forms an ink. We apply
a small piece to the orifice of the Artery, the
larger pieces, & support all by a proper bandage.
But supposing these methods to fail, or that the
wound of the Artery is large, & perhaps Callous,
& that a considerable quantity of blood
is in danger of being lost; there is one further
method, of which we have only one example
by Mr. Lambert an ingenious Surgeon at
Newcastle; he passed a small pin thro' the
Artery, & secured it with a thread, as in the
Hare-lip, & he made a cure in five weeks;
during

393
during the whole time, the pulse cou'd be felt,
the blood continued to flow thro' the trunk
of the Artery. - But supposing that this
method shall also be found impracticable,
& that the patient is in danger of loosing his
life from repeated Hæmorrhagies, it only remains
that we have recourse to the usual method
of tying the Artery above & below the place
of the wound. We shall consider all the steps
of this Operation. - First we apply a Tourniquet
at the inner side of the Biceps Muscle,
to compress the Artery; we next make an Incision
opposite to the wound in the artery, &
this ought to be of considerable length, 2 or 3
inches or more according to the size of the
tumor, that the Surgeon may have room to
take hold of the Artery & tie it. The Artery
runs at the inside of the Biceps muscles, behind
the Aponeurosis; here too the Median
Basilic vien runs, & generally speaking,
there

394
there is a necessity for cutting that vien thro'
in the Operation, & where the Aneurism has
continued long, the Vien may bleed considerably,
& it may be necessary to tie it also. The
wound of the Artery is almost always on the
fore part, & the blood escapes between the Artery &
Skin, so that the Artery is at the back of the tumor.
But in a case that occured three years ago
in the Infirmary, the Artery was wounded behind,
from the Surgeon raising the point of the Lancet,
so the blood lay between the Artery & Vane,
& the stroke of the Artery was seen the whole way
on the surface of the tumor, which was about
the size of a turkey's Egg, & the wound was
large enough to admit a crows quill, with
thick callous lips; As this circumstance therefore
may occur, the Surgeon ought to be
cautious how he makes his incision. - I
begin the incision with a common Scalpel,
& as the tumor extends more upwards
than

395
than downwards, for downwards a resistance is
made by that connection which the tendinous
Apaneurosis has with the muscles of the fore arm,
but upwards, the Apaneurosis is looser, & degenerates
almost into the Cellular substance; this
Apaneurosis constitutes for the most part the outer
coat of the tumor. We divide it in the direction
of the Artery, which is now brought fully into
view by the Vena Comites. - The Surgeon is
perhaps not absolutely certain of the wound,
which is not readily discovered in all cases;
we first wipe the part, & slacking the Tourniquet,
we see the blood thrown out with violence,
& at the same time we have a probe &c.; (See
the steps of the Operatiopn in the Medical Essays
by my father.) Before he wrote, it was the common
practice to dissect the whole tumor round;
Surgeons tho' they knew that it depended upon
a wound in the Artery, proceeded in their
manner of operating as where there was a
dilatation

396
dilatation of all the coats, so followed the Aneurism
its whole length in order to seperate from
all the contiguous parts. But he directs to open
the tumor length ways, to take out the clotted
blood, & with a common probe bent to hold
the Artery, which is a simple way of being sure
of the orifice. - Next, are we with several
eminent Surgeons to pass a needle round the
Artery, including the neighbouring parts, & with
Sharp, to say that taking in the Nerves is no
great inconvenience? Surely not; it is proper
to avoid it. A Ligature on a Nerve may be
more or less dangerous according to the
degree of tightness, & most Surgeons draw
the ligature too tight, which must affect the
Nerves, & I see mentioned as a symptom of
the operation, a Locked jaw, which might depend
upon including the Nerve in doing
the operation carelessly; so my father recommended
bending the patients arm in order
to

397
to slacken the Artery, & drawing it out a little, we
take hold of it with the thumb & forefinger of
the left hand, & pass the Needle behind it alone,
including nothing but the Artery & Cellular substance.
Surgeons have used a needle with a
handle, & the eye at the point, but this is not
so manageable as the common crooked needle.
We use a large thread waxed, & pressed flat, to
make it less liable to cut the Artery. - As we
trust in the Cure to the blood being conveyed
freely downwards by the lateral branches into
the lower part of the [Muscle] Trunk, & that it may [crossed out]
ascend from the fore arm to the wound, we
pass a second ligature, on each side of the wound;
we only cross the threads, without using the
Surgeons knot, as it grasps the Artery closer,
but before we tie the knot, we desire the
Assistant to slacken the Tournequet, to see that
the orifice be between the threads; we then
tie near to the hole, the nearer the better;
Surgeons

398
Surgeons are apt to go too high up, & perhaps
may stop the descent of blood into some
material lateral branch. Having made
a second knot, we cut the ends of the threads
short enough to lie within the wound, &
only so long that we can take hold of them with
a pair of forceps in the process of the Cure,
but if they are left too long, the dressings
may stick to them, & they may be pulled away
too soon. - In order to form a Prognosis, we
slacken the Tournequet, & try to feel the Pulse,
but even tho' after some hours we do not
feel the Pulse, we are not to dispair, experience
has proved that a quantity of blood can
descend into the arm sufficient to maintain
it without occasioning any pulsation, &
it may be some days before we feel the pulse;
but if we see some blood run out at the hole,
we are certain that the Cure is to succeed,
& whether we see blood or not, we are to tie
the under orifice, that we may not run the
chance

399
chance of Hæmorrhagy. We next relax the Tournequet,
& again examine the wound, as we may
have cut some lateral branch of the Artery, so we
wait a little to see that there is no further bleeding;
then we apply the dressings very loose, & a bandage
that barely confines them. We put the arm
in a hanging posture to let the blood rush into
it with an increased impetus, & instead of adding
to the warmth by fomentation, it will be
sufficient to cover the arm with wool or
flannel to keep in the natural heat. We
leave the Tournequet perfectly slack upon the
arm, or let it lie beside the patient, having
instructed an Assistant how to manage it;
& if it shou'd break open, the Surgeon can renew
his Ligature. -
Next suppose a Case of Aneurismal Varix,
are we to avoid an operation in this case?
This has been advised, but I imagine that we
are by no means to follow the advice
We

400
We cannot as yet reason altogether from facts, but
as the force of the blood in the Arteries is so
much greater than in viens, thus Dr. Hales found
that the Momentum of the Carotid Artery is
ten times greater than in the corresponding viens.
From the exertion of the Muscles indeed pressing
upon the viens, the momentum of the blood in
particular actions in the viens may be brought
more nearly equal to that in Arteries, or where
the vien is so much enlarged as to be called
Aneurismal, the same Cause continuing to act,
will probably enlarge the vien to a much greatr
degree, & the patient will have two diseases
to struggle with in place of one, the wound
of the Artery & dilatation of the vien, which going
upwards, may remain, & then supposing an operation
becomes needful, it will be found
impossible to operate upon the vien; therefore
instead of dillining the Operation, we shou'd
have recourse to it with double anxiety.
Next

401
Next, what we have said of the wound of the Artery,
applies nearly to the true dilatation. Where
the Dilatation is of the shape of an Egg, we must
make use of Ligatures above & below the place
dilated, & the chance of recovery here is less, as a
number of the lateral branches must be intercepted.
The only farther observation I need to make here is,
that in the true Aneurism, instead of following
Surgeons in their tedious dissection of the Cyst,
we cut into the tumor, & having emptied it of its
blood, we can seperate it from its adhesions more
readily, we can see the orifice, raise it on the
finger with the utmost ease, without giving the
pain of a tedious Dissection.
Amputation

402
Amputation - The manner of taking
off, chiefly the Extremities of the body.
This operation is frequently performed by Surgeons
where it ought to be avoided, particularly in Compound
fractures, where with a breaking of the
bones, there is a laceration of the softer parts,
& a protrusion of them. In such cases Surgeons find
it difficult or impossible to replace the member
in the common manner, & therefore proceed
to Amputation; but unless there is complicated
with the fracture a violent contusion of the
neighbouring larger joints, the limb may be
saved by cutting off portions of the bones, for
even in diseased habits bone can be regenerated,
& this happens still more readily where the constitution
is good. In the last edition of Gooches
works, you'll find not less than 12 examples, where
the bones, especially the Tibia, has been taken off
to 5, 6 or 7 inches in length; & we may apply
what

403
what we find in those cases a little farther, where
a bone is loosened, & there is no dangerous
symptoms present, the Surgeon may take it out &
trust to nature for a supply; in like manner,
if a bone be laid bare, & appears carious, Surgeons
run to the Amputation, but we wou'd
first discharge the matter in the bone, by making
free openings in it, which may be done with
common instruments, we may apply the Trepan
here, & in the Medical Essays you will find Cases
discribed by my father where limbs were even
saved in that way, & we may take out the whole
Cylinder of the bone.
Next, Surgeons shou'd be sparing of Amputation
in Scrophulous cases, for generally the
disease breaks out in some other part; nay if
nothing is done, greater changes are made in
Scrophulous cases by nature than we wou'd
have often expected; I have saved the limbs
of several by having the Amputation delayed,
where

404
where the disease was in the knee, & the swelling
was called White Swelling, but the matter broke
outwardly without communicating with the cavity
of the joint, but if the patient has not the
disease in a great degree, & yet the matter
already formed communicates with the joint
& the patient is hectic, & sinking under the disorder,
I wou'd give him the chance of Amputation.
But a writer of great experience goes farther, Belgar,
one of the cheif Surgeons of the King of Prussia,
& has wrote of a book against the utility of
Amputation in any case; the plain history of
it, is this - The King of Prussia for reasons but
known to himself, discouraged it in a great measure,
to forbad Amputation to be performed in his
army, this obliged the Surgeons to have recourse
to other remedies. Belgar tells us that after a
battle, he had under his care at one time 6000
wounded men, of that number, 1000 were wounded
in the Joints, so that Surgeons wou'd have thought
that

405
that Amputation was necessary, yet by making
proper incisions, giving the Cortex largely, (which he
observed had a specific virtue not only in preventing
but in curing mortifications, a circumstance of the
highest moment, as Sharp has taken the notion
of disputing the usefulness of the Bark in such cases;)
of the 1000, 600 died, 200 recovered, while the remaining
200 had motion of the limbs tolerably
well restored, so as to be able to do Garrison
duty. - Now from this comparison he rejects
Amputation, & alledges that as many lives wou'd
have been lost in the common way. But I
cannot help calling in question his conclusion;
if you look into the Medical Essays, you will
find an exact account of the first hundred
patients treated in the Infirmary for amputation
of the large extremities, of that number
only eight died, without making allowance for
the nature of the disease which gave occasion for
the

406
the Operation. Now we might expect greater success
in a recent case where the patient is in full
health, as Soldiers are, so that if Amputation had
been performed, instead of 600, Belgar ought
to have lost but 80. - But suppose next that
notwithstanding the better health of the Soldiers in
the army, conveniences are not equal, I shall
almost triple the number, & suppose that 200
wou'd have died in the common practice, we
save 800, whereas Belgar only saved 400; but
200 in wooden legs wou'd be in as good condition,
as where the cure was not compleat, but the
patients must have suffered pain & dragged
their limbs after them as an useless load; we
have 600 remaining with wooden legs to
ballance the 200 where the motion was restored
tolerably well; so that it is beyond all
doubt that in the common manner of Amputation,
where the joints are much wounded,
we save many more lives than in Belgars method.
I

407
I now proceed to the steps of the Operation. The
Antients were very sparing of Amputation, because
they had not thought of proper instruments
for stopping the blood during the time of the
operation, they had not contrived the Tournequet,
which improvement was only made in the last
Century, & they did not know the use of Crooked
Needles for surrounding the Arteries, nor did
they think of drawing them out; this contrivance
was first thought of by Guido, & first practised
by Parri; they used the Actual Cautery, & for vessels
of a smaller size this might do, but where the
larger are divided, it has less effect than might
be imagined, the contraction of the Artery, the
clotting the blood, & the swelling of the neighbouring
parts have all been ascribed to the hot iron.
Neither had it occurred to them to divide the
softer parts to hinder the projection of the bone
beyond the Muscles; for the present method of
cutting the softer parts, we are endebted to Celsus.
Let

408
Let us begin with the Amputation of the larger
Extremities, as the Arm, fore-arm, thigh, & Leg.
It is evident that the Surgeon ought to save
as much as he can of the arm, provided the
wound be not made in a place little disposed
to heal. In Amputation of the Leg, the patient
bends the knee so as to rest on the Artificial
leg, & in a disease of the foot, if the
Amputation is made immediately above it,
a great part of the foot becomes an useless
load standing out behind; in common
practice therefore we save no more than is
sufficient for a rest.
Next let us attend to the posture of the patient
& of the Surgeon in the time of the operation, & so
the Instruments which are necessary.
The Superior Extremities may be very well
amputated whilst the patient lies in bed, with
the arm laid over the side of the bed; but generally
the patient is placed in a low Chair;
[the]

409
The Surgeon, if he is to amputate the Humerus,
is under the necessity of standing upon the outer
side, but if he is to amputate the fore arm, he
may take his chair, but the outer side will
answer best, as it is easier to place a saw for
cutting the two bones, the difference however is
not very great. - If we are to amputate 
the lower extremities, we place the patient on
a table, & for the thigh, the patient necessarily
places himself on the outside, but if he is
to amputate the leg, he is under the necessity
of placing himself between the legs, to cut both
bones at the same time, & to cut thro' the Fibula
before he has done with the Tibia.
The first Instrument to be used is called Tournequet,
for compressing the blood vessels in the time of
the operation, & it answers to chill the feeling
of the Nerves at the same time, tho' little attention
need be paid to the last. The most common
Tournequet is made in a very simple way;
we

410
we take a roller, not made very tight, that the
shape of it can be altered a little, we sew a
piece of cloth or flannel to it, merely to keep
it on, & to defend the skin from the rope we are
afterwards to twist; the cushion is laid upon
the course of the Artery; the course of the Humoral
Artery is along the inner side of the Biceps,
& if you are to amputate higher than the
elbow, you place the cushion of the Tournequet
pretty high, to have sufficient room, but for
the fore arm, we bring the Cushion down to
near the Joint. In like manner, if we are to
amputate above the knee, we place it in the
hollow between the Sartorias & Adductor fæmoris;
if below the knee, we place it between the Hamstrings.
He uses a rope such as windows are
hung with, or a piece of very strong tape,
& to prevent the patient from being hurt we
apply a bit of paste board, horn, or a bit of
White Iron lined with leather; we make the
rope

411
rope or tape long enough to go twice round the
member, & to give it room for tying, & in making
the knot, we are to leave no more room than
is sufficient to admit the stick, & in this way
with the slightest touch of the stick, we twist
very strongly. Now this requires the Assistance
of another person well skilled in the Operation,
hence Petit has invented a Screw Tournequet
with two plates of Iron, which we can use
without an Assistant; it is tied upon the
member, & turning the Screw, you straiten the
rope gradually, thereby making sufficient pressure
upon the Artery during the Operation. Upon
the same principles, Platsier has contrived a
Tournequet of wood, which can be made by
work men for a trifle; there are other inventors,
but the best is that which is said to be
Mr. Cranes, with the same screw, we work twice
as quick as with Petits, yet it grasps the
member every where, & the others leave an opening
at

412
at the side, and the lateral branches of an Artery
may pour out blood during the time of
the operation.
Now let us suppose the Instrument to be put on,
and that we are to perform the operation on
the Leg, which is the most troublesome, there
being two bones; we make the incision with
a large knife; some fancy to have it made
concave, meaning to compleat the incision at
one stroke, but this does not answer so well
as one made nearly straight, & we need only
attend to its length, & one 7 or 8 inches will
answer for any case that can occur. We are
advised to direct the incision by a piece of
tape or cloth, but I really beleive that this may
be thrown asside altogether, as we can judge
sufficiently by the Eye. The Tournequet is managed
by an Assistant. We next determine where
the Amputation shou'd be done, & in an Adult,
the Surgeon lays his hand breadth under the knee,
&

413
& we will hit the place pretty well, leaving sufficient
rest, & material Muscles, which are
employed naturally in bending the Leg, but where
the Joint of the knee is fixed, they serve to
move the whole body. The skin draws back
more than the Muscles, & evidently the muscles
draw back very considerably, so an Assistant
draws up the skin, while the Surgeon puts
on the strap. Now most Surgeons observe a
rule of allowing a little bit behind more
than before, so more skin is wanted to
cover those muscles. He then takes the knife
firmly in his hand, & in order to make a
compleat circle, most Surgeons put the knee
to the ground, but it is better to make two semicircles;
we begin on the outside, & immediately
go from that to the bottom, & we draw the [skin]
knife so as to divide the skin & perhaps to encroach
on the muscles a little; we then turn
the knife, & finish the circle with great ease;
We

414
We have now no more use for the strap, we
throw it asside, & it shou'd be taken off instantly
& if we find some parts of the Cellular Membrane
not fully divided, that hinders the retraction,
we divide them, & desire an Assistant to pull
the skin firmly upwards; we then proceed to
finish the next incision in the same manner
drawing the knife the whole round of it,
till it rubs upon the bone; it remains that we
cut between the bones with a double edged
knife. Next we go a step farther, pushing the
Muscles back a little, seperating them from the
bone, that we may cut the bone as high as
possible. We are next desired to cut & scrape
away the periosteum, now really that part may
be very much neglected. We are next to saw
thro' the bones, & I shew you the Saw for the
purpose, & I have no doubt but that it is one
of the best kind, because it resembles that most
in use with Workmen; I have added to that
painted

415
painted by Sharp, a hole for putting the two fingers
in. You observe that the flesh comes in the way
of the Saw; now to remove this inconvenience,
[my] father said that a piece of Linnen rag split
& applied to keep up the flesh, wou'd answer, but
several ingenuous Surgeons, particularly Gouch,
has found the linnen inconvenient, so we use
leather, which answers very well when there is
a single bone, but what it still better, I have
substituted metal, & we have the hole either
circular for the humerus, or thigh bone,
or we make it oblong, to take the bones of the
fore-arm or Leg, & we have also a piece of
metal for pressing between the bones, & the two
plates may be made to move upon a hinge.
In sawing, we begin upon the principal bone
the Tibia, & we make the strokes short at first
till we enter the saw, & get a direction for it, when
we gradually make them longer & longer.
It is the business of the Assistant to hold the Leg
very

416
very streight, without either bending it backward
or forwards, least he catch the teeth of the Saw,
or be in danger of snaping thro' the bones at
the end of the sawing, when the bone snaps,
altho' I beleive it wou'd be of no hurt during
the Cure, least it shou'd, Surgeons are provided
with a pair of strong forceps, with which they
can take off any sharp point. Having
finished the Amputation, we next tie the
blood vessels, & the more exactly we surround
the Artery the better, we pass the thread but once,
& bringing the knot almost closs, we press
in the threads with the thumb, least it slip
over the orifice, then drawing it, we desire
The Tournequet to be slackened, to see that we
have drawn it with force enough to stop
the bleeding; having secured the first knot, we
make a second, & cut the threads with a pair
of Scissars so short as to lye within the edge
of the wound, & so long that we can afterwards
find

417
find them easily, & take them out, which shou'd be
done as soon as possible. Suppose that the
Artery cannot be taken up by the Tenaculum,
nor surrounded by the Needle, from its particular
situation, or where the flesh is very
rotton, we have recourse to Astringents & Compresses
but we cheifly trust to the compress,
for the Astringents approach to the nature
of Caustic, & irritate the Nerves, so we wou'd
rather use Agaric or Sponge, as I shall explain
afterwards. Now what I proposed is all that is
necessary in common Amputation. -
Suppose next matter is collected, & caries in consequence
of this occasioned in the head of the
thigh bone or Humerus, that the joint is spoiled;
it has been proposed to take off the whole limb
at the Articulation, & in the superior extremity
the Operation has been done several times.
Now in such cases we wou'd prosecute Belgars
method, & in Mr. Whyles Book we have a most
excellent

418
excellent example shewing the possibility of saving
the limb, not only making an incision of the
softer parts, but cutting out the head of the bone,
& where in Compound Luxations, not only the
limb was saved, but the motion of the Joints
restored. Here too was a caries in the joint of
the Humerus, & Mr. Whyte made an incision,
pushed it out, & tho' no particular pains
were taken to retain the Member, yet the motion
of the joint was perfectly restored, Cartilages
& even Ligaments seem to have formed. I shall
not only shew the way of imitating Whytes operation,
but of doing the Operation where that
is necessary, in the superior extremities in a
way more simple than that proposed by Mr. Sharp.
I begin where I am determined to amputate
with being able to secure the blood vessels by
making an incision between the Pectoral Muscles
& Latissimus Dorsi in the arm pit
& from that downwards in the course of the
large

419
large vessels to lay those in view, & having divided
the skin sufficiently, I take a large needle, &
take up the whole Chord of vessels & nerves; I
do not tye them, but here is a certain way
of preventing a great loss of blood, as I can pull
it when I please; I next make a circular incision
with my Scalpel with which I begin the Operation;
we save the skin here as in the former operation,
which is pulled up by an Assistant, &
we finish the incision of the skin before we
make any incision of the Muscles; next we
cut the Muscles on the outerside, & we shou'd
have cut the skin only on the outer side if
we had meant to save the limb. - We next
divide the Capsular ligament with the Bursa
Mucosa over it, & in case of a Caries, we can
now saw off the end of the bone, nay we
can even get at the head of the Scapula with a
sharp pointed Instrument, without dividing
any material blood vessels. But suppose
next

420
next that I am to divide the larger vessels, I have
an Assistant ready with a hard compress above
the first rib, & I divide the larger vessels, then having
finished the Amputation, I remove the arm,
& I take hold of the trunk of the artery, draw
it out, & tie it; but suppose I shou'd not be
able to catch it, I have my Ligature ready, &
I leave it to the first dressing, that I may
stop the bleeding with absolute certainty. - As
for the operation on the top of the thigh, even
the cutting off the end of the bone, it is barely
possible, but I wou'd not choose to engage in it;
we give the matter a free discharge, & we
may turn out the end of the bone, & cut
it according to the method proposed by Whyte.
These are the common methods, but another
has also been proposed & practised, that of making
Flaps, i.e. covering the stump with flesh; thus
if we are to cut the thigh bone in the middle,
it is proposed to take a long knife, & to shape
the

421
the flesh with our eye, first on the outer side, then
on the inner side, then we cut the remaining flesh
with any common knife, & having tied up the vessels,
we endeavour to make the two flaps tight to one
another. - Now the objections to this method are
these, the blood gets in between the flaps, & if a
larger vessel breaks out, we get at it with difficulty,
& from the great surface there is an immense
suppuration, unless the cure forms to a
very wish; so a late writer has proposed an
improvement, O'Halloran, whose book is worth
your looking into; he proposes that we shou'd
not make such large flaps, but rather to make
them in the fore or back part, then we are
not to join them till the suppuration has gone
on for 10 or 12 days, when we unite them with
equal certainty, & with greater safety; but if the
common operation is done properly; the practice
of flaps is very unnecessary, especially as the
body is not supported in the very end of the stump,
but

422
but rather on the side.
It remains to mention the Amputation of
the lower Extremities. Surgeons formerly attempted
to amputate with the stroke of a
chisel, bruising as well as cutting. We do an
operation on a finger as on the larger extremities,
we draw back the skin after cutting it with a
concave edged knife, & saw the middle bone
defending the other fingers. Or we take the
fingers off at the joint with the same knife,
& are directed into it by the nail of the
thumb and forefinger; we take off the Cartilage
on the end of bone, & we make the Flaps.
Suppose the Metacarpal bones diseased, Surgeons
frequently in this case take off the whole hand.
Now I have seen an excellent operation by
Mr. Adie in the foot, there was a very ugly
caries covering the fore part of it, & he slit between
the great toe & the one next it, & took
out three toes with all the Metatarsal bones;
the

423
the void was filled up most compleatly, & with
a Cushion to fill it up, he walked without
any distinguishable halt; but even this may be
unnecessarily severe, if the Metatarsal bone
is diseased, he may take it out, or he may cut
it thro' with the Trepan, & take out the part that
is diseased, & the void may be filled up with
an Osseous substance so firm as to answer
the purpose of bone, & we have needles to take
up the vessels in case they shou'd bleed much.
I have now endeavoured to explain all the
Operations in Surgery that require particular
caution; if these are well understood, & the
Anatomy of the parts at the same time; you will
find little difficulty in adapting them to any
case that may occur. -
Operations

424
Operations on the Teeth
I have observed that the dangerous
Symptoms which often attend Teething, depends
on the irritation of the Gum covering
the points of the teeth, & inferred the necessity
of dividing the Gum. We make a Crucial
Incision on the swelling over the points of the
tooth, which may be done in one direction
with a common knife, blunt at the point, tolerably
well, but we cannot always apply
it conveniently to cut at the side of the mouth,
so I have caused make two concealed Lancets,
the one for making the one incision, & the
other the other incision.
Next, when the first set of teeth come to be
loosened by the second, we ought to extract
them, which we readily do with a pair of forceps,
for

425
for which they are carious, & their shape somewhat
altered, they are raised a little at the
same time.
Next, you know the stony crust that frequently
forms upon the teeth, called Tartar, from
the Idea that it is formed from the acid
parts of our food, as Tartar does from wine
& were this the case, a person washing his
mouth with water after eating, wou'd prevent
the growth; but I am satisfied it is a Salivary
concretion, similar to these in the Ducts of the
Salivary glands, & we often observe it, cheifly
about the fore teeth of the under jaw, where
the Saliva falls down by its weight. As
it is a spongy substance containing moisture for
a length of time, it necessarily will be disposed
to putrify, or to be the cause of putrifaction,
& by its bulk, it sometimes pulls away the
Gum from the teeth, & adhering closely, it stops
the Circulation in the Peritoneum, so may be a
cause

426
Cause of Caries; therefore it ought to be carefully
removed, or the teeth ought to be sealed as the
Dentists speak, & for this purpose we have a
number of Irons that are fitted to the same
handles, by which the surface can be scraped,
& we ought to make the seperation with care,
for if we leave little particles remaining upon
the teeth, it grows again more quickly; in time
of doing it we prevent an uneasy feeling
by applying the finger to the tooth to prevent
the tremor.
Next, we proceed to the disease in which the structure
of the teeth is concerned, & as these agree
in texture with the rest of the body, are
provided with Circulating vessels, Lymphatics
& Nerves, it is evident that the diseases
must be similar, & therefore that besides
the exposure of the teeth to accidents, to blows &c.
or to heats or Colds, & a variety of matters received,
they will frequently be injured from
internal

427
Internal Causes, as where the general habit suffers,
as in Scurvey, Rickets, Lues Venera &c.
by which their sockets come frequently to be affected.
Nay, as certain diseases affect particular parts,
as the Gout more especially affects certain
parts of the feet, so there is a disproportion in
some cases, that humours fall readily in upon
the teeth. The Scurvy very readily appears here,
& what are called Rheums, so that when some
from catching cold are affected with Coryza,
others are affected with Toothach. If an inflammation,
from whatever cause excited, forms
in the tooth, & comes to Suppuration, as it
is generally within the bone where the parts
are most sensible, it will run on to the
greatest extremity, pus will be formed in
the cavity of the tooth, & the effect will be
nearly the same as if it has landed in Gangrane,
the pus corroding the Nerves &
other parts within the teeth; & accidents
of

428
of this kind will happen more frequently
that persons do not pursue the Antiphlogistic
course with such exactness are where
organs essential to life are affected. Nay there
is not only a disproportion of diseases to affect
the teeth in general, but further the similar
Teeth have a certain sympathy, as, if there is
a caries in the Dens Caninus, the next-that
suffers will readily be one of the same kind,
tho' there are many exceptions to this rule.
The Molares are most readily affected with
the Toothach, because the chance is most against
them, & they are more exposed to the violent
action of the jaws, from their nearness to the
centre of motion, & their Enamel is thinner
so they are less able to resist. If a Caries begins
on the surface & goes inwards, it scarcely
is attended with pain, & the only sign of the disorder
is a blackness without, & Surgeons have
laid it down as a rule that we ought to
file

429
file off the first appearance of caries, because it
is apt to spread. Now I wou'd not object to this
in general, I wou'd only observe that we are
not well assured that its beginning in a spot
is the Cause of a Caries proceeding farther, &
a black Enamel may be better than none, for
tho' it is not cheifly intended to defend the bone
from Caries, yet when it is removed, the bone
is more exposed to injury from heat & Cold, as
well as pressure. -
Now in order to lessen the pain, we may try various
expedients. - First, we endeavour to lessen
the insensibility of the whole system by large doses
of Opium, or what an eminent Dentist substitutes
in its place, Camphor, or Camphor & Opium
united, or shou'd the pain still continue, an
Electrical shock made to pass thro' the affected
tooth, or the burning a part near to it,
as the Ear, which was chosen from a supposed
communication between the Nerves of the Ear & Jaw;
An

430
An Iron made red hot & applied to the ear has
cured several persons of a violent toothach in
an instant, but the cure does not depend on
any connection of Nerves, nor upon the pain given,
but rather upon the affection of the mind, for
it generally fails when attempted a second time,
& therefore, instead of concealing the hot iron,
we bring it before the patients face, to increase
the tremor. - As we next endeavour
to lessen the Sensibility of the tooth itself, by
touching the bare nerve with Opium, which
operates here in a topical way, & a small particle
of it will affect the nerve more than a
greater quantity taken into the stomach; or
we use Camphor, or Ardent Spirits, which
also releive the pain. These still failing, we
destroy the Nerve within the tooth altogether,
by introducing for instance the button of a bent
probe red hot into the cavity, or we introduce
a small bit of Caustic, & stuff up the hole with
lint

431
lint so as to prevent it from spreading, or
we stuff the tooth with thin films of lead,
which answers better than Mastich, & such [illegible]
bodies. - But if a patient will submit,
after a tooth is very much carious, tho' still
the sensibility remains, the easiest Cure is extracting
the tooth, or detaching it. & perhaps
replacing it again, so we proceed to consider
the steps to be taken in Extracting, & the Instruments.
First, we study the direction in which the teeth
are to be drawn, & this depends on what we
know of the roots & sockets. If we are to operate
on the under jaw, the hand applies
best when the patient is set on a low stool
before the Surgeon, bringing the jaw a little
beneath the hand; but the sitting posture
is inconvenient for the upper jaw, the Instrument
falls away by its weight, & we
do not see the tooth very well, so the plain
rule is to bring the upper jaw into the situation
I

432
I mentioned as convenient for the under jaw,
by setting the patient on the floor, & turning
the head back, whereby we bring the jaw a little
between the knees, which is the posture Fouchard
recommends in all cases; or let a patient be
laid across a bed, with the head over it, which
brings the jaw into the posture we prefer, the
Surgeon being seated, or standing before the patient.
We next detach the Gum from the Collar of the tooth,
& likewise from the socket a little way, that there
may be full room for fixing the instrument
where the tooth grows narrower, between the base
& root; for this purpose, we use the common
scarifying instrument, which shou'd be pretty
sharp; we first cut it down lengthways, then
press it away from the tooth & top of the socket,
& we do the same on the inner side. Now
this is all that is ever proposed to be done, but
I am about to draw one of the fore teeth suppose,
& that my instrument which I find the
best

433
but, is not much calculated for raising the tooth
upwards, I wou'd further split the socket with
a bit of Iron made sharp, & we give it a slight
stroke, cutting it length ways, for the dividing
of it where it encloses the tooth that is drawn,
is of little moment, for the socket is wore down
& in a manner useless, nay cutting a bit of it
off wou'd be a real advantage to the patient.
(The Different Instruments shewn)
After extracting the tooth, if the part blood considerably,
and the common styptic medicines
do not check it, we fill the socket with a
bit of Sponge, & tie the jaws together, or shou'd
these measures fail, which will seldom be the
case, we may stop it with a bit of Caustic, &
by using pressure.
Now after considering the Extraction of teeth, I
wou'd propose the addition of replacing them. Several
of the French Dentists have proposed this,
which is certainly preferable to labouring to fit
artificial

434
artificial teeth, so where a tooth is tolerably sound,
we ought to replace it instantly, & generally,
if it is extracted with caution, it grows in the
Jaw, & has the further advantage that there is
no return of pain, the part not recovering its
sensibility; perhaps it may be only necessary to
luxate the tooth, to raise it a little, & then replace
it. If this is not done, or the teeth are
very much spoiled, Surgeons have recommended
artificial ones, they are put into the middle
of the socket & then tied, but they prove
uneasy, & there is a continued effort of nature
to throw them off; however from the inconveniency
that attends the want of them, as
one of the fore teeth, which assists in pronouncing
the letters, we have recourse to an artificial
one. It is best to tie it in with a silk thread,
as wire is apt to cut in upon the Enamel
of the neighbouring Teeth.
Of Wounds

435
Of Wounds. These are of various kinds,
& first it may be of use that we attend a little
to the changes that happen in Inflammation,
whether breading spontaneously, or occasioned by
Wounds, for I generally observe that Authors
are apt to reason too little or too much upon
this subject, & endeavour to explain circumstances
that are much beyond our reach. The
danger in general attending wounds has been
an effect explained in speaking of the properties
of our different organs. You know that the
danger must be from Wounds of the large parts
of the Circulating system, or from the Nerves, you
also know that the smallest nerve of the
body, such as escapes us in discription,
can be irritated so as to produce fatal symptoms
& this is one effect or termination of Inflammation
which is generally not sufficiently
attended

436
attended to, that the danger arises not from the
mere functions of the part being disturbed,
but from the affection of its Nerves, of which
we shall never be able to conceive any very
just idea.
If a part is inflamed, & the inflammation does
not kill the Animal, & is not discussed, it
remains that it suppurates, or that it mortifys,
or an appearance is observed in the part afterwards,
which is called Schirrus. - If we
mean to discuss an Inflammation; we do
it first by lessening the general impulse of the
fluids, & this is most effectually done by
drawing blood first perhaps from the neighbourhood
of the part, afterwards from the large
vessels, & we divert the course of the liquors
from the part inflamed by giving Purgatives,
which draw the tumours from the channel
to which they tend in topical inflammation,
at the same time, we endeavour to lessen the
irritation

437
irritation in the part by topical applications.
If we find it impossible to discuss any inflammation,
or that it is adviseable to bring on a Suppuration,
before we rashly venture on Medicines,
let us consider what happens in Suppuration.
You know that before this forms, there is a considerable
heat, the inflammation continues for
a length of time, then tumors begin to be collected,
we find an evident effusion into the
interstices of the several soft parts, & whilst the
liquors are effused, they undergo changes, &
the Solid parts are also changed. We can only
perhaps fully explain the changes in either way
by supposing that there [are] is a certain process
resembling Chemical fermentation, that
takes place, & the tumour is continually changing
its qualities, that at length, remaining
longer in the part, & the acrimony increasing,
not only the softer, but the most resisting
parts are destroyed, making its way where the
resistance

438
resistence is the least; therefore, to promote Suppuration,
we must not divert too much the
course of the humors, by giving Purgatives, nor
are we to dilute too freely, nor to throw in
quantities of Acids & Ascescents, & while we
apply to the tumor relaxing substances to soften
the teguments, & promote the effusion, we at the
same time stimulate the part, that the change
which was at first begun by a Stimulus, may
continue to take place.
An Inflammation from the Internal Cause
may discuss, but if it is the consequence of a
wound, it is evident that a certain degree, more
or less, (according to the treatment,) of Suppuration
must take place, for the division of the
Nerves gives the Stimulus, & the division of
the vessels occasion an effusion, & that stagnating
in the wound, the vessels are stimulated,
& there is a formation of pus, which very much
depends upon a degree of change made even
by

439
by the heat of the body upon the Coagulable &
Lymphatic part of the blood; I have seen a
curious proof of this, on tying the Lymphatic vessels
of Animals, we have them emptied of their contents,
by a crust of yellow matter like pus inspissated,
which covers them in their whole length.
Next suppose the inflammation is still more
violent, & threatens a mortification, it has been
laid down as a rule by Surgeons to make incisions
into the part; now I scarcely see the
propriety of this, excepting where the mortification
arises from & great degree of Plethora &
Stimulus. If letting blood in such a case wou'd
be improper, there is no just reason for proposing
incision into the place suspected, this
must add fire to flame, by increasing the
Stimulus; at least I am in doubt with respect
to the propriety of the practise. -
Next suppose the complaint runs into mortification;
we observe that this is more ready
to

440
ready to happen in elderly persons, & in certain
habits, as in the Scorbutic & Dropsical; but
in all ages & constitutions, it may be the
consequence of violent contusions, or even the
consequence of spontaneous inflammation,
when there is a general affection of the coloured part;
not that the mere effusion is to be considered
as the principal cause, it is rather an effect
for a simple inflammation is not attended
with any such danger, there may be a considerable
effusion of a florid colour, & yet the
inflammation discuss, but the unfavourable
effusion follows a change produced on the
vessels, on which the complaint seems to depend,
& if we macerate a dead body in [Spirits]
water, in a few hours it undergoes such a
change as we see in the mortified limb of
a dead person, so it is rather the change induced
upon the solids, than the mere effect of effusion
that we are to treat [off] here. If the 
Mortification

441
Mortification has formed fully, & the part is dead
to a certain depth, how are we to heal it? the
common rule by the most eminent Surgeons is to
make incisions thro' the mortified parts into the
quick, till the patient feels the pain every stroke;
Now this is a rule I cannot see any foundation
fore, nay I think we ought with caution to
avoid wounding the subjacent sound parts,
for if the disease has made this progress, it is
allowed that the letting blood even in small
quantity, is hurtful, besides, we add to the irritation,
& allow the corrupted to be absorbed; however,
the incision of the corrupted part is proper,
for by the mechanical division of the crust,
the sound flesh throws off the dead part readily,
just as an Eschar formed by the Potential Cautery
Separates more easily by cutting into it. Having
made a sufficient division of the mortified parts,
the dressings employed have a better effect,
& the applications must be such as tend to
correct

442
correct its nature, as Spirits, Resinous bodies &c.;
perhaps we ought to join the Bark, as this has
a singular virtue in such cases given inwardly;
Belgar observes that the Bark has a specific
virtue in preventing & curing mortification;
& further to correct the putrescent tenderness,
we give Antiseptic & Cordial Medicines. -
If the part has been wounded, it seldom goes
into the Schirrous state, but runs into Mortification,
nay tho' inflammation in the breast
sometimes occasions Schirri, in general the
Schirrus breeds slowly; & in the end produces
inflammation, so it is more frequently the
Cause than the consequence, whilst there is as
much circulation as preserves life in the part,
there is considerable resistance to the circulation
by the substance in the intermediate spaces,
& from irritating, is liable to be inflamed.
If we are to heal a wound, in which the
healing goes on in the common way without
the

443
the danger of such bad accidents, our treatment
ought to be very simple; by observing what nature
does we are led at once to the cure; after a wound
there is first a discharge of red blood, by degrees
the vessels exclude the red parts, & the lymph
& serous parts come only to be discharged, & these are
perhaps somewhat changed, so that we may consider
a wound as a Gland making a particular
kind of secretion. It is evident that the
purulent matter is the best application that can
be made to recent wounds, & the Surgeon is not
to wipe it away anxiously, he is only to correct
certain bad qualities of it; in general we need
only defend the part from the air & accidents,
for on the authority of Belgar, I consider the air
as hurtful, he warns Surgeons in dressing a
wound to have all the new dressings ready,
for the cure is more tedious where the part is
exposed to the air; I mention this because Sharp
doubts of it. The access of air is particularly
dangerous

444
dangerous in wounds penetrating into the Abdomen.
Suppose a wound formed, & we apply the common
dressings to it; but perhaps the wound or
complaint may be of such a condition as to
require that some foreign substance shou'd be
thrust into it, to hinder the external parts from
closing before the internal are rightly filled
up, as in an Abcess or Fistula; in such
cases, we introduce some lint doubled or made
into a Cylindrical or Conical shape, which is
called a Tent, or in order to dilate the opening
still more, we form the tent of sponge dipped in
an adhesive substance, as a solution of the Ichthyocola,
& the parts squeezed together till the watery
solution hardens, or till the solution of Oily or
resinous materials cools; this being put into
the narrow opening, by the heat of the body
the materials are dissolved, & the elasticity of the
Sponge taking place, the opening is enlarged.
Now this is the only power we shou'd ascribe
to

445
to these Tents, & we are not to consider them as conveying
Balsamic substances to the bottom of the
Fistula; nay it is seldom they have any good
effect, they stimulate in an unnatural way, &
in general where there is any ulcer, they make
it less disposed to heal; in such cases we may
do somewhat by external applications, but the
cheif changes are to be produced by internal
Medicines & a proper regimen.
If a substance resembling the Tent be made into an
oblong shape, the lint folded, & put into a superficial
opening, it is called by Surgeons a Dossil;
thus suppose after the Operation for the Fistula
Lacrymalis, & the teguments are disposed to shut
before the wound is healed from the bottom, we introduce
this, & that we may take it out readily,
we put a thread about it.
Next, we need to apply the lint folded in forming
Pledgets or external Compresses, for the purposes
already mentioned in a general manner,
when

446
when about to dress a wound or sore. -
Next, we use a bandage, or in slight cases
we sometimes make the cure by Plaister
Bandages for the Head - First the
Couvrechef; it is either made of a Serviet,
or piece of rag; we double it, but make the
one side a little longer than the other, & fold
it a second time to get the middle, & in applying
it, we use both hands, & we bring it
down to the eye brows, with the broadest [fold]
hanging down to the point of the nose; We
next give the two outer tails to an Assistant,
& taking hold of the inner tails, we pull them
foreward till we bring them closs in upon
the neck, then turning them back over the
outer

447
outer tails, we tie them behind the head in a
slight case, or cross them behind & pin them; we
next fix the two outer tails, which is done by a
knot made under the chin, & thus we form a
very equal covering for the whole head, which
fits it exactly, & which is readily lifted off again.
Next with a Handkerchef we can form a bandage
for the whole head, by folding it equally with
the two opposite angles applied to one another; we
lay it down above the eye brows, & bring the tails
round the hind part of the head, & tie or pin
them as before, & Also turning the other tails up
behind, we pin them. This is called the Triangular
or lesser Couvrechef, but from the want of Straps
under the chin, this bandage is not so secure.
Surgeons not contented with these simple
bandages, have composed one made of a double
headed roller, for its security we put it round
the head, then begin to make reserves, bring
the one strap forwards, then turning it back again,
with

448
with one head discribing Circulars, whilst with
the other we discribe reverses, so we have it
in our power to cover the whole head, & then
we finish with the two circulars. This bandage
may be of use in making great pressure
upon the head, as after performing an operation
for the Hydrocephalus, & we mean to make
pressure on the crown of the head, but from
the difficulty of applying it & taking it
off, we wou'd seldom have recourse to it.
A night Cap that draws behind, & a Strap
added to come under the chin, makes a
very good Bandage.
Next suppose we need dressings for particular
parts of the head, or suppose we are to let blood
in the temporal Artery, we stop the blooding
with Dr. Butlers Tournequet, or we use a
double headed Roller, crossing them just over
the part wounded, which forms a knot, which
can be repeated at pleasure;- Next suppose
a

449
a Longitudinal wound, or even a transverse one
in the head, we use for it what is called the
Uniting Bandage, one with a slit in it; the
manner of using it is to bring the two heads
together, & to pass one thro' the slit where the
skin is drawn together, we then make more
turns & pin it, having finished with a few
Circulars round the head.
Next suppose a slight wound in the fore head,
or that we have let blood in the frontal Vien,
to give the bandages a neat appearance, as
well as firmness, the Surgeon first takes off
as much of the bandage as reaches to the Nape
of the Neck, & having made two or three,
Circular turns round the head, he turns this
strap over the head, & pins it at the nape
of the Neck, & it not only looks well, but
answers its purpose very fully, & to give it
still more the appearance of art these Straps
may be passed in a slanting direction;
the

450
the former is called Discrimen, while this is
called Scapha, forming the figure of a boat
on the crown of the head.
Suppose it necessary to apply a dressing to the
Nose, we have a double headed roller, & a
Strap to turn over the head, & there are holes
in it for the patient drawing breath.
Next suppose that the lower jaw needs a
bandage, & that it is applied with considerable
tightness, as in cases of fracture of the jaw,
a single or double headed roller is recommended;
having applied bits of past board or other Compresses,
we begin on the fractured place, & cover
it with a few turns, & going forewards with
edgings, we include the whole, then we come forewards
from the nape of the neck in order to
include the jaw on the fore part, & conclude
by a few other terms over these by which all
the other edges are drawn in, & the application
equal. We do this more expeditiously with
the

451
the double headed roller, but the single is preferable,
because the Surgeon has more the command
of the other hand to fix the bone, or to do any
other thing necessary. - But we may supply
the place of these by a single or four-tailed
bandage with a small hole in the middle
for including the chin; we turn the undermost
tails over the head, while the uppermost
are fixed behind, & we can draw them sufficiently
tight, & this is the most useful for treating
Ulcers & Wounds of the fleshy parts. In a fracture
of jaw we might make a bandage of the same
sort, only stronger, as of folded cotton, & we
may give it six tails instead of four, & adding
to their length, we repeat the turns as often
as we please; we have a certain degree of
opening that the patient may take food,
& which by an effort of the muscles may be open'd
wider, or where the fracture is considerable,
some soft substance may be put in between the
teeth

452
teeth.
Next suppose the tongue to be wounded, as from
a stroke given to the jaws when the tongue is
between them, or in Convulsive cases; here is a
contrivance proposed in the French Memoirs,
it consists of a bag, the size of which is proportioned
to the tongue & the place of the wound, this is
kept on the tongue by a piece of wire, which
goes into the mouth, & which is secured by a
bandage, & it gives all the security we can require.
I formerly shewed you a good way of excluding
too strong a light from the eyes, at the same
time admiting the air by means of a Circular
piece of wood, or sort of box covered
with Gauze single or double, the holes finer
or courser according to the degree of light we
want to admit, this ties with a ribband behind,
& has a middle piece to go over the head
to the nape of the neck.
The last bandage adapted to the face is the
mask

453
Mask, which may be useful in several cases,
it consists of a piece of cloth shaped to the
face, with six tails; we first tie the upper
tails at the nape of the neck, the the under
two over the head, then the middle two
behind. This is useful where the skin of the
face is burnt, for applying a poultice, or
Oily matters, or in the small pox, which leaves
marks where the skin is exposed to the air, so
applying this oiled, we keep the skin soft, & prevent
the crusts hardening, & confining the
sharp humours so as to corrode the skin; or
where we want to apply any wash, or
particular medicines to the face where the skin
is tender or subject to inflammation, or where
there are pimples, to which we may apply a
Solution of Sacch. Saturn. or white Vitriol;
there is not so much danger in trying these
as is generally thought.
Bandages

454
Bandages for the Neck. There is no great room
for any great variety of turns here, we can use
merely a bandage for retaining dressings, the Retentive
Bandage, as when the patient is let blood
in the Jugular Vien; where the neck is long
we support the bandage by laying a strap over the
head & making a few turns.
Bandages for the Trunk. In Heister & others you
find discriptions that are very tedious, & not a
little perplexing, one wou'd imagine that there
were an infinite variety of bandages necessary
or possible here, whereas we may reduce them to
a very great simplicity, & more than one half
are of very little use. The different turns that
can be made are first a figure of 8 on the
Chest or back only, or on the fore & back parts
alternately, & that either with the simple or
double headed roller, or we can apply the same
with edgings, or we can make the figure of 8
on one or both shoulders. - Next taking
advantage of the shape of the body we can
secure

455
secure the bandage in a different way by making
a circular or two round the trunk with one
head, & reverse the other head over the shoulders,
fixing the first turn with a pin we readily
secure the rest. This is called Quadrige, because
persons driving Chariots give a firmness to their
bodies by bandages resembling these. Now it
is evident that I can make the same applications
to the lower part of the Trunk; if I am
to form a figure of 8, I pass round the Os Ileum
& return again at pleasure.
It is evident then that all the variety here may be
reduced which agree in the general manner of application,
but considering the troubles of pulling
them on, that the patients body must be exposed, &
that every turn we make round the Axilla & between
the legs, the bandage is drawn in & corrodes
the parts, we shou'd endeavour to supply their
place by simple contrivances, & these are only
useful where the considerable pressure is of use, as
in

456
in Luxations of the Clavicle or os humeri, where a
Spica may be put on; filling up the hole with
Compresses; but for wounds, or tumors that have
been cut, it is better to use a simple Retentive
bandage, as a thin waistcoat of linnen or cotton
drawn together with a lace; or a piece of square
cloth with straps put to it.
Next of some bandages for the trunk that are in
more frequent use than these rollers - Thus suppose
a disease to have formed in the Mamma, we may
use various bandages to support our dressings,
as the Sling Bandage, the ends of which are put
over & under the Shoulder; the effect of this is
also had from the T. bandage, & crossing the two
pieces of the cloth we form a bag for holding
a poultice or other such dressings, & the patient 
herself can manage the bandage; or suppose a
sore under the arm pit, it answers very conveniently.-
There is a third kind more frequent
in use in such cases, where containing the
dressings

457
dressings is the principal object; it consists of a
roller made very broad, & put round the body,
& we apply a Scapulary over the shoulders, & by
pining this to the circular we make it very
secure; it is called the Napkin & Scapulary.
Suppose a require more pressure, instead of a linnen
roller we might make it of flannel, as in a
fracture of the ribs, after compresses we apply
the flannel roller, & support it as before with the
Scapulary. - The same applys to wounds in the
Thorax, adding straps below to make the bandage
more secure; or to wounds of the Abdomen, or we
may apply the T bandage to the Pelvis, which
is here mostly used, as in cases of wounds about
the Pelvis, Caries of the Os Sacrum, Luxations &
Caries of the Os Coccygis, the operation of Fistula
in Ano, Lithotomy when the urine passes pretty
well thro' the Urethra; after Castration, Hydrocele,
the operation for the Inguinal or Crural Hernia,
or for Buboes. - For the Inguinal Hernia
we

458
we use a truss, & the shape of the body is to be
taken for it very accurately; it has one or two
cushions as the disease is on one or both sides;
the Circular is made of metal properly stiffed.
But for a Child we use a cotton bandages
with a cushion, cork perhaps covered with leather;
in general they are made too soft so that the
bowels insinuate, & then a slight pressure has
a worse effect than a greater pressure has when
within the abdomen. Here is a cushion that was
used by a poor man, it consists of a bit of
wood covered with tow, & that with leather, & the
head band of the bretches served for a Circular.
In like manner for Umbilical Hernia, we
use a cushion with a spring to humour the
Respiration, so that it may be kept tolerably
well applied.
In case of Prolapses Ani we may use a similar
kind of Truss consisting of a Circular, & a plate
of metal stuffed to press upon the Rectum.
To support the Uterus when it falls down
several

459
several contrivances have been thought of; the
Os Uteri may be received into a hollow piece
of Ivory which is supported by a smaller piece
laying in the Vagina, which is made with a
ball & socket at its extremity, & this is secured
by a bandage; but in experience, it has
been found that a ring answers the purpose
better, the size is adapted to the part, it is
introduced side ways, & turned so as to receive
the Uterus, & it makes a considerable resistence.
I have read of a case where a ring of this kind
was forgot, & continued for several years till the
woman fell with child, when there was a
necessity of extracting, a proof of the case
with which a substance of that kind may remain
for a length of time; but from time to
time it is proper to take it out & change it
for one of a different size, so that the pressure be
not always made at the same time part of the
neck.
Bandage

460
Bandages for the Extremities. If we are using
a bandage about the elbow or knee, as after
letting blood, we can discribe a figure of 8; the
bandage is made to pass three times, & if we
are to pin it we begin with the end, but if
we are to tie it we leave a piece, & throw the knot
upon the vien immediately on the orifice. After
the operation for the Aneurism we use the same
bandage, only broader, & applied very slight.
Next supposing any disease in the hand, there
is room from the shape of the part to vary the
turns, to make edgings, to discribe circulars, or
run up upon the fingers, or to discribe the Gauntlet,
or half Gauntlet, covering the hand & fingers,
or hand only, & this is used in the case of burnings
&c.; but in burns we are never to use
such bandages, because of the pain we give
in seperating the fingers; we use bits of oiled
rag, or with the Ung: Saturn: laid between
the fingers & over all the parts affected, so as
to

461
to prevent them from growing together.
In like manner we can apply the bandages
to the feet, & the manner of making the turns
is so evident that it hardly needs to be shewn.
At the same time, however simple all the
bandages may appear, I wou'd advise those
who practice Surgery to use themselves to their
application, for besides the real advantage to
the patient, you are to consider that every bye
stander is a judge whether a bandage answers
its purpose, & it is allowable for
them to judge of a Surgeons skill from
what they see.
Of Luxations. I have already attempted to
prove that in such cases, especially where a
large bone is displaced, the Capsular ligament
is almost always tore, & from this
idea it appears that there is a number of
circumstances which concur in rendering the
reduction

462
reduction of a bone difficult; it is evident that
the rent in the ligament may be so situated
that the Surgeon shall find it difficult to direct
the head of the bone into it, I apprehend
however that this is seldom a principal
cause of the difficulty, because the laceration is
generally so much larger than the head of the bone,
& the rest of the ligament confines the bone so
nearly in its place that the Surgeon will find
little difficulty in replacing it, but this operates
more or less according to the extent of
the luxation. - Next it is evident that the
ends of the bones are mechanically fixed;
the extremities of all our bones are larger than
the neck or middle part, or when it slips off,
the heads of both come to press against the
neck of the other, hence unless they are previously
seperated by being drawn asunder, the
one head acts against the other.
Next you'll consider the effect which the Luxation
must

463
must have upon the Muscles merely considered
as Cords connected to the bones being thrown out
of their natural place, they pass across the cavities,
so hinder the head from occupying its
proper place, thus in the Luxation of the Humerus
the tendons of the Biceps are thrown
across the cavity of the Acetabulum. Next you
are to consider that the muscles from the sensibility
after remaining a little while out of their
sensation, & being put on the stretch, swell,
are shortened, & their tension from passing over
the Capsules, is considerably increased, the muscles
are immediately thrown into considerable
action upon the Surgeons attempting to reduce
the bones, they swell, grow hard, & more sense.
The longer the Luxation is in being reduced, the
chance of success is the less, the time however
is now way determined, some are reduced
after three or four months, in other cases
the same luxation cannot be reduced after
as

464
as many [months] weeks, & therefore is general
we shoud attempt to reduce a luxation, unless
we find the shape of the bone sensibly altered,
a fracture along with the dislocation &c. To
delay the reduction till the swelling has mostly
subsided may sometimes be proper, but I apprehend
if this general rule was reversed
it wou'd be attended with more successful
practice; tho' the patient may suffer immediate
pain, this is not to be ballamed with allowing
the bone to stay out of its place, for unnatural
adhesions begin to form, & this will the
sooner happen as the accident has been more
violent. - Next the posture of the limb
luxated must be studied, the whole body must
be made secure, otherwise the attempts of the
Surgeons may be eluded. - Next we consider
the effects of all the muscles concerned, & we
relax them as much as we can, least in
attempting to reduce the joint any muscle
may

465
may pass over it, & when any of the muscles
pass over a neighbouring joint we must
relax these also, so in the luxation of the
Humerus we bend the fore arm, some of the
muscles passing over both joints, but we
cheifly attend to the muscles connected to the bone
luxated. - Next, we confined the Extension and
Counter extension, or the pulling & resistence
only to the joint that is affected, not exposing
any other joint to suffer from the streatching, so
we do not extend the fore arm in the reducing
the Humerus. - Next, we employ our force
by slow degrees, we are not, because in one case
we have seen a certain degree of force necessary,
to suppose that in a patient of the same strength
& in the same joint, the same force will be
required, nothing is more uncertain than the
force required, & in general so great a force is
not necessary as many Surgeons have imagined,
from their not attending to the several
circumstances

[3]466
circumstances that I have mentioned; but on
the other hand, it is rediculous to observe
some talking of the great case with which the
large bones may be reduced, building upon
a single instance where the Humerus was
found to have got into its place in the time
of sleep, after the reduction had been attempted
in vain, from the Biceps muscle having
got into a better situation. If I were to mention
a general rule, suppose the humerus luxated,
so far as I have seen, it will require the strength
of two persons to seperate the bones in an adult,
nay in the small bones I have seen a great
deal of force necessary. - But if a certain
degree of force fails we are by no means to
run immediately to a greater degree, but to continue
our efforts, for by long continuance
we may come to succeed where the same force
at first failed, for the muscles of the patient
come to be fatigued, & the effort to contraction
grows

467
grows much weaker, & as a plain proof that this
is a very material circumstance, we observe
that when a patient happens to faint, thus is
the time to succeed; there is an appearance
of cruelty in attempting to replace it in that
situation, yet by doing so a few further attempts
will generally prove sufficients. - Now having
mentioned the leading circumstances, I shall
choose out an example, & shew the manner
of treatment, & I shall take as being most
frequent, & of considerable importance
Luxation of the Humerus. You recollect the
situation of that bone, that it is pushed forewards
on the ribs, & within the two pectoral
muscles. The patient is set on a low chair with his
side to the Surgeon, we bend in the fore arm to
relax the Biceps muscle; next we determine the
posture of the Humerus, & upon the whole, if we
are to pull in the ordinary way, it is better
to bring the elbow a little further in toward
the

468
the body than when the arm hangs, whereby we
relax some of the principal muscles covering
the head of it, particularly the Pectoral Muscles;
next we keep the arm at an acute angle
with the body, but we do not press it down
to the side, which woud stretch the Supra-spinatias
Muscles, which are strong, & raise the body.
The Surgeon next fixes a Garter or Napkin to
the lower end of the Humerus above the elbow,
leaving two tails, which he throws behind, &
gives to one or two Assistants, who place
themselves before the patient, & their business is to
pull in the direction given to the arm; the
resistence is to be made by the same number,
one lays hold of the Scapula, & the second
generally lays hold of the first, but tho' a 
hundred were to lay hold of one another in
this manner, it wou'd have no more effect
than if one only pulled, therefore unless
we

469
we can make the resistance, let one, & tie the
strongest, stand at the back, take hold of
the Scapula, & the other at the other side take
hold of the body. The Surgeon does not attempt
to raise the head of the arm till a
sufficient extension is made, & when it changes
its situation, a small force will bring it into
its place, drawing it a little more downwards,
& directing it into the Socket. Some tie a
Serviet round their own neck, others cover a
roller with a serviet, pass it under the neck
of the humerus, & strive to lift it, but this will
not do unless the extension is made, & then
it is unnecessary, & we may bruise the soft
parts against the bone. - Some lay the
patient on a floor, a strong Assistant lies
down with him with his head the other way,
he puts his heels into the patients Axilla,
takes hold of the Serviet with his two hands,
draws down, while he pushes up with his feet.
This

470
This is really not materially different, & if the
one way succeeds, the other with the same forcee
will do the same.
But suppose next that these methods fail, are
we as many have directed, to pass the patients
arm over the spokes of a ladder, & an Assistant
to lay hold of the end of the humerus? or are
we to employ the Ambi of Hippocrates, when
the body is held down, & the os humeri raised?
now the latter of these methods is preferable,
for as it raises the humerus it at the same
time makes the Extension; but it begins to push
the humerus up before it is detached from
the Scapula, so we need scarcely stink of it.
We are provided with other machines that are
more effectual, & first we can employ a case
of Pullies; we tie the one cord to a place
that will make sufficient resistence, & the patient
must be tied to another; now by pulling
the rope of the pullies, we can extend the arm
powerfully

471.
powerfully; if there was no resistance from the
friction of the four pullies, it wou'd be as
good as 8 to 1. - Now this may be fitted
to the Ambe of Hippocrates, which is done by
the late Monsr. Petit; we apply a piece of
leather to secure the patients body, & particularly
the Scapula, & by means of it we make the
resistence; next we fix the lague to the patient's
arm, to which we fix the pullies by a strong rope,
& with the machine it is evident that I can
increase the pulling with a power that is irresistable.
There are several objections to this
machine, we have little hold of the top of the
humerus, nor can we give it the proper direction,
& if we relax the pullies it may slip
back into the hollow. Now several of these are
removed by the late Mr. Freke, his machine
is made quite portable, consisting of a box,
which is opened & [shut] fixed by hooks, & the whole
machine is fixed to the floor by pins that shou'd
be

472
be screwed, & the box shou'd be very strong wood
so as not to shake in the least; next we fix
the lack to the humerus, this is broad & made
of thick leather to prevent the soft parts from
being hurt, & with two iron hooks, upon these
we pass the [?lopes] of the pullies, & the patient is
seated on a low chair, till raising the Instrument
it enters the Axilla. Now we can extend
the arm at pleasure, having all the advantages
which Petits instrument has from the Pullies;
next having made a necessary extension, we
have the use of Hippocrates's Ambe, raising the 
bone at the same time from the Axilla upwards
into its place; if necessary, we cant at
the same time turn it inwards or outwards;
so that this seems almost to have every advantage
that we can give to a machine
of this kind; we secure the body by people
holding it, or with a belt laid over the shoulder
to keep down the Scapula, & we secure
the

473
the belt by a hook entered into a ring that is
secured to the floor. Yet with all the advantage
of this machine we sometimes fail, I have
known it used & tried very fairly, & to little effect;
another method I am to mention succeeding
perfectly well. An account of that was first
given by Mr. White, tho' I find that several
others in different countries have practised
nearly the same thing. It is to raise
the patients body by the arm his whole weight
from the ground. Mr. White erred in doing it
by the wrist, it can be done after bending the fore 
arm. The patients body is to be elevated in this
manner from the ground, & the weight sometimes
serves very much to disengage the bones,
but suppose that not sufficient, the thing is to
rouse the body by a signal, suppose a foot,
& then by a second signal to let go the rope
with a shock. Now I have tried this in a
case with Mr. [Wardre?o], where a Bone setter
in

474
in the country had evidently used great force,
for the soft parts were much gall'd; we laid
a couple of thick beds on the floor, & the
patient was laid on the bed, the fore arm
was bent, & kept so, an Assistant took hold
of his Legs & raised them, then the patient was
raised up by a pully fixed to a beam in
the roof; I then proposed the giving him a
shock, which I think is not mentioned by
Mr. White; after 5 or 6 we observed a loosening
of the bone, & after he had got above
a dozen the bone went in with the slightest
touch of the finger, nor did the patient suffer
half the pain he had endured from the
Bone-setter & Machine. - Or we place the
patient on a stool, tie the arm to a beam
on the roof, & then kick away the stool,
& I am convinced that the weight of the body
& this posture together, the muscles taking
all their natural direction, will have an
excellent

475
excellent effect, as we only beat upon these that
make the resistence, and an attempt in this
manner will be found to succeed when we
shall fail by the more common methods.
So far for the Luxation of the Humerus.
Let us next see if there is any thing particular
in the other joints.
With respect to the Spine, I shewed the manner
of reducing Luxations of it, as also the manner
of treating luxation of the lower jaw, which
comes before the Zygomatic process; generally
both sides are luxated, but we shall succeed better
when instead of making the pressure on both
sides, we confine it all to one side; using
the other Condyle as a centre of motion.
Suppose the fore arm dislocated, it may be out
in all directions, for as the ligaments are
tore it may be twisted any how. Surgeons
from conceiving the ligaments only relaxed
think it impossible that the ends shou'd be brought
foreward

476
forewards, but this can happen; or they may both
slip on the back of the humerus which is
more common, or they may slip inwards or
outwards, and the Ulna alone may have hold
of the Humerus; but the most common kind
is when both bones slip behind the Humerus o
are remain connected. Now Surgeons generally
attempt to take hold of the hand, & to thrust
in the elbow into the joint, but the same objections
lie against this practice as against
the Ambi of Hippocrates, that we do not sufficiently
extend the joint, & we will succeed
best by having the proper extension made,
& when the bones are disengaged, we readily
push them into their place.
Next the Wrist is sometimes luxated, tho'
this rarely occurs, & the bones may generally
be replaced without much force.
With regard to the fingers I have no particular
observation to make, only that you will
sometimes

477
sometimes be obliged to use more force to make
the extension, than at first sight you wou'd
expect.
If the Ankle is disjointed, we distinguish
the complaint by the length of the foot, its
sliding out before or behind, owing to the direction
given to it by the lateral ligaments.
We lay the patient on his side, & bend the knee
to slacken the Gastrocnemius muscle, & the reduction
is made with no difficulty.
I have mentioned the manner of reducing the Patella,
which is to push it backwards, so we turn it round
& make it slide readily into its place.
Next, the whole knee may be disjointed; there is
an instance of this in Heister, where the leg was pushed
upwards to the length of the thigh bond; Chesleden
gives us another. Suppose it was in view to replace
the parts, Chesleden did not give all the
chance of recovery he might have done, from
the idea that the ligaments are generally relaxed 
and

478
and lacerated, so considered it as a desperate case;
but Mr. Anderson at Luth met with a case where
there was a compleat Luxation of the knee, the leg
bone passing up behind, & he found no difficulty
in making the part move upon bending
the leg, & kept it bent in time of the Cure.
With regard to the Luxation of the thigh, I formerly
shewed you that it may be inwards
or outwards, & also the different postures to be given
in attempting to reduce it. If it is inwards,
the head is lower than the socket, so less extension
is necessary, but some is, because the
round ball sinks into the Foramen Thyrordium.
First we relax the muscles by bending the thigh
& rolling the leg a little to relax the tendons of the
flexors of the thigh, then we hold the Pelvis, &
make some degree of extension by putting the
knee, an Assistant does this, he pulls the knee
outwards to him, fixing the Pelvis perhaps with
his foot; that being done moderately, the
Surgeon

479
Surgeon pushes in the knee with one hand,
& draws out the thigh bone with the other,
& it will probably pass in with ease.
But if the luxation is backwards, the thigh is
shortened, & the bone presses in within the
Glutӕr muscles; we first relax these by bending
the thigh as before, when these muscles become
Rotators, draw the leg outwards, then we
make considerable extension; this being done, the
Surgeon drawing out the knee, pushes the top
of the thigh inwards, & turning the head of the
bone round directing it outwards to the Acetabulum,
he can with little force push it inwards to its
place, tho' this luxation will be more difficult
to reduce than the other.
After Luxations are reduced, we are to apply Bandages
to keep the bones in their places. Formerly
the manner was to fix Compresses in all the holes
round the Articulation, then to apply one or more
bandages with the same accuracy as when there
is

480
is a fracture, & they allowed these to continue,
and the joint to remain without motion
for several weeks. Instead of this, of late,
several Surgeons of eminence tell us that
bandages are no ways necessary, but in following 
these Gentlemen, I apprehend we wou'd
run into the opposite extreme, & in speaking
in that manner they have not made allowance
for the shape of the joints, & have had
in their eye the luxation of the thigh, where
from the depth of the socket the patient
may walk with tolerable ease & safely immediately
after the reduction. But we shou'd at
least have the appearance of a bandage
otherwise the patient will use more freedom
than is safe, & the Surgeon be brought to
answer for every indiscretion he happens
to commit. If the thigh bone, is luxated, instead
of applying the figure. of 8, you will find
it sufficient, if inwards, to keep the knees from
being seperated, by fixing them together with
a

481
a Garter, that the patient may not give the
limb such a situation as throw the thigh
out of its socket. If the Luxation is upwards
and outwards, more attention may be necessary,
& besides fixing the knees, we shou'd apply
a compress upon the outer side, & make a few turns
of the Spica Bandage.
If the Humerus is luxated forewards, we shou'd
in like manner keep the humerus inwards, by
causing the arm to be supported by a scarf
pined to a waistcoat without sleeves; or if the
Joint is very loose, & a very small motion is
in danger of throwing it out of its place,
we may add a few turns of the Spica Bandage.
If the Knee or Elbow is luxated, more attention is
necessary, from the want of sufficient depth
of socket, so we study by applying compresses
& bandages to secure these joints. - If the
fore arm is luxated upwards & backward, a
thick compress applied above the Olecranon,
with a few turns of a bandage, gives security
against

482
against the accident returning.
If it is the Wrist or Ancle, still more attention
is necessary, the bones having little hold
of one another, so they must be secured by a
Compress & Roller, but from time to time
during the cure, we let the bandage be loosened,
& holding the bones, we give the several bones
a gentle play in different directions, to prevent
prӕternatural Adhesions.
Treatment

483
Treatment of Fractures. Where a bone is
broke, whether in one or more places, without
a wound of the skin, most Surgeons call it
a Simple Fracture; but some apply the term
of Compound if the bone is broke in more
places than one; generally however that term
is understood to express a breaking of the bone,
with a wound of the softer parts, that the flesh
or skin is cut or lacerated. - We shall
begin with simple fracture, for whether the breaking
is in one or more places, the general management
is the same. - We discover a fracture
from the nature of the Accident, the shortening or
bending of the limb, & rubbing of the broken
pieces against each other.
In the treatment, the rule laid down for Luxations
is still more necessary here, that we shou'd reduce
the fracture as soon as possible, notwithstanding

484
notwithstanding that a swelling to a considerable
degree has come upon the part, because the
sharp edges of the bone drove out of their place,
irritating the Muscles & Nerves, may produce
still more mischeif than the smoth ends of
the luxated bones. In order to reduce the broken
pieces, & to bring them to a right direction, we
study the posture of the member, for it is
evident that the muscles are the cheif organs
which can make a resistence, & that these in
certain situations pull the ends of the bones
nearer to each other than in other situations.
Now what we will find best is this, if we
are to reduce the fracture of the thigh or
leg, let us not extend the members as was 
formerly the general practice, for then all the
Flexor tendons are put on the stretch, & every
effort of the patient drawing the ends nearer,
the broken pieces are necessarily made to pass
one another; therefore, if the thigh is broken,
we

485
we bend the thigh & leg to nearly a right angle,
& if this posture relaxes the bones most, & allows
the reduction to be made, the member ought afterwards
to be retained in this posture, & therefore
the patient is not to be laid upon his back, or
the member upon its back, but upon the outer side,
& that is in general the best situation for the
Inferior Extremities.
For the Superior, if the Humerus is broken, we
relax most by bending the fore arm, & raising
the Humerus a little, whereby the muscles are
more at their ease, & the patient may remain
conveniently in a sitting posture, may be kept
erect, & the weight of the member rather serves
to draw the parts asunder. - If the fore arm be
broke, we bend it nearly to a right angle
with the Humerus, & Keep a medium between
the Pronation & Supination, or allow it to lie in
the easiest posture, & with the fingers moderately
bent, or in that situation they naturally
fall

486
fall into when we make no effort, hence if the
patient is laid in bed, we lay it on a pillow,
or contrive a case which has nearly the same
effect, & allow him to walk about. -
If these rules are attended to in practice, there
is no use for the antient machine for extending
fractured limbs, such as are used for extending
the bones in luxations, it is enough to do this
with the [han?], an Assistant pulling moderately
whilst the Surgeon puts the bones in their
proper situation.
Next the posture which we agree upon necessarily
determines the kind of bandage; we either
employ a roller as the principal Retentive,
or a piece of slit cloth, a bandage with a number
of tails, which is laid on the fractured place,
grasped by means of it, it is called a Compound
Bandage. Now it is evident that if the leg is to
rest on its side we wou'd use a bandage
that can be opened without lifting, or running
any

487
any risque of the pieces being displaced. In general
you will find that in a full grown
person it will require at least six weeks to
compleate the Cure of the fore arm, a couple
of months or so to the Cure of the Leg or Humerus,
& perhaps three months to make a
compleat cure of the thigh bone.
Having mentioned these circumstances let
us next review the machine which Surgeons
have proposed to use & see whether they may
be employed with propriety.
The common manner of treatment is this -
An Assistant holds the member in a proper
situation, the Surgeon replaces the bones, & immediately
applies a compress, & it is very common
to use a bit of rag slit at one or both
its ends, or some few apply a plaister, but the
greater number reject these, because they gall
the part & make the Dressings adhere; after
such a compress, if a roller is to be employed,
they

488
they apply an inner roller, first beginning
with the turns on the fractured place, &
contining them upwards & downwards, & they
purposly make this application slack; they
next use what are called Splints, made of
some firm substance, as leather glued to wood,
which is split, afterwards two or more are
applied, avoiding the ridges of bones & the
subcutaneous vessels; over such coverings of
wood or Pasteboard with a compress within
them, another roller is put on & drawn tight,
after which certain machines are employed
to prevent this bone from moving without
the others be moved along with it, as lunks
of wood covered with straw, & tied the whole length
of the member, then a covering is raised to keep
off the weight of the bed cloths; or in place of
the last Instrument, the patients leg is put into
what is called a Fracture Box.
If instead of rollers the Compound Bandage is
employed, & the common one is a triple one,
there

489
there are three pieces of cloth sewed together, which
are slit into six tails, each, making an 18
tailed bandage; over the inner roller, the inner
six tails are applied, after that a compress with
Splints, then the outer, then the same machines
be where the roller is employed. - Now what is
the use of the inner tails of the Compound Bandage?
surely where it is applied loose a
bit of a rag might serve the same purpose,
or do you perceive any use in this inner
roller? surely both may be laid aside, where
a bandage with 12 tails may be sufficient.
In like manner why employ this inner compress?
it is a mere embarrassment to the Surgeon,
it does nothing to sustain the fractured bone,
so it likewise ought to be laid aside. Next
the Splints have been very improperly used
short, for two evident reasons, first the bandage
applied press them too violently in, & press against
the most sensible part of that member; secondly,
if

490 
if they are long so as to fix the ends of the bones
we do more to prevent the motion in the middle
than by fixing them near to the fractured place;
so the splints ought first to extend the whole length
of the broken bone, but it is of advantage that
they shou'd go farther, because their ends come to
restrain the motion of the neighbouring bones.
I apprehend upon the whole that we ought to
treat broken limbs in the following manner, I
shall take one or two examples to explain the whole.
Let us suppose a fracture of the Humerus - the
patient is set in a chair, & he inclines to the opposite
side whilst the Surgeon dresses him, or he
may be laid in a bed; and laying asside Inner Compresses,
Inner Rollers, & side plasters, we begin with
the Splints defended by linnen cloth; pasteboard
is one of the best substances for making the
Splints, & that it may apply exactly, we wet it with
water, & when it dries it keeps the shape, & applies
very neatly, & we might perhaps undertake
to manage a fracture tolerably well
with

492
with two bits of Splints, & bits of tape to tie
them together, but I wou'd prefer the application
of a roller. We put one Splint upon the inner
or back part; avoiding the place of the principal
subcutaneous viens, & we bring the
other to the outer side, & we make them come
over the fore arm so as to confine it a little;
the thicker the Splint is made, it is not only
better by its firmness, but also, in that the bandage
is a little raised off from the Subcutaneous viens.
Next suppose the fore arm the part fractured,
we introduce a Splint beneath in order to take
hold of the Ulna, & bringing it down to take
hold of the hand, tho' we need not come so
far as the points of the fingers, & here instead
of a roller, we may apply the 18 tailed bandage,
the ends of which shou'd be long enough
to pass over one another, & to give a proper security
we may put in pins. If the patient
is to walk about, we further suspend the
fore

493
fore arm by means of a large serviet, & to
prevent the swing of the arm, we secure it
both above & below the joint of the Elbow.
Suppose the thigh bone fractured, the patient
is to be laid side-ways, & under the thigh we
place a large splint reaching the whole length
of the thigh bone, & under it the proper bandage,
& we apply another of the paste board
upon the inner side. Whoever considers the
thigh, will find, that whilst we relax the muscles
most, in that situation we also support
the bone better; as it is not covered with muscles
near so thick on the [posterior part] outerside
as on the posterior part, so the splint
laid in makes the whole surface smooth.
If we are treating the Leg, we adapt the Splints
to the shape of the leg, & Mr. Willm.. Sharp of London
uses them adapted to the foot also, & with a hole
cut for the ankle bone; he makes them of
leather hardened with glew, but you will find
the

494
the paste board answer fully as well. We put
over these an 18 tailed bandage, & from the
situation of the leg, we have little occasion
for any instrument, such as is used for keeping
off the weight of the bed cloths, when laid side
ways, the weight is so equal along the whole
member, there is little occasion for it. I have
caused pieces of wood to be made with holes in
the sides, into which we fit bits of cane, to
make the arch, & we let it out or draw it in
by means of a cross piece of wood. - Or
suppose next that the patient tires of any one
situation, & that the Surgeon wants to change
the posture to that which has been more common,
let him be provided with such a box as
that invented by Petit; we can raise the
bottom at pleasure, so as to alter the angle
of the knee, & by raising the sides of a foot
board, the weight of the cloths is sufficiently
kept off, & even a degree of motion allowed to the foot;
&

495
and we stuff this by means of a pillow; if any
place is too loose, we put in tow. If there shou'd
be a necessity of transporting a patient from one
place to another, as in Armies, Mr. Gouche has
proposed that a firm substance shou'd be laid
upon the Leg, to lessen the stroke in the time of the
carriage; but for common purposes this substance
is more cumbersome than useful, & the
paste board will answer every purpose of it.
If in time of applying the Dressings, a part of
the end of a bone is observed to project, instead
of attempting to push it down by force, we raise
the inferior portion, & bring the bones to a level.
Next suppose that the bones are broke with a
degree of obliquity, & that the pieces have not a
proper hold of each other, it has been proposed to
make a powerful Extension & counter-extension,
but attention being paid to the posture of the limb,
the common bandage will be sufficient, & I therefore
proceed now to - Compound

496
Compound Fractures. Where the skin is broke,
and the air admitted, we find from a number
of cases compared, that the chance of cure is
much lessened by the wound, nay there is a
great reason to suppose, that if one leg is broke
by a blunt Instrument, & the other with the
sharp edge of the same instrument, suppose an
Ax, tho' in the latter there is a clean wound, & the
lasion of the neighbouring parts much less, yet
it will be found in practice that the leg wounded
will be longer in healing than the one broke
merely by the Contusion; i.e. the access of the air
seems to have a dangerous effect upon the deep
seated organs; the bones, muscles, & other parts are
irritated by it.
Now where the bone is broke, & the soft parts wounded,
we replace the bones by the rules given for simple
fractures, & I need not add that we shall succeed
by putting the limb into proper posture, when by
extending it, that may be impracticable. But
suppose

497
suppose that in all postures, whether from the violent
action of the muscles, these being spasmodically
affected, or from the inflammation & swelling, it
shall be found impracticable to replace the
broken ends, are we immediately to have recourse
to Amputation? or are we with Mr.
Gouch & some others to cut off the extremities
of the bones, & endeavour to save the limb, tho'
there may be a necessity for cutting off several inches
of the bone? - I apprehend that no absolute
rule can by laid down, & that a Surgeon is
to be directed by particular circumstances, and
what I wou'd say of the Compound Fracture,
ought to be applied to the Compound Luxation,
where the bones are pushed thro' at the Teguments.
If the patient is healthy & young, & there is
no sign of a very violent contusion, I shou'd
never hesitate to attempt to save the limb, tho' a
considerable portion of the bone needs to be removed;
but if the patient is elderly, has been
unhealthy

498
unhealthy, & the parts are violently contused & swelled,
perhaps the best rule is to proceed to Amputation,
for our success will be much greater if it is done
before a Mortification than after that has begun.
Let us suppose then the best way is to save the
leg or limb, that we cut off the proper portions,
& put the limb into the right direction; in consequence 
of the void & want of resistence to the
natural action of the muscles, & which will be more
when they are irritated & swelled, Surgeons have
been led to propose machines to counteract their
effect, to make an extension. Here is one contrived
by my father for a particular case, where the
thigh bone was broke by a bullet, & three
inches of the bone had been taken out; it is
evident, that leaving the cure to nature, the
limb wou'd be considerably shorter than the
sound one, so he contrived a box, which is made to
rest against the Pelvis, with a cushion, & a lack
fixed above the knee, & brought thro' holes
at the extremity of the box, to make the extension,
&

499
and the wound was dressed by pulling out a
part of the boe. The machine seemed to answer,
but the pressure grew so intolerable on the Pelvis,
that there was a necessity for laying it aside.
Here I shew you another machine that has a
similar effect, contrived by an ingenious Surgeon
in town Mr. Aiken; it is made to fit about
the Pelvis, & has a circular above the knee,
& between these are placed in the direction of the
thigh three pieces of iron, which keep the thigh
extended. Now this seems well calculated for
its intention, but the objection against this as
well as ye. former is, that they imply that the
limb is to be kept in the extended posture, &
hence perhaps in such a Case we are directed to
a machine that will answer its intention
fully better, the contrivance of Mr. Gouch;
It consists of a Circular adapted to the thigh above
the place fractured, defending the thigh with a
turn or two of a soft linnen roller; & another
below it, with two pieces of iron between them,
and

500
and with a screw we can make an extension &
counter-extension, & to change the place of the test,
we need only have a third circular made under
the knee with a hinge, that we may allow the
joint to play when we please. I have caused
one to be made on the same model, of wood, which
can be adapted most exactly, & instead of two pillars
I have made three, to make the extension more
equal. - Now in regard to the machine, I wou'd
observe, that tho' in some cases they may be
of advantage, yet we are not to imagine that
we are to tear asunder the muscles when they
are in a state of Inflammation, & strongly
irritated, but in the after part of the cure, I
have no doubt but that we shall better pressure
the situation of the part, as well as make sufficient
room for the growth of the Callus, by
their use. Another plain effect is, that in any Case
of common fracture, when the patient begins to
go about, he may use more freedom by employing
one

501
one of these machines, which keeps the weight of
the body from bearing upon the place of the fracture.
Where a large Suppuration occurs, let us carefully
examine the place in which the matter
lodges, that there are no splinters of the bone
lurking in the flesh, which must be removed,
& we must make a free discharge at the most
depending part, that it may heal, & we support
the strength of the patient by the use of Bark,
wine, & light nourishing Diet after the state
of inflammation is gone off, & we try the
effect of these before we proceed to the only
remaining remedy, Amputation.
I have endeavoured to shew that the treatment
of Fractures of the extremities may be reduced
to very great simplicity, that if we attend to the
posture, very few dressings are necessary, that
perhaps we scarcely need more than splints properly
lined, with Compresses, & a simple Retentive
Bandage. - Some few bones, or parts of bones,
require

502
require particular treatment, for what has been
mentioned, applies cheifly to the long bones of the
extremities; but suppose that the Clavicle
is fractured, from its situation & use, that it is
to bear out the superior extremity, that whilst
the arm by its weight pulls the outer end beneath
the inner, the shoulder falls in nearer the
breast, so that the ends are placed the one
lower than the other, & the outermost is drawn in
towards the Sternum. Now to counteract these
effects, it is necessary to raise the elbow, pushing
the Acromion upwards by means of a Suspensory
or Scarf, next to prevent the shoulder from falling
inwards by making resistence upon the sound
Clavicle or shoulder. - A Surgeon therefore about
to treat a fracture of the Clavicle, places the
patient in a low chair, an Assistant standing
at his back draws back the shoulder, whilst the
Surgeon pushes up the top of the shoulder by
raising the elbow, then the parts being thus secured,
&

503
and pressing down the place of the fracture,
he gives an easy security by throwing a figure
of 8 round the shoulder & back, only putting
Compresses under the Arm pits; he then applies
to the fractured place a firm compress,
somewhat firmer than that commonly in use,
& thicker, as a piece of paste board rolled in
linen, which is laid especially above the
Clavicle, that it may not compress the Artery
going to the arm, he then secures this with
a few turns of the Spica Bandage, & puts
the Arm in a Scarf, or a waist coat with proper
straps may be fitted to the part, & made to
serve this purpose. -
Next, I shall suppose that the extremity of
the Ulna is broke, or the end of the Acromion,
or ankle, the Malleoli, or any other bones
projecting over the joints, in such a case, we
are certain to counter act the general rules;
if the Olecranon is broken, the fore arm
must

504
must be extended, which contributes to the relaxation
of the muscles attached to the fractured portion.
In like manner, if the Acromion is beat downwards,
or a part broken off, in time of the Cure,
we relax especially the Deltoid Muscle, (which
comes from the whole cicumference of the Acromion,)
by raising the elbow a little from the
side, & in time of the Cure, least a luxuriant
Callus, or wrong direction of the bones prevent
the necessary motion, we now & then give
the joint a gentle play.
Now as our Patella represents the end of
the Ulna, or does its office, we shall next consider
the treatment of its fracture, & this happens
not only by a stroke given, as by the edge
of any hard substance, but by a violent
effort of our muscles whilst we attempt to
save ourselves from falling, & where the knee
has not touched the ground. But in whatever
manner the fracture happens the general
manner

505
manner of treatment is nearly the same. The
method formerly employed was to extend the
member, then to draw together the broken pieces,
& to keep them joined by a thick compress, which
is secured by an uniting bandage; we lay in
a piece of paste board shaped like the Patella,
wraped in cloth, & lay it above the Patella,
& we lay another such piece below it, which
are held by an Assistant; we then defend the Ham
by any soft compress, to prevent it from being
galled, then with a double headed roller we
pull down the upper compresses, & crossing the Ham,
we draw up the under Compresses, & repeat these
turns at pleasure. Some further apply a bit
of cloth slit, over the Compress, & making the
turns of the bandage by pulling the opposite
sides of the slit compress, we draw the Paste-board
Compresses nearer to each other; we then
secure all by pins, & to prevent the flexion of
the member, we put on a Case of pasteboard
& bits of [illegible], or any hard substance
at

506
at the sides, and we are directed to keep the knee
in this situation till the broken pieces are fully
united, i.e. for the space of six weeks or two
months. Now of late years a very different
practice has been recommended, & those who
propose it have been led into it by observing
that in several cases, where nothing had been
done, & the Cure left to nature, the patient cou'd
walk tolerably well, especially on plain ground,
& hence we are advised by Surgeons of eminence
not to apply bandages, nay even the
contrary, to advise patients to bend & extend
the leg. Now I cannot help thinking in this
way we are in danger of running into a
very opposite extreme, & equally hurtful to the
patient; & if cases can be produced where
nothing was done, & yet the patient walked
tolerably, there are other cases where the patient
was altogether lame by a luxuriated Callus,
or where he cou'd not walk better than if
the

507
the parts had been joined by Anchylosis. Now
these very gentlemen allow that the Callus is
more or less luxuriant according to the accuracy
with which the bones are set, nature filling
up the void by a luxuriant Callus, & I know
that limbs have been very well cured treated
in the old manner. I have caused to be made
this instrument which I have no doubt will
be found very necessary & usefull. We put two
straps above & below the Patella, round the
limb, & we bring these together by means of
three straps, & we add further a case of paste board
beneath which, & it is tied moderately to prevent
any motion of the joint. We do this
for ten days, till the callus begins to change
into bone, then from time to time we give the
Patella a gentle play backwards & forewards,
& that is to be continued for ten days more
& it is only after three weeks or a month that
the patient will begin cautiously to give the
limb flexion & extension, in order to prevent
the

508
the rigidity of the Joints, & in this way better than
by either the old method, or that proposed of late,
we will succeed in making a Cure. - If the
fracture of the Patella is longitudinal, the case is
more simple, we need only confine the pieces by
laying Compresses at the sides, & we can allow the
the patient to use much more freedom with the
limb, the flexion & extension may be allowed very
early, but so as not to give pain or excite Inflammation,
which tends to make broken bones throw
out more Callus, & the vessels to grow more
luxuriately. - If it shall be found notwithstanding
all our pains that the bones are not
joined together, but that the Callus remains
soft, suppose in the Humerus, there is one method
which has been found successful, to let in
air by an incision, & to cut away luxuriant
cartilaginous substances, which fill the place of
the bone; or we saw off little bits, & reduce it
to the state of a Compound fracture, only the
danger

509
danger here is much less, as there are no muscles
or Nerves lacerated.
Lacerated Tendons. From considering
the treatment of fractures of the Patella, I apprehend
we may judge of the proper treatment
where the Tendon above & below it is tore.
Both Cases have occurred so often, the Surgeons
have suppose that it is always the Tendon
that is lacerated, but in all the different cases
that happen, the fracture of the Patella is most
frequent, next the laceration of the Ligament
joining the Patella to the Tibia, then of the Tendon
connecting the Extensor muscles to the Patella.
Suppose this last case to happen, which is the
most difficult, from the retraction of the muscle,
having extended the limb, we apply a broad
linen roller, beginning from the top of the
thigh

510
thigh, in order to press down the muscles; we come
down by edgings, & draw the roller pretty
tight to prevent the retraction, & bring it down
to the broken part, & to give further security to
this bandage, we may put a circular round
the Pelvis, & bring down one strap before, & another
behind; & pin these to the several turns
of the bandage. We may then apply two such
leather straps as I shewed you, above & below
the Patella, which are brought together by three
straps, & over all we apply a large case of
paste board from the middle of the thigh to
about the middle of the leg, & we keep the
patient in that situation till the Tendon is
firmly united, which may require some months.
Next suppose the Tendo Achillis is tore,
from the effort of the muscles. My father was
a sufferer in this way, he had his tendon
entirely divided. I may observe that instead
of the Tendon sometimes suffering, the body
of

511
of the muscle is tore, the fleshy fibres give way.
The Cure of this complaint depends upon proper
posture, & that you can determine from
knowing the connection of the Gastrocnemius
Muscles; first, as these serve for the
extension of the foot, the foot ought to be extended,
whilst with a proper bandage or instrument
we pull down the Belly of the
Muscles towards the heel, & further, we bend
the knee, for the Gastrocnemius Externas
comes by two heads from the Os femoris,
so we ought to lay the patients limb something
in the posture given in the fracture, resting
it on the outside; & to secure it in that
posture I shall shew the Instrument my
father used with great success - First, with
a bandage put round below the knee, we
secure the Calf of the Leg, it may be laced
on the outside, or what will answer better,
made with buckles & straps, & may be of leather;
then

512
then we apply a Slipper to the foot, open at the toes,
& we join these by means of a strap & buckle,
whereby we extend the foot, & draw down the Calf
of the leg, & the leg is kept bent by putting
a strap above & below the knee, or we apply
a piece of metal so shaped as to grasp the thigh
& leg, and as a further security when the
patient begins to walk, he may have a plate
of metal properly defended, & made to rest before
on the foot & leg, so as to prevent any quick
motion of the joint. When my father began to
use more freedom, he had the heels of his shoes.
made more than two inches higher. In
going up & down stairs, mounting on Horseback
&c., the patient will take care not to rest
the weight of the body on that leg. In time
of the Cure we give the leg exercise by rubbing
frequently, so as to prevent in some measure the
shrinking of the flesh.
Now if by posture we can heal a Tendon that
is

513
is tore, tho' we do not see the manner in which
the ends are applied, surely where it is divided,
& we see it distinctly, a similar method will
generally succeed, therefore the Suture of Tendons
is not so necessary as some have imagined;
but if it appears that the two ends are not so
likely to unite, I wou'd by no means make
the objection against sewing them together,
that is cheifly made, for tho' some degree of Inflammation
may thereby be excited, it is in
no degree proportioned to what has been
imagined . .
Suppose next that any of our joints from the
situation mentioned, have grown stiff, besides
all the methods in common practice to counteract
the stiffness, & bring it to its proper play,
as fomentations, Oily frictions, & especially
giving such flexion & extension as not to occasion
pain, some have found benefit from sweating
the member. - Next

514
Next, if any of our Joints are distorted, we may
by such means as have been shewn keep the
weight of the body a good deal off from the
joint affected, thus suppose one of the knees
bended inwards in a Child, if we fix a machine
like that of Gouches for fractures, above &
beneath, we keep the weight from bearing more
immediately against the joint, & by making
a hinge in the middle, the patient may continue
to use the joints, & whilst we bear off
the weight from the joint, we are doing all
we can to pull it out-wards, & in once Case
I have seen advantage from such a machine.
Next suppose a distortion in the foot, a
disease which has been treated of again & again
under the name of Club-foot. Now Surgeons mistake
about the seat of the disease, it is born
with us, at birth the toes are turned inwards
nearly at a right angle with the foot, but
with this circumstance, that taking hold of
the

515
the foot, we can draw them straight, without
seeming to give the Child any considerable degree
of pain; There is therefore too great a degree
of motion, which is made not at the
ancle, but at the fore end of the Astragalus,
so we cheifly regard the joint of the foot in the
treatment. But we find afterwards that every one
of the bones of the Tarsus has undergone an
alteration of its shape greater than what there
was at birth. Cheselden advises to turn the
foot into its former direction, & to tie it up
with a bandage that will grow firm, as by
covering a strap of linnen by floor & the
White of an Egg; now tho' I have remarked that
often we can turn the foot straight without
the patient complaining, we are by no means
to expect that we can at once bring it into
its true situation, the continuance of the turn
gives intolerable pain, therefore on this account
I take it for granted that the method proposed
by

516
by Cheselden will not often be found practicable,
and it will answer better to make the
change gradually, & that, by making the two feet
counteract one another; We put a shoe upon
each foot, open before, with two thin plates of
wood or metal fixed to their under part, the
one upon the heels of the shoes, the other upon
the soles of the fore part; there are a number
of holes upon the fore part in the sole piece,
into one of these we screw a pin, which
fixes the shoes at a certain angle with 
respect to one another, & by degrees we alter
the holes till we bring the feet to a proper
direction; or what is neater, the two shoes
may be made to move upon an Axis, & the
Child has little inconvenience, for it has the
ful motion of both knees, & further, with
a strap brought over the foot obliquely, we
press down the top of the Tarsus, the foot
being too convex on the upper side.
Upon

517
Upon the whole, tho' I mention these contrivances
as giving some chance, we are not to promise
too much, for tho' in some it may be
owing to a looseness, yet there is reason
to suspect that there is generally an original
difference in the shape of the bone,
which may be out of the power of art to
remedy. -
Finis





Index
Introduction . . . Page 1
Cataract . . . . . 5
Dropsy of the Base, Extirpation
of Dillo, & Other diseases of
the Eye . . . . 30
Fistula Lachrymalis . . . 41
Sutures in General . . . 67
Lithotomy . . . . 78
Incontinence, & other complaints
of the Urinary Organs . 123
Cæsarian Operation . . 140
Phymosis & Paraphymosis, &c.. . 148

Index
Fistula in Perineo . . . Page 158
Hydrocele . . . . . 165
Schirrous Testicle . . 185
Fistula in Ano . . . 197
Treatment of the Natural
Passages shut up . . . 207
Treatment of Hernia . . 212
Dropsy . . . . 235
Abcesses, Hydatides, Atheromata,
Meliceres, Talpa; Skatoma,
Sarcoma, & Cancer . . . 292
The Recovery of Drown'd persons . 318
Wry Neck . . . . 322
Bronchotomy . . . . 324

Index
Bronchocele . . . Page 334
Hare Lip . . . . 336
Tumors growing in the different
Cavities, the Rectum, Nose, &c. . 343
Trepan . . . . 353
The Different Methods of
drawing off the Circulating fluids 372
Accidents from Bloodletting . 386
Amputation . . . . 402
Operations on the Teeth . . 434
Of Wounds . . 435
Bandages . . 446
Luxations . . 461
Fractures . . . 483
Lacerated Tendons . . 509