gd-i'. %o£»2S ^'iV^; r*-v 'i-v Si 'A', :':\ fcTjr-tf/^ ^"" ■■A/-^->*v - ,-i r . r*. ■■■'-■■ i'j ... : I ' :t<: M^W3s$&y-£' :v"f.." S^!;:::;;;;';'jv::-'; •y^ri'-^-^v '.v..m ■..-■•;.'-.■ '-■..■ ^tXfffVc-V-;/::.- ,' -■, -■ ■^C'-d^.iyf^!r{- -.-. ..",■; : ., "Vj-it.'-"' • -^ '• W-1'---: •"•'■-■ -' ■ ■ oj&joo <;"yr-r :^ -:i , . -. . ■..- •wlicgXC*<*J^ \-?:'-...;;;/; . ARMY MEDICAL LIBRARY FOUNDED 1836 WASHINGTON, D.C. f If M ^rfzorfy *J^ W 'U/a£ J&m<£6t4l- IfooJpr^ INSTITUTES AND PRACTICE SURGERY: BEING THE OUTLINES A OOWSSH (EDS' aaSffiWSSUSe WILLIAM GJBSON, M. D. »■•* PROFESSOR OF SURGERT IN THE UNIVERSITY OF PENNSYLVANIA, SURGEON AND CLINICAL LECTURER TO THE ALMS-HOUSE INFIRMARY, &C. Segnius irritant animos demissa per aurem, Q,uam quue sunt oculis subjecta fidelibus.—Hot. FOURTH EDITION, GREATLY ENLARGED. U(^ VOLi. II. PHILADELPHIA: CAREY, LEA & BLANCHARD; 1835. G45U IS35" V. S; Eastern District of Pennsylvania, to wit:— BE IT REMEMBERED, that, on the twentieth day of January, in the forty- eighth year of the Independence of the United States of America, A. D. 1824, William Gibson, M. D., of the said district, hath deposited in this office the title of a book, the right whereof he claims as Author, in the words follow- ing, to wit:— " The Institutes and Practice of Surgery: being the Outlines of a Course of Lec- tures, by William Gibson, M. D., Professor of Surgery in the University of Pennsylvania, Surgeon and Clinical Lecturer to the Aims-House Infirmary, &c. Segnius irritant animos demissa per aurem, Quam qua sunt oculis subjecta fidelibus.—Hor." In conformity to the Act of the Congress of the United States, entitled, "An Act for the Encouragement of Learning, by securing the Copies of Maps, Charts, and Books, to the Authors and Proprietors of such Copies, during the times therein mentioned"—And also to*the Act, entitled, "An Act supplemen- tary to an Act, entitled, ' An Act for the Encouragement of Learning, by se- curing the Copies of Maps, Charts, and Books, to the Authors and Proprietors of such Copies, during the times therein mentioned,' and extending the bene- fits thereof to the arts of designing, engraving, and etching Historical and other Prints." D. CALDWELL, Clerk of the Eastern District of Pennsylvania. GRIGGS & CO., PRINTERS. CONTENTS OF VOLUME II. CHAPTER I. DISEASES OF THE NOSE AND ANTRUM .... Page 9 Sect. 1. Polypus of the Nose ------- 10 Treatment of Polypus of the Nose .... H 2. Ozaena......... 13 Treatment of Ozaena ---.-.. 13 3. Polypus of the Antrum ...... 15 Treatment of Polypus of the Antrum .... 15 CHAPTER II. DISEASES OF THE MOUTH...... 18 Sect. 1. Labium Leporinum, or Hare Lip ..... ig Treatment of Hare Lip ...... 19 2. Ranula..........21 Treatment of Ranula...... 21 3. Malformation of the Fraenum Linguae 22 Treatment of Malformation of the Frsenum Linguae - 22 4. Enlarged Tonsils........24 Treatment of Enlarged Tonsils .... 24 5. Elongation of the Uvula ....... 29 Treatment of Elongation of the Uvula ... 29 6. Fissure of the Palate .---... 31 Treatment of Fissure of the Palate .... 31 7. Epulis, or Tubercle of the Gums.....38 Treatment of Epulis...... 39 CHAPTER III. DISEASES OF THE NECK.......40 Sect. 1. Extraneous Bodies in the CEsophagus - 40 Removal of Extraneous Bodies from the Oesophagus - 41 2. Stricture of the Oesophagus ..... 44 Treatment of Stricture of the Oesophagus ... 45 3. Extraneous Bodies in the Larynx and Trachea - 47 Removal of Extraneous Bodies from the Larynx and Trachea ........ 47 4. Ulceration of the Glottis...... 50 Treatment of Ulceration of the Glottis - ... 50 IV CONTENTS. Sect. 5. Bronchocele, or Goitre......Page 52 Treatment of Bronchocele ------ • ^ 6. Torticollis, or Wry Neck...... 79 Treatment of Wry Neck......79 CHAPTER IV. DISEASES OF THE THORAX...... 82 Sect. 1. Hydrothorax, or Dropsy of the Chest 82 Paracentesis Thoracis ------ 83 CHAPTER V. DISEASES OF THE ABDOMEN...... 85 Sect. 1. Ascites or Dropsy of the Abdomen ----- 86 Paracentesis Abdominis ------ 86 2. Poisons in the Stomach ------- 90 Treatment of Poisons in the Stomach ... 91 3. Hernia..........94 General Treatment of Hernia..... 97 4. Inguinal Hernia --......100 Treatment of Inguinal Hernia ----- 103 5. Femoral Hernia ----.... 108 Treatment of Femoral Hernia - - - - - 111 6. Umbilical Hernia --......114 Treatment of Umbilical Hernia .... 115 7. Congenital Hernia.......119 Treatment of Congenital Hernia ... - 120 8. Artificial Anus........122 Treatment of Artificial Anus.....123 CHAPTER VI. DISEASES OF THE RECTUM......128 Sect. 1. Prolapsus Ani ---.....- 128 Treatment of Prolapsus Ani ..... 130 2. Tumours within the Rectum ..... 133 Treatment of Tumours within the Rectum - - - 133 3. Hemorrhoids........135 Treatment of Hemorrhoids......136 4. Fistula in Ano........144 Treatment of Fistula in Ano ..... 145 5. Encysted Rectum ---.... 151 Treatment of Encysted Rectum.....154 6. Stricture of the Rectum......156 Treatment of Stricture of the Rectum ... 157 7. Imperforate Anus.......160 Treatment of Imperforate Anus.....161 8. Foreign Bodies in the Rectum.....164 Removal of Foreign Bodies in the Rectum - - - 165 CONTENTS. V CHAPTER VII. DISEASES OF THE TUNICA VAGINALIS AND TESTIS Page 168 Sect. 1. Hydrocele.........168 Treatment of Hydrocele......170 2. Hematocele........176 Treatment of Hematocele - - - - «, - - 176 3. Irritable Testis......- - 178 Treatment of Irritable Testis ----- 179 4. Chronic Enlargement of the Testis .... 180 Treatment of Chronic Enlargement of the Testis - - 181 5. Encysted Testicle.......183 Treatment of Encysted Testicle.....184 6. Tumours of the Scrotum ------ 185 Treatment of Tumours of the Scrotum ... 186 CHAPTER VIII. DISEASES OF THE PENIS......188 Sect. 1. Wounds of the Penis.......189 Treatment of Wounds of the Penis - 190 2. Ulcers of the Penis.......192 Treatment of Ulcers of the Penis - 193 3. Phymosis.........195 Treatment of Phymosis......196 4. Paraphymosis --.-.-.. 198 Treatment of Paraphimosis ----- 198 CHAPTER IX. DISEASES OF THE URETHRA AND BLADDER - - 200 Sect. 1. Stricture of the Urethra .... . 200 Treatment of Stricture of the Urethra - 202 2. Fistula in Perinseo.......207 Treatment of Fistula in Perinseo - .... 208 3. Enlarged Prostate.......210 Treatment of Enlarged Prostate.....211 4. Retention and Incontinence of Urine - - - - 212 Treatment of Retention and Incontinence of Urine - 214 5. Urinary Calculus ------- 219 Treatment of Urinary Calculus.....223 6. Lithotrity.........235 CHAPTER X. DISEASES OF THE EYE.....245 Sect. 1. Conjunctival Ophthalmia ----- 247 Treatment of Conjunctival Ophthalmia - - 249 VI CONTENTS. Pai?e 251 Sect. 2. Sclerotic Ophthalmia - s Treatment of Sclerotic Ophthalmia - 3. Iritic Ophthalmia - Treatment of Iritic Ophthalmia - - '*** 4. Psorophthalmia ------ 255 Treatment of Psorophthai mia - - - 256 5. Pterygium ------ ^57 Treatment of Pterygium - - - - 257 6. Encanthis ------- 259 Treatment of Encanthis - - - 259 7. Opacity of the Cornea - - - - - 260 Treatment of Opacity of the Cornea - - - 261 8. Ulcer of the Cornea - - - - - 262 Treatment of Ulcer of the Cornea - - - 262 9. Staphyloma - - - - - - 264 Treatment of Staphyloma ... - 264 10. Hypopion.......266 Treatment of Hypopion - 266 11. Hydrophthalmia - - - - - - 268 Treatment of Hydrophthalmia ... 268 12. Obliterated Pupil......270 Treatment of Obliterated Pupil - - - 270 13. Procidentia Iridis ------ 272 Treatment of Procidentia Iridis - - - 272 14. Cataract ------- 273 Treatment of Cataract .... 274 15. Congenital Cataract ----- 280 Treatment of Congenital Cataract - - - 280 16. Amaurosis ------- 282 Treatment of Amaurosis - - - 283 17. Hordeolum - .....284 Treatment of Hordeolum - 284 18. Encysted Tumours of the Eyelids - - - - 285 Treatment of Encysted Tumours of the Eyelids - 285 19. Entropeon ------- 286 Treatment of Entropeon .... 286 20. Ectropeon ------- 288 Treatment of Ectropeon - - - . 288 21. Fistula Lacrymalis - - - - - 290 Treatment of Fistula Lacrymalis - - . 291 CHAPTER XI. DISEASES OF THE EAR.....294 Sect. 1. Diseases of the External Ear, and Meatus Auditorius - 295 Treatment of Diseases of the External Ear - - 297 2, Diseases of the Tympanum and Eustachian Tube - - 299 Treatment of Diseases of the Tympanum, &c. - 300 3. Diseases of the Internal Ear .... 392 Treatment of Diseases of the Internal Ear - - 303 CONTENTS. vii CHAPTER XII. DISEASES OF THE ARTERIES - . . page 304 Sect. 1. Aneurism ---... 308 Treatment of Aneurism - - . . 311 2. Aneurism of the Aorta - 318 Treatment of Aneurism of the Aorta - - . 320 3. Aneurism of the Carotid - - . . 321 Treatment of Carotid Aneurism - - - 322 4. Axillary Aneurism ..... 324 Treatment of Axillary Aneurism ... 324 5. Brachial Aneurism - - - . . 329 Treatment of Brachial Aneurism ... 329 6. Inguinal Aneurism - 331 Treatment of Inguinal Aneurism - 331 7. Popliteal Aneurism ----- 336 Treatment of Popliteal Aneurism ... 337 8. Aneurism by Anastomosis .... 338 Treatment of Aneurism by Anastomosis - - 338 9. Varicose Aneurism ..... 343 Treatment of Varicose Aneurism ... 345 CHAPTER XIII. DISEASES OF THE VEINS ... 346 Sect. 1. Varicose Veins ------ 347 Treatment of Varicose Veins ... 348 2. Cirsocele -*■ ------ 350 Treatment of Cirsocele - 350 CHAPTER XIV. INJURIES OF THE HEAD - - - - - 352 Sect. 1. Fracture of the Skull ----- 353 Treatment of Fracture of the Skull ... 354 2. Concussion of the Brain .... 356 Treatment of Concussion of the Brain ... 357 3. Compression of the Brain ... - 358 Treatment of Compression of the Brain - - - 360 4. Inflammation of the Brain .... 364 Treatment of Inflammation of the Brain - - 365 5. Fungus Cerebri, or Encephalocele ... 366 Treatment of Fungus Cerebri ... 367 CHAPTER XV. LOCAL DISEASES OF THE NERVES 369 Sect. 1. Neuritis .-----. 370 Treatment of Neuritis 371 viii CONTENTS. Sect. 2. Neuralgia ----- Page 372 Treatment of Neuralgia ... - 374 3. Neuroma.......376 Treatment of Neuroma - 378 4. Tetanus ------- 380 Treatment of Tetanus - 382 CHAPTER XVI. AMPUTATION......384 Sect. 1. Amputation of the Thigh ----- 391 2. Amputation of the Leg .... 395 3. Amputation of the Arm and Fore-arm - 397 4. Amputation at the Shoulder Joint ... 398 5. Amputation at the Hip Joint .... 400 6. Amputation of the Fingers and Toes ... 402 CHAPTER XVII. HYSTEROTOMY OR OESARIAN SECTION - - - 404 DIRECTIONS TO BINDER, FOR VOLUME SECOND. Plate I. opposite.....Page 26 II...........35 HI...........148 IV...........229 V...........275 VII...........276 VIII.-. .........326 IX...........327 X...........341 XI...........344 XLT...........361 THE INSTITUTES AND PRACTICE OF SURGERY. CHAPTER I. DISEASES OF THE NOSE AND ANTRUM. The subjects embraced in the first volume of this work cor- respond, with the arrangement of the anatomical lectures in the University, so closely, that by the time the latter are disposed of, the former may be entered upon. The same correspondence, however, has not existed, hitherto, in the arrangement of the matter of the second volume. To effect this, the distribution of the text, in the present edition, has been altered. If upon any occasion, then, the diseases should appear in this volume disjointed, let it be remembered that accurate collocation has been sacrificed to convenience and expediency. With these views, I commence with diseases of the nose and antrum. The mucous membrane which lines the cavity of each nostril, not only covers the spongy bones, but extends to the antrum maxillare, to the frontal, ethmoidal and sphenoidal sinuses, and even to the mouth and throat. Hence a similarity of disease is found to pervade each of these parts, the foundation of which may be said to be laid, generally, by inflammation produced by cold, specific diseases, and other causes. The most common diseases of these cavities, are polypous tumours, collections of purulent matter, and ulcerations. Vol. II. 2 10 Polypus of the Nose. Section L- Polypus of the Nose. A polypus may spring from any portion of the Schneiderianr membrane: it originates, however, most frequently either from the superior or inferior spongy bone. In shape it is usually pyriform—being narrow at its root and expanded below; though this will depend very much upon the natural form of the cavity it occupies. Sometimes the base of the tumour is exceed- ingly broad. Not unfrequently a polypus originates high in the nose, and instead of falling forwards or towards the anterior nares, takes a backward direction, hangs behind the palate, and sometimes reaches the pharynx. One or both nostrils may be the seat of this disease. When both are filled, the patient breathes with difficulty, and with a peculiar rattling noise. In damp weather, the tumours often project beyond the nose, and contract and disappear as soon as the weather becomes dry. The consistence of polypus is not less variable than its form. Firm, fleshy, and very solid, in some instances; it isuponother occasions extremely soft, and so tender as to tear upon the slightest touch. The most common variety, so far as my experience goes, is that which bears, in consistence, shape, colour and size, a striking similitude to the common oyster. Most polypi are extremely vascular, and if rudely handled, bleed profusely. No age or sex are exempt from the disease, which sometimes assumes a malignant form, at other times destroys the patient, by exciting, from pressure, caries of the spongy ethmoid bones, inflammation of the brain, &c. Polypus of the Nose. 11 Treatment of Polypus of the Nose. Several operations, very opposite in character, have been* practised for the removal of nasal polypus. I prefer in most cases the use of the forceps. These, when properly made, should be stouter than the common dressing forceps, with their extremities slightly curved, serrated, and a considerable slit or hole in each blade, about half an inch from its point. The pa- tient being seated before a strong light on a low chair, with his head moderately thrown back and firmly supported by an assis- tant, the surgeon carefully introduces the instrument with its blades expanded, as far as the root of the tumour, takes firm hold of it, and by two or three turns of the instrument, instead of pulling in a straight line, twists it away. A copious gush of blood generally follows, especially if the tumour be partially re- moved. Clearing this away, the forceps are again and again in- troduced until the whole nostril be free, the strongest proof of which will be the freedom with which the patient can breathe or force air through the nostril. In performing this operation, great care must be taken not to use unnecessary violence, be- cause it has sometimes happened that the ethmoid bone has been broken up, and other mischief produced sufficient to lead to fatal consequences. This operation is chiefly adapted to polypi with narrow necks, and confined to the cavity of the nostril. The operation of excision has been recommended by J. Bell, Whately and others, for the removal of polypi of large size and broad base. There are very few cases, it appears to me, requiring such a measure. Independently of the difficulty of the opera- tion, the hemorrhage is always very profuse, and, besides the uncertainty of removing the whole of the disease, the surgeon will run considerable risk of injuring the sound parts in the neighbourhood of the tumour. Mr. Whately employs a sheathed knife, somewhat similar to Dr. Physick's bistoury for fistula in ano. The ligature, although recommended by some writers for every variety of polypus, can seldom be employed advantageous- ly, except where the tumour arises by a narrow neck and hangs beyond the posterior nares. In such cases, a silver or iron wire, 12 Polypus of the Nose. or a piece of catgut, eighteen inches long, should be doubled so as to form a loop, and introduced into the nostril until it ap- pears below the palate, when it should be caught by a pair of narrow forceps, and drawn towards the mouth, and the loop at the same time expanded by the fingers of the surgeon. As soon as this is accomplished, the operator, still holding the loop with one or two fingers, draws the projecting ends of the wire with the other hand from the nostril, and thus by one simultaneous movement, carries the loop over the base of the polypus, and thence to its neck. The ends of the wire are next passed through the double cannula of Levret, and after being drawn so firmly as to constrict the neck of the polypus, are twisted upon the wings of the instrument and secured. In proportion as the wire becomes loose from the shrinking of the tumour, its ends must be tightened every few hours until the polypus drops off, which it does sometimes so suddenly as nearly to suffocate the patient. If the surgeon should experience any difficulty, as he often does, in introducing the wire and noosing the polypus in the manner directed, he may resort with advantage to the can- nula of Bellocque. Whatever method may be practised for the removal of poly- pus there are two points which must always be particularly at- tended to—the suppression of hemorrhage, and the removal of any fragments of the tumour so situated as to elude the instru- ments directed against them. The first may be accomplished, generally, by cold astringent solutions thrown up the nostrils by a syringe, or if these do not succeed, by passing a catgut, to which two or three dossils of lint are secured, through the nostril and mouth. The pressure thus created, hardly ever fails to stop the flow of blood. To guard against the return of the disease, from portions of the tumour being left behind, the argentum nitratum, repeatedly applied, will be found the most effectual remedy. See Pott's Chirurgical Works, by Earle, vol. 3, p. 165—J. Pell's Principles of Surgery, vol. 3, p. 89— Whately's Cases of two extraordinary Polypi removed from the Nose, the one by Excision with a new Instrument, the other by Improved For- ceps, 8vo. 1805—Callisen's Systema Chirurgix Hodiernse, vol 2, p. 207—Lassus' Pathologie Chirurgieale, torn. 1, p. 528—Deschamps' Traits des Maladies des Fosses Nasales, &c.—C. BeWs Operative Surgery, vol. 1, p. 208. Ozaena. 13 Section II. Ozcemt. A troublesome ulceration of the lining membrane of the nostrils, attended with fetid discharge, and sometimes followed by destruction of the cartilage and by caries of the bones of the nose, is denominated by most modern writers ozaena. The ori^ gin of the disease is very obscure, though there is reason to be- lieve that, in most instances, it is connected with the primary or secondary forms of syphilis. In other- instances, marks of the purely scrofulous character are apparent. One of the most troublesome attendants of the disease is the accumulation of in- spissated mucus, or of incrustations in the cavities of the nose. These are sometimes so considerable in quantity, as to block up entirely the passages. After the ulceration is fairly established, it not only takes possession of the cartilaginous septum, the eth- moid and spongy bones, and the other bones of the nose, but ex- tends to the cheek. If the patient should recover after such ra- vages, he must for ever remain horribly deformed. Treatment of Oztzna. The remedies best adapted to the cure of ozaena are bark, iron, the mineral acids, muriate of lime, sarsaparilla, and antimony. When there is any suspicion of the disease having originated from syphilis, mercury alone, or conjoined with other prepara- tions, should be employed. During the height of the inflamma- tion, solutions of opium and of the acetate of lead, may be injected into the nostrils, or applied to the ulcerated surface on lint Vol. II. 3 14 Oztzna. Some of the mild animal oils introduced into the cavities of the nose, will also prove serviceable, by softening the incrustations and lessening pain. After the inflammation has abated, more stimulating materials may be employed, such as solutions of lu- nar caustic, sulphate of copper, the ointment of the red oxide of mercury, citrine ointment, &c. Within the last five years, chloride of lime has been re- commended, particularly in ozaena, by Dr. Horner. The first case in which it was tried was a very inveterate one of several years' standing, large quantities of very fetid matter being con- stantly discharged from both nostrils, and after passing into the stomach occasioning great sickness and loss of appetite. A tea- spoonful of chloride of lime was put into a wine-glass full of water; the clear solution was then injected into each nostril twice a-day, and the practice having been continued for a few weeks, a perfect cure was accomplished. Other similar in- stances have been reported, but time will show whether the medicine can he depended upon in the generality of cases. On the subject of Ozaena, consult Pearson's Principles of Surgery, p. 279—Hor- ner's Case of Ozaena, in American Journal, No. XI, May, 1830.—Craighie's Case of Pereostitas with Ozaena, in Ed. Medical and Surgical Journal, for January, 1834. Polypus of the Antrum. 15 Section III. Polypus of the Antrum. Fungus or polypus of the antrum maxillare, is less frequent- ly met with than abscess of that cavity—a disease already treated of in another place.* It is, however, one of the most formida- ble affections in surgery, and unless speedily arrested, generally proves fatal. The tumour sprouts from the lining membrane of the antrum, from what cause it is always exceedingly diffi- cult to determine, and grows with more or less rapidity, until it fills the whole of the cavity. By this time, considerable pain is experienced in the cheek and eye of the affected side, and soon after a perceptible enlargement of the face may be ob- served. These symptoms are, in the course of time, followed by distortion of the nose, projection of the eye, enlargement of the gums corresponding to the antrum, pro/use discharges of sanious fetid matter, and finally by protrusion of the bones of the face and alveolar processes, and, as a necessary result, by hideous deformity. In consistence, the tumour is generally firm and fleshy, sometimes soft, and in a few rare instances, osteo-sarcomatous or even bony. Treatment of Polypus of the Antrum. If, instead of temporizing, as is too common, until the disease is so advanced as to leave no reasonable hope of effecting a • See Vol. I. p. 128. *" Polypus of the Antrum. cure, the surgeon were always to follow the practice of the en- lightened and fearless Desault, and operate at an early period, most patients, perhaps, would recover. As soon, therefore, as the nature of the tumour is ascertained, the surgeon should not only determine to remove it, but resolve to set no limits to the sacrifices it may be necessary to make. With this view he must provide himself with several curved and angular scalpels, of un- usual strength and thickness, two or three cauterizing irons, a key for pulling teeth, chisels, gouges, a mallet, &c. Every ar- rangement being made, the surgeon first separates, with a com- mon scalpel, the cheek from the maxillary bone, by opening the patient's mouth as widely as possible, and cutting through the internal membrane. His next object should be to remove the molares teeth and their alveolar processes corresponding with the floor of the antrum. This may be done by the tooth key, or by two or three strokes of a gouge and mallet. Having in this way exposed the cavity of the antrum and the surface of the tumour, the curved and angular knives must then be em- ployed until every remnant of the disease is rooted out. The hemorrhage that follows the operation is sometimes extremely profuse, but may be instantly arrested, and with little pain to the patient, by one or two applications of the cautery. I have, however, performed several operations of the kind without ever being under the necessity of doing more towards stopping the flow of blood than plugging the antrum with lint or tow. If the operation prove successful, the antrum is filled in a few weeks with healthy granulations; but if the disease return, this is soon rendered evident by the reappearance and rapid growth of the fungus. To repress this, repeated applications of caustic, or the cautery, will be found necessary, or perhaps a second operation may be demanded. Sometimes the teeth and alveolar processes appear sound. In such cases, an incision should be made through the cheek from its outer surface, the anterior walls of the antrum perforated by a trephine, and the tumour removed through the opening. I say nothing of the modern proposal of curing polypus of the antrum by tying the carotid, because I have reason to be- lieve that all attempts of the kind hitherto made, (in which the ligature of this vessel was entirely depended upon,) have proved abortive. I should conceive it equally unnecessary, and Polypus of the Antrum. 17 not less reprehensible, first to tie the carotid, and afterwards to extirpate the tumour, inasmuch as the patient's danger must be increased tenfold, and without any adequate compensation. Cases occur, now and then, in which spontaneous cures of this formidable disease are effected. Twelve or fourteen years ago, a mulatto man with a large fungus of the antrum, came to me from Petersburg, Virginia, but refused to submit to an ope- ration, and returned home. From that period the tumour ceased to grow, and never afterwards, I have reason to believe, occasioned inconvenience. Seven years ago, a negro man from Fredericktown, Maryland, visited Philadelphia and consulted me respecting a similar tumour of the antrum. I advised the operation, but he, also, refused to submit to it. A few months afterwards, the inflammation subsided, and eventually, the tu- mour was converted into bone. It has so remained ever since, is now entirely free from pain, and the health of the patient has long been excellent. Consult Desauli's Works, by Smith, vol l,p. 141—Desaulfs Parisian Chirur- giccl Journal vol. 1, and 2—TraiU des Maladies Chb-urgiccdes, et des Operations qui leur Conviennent par MM. Chopart, et Desault, torn. 1, p. 195—J. L. Des- champs' TraiU des Maladies des Fosses Nasales et de leur Sinus—Suite d1Observa- tions sur les Maladies des Sinus Maxillaire, par M. Bordenave, in Memoirs de VAcademic Royale de Chirurgie, torn. 13, edit, duodecimo, p. 367—Aber- nethy's Account of a Singular Disease in the Upper Maxillary Sinus, in Trans- actions of a Society for the Improvement of Medical and Chirurgical Knowledge, vol 2, p. 309—Gibson on Bony Tumours, in the Philadelphia Journal of the Me- dical and Physical Sciences, vol 3, p. 100—C. BeWs Surgical Observations, vol. 1, p. 413. 18 Diseases oftfie Mouth. CHAPTER II. DISEASES OF THE MOUTH. Under this head may be included several diseases, some of which have already been treated of in the preceding volume. The principal affections of the mouth, and of the parts in its im- mediate vicinity, are hare lip, cancer of the lip,* cancer of the tongue,! ranula, malformation of the fraenum linguae, enlargement of the tonsils, elongation of the uvula, epulis or scirrhus of the gums, and caries of the teeth. To give even a general account of the diseases of the teeth, and of the various operations prac- tised upon them, would alone occupy a volume. The present state of surgical science, however, and the subdivision of pro- fessional labour, would seem to obviate altogether the neces- sity of treating of these affections in a work of this description. Section I. Labium Leporinam, or Hare Lip. This is a congenital deformity, and takes its name from a supposed resemblance to the lip of a hare or rabbit. There are two varieties of the disease—the single and double. The for- mer is the most common, and is a simple fissure or slit, extending * See Vol. I. p. 171. f Vol. I. p. 174. Labium Leporinum, or Hare Lip. 19 from the edge throughout the substance of the lip to a greater or less extent: the latter is comparatively rare, and differs from the single variety chiefly in having a wider opening, and an intermediate hanging portion. Both varieties are often com- plicated with a cleft or opening in the bones of the palate. The upper lip is in nine cases out often the seat of the disease, and the borders of the fissure are invariably rounded, and covered with the red and delicate membrane peculiar to the edges of the na- tural lips. Hare lip, independently of its deformity to the in- fant, proves a serious inconvenience by interfering with its powers of suction, and to the adult by interrupting speech, and preventing the articulation of labial sounds. Sometimes one or more of the incisor teeth project from the upper part of the hare lip nearly in a horizontal direction, and add very much to the deformity. Treatment of Hare Lip. The only effectual remedy for hare lip is an operation, and the sooner this is performed the better. If the fissure in the lip is single, it will be sufficient to remove each of its rounded edges in the following way. The infant being firmly held in the arms of a nurse, or laid on a pillow with its head elevated and securely fixed by an assistant, the surgeon having previous- ly separated the internal membrane of the mouth and its frae- num, introduces between the lip and gums a narrow flat piece of wood five or six inches long. This being held by another assistant, the operator himself stretches the lip upon the board, and commencing near the nostril, makes an incision downwards, and at a single cut removes in a straight line the edge of the lip. The opposite edge is next detached in a similar manner, when the chasm left will resemble the letter V inverted. It only remains to draw the edges of the wound together, and retain them by the twisted suture, taking care to commence by passing 20 Hare Lip. a pin first through the hanging edge or lower portion of the lip, instead of the upper. Two or three pins will generally be sufficient. They should be passed horizontally, at regular in- tervals, and rather nearer the internal than the external surface of the lip. The close contact of the edges of the wound, and the pressure necessarily occasioned by the tightening of the ligatures, are sufficient to arrest the hemorrhage. Each pin should be surrounded by a separate ligature passed about it in the form of the figure 8. In four or five days, the adhesion is usually complete, and the pins may be withdrawn, to prevent them from exciting ulceration. When the operation for double hare lip is performed, it should be conducted upon the principles just laid down. But four in- stead of two incisions should be made—one on each side of the intermediate projection, which may then be dove-tailed, as it were, with the outer edges of the lip by one or two pins passed entirely across. The cleft in the bony palate, should it exist, generally closes up, sua sponte, provided the operation be not too long delayed. When it is said, " the sooner the operation is performed the better," it should not be understood that it must be done immediately after birth. Infants of two or three weeks old, are very apt to die in convulsions, from operations. Four or five months after birth, will be a favourable period for the operation. See Sabatier de la Medicine Operatoire, torn. 3, p. 273, 8vo. 1810—Lassus' Pathologie Chirurgieale, torn. 3, p. 451—Richerand1* Nosographie Chirurgieale, torn. 2, p. 255—Dictionnaire des Sciences Medicates, torn. 3, p. 55, article Bee de Lievre—Desault's Works, by Smith, vol. \,p. 148—B. Bell's Surgery, vol. 4, p. 447—C. Bell's Operative Surgery, vol 2, p. 38—Kirby's Cases in Surgery,p. 61, Ranula. 21 Section II. Ranula. An obstruction of one or more of the ducts of the sublingual gland gives rise to the formation of a semipellucid soft tumour, denominated by the older surgeons ranula—from an imaginary resemblance to the belly of a frog. This tumour is generally filled with saliva, or with a viscid fluid resembling the white of an egg. Sometimes it attains so large a size as to interfere with speech and deglutition, and even to displace the teeth. It arises either from adhesion, or natural imperfection of the duct, or from the lodgement of a calculous concretion within its passage. Children and infants are more subject to the complaint than adults. Treatment of Ranula. A simple evacuation of the fluid with a lancet answers no purpose, inasmuch as the opening closes again in a few hours. To effect a permanent cure the cyst must be laid open freely, or a portion of it removed with scissors. The application of caustic may afterwards become necessary. See Lassus' Pathologic Chirurgieale, torn. 1, p. 402—C. Bell's Operative Sur- gery, vol. 2, p. 24^-Callisen's Systema Chirurgiae Hodiernae, vol 2, p. 108. Vol. II. 4 22 Malformation of the Fmnum Lingua. Section III. Malformation of the Fmnum Lingua. It sometimes happens, though not so frequently as imagined, that children are born with the fraenum of the tongue so short, as to prevent them from sucking. To ascertain whether this be really the case, the surgeon should endeavour to raise the point of the tongue with a spatula. If he should fail in this attempt, and the tongue appears upon examining it on the side to be un- naturally confined, little doubt can remain of the fraenum being defective. Treatment of Malformation of the Frcznum Lingua,. Although the division of the fraenum linguae is usually looked upon as a trifling operation, it is one that should not be lightly performed, and upon every common occasion. Petit relates two instances, in which death followed from the fraenum being so much loosened, as to permit the tongue to fall backwards kito the pharynx, and suffocate the patient. Other cases are recorded of fatal hemorrhage from wounds of the ranine ar- teries and veins. To guard against accidents of this description, the operator should use a pair of probe-pointed scissors, and take Malformation of the Frcmum Linguae. 23 care to direct their points downwards, and divide no more of the fraenum than is absolutely necessary. Dr. Dewees, whose experience in the treatment of the diseases of infants, is equal, perhaps, to that of any practitioner living, objects to the use of scissors in the division of the fraenum linguae, and employs, instead of them, a common gum lancet. He has never met with a case in which the tongue was swallowed, or of hemor- rhage, from the division of the ranine arteries, or other vessels. Hence it may be fairly inferred that such accidents must be ex- ceedingly uncommon. According to the same practitioner, there are two causes that may give rise to an operation, the one an adventitious membrane, which pursues the natural fraenum throughout its whole course, and even continues beyond the fraenum, and ties the tongue so completely down, that the child cannot raise the tongue, or carry it beyond the lips—the other, an actual shortening and thickening of the proper fraenum itself. See Petit's Traiti des Maladies Chirurgicales, torn. 3, p. 260—Burns' Surgi- cal Anatomy of the Head and Neck, p. 264— C. Bell's Operative Surgery, vol 2, p. 28. 24 Enlarged Tonsils. Section IV. Enlarged Tonsils. Enlargement of the tonsils is very common among scro- fulous children, and arises from exposure or repeated attacks of catarrh and sore throat. Sometimes, however, the disease is slowly induced without being preceded by pain, swelling, or any of the characteristics of acute inflammation. If suffered to remain for any length of time, the tumours occasionally at- tain so large a size as to interfere materially with respiration and deglutition. Persons troubled with this disease, have a peculiar hoarse, husky, or croaking voice, and when labouring under cold, wheeze excessively. Treatment of Enlarged Tonsils. The knife and ligature have been frequently employed in the removal of enlarged tonsils. To the latter the preference is usually given, inasmuch as there is no risk of hemorrhage, a consequence sometimes apt to follow the use of the knife even when employed with the utmost caution. Formerly the liga- ture was suffered to remain upon the enlarged gland for several days, or indeed until the tumour sloughed away, and from this practice great irritation about the fauces, tongue, and mouth, en- sued. To obviate these inconveniences, Dr. Physick first sug- Enlarged Tonsils. 25 gested the following mode of practice. The operator takes a double cannula, about four inches long, and passes through it, doubled, a piece of soft, flexible iron wire, one twenty-fourth part of an inch in diameter, secures one end of the wire to an arm of the cannula, and permits the other end to project about five or six inches beyond the opposite barrel of the instrument. The cannula being thus armed, the loop of wire is spread out to a sufficient extent to pass over the tumour, and is bent a little to one side, that it may with the greater facility approach its base. An assistant holds down the patient's tongue with the handle of a large spoon, while the operator conveys the wire over the base of the tumour, and taking hold of its projecting end draws it loosely in order to ascertain whether it is properly fixed. Finding this to be the case, and that the uvula is not included, the end of the wire is then seized with a pair of flat pliers, drawn as firmly as possible, and secured by wrapping it around the remaining arm of the cannula. The wire, thus applied, should be permitted to remain on the tonsil twenty-four hours, and then disengaged in the following way. The cannula being firm- ly held with one hand, the other is employed in loosening the end of the wire from the arm of the instrument; having ac- complished which, the surgeon straightens the wire with the pliers, and pushes it backwards until it is removed from the tonsil. In a few days the tumour drops off entire, or in frag- ments, and the ulcer left heals without difficulty. For several years Dr. Physick pursued the above practice; but experience taught him that although the operation, thus mo- dified, was free, in a measure, from the inconveniences of the old method of using the wire, there were yet objections to the practice which he had not anticipated. In particular, he found that, in some instances, profuse ptyalism, swelling of the throat, difficulty of breathing and swallowing, (sometimes followed by ulceration of the soft palate and fauces,) were induced. Of late years, therefore, he has abandoned the ligature, in toto, and em- ployed the knife. The instrument he uses was originally in- vented by him for truncating the uvula. " In the operation for cutting off the uvula, Dr. Physick has, until very lately, used scis- sors; but being unable to complete the operation by one applica- tion of that instrument, several have been necessary to effect the 26 Enlarged Tonsils. division of the part. To obviate this difficulty, he determined to try the old instrument, as modified and represented by Benjamin Bell, in his System of Surgery. He found, however, that al- though he could divide with that instrument the greater part of the uvula, a portion of the membrane that covers the back part of it was not always divided, making the use of the scissors necessary to cut it through. To remedy this inconvenience, he caused an instrument to be made having two plates instead of one, between which the knife was passed; but still the same dif- ficulty was experienced in cutting through the membrane on its posterior part. He then thought of wrapping a strip of waxed linen over the semicircumference of the opening, to sup- port the membrane until it should be divided by the knife. Thus constructed, the instrument answered the purpose com- pletely, and cut through the whole substance of the part in an instant. Dr. Physick has since used an instrument of similar construction, for the removal of scirrhous tonsils. He finds it easy to cut off the whole, or any portion that may be necessary, of the enlarged tonsil in this manner. The operation can be finished in a moment of time. The pain is very little, and the hemorrhage so moderate that it has not required any attention in four cases, in which he has lately performed it. The size of the perforated end of the two plates, and of course that of the knife, must be larger in the instrument for extirpation of the tonsils, than in that for truncation of the uvula."* The con- struction of this instrument will be better understood by ex- amination of Plate I. fig. 1 and 2. In a subsequent account of Dr. Physick's instrument, it is remarked, that " occasionally there is some difficulty in passing the circular aperture in the extremity of the two plates completely and speedily over the tonsil to its base. In such cases the operation may be much facilitated, by using a forceps with alunated extremity, to which teeth are adapted, invented by Dr. Physick, by means of which the tonsil may be seized and drawn through the aperture to any distance that may be deemed proper, when its extirpation can be immediately effected. It may not, however, be improper to observe that, under ordinary circumstances, the aid of the forceps * American Journal of Med. Sciences, Feb. 1828. Enlarged Tonsils. 27 is altogether unnecessary. The forceps is about seven inches long, curved near its extremity, which is lunated and armed with teeth."* Having experienced more or less difficulty in the removal of enlarged tonsils—owing, chiefly, to the number of instruments, such as spoons, hooks, forceps, &c, required—it occurred, to me that an instrument might be contrived that would answer the purpose of all these—by keeping down the tongue, holding the gland firmly, and separating it nearly at the same moment. Such I accordingly projected, and ordered made, and upon trial found to answer my most sanguine expectations. For several years past I have used it, in a number of instances, and have seen it used by others, and can, therefore, speak of it decisively. It consists of a pair of forceps nine inches long, the eighth of an inch thick, half an inch broad, when shut, with extremities an inch and a half long, slightly serrated and somewhat curved, in- cluding, when closed, an oval space a quarter of an inch wide, and terminating, at the other extremity, in handles which stand off obliquely from the shafts of the instrument. A knife, or blade, the length and breadth of the forceps, rounded on its cut- ting edge, and having a button placed perpendicularly to its axis on the opposite extremity, works backwards and forwards by means of a groove, to the extent of an inch and upwards, be- tween the blades of the forceps, to one of which it is secured by screws. A sheath upon each end of the forceps, to keep the knife from starting off the moment it touches the tumour, com- pletes the instrument^ See Plate I. fig. 3. To apply the instrument properly, it will only be necessary to introduce it into the patient's mouth with the blades closed and resting flat upon the tongue, which is thus kept depressed. The instrument is then turned on its edge, still resting on the tongue, its blades expanded, placed fairly around, and completely behind the tumour, which is then seized, and firmly held, while the thumb, resting on the button-like extremity of the knife, pushes it forwards and instantly separates the enlarged tonsil, which is immediately brought away in the grasp of the forceps. • Am. Journal of Med. Sci. May, 1828. | This instrument, as well as Dr. Physick's for the same purpose, was manufac- tured by Mr. H. Schively. 28 Enlarged Tonsils. To prevent any portion from being left, or the tumour from hanging by a narrow neck, the surgeon should see that the knife reaches to the very extremity of the forceps, and should be sure that the whole of the tumour is fairly within the grasp of the in- strument. The instrument may be applied indifferently to either tonsil—care being taken always to place the surface of the forceps on which the knife rests to the base of the tumour. Profuse hemorrhage sometimes follows the excision of the tonsils. The surgeon, aware of the possibility of this, should take care not to apply the knife too near the base of the tumour. More than twenty years ago, I cut off an enlarged tonsil with scissors* from a medical student, now a respectable practitioner at Bedford, Pennsylvania, and had great difficulty in preventing the hemorrhage from terminating fatally. Wisemen and Moscati point out danger from another source—the falling of the tonsil backwards, when partially cut, upon the rima glottidis—and re- late cases of suffocation from that cause. See Desault's Works, by Smith, vol. l,p. 193—Sharp's Treatise on the Opera- tions of Surgery, p. 199, edit. 9—Chevalier's New Mode of Tying Diseased Ton- sils, in vol. 3, p. 79, Medico-Chirurgical Transactions—Dorsey's Surgery, vol 1. p. 422—The Double Cannula and a Wire, recommended in the Operation of Ex- tirpating Scirrhous Tonsils, and Hemorrhoidal Tumours, by Philip Syng Physick, M. D. in vol. 1, p. 17, of the Philadelphia Journal of the Medical and Physical Sciences—Case of Obstinate Cough, occasioned by Elongation of the Uvula, in which a portion of that organ was cut off, with a Description of the Instrument employed for that purpose, and also for Excision of Scirrhous Tonsils, by Philip Syng Physick, M. D., Professor of Anatomy in the University of Pennsylvania, in Journal of Medical Sciences, for 1828—Description of a Forceps employed to faci- litate the Extirpation- of the Tonsil, and invented by P. S. Physick, M. D. Id. 1828. Elongation of the Uvula. 29 Section V. Elongation of the Uvula. The uvula, from colds or other causes, is frequently enlarged or elongated. If it continues so for any length of time, trou- blesome irritation about the epiglottis, nausea, vomiting, and even haemoptysis, and phthisis pulmonalis may be induced. Treatment of Elongation of the Uvula. To obviate some of these consequences, an operation has been practised from time immemorial—the excision or amputation of the uvula. This may sometimes be performed by a hook and common scissors, or by the particular scissors described and en- graved by Mr. Samuel Cooper, in his "First Lines of the Prac- tice of Surgery."* These are so contrived, as, by means of a transverse projection from one of the blades, to support the uvula, and keep it from falling backwards at the moment the operator attempts to divide it. Even with this instrument, however, the operator is extremely apt to fail, or else divide a part only of the uvula, which is immediately drawn upwards, and lodged be- hind the velum in such a way as to render it difficult afterwards to remove it. It will be better, therefore, to resort to Dr. Phy- sick's instrument for the removal of the tonsils, or to the one I have recommended for the same purpose. The instrument, how- ever, should be made smaller for the uvula than the tonsil. Mr. Benjamin Bell states that he has known very profuse hemorrhage to follow amputation of the uvula. I have often Vol. I. p. 526, edit. 4. Vol. II. s 30 Elongation of the Uvula. performed the operation, but never met with an accident of the kind. The real importance of amputation of the uvula has only been estimated of late years, and it remained for Dr. Physick to point out the cases to which it was peculiarly adapted. He had met with several instances of troublesome cough, followed by ema- ciation of the whole body, sometimes by hemorrhage from the lungs, and eventually phthisis pulmonalis, which were produced apparently by elongation of the uvula. This determined him to try the effect of an operation in the early stages of the disease, and the result was favourable in the extreme—the cough and other urgent symptoms disappearing almost immediately, and the patients recovering perfectly in a very short time. From experience I can speak confidently of the value of the remedy, and have reason to believe that it seldom fails unless too long delayed. Fissure of the Palate. 31 Section VI. Fissure of the Palate. A deficiency of the soft palate, or rather a division of it, either conjoined with or independent of, a cleft in the palate bones, is a congenital malformation, almost as common as that of hare lip, with which, indeed, it is not unfrequently associated. Like hare lip, too, it not only, during infancy, interferes with the suction of the child, but in after life impedes deglutition, and in many instances renders articulation nearly unintelligible. Many patients, indeed, fall a sacrifice to the disease, from extraneous matters getting into the windpipe, and bronchiae, and laying the foundation of pulmonary affections. At other times, the patient suffers extremely from fluids, and even solids, being thrown from the stomach, or mouth, into the nares, where they excite sneezing, great irritation, and even ulceration. Treatment of Fissure of the Palate. Although surgeons had long been acquainted with the exist- ence and nature of malformation of the palate, few, if any, at- tempts had been made to obviate the deformity, until Roux, an eminent Parisian surgeon, drew the attention of the profession to an operation which he denominated Staphyloraphy', and by which he had succeeded in reuniting the edges of the soft palate in twelve cases. These cases were published in 1825. 32 Fissure of the Palate. Since that period, Roux has performed, with more or less suc- cess, the operation fifty-one times. Out of this number, but one case has been followed by death.* It occurred in a young female, who, on the evening of the operation, was seized with inflammation of the throat, and, subsequently, with that of the chest, and died on the eighth day. Roux's operations were soon followed by those of Graefe, Dieffenbach, and others, on the con- tinent of Europe; by Alcock, in Britain; and, subsequently, by Warren, Stevens, and Hosack, of our own country. The first case upon which Roux performed his operation, was that of a Canadian student, attending lectures in Paris. Be- fore cutting away the edges of the soft palate, as in hare lip, Roux determined to introduce three stout ligatures into the border of the palate, and at regular distances from each other. To accomplish this, he employed a small, curved needle, fixed in the porte-aiguille; passed it through the palate about a quar- ter of an inch from its edge, then seized its point with the com- mon dressing forceps, and drew it, together with the ligature, forward. In like manner the other ligatures were introduced, always carrying the needle from behind forwards. The edge of the palate was then cut away by the knife and curved scis- sors, to the extent of a line in thickness. The same operation having been performed on the opposite side of the palate, the edges of the wound were approximated by drawing each inter- rupted suture, tying it, and then cutting off the ends of all the ligatures. To prevent the first knot from slipping, it was held by a pair of forceps, called pince a anneaux, until the second knot could be secured. The patient was kept on low diet, and not permitted to speak. At the end of the third day, the two upper ligatures were removed, and, on the fourth day, the re- maining ligature. Lest the reunion, which had taken place throughout each edge, might be endangered, the patient was not permitted to speak until the eighth day. By that time, how- ever, the adhesion was complete, the cicatrix firm, and the de- formity, with all its inconveniences, namely, imperfect articu- lation, difficult deglutition, &c, completely removed. Roux's object, in first inserting the ligatures, and subsequently paring • Lancette Franf aise, 1830. Fissure of the Palate. 33 the edges of the palate, was to prevent the hemorrhage from in- terfering with the operation by obstructing the view of the parts, in which view most surgeons will probably concur with him. Professor Warren, of Boston, was the first to perform, there is reason to believe, staphyloraphy, in the United States. The ligatures were introduced by an instrument, apparently very simple, resembling a common dissecting hook in form, with an eye near its extremity, through which passed a triple thread of strong silk. "The palate was pierced by the hook at one- third of the length of the fissure from the upper angle of the wound, so as to include about three lines of the edge of the soft palate. The eye, with the ligature, being seen, the latter was seized with a common hook, and drawn out. The eyed-hook was then drawn back, turned behind the palate, and the other edge transfixed in a similar manner." Two other stitches were made in a similar way, the edges of the palate drawn toge- ther, and the knots tied without difficulty with the fingers. Un- like Roux's operation, the edges of the palate were cut away by a bistoury previous to the introduction of the ligatures. The patient recovered perfectly, and in a short time. In a second operation of the kind, performed by Dr. Warren on a boy during the prevalence of influenza, the inflammation, owing to that disease, was so high as to require the ligatures to be removed. The operation consequently failed, although adhesion had taken place, but was afterwards destroyed by the fingers of the boy, in attempting to relieve his cough. Dr. Warren has improved, subsequently, his instrument, by making the point removable, so that the ligature and point can be drawn out together. The operation of staphyloraphy was performed by Dr. Ste- vens of New York, in 1826. The ligatures were introduced by a curved needle attached to a handle by means of a screw, and the edges of the velum supported by forceps, afterwards dis- sected away by a cataract knife. Reunion speedily took place, and by the tenth day the patient returned home with the voice much improved, but not so perfectly restored as in some of the cases reported by Roux. But my friend Dr. Alexander E. Hosack of New York, an excellent surgeon, has paid more attention, perhaps, to staphy- 34 Fissure of the Palate. loraphy than any one else in the United States. In a memoir by him on the subject, published in 1833, at the request of the Medical Society of the City and County of New York, in- teresting observations are made, cases reported, and ingenious instruments invented by himself, described, which ought to be familiar to every one before undertaking one of the most diffi- cult operations in surgery. Under these impressions I shall insert a short account of Dr. Hosack's instruments, which, to- gether with the plate and explanation of them, cannot fail, I hope, to render them perfectly intelligible. " It occurred to me," says Dr. H. " that as the greatest difficul- ty and delay were experienced in the passing of the ligatures,— arising both from the irritability and constant motion in the palate, as well as the unavoidable disposition to swallow,—an instrument might be constructed, calculated to lessen the incon- venience, as well as shorten the time. I consequently caused one to be made, as represented in the plate, and which I have since improved, and find perfectly to surmount the objections. In the application of this instrument, the surgeon is enabled to fix his eye on the part through which the ligature is to pass; the palate is at the same time, and with the same instrument firmly held, so as to avoid displacement, by any involuntary motion that may occur. The time required for passing each needle is but an instant, and it can always be accomplished with the greatest accuracy, as regards the relative distances, as well from the borders as from each other. This point being determined, I directed my attention to the second step of the operation, which is properly that of excision.—The straight bis- toury, and the ordinary angular scissors, are as yet, the only instruments used for that purpose.—In offering objections to them, I trust I may escape being censured for a great desire of finding fault, as well as from any unreasonable prejudice, in favour of invention. Having performed the operation, I feel myself at liberty to suggest an alteration in the scissors, which, while it embraces all the advantages possessed by the above in- strument, offers facilities to the surgeon. He is at once enabled to follow with his eye every movement of the blades, un- til the borders are entirely separated, and thereby control the extent and amount of substances to be removed. Two scissors will be required—one for either side, six inches in length. N°2. JEzH........ fnn'Ti'iii'iff'""""!"" nil""111111111 R oiiiiiiiiiujiiiiiiJniNiiiiuuiiii|uniiu H ATI Drawn, by JHm Fissure of the Palate. 35 When viewed in profile, their form inclines to that of the letter /. The blades form the junction to the point, and curved late- rally and forwards, so as very much to resemble the beak of an eagle, or any other bird of that class, and which, when applied to the palate, adapt themselves to the arched sides of the cleft No. 1, represents a front view of the instrument for passing the needle. A, the hollow shaft with the curved extremity. B, an aperture, through which the eye is to direct the head of the needle into the thimble—C, the rod drawn out, with the chain, and thimble-like extremity attached to it. D, the bayonet fix- ture, adjusted upon the shaft, with the forceps for receiving the needle. E, a profile view of the forceps holding the needle, F, the rings for receiving the first and second fingers of the right hand. G, the guard upon which the thumb, of the same hand, is to rest. H, the wheel, or the part of the bayonet fixture, by which its motions are controlled. The index finger of the left hand is to be placed upon it; by which means it is turned, un- til brought opposite to the crook, in which the needle is con- cealed; it is then to be pushed quite up, holding the palate be- tween. The thumb, of the right hand, is at that moment to glide through the guard upon the button of the rod, which is to be thrust forward, driving the needle, armed with the ligature, into the forceps; the bayonet fixture is then drawn back and turned off, carrying the needle with it.—No. 2, a profile view of the same, in the act of receiving the needle." See Plate II. I have reason to believe that the operation of staphyloraphy has been performed, likewise, by Dr. P. Metteaux, an eminent surgeon of Virginia, as I recollect to have seen, some years ago, an ingenious instrument devised by Dr. M. for that purpose, in the hands of the maker-—the celebrated Schively. It may have been performed by other surgeons in America; but if so I am not aware of the fact. An interesting case of extensive wound of the soft palate, cured by drawing together with sutures the divided edges, is reported in the tenth volume of the American Journal, 1832, by Dr. Wells, of Columbia, South Carolina. " A lad, aged five years," says Dr. Wells, " was running with one end of a piece of reed cane, a foot long, and about an inch in diameter, and square across at the extremities, in his mouth. He fell forward; the end of the cane coming in contact with the ground, it was 36 Fissure of the Palate. thrust violently into his throat. I saw him very ™» ■*"J*e accident happened. There were two lacerated incisions extend- ing from the centre of the back part of the bony arch of the mouth, backwards and outwards on each side, something more than an inch, and terminating within less than half an inch of the inferior margin of the velum palati. The soft parts were cut, or torn through, making a triangular flap, the apex of which had fallen forwards and downwards, and hung dangling upon the root of the tongue, leaving the posterior nares and pharynx fully exposed. There was considerable hemorrhage, and the child and friends were extremely alarmed. A short common surgeon's needle was heated in the flame of a lamp, bent to a proper curve, armed with a ligature, and confined in Dr. Physick's forceps for taking up deep-seated arteries. The patient was placed upon a table and held by assistants. The mouth was kept open by a large cork placed between the back teeth, and his tongue depressed with a spatula. The needle was passed through the apex of the flap, and then through a corresponding portion of the mucous membrane, and cellular substance on the roof of the mouth, and the ligatures tied by the common stems for such operations when the fingers have not access. It was not attempted to insert more than one suture, although this did not bring the parts into exact contact; but the swelling which supervened in the course of a fe\v hours, as was anticipated, fully obviated that difficulty. He was kept as quiet as possible—not allowed to swallow any thing for the first four days, except a little milk and toast water, and then as seldom as practicable. At the end of this period adhesion was found to have taken place at every point. There is not the slightest deformity of the parts remaining. There was considerable dif- ficulty in this little operation, from the struggles of the patient and the contracted space left for us to act in—the mouth being already pretty well occupied by the apparatus for keeping it open and depressing the tongue; indeed, without the above in- struments, or others equivalent, it would have been found im- practicable either to pass the ligature or to tie it." On Staphyloraphy, consult Memoire sur la Staphyloraphie, ou Suture du voile, du Palais, par Phil Jos. Roux, Paris, 1825— On an Operation for the Cure of Fissure of the Palate. 37 natural Fissure of the soft Palate, by John C. Warren, M. D., Professor of Ana- tomy and Surgery in the Medical Institution of Harvard University—in Ameri- can Journal of Medical Sciences, vol 3d, 1828.—Staphyloraphy* or Palate Suture, successfully performed, by A. H. Stevens, M. D., Professor of Surgery, in the College of Physicians and Surgeons, New York, in North American Medical and Surgical Journal, Pol 3d, p. 233, 1827—A Memoir upon Staphyloraphy, with Cases and a Description of the Instruments requisite for the Operation, by Alexander E. Hosack, M. D., one of the Surgeons of the Marine Hospital. New FarA:„1833, Vol. II. 6 38 Epulis, or Tubercle of the Gum*. Section VII. Epulis, or Tubercle of the Gums. This disease, like polypus of the antrum, sometimes assumes a malignant form, and, involving the teeth and adjoining parts, is soon beyond the reach of surgery. This will show the pro- priety of attending, in the commencement, to every small tu- mour about the gums, however harmless may be its appearance- Any one, indeed, who will peruse the melancholy but instruc- tive cases detailed by Messrs. John and Charles Bell, the only writers who appear to have taken a deep interest in the subject, will need no further proof of the importance of the disease. Epulis generally sprouts from the sockets of the incisor teeth of the upper or lower jaw. The teeth themselves are frequent- ly sound and prefectly white, and in many instances long before the tumour it perceptible, are loosened and carried above the range of the adjoining teeth. In other cases, a small seed-like excrescence is seated upon the gum between the teeth. This remains stationary for months together, or it grows so slowly, and is attended with so little inconvenience, as scarcely to attract the patfent's attention. At last it loses its hard and solid feel and gristly appearance, becomes soft and rugged on the surface, bleeds upon the slightest touch, and throws out a prolific fun- gus. After this, no bounds are set to the increase of the tumour, the teeth are successively displaced, the lymphatic glands and other soft parts in the neighbourhood contaminated, the mouth filled with a mass of disease so large as to embarrass the breathing and swallowing, the texture of the bones of the face or lower jaw broken up, and the patient eventually destroyed by hemorrhage, suffocation or irritation. Epulis, or Tubercle of the Gums. 39 Treatment of Epulis. Extirpation of. this tumour, in its very incipiency, is the only remedy likely to effect a permanent cure. In performing this operation the surgeon will find it necessary to provide him- self with forceps and other instruments, for pulling teeth, one or two short and very strong scalpels, two or three fine watch- spring saws, tenacula, sponges, a vial of the muriated tincture of iron, lint, &c. If there is strong evidence of the tumour having originated deep among the sockets of the teeth or in the cells of the bone, the teeth surrounded by the tumour, however, perfect they may appear to be, must be sacrificed, and not only the teeth, but the alveolar processes also. The cut in this case should be made with one of the fine saws perpendicularly through the bone on each side of the tumour. By these means it will be so loosened as to be easily detached with a pair of strong forceps. The hemorrhage that follows is commonly very profuse, but may be speedily arrested by dipping a piece of lint in the mu- riated tincture of iron, and thrusting it to the bottom of the wound (placing above the lint a bit of cork or some elastic sub- stance to support the lint,) closing the patient's jaws, and se- curing them by a bandage. In twenty-four or thirty-six hours the lint may be removed, and if necessary the application of the muriated tincture renewed at each succeeding dressing; or the lunar or vegetable caustics may, with the same view, be applied. By adopting this plan, (the one suggested and practised by Sir Charles Bell,) I have in several operations of the kind suc- ceeded perfectly. In other instances, where I have merely re- moved the tumour with the knife and caustic, it has invariably returned. See John BeWs Principles of Surgery, vol 3, p. 178—Charles Bell's Surgical Observations, being a quarterly Report of Cases in Surgery, vol. 1, p. 413—Gib- son on Bony Tumours, in the Philadelphia Journal of Medical and Physcial Sciences, vol. 2,p. 145. 40 Diseases of the Neck. CHAPTER III. DISEASES OF THE NECK. The importance of the diseases of the neck can be fairly esti- mated only by those who possess an accurate knowledge of the structure and functions of its numerous and complicated organs. The student should use, therefore, in prosecuting his anatomical investigations of these parts, more than ordinary diligence. Besides the great blood vessels, and nerves of the neck, the pharynx, oesophagus, larynx, trachea, thyroid gland, are subject to accidents and diseases of the most pressing and grievous na- ture. Wounds of these different parts have already been con- sidered;* but it still remains to treat of several other affections. These are the lodgement of foreign bodies in the pharynx and oesophagus, foreign bodies in the larynx and trachea, ulceration of the glottis, bronchocele wry-neck, &c. Section I. Extraneous Bodies in the (Esophagus. It frequently happens that persons, from hurry or voracious- ness, in attempting to swallow a large piece of beef, tripe, gristle, cheese, bread, and other similar substances, are choked, and in • See Vol. I. p. 106. Extraneous Bodies in the (Esophagus. 41 danger of suffocation. In other instances, fish bones, chicken bones, pins, and needles, pieces of coin, stick in the pharynx or oesophagus, and excite irritation in proportion to their size, shape, &c. There is reason to believe, in most cases of the kind, that the difficulty of breathing which ensues, arises from the spasmodic action of the muscles of the glottis by which this chink is preternaturally constricted. Death may follow from this cause, or from the foreign body distending the oesophagus to such a degree, as to press upon the trachea and interrupt the passage of air, or the patient may die at some subsequent period from inflammation or gangrene induced by the continued pres- sure of the extraneous body, or injudicious and violent attempts to remove it. Removal of Extraneous Bodies from the (Esophagus. When a large substance is swallowed, it generally sticks in the pharynx or between the cornua of the os hyoides and thy- roid cartilage, and often may be seen or reached with the finger. In like manner, fish bones and other small and irritating bodies, when similarly situated, may be removed by a pair of forceps, or by tickling the fauces with a feather, or by holding a solu- tion of tartar emetic in the mouth. These last, by exciting vomiting, have the effect of expelling the foreign body. There are, however, several regular instruments well adapted to the removal of articles lodged in the throat; but the surgeon, if sud- denly called to a patient apparently choking and in imminent danger of his life, should waste little time in searching for these instruments. On the contrary, he should seize upon any thing that happens to be in his way, calculated to dislodge the morsel —such as a horse-whip, the handle of a spoon, a rattan, &c. As a general rule, digestible articles, provided they are free from asperities, should be forced into the stomach by the probang__ a whalebone rod, having a round piece of sponge fixed upon one end and a blunt hook upon the other. This instrument (its sponge being previously softened a little) may be easily intro- duced by thrusting it against the back part of the pharynx. The 42 Extraneous Bodies in the (Esophagus. sponge imbibing freely the moisture of the passage fills it up en- tirely, and carries the body before it, unless very firmly fixed. Copper coins, and all sharp or ragged bodies, should, if pos- sible, be extracted by the gula forceps, probang hook, or by a hook made of a piece of bell wire, upon the spur of the occa- sion. Sometimes a rod of whalebone, with numerous loops of thread or horse hair attached to one end of it, answers an excel- lent purpose, by entangling fish bones and other sharp bodies. After extraneous substances have been pushed into the stomach, the patient should take, for several days successively, purgatives and mucilaginous draughts, to promote their passage through the intestines. For several years Dr. Physick has been in the habit of prescribing rice, and other similar articles, in large quantities, with a view of defending the coats of the stomach from the ac- tion of foreign bodies—and usually with great success. Nee- dles and pins that have been swallowed, not unfrequently per- form extensive journeys throughout the body, and at last are discharged through the skin. Dr. Henry Bond,* of this city, has made a very ingenious improvement on the common gullet forceps. That instrument, as is well known, is defective, chiefly, on account of the blades closing upon each other with a fiat surface, thereby leaving, necessarily, four sharp or angular edges, well calculated to pinch the lining membrane of the oesophagus. To obviate this inconvenience and danger, Dr. Bond's forceps have been bevel- led off from the edges to the centre of the inner surface of each blade, so as to produce two convexities, or ridges, which are slightly serrated, and meet each other at a single line. Besides holding the foreign body with sufficient firmness, the narrow rough line allows the article, contained in its grasp, " to vibrate freely and to assume a position nearly parallel to the blades." A case occurred, some years ago, in the Eastern States, where a fish hook, with part of the line attaehed to it, was swallowed. In the attempts to remove it, by pulling upon the line, the hook became fixed in the side of the oesophagus. After much diffi- culty, it occurred to an ingenious person present, that the pro- per mode to extricate the hook would be, to take a large leaden • Observations on the Removal of foreign Bodies lodged in the Oesophagus, by Henry Bond, M. D., in North American Med. and Surg. Journal, for October, 1828. Extraneous Bodies in the (Esophagus. 43 bullet, drill a hole in its centre, pass the line through it, and let it be swallowed by the patient. The experiment was accord- ingly tried, and with success—the bullet, by its weight, first disengaging the hook, and then its point being afterwards brought in contact with the lead, was prevented from stick- ing again in the oesophagus, in the act of drawing upon the line, so that both the bullet and hook were drawn out together. These particulars were communicated to me formerly, by a very intelligent student, Dr. Bradley of Maine; but I have for- gotten the name of the surgeon concerned in the case. The operations called pharyngotomy and ozsophagotomy should seldom, I conceive, be performed; but in order to sus- tain the patient's breathing, during the attempts to remove a large body from the pharynx or oesophagus, it may possibly become expedient to resort to bronchotomy or tracheotomy, as will be explained hereafter. , 44 Stricture of the (Esophagus. Section II. Stricture of the (Esophagus. The oesophagus, like the urethra, is sometimes the seat of stricture, either of the spasmodic or permanent kind. Nervous and hysterical patients are most subject to the former disease, and the latter may occur in patients of every variety of constitution. Occasionally, the two affections are combined. Permanent stric- ture is met with in two or three different situations. Its most common seat, however, is immediately behind the cricoid car- tilage, or in the commencement of the oesophagus. The con- traction is generally found to consist of a fold of the internal membrane of the tube. In advanced cases of the disease, the whole cavity of the oesophagus is often entirely closed, and to a considerable extent, arising, probably, from the effusion of lymph, or from the glands of the passage assuming a scirrhous or cancerous action. The symptoms of permanent stricture of the oesophagus, are difficulty of swallowing in proportion to the duration of the disease, pain in the stomach, nausea, troublesome eructations, pain in the fauces, and extending thence along the base of the skull. In addition to these symptoms, the patient often finds it impossible to pass either solids or fluids in the smallest quantity, and as a necessary result, emaciation ensues. Some patients, however, can readily swallow fluids, especially when sipped in small quantity; others find it easier to swallow solids. The causes of this disease are very obscure. In most in- stances, there is reason to believe, that the permanent stricture is the result of inflammation, however induced. By Dr. Bur- well, an intelligent practitioner of Buffalo, I am informed that several cases of the disease have occurred in his neighbourhood, from drinking of the liquor of pearl-ash, kept by most house- wives to lighten their bread, and generally deposited in the Stricture of the (Esophagus. 45 same closet with spirits, for which it has been mistaken. Simi- lar cases have been reported by Sir Charles Bell*—from the accidental swallowing of soap-lees, A disease very opposite in character to stricture of the oesopha- gus, is sometimes met with—paralysis of the oesophagus. This occurs, for the most part, in old people, and frequently as a con- comitant of palsy in other parts of the body. The power of the muscular fibres of the oesophagus being impaired or lost, the patient can take neither solids nor fluids, and, unless speedily relieved, must die of inanition. Treatment of Stricture of the (Esopliagus. Bougies, either alone or armed with lunar caustic, may be considered the only remedies for this disease. To ascertain the situation and extent of the stricture, a soft wax bougie is employed. This may be readily introduced, by directing the patient to draw back his tongue and imitate the action of swal- lowing. If the stricture is ascertained, from the resistance and the impression made on the end of the bougie, to be a perma- nent one, the caustic bougie may be immediately carried down, and kept in contact with the stricture three or four minutes. In two or three days the operation may be repeated, and kept up occasionally until the stricture is destroyed, or until a com- mon bougie will readily pass. For the relief of spasmodic stricture of the oesophagus, I have often employed the unarmed bougie, and with the happiest ef- fect. In such cases, also, the internal use of valerian, camphor, opium, ether, will be found highly serviceable. Paralysis of the oesophagus may be sometimes removed by electricity. To nourish the patient during the cure, the gum elastic oesophagus tube is essential. The surgeon should take • Surgical Observations. Vol. II. 7 46 Stricture of the (Esophagus. care that fluids conveyed through it are not too hot, otherwise the stomach may be scalded. From this cause, several patients have lost their lives. When the oesophagus, from stricture or any other cause, is so completely closed that a bougie or gum elastic tube will not pass, the patient must be nourished by glisters. The cardiac, as well as other portions of the oesophagus, is not unfrequently the seat of scirrhous and cancerous affections. The progress of the disease is generally very slow and gra- dual. Often it is mistaken for common stricture of the oeso- phagus, and treated accordingly; by which the symptoms are aggravated and ulceration hurried on. In many instances, the disease extends to the stomach, all the coats of which, as well as those of the oesophagus, are indurated and often ulcerated to a great extent. Such affections are, of course, incurable. The ce- lebrated Napoleon died of cancer of the stomach. Tumours situated between the trachea and oesophagus, en- largement of the thyroid gland, indurated lymphatic glands, aneurism of the aorta and other affections, may, by pressure, in- volve the oesophagus, and generally admit of no relief- Extraneous Bodies in the Larynx and Trachea. 47 Section III. Extraneous Bodies in the Larynx and Trachea. During the act of deglutition, articles of food, instead of pass- ing into the oesophagus, are sometimes suddenly diverted from their course, and thrown into the glottis. An instantaneous, violent, convulsive cough, and laborious respiration, are the immediate consequences. If the extraneous body should be de- tained in the glottis, death speedily follows from suffocation; but in many instances, the body passes entirely through the chink of the glottis into the trachea, or else it is forced by the cough into the laryngeal pouches. In either case, the pa- tient is saved for the time, or eventually may recover. The lodgement, indeed, of a morsel in the sacculus laryngeus, is com- paratively harmless, and the irritation occasioned by its presence soon subsides. I have known extraneous articles to remain in these cavities for years, without inconvenience, and indeed without the patient being sensible of their presence. When, however, the substance descends into the trachea, incessant irri- tation is kept up, and, although the patient, even under these circumstances, may survive for weeks, months, or years, yet in the end, unless relieved by an operation, he is sure to die— from effusion into the cells of the lungs, from phthisis pulmonalis, &c. Removal of Extraneous Bodies from the Larynx and Trachea. It is very seldom that the surgeon succeeds in extracting by instruments an extraneous body lodged even in the vicinity of the larynx; of course, the removal of it from the larynx or tra- chea, by such means, is out of the question. But to obviate in- stantaneous suffocation, or to remove the foreign body, an opera- tion may be required. Laryngoiomy and tracheotomy, (so denominated according 48 Extraneous Bodies in the as the larynx or trachea may be the seat of the operation,) are both occasionally required. The former, however, is best adapt- ed to the removal of extraneous bodies, and is performed in the following manner. The patient being laid on a table, with his head supported by a pillow, and thrown moderately backwards, the surgeon feels for the membranous space situated between the thyroid and cricoid cartilages, makes a perpendicular incision about an inch in length through the integuments,platysma-myoi- des, and between the sterno-thyroidei and Sterno-hyoidei muscles. Any vessels that may have been divided, are next carefully se- cured, and the bleeding having entirely ceased, it only remains to push the knife through the crico-thyroid membrane, when the ex- traneous substance will be either immediately thrown out or pre- sented at the wound. Sometimes it is too large to pass through the membranous space. In that case, the incision should be pro- longed upwards by separating from each other the two lateral parts of the thyroid cartilage. As soon as the foreign body is removed, and the patient's breathing restored, the wound may be drawn together by adhesive straps, and permitted to heal. Tracheotomy is now seldom resorted to, both on account of the difficulty of the operation, and the danger of wounding important blood vessels. Should it ever become necessary, however, it may be done in the following way. The surgeon makes an incision, from below the cricoid cartilage, and extends it through the skin and platysma-myoides, nearly as far as the sternum. The sterno-hyoidei and sterno-thyroidei muscles are next carefully pushed aside by the fingers, until the surface of the trachea is cleared, and when all hemorrhage has ceased, two or three of the rings of the trachea may be divided by a perpen- dicular cut. These operations may be required for other purposes than the removal of extraneous bodies, and in that case the surgeon will generally find it necessary to keep the orifice of the wound open for some time afterwards. This should not be done, I conceive, by a cannula, which, independently of its liability to become clogged by the mucus of the passage, excites always a great deal of irritation. Upon two or three occasions in which I have found it necessary to open the membranous space, in order to cor^r 'r6 P&tient,S bre*thing, I have dissected away the corners of the cricothyroid membrane, and instead of Intro- Larynx and Trachea. 49 ducing a cannula into the larynx, have merely prevented the integuments and muscles surrounding the opening from closing, by passing a piece of tape around the patient's neck, having at- tached to each of its extremities a piece of silver wire doubled, and bent in the form of a hook, and calculated, by pulling these parts in opposite directions, to keep them asunder—at the same time covering with a bit of gauze the opening in the larynx, to prevent the admission of dust and other extraneous matters. Laryngotomy and tracheotomy will sometimes be necessary, on account of substances lodged in the eesophagus, for cynanche trachealis or croup, for enlargement of the tongue or of the ton- sils, for ulceration of the glottis, for suspended animation in persons apparently drowned, &c. In cases of croup-, the opera- tion seldom succeeds, owing to effusion having generally taken place in the lungs before the expedient has been resorted to. Some surgeons, and particularly Desault, in place of opening the larynx or trachea, on account of obstructions in the oesophagus, introduce a gum elastic tube into the windpipe, from the nose or mouth, with a view of sustaining respiration until the ob- structions are removed. The practice, putting the difficulty of the operation aside, in my estimation, is injudicious and censu- rable. 50 Ulceration of the Glottis. Section IV. Ulceration of the Glottis. From syphilis, abuse of mercury, and from other causes, the glottis is sometimes ulcerated, the epiglottis destroyed, the bony portion of the thyroid cartilage rendered carious, and covered with abscesses. This disease originates in the glandular struc- ture of the larynx and trachea, and increases gradually, if not ar- rested, until it destroys the patient. The symptoms are a troublesome, hacking cough, with purulent and bloody expec- toration, great difficulty of breathing, a peculiar, husky, wheezing, whistling, almost inaudible voice. After labouring under the disease for a few months, the patient dies from suffo- cation, from effusion upon the lungs, or from irritation. Some- times the disease appears to be hereditary; at least, I have upon several occasions known different members of the same family attacked in succession by it. Some years ago, I attended with Dr. Shaw, of this city, a female, who laboured under-the disease, and finally died from it. Her sister, a stout healthy young woman, was attacked a few months afterwards in a similar man- ner, and also died. Treatment of Ulceration of the Glottis. When there is reason to suspect that ulceration of the glottis epiglottis depends upon a syphilitic taint, mercury, sarsapa- la, the nitro-muriatic bath, and other remedies of similar cha- Ulceration of the Glottis. 51 racter should be employed. As a local application, there is nothing so serviceable as a solution of the argentum nitratum in the proportion of forty grains to an ounce of water. The prac- tice originated, I believe, with Sir Charles Bell: his mode of applying the caustic is to attach a pad of lint to a piece of wire, dip it in the solution, and, taking care to depress the tongue with a finger, place the lint in contact with the ulcerated surface. As a measure of necessity, Mr. Bell once performed the operation of laryngotomy, for ulceration of the glottis, with instantaneous relief to the patient, who continued to breathe freely through the opening for six weeks, but at last died in consequence of closure of the aperture by fungous granulations, the growth of which it was found impossible to repress. 53 Bronchocele, or Goitre. Section V. Bronchocele, or Goitre. The terms Bronchocele, tumidum Guttur, Hernia bronchialis, Gongrona, Hernia gutturis, and others of similar import, are employed to denote a morbid enlargement of the thyroid gland. The word Goter or Goitre, was invented by the Swiss, and is probably a corruption of the Latin phrase Guttur. In England the disease is known in popular language, under the name of Derbyshire neck, or monstrous craw. Bronchocele has prevailed, in certain countries, from time immemorial. It is noticed by some of the ancient poets, and by many of the early writers on medicine. It is met with oftener in mountainous than level countries, and is frequently endemial and hereditary. According to Coxe, the disease is common in the neighbourhood of Berne, Friburg, Lucerne, Aigle, Bex, Dresden, in the valleys of Piedmont and Savoy, in most parts of the Vallais, in the Valteline, &c* In the village of La Batia, Dr. Reeve saw many cretins and goiterous persons, who all lived in adjoining houses.t The village of Villeneuve d'Aoste, which is surrounded by very high mountains, contains an im- mense number of persons who labour under goitres of enormous magnitude.^ The late Dr. Howard of Baltimore, during his rambles in Switzerland, first met with goiterous persons and cretins near Sion. The number of each continued to increase as he approached Martigny and St. Maurice, at which places they were exceedingly numerous. As he descended the Rhone * Coxe's Travels in Switzerland. f Reeve's account of Cretinism, in the Edinburgh Medical and Surgical Jour- nal, vol. 5, p, 33. * Saussure's Voyages dans Les Alpes. Bronchocele, or Goitre. 53 their numbers decreased. In the year 1800, the villages of St. Jean, St. Michel, St. Maurice, and the vicinity of Aiguebelle, according to Fodere, contained a greater proportion of cretins and persons labouring under goitre than any other part of Swit- zerland. Dr. Howard was informed that both cretinism and goitre had diminished within the last few years, in consequence of the richer inhabitants sending their children, until their tenth or twelfth year, to the mountains, where their wives also remained during pregnancy, and for some time after parturition. In the mountainous parts of Spain and Germany goitre prevails to a considerable extent. In France it is chiefly met with in the districts of Cevennes, Soissonais, Vosges, Rouergue, Doubs, and Ardeches. In England it is very common in the moun- tainous parts of Derbyshire, in Buckinghamshire, Surry, and in the county of Norfolk. Occasionally it is seen in Nottingham- shire.* Sir George Staunton says, that goitres are very common in those parts of Chinese Tartary which resemble the mountains and valleys of Savoy and Switzerland.! " In Bengal," says Turner, "this unsightly tumour is known by the name of gheig and aubi; and in Boutan is called ba or ke ba, the neck swelling, and forms itself immediately below the chin, extending from ear to ear, and sometimes growing to such an enormous size, as to hang from the throat down upon the breast. It is particularly observable among the inhabitants of the hills of Boutan, imme- diately bordering upon Bengal, and in the tract of low country watered by the rivers that flow from thence to the south, beyond the space of a degree of latitude. The same malady prevails among the people inhabiting the Morung, Nipal, and Almora hills, which, joined to those of Boutan, run in continuation, and bound, to the northward, that extensive tract of low land em- braced by the Ganges and the Burrampooter. The same dis- ease is also more particularly met with in the low lands adjoin- ing those hills. From the frontier of Assam, north latitude twenty-seven degrees, east longitude ninety-one degrees, it is to be traced through Bishee, Gooch, Bahar, Rungpore, Dinage- pore, Purnea, Tirroot.o, and Betiah, along the northern boundary * Clark's Reports from the general Hospital near Nottingham, in the Edinburgh Journal, vol. 4. f Staunton's Embassy to China. Vol. II. s 54 Bronchocele, or Goitre. of Oude, in Gooracpore, Barraitch, Pillibeat, and on the con- fines of Rohilcund to Hurdwar, situated in north latitude thirty degrees, east longitude seventy-eight degrees twenty-five mi- nutes. It has the effect, or is rather accompanied with the effect arising from the same cause, of debilitating both the bodies and the minds of those who are affected with it."* Park, in giving an account of the diseases of the Mandingo negroes, states that goitres are very common in some parts of Bambarra.t Throughout the island of Sumatra, bronchocele is met with as an endemic disease, and is particularly frequent in those valleys which are surrounded by the highest mountains.^ In some of the Spanish settlements of America, goitres are so common, that the greater number of the inhabitants labour under the disease; and at the village of Jacaltenango, near Sacapula, it is said that no individual can be found without an enlargement of the thy- roid gland.§ In Santa Fee, Guatemala, Nueva Gallicia, and Nicaragua, the complaint has long been known. It is common alsoamongthe Indians who inhabit the valleys of the Cordilieres. According to Humboldt and Bonpland, goitre is an endemic disease at New Grenada, and is so common at the small villages Hunda and Monpar, on the borders of the Magdelaine river, that it is difficult to find an individual who is exempt from it. It affects indiscriminately all classes of inhabitants, except the blacks and those who lead a very laborious life. The ferrymen at Carthagena are not subject to it. Females are oftener affect- ed than males. At the Isthmus of Darien many persons are horribly disfigured by enormous bronchoceles.|| In various districts, and throughout whole tracts of country in North America, bronchocele prevails as an endemic. It is very fre- quent in many parts of Lower Canada, especially near the marshes between St. John's and Montreal. At Detroit, Lake Ontario, Oneida, Erie, Huron, and among the Tuscorora, Sene- ca, Oneida, and Brothertown Indians, it is very common.! In many parts of the state of Vermont, especially Bennington and Chittenden, bronchocele is well known. It is also found at • Turner's Account of an Embassy to Tibet. f Park's Travels in Africa. * Marsden's History of Sumatra. § Barton's Memoir on Goitre. I Alibert's Nosologic Naturelle, p. 470. 1 Barton's Memoir. Bronchocele, or Goitre. 55 Camden, Sandgate, and Chester, in the same state. Sandgate, some years ago, contained one thousand and twenty inhabitants, and out of that number one-fourth of the females were affected with the disease.* According to Dr. Trask, bronchocele is so common a disorder at Windsor in Vermont, that hardly any fe- male is exempt from it.t In the state of New York goitre pre- vails principally in the neighbourhood of Old Fort Schuyler? the Oneida village, the German Flats, Fort Herkimer, Fort Dayton, Henderson town, Onondago valley, Canasaraga, Bro- thertown, the townships of Manlius, and the whole of the mili- tary district. J I am informed by Philip Church, Esq., who re- sides at Angelica in Alleghany county, state of New York, that goitre is a very frequent complaint in his neighbourhood and the surrounding country. In Pennsylvania, where bronchocele is very common, it is found chiefly at Pittsburgh, on the waters of the Alleghany, Sandusky, Monongahela, French Creek, at Canonsburgh, Brownsville, and throughout the county of So- merset. In some parts of Virginia, especially at Morgantown and on the banks of Cheat river, it is by no means unfrequent. In certain situations on the western shore of Maryland, and in North and South Carolinas, the disease is occasionally met with.§ • Dorr's Facts concerning Goitre, New York Medical Repository, vol. 10. | Mease's Observations on Goitre. i Barton. Dec. 22d, 1831. § Da. Gibson-, Sir, I take the liberty of communicating to you a fact, which has fallen under my observation, relative to the disease known by the name of goitre, or broncho- cele, which, if it be not useful in throwing some light on the cause of this inex- plicable affection, will at least prove curious to the surgeon and physician. At King's Saltworks, in the county of Washington, Virginia, and not far from my own residence, this disease has prevailed for a number of years; for any thing that I know to the contrary, its existence is coeval with the commencement of the manufacture of salt at that place. Hitherto, it has been confined exclusively to females, and to those who reside at the very spot where the process of vaporiza- tion is carried on; the subjects of it consisting chiefly of the families of the im- mediate superintendents. Persons living at the distance of a half, or even quarter of a mile are not subject to the disease. Contrary to what might be supposed from the aspect of the neighbouring coun- try, this disagreeable affection is of exceedingly rare occurrence in this part of the slate, with the exception above alluded to. No satisfactory reason has been assigned for its existence at this place. It has, however, been ascribed to the water used 56 Bronchocele, or Goitre. It is probable, indeed, that goitre may be found as an endemic disease, in almost all the mountainous and marshy districts throughout the United States. All writers on the complaint, agree that it generally prevails in valleys at the bottom of the highest mountains, which are particularly exposed to the in- fluence of easterly and southerly winds. In those situations, moreover, where the temperature is mild and uniform—where the atmosphere is moist—in the neighbourhood of rivers, of falls or lakes, or of the sea,—where the soil is rich and the habitations surrounded by fruit trees, goitres are commonly found. Every age and sex is liable to goitre, but females are oftener affected than males. In children, it seldom occurs until after the eighth or tenth year, and old people are little subject to it. Three instances,however, are mentioned by Fodere, where it was found at birth, and another, in an infant fifty days after birth.* Dr. Sterndale has also furnished an example, where a child in Der- byshire, was born with a goitrous tumour of considerable size.t Those females who are not subject to bronchocele before mar- riage, generally perceive its commencement during pregnancy.J Persons of relaxed constitutions, of white and delicate skins, and whose complexions are red mixed with a brownish tinge, are most predisposed to the disease. Children who are to be- come goitrous, have large blue, sprightly eyes, beautiful skins, and fair hair. Their memory is very forward. When the dis- ease appears, every thing is changed. As it advances, the eyes become dull, the face acquires a white colour and unmeaning look, and the faculties are at a stand. When the goitre is very large, respiration becomes difficult, the pronunciation of consonants for drinking. I have drunk of the same water myself, and found it insipid and unpalatable; but was unable to detect in it the presence of any other mineral but lime, which is the common character of the water of the country. It may, per- haps, be proper to state, that a removal to another situation is not attended with a removal of the complaint. Whatever may be the cause of this disease, as it exists here, which, I think, is entirely inscrutable, such is the certainty with which it attacks those who come within the sphere of its influence, that every woman who goes to King's Salt- works to live, previously makes up her mind to become sooner or later a subject of goitre. John T. Smith, M. D. • Traite du Goitre et du Cretinisme. f London Medical Repository, vol.x. p. 200. * Fodere, p. 62. Bronchocele, or Goitre. 57 imperfect, and the body ceases to increase except about the head and shoulders. In a goitrous country, the children are born goitrous after two generations of the intermarriage of goitrous parents. After the third marriage, the child becomes a cretin. A semi-cretin, weak and ricketty, married to a goitrous woman, has children born goitrous.* During the winter, a goitrous tu- mour is diminished in size, but it augments with the return of warm weather, and is larger during autumn than at any other season. The disease is not confined to the human race; horses, horned cattle, calves, sheep, dogs and other inferior animals are subject to it.t In the commencement of bronchocele, a small tumour may be perceived, either on one or both sides of the trachea and larynx. Sometimes the swelling occupies each lobe of the thy- roid gland, together with its isthmus, so as to constitute a uni- form tumour; at other times, there is a depression at the centre, following the course of the trachea, and marking the natural division of the lobes. Occasionally the enlarged lobes are stud- ded over with a number of lobules. The swelling generally continues small and circumscribed for a considerable time, and often extends backwards, so as to render it difficult to ascertain by inspection or examination, whether goitre exists or not For the most part, it is soft to the touch, and possesed of so little sensibility, that it may be rudely handled, without producing much uneasiness. It is sometimes closely compressed by the muscles which cover it, and is then elastic and firm. Although the thyroid gland, both in its natural and enlarged condition, is not very susceptible of inflammation, yet, when this state is once induced, it becomes exquisitely tender, and is accompanied with a difficulty of respiration and deglutition, which the most active antiphlogistic measures can hardly subdue. Almost all the goitres which have come under my notice in America have commenced in one lobe of the gland—the other lobe in a short time being affected in a similar manner. Alibert says that he has found the right lobe oftener enlarged than the left-J In the worst cases of goitre I have seen, the tumour has exceeded in size a large cocoa nut, and has become at particular times very • Fodere, also Chapman's Notes on Allan's Lectures. f Coxe's Travels, Barton's Memoir, Clark's Reports. t Nosologic Naturelle. 58 Bronchocele, or Goitre. troublesome to the patient, by its weight and pressure upon the trachea and adjacent parts. In countries where the disease is endemic, it is not uncommon for the tumour to attain an enor- mous magnitude. Fodere relates instances of such tumours weighing seven or eight pounds.* A case is recorded by Ali- bert, of a man thirty-eight years of age, who had a goitre which extended below the middle of the chest and equalled in size a large pumpkin. " La poche enorme qui s'estformee au dessous de son menton, resemble a celle de l'oisseau designe commune- ment sous le nom de pelican, et qui figure comme object de cu- riosite dans les cabinets des naturalistes."t The same author details the case of a female, upwards of sixty years old, who had resided the greater part of her life near Chamouny at the foot of Mont Blanc, and who, from her infancy, had laboured under a bronchocele, which was divided into innumerable lobes, which extended from ear to ear, blocked up the cavities of each, so as to destroy the hearing, and finally descended on the chest, lower than the mammae, interrupting the breathing and swal- lowing to such a degree, as almost to produce suffocation, every time she attempted to take the least particle of nourishment, solid or fluid. But cases have been related by Mittlemayer and others, in which goitrous tumours have descended below the umbilicus, and even to the knees.f We have no reason to sus- pect these accounts exaggerated, when we remember the reports of Sir Robert Wilson, Larrey and others, respecting those pro- digious tumours, common in Egypt and many warm climates, in consequence of the descent of the abdominal viscera, which. in some instances, have reached the ground. The cases of enor- mous hydroceles, also, recorded by Keate, and the voluminous cutaneous excrescences described by Mr. John Bell and by Dr. Roper of Charleston, leave no doubt on the subject. Notwithstanding the peculiarities of goitre, it is not easy always to distinguish it from other diseases. It may be con- founded with aneurism of the carotid artery, with scrofulous enlargement of the lymphatic glands, with encysted and sarco- matous tumours of the trachea and its vicinity, with dilatation of the internal jugular vein, and perhaps with other complaints. From aneurism it may be distinguished, in general, by want of • Traite du Goitre, &c, p. 467. f Nosologic Naturelle, p. 468. t Dissertatio de Strumis et Schrophulosis 1723. Bronchocele, or Goitre. 59 pulsation, by the comparative insensibility of the tumour, by the softness of its texture, by its mobility, and by the circum- stance of the swelling accompanying the motions of the larynx and trachea, when the patient is desired to imitate the action of swallowing. But sometimes the goitre is so large, and is so identified with the adjacent cellular texture, that little or no movement of the trachea can be observed. When goitre is ex- tensive, and occupies one side of the neck only, and when, at the same time, there is a pulsation in it from the enlarged and varicose state of the vessels, we shall not find it always easy to discriminate between it and aneurism. Occasionally a pulsation is communicated from the carotid to a goitrous tumour, which happens to lay over it. One instance is noticed by Burns, where the carotid was deeply imbedded in the aubstance of an enlarged thyroid gland. " The carotid artery being placed," says he, " in the body of the tumour, is neither very rare in occurrence, nor very difficult to explain. It is, indeed, a natural consequence of the extension of the tumour laterally; yet it will not happen in every tumour: it will only occur in those cases, where the consistence of the morbid parts is soft. When the tumour is firm, it pushes the artery, nervus vagus, and internal jugular vein aside. When it is soft, these, as in the present instance, sink into its substance."* In most in- stances of aneurism, however, the carotid is deeper seated than bronchocele, and the pulsation so strong as scarcely to be mis- taken. Notwithstanding this, cases have been related where the most able surgeons have found it impossible to offer a de- cided opinion. A creole negro had a tumour on the neck, which was submitted to the inspection of some of the most celebrated surgeons in America, Paris, and London; all of whom pro- nounced the disease an aneurism of the carotid artery; but it was afterwards ascertained, by Boyer, that no such disease ex- isted—but simply an extensive enlargement of the lymphatic and other glands of the neck.t The late Dr. Samuel P. Grif- fitts has furnished us with an interesting history of a tumour of the neck, bearing so strong a resemblance to carotid aneurism, as to be mistaken for the disease by himself, Drs. Chapman and • Surgical Anatomy of the Head and Neck, page 224. ■J- Dictionnaire des Sciences Medicales, vol. xviii. p. 541. 60 Bronchocele, or Goitre. Morgan, and the late Dr. Dorsey. Upon dissection by Dr. Par- rish, it was distinctly ascertained that the carotid was free from disease, and that the tumour was composed entirely of the thy- roid gland. " It was elongated," says Dr. Parrish, " and had obtained a situation directly over the carotid artery; the patient's neck was very short, the pulsation in the carotid was imparted to the tu- mour lying over it; and, I am informed, there was a strong re- semblance to the aneurismal jar or thrill. We are aware, that in dropsy of the chest and pericardium, the heart often palpi- tates most violently; and this morbid pulsation may explain the throbbing of the carotid, which bore so strong a resemblance to aneurism."* One circumstance which deceived Dr. Griffitts, was the impossibility of drawing the tumour from the artery. " I had frequently endeavoured," says he, " to remove, with my fingers, the tumour from the artery, wishing to think the disease was glandular, but could not succeed, as the tumour was so firm- ly fixed over the vessel as not to be moved from it; and the pulsation was such as to convey the idea that there was no in- tervening substance." Under ordinary circumstances, this plan of drawing the tumour from the artery is excellent. It was by relaxing the muscles of the neck, and separating with the fingers the tumour from the artery, that Boyer was enabled, in the case referred to, to discriminate between the disease and aneurism. By similar means, I have often succeeded in distinguished en- larged glands and other tumours situated over large arteries, in different parts of the body. Many writers have confounded goitre with scrofula: but there would appear to be no legitimate foundation for such a conclusion. In scrofula, the lymphatic glands of the neck and other parts of the body are particularly involved; and other marks in the system, too well known to require description, evince the existence of the scrofulous constitution. These symptoms do not generally accompany the goiterous tumour. Goitre is strictly a local complaint—scrofula affects the whole system, and appears at a much earlier period of life than goitre. In countries where bronchocele is endemic, the scrofulous are equally liable, no doubt, with others, to the complaint. Persons * Eclectic Repertory, vol. ix. p. 120. Bronchocele, or Goitre. 61 who remove from settlements where goitre does not exist, into countries where the disease prevails, are subject to it; but on residing again for some time at their original home, the tumour disappears generally in a short time. This is seldom the case with scrofula, which is little influenced by change of climate. The scrofulous tumour is harder to the touch, and more pain- ful than the goitrous tumour. It is more disposed to suppurate than bronchocele; besides, goitre is nearly unknown in certain countries, where scrofula is the common disease. In Scotland, scrofula is almost universal,—goitre hardly ever met with. In Switzerland, goitres are very common, and affect all classes of society, while scrofula is very rare. It is possible for an en- larged thyroid gland to extend so far beyond its natural boun- daries, as to occupy the situation of the lymphatic glands of the neck. Mr. Burns has furnished a very instructive case of this kind, in which it would have been impossible, perhaps, without dissection, to have ascertained the true nature of the swelling. " Beneath the sterno-mastoid muscle," says he, " the enlarged gland was lobulated and clustered into small processes, precisely resembling a chain of enlarged concatenated glands. Indeed, had I alone trusted to the impressions received before dissection, I would have been led to believe that the lymphatic glands of the neck were actually swelled, and, besides that, several of the conglobate glands, placed behind the sterno-mastoid muscle, be- tween it and the trapezius, were also affected; for into that space processes from the left lobe of the thyroid gland extended."* A dilatation of the internal jugular vein is not an uncommon disease, and may sometimes be mistaken for goitre. It may be distinguished, generally, by its low situation—the swelling ap- pearing just above the sternum. The tumour may also be known from goitre, by its softness and compressibility, by its pulsatory and tremulous motion—by the sudden return of the tumour, when pressure is removed—by more or less turgescence, along the whole course of the vein. I once attended a patient, four or five years of age, with Dr. Jennings of Baltimore, upon ac- count of a large swelling of the neck, the precise nature of which, it was difficult to ascertain for some time. It resembled in many respects the enlarged thyroid, and in others, diseased lymphatic * Surgical Anatomy, p. 196. Vol. II. 9 62 Bronchocele, or Goitre. glands, but turned out to be a dilatation of the internal jugular. The interesting case of a tumour of the neck, detailed by Mr. Hey, the nature of which he could not ascertain, I have no doubt, was an enlarged vein, and^ probably the jugular.* The morbid distention of this vessel has been confounded occasion- ally, with aneurism of the aorta.t An encysted tumour may occupy the anterior surface of the trachea; in many respects it is analogous to goitre—is free from pain—is soft and doughy to the feel—follows the motions of the larynx and trachea, and may attain a considerable size. It extends on the trachea as high as the thyroid gland, and de- scends behind the sternum. The disease has never been de- scribed, I believe, as occupying this situation. I have seen only two or three cases of it. An officer of the army consulted me, some years ago, respecting such a tumour, which had been shown, previously, to several practitioners, who could not give a decided opinion as to its nature. At first I suspected it to be a goitre, but the patient assured me that it had emerged, original- ly, from behind the sternum, and was occasioned, so far as he could determine, by the pressure of a leather stock, which had been worn unusually tight. This circumstance inclined me to believe, that the tumour had no connexion with the thyroid, gland, and determined me to puncture it with a lancet. A thick, yellow, cheesy matter, extremely offensive, and three or four ounces in quantity, was discharged from the wound by pressure. The opening was then enlarged, and a probe could be passed to a considerable distance behind the sternum, and upwards along the trachea. The cavity was filled with lint and stimulating in- jections were frequently employed. Suppuration was established with difficulty, and the cavity was filled up in the course of two or three months. I met with a similar disease afterwards, in a young woman seventeen years of age, and removed it by the same treatment. The wound, however, remained fistulous for a considerable time, in spite of every remedy used. In both cases, these tumours extended so far upwards, and were so deep- ly imbedded under the sternum, that any attempt at excision would have been hazardous, if not impracticable. In its natural state, the thyroid gland is found to vary in dif- * Hey's Practical Observations in Surgery, third edition, p. 448. t Burns on the Diseases of the Heart, p. 259. Bronchocele, or Goitre. 63 ferent subjects. In females, it is larger than in males. It is ge- nerally made up of distinct lobules, which are collected into numerous lobes or tuberculated masses, joined to each other by a very fine cellular membrane. Rounded vesicles, containing a colourless, but sometimes yellowish fluid, are mixed with the lobes. In many subjects these vesicles cannot be discovered, and the existence of a fluid is ascertained, only by rubbing slices of the gland between the fingers, when a peculiar feeling of viscosity may be observed.* There is no proper investing membrane or capsule to the thyroid gland; but the cellular tex- ture is slightly condensed on the surface, so as to furnish a very thin covering, from which processes proceed internally, and form septa or partitions in various directions. The substance of the gland generally consists of two portions, which are placed on each side of the trachea and larynx, and united to each other by a transverse band or slip of the same substance. Sometimes this band is wanting, and then there are two distinct thyroid glands.t No unquestionable excretory duct has yet been dis- covered. But small openings or canaliculi, described by Mor- gagni, Bordeu, Walter, and some other anatomists, have been found on the internal surface of the trachea. These openings uniformly occupy one situation, and are two or three in number. They may be found about the middle of the internal surface of the first cartilaginous ring of the trachea. Bordeu, in speaking of this ring, says, " Nous avons aussi remarqud, qu'il est, dans tous les sujets ou divise par une fente plus ou moins etendue et situee vers le devant du cartilage, on perce d'un ou deux, et meme de trois trous bien apparens et places aussi, vers le milieu du cerceau sur le devant, ou un peu a cote. "Ces trous nous frapperent la premiere fois que nous les vimes: cetoit a Montpellier, en 1741, en dissequant un larynx aupres du feu; la glande thyroide qui etoit extremement grosse, etant enlevee, nous trouvames le premier cerceau presque osseux, mais assez transparent pour laisser apercevoir, au moyen du feu, les deux trous qui n'etoient recouverts que par des membranes laches qu' on emporta facilement. " Apres bien des recherches, on trouva un sujet mort de morte violente; nous examinames d'abord la face posterieure • Anatomie Descriptive, par X. Bichat. t Soemmering de corp. hum. fabric, vol. 6, p. 39. 64 Bronchocele, or Goitre. du cerceau de la trach^e, sans avoir touche la thyroide; la mem- brane interne de ce cerceau etoit pleine de petits trous difficiles a apercevoir; nous introduisimes des soies dans cinq de ces trous, et en les conduisant legerement, elles allerent se rassem- bler en deux endroits, trois dans Pun et deux dans 1'autre; ces endroits etoient precisement les deux trous du cartilage; ces soies allerent, en les pousant, se perdre dans la glande. M. Bar- buot, medecin de Semur, etoit present a cette operation."* From a perusal of these and other passages in Bordeu, some years ago, I was induced to examine the openings described, in a great many subjects, under an impression that they were the mouths of excretory ducts from the thyroid gland. To ascer- tain this, I made a number of experiments with the mercurial injecting apparatus, the small pipes of which were introduced directly into the openings in the cartilage, and found that the mercury sometimes passed with facility through these small canals, but met with resistance when it reached the thyroid gland. In three or four instances I succeeded in pushing it to a considerable distance under the cellular covering of the gland, and even among the cellular texture into the substance of the gland, as I afterwards ascertained by cutting it open. But, in all pro- bility, the mercury passed, in each case, from rupture of the cel- lular tissue, and did not follow the natural course of the duct. I endeavoured to find a communication between the thyroid gland and the ventricles of Galen, and with this view introduced the mercury into the bottom of each of these cavities. Af- ter several ineffectual attempts, I succeeded in filling the cellu- lar texture of the thyroid, and to a much greater degree than from the openings of the trachea. I mention these circum- stances to corroborate the suggestions of Morgagni and Bordeu, that there are passages from the thyroid gland, which serve to deposite its secretions in the trachea, and perhaps in other places. The observation may be useful to those who feel disposed to in- vestigate the subject further. In addition, I may state, that Fodere succeeded in blowing air from the larynx into the thyroid gland, so as to distend it considerably. In another instance he filled the trachea with spirit of wine, and upon cutting into the thyroid gland, the smell of the liquor was distinctly perceivable. * CEuvres completes de Bordeu, par Richerand, torn. 1, p. 98. Bronchocele, or Goitre. 65 " Qu'on prenne," says he, " un larynx auquel, cette glande est attachee, bien lave et netoye avec une legere dissolution de potasse, et ensuite seche, qu'on en bouche exactement l'extremite" inferieure, puis qu'on adapte au trou de la glotte, un tube con- tigue a une vessie pleine d'air, et qu'on lutte bien l'appariel; en comprimant la vessie, on verra la glande thyroide augmenter de volume. " La meme experience reussit, quo! qu'a un moindre degre, avec l'alcohol. En coupant la glande apres avoir comprime, la vessie, on sent distinctment l'odeur de ce fluide."* Lalouette discovered an immediate connexion between the thyroid gland and the lymphatic vessels which pass along the thyroid and cricoid cartilages.t Many cases have been record- ed by different writers, where an enlargement of the thyroid gland has been suddenly produced in consequence of violent exertions of the muscles of the neck in lifting heavy weights, or in consequence of laborious efforts of the patient during pro- tracted and difficult parturition. It has been maintained, also, that goitre is produced among the inhabitants of certain Euro- pean districts, from the habit, which is frequent among the lower order of people, of dragging burdens up the hills by cords tied round the upper part of the chest. According to Mr. Heckewelder, who often met with goitre among the American Indians, the disease never made its appearance among the girls until they began to carry heavy burdens on their heads. J These circumstances would favour the idea of Bordeu, Fodere, Mor- gagni, and others, of the existence of a direct communication between the trachea and thyroid gland.§ Many theoretical uses have been assigned to the thyroid gland, besides those al- ready mentioned. It does not come, however, within the scope of my purpose to detail them.|| When a goitrous tumour is examined by dissection, several circumstances are presented worthy of notice. One or both lobes, and sometimes the middle lobe or isthmus of the gland, are found enlarged beyond their natural boundaries. Upon cutting * Traite du Goitre et du Cretinisme, p. 58. ■J- Haller Elementa Physiologic. $ Barton's Memoir, p. 46. § See Morgagni's Adversaria, 5, p. 66. || Those who wish for information on the subject may consult Holler's Ele- menta Physiologic, lib. 9, p. 22. Soemmering de corp. hum. fabr. vol. 6, p. 41. Coxe's Museum, vol. 3, p. 27. 66 Bronchocele, or Goitre. into their substance, the texture is found more or less compact, intermixed with numerous cells, containing a transparent glu- tinous liquor, which may be drained off in such quantity, by pressure, as to reduce considerably the bulk of the tumour. These cells vary in size; some being large enough to contain a pea, while others are exceedingly small. The fluid they con- tain becomes a solid transparent jelly, when the gland has been immersed for some time in proof spirits.* Although the thy- roid gland in its natural state is abundantly supplied with large arteries, yet its capillary vessels are comparatively few, and the quantity of blood determined to its substance not so great as commonly supposed. In bronchocele all the vessels are great- ly enlarged, and varicose, and the quantity of blood materially increased, as is evinced by the throbbing of the tumour during life, and by injection of it after death. This preternatural ac- cumulation of blood so frequently accompanies the kind of dis- eased enlargement of the gland which I have described, as to cause some writers to rank it as a particular species of goitre,— denominated sanguineous goitre. This distinction, as well every other division of the disease into species, is perhaps im- proper, inasmuch as the appearances presented on dissection are never sufficiently uniform to enable us to characterize with precision each morbid change of structure. It is certain, how- ever, that an unusual determination of blood generally accom- panies the structure I have described,—and which nosologists have called the sarcomatous bronchocele. In all probability, the other species mentioned are but varieties of this common and perhaps original form of the complaint. Sometimes the texture of the goitrous tumour, instead of being compact and solid, is soft and spongy, and large cavities or membranous vesicles are dispersed throughout, which con- tain a thin, limpid, or serous fluid. This has been called the encysted, serous, or watery bronchocele. It is a modification only of the common disease; for sometimes the fluid changes into a yellow tenacious, and melicerous matter. The cells of the thyroid gland are said to have been filled, occasionally, with hydatids; but such appearances may have been confounded with the watery collections just described. The bronchocele ventosa cannot be considered as a variety of goitre, but only an emphy- :'• Morbid Anatomy, p. 86. Also, Engravings, Fasciculus, 2, p. 25. Bronchocele, or Goitre. 67 sematous tumour of the gland, or of the adjacent cellular tex- ture. . It is not uncommon to find in the substance of goitres, of long standing, bony particles, and even considerable masses of ossi- fied matter. Several examples of the kind are mentioned by Bonetus, Morgagni, Kerkringius and other old writers. Dr. Baillie,in his Morbid Anatomy, speaks of the thyroid gland being sometimes converted, in old people, into a bony mass. In this respect the disease nearly resembles other sarcomatous tumours, in which we are accustomed to meet with cartilaginous and ossified productions. Calcareous concretions are said to have been discovered, in the substance of the thyroid gland, affected with goitre.* Pieces of tuft stone have been removed from the thyroid gland, in several instances, by a Swiss surgeon.t The substance of bronchocele is seldom converted into, puru- lent matter. But cases have been recorded by Petit and Hevin, where spontaneous cures were affected in this way. Severinus relates a case in which purulent matter was discharged from a bronchocele mixed with a substance resembling charcoal.^ Dr. Baillie has given a drawing of a preparation contained in the Hunterian cabinet, where an abscess formed in the right side of the thyroid gland and afterwards communicated by ulceration with the trachea, so as to suffocate the patient.§ Alibert re- lates the case of a patient in the hospital of St. Louis, who laboured for years under an enormous bronchocele, and was eventually relieved of his burden by suppuration taking place in its substance. Ulceration was spontaneously established, and upwards of five pounds of purulent matter discharged.|| Burns gives an instance, where suppuration took place in both lobes of the thyroid gland. The matter was slowly se- creted and the integuments became gradually distended, until they formed a large pouch which hung over the sternum, and contained several pounds of pus. The sides of the cyst united, and the patient was ultimately cured.TI In speaking of abscess, • Mailer's Elementa Physiologic, Vol. III. p. 400. \ Coxe's Travels. t De Recondita Abscessum Natura, p. 194. § Series of Engravings, p. 27. U Nosologie Naturelle, p. 467. 1 Surgical Anatomy, p. 188. 68 Bronchocele, or Goitre. following bronchocele, Portal remarks, that the cartilages of the larynx and rings of the trachea, are sometimes eroded by caries. "On atrouvedans des sujets qui etaient morts de suffocation, les cartilages thyroide, cricoide, et les anneux cartilagineux de la trache'e artere, rouges par la carie, a la suite d'un abscess dans la thyroide. Valsalva, Morgagni, Lieutaud ont cite de pareils exerhples dans leurs ouvrages."* I have had three opportunities of dissecting goitrous tumours. The first was in a man upwards of sixty years of age, who had laboured under a very large and turberculated swelling of the thyroid, almost from infancy. The tumour occupied both sides of the trachea, and was very solid, and insensible to the touch. It produced very little inconvenience, and the patient died of another complaint. Upon dissection, I found each of the en- larged lobes completely sarcomatous, without any membranous vesicles, or fluid, except a thick yellowish, lardaceous or olea- ginous matter, in small quantity, which could be pressed, by force, from the diseased mass. Fibrous bands, similar to those which occur in the scirrhous breast or testicle, intersected the tumour in various directions. The larynx and trachea were not altered in structure, but the mouths of the small muciparous ducts, which open on the lining membrane of the trachea, were not perceptible; and the tracheo-thyroideal passages of Bordeu appeared less conspicuous than usual. Some years ago I had an opportunity of inspecting the body of a woman thirty-five years of age, who died of apoplexy. A large tumour occupied the left side of the thyroid gland. Upon turning aside the sterno-thyroidei and omo-hyoidei mus- cles the gland was brought into view, and presented an immense number of varicose veins distributed over its surface; all the parts in the neighbourhood, seemed vascular in the extreme. Upon opening the gland a considerable quantity of thin greenish fluid was discharged, and the small cells which contained it were distinctly perceived. The right side of the gland, to- gether with the isthmus, was slightly enlarged; but in other re- spects appeared to possess its natural structure. This woman, as her husband informed me, had suffered occasionally from inor- dinate pulsation in the tumour, and from its pressure on the tra- * Cours d'Anatomie Medicale, tome iv. p. 564. Bronchocele, or Goitre. 69 chea, but in general, experienced little inconvenience. She was a native of Holland, where the disease commenced about the tenth year of her age, and had slowly increased. It appeared to have had no connexion with the complaint of which she died. With the history of the third subject, I am unacquainted. It was a girl about fourteen years old, who was much emaciated, and had laboured, apparently, for a considerable time, under constitutional disease. Both sides of the thyroid were involved; but the disease was evidently in its commencement. The vessels of the gland were slightly varicose, and the cellular structure of the interior contained a small quantity of transparent fluid. The larynx and trachea were unaltered, and the small openings of the first cartilaginous ring were distinctly observable. The causes of goitre are involved in much obscurity. This will account for the numerous, diversified and contradictory speculations on the subject. By many, the disease has been at- tributed to the use of particular alimentary substances, especially poor and unwholesome diet;—to the drinking of cold or snow water, or water strongly impregnated with limestone, or other calcareous matters; the immoderate use of spirituous and vinous liquors, debauchery, the repulsion of cutaneous diseases, and many similar explanations have likewise been resorted to; all of which are too hypothetical, and so frequently contradicted by facts, as to deserve no attention. It is certain, that goitre pre- vails as an endemic disease chiefly in countries where the at- mosphere is loaded with moisture, in valleys enclosed by lofty mountains, and which are exposed to the direct and reflected heat of a powerful sun. In some of these valleys, the fo°-s are visible every morning, rise with the sun in a thick body, and seldom disappear entirely, until the afternoon.* It is, however, well ascertained, that those persons who do not reside in or near the valleys where goitre prevails, but live on the sides or tops of the adjacent mountains, do not labour under the disease. Again, it is a fact established beyond all doubt, that the mere removal of a goitrous person from the valley where he acquired his disease, to the top of the contiguous mountain, will diminish * Marsden's History of Sumatra. Vol. II. 10 70 Bronchocele or Goitre. the size of the tumour, and in time, remove it entirely. The same observations, perhaps, to a limited extent, may be applied to cretinism, a disease so often concomitant, but probably inde- pendent of goitre. " All the cretins that I saw," says Dr. Reeve, " were in adjoining houses, in the little village called LaBatia, situated in a narrow corner of the valley, the houses being built up under ledges of the rocks, and all of them very filthy, very close, very hot and miserable habitations. In villages situated higher up the mountains, no cretins are to be seen, and the mo- ther of one of the children told me of her own accord, without my asking the question, that her child was quite a different being when he was vp the mountain, as she called it, for a few days."* Frequent opportunities are offered in this country, of observing the effects produced on goitre, by the removal of individuals afflicted with it into districts where the disease is unknown. Numerous cures, of very large goitres, have been effected in persons, who acquired the complaint at Pittsburg— simply by spending a few months in Philadelphia, or other distant places. These circumstances indicate, beyond doubt, something peculiar in the atmosphere or in the exhalations from valleys or other places where goitre is found. That the disease, at all events, is not owing to poor living or to the drinking of snow water, is sufficiently proved by the circumstance of its not pre- vailing in certain countries where the inhabitants are accustomed to subsist on a very meagre and scanty diet. Besides,—the rich inhabitants of the Vallais and of the state of New York, are equally subject to the complaint with the poorer people. In Greenland, and Lapland, where the inhabitants use snow water almost entirely, there is no goitre, while in Sumatra, in Bambarra, and in many other warm countries, where snow is never seen, the disease is very common.! In those parts of the state of New York, New Hampshire and Vermont, particularly along the course of the Connecticut river, where goitre prevails, it is remarkable that the disease is most common in those places which are covered with wood and are uncultivated; but in proportion as the country is settled and the lands cleared, the disease is found to decline, and in many • Account of Cretinism, Edinburgh Journal, vol. v. p. 33. f Vide Marsden, Park's Travels, Humboldt and Bonpland, &c. Bronchocele or Goitre. 71 places is already nearly extinct* In 1798, bronchocele was so common at Pittsburg, that, out of 1400 inhabitants, not less than 150 had the disease.! Since that period, the complaint has so much declined, in the same place, that it is said very few now la- bour under it. The change is usually attributed by the citizens of the town, to the general introduction of coal fires. All these circumstances tend to show that bronchocele is produced by a peculiar atmosphere, or by certain morbid exhalations from marshes or other grounds. What the peculiar nature of this exhalation is, we have no more means of ascertaining, than we have of finding out the constituents and mode of action, of marsh miasma, or of the agents which create yellow fever, or any similar disease. The late Professor Barton imagined goitre to arise from the same causes which produce intermittent and bilious fevers.J But it has been ascertained that goitre origi- nates in many districts where intermittents are unknown, and intermittents, on the other hand, are frequent where goitre has never been seen. Along the shores of the Delaware and Che- sapeak bays, intermittent and bilious fevers universally prevail, and goitre is seldom found. It is possible, however, that the cause of goitre may be allied to that of intermittent, but so mo- dified by particular circumstances, which we shall probably never be able to ascertain, as to produce very different effects. But those who are anxious for information, respecting all the supposed causes of goitre, should consult the work of Fodere, Coxe's Travels, Saussure's Voyages, Gautieri de Tyrolensium Struma, &c. Whatever may be the remote physical causes of goitre, I am inclined to believe, that the disease arises immediately from an obstruction of the tracheo-thyroideal passages of Bordeu, of the openings, communicating with the sacculus laryngeus and the thyroid gland, of which I formerly had occasion to speak, or of other passages with which we are unacquainted. I am in- clined to draw this conclusion from the circumstance of a watery fluid being found to occupy naturally, the cells of the thyroid gland—from this fluid being increased in quantity in almost every goitrous tumour, and from the passages of Bordeu being much * Mease's Observations. | Barton's Memoir. * Vide Barton's Memoir—also, Caldwell's Medical and Physical Memoirs, p. 279. 72 Bronchocele or Goitre. smaller in the first dissection I made of bronchocele, than they are usually met with in subjects without such disease. This is a mere conjecture. Neither is it original—but was advanced by one of the older writers on surgery. I mention it, merely to induce those who have frequent opportunities of investigating the struc- ture of bronchocele by dissection, to attend to the appearances of these passages and to endeavour to discover other communi- cations with the gland. Treatment of Bronchocele. The remedies proposed for the removal of this disease are countless—the strongest proof of their inefficiency. It will be sufficient to enumerate the principal—burnt sponge, mercury, pumice stone, muriate of barytes, sulphuret of potash, egg-shells, muriate of lime, digitalis, muriate of iron, belladonna, electricity, pressure, friction, issues, setons, blisters, caustic, excision, and ligature of the thyroideal arteries. In the commencement of my practice, I employed the burnt sponge in the form of powder, mixed with honey and other materials,—the lozenges of Ring, which consist of cinnamon, gum Arabic, sirup and burnt sponge mixed—the simple decoction of the sponge, as recommended by Herrenschward of Berne, in Switzerland,—but generally with- out any decided effect.* In two instances, I succeeded in re- moving small goitres by the use of sulphate of potash, continued for several weeks in large doses. This remedy is said to have effected many cures, in the hands of Fodere and other practition- ers. The different preparations of mercury and antimony, muri- ates of lime and barytes, I have tried without the slightest advan- tage. In one case, after the inefficacious exhibition of many of the remedies mentioned, the late Dr. Cromwell, of Maryland, ef- fected a complete cure in a patient upwards of twenty years of • For an account of the use of these remedies, see Fodere, p. 110. Ring, in the 4th, 5th, and 11th volumes of the London Medical and Physical Journal. Bronchocele, or Goitre. 73 age, who had laboured for some time under a goitre,—by the re- peated application of blisters. Mr. Benjamin Bell says, that he arrested the progress of a very large bronchocele by the same means. Stimulating frictions with flannels, immersed in cam- phorated liniments, and other applications of a similar nature, are commended by Underwood. Fodere remarks that he frequently cured small Spanish dogs of goitre by the same means, at Maurice, where these animals are very subject to the complaint.* Fric- tions with mercurial ointment and various stimulating plasters, have likewise been extolled by different writers. Boyer has employed, for many years, cataplasms, or bags of emollient herbs, applied directly to the tumour, and worn night and day for weeks or months, and often with success. Compression has sometimes been found serviceable by Fodere; and Dr. Physick once succeeded in effecting a complete cure of the disease, in a lady of this city, by keeping up a continued but moderate pres- sure by means of a bandage for several months. Mr. Holbrook, a surgeon of Monmouth in England, where goitre is endemic, has cured a number of patients, by the use of steady pressure, after the failure of other remedies-! But I have found no general or local remedies so efficacious as the extract of cicuta. Indeed, for several years, I have de- pended chiefly upon the use of this medicine, and may declare that I have seldom had recourse to it in the early stage of bron- ehocele, without some benefit. I found by experience, that from the age of ten or twelve years up to twenty, and in cases where the goitre was large and spongy to the touch, and had not existed very long, that the cicuta was almost a certain reme- dy; but, on the other hand, when it occurred in adults beyond the age mentioned, and in old people, that although it sometimes diminished the size of the swelling, yet, in general, it was pro- ductive of no advantage. The seton, employed so frequently by the older surgeons, and recommended a few years since, by Quadri of Naples, I tried repeatedly in the case of a German boy from Lancaster, whose neck was covered with a lobulated goitre of enormous dimensions—without any other benefit than the copious discharge of a thin greenish fluid, which diminished * Fodere, p. 115. ■j- London Medical Repository, vol. 8, p. 288. 74 Bronchocele, or Goitre. the tumour for a time, and relieved the patient of the uneasiness occasioned by its pressure on the windpipe. Within the last ten years, a remedy for goitre has been intro- duced into practice, by Dr. Coindet of Geneva, which has ex- cited, in a great degree, the attention of the profession in almost every European country, and in America. I allude to the pre- paration termed iodine. The reports of Coindet in favour of this medicine were soon fully confirmed by many other conti- nental surgeons; and its reputation rose speedily to the highest pitch; strange as it may seem, however, its decline has been al- most as rapid as its rise, being now considered, in the estimation of many practitioners nearly inert, and by others pronounced a most virulent poison. But from all the statements made on the subject, we have, I think, fairly a right to infer, that it is a me dicine of great power, calculated, in some cases, to produce a very strong impression on goitrous and other tumours, as many well attested cases decidedly show; and that, on the other hand, it is followed occasionally by tremendous symptoms, and even death. Again, it is equally certain, that upon other patients not the slightest impression has been made by its use, either upon the tumour or upon the constitution of the individuals who have taken it, sometimes for months together, and in the largest doses. My own experience in its use is very limited, but judging from this and from the reports made to me concerning it by my colleagues in the Alms House Infirmary, I should feel inclined to doubt its efficacy. Still it is possible we may have been deceived, either by the bad quality of the medicine, or by other circumstances. Lastly, it may be stated, that Dr. Coindet himself, has abandoned the internal use of the remedy, and merely employs it in the form of inunction, from which he states that he has derived very beneficial results. Bronchocele sometimes disappears spontaneously. Occasion- ally, the tumour is removed suddenly. Several examples of the sort are related by Alibert. In one instance, during the French revolution, a woman was seized with a fit of melancholy, and a large bronchocele, from which she had suffered exceedingly, disappeared with the utmost rapidity.* Bronchocele may become so large as to endanger suffocation. * Alibert's Noveaux Elemens de Therapeutique. Bronchocele, or Goitre. 75 In this case, extirpation, an operation first recommended by Celsus, has been resorted to, and sometimes with success. But such favourable terminations are extremely rare—as many of the older, and some of the modern French and English surgeons have sufficiently proved. Palfin, in his Surgical Anatomy, relates the case of a lady of rank in Paris, who perished from hemorrhage, in consequence of the removal of a large goitrous tumour, by an adventurous surgeon, who undertook the opera- tion in spite of the remonstrances of some of the most experi- enced practitioners. The operator had scarcely left the house, before the hemorrhage broke out, with tremendous violence, and destroyed the patient in a few minutes.* Gooch mentions three cases, in which the operation was performed contrary to his advice, and that of some other surgeons. Two of the pa- tients lost their lives from hemorrhage, and the third was only saved by constant pressure, kept up day and night for the space of a week, by the fingers of several persons employed for the purpose.! Mr. John Bell mentions more than one instance, where surgeons have opened tumours arising from or connected with the thyroid gland, from which the flow of blood has been so copious, as to oblige them to abandon the operation and close the wound as speedily as possible.:): Desault, upon one occa- sion, undertook to remove a bronchocele from the neck of a wo- man, but the blood issued with such rapidity, as to force him to stop and endeavour to secure the vessels by throwing a ligature around a considerable portion of the tumour which he had dis- sected up. The patient died in a very short time, in convul- sions, occasioned, it was supposed, by irritation from the liga- tures^ Another case is recorded of a patient who had a large bronchocele, which was productive of no inconvenience to him, removed by the knife, by the advice of Desault, and contrary to the opinion of Baron Percy and Louis. It was found impos- sible to stop the blood, and the gentleman expired almost im- mediately. Many examples of a similar nature are recorded by Bonetus, Severinus, and others of the older writers. But, perhaps, the most remarkable operation of the kind to be found * Anatomie Chirurgieale, tome ii. p. 313. j- Chirurgical Works, vol. iii. p. 158. $ Principles of Surgery, vol. iii. § Dictionnaire des Sciences Medicales, tome xviii. p. 556. 76 Bronchocele, or Goitre. in the annals of surgery, was executed, a few years ago in Paris, by the celebrated Dupuytren, on a young woman who had la- boured for a great length of time under an enormous broncho- cele, which interrupted respiration and deglutition to such a de- gree, as almost to destroy her. The patient had presented her- self frequently at the Hotel Dieu, in expectation of having the tumour removed by the knife. At several consultations held on her case by the most distinguished surgeons of Paris, it was unanimously determined, that no operation could be performed with any prospect of success. The tumour, however, still con- tinuing to increase.in size, and the entreaties of the patient for its removal becoming more urgent, Dupuytren, at last, con- sented to engage in the undertaking. By slow and cautious dissection he succeeded in detaching the left side of the tumour, without dividing any of the large arteries, veins or nerves of the neck. The thyroid arteries, in particular, which were very much enlarged, were each drawn out and tied with two ligatures before they were cut. The right portion of the tumour was then removed, in a similar manner, and the whole operation completed, with the loss only of a few spoonsful of blood. But the patient suffered extremely, as the operation was necessarily protracted, and the dissection carried on among parts of the ut- most delicacy and sensibility. She never recovered from the shock communicated to the nervous system, and expired in thirty-five hours after the operation.* It would appear, from these details, that the extirpation of even a small tumour of the thyroid gland, is attended with diffi- culties which should dismay the most expert and enterprising surgeon. Cases are recorded, however, where operations of the kind have been attended with success. Fodere states that a barber relieved his wife of a very large bronchocele by excision. The same author mentions two other instances within his own knowledge, where Giraudi, an adventurous surgeon of Mar- seilles, succeeded in curing his patient, by the same means.! Desault dissected out the right side of an enlarged thyroid gland of a female patient in the Hotel Dieu, who recovered without a * Dictionnaire de Sciences Medicales; also, Pelletan's Clinique Chirurgieale, vol. 1, p. 215. f Traite du Goitre, &c. p. 118. Bronchocele, or Goitre. 77 bad symptom in a month after the operation.* Two cases of successful extirpation of bronchocele are detailed by Dr. Harris, of New York. In the first case the tumour was not larger than a pullet's egg, in the second it was of considerable size. " About three months since," says Dr. Harris, "an application was made to me by a lady from South Carolina. I think the bronchocele was full as large as any I had ever seen. The tumour had been increasing for twenty-two years. It extended from the chin, which it buoyed up, along the trachea, until it descended an inch, or perhaps more, under the breast bone, and spread la- terally a medial distance to each ear."f No hemorrhage of con- sequence followed either operation, and both patients recovered in a very short time. There is great reason, however, to be- lieve, from the histories of these cases, that the tumours neither constituted a part of the thyroid, nor were connected with it. But, from all the information I have been able to collect, on the subject of the removal of this gland by the knife, I am inclined to believe that less danger would attend its excision, as respects hemorrhagy, than is commonly imagined. Our knowledge of the means of arresting hemorrhage has been greatly improved within a few years; and it will be seen, that Dupuytren, by adopting a practice long ago recommended and employed with the greatest success, in this country, by Dr. Physick (the tying of large arteries before they are cut) was enabled to extirpate an enormous bronchocele, with the loss of only a small quanti- ty of blood. But I very much question the propriety of at- tempting the removal of a goitrous tumour, in any case, inas- much as I conceive that hemorrhage is less to be dreaded than the inflammation and irritation which follow the operation. Under ordinary circumstances, the tumour may attain a very large magnitude, without endangering the patient's life or pro- ducing much inconvenience; and if it should increase to such a degree as to render death inevitable, there is very little proba- bility that the patient can be saved by so severe an operation as must necessarily be encountered. But although I would not recommend the excision of the thyroid gland, there is another operation to which I would * Surgical Works, vol. 1, p. 257. f New York Medical Repository, vol. 11, p. 242. Vol. II. H 78 Bronchocele, or Goitre. not hesitate to resort in case of necessity. I allude to the tying up of the great arteries in the vicinity of the tumour, from which it chiefly derives support. Mr. Thomas Blizzard, of London, was the first, I believe, to execute the operation. The thyroid arteries on each side of the neck, were included in a ligature, and the tumour diminished, in the course of a week, one-third in size. The patient, however, did not recover, but died from repeated secondary hemorrhage, occasioned by an attack of hos- pital gangrene. But he lived long enough to evince the pro- priety and practicability of the operation.* In 1818, a similar ope- ration was performed by Professor Walter, of the University of Landshut, on a man twenty-four years of age, who had an enor- mous bronchocele, from which he suffered extremely. The in- ferior thyroideal artery of the left side was taken up, and at the end of a fortnight the left portion of the tumour had diminished so much in bulk as to induce the operator to include the supe- rior thyroid of the right side in a ligature. No inconvenience followed either operation, and the bronchocele, in a short time, almost disappeared, leaving behind only the elongated skin, which hung from the neck in the form of an empty sack.f * Bums' Surgical Anatomy, p. 202. f Bulletin de la Societe Medicale d'Emulation, 1818. Torticollis, or Wry Neck. 79 Section VI. Torticollis, or Wry Neck. From exposure to cold, from rheumatism, twists of the neck, or strains of the platysma-myoides, and sterno-mastoid muscles, from the cicatrices of burns, &c, the head is sometimes drawn to one side, or towards the shoulder or sternum, in such a way as to produce great deformity. Occasionally, the disease arises from paralysis; in other instances, it proceeds from some defect or malformation of the vertebrae of the neck. The clavicular is oftener affected than the sternal portion of the sterno-mastoid muscle; each, however, is liable to be converted into a substance resembling gristle. The whole of the muscle also is shortened, has an indurated, stringy feel, and is painful to the touch. Great pain is frequently experienced upon attempting forcibly to restore the head to its natural position. Treatment of Wry Neck. When the disease depends upon paralysis of the muscles, or upon malformation of the vertebrae, it may be looked upon, generally, as incurable; but when it arises from morbid con- traction of the fibres of the platysma-myoides, or sterno-mastoid muscles, an operation will, in many instances, effect a cure. It should be done in the following manner. The patient is seated on a chair, and his head supported by an assistant standing be- 80 Torticollis, or Wry Neck. hind him. An incision is then made two or three inches long, in the course of the muscular fibres, through the integuments; and the contracted portion having been fairly exposed, the han- dle of a knife, (or a small curved spatula,) is carried behind it, in order to protect the vessels beneath. By one or more cuts of a bistoury, the muscle is next separated, and when this is ef- fectually done, the head may immediately,* in most cases, be restored to its natural situation. Very frequently it happens, that several strings of muscular fibres, in different places, require to be cut across. In such cases, the surgeon must persevere un- til he has loosened the whole. After the operation, the head should be supported in its proper place by bandages or a stock of leather, and the edges of the wound, for some time, kept se- parated by lint. Sometimes, especially in females, it may be deemed expedient, in order to obviate deformity arising from the cicatrix, to pinch up the contracted portion of the muscle, along with the skin covering it, and divide it with a narrow and sharp-pointed bistoury. Dupuytren has related a case in which he succeeded perfectly by adopting this plan. Professor Jorg, of Leipsic, has attempted the cure of wry neck by machinery, and sometimes, it is said, with success. On Diseases and Accidents of the CEsophagus and Trachea, consult—Pelletan's Clinique Chirurgieale, torn. 1—Desault's Works, by Smith, vol 1—C. BelPs Operative Surgery, vol. 2—C. Bell's Surgical Observations, vol 1—Lawrence on some Affections of the Larynx, &c. in Medico-Chirurgical Transactions, vol. 6— Chevalier's Case of Croup, vol. 6, of Medico-Chirurgical Transactions—Monro's Morbid Anatomy of the Gullet and Stomach—Burns' Observations on the Surgical Anatomy of the Head and Neck—Hopkins' Case of a Shot in the Trachea, in Pot- ter's Medical Lycaeum. In this case, the shot was removed from the trachea of a young lady, by her mother, who, without apprizing the patient of her intention, suddenly seized her while lying over the edge of a bed, and forced her head and shoulders towards the floor. The shot, being carried by this movement towards the glottis, was instantly discharged. On Bronchocele, consult—A Memoir concerning the Disease of Goitre, &c, by Benjamin Smith Barton—Reeve on Cretinism in Edinburgh Medical and Surgi- cal Journal, vol 5—Fodert Traits du Goitre et du Cretinisme—Dictionnaire des • I performed an operation, several years ago, upon a young girl, sixteen years of age, whose head had been drawn for several months towards the right shoul- der, from a contraction of the clavicular portion of the sterno-mastoid muscle. As soon as the muscle was cut across, the head was instantly restored to its natural position, and has so remained ever since. Torticollis or Wry Neck. 81 . * Sciences Medicates, vol 3—Gooch's Chirurgical Works, vol 2—Baillie's Series of Engravings to illustrate Morbid Anatomy—Alibert's Nosologic Naturelle—Gibson on Bronchocele, in vol 1, of the Philadelphia Journal of the Medical and Physical Sciences—An Essay on the Effects of Iodine on the Human Constitution, with Prac- tical Observations on its Use in the Cure of Bronchocele, Scrofula, and the Tuber- culous Diseases of the Chest and Abdomen. By W. Guirdner, M. D. 8vo. Lon- don, 1824—Medical Researches on the Effects of Iodine, in Bronchocele, Paralysis, Chorea, Scrofula, Fistula Lacrymalis, Deafness, Dysphagia, White Swelling, and Distortions of the Spine. By Alexander Manson, M. D. On Wry Neck, consult—C. Bell's Operative Surgery, vol. 1—Gooch's Chirur- gical Works, vol. 2—Sharp's Treatise on the Operations of Surgery—B. Bell's System of Surgery, vol. 5—Boyer's Traite" des Maladies Chirurgicales, torn. 7— Kirby's Cases, with Observations on Wry Neck, &c.—Cooper's First Lines of the Practice of Surgery, vol. 1, p. 558; in which will be found an Engraving and De- scription ofJorg's Apparatus. 82 Hydrothorax, or Dropsy of the Chest. CHAPTER IV. DISEASES OF THE THORAX. Gun-shot and other wounds of the chest, emphysema, collec- tions of purulent matter, and of blood, mammary abscess, car- cinoma of the breast, fractures of the ribs and sternum, aneu- rism of the aorta, caries of the spine, having been already treat- ed of in other places, it only remains to notice hydrothorax, and to describe the operation necessary for its removal, after the physician has exhausted his skill in the trial of medicines. Section I. Hydrothorax, or Dropsy of the Chest. This disease is either idiopathic or symptomatic. The for- mer is very rare, the latter frequent. Idiopathic hydrothorax generally occupies one side of the chest only, and is frequently unaccompanied by dropsy in other parts of the body. The pleura itself is seldom much diseased, and merely contains a serous fluid. The lung of the affected side is collapsed, and the patient complains of great difficulty of breathing. Symptomatic hydrothorax is exceedingly common, and is characterized by the following symptoms. The patient finds it difficult, if not impossible, to lay in the horizontal position, or on the unaffected side. His respiration is hurried and la- borious, pulse irregular, thirst incessant, urine diminished and high-coloured. In addition to these symptoms, a troublesome cough and palpitation of the heart usually attend the disease. One of the most certain symptoms, however, is a sensation re- sembling the movement of water within the chest. This par- Hydrothorax, or Dropsy of the Chest. 83 ticular sensation may often be discovered by the surgeon him- self, while the patient is in the erect position, by forcibly striking the chest, and still better by the use of the stethoscope. A collection of water in the pericardium may give rise to all the symptoms of common hydrothorax. Sometimes both sacs of the pleura are filled with fluid. In other instances, the ca- vities are occupied by hydatids. The most common causes of symptomatic hydrothorax, are intemperance, gout, asthma, ana- sarca, pleurisy. Paracentesis Thoracis. This operation is seldom resorted to until the case is hope- less—a sufficient explanation of the unfavourable termination that generally awaits it. When performed early, however, and under favourable circumstances, it is calculated to afford great relief, even if it should fail to remove the disease. The situa- tion most favourable for the evacuation of the fluid, is between the sixth and seventh ribs, counting from above downwards. Having placed the patient nearly in an upright position, with his back supported by pillows or by an assistant, and the head and shoulders directed backwards, the surgeon makes an inci- sion three inches long, with a small scalpel or bistoury, through the integuments, cautiously penetrates the layers of the inter- costal muscles (keeping close to the upper edge of the seventh rib to avoid the intercostal artery) and makes an opening through the pleura large enough to admit a full-sized cannula or gum elastic catheter, which should be introduced as soon as the wa- ter begins to flow. Care must be taken, however, not to push the cannula too far, lest its extremity irritate the lungs, and ex- cite coughing. This happened to me during the winter of 1824, in the Alms House Infirmary, in a case of hydrothorax under care of Dr. Jackson, and brought on immediately a most severe cough, that distressed the patient exceedingly. If a very large quantity of fluid has collected, it will be improper to remove the whole of it at a single operation—lest the patient suddenly 84 Hydrothorax, or Dropsy of the Chest. die from the pressure being taken off from the heart and lungs. When both sides of the chest are occupied by the fluid, an ope- ration will be required on each side: but they should never be performed simultaneously, inasmuch as the lungs generally col- lapse as soon as the chest is opened, in which case the patient must necessarily die. After the fluid has been evacuated the lips of the wound should be closed by sticking plaster, and made to unite. Should the water accumulate again, as it often does, the operation may be repeated. " The operation for empy- ema, or paracentesis, is seldom resorted to in this country," says Dr. Jackson, "or England, for the relief of morbid effusions into the chest. Though of greater frequency, on the continent of Europe, yet, in comparison with the practice of former periods, it appears to be falling into disusage. The nature of these ef- fusions, and their causes, are widely different. The operation is not calculated to afford equal benefit in all cases in which they exist, while, in many, it is wholly useless. From a re- currence to it without discrimination, it has, no doubt, often proved of no service, and may have been sometimes of disad- vantage; and, in consequence, the benefits that maybe obtained from the apposite performance of this operation, have been too much underrated. Many striking instances of unequivocal relief, and some complete cures in desperate cases, are on record, as having been obtained by these means; nor can it be questioned, that, employed with judgment, it will seldom fail to afford re- lief from distressing symptoms, will often protract life, and, sometimes, prove auxiliary to the completion of a perfect cure. The operation itself is simple, unattended with much hazard, being but little more formidable than the opening of a large abscess, and, when an effusion into the chest is clearly indicated, may, with perfect propriety, be performed, merely with a view to alleviate the distress and suffering of the patient, even when it holds out no expectation of an ultimate recovery." See B. BelFs System of Surgery, vol. 5, p. 188—Laennec on the Diseases of the Chest—S. Cooper's First Lines of the Practice of Surgery, vol. 1, p. 584— Archer's Case of Paracentesis, in vol 1 of Transactions of the King's and Queen's Colleges of Physicians in Ireland—Jackson's Case of Effusion into the Chest, in which Paracentesis was performed, in the Philadelphia Journal of the Medical and Physical Sciences, vol 10, p. 19. Diseases of the Abdomen. 85 CHAPTER V. DISEASES OF THE ABDOMEN. With few exceptions, the surgical diseases of the abdomen are as numerous, diversified and important, as those of any other part of the body. Many of them, too, are extremely intricate, and will require all the student's industry and skill to unravel them. This is strikingly the case with hernia, which, from the complicated anatomical relations of that disease, its extraor- dinary frequency, the numerous varieties of the complaint, the distinct modes of treating each, recommended by some surgeons, and condemned by others equally eminent, the necessity, upon many occasions, for delicate operations, called for, often, upon the spur of the occasion, and without a moment's warning, should be sufficient, as a distinguished writer has remarked, " to infuse fear into the heart, and agitation into the conscience of all who presume to call themselves qualified surgeons, without having first duly considered every thing relating to so impor- tant a branch of their profession." In the ensuing sections, I propose to consider dropsy of the belly, poisons in the stomach, and the principal varieties of hernia. Abscess of the liver, aneurism of the abdominal aorta, lumbar abscess, and wounds of the abdomen, have been already treated of in their proper places. Vol. II. 12 86 Ascites, or Dropsy of the Abdomen. Section I. Ascites, or Dropsy of the Abdomen. In the commencement, this disease is marked by difficulty of breathing, cough, dryness of the skin, constipation of the bowels, diminished secretion of urine, loss of appetite, prostration of strength. These s}rmptoms are soon succeeded by general ful- ness of the abdomen, and by a sense of fluctuation easily per- ceived by laying one hand on the belly, and striking it with the other. Ascites, for the most part, is the consequence of organic dis- ease of the viscera of the abdomen, particularly scirrhus of the liver, pancreas, or spleen. Sometimes it arises from an accu- mulation of water in the cavities of the pleura or pericardium, at other times it follows an enlargement of the mesenteric glands. In general, the fluid is contained in the sac of the peritoneum, and sometimes accumulates in prodigious quantity. Paracentesis Abdominis. By the internal use of volatile tincture of guaiacum, squill, gamboge, calomel, digitalis, elaterium, and other similar medi- cines, I have frequently succeeded in removing, entirely, dropsy of the belly. The disease, however, often terminates fatally for want of a timely operation. There are two situations in which Ascites, or Dropsy of the Abdomen. 8". this may be performed—mid-way between the spine of the ilium and umbilicus, or in the linea alba. The former has of late years been mostly abandoned, owing to the thickness of the mus- cular parietes, and to the epigastric artery, from irregular distri- bution, having sometimes been wounded. A trocar,either round- ed or flat, is the instrument commonly used in this operation; or a common lancet may be employed, as advised by Dr. Phy- sick. ' Preparatory to the operation, the abdomen should be sur- rounded by a piece of flannel, broad enough to cover its whole surface, and sufficiently long to go twice round, the ends of which are split in three or four places. The middle of the ban- dage is placed over the front of the abdomen, and the ends are crossed upon each other, and left hanging on each side. Having marked the spot in the linea alba best adapted to the operation— about two or three inches below the umbilicus—the surgeon makes a slit in the flannel, corresponding to the part, and through this penetrates with the trocar or lancet, the integuments, tendons and peritoneum. The instrument being withdrawn, the water instantaneously follows the puncture, and in proportion as it flows, assistants placed on each side of the patient tighten the flannel by pulling at its ends. This serves the purpose of keep- ing up the general support of the abdomen, and prevents the pa- tient from fainting. If a very large quantity of fluid has accu- mulated, it may, perhaps, be imprudent to draw it all off at once, lest the patient be too much exhausted. On the contrary, the better plan will be to close the orifice from time to time, until the whole is evacuated; after which, the opening may be permit- ted to heal. Should the surgeon prefer a common lancet for the operation, he must be prepared with a flat cannula, correspond- ing to the size of the instrument, and introduce it into the open- ing immediately after the lancet is withdrawn. Sometimes the flow of water is suddenly interrupted by the intrusion of a par- ticle of fat within the cannula. When this happens, the obstacle should be removed by a probe. The operation of paracentesis abdominis, is one which in general requires frequent repetition. Incredible quantities of fluid have been drawn from some patients at once, or at separate operations. Many patients sink under the disease in a few weeks or months; others live for as many years, and experience temporary relief from operations. A few recover perfectly. 88 Ascites, or Dropsy of the Abdomen. It sometimes happens that pregnancy so closely resembles abdominal dropsy as to be mistaken for it, and cases are related in which the uterus has actually been" tapped. The following remarks on this subject by Sir Astley Cooper are well calculated to put the young surgeon on his guard. Speaking of encysted dropsy, he says, " I will here mention two circumstances, in one of which my character was exposed to considerable risk; of the other I was informed by a medical man who was invited to wit- ness the operation. In the first case I was desired to see a lady who I was told laboured under dropsy. When I entered the room I saw a tall delicate female, with an immense abdominal swelling, giving a distinct sense of fluctuation. I requested the physician accoucheur, whom I met, to examine if the lady was not with child; he said he thought it was unnecessary, as the fluctuation was very distinct, but that he would do so and let me know the result in a few days. I heard no more of her for a week, and then I learned that she had been put to bed on the morning following my visit. I would not have performed the operation of paracentesis for the universe. The circumstances which were told me of the other case were as follow: a surgeon in a country town called upon another surgeon, and said, '1 am going to tap a woman to-morrow; perhaps your j^oung gentle- men would like to be present.' As it was an operation they had never witnessed, they most readily accepted the invitation: they were shown into a room in which the patient was already prepared to undergo the operation; she was sitting at one end with her abdomen bare. The surgeon, then, taking his trocar and cannula, went to some distance, and walking up to the pa- tient with the trocar presented, he charged, as it were with a bayonet, and plunged it into the abdomen; then withdrawing the trocar with an air of triumph, it was with no small chagrin he found not a drop of water escape; but, however, still undis- mayed, he withdrew the cannula, and again renewing his attack, he a second time introduced the trocar into the abdomen, but was equally as unfortunate as before, in finding that no water followed. Waiting a few moments, he withdrew the cannula, and turning round to the gentlemen, he said, ' You may do her up;" by which he meant they might apply the bandages; and he added, ' This, gentlemen, is an operation which you probably Ascites, or Dropsy of the Abdomen. 89 never saw before, and which most likely you may never see again. This is what we call the operation of dry tapping!"* The encysted, or ovarian dropsy, differs essentially in cha- racter and situation from common ascites. The latter is con- tained in the bag of the peritoneum, in the greater number of in- stances, in contact with the intestines; the former is confined to the ovarium, and originally contained in separate cells, the par- titions of which are afterwards broken clown or absorbed. A few of these cells, however, generally remain. The fluid of ovarian dropsy, also, is not commonly so thin and transparent as that of ascites. It is generally thick, tanacious and turbid, of a brown or yellow colour, and often resembles sero-purulent mat- ter. From an enormous tumour of this description, which I opened some years ago, were discharged several gallons of fluid, of the consistence and colour of honey. But, in other cases I have drawn off large quantities of perfectly transparent serum. When the ovarian dropsy becomes so extensive as to occupy the abdomen, it is very difficult to distinguish it from ascites- but after an operation the walls of the ovarium can be distinctly felt, in shape of a tumour large as a child's head, on one side of the abdomen. See C. Bell's Operative Surgery, vol 1, p. 318—Dorsey's Surgery, vol 2, p. 364. • Sir A. Cooper's Lectures on Surgeiy, by Tyrrell, Vol. II. p. 378. 90 Poisons in the Stomach. Section II. Poisons in the Stomach. Accidentally, or by design, poisons are often taken into the stomach, and, according to their particular quality and quantity, produce, in greater or less time, violent symptoms or death. Poisons from the mineral, vegetable, and "animal kingdoms, are all capable of these effects. With few exceptions, however, mineral poisons are more active and deleterious than either ve- getable or animal. The principal mineral poisons are arsenic, corrosive sublimate and some other preparations of mercury, acids, and alkalies, lead, tartrite of antimony, and lunar caus- tic. These, when taken into the stomach, operate by exciting violent inflammation, or by producing excessive vomiting, pal- sy, or convulsions. Arsenic and corrosive sublimate give rise nearly to the same symptoms: these are swelling of the tongue, extreme thirst, a burning sensation throughout the gullet, vio- lent spasmodic pain in the stomach and intestines, incessant vo- miting and purging, and the evacuation of viscid mucus mixed with blood. If relief be not speedily afforded, cold sweats, faint- ings, twitchings of the limbs succeed and destroy the patient in a few hours. When examined after death, the stomach and oesophagus exhibit marks of violent inflammation, and are some- times perforated with numerous holes. Among the vegetable poisons most deleterious, may be enume- rated opium, cicuta, aconitum, hyoscyamus, digitalis, belladonna, hellebore, savin, laurus cerasus, and many varieties of fungus or mushroom. These, when introduced into the stomach in large quantity, occasion palpitation of the heart, stertorous breathing, vertigo, dimness of sight, torpor, distention of the stomach, con- vulsions and death. In addition to these symptoms, opium and laudanum, in large doses, have the peculiar power of inducing Poisons in the Stomach. 91 profound sleep, which generally terminates in apoplexy, para- lysis, or death. The animal poisons capable of producing violent symptoms, or fatal consequences, by being taken into the stomach, are comparatively few in number. The principal are cantharides, and certain varieties of fish.* Prussic acid, which belongs both to the animal and vegetable kingdoms, is a most subtile poison, and, sometimes, even in very small quantity, produces instan- taneous death. Cantharides is more protracted in its operation, but is capable of inducing tremendous symptoms, and not un- frequently proves fatal. Some .poisonous fish, when eaten, de- stroy life in a few hours. Treatment of Poisons in the Stomach. When the nature of the poison taken into the stomach can be ascertained, it may be possible sometimes, by antidotes, to ob- viate its deleterious effects. A large quantity of albumen, or white of eggs, for example, is looked upon as the proper cor- rective for corrosive sublimate; lime water, charcoal, or carbo- nate of magnesia for arsenic; muriate of soda for lunar caustic; calcined magnesia for the mineral acids; acetic acid for the alka- lies. It must be understood, however, that in general neither these nor any other articles of similar description are calculated to produce very beneficial effects, and that our reliance must be placed mainly upon speedy and copious vomiting, and upon the removal of the poison by means of the gum elastic tube and syringe. The last is a remedy of modern origin, and one of * Poisonous fish are by no means uncommon in some parts of the West Indies. Those reputed the most deleterious are the yellow billed sprat, dolphin, the rock fish, barracuda, smooth bottle fish, the king fish, the gray snapper, the white land crab, and the conger eel. 92 Poisons in the Stomach. immense importance. By whom the idea was first suggested, is not positively known. Renault, however, in his work on poisons,* expressly recommends an apparatus (somewhat similar to the one now in use) for removing arsenic from the stomach. Dr. Monro, afterwards, in his thesis,t gave drawings of instru- ments for the removal of laudanum from the stomach, and at the same time published a case in which the experiment had been tried—though without success. Quo laudani effectus leniores essent ei in vetriculum, instrumento in tab. XIV. depicto, per magnam aquae tepidae quantitatem injeci, faucibus simul per ori- speculum diductis."J It remained, however, there is reason to believe, for Dr. Physick to prove the utility of the invention; for until the successful issue of the experiment performed by him in 1812, on a child of three months old, poisoned by lau- danum^ little importance was attached by the profession either to Renault's or Monro's proposal. Since that period every apothecary's boy in Philadelphia has become fully acquainted with the operation, which, perhaps, has been performed hun- dreds of times with the most favourable result. Strange as it may appear, European, or at least British, surgeons are just be- coming acquainted with the practicability of the operation, for we find from the statements of a Mr. Read, and from remarks in the periodical work called the " Lancet," that the proposal has been considered by Sir Astley Cooper, Messrs. Scott, Jukes, and other surgeons, as perfectly novel, and this so late as the year 1822!! When called to a patient suffering from poison, whether cor- rosive sublimate, arsenic, or any other article of the kind, the surgeon should resort immediately to a powerful emetic, and, if this does not answer, to the gum elastic tube, (an instrument about two feet in length, and three-eighths of an inch in diameter,) and by means of a common pewter syringe applied to its upper extremity, inject into the stomach a quantity of tepid water. The water, mixed with the contents of the stomach, should be * Experiences sur les contre Poisons de 1'Arsenic, 8vo. f De Dysphagia, Edin. 1797. \ De Dysphagia, p. 95. § See Eclectic Repertory, vol. 3, p. 111. Poisons in the Stomach. 93 immediately afterward withdrawn, and a fresh supply thrown in, and by this alternate injection and evacuation, the stomach may in a little time be thoroughly scoured out, the poison re- moved, and the patient recovered—provided there has not been too great delay. The common syringe and tube I prefer to the more complicated and expensive instruments of Jukes and Read —after repeated comparative trials with each. Of late years, however, several instruments for pumping out the stomach have been invented, less complicated and more effectual than the ones just referred to. In particular, a syringe invented by Dr. C. Mathews,* of this city, is worthy of the praise which has been bestowed upon it. English surgeons, especially, I presume, must have been pleased with it; for soon after an account had been published of it in the London periodicals, Mr. Weiss, a celebrated cutler, manufactured one upon the same principle exactly, but without reference to the source from which he, probably, derived it. Mr. Weiss' pump has since been intro- duced into general practice, and is, certainly, a very beautiful, simple, and useful instrument. But an instrument still more simple,t equally useful, and infinitely cheaper, has been in- vented lately by Dr. Goddard of this city; an account of which, I regret to say, has been received too late for insertion in this place. Consult Monro's Morbid Anatomy of the Human Gullet, Stomach, and Intes- tines, p. 79—Thomas' Modern Practice of Physic, edit. 7, p. 311—Dictionnaire des Sciences Medicates, torn. 43, p. 525—Orfla on Poisons—Chiskolm on the Poi- sons of Fish, in vol. 4, of the Edinburgh Medical and Surgical Journal, p. 393— Brodie's Observations on the Action of Poisons on the Animal System, in Trans- actions of the Royal Society of London, 1812—Bostock's Experiments, Showing that a Mineral Poison may produce sudden and violent Death, and yet be incapa- ble of Detection in the Contents of the Stomach, in Edinburgh Medical and Sur- gical Journal, vol. 5, p. 14—Account of a New Mode of extracting poisonous Sub- stances from the Stomach, by P. S. Physick, in the Eclectic Repertory, vol. 3, p. Ill and 381—Read's Appeal to the Medical Profession, on the Utility of the Im- proved Patent Syringe, bc—IVie Lancet, vol 1, No. 8. * See American Medical Recorder for 1826. f See Journnl of Franklin Institute, for April, 1834. Vol. II. 13 94 Hernia. Section III Hernia. A protrusion of any of the abdominal viscera, covered by the peritoneum, through natural or preternatural apertures in the tendinous or muscular parietes, may be denominated hernia. The term has been extended, though improperly, to several other diseases bearing no analogy to the one under present con- sideration. Hernia is a very common disease; so much so, that one-eighth of mankind, it has been imagined, is troubled with it—-a pro- portion, however, immensely overrated. Certain general ap- pellations expressive of the particular condition or contents of a hernial tumour, are employed by most modern surgeons— reducible, irreducible, and strangulated hernia, enterocele, epi- plocele, and entero-epiplocele. By reducible hernia is under- stood a tumour easily replaced by pressure, or by laying the patient in the horizontal position, but descending again as soon as the pressure is discontinued, or the upright posture resumed. The term irreducible hernia implies permanent protrusion from adhesion between the sac and its contents, or from extraordinary bulk. Strangulated hernia is that state of the disease in which the parts are confined by stricture, and are liable to mortify, unless the stricture be speedily removed. When the protru- sion consists of intestine alone, the disease is denominated en- terocele; when it contains omentum merely, it is called epiplo- cele; and, if intestine and omentum together, entero-epiplocele. Hernise are, also, designated according to the situation they happen to occupy. Thus, we have bubonocele or inguinal hernia, oscheocele or scrotal hernia, merocele or crural or femoral her- nia, exomphalos or umbilical hernia, congenital hernia, ventral Hernia. 95 hernia, ventro-inguinal hernia, and several other varieties of comparatively rare occurrence. Every hernia is furnished with a peritoneal investment, or sac; this is pushed before the protruded viscera, and passes through a natural or preternatural opening, to the margins of which it speedily forms an intimate adhesion. That portion of the sac communicating directly with the abdomen is called its mouth; its lower extremity, or that most remote from the internal sur- face of the belly its fundus, and the part immediately sur- rounded by the aperture in the tendinous parietes, its neck. The sac, although originally thin, as the rest of the peritoneum, soon acquires an increased thickness, and in hernia of long standing, is sometimes greatly condensed. On the other hand, it is frequently found attenuated to an extreme degree, or en- tirely wanting—as the result of absorption. That it is suscepti- ble of extreme extension, is proved by those enormous hernial tumours, so common in very warm climates, and sometimes met with in this country. The causes of hernia are very numerous, and are either ex- citing or predisposing. Severe exercise on foot, or on horse- back, lifting heavy weights, playing on wind instruments, vo- miting, costiveness, strictures of the urethra, the hooping-cough, crying, parturition, tight clothes, jumping, often produce the complaint either immediately or remotely. Among the pre- disposing causes of the disease, hereditary conformation and preternatural laxity of the abdominal apertures, may be con- sidered the most common. Reducible hernia is distinguished from other varieties of the disease by the following symptoms. The tumour, as already mentioned, descends in the erect, and retires within the abdomen during the recumbent position, or when pressure is made upon it. If the sac should contain intestine, a peculiar rumbling or guggling noise will be perceived both by the patient and surgeon, at the moment the gut slips into the abdomen. The tumour will also be tense and elastic to the feel. Omentum, on the contrary, communicates to the finger a doughy sensation, and is with great- er difficulty restored to the abdomen. Besides these indications, a reducible hernia may be distinguished from other diseases by the circumstance of its being larger after a meal than when the stomach and intestines are empty, and by,an impulse being com- 96 Hernia. municated from the tumour to the surgeon's finger when the pa- tient is directed to cough. If suffered to increase, the reducible hernia may in time become enormously large, and the patient will not only experience great disorder of the digestive organs, but his life will be endangered by strangulation of the gut. Irreducible hernia may arise from three different causes— from adhesion between the sac and its contents—from the for- mation of membranous bands across the sac—and from an extra- ordinary enlargement of the omentum, or great increase in volume of the intestines. The two last causes are more common than the first. Effusion of lymph upon the inner surface of the sac, and upon the outer surface of its contents, gives rise to the bands that intersect the intestine and omentum, and fasten them at different points to each other. When the omentum has re- sided for a long time in a hernial sac, it is apt to become en- larged and indurated, and in this state cannot pass through the neck of the sac and be restored to the abdomen. Sometimes a mass of hardened omentum serves as a truss, and prevents the descent of the intestines. Slow inflammation, from neglect, from blows upon the tumour, and other injuries, is the most fre- quent cause of hernia being changed from the reducible to the irreducible state. The symptoms of strangulated or incarcerated hernia, are, in most instances, so strongly marked, as to admit of no decep- tion; yet it happens, now and then, that the disease is confound- ed with ileus and other intestinal affections. If, from irregu- larities of diet, violent corporeal exertions, injuries, or other causes, the contents of a reducible or irreducible hernia should become constricted, the faecal evacuations will be suppressed, the patient will complain of general soreness of the abdomen, of pain around the navel, resembling the sensation produced by a tight cord, of sickness of the stomach, and of severe pain in the tumour itself. To these symptoms are speedily added, vomiting of bilious or stercoraceous matter, hiccup, a quick, hard pulse, an increase of tension in the abdomen, cold sweats, great anxiety of countenance. If by this time the patient does not experience relief, a remarkable change in the symptoms will soon take place. The pulse becomes small and thready, the patient feels suddenly easy, the tumour when pressed upon crackles beneath the fingers, and assumes a leaden colour. To these succeed Hernia. 97 enormous distention of the abdomen, a fluttering, intermittent pulse, and death. When examined by dissection, the intestine will be found of a dark brown or chocolate colour, interspersed with black or mortified spots, and coated in particular places with a brownish or bloody lymph. The omentum is seldom altered in appearance. The sac contains, in proportion to its size, and the duration of the strangulation, more or less of a bloody fluid. At the strictured part, the intestine is generally ulcerated or detached. Throughout, the peritoneum exhibits marks of high inflammation, and in numerous places the intes- tines are glued together, and their surface streaked with red vessels. It might, perhaps, be supposed that a stricture upon the omentum merely, would not give rise to constipation and the other symptoms of strangulation above enumerated. Expe- rience, however, proves the contrary. With regard to the length of time strangulation may continue, much will depend upon the age and size of the tumour, and upon its contents. Re- cent and small hernias, generally speaking, are more dangerous, and terminate sooner, when strangulated, than the old and large. An intestinal hernia, also, runs its course quicker, and is more violent in its symptoms than an omental hernia. Some stran- gulated hernias prove fatal in six or eight hours; others continue for as many days. The disease, when left to itself, is not inva- riably mortal. On the contrary, the parts exterior to the stric- ture, in some instances, mortify, and are thrown off in the form of slough, an artificial anus is established, and the patient reco- vers. The seat of the stricture in strangulated hernia must de- pend upon the particular situation the hernia happens to occupy. General Treatment of Hernia. Reducible, irreducible, and strangulated herniae all require distinct and particular modes of treatment. For reducible hernia, an appropriate truss is the only remedy, and the sooner this is applied the better. Formerly an opinion 98 Hernia. prevailed that such instruments were not adapted to infants; the error has been amply rectified by modern experience, and much mischief thereby prevented. Trusses are either elastic, or non-elastic: the latter are now seldom employed, and never can be to advantage. A well constructed steel truss often effects a perfect cure, especially in children and young subjects, by ex- citing a degree of inflammation sufficient to agglutinate the sides of the sac, or the edges of the opening through which the hernia has passed. To accomplish this purpose, great attention must be paid by the surgeon in adapting the instrument to the parts, and by the patient in wearing it without intermission. The best mode of fitting a patient with a truss, is to try a number of instruments, and select the one that adapts itself best to the hol- lows and projections about the abdomen and pelvis, and can be worn with the least inconvenience. When no opportunity of selection offers, a measure may be taken by means of annealed wire, doubled and passed around the body, taking care to leave the wire an inch or two longer than the size of the patient—to allow for the stuffing of the instrument. A well contrived truss will fit accurately in every part, and set closely to the body, neither bulging in particular places, nor binding too closely. Every patient should be provided with a spare truss—in case of accident. To prevent the pad of the truss from imbibing per- spiration and becoming hard, a bit of calico, muslin, or rabbit skin should be placed between it and the tumour. With a view, also, of obviating rust, to which the spring is very liable, the instrument may be thickly covered with durable leather, or some similar material, and with oil-cloth, or gum elastic, when the pa- tient has occasion to bathe. A truss, to derive full benefit from it, must be worn night and day, and for months and years to- gether. Particular varieties of truss will be noticed when the different species of hernia are described. Irreducible hernia, particularly that variety of it dependent upon adhesion between the sac and its contents, very seldom admits of relief. Cases are recorded, however, by Arnaud Le- dran, and Hey, of the diminution and final restoration to the ab- domen, of immense hernial tumours, by low diet, blood-letting, purging, and confinement, for many months together, to the horizontal position. In most cases, a suspension of the tumour Hernia. 99 by a bag truss, and strict attention to diet, are all that can be done. For strangulated hernia, various remedies have been em- ployed—such as blood-letting, purging, the cold and warm baths opium, fomentations, and poultices, the application of cold, the taxis, tobacco injections, and an operation. The three last only are to be relied upon. By taxis is understood an effort to restore the protruded intestine or omentum, by manual pressure, to the cavity of the abdomen. This should be attempt- ed always before any other plan, and is frequently successful. To increase the chance of success, the surgeon must endeavour to relax the abdominal muscles as much as possible—by ele- vating the shoulders and pelvis with pillows, bending the pa- tient's legs on his thighs, and his thighs on the pelvis, and at the same time drawing them towards each other. Upon the tu- mour, steady, but not violent pressure, should then be exerted and kept up unremittingly with the fingers or hands for half an hour. If this fail, the taxis must be discontinued, lest it increase the inflammation in the protruded parts. The surgeon may next have recourse to the tobacco enema, which, (as it is a very powerful and dangerous medicine, if incautiously administered,) should be carefully prepared by infusing a dram of tobacco in a pint of boiling water for a quarter of an hour. When cool, the liquor may be strained, and one-half of it thrown up the rec- tum by a syringe, and the remainder half an hour afterwards, should the first prove inefficient. The effect of tobacco, thus administered, is to prostrate the system, excite the action of the intestines, and relax the abdominal muscles. As soon as these ends are accomplished, a slight effort, in the way of taxis, will often succeed in overcoming the stricture, and in restoring the parts to the abdomen. If the tobacco fail, the knife is our only resource; but in the use of this, the surgeon must be governed by the particular seat of the hernia—as will be explained in the ensuing sections. 100 Inguinal Hernia. Section IV. Inguinal Hernia. After the general account given of hernia and its treatment, it will be proper to consider the varieties of the disease, the principal of which are inguinal, crural, umbilical and congenital hernia. To each of these, it will be necessary to prefix a short account of the anatomy of the parts. When the integuments of the abdomen are turned back, a thin but compact sheet of cellular substance, described by modern anatomists under the name of superficial fascia, will be found to cover the whole surface of the abdominal muscles. Not only does it cover these muscles, and their tendons, but extends upwards to the chest, and downwards to the thighs, and, in fact, may with propriety, perhaps, be said to form a sort of general investment to the body. Its attachment to Poupart's ligament, and to the surface of the spermatic cord, is particular- ly close. On the surface of the fascia, and running over Pou- part's ligament towards the umbilicus, an artery and vein may be observed. These are branches of the external pudic, and from being concerned in the operations for strangulated inguinal and crural hernia, should be noticed in the dissection of the parts. Besides these vessels, numerous inguinal glands will be seen lying beneath the fascia, and intermingled with its fibres. Under the superficial fascia, lies the tendon of the external oblique muscle. The lower margin of this constitutes Pou- part's ligament, which extends from the anterior superior spi- nous process of the ileum to the pubes; and as it approaches this part, splits into two columns, the upper of which is inserted into the symphysis, the lower into the tuberosity of that bone; Inguinal Hernia. 101 leaving between them a triangular space, called the external ab- dominal ring, out of which emerges the spermatic cord. When the tendon of the external oblique is cut away, or turned down upon the thigh, the internal oblique muscle is brought into view. The lower margin of this arises from the outer half and inner surface of Poupart's ligament, and passing above the spermatic cord, in a vaulted form, is fixed by a ten- don into the symphysis pubis. From the edge of the internal oblique, the cremaster muscle arises, is inserted into the sper- matic cord, and descends with it into the scrotum, The lower edge of the transversalis muscle, like that of the internal oblique, arises from the outer portion of Poupart's liga- ment, crosses over the spermatic cord, and uniting its tendon with that of the internal oblique, is inserted into the pubes. These three muscles—the external oblique, the internal ob- lique, and the transversalis—serve to cover in the abdomen, and support the viscera. From the manner, however, in which the two last are formed, (being deficient as it were in part, or not wholly inserted into Poupart's ligament,) this support would be very inadequate, were it not for the co-operation of an addi- tional structure—the fascia transversalis. This fascia consists of condensed cellular membrane, lines the internal surface of the transversalis muscle, and is interposed between it and the peritoneum. Its extent is very considerable, for it not only covers the whole of the lower part of the abdo- men and passes out along with the femoral vessels upon the thigh, but ascends to the diaphragm. In this fascia, an opening is left for the passage of the spermatic cord—called the internal abdominal ring. The spermatic cord, consisting of arteries, veins, lymphatics, nerves, the vas deferens, and a membranous sheath, enters the internal abdominal ring—which is situated about half an inch above Poupart's ligament, and midway between the spine of the ileum and symphysis pubis—and taking a course inwards and downwards, passes along the edges of the internal oblique and transversalis, and finally emerging at the external ring, de- scends nearly in a perpendicular direction into the scrotum. Along the under and inner side of the spermatic cord, and be- tween it and the pubes, passes the epigastric artery, a vessel Vol. II. 14 102 Inguinal Hernia. materially concerned in the operation for strangulated inguinal hernia. From the above account of the structure of the parts imme- diately concerned in inguinal hernia, it will appear—that there are two abdominal rings, the external, formed by a splitting of the fibres of the external oblique tendon, the internal, by an opening in the fascia of the transversalis muscle. To make this structure more intelligible to the student, it will be proper to observe that these rings are distant from each other, in most full-grown subjects, about an inch and a half, that between them there is a canal for the passage of the cord, that the cord enters the internal ring, passes obliquely downwards under the internal oblique and transversalis muscles, (not through them, as formerly supposed,) until it reaches the external ring, after which its course is perpendicular. To understand the reason of the cord not perforating the internal oblique and transversalis, it will only be necessary to remember that these muscles are not at- tached to the whole of Poupart's ligament, but only to the outer half of it, and consequently that they may be said to be want- ing from that part as far as the symphysis pubis. In most instances, the hernial sac and its contents enter the internal abdominal ring anterior to the spermatic cord, and having reached the origin of the cremaster muscle, passes be- tween it and the cord. Sometimes, however, the cord is placed on the side of the sac, at other times on its front. The epigas- tric artery runs along the under and inner side of the sac, and between its mouth and the symphysis pubis. In immediate con- tact with the sac, and on its anterior surface, is spread out, from pressure, the cremaster muscle, which forms one of the coverings of the sac. Above the cremaster is the superficial fascia, and next to it the integuments. If a dissection, therefore, is made of the coverings and contents of the inguinal hernia, commencing at the skin, the parts will be presented in the following suc- cession—the integuments, superficial fascia, the cremaster muscle, the hernial sac, omentum or intestine, and perhaps both. v The symptoms of reducible, irreducible, and strangulated inguinal hernia do not differ from those of hernia in general and these have been already pointed out in the preceding section' Uul it is important to distinguish between this disease, and others Inguinal Hernia. 103 bearing to it some similitude. Inguinal, or rather scrotal her- nia, may be confounded with hydrocele, cirsocele, enlarged tes- tis, and some other affections. From hydrocele, it may be dis- tinguished by the circumstance of the tumour commencing above the abdominal ring, and descending towards the scrotum, where- as hydrocele always begins in the lower part of the scrotum, and gradually ascends. Cirsocele sometimes bears a striking resemblance to scrotal hernia, but it may be distinguished from it by placing the patient in a recumbent position, pressing firm- ly upon the upper part of the ring, and then directing him to rise, when, if it be cirsocele, the tumour will reappear, and of an increased size; if hernia, it will be retained within the ring until the finger be removed. An inguinal hernia is sometimes contained within the canal leading from the internal to the external ring. It is then called concealed inguinal hernia. As in cases of this description there is commonly no external tumour, the surgeon should be on his guard, and suspect the existence of this disease, if the symptoms of strangulation be present. The hernial sac in such cases is generally covered, in addition to the usual investments, by the tendon of the external oblique, and edges of the internal oblique and transversalis. Scrotal hernia in shape is commonly pyriform, and in size is very various, descending in some instances to the patient's knees, at other times is not much larger than a natu- ral scrotum. Occasionally, the disease is met with on both sides. Males are more subject to the disease than females, and when it occurs in the latter the tumour bears the same relation to the round ligament that it does to the spermatic cord in the male. Treatment of Inguinal Hernia. For reducible inguinal, or scrotal hernia, an appropriate elas- tic truss should be selected. Above most instruments of this 104 Inguinal Hernia. description, I prefer that of Wright of Liverpool, formed upon the principle of Whitford's truss, described in the work of Mr. Lawrence on hernia. The peculiarity of these instruments consists in their not forming a perfect oval, but in being straight or nearly so behind, where they cross the small of the back, and rising from the posterior part of the pelvis, and descending in front towards the groin. Of the truss of Salmon and Ody, (com- monly called Hull's truss,) I have also a favourable opinion. This, instead of passing entirely around the pelvis, is formed of a semicircle of steel, with a pad at each extremity—one of which is adapted to the groin, the other to the back. In fitting a patient with a truss for inguinal hernia, the surgeon should take care to adapt the instrument to the lower part of the internal ring; for if it be placed, as is too often done, upon the external ring, it not only presses upon the cord, gives unnecessary pain, and injures the function of the testicle, but does not answer the purpose of supporting the hernia. Every patient should habi- tuate himself to return his own hernia and to apply the truss; and the most convenient time for effecting this is in the morn- ing before he rises, as the intestines and omentum, during the night, generally retire within the abdomen. The irreducible scrotal rupture subjects the patient, when it attains a large size, to great inconvenience, by impeding co- pulation and by arresting the flow of urine, which, from the pe- nis being buried among the integuments, excoriates the parts and gives rise to small abscesses. To prevent the growth or in- crease of the swelling, a bag truss is the only remedy. Strangulated inguinal or scrotal hernia, should the taxis and to- bacco injection fail, will require an operation, and the sooner this is performed, after it has been determined upon, the better; for there is reason to believe that many lives have been lost by delay, and few, if any, from the operation itself. The patient be- ing placed upon a table of ordinary height, with his thighs some- what separated, and each foot resting upon a chair, the surgeon sits before him, and grasping the tumour with one hand, makes an incision with the other, commencing at the upper part of the tumour, and extending downwards nearly to its base. Having divided the integuments, a branch of the external pudic artery generally springs, and may require the ligature. Immediately beneath the integuments, lies the superficial fascia: this should Inguinal Hernia. 105 be divided by successive touches of the knife, until the cremaster muscle appears; the fibres of which may be elevated carefully by the dissecting forceps, or by running the directory beneath them, until the whole are cut through, and the sac exposed. To open this without risk of injuring the intestine, a portion of it may be pinched up and rubbed between the fingers previously to its division. As soon as the sac is opened, a quantity of fluid gushes out, and part of the intestine or omentum appears at the opening. Fluid, however, is not invariably met with, and it is highly important that the operator should be aware of this, otherwise he might, in expectation of finding it, continue to penetrate with the knife, until he wounds the intestine. The opening in the sac should be enlarged upwards and downwards to the extent of two or three inches, and if its contents are found in a proper condition to be returned into the abdomen, the next step of the operation is to carry the fore-finger of the left hand upwards between the sac and protruded parts, and search for the stricture, which will be found either at the edges of the ex- ternal ring, the internal ring, or the mouth of the sac. In very old and large hernias, the external ring is the most common seat of the constriction, but, in ordinary cases, the internal ring. By gentle pressure with the fingers upon the intestine or omen- tum, these parts may sometimes be restored without dividing the stricture; if the attempt fail, however, the operator then in- troduces a common curved probe-pointed bistoury, (the edge of which, with exception of half an inch of its extremity, is co- vered by a piece of riband or muslin,) with its flat surface between the sac and its contents, and with the fore-finger as the guide, carries its point beneath the stricture, turns up the edge of the instrument, and divides it. A very slight incision, even the eighth or sixteenth part of an inch in extent, will be often suffi- cient to liberate the parts. The moment this is accomplished, repeated and gentle efforts should be made to return them to the abdomen, after which the edges of the wound must be brought together and retained by adhesive straps. In the course of three or four hours after the operation, should the patient not have a stool within that time, a dose of castor oil must be administered. During the cure, the patient should be confined to bed, and not suffered to rise until the parts are so completely cicatrized, as to 106 Inguinal Hernia. bear the pressure of a truss—an instrument still more necessary after an operation for strangulated hernia, than before. In dividing the stricture, in all cases of strangulated inguinal hernia, whether seated at the external or internal ring, or at the mouth of the sac, there is one rule extremely important to ob- serve—to carry the knife directly upwards, (a practice first sug- gested by Rougemont, and afterwards adopted by Sir Astley Cooper,) by which we avoid wounding the epigastric artery. If, in the ordinary situation, for example, of this variety of her- nia, the stricture be divided upwards and inwards, or towards the linea alba, and the incision prolonged to any extent, the epi- gastric will, almost to a certainty, be cut across. On the other hand, if the knife be carried upwards and outwards towards the ilium, and the hernial sac should descend, as it. sometimes does, on the inner side of the epigastric, (constituting the variety of hernia called Ventro-inguinal,) this vessel may possibly be divided. It is proper to observe, however, notwithstanding these precautions, that there are few examples of fatal hemor- rhage from wounds of the epigastric, although the vessel has been cut in numerous instances by awkward and careless ope- rators. With regard to the condition of the intestine or omentum, it may be observed—that if mortified spots appear on the former, they should be included in a fine ligature before returning them to the belly; and that if the omentum be in an indurated state, and form too large a protuberance to admit of repassing the ring, it should be retrenched, taking care to tie up any particular ves- sels that may spring, instead of including the whole mass in a ligature, as was formerly practised. Sir Astley Cooper, and some other surgeons have recommended, in large herniae especially, to divide the stricture on the outside of the sac—leaving the sac unopened. To this plan, however, there are many objections. The operation for small, or concealed inguinal hernia, does not differ materially from that of the common variety of the disease. If the operation for strangulated inguinal hernia has been so long delayed as to permit the parts to fall into gangrene, and they are found in this condition by the surgeon after having Inguinal Hernia. 107 opened the sac, he should not think of pushing them, in this state, into the abdomen, even if he could effect it, because they would then act as extraneous bodies, and excite irritation. By the time, however, the process of slouging is completed in the parts exterior to the stricture, it generally happens that the parts within the abdomen or its immediate vicinity are united by ad- hesion to the internal surface of the ring, and therefore, that the protrusion could not be returned without previously breaking up those adhesions, upon which, indeed, the safety of the patient must now in a great measure depend. Some surgeons have attempted to cure inguinal and other va- rieties of hernia radically—by relieving the stricture, returning the protruded parts, and afterwards dissecting up the hernial sac, and either restoring it to the abdomen, or removing it entirely, and tying its mouth with a ligature. The practice, I conceive, is seldom justifiable. Many jrears ago I performed the operation, but the case terminated fatally. Experience proves, moreover, that a new sac, even if the patient recover, is almost sure to form. 108 Femoral Hernia. Section V. Femoral Hernia. The contents of a femoral or crural hernia, instead of passing through the abdominal rings, are protruded beneath Poupart's ligament through an opening termed the crural ring. This ring is bounded on the outer, or iliac side, by the femoral vein, on the inner or pubic side, by Gimbernat's ligament; anteriorly, by Pou- part's ligament, and posteriorly by the pubes. Poupart's liga- ment arises from the spine of the ilium, and is implanted by a broad insertion into the symphysis pubis, into the tuberosity of the pubes and into the ligament of the pubes over the linea ileo pectinea. By this last insertion a sharp crescentic edge is formed, the concavity of which looks towards the crural vein, and is sup- posed by most writers, to contribute mainly to the constriction in cases of strangulated crural hernia. From having been parti- cularly described by Gimbernat, a Spanish surgeon, it is frequent- ly called GimbemaVs ligament. There are two margins to Pou- part's ligament, an anterior and posterior, the former of which is straight, the latter concave, in the vicinity of the pubes. The fdscia lata of the thigh, as it approaches Poupart's liga- ment, divides into two portions—the iliac and pectineal, (some- times called sartorial.) The former is connected to Poupart's ligament throughout the greater part of its extent; the latter is attached to the pubes, covers the muscles that spring from that bone, and unites with the iliac portion below, at the spot where the vena saphena major enters the femoral vein. In thickness and strength the iliac portion of the fascia lata greatly exceeds the pectineal portion. It lies, moreover, conside- rably above the plane of the latter, and covers the femoral vessels, the anterior crural nerve, and the iliacus internusand psoaae mus- cle. Towards the pubes its edge is concave, and on this account Femoral Hernia. 109 was denominated by Burn's, of Glasgow, the falciform process. Its superior horn received from Mr. Hey the appell.ition oi femoral ligament, and is at the present day commonly known under the name of Hey's ligament. " It has already been stated," says Colles, " that the iliac portion of the fascia lata passes before the femoral vessels. We observe, in this part of its course, that it loses somewhat of its strength and firmness of texture ; however, it generally retains a good deal of its ligamentous nature even when it has reached the pubic side of these vessels; except in the immediate neighbourhood of the vena saphena, where it dif- fers but little from the cellular substance. Having passed before the femoral vessels, we find it now to descend on their pubic side; and here we see it attach itself very intimately to the pec- tineal fascia. This attachment is made in a straight line along the pubic side of the vein, from the place of insertion of the sa- phena to within a quarter of an inch of Poupart's ligament. At this place we observe that the line of attachment is curved; and having here formed a sweep towards the pubes, that the attach- ment now takes place in a line across the top of the thigh."* In most subjects, I have found the iliac portion of the fascia lata to consist of two layers, the innermost of which passed backwards behind the femoral vessels and united with the pectineal portion— leaving the falciform process double, like the margin of the cuff of a coat, and forming a round instead of a sharp edge. Beneath the fascia lata, and in immediate contact with the femoral vessel, lies the fascia transversalis. This fascia, as for- merly mentioned, under the head of inguinal hernia, not only lines the internal surface of the abdomen, but passes out upon the thigh under the posterior edge of Poupart's ligament. De- scending in front of the crural artery and vein, it becomes united to their sheath and forms for them an additional investment. On the inner side of the crural vessels numerous absorbents may be observed passing through the transversalis fascia, on their way to the abdomen. The fascia iliaca is but a continuation of the fascia trans- versalis, and differs from it only in situation. It lines the sur- face of the iliacus interims and psoae muscles, adheres to the posterior margin of Poupart's ligament, descends with the cru- * Surgical Anatomy, p. 68. Vol. II. 15 110 Femoral Hernia. ral vessels to the thigh, and affords them posteriorly a strong investment. The union of the fascia transversalis and iliaca has been compared,* not unaptly, to a compressed funnel, the ex- panded part of which may be said to occupy the lower part of the abdomen and hollow of the ilium, while the pipe is repre- sented by the prolongation which covers the femoral vessels and forms their anterior and posterior sheaths. Although the space between the os innominatum and Pou- part's ligament is filled up by the iliacus internus and psoae muscles, these would not prove a sufficient barrier to the de- scent of a femoral hernia in various situations between the spine of the ilium and symphysis pubis. Such descent, however, is effectually guarded against, except at the crural ring itself, by the union of the fascia transversalis and iliaca. These fasciae, indeed, are so closely connected with each other, with the pos- terior edge of Poupart's ligament, and with the surface of the psoas and iliacus internus muscle, and send off so many parti- tions between the crural artery and vein, and the adjoining parts, as to preclude effectually the escape of any of the viscera between them. In dissecting the parts concerned in crural hernia, it is im- portant to notice particularly the situation of the spermatic cord and epigastric artery. The former lies about half an inch from the mouth of the sac, above Poupart's ligament; the latter runs upon the outside of the hernial sac, and takes a course upwards and inwards on its way to the rectus muscle. Sometimes the obturator artery is sent off by the epigastric, and, running along the inner margin of the sac, and sometimes encircling it, is liable to be wounded, in performing the operation for strangulated fe- moral hernia, if the incision be prolonged too far inwards or to- wards the pubes. A portion of omentum, or intestine, surrounded by the pe- ritoneum, having entered the sheath of the femoral vessels, formed by the union of the iliac and transversalis fasciae, passes along the inner edge of the crural vein, and carries before it the loose cellular membrane that naturally occupies the orifice of the crural ring. This membrane, (which has received from Sir Astley Cooper the name of fascia propria,) being pushed for- * Colles, p. 63. Femoral Hernia. Ill ward by the hernial sac, is carried along with it through one or more of the holes on the inner side of the crural sheath, and uniting with that sheath, the two fasciae are " consolidated into one." Above the fascia propria will be found the superficial fascia and the integuments. If a dissection, therefore, be made of a femoral hernia, commencing at the surface of the bend of the thigh, the parts will be presented in the following order :— the integuments, superficial fascia, fascia propria, hernial sac. This last will be found resting in the hollow between the iliac and pectineal portions of the fascia lata, and, consequently, on the outer surface of that aponeurotic expansion. There is a variety, however, of femoral hernia, (in which the sac and its contents, not passing through the absorbent holes, is continued along the sheath of the femoral vessels,) covered by the fascia lata. Women are more subject to femoral hernia than men, owing partly to the great breadth of the female pelvis, compared with that of the male. In shape, femoral hernia differs entirely from inguinal—its longest diameter being placed transversely with respect to the thigh. In general, moreover, the tumour is much smaller than that of the inguinal. On this account it is par- ticularly liable to be confounded with other diseases, especially with enlargement of one or more glands of the groin, with vari- cose enlargement of the crural vein, psoas abscess, &c. In one patient, however, an old man in the Aims-House Infirmary, in 1833,1 found the tumour as large as a child's head. Not un- frequently it is mistaken for inguinal hernia—owing to the tu- mour rising, from the oval space in the fascia lata, upon Poupart's ligament. The edge of this ligament may, however, in femoral hernia, always be traced above the tumour, while, in bubonocele, it is below it. A very common symptom of reducible femoral hernia, is pain in the groin, from extending the thigh, which is sometimes so severe as to produce nausea and vomiting. Treatment of Femoral Hernia. The truss for reducible inguinal hernia, will answer also for femoral, provided the pad of the instrument be bent downwards 112 Femoral Hernia. about an inch, in order that it may rest on the top of the thigh instead of the groin. Irreducible femoral hernia, when its con- tents consist chiefly of omentum, sometimes attains such a bulk as to prove very inconvenient to the patient. Under these cir- cumstances, it has been advised by Sir Astley Cooper to apply a hollow truss to the tumour, (taking care previously to reduce the intestine,) with a view of promoting, by pressure, the ab- sorption of the protruded parts. Strangulated femoral hernia must be treated upon the prin- ciples formerly laid down. Instead, however, (in performing the operation of taxis,) of pressing the tumour directly upwards, as in strangulated inguinal hernia, the surgeon should first en- deavour to disengage it from the edge of Poupart's ligament, by pressing it downwards and inwards; after which a slight pres- sure upwards will often succeed in restoring the omentum or in- testine to the abdomen. If the taxis should fail, and an opera- tion become necessary, there should be the least possible delay; for the disease runs its course with much greater rapidity than most other varieties of strangulated hernia. The patient being placed horizontally on a table, the shoulders elevated by a pillow, the thighs somewhat relaxed and brought near to each other, the diseased parts shaved, and the bladder emptied, an incision is made, commencing about an inch above Poupart's ligament, and extending downwards to the middle of the tumour, through the integuments. At right angles with this another cut is made—the two representing in form the letter T reversed. The superficial fascia being exposed and careful- ly divided, the fascia propria is brought into view. This being likewise divided, more or less adipose substance will be ge- nerally found between it and the sac. To open the sac, which should next be done, without risk of injuring the intestine, (for in this variety of hernia there is seldom much fluid in the sac,) a portion of it should be carefully pinched up and rubbed be- tween the finger, and divided by carrying the knife horizontal- ly through it. As soon as the intestine, or omentum, is dis- covered, a finger may be introduced into the opening, and upon this a curved bistoury, with which the sac may be enlarged, to the extent, if necessary, of several inches. The next object of the operator will be to ascertain the seat of the stricture. This will be found either at Hey's ligament, in the crural sheath, at Femoral Hernia. 113 Gimbernat's ligament, or in the mouth of the sac. When the hernial tumour is large, more or less constriction will always be made upon it by the falciform process of the fascia lata, and particularly by that portion of it called Hey's ligament. In or- dinary cases, however, I am inclined to believe that the sharp posterior border of Poupart's ligament, or the ligament of Gim- bernat, as it is called, contributes more than any other part to keep up the symptoms of strangulation. But be this as it may, the surgeon must proceed in his operation until he has removed every obstacle. With this view, passing the fore-finger of his left hand gently between the sac and its contents, he carries it upwards until he meets resistance. The bistoury should then be passed, with its flat edge towards the finger, until it is fairly within the strictured part, when its edge may be turned up and pressed lightly against the obstruction. 'If the parts are not suf- ficiently liberated to be returned by moderate pressure, the fin- ger should be carried higher, and other obstructions sought for. These, if found, must likewise be divided, taking care in making each incision to carry the bistoury upwards and slightly inwards. The operator, if regardless of this rule, might, by prolonging his incision outwards, or upwards and outwards, in jure the crural vein and epigastric artery. On the contrary, by directing the knife too far inwards or towards the pubes, the obturator artery, in case it should happen to spring from the epigastric and take an inward course, would be endangered. By the inward incision, moreover, there is great risk of wound- ing the intestines. Having relieved the stricture and restored the contents of the sac to the abdomen, the after treatment will not differ from that pointed out in some of the preceding sections. 114 Umbilical Hernia. Section VI. Umbilical Hernia. The umbilical vein, and its two arteries, in the foetus, perfo- rate the tendons of the abdominal muscles about the centre of the linea alba, and leave an opening called the umbilical ring. Soon after birth these parts are consolidated, and a firm cicatrix is formed, externally, by the contraction of the integuments, in- ternally by the peritoneum, and between the two, by the re- mains of the umbilical vessels. The ring being thus closed and fortified, protrusions of the abdominal viscera, in most subjects, are guarded against. Sometimes, however, it happens, that the ring is imperfectly closed, or its edges so weak, as readily to yield to any force the viscera may exert against it. Under these circumstances, an umbilical hernia will be produced. It is still a disputed point whether the protrusion takes place at the centre of the umbilical ring, or at its edges. Sir Astley Cooper inclines to the former opinion. There is reason to be- lieve, however, that both occurrences are not unfrequent. Many of the older writers believed the umbilical hernia to be destitute of a sac or peritoneal covering, erroneously supposing that the umbilical vessels were naturally situated behind that membrane, and, consequently, that the abdominal contents were protruded through the imaginary opening, in the peritoneum, for the transmission of these vessels. The fact, however, that the ar- teries and vein, while on their way to the umbilical cord, lie between the abdominal tendons and peritoneum, has long been known. The inference, therefore, is not less plain than true,__ that the umbilical, like most other varieties of hernia, is covered by a peritoneal sac. There is some variety in umbilical hernia, according as it occurs in the infant at birth, in the young subject, or the adult. Umbilical Hernia. 115 The con"-enital umbilical hernia, as it is called, is often com- plicated with spina bifida, and with extraordinary enlargement of the liver and other abdominal viscera. The contents of the abdomen are protruded through the umbilical ring into a trans- parent bag, formed out of the cellular membrane that connects the vessels of the cord. So transparent, indeed, is this invest- ment, that throughout the greater part of the tumour, the hernial sac may be distinctly seen. The umbilical hernia of young subjects is, unlike the con- genital variety, covered by the common integuments of the ab- domen, and generally makes its appearance about the third or fourth month after birth. It seldom attains, unless very much neglected, a large size; indeed, in many instances, the tumour scarcely exceeds a common marble in bulk, and when pressed upon, readily retires into the abdomen; returning again, however, as soon as the pressure is discontinued. Its figure is commonly round. A fold of intestine generally occupies the hernial sac, and omentum is scarcely ever met with. The disease is often accompanied by disorder,of the bowels and digestive organs. Amongst adults, the most common causes of umbilical hernia are, pregnancy, laborious parturition, and inordinate fatness. Hence, women, and especially those who have borne many children, are the most subject to the disease. The tumour may, perhaps, remain stationary, or nearly so, for years; in the end, however, it is almost sure to attain considerable bulk, and some- times exceeds in magnitude the patient's head. Nausea, eruc- tations, constipation of the bowels, are very common attendants upon this variety of hernia. In general, the omentum consti- tutes a very large proportion of the contents of an old umbilical hernia, and the colon is oftener found in the sac than any other intestine. Treatment of Umbilical Hernia. Congenital umbilical hernia, provided there be no extraor- dinary deficiency of the tendinous parietes, or other morbid 116 Umbilical Hernia. complication, may be cured frequently by a well contrived bandage, or by surrounding the sac and integuments, (having previously reduced the intestine,) with a ligature—drawn with sufficient firmness to occasion the parts included in its embrace to slough, and the edges of the umbilical ring to cicatrize. The last is the most certain and expeditious mode of effecting a cure. Instead of the simple ligature, Dr. Hamilton, of Edinburgh, approximates the edges of the ring by silver pins and adhesive straps. His example, however, should not, I conceive, be imi- tated. The ligature was frequently employed by the ancients, in the cure of umbilical hernia of young subjects, and, in modern times, has been extensively used and highly extolled by Desault. In several instances I have performed the operation with complete success, and with little pain or inconvenience to the patient There is no risk in the operation, provided the surgeon suc- ceeds perfectly in restoring the protruded parts to the abdomen, before he ventures to apply the ligature: which should be of considerable thickness and strength, and drawn so firmlv as to ensure the speedy destruction of the parts surrounded by it. After the slough is detached, the sore that remains may be dressed with dry lint or some mild ointment until perfectly healed. For two or three months afterwards it will be proper to support the new-formed cicatrix by a compress or truss, to guard against its laceration and the consequent reproduction of the disease. To the reducible umbilical hernia of adults the ligature is not adapted. In such cases the surgeon must depend upon a truss, which, so long as it keeps the intestine or omentum within the abdomen, will at least prevent the increase of the tumour, and may eventually, perhaps, by exciting a slow inflammation, effect a cure. Sir Astley Cooper, in small herniae, prefers the common inguinal truss, which, if it form a perfect oval, will without difficulty adapt itself to the body, and furnish the re- quisite support to the tumour. For large umbilical herniae however, the trusses invented by Morrison, or Eagland, of Leeds, and described in most modern systems of surgery, will be found to answer a better purpose than any others. When the hernia is irreducible, and of very large dimensions, a hollow Umbilical Hernia. ill truss, or a wide belt, carried under the tumour and over the pa- tient's shoulders, may be resorted to advantageously. Strangulated umbilical hernia very frequently proves fatal, as much from disorder of the intestinal functions, as from the strangulation. When the usual remedies fail, an operation should be resorted to. This may be done in the following way. An incision, several inches long, is made, very cautiously, through the integuments and superficial fascia, when the sac, if not absorbed, as is often the case, will appear. Into this a small opening should be made, from which fluid in considerable quan- tity generally issues. The opening may then be enlarged, and a finger carried upwards between the omentum and intestine as high as the umbilical ring. Upon the finger a bistoury is next carried through the linea alba, to the extent of an inch, which, in most cases, will relieve the stricture sufficiently to enable the operator without much difficulty to restore the parts to their former situation. To guard against peritoneal inflammation, which is sometimes apt to follow the operation just described, Sir Astley Cooper, in two instances, adopted the following mode of procedure. " As the opening," says he, "into the abdomen is placed towards the upper part of the tumour, I began the incision a little below it, that is, at the middle of the swelling, and extended it to its lowest part. I then made a second incision at the upper part of the first, and at right angles with it, so that the double incision was in the form of the letter T, the top of which crossed the middle of the tumour. The integuments being thus divided, the angles of the incision were turned down, which exposed a considerable portion of the hernial sac. This being then care- fully opened, the finger was passed below the intestine to the orifice of the sac at the umbilicus, and the probe-pointed bis- toury being introduced upon it, I directed it into the opening at the navel, and divided the linea alba downwards to the requisite degree, instead of xipwards." Dr. Physick has proposed, in strangulated umbilical hernia, to make a crucial incision through the integuments, as far as the neck of the sac, then open the sac at its upper part to an extent sufficient to enable the operator to examine its contents, and re- duce them, if possible, without dilating the umbilical ring. Vol. II. 16 118 Umbilical Hernia. Should the latter expedient, however, become necessary, the stricture must be divided on the outside of the sac. After the omentum and intestine are restored to the abdomen, a ligature should be drawn around the neck of the sac with a view of closing the cavity and obviating peritoneal inflammation. The late Dr. Wistar once performed the operation with success. In the case of a Mrs. N., a very respectable Jewish lady, I performed a similar operation about ten years ago. The tumour, however, was as large as a child's head, and had been strangulated several days before I saw the patient, and, on this account, the ope- ration did not succeed. The patient, toq, was advanced in years, extremely corpulent, and had long suffered from derangement of the functions of the stomach and intestines. Under these circumstances, no operation, probably, would have answered the purpose, even ifperformed in the very commencement of stran- gulation. Congenital Hernia. 119 Section VII. Congenital Hernia. This, as its name implies, is met with at birth, or, as general- ly happens, a short time after birth. It differs from common inguinal hernia, in being destitute of a distinct peritoneal sac, and in being lodged in the tunica vaginalis, in contact with the testicle. " In a common rupture," says Mr. Samuel Cooper, " the viscera push out with them a portion of the great bag of the peritoneum, which thus forming one of the most regular in- vestments of the displaced bowels, is called the hernial sac. But in the congenital inguinal hernia, the sac, in which the vis- cera lie, is not thrust forth in this manner, by the displaced bowels: on the contrary, it is a production of peritoneum origi- nally formed and placed ready for the reception of the testes on their descent from the loins, but into which the bowels are sometimes accidentally propelled, before the passage leading into it from the belly is duly closed. The congenital inguinal hernia, therefore, differs from the generality of ruptures in having no hernial sac, formed and produced by the peritoneum being thrust forth from the belly by the displaced bowels them- selves. There is, indeed, one very uncommon species of scrotal hernia, contained in the tunica vaginalis, yet in- cluded, also, in a common hernial sac, so that the protruded ^bowels neither lie in contact with the preceding membrane, nor with the albuginea. This particular case was first noticed and described by the late Mr. Hey. It seems to be formed after the communication of the cavity of the peritoneum with that of the tunica vaginalis has been obliterated, but previously to the closure of the passage lower down."* In most respects, the * First Lines of the Practice of Surgery, vol. ii. p. 23, edit. 4th, 120 Congenital Hernia. anatomy of congenital hernia resembles that of the inguinal. The spermatic cord, and the spermatic artery lie behind the her- nia. The testicle, from being surrounded by the intestine or omentum, can seldom be distinctly felt. Congenital hernia sometimes resembles hydrocele so closely as to be mistaken for that disease—owing to water accumu- lating in the abdomen and passing along with the hernia into the tunica vaginalis. It is very important to distinguish the one disease from the other; which may generally be done by placing the patient in the horizontal position, returning the hernial con- tents to the abdomen, and there retaining them by a finger pressed upon the abdominal ring. In the mean time, the water alone remaining in the tunica vaginalis may be easily distin- guished by its transparency and peculiar feel. Treatment of Congenital Hernia. The reducible congenital hernia, if attended to soon after the disease is discovered, may be readily cured by a well construct- ed truss—inasmuch as there is a strong disposition in the tuni- ca vaginalis at the ring to close of itself after the descent of the testicle. A spring truss can seldom be used in a child im- mediately after birth, but a linen compress, covered by a bandage, if well applied, will generally answer every purpose; and after the lapse of a few months a truss with a weak spring may be employed. It sometimes happens that the testicle is detained at the ring, and that the omentum or intestine is placed' above or along side of it. In such a case a truss should not be applied, as it will either prevent the descent of the testicle, or bruise the hernial contents. Strangulated congenital hernia, if not relieved by the usual remedies, will require an operation, which differs from that of common inguinal hernia, chiefly in this particular—that the in- Congenital Hernia. 121 cision of the sac should never be prolonged further than the up- per part of the testicle, in order to obviate inflammation of the tunica vaginalis, to which this membrane is particularly prone. That inflammation is propagated, more readily, to the peri- toneum within the abdomen, after the operation for strangulated congenital hernia than for that of castration, is owing to the tunica vaginalis, in the former case, being continuous with the peritoneum, whereas in the latter it is closed immediately af- ter the descent of the testicle. In certain quadrupeds (as in the horse) the tunica vaginalis communicates directly with the abdomen and is continuous with the peritoneum. If, therefore, in castrating such animals, care be not taken to sear the cord and edges of thet unica vaginalis, by hot irons, as practised, with pro- priety, by farriers, death will be very apt to follow. Twenty years ago, I performed the operation, to oblige a friend, on a colt, and tied up the vessels as I would have done in the human sub- ject. Violent inflammation followed and the animal was saved with great difficulty. Sir A. Cooper mentions a similar in- stance. Searing obliterates the passage between the abdomen and tunica vaginalis, and produces the same effect as natural adhesion in the human subject. In large congenital herniae that have long remained irreduci- ble, Sir Astley Cooper advises the return of the parts without in- spection, provided the stricture can be removed without opening the tunica vaginalis. 122 Artificial Anus. Section VIII. Artificial Anus. When the operation for strangulated hernia has been too long delayed, and the intestine has mortified, it- sometimes happens that an artificial anus is formed. In such cases the inflamma- tion, instead of extending throughout the peritoneum and pro- ducing the patient's death, is limited to the neighbourhood of the stricture, and, terminating in the adhesive stage, glues the sound portions of intestine to the hernial sac. This adhesion becomes firmer and firmer, in proportion as the sloughing pro- cess going on in the protruded parts advances, until the sloughs are thrown off and fasces are discharged externally. By this provision of nature, effusions into the cavity of the abdomen are, in nine cases out of ten, effectually guarded against. As in every case of hernia the intestine is doubled upon itself, it fol- lows that the two portions must lie parallel, or nearly so, with each other, and that when an artificial anus is formed, an inter- mediate ridge or projection will be the result To the free ad- mission of the faeces from the upper to the lower part of the canal this ridge will prove, in general, a serious obstacle; in most cases, indeed, there is a total cessation of faecal discharge o by the rectum; so much so that the intestine is constantly empty, or, at most, contains only a glairy mucus. After a time, how- ever, faeces in small quantity occasionally pass through the low- er part of the canal, and are discharged from the rectum. This is owing, in part, to the contraction of the external orifice of the artificial anus, and at the same time, to an enlargement of the passage between it and the orifice of each gut As soon. therefore, as the faeces leave the upper intestine, they fall into a " funnel-shaped" cavity, and meeting with some resistance from the contracted mouth of the opening in the integuments, are propelled by a circuitous route towards the orifice of the lower gut. Artificial Anus. 123 An artificial anus, whether induced by a wound of the abdo- men, or by hernia, is a very grievous disease, not only subject- ing the patient to great inconvenience, but endangering his life. Most patients, labouring under the infirmity, are troubled with colic and other derangement of the intestinal functions. Besides, they have no control, for want of a sphincter, over the faecal discharge. A prolapsus from one or both openings of the intestine, is by no means uncommon, and is sometimes exqui- sitely sensible. Artificial anus, when situated high up, or among the small intestines, is apt to terminate fatally—from inanition. Treatment of Artificial Anus. Nature will often make surprising efforts towards restoration, and is sometimes abundantly successful. Aware of this, the surgeon must not be officious, but patiently wait, so long as there is any prospect of a favourable termination. In the mean time, the patient should be supplied with a common truss, the pad of which must be broader than usual, and covered with a piece of bladder or oiled skin. This serves the purpose of restraining the faeces, and at the same time contributes, by blocking up the external opening, to direct them to the lower intestine. If it should be found, however, after the lapse of months, that there is no prospect of amendment, an operation may be attempted for the relief of the sufferer. The indication to be fulfilled by this is to overcome the ridge-like barrier situated between the two intestines, and which prevents the direct descent of the excre- ment from one to the other. Desault, with this view, in- troduced into each orifice of the gut, plugs of lint or linen, and by these means frequently succeeded. A more expeditious, effectual, and less troublesome operation, was proposed and executed by Dr. Physick, between the years 1808 and 1809. A crooked needle, armed with a ligature, was passed for some distance within the orifice of one gut, and brought out at the other—traversing in its passage the coats of each. The ends 124 Artificial Anus. of the ligature were then tied at the external opening, and formed a loose loop. This being suffered to remain for a week, caused the sides of the intestines to adhere to each other. Through the consolidated ridge, thus formed, an incision was afterwards made,and adirect communication established between the upper and lower intestine. An operation, similar to that of Dr. Physick, was afterwards performed by the late Baron Du- puytren, in Paris, and to him the merit of the proposal is award- ed by European writers—without the slightest foundation. Dr. Physick's claim to priority, as respects the operation for artificial anus above described, having, as just mentioned, been contested by European surgeons, the following statement on the subject from the able pen of Dr. Benjamin H. Coates, of this city, must carry conviction to the mind of every unprejudiced person. " John Exilius, a Swedish sailor, aged ninteen years, was ad- mitted into the Pennsylvania Hospital on the morning of the 20th of October, 1S0S, affected with a congenital hernia. He stated that he had passed the last fourteen days without having had a stool, and that on the 29th, he had been affected with ster- coraceous vomitings. These were renewed after his admission. After several other means had been employed to produce a re- duction of the hernia, the operation was proceeded to at half past three o'clock the same afternoon, by the late Professor Wistar, in the presence of Dr. Physick. The sac being opened, the in- testines were found firmly adherent to the testicle, and partially so, but with equal firmness to the abdominal ring, so as to ac- count for the impossibility of effecting a reduction by the taxis— they appeared to be a part of the ilium. A perforation existed in the side of one of them, of sufficient magnitude to permit the dis- charge of a considerable amount of faeces. There were, however, no marks of mortification found, and the opening appeared to be the product of mere ulceration. After the removal of the stric- ture, and the application of a dressing, a dose of laudanum was administered, and the patient was returned to his bed. Much enlargement of the abdomen continued, accompanied with great general restlessness, and but a small quantity of the faeces was discharged from the wound, though various means were em- ployed to procure their expulsion. On the 22d and 23d, ster- coraceous vomiting returned, and it was not till the 23d that Artificial Anus. 125 much relief was obtained. This was the result of a copious dis- charge produced by the injection into the bowel of an infusion of senna. On the 24th, Dr. Wistar divided a small portion of the ten- don of the transversalis abdominis, as well as of the neck of the sac, from which ensued much greater facility for the escape of the faeces. On the 30th of October, the patient, by the regulations of the hospital, came under the care of Dr. Physick. On the 24th of December, the projecting portion of the intestine was cut off close to the ring. This was done under the expectation that the open ori- fices thus left in the intestine would gradually be retracted within the abdomen. On applying a ligature to a divided mesenteric ar- tery, severe pain was produced in that cavity, which was relieved by rhubarb, laudanum, and aniseed. After waiting some time, and finding that retraction did not take place, as hoped for, another process was resorted to. A roll of waxed linen, such as is used in making bougies, and of the size of the fore-finger, was bent double and each end introduced into one of the orifices of the intestine. The dresser then pressed the angular part of this tent backwards, in such a manner as to approximate the adherent intestine to a straight position. So much pain, of a kind similar to colic, was produced by this pressure, that the plan was necessarily abandoned. The two ends of the intestine were found, by a careful examination, to adhere to each other for some distance, and the form, thus presented, has been com- pared in this case to that of a double-barrelled gun. The next method proposed by Dr. Physick, was to cut a lateral opening through the sides of the intestine where they were adherent. But not knowing the extent of the adhesion inwards, he thought it necessary to adopt some preliminary measure for ensuring its existence to such a depth as might admit of the contemplated lateral opening without penetrating the cavity of the peritoneum. By introducing his finger into the intestine through one orifice and his thumb through the other, he was enabled to satisfy him- self that nothing intervened between them but the sides of the bowels. He was thus enabled, without risk, to pass a needle, armed with a ligature, from one portion of the intestine into the other, through the sides which were in contact, about an inch within the orifices, which ligature was then secured with a slip- knot. Thisoperation was performed on the 28th of January, 1809. The ligature was merely drawn sufficiently tight to ensure the Vol. II. 17 126 Artificial Anus. contact of those parts of the peritoneal tunic which were with- in the noose. When drawn tighter, it produced so much pain in the upper part of the abdomen, of a kind resembling colic, that it became necessary immediately to loosen it. The ligature, in this situation, gradually made its way by ulceration through the parts which it embraced, and thus loosened itself. It was at several periods again drawn to its original tightness. After about three weeks had elapsed, concluding that the re- quired union between the two folds of peritoneum was sufficient- ly ensured, Dr. Physick divided with a bistoury all the parts which now remained included within the noose of the ligature. No unfavourable symptom occurred in consequence. On the 28th of February, the patient complained of an uneasy sensa- tion in the lower part of the abdomen, and on the 1st of March he extracted with his own fingers some portions of hardened faeces from his rectum. On the 2d of March, two or three evacuations were produced in this manner. On the 3d, an enema, consisting of a solution ofcommon salt, was directed to be given twice every day. The first of these occasioned a na- tural stool, about two hours after its administration. The same effect was produced on the 4th, 5th, and 6th, and the discharges from the orifices in the groin now became inconsiderable. Ad- hesive plasters, aided by compresses, were employed, not only to prevent the discharge of faeces from the artificial opening, but with the additional object of procuring the adhesion of the sides. This last effort was unsuccessful. On the twenty-fourth of June, an attempt was made to unite them by the twisted suture. Pins were left in for three days, and adhesion was, in fact, effected; but owing to the induration of the adjacent parts, the wound again opened. On the 27th of July, a truss of the common con- struction, furnished with a very large pad, and surmounted by a large compress, was applied to the wound. By these means the discharge of faeces from the groin was completely prevented, and the patient had regular evacuations per anum, except when from improper diet or cold, he became affected with diarrhoea. At such times, a small portion of the more fluid matter escaped by the sides of the compress. Not satisfied with this state of things, Dr. Physick made several attempts to improve the pav tient's condition. On the 2d of August, a mould of the parts was taken in plaster of Paris, and being covered with buckskin Artificial Anus. 127 was employed as a pad for the truss. This expedient answered extremely well, as long as the patient continued in the same posture in which the mould was made; but as soon as the form of the parts was altered by a change of position, faeces escaped from the orifice. A bandage was then applied to the body, fur- nished with a thick compress, and having that part of it which crossed the patient's back formed of elastic, extensible wire springs, such as are used in suspenders. This, also, however, proved ineffectual. The truss, with a compress and a large pad, stuffed in the common way, was then reapplied, and found to answer completely the purpose of preventing the discharge of faeces, the hope of an entire closure of the orifice being aban- doned. On the 10th of November, he was discharged from the hospital in good health and spirits, and applied himself with very good success, to acquire the profession of an engraver."— Dupuytren has since invented a forceps of peculiar construc- tion, called enterotome, for the purpose of bruising and break- ing down by force the sides of the two intestines, and in this way opening a passage from one to the other. Dr. Physick's operation, it appears to me, in every respect, merits the prefer- ence. On Hernia, Consult—Pott's Works, by Earle, vol 2—Hey's Practical Observa- tions in Surgery, edit. 3-The Anatomy and Surgical Treatment of Inguinal and Congenital Hernia, by Astley Cooper, fol. Land. 1804—Ditto the Anatomy and Surgical Treatment of Crural and Umbilical Hernia, part 2, 1807—Lawrence on Ruptures, edit.3-Scarpa's Treatise .on Hernia, translated from the Italian, by John Henry Wishart, Edinburgh, 1814-7. Cloquet, Recherches Anatomiques sur les Hernies, 1817—A Treatise on Surgical Anatomy, part the first, by Abraham Colles, Philadelphia, 1820-C. Bell's Surgical Observations-Drawings of the Anatomy of the Groin, by William E. Darrah,fol. Philadelphia, 18:50. On Artificial Anus-Desault's Works, by Smith, vol. 1, article Preternatural Am, p. 306—Trovers on the Intestines, p. 295—Scarpa on Hernia, Memoir 4th, p. 288—Hennen's Military Surgery, 2d edit. p. 407—Dorsey's Surgery, vol. 1, p. 96—Reybardsurles Traitement des Anus Artificiel, 8vo.—Account of a Case in which a new and peculiar Operation for Artificial Anus, performed, in 1809, by Philip Syng Physick, M. D., then Professor of Surgery in the University of Penn- sylvania. Brawn up for publication by B. H. Coates, M. D., in North American Medical and Surgical Journal vol 2, p. 269. 128 Diseases of the Rectum. CHAPTER VI. DISEASES OF TflE RECTUM. It is but too common for students to pay particular attention to favourite subjects, and neglect others not less important. The diseases of the rectum, I have frequently perceived, are little relished; being considered not only loathsome and uninteresting, but very simple in their nature, and easily cured. Experience teaches the reverse. Many a patient has lost his life from an ill-managed fistula in ano, or from an operation upon it, unneces- sarily, or improperly performed. A small portion of dissecting- room labour, (too often wasted upon the muscles,) is the proper corrective for this error. The principal diseases of the rectum are prolapsus ani, tu- mours within the rectum, hemorrhoids, and fistula in ano: those less frequently met with, are imperforate anus, foreign bodies in the rectum, neuralgia and spasms of the anus, atony and inju- ries of the anus, blenorrhagia, strictures and fissures of the rec- tum. The latter disease, (fissure,) I have never met with, nor do I find, upon inquiry, that it is known, personally, to any other surgeon in this country. On this account, I shall not treat of it, but refer, for information on the subject, to Euro- pean writers. . t v 'A. M *A Section I.- Prolapsus Ani. From habitual costiveness, straining at stool, diarrhoea, dy- sentery, hemorrhoids, strictures in the urethra, stone in the Prolapsus Ani. 129 bladder, drastic purgatives, irritation from ascarides, and vari- ous other causes, the lining membrane of the rectum, immedi- ately above the internal sphincter, is sometimes inverted, and protruded to a greater or less distance beyond the verge of the anus. Infants, and very old people, are most liable to the com- plaint, which, if the tumour be large, recent, and accompanied by much inflammation, may terminate in gangrene, or give rise to symptoms of strangulated hernia. In general, however, this re- sult is not to be apprehended, and the disease must be considered as rather inconvenient and troublesome than dangerous. In some cases there is reason to believe that there is an intussusception of the gut itself, instead of an eversion of its lining membrane. In other instances, the sigmoid flexure, and other portions of the colon, may be invaginated and finally protruded at the anus. Even the caecum may undergo a similar displacement. Not unfrequently, the upper part of the rectum descends and lodges in the pouch of the same intestine. But these affections differ, in toto, from genuine prolapsus ani. To understand the true na- ture of prolapsus, it should be recollected that perpetual strain- ing from irritation, however induced, may give rise to infiltra- tion in the cellular tissue, beneath the villous coat, and that this congestion must have the effect, finally, of causing protrusion of the lining membrane of the gut. In chronic cases of the disease, or where unusually large protrusions have taken place, there is reason to believe that the folds of the inner coat, which line the pouch or natural sinus, above the internal sphincter, and which are uncommonly numerous and relaxed, are forced by the action of the abdominal muscles from their lurking-place, and carried in volumes beyond the verge of the anus. Several cases of the kind I have seen, and one especially during the winter of 1835, at the Aims-House Infirmary, in a man 36 years of age, named Dubois, in whom the protrusion, equal in bulk to the fist, and of a dark red colour covered with irregular ridges and furrows, not unfrequently descended five or six inches, be- yond the margin of the anus. *• According to Mr. Mayo, of London, not only the mucous and submucous coats of the rectum are liable to eversion, but the muscular coat also—as is proved by a preparation in the Mu- seum of King's College, of which Mr. Mayo has furnished a drawing. 130 Prolapsus Ani. Treatment of Prolapsus Ani. In the treatment of this disease, it is highly important to re- turn the protruded parts as speedily as possible. This is best accomplished by placing the patient on his back, elevating the hips and shoulders, and pressing gently with the fingers, (pre- viously oiled,) upon the tumour. Should the parts be very tender and inflamed, and offer much resistance, the efforts to- wards reduction must be discontinued, until full benefit has been derived from general and local blood-letting, mild purgatives, cold poultices, astringent washes, &c. To support the protru- sion, after it has been reduced, and to prevent its recurrence, a piece of lint, covered with some mild ointment, should be ap- plied to the anus, and over it a soft sponge and bandage. Rest, also, for some time in the horizontal position, will prove essential. Dr. Physick has sometimes cured prolapsus ani by confining the patient for a considerable time to a diet of rye mush and sugar. It must be obvious, however, from what has been stated, that much will depend upon the cause of the disease, as respects the prospect of a permanent cure; and that so long as many of the causes pointed out continue to operate, little advantage can be gained by any mode of treatment that may be instituted. The protruded parts, now and then, become in- durated and incapable of reduction. Under such circumstances, it may be necessary to remove them, either with the ligature or knife. When the tumour appears to be very vascular, and is small, I should prefer removing it by the double cannula and wire, as used by Dr. Physick for hemorrhoids. But when it has long remained protruded, is disorganized, and has, apparently, very little connexion with the parts within the rectum, I should re- sort to the operation long ago practised by Hey—the removal of one or more flaps, or of the whole mass, by excision. This I have practised successfully, in several cases, without incon- venience. At other times, considerable hemorrhage has fol- lowed the operation. The young surgeon should be on his guard, therefore, and take care how he ventures to cut off a large re- ducible prolapsus of the mucous membrane; and, above all, that Prolapsus Ani. ]3i he does not amputate an invaginated colon or caecum, under the idea that he is merely removing folds of the lining membrane of the rectum. An ingenious operation, first suggested and practised by Du- puytren, (and for which, in a former edition of this work, I have failed to award him the credit he deserves,) is better calculated, so far as I can determine, by a few trials of it, to effect a cure of prolapsus ani than any other ever invented. Instead of cut- ting away the mucous membrane of the gut, Dupuytren seizes with a pair of small forceps a greater or less number of the ra- diating folds of skin which naturally surround the outside of the anus, and with a pair of curved scissors, cutting from with- out inwards, removes them. When the prolapsus is large, these folds should be pinched up in two or three different places and cut off: but in small tumours of the kind, such as are generally met with in children, the removal of two or three folds at a sin- gle spot will commonly prove sufficient. Occasionally, it is ne- cessary to prolong the incision into the rectum as far as the point where the radiating folds are fused insensibly into the mucous membrane of the rectum. The object of this operation, as will be understood immediately, is to contract (through the medium of a cicatrix, which must necessarily form when the wound made by the scissors has healed up,) the margin of the anus, or to diminish the size of that opening, and thereby to af- ford a support to the loose folds of the mucous membrane of the gut they were destitute of in the relaxed condition of the parts, as usually found in cases of prolapsus. In an obstinate case of this disease, in a girl three years old at the Aims-House Infir- mary, during the winter of 1835, (and where the protrusion, the size of an egg, had been partially removed, previously, by dissecting off ribands of the lining membrane with a view of ex- citing the adhesive inflammation,) I succeeded in effecting a per- fect cure of the prolapsus, merely by cutting away, in two places, the converging folds of skin, in the manner described. In the case of Dubois, referred to above, I performed a simi- lar operation; but the long standing of the disease, and the ex- traordinary bulk of the tumour, prevented me from succeeding. However, as regards both the operations of Hey and Dupuy- tren, it should be remarked, that, if carried too far, there may be a possibility of producing such a contraction of the parts, 132 Prolapsus Ani. within the rectum and at the anus, as to interfere, ever after- wards, with the evacuation of the faeces. Cases of the kind have been reported by Chesselden, and by the old anatomist Keil, where the patients could never procure a stool without the assistance of a clyster, and, even with that alternative, suffered immensely. It must not be supposed, from the remarks already made, that an operation will be required, necessarily, for the cure of pro- lapsus ani. On the contrary, many cases occur, in children espe- cially, where by early attention to the disease, the use of sa- turnine and astringent injections, keeping the bowels in a solu- ble state, and, above all, by obliging the child to evacuate the faeces whilst in a standing position, perfect cures will be ef- fected in a few weeks or months. Perforated ivory balls, gum elastic and other pessaries, the craw of a turkey, lint plugs, sponges, steel trusses, and other contrivances, have been resorted for sustaining the prolapsed parts, or for effecting radical cures through the medium of adhe- sive inflammation, but generally without effect. As some pa- tients, however, have derived benefit, undoubtedly, from them, they should in certain cases be tried. But if, upon trial, they are found, as is generally the case, to act as suppositories, they will do more harm than good, and should be abandoned. On Prolapsus Ani, consult Monro's Essay on Procidentra Ani, in Edinburgh Physical and Literary Essays, vol. 2d, p. 353—Chesselden's Anatomy of the Hu- man Body, 1792—Chevalier on Relaxed Rectum, in Medico-Chirurgical Transac- tions, vol. 10, p. 401, 1819—Sabatier, Memoires sur les Anus contre Nature, in Memoires de la Academie Royale de Chirurgie, torn. 15, 12mo edit.—Hey's Practical Observations in Surgery, p. 438. London, 1814—A Treatise on the Diseases of the Urethra, Vesica Urinaria, Prostate, and Rectum, by C. Bell, with Notes, by J Shaw, p. 324. London, 1820—Dupuytren on Prolapsus of the Rec- tum, in Clinical Lectures on Surgery at Hotel Dieu, &c, translated by Doane, p. 99—Observations on Injuries and Diseases of the Rectum, by Herbert Mayo, p. 28. London, 1833—American Cyclopaedia of Practical Medicine and Surgery, Edited by Isaac Hays, M. D., Part 6, p. 96. Philadelphia, 1835—Colles' Surgi- cal Anatomy, p. 139. Tumours zoithin the Rectum. 133 Section II. Tumours withifi the Rectum. Sarcomatous and other tumours occasionally sprout from the surface of the lining membrane of the rectum, and accord- ing to their bulk and figure, excite more or less irritation, diarrhoea, &c. Sometimes they originate between the coats of the intestine. Mr. John Bell* speaks of enormous tumours of the rectum, soft, woolly, lubricous, of a shining red colour, in- volving the whole circle of the anus, extending beyond it many inches, and retiring deeply within the cavity of the gut. Such I have not seen. Treatment of Tumours within the Rectum. When the tumour originates by a very narrow pedicle, and moves freely about, it may sometimes be pulled away with a pair of forceps; but when its base is broad, the ligature will prove the safest and most effectual remedy. It will answer no purpose, however, merely to encircle the swelling with a single cord. Many years ago, I was consulted by a gentleman of Maryland, on account of a fleshy excrescence, about the size of an egg, which arose from the walls of the rectum an inch and a half above the sphincter ani. A surgeon of eminence had undertaken to re- * Principles of Surgery, vol. iii. p. 138. Vol. II. 18 134 Tumours within the Rectum. move the tumour by a single ligature; but, unable to noose the base of the swelling, its anterior part only was destroyed, and the operation proved fruitless. I determined to proceed in a different way. Directing the patient to sit for half an hour over a tub of warm water, and by straining, to force the tumour as far as possible below the sphincter, I passed a crooked needle, armed with two ligatures, through its substance, as near as pos- sible to the coats of the bowel, and tied one on each side. In four or five days the diseased mass sloughed away, and a per- fect cure followed. By similar means I have removed, repeatedly, since, both large and small tumours, and almost invariably with success. The knife, upon such occasions, should never, I think, be em- ployed, on account of the hemorrhage which would be almost certain to follow the extirpation of a vascular tumour within the walls of the rectum, and the difficulty which the surgeon would experience, necessarily, in securing the vessels in that situation. The advantage possessed by the double, over the single ligature, is, that two portions of the tumour being embraced, at the same moment, the sloughing will be accomplished with greater ra- pidity than if the wrhole mass were encircled. Besides, the li- gatures having been passed through the substance of the tumour, cannot be detached until the tumour is removed. On Tumours of the Rectum, consult C. Belts Operative Surgery, vol 1st—J. Bell's Principles of Surgery, vol 3d, p. 191—A Treatise on the Diseases of the Urethra, Vesica Urinaria, Prostate and Rectum, by C. Bell, p. 323. Hemorrhoids. 135 Section III. Hemorrhoids. Hemorrhage, occasional, or periodical, from the verge of the anus, or from the cavity of the rectum, is very common among persons of indolent and sedentary lives, and of full habits of body. Costiveness, pregnancy, severe exercise on horse-back, and many other causes may give rise to the complaint. It is still a disputed point whether the blood proceeds from varicose dis- tention of the hemorrhoidal veins, or is poured into cysts formed of the cellular membrane, between the coats of the bowel, or be- neath the integuments of the anus. Both opinions are, I am sure, well founded. In by far, however, the greater number of in- stances, hemorrhoidal tumours are formed by enlargement of the veins of the rectum. This varicose condition of the veins is brought about, there is reason to believe, by repeated strain- ing at stool, during which the sphincters are of necessity re- laxed, so that a column of blood, unsupported by valves, and driven by the action of the abdominal muscles against the me- senteric veins, dilates, and, not unfrequently, bursts them. In the course of time, from repeated attacks of inflammation, co- agulable lymph is thrown around the distended veins, their coats are thickened, and fleshy tumours created, which enclose the veins in their substance, and either diminish, or obliterate, altogether, their cavities. But more or less of the cavity of the vein generally remains, concealed within the tumour, and often this cavity is much larger than the original vessel, and, if opened, will shed blood profusely. Hemorrhoidal tumours, so long as they remain within the cavity of the rectum, are mostly free from pain; when they protrude, however, beyond the anus, and are compressed by its sphincter, they frequently become ex- 136 Hemorrhoids. quisitely sensible, and greatly enlarged. The margin of the anus is sometimes surrounded by a cluster of tumours of a dark red or purple colour; at other times only a single protuberance is visible. Treatment of Hemorrhoids. The remedies for this disease are either palliative or radi- cal. Among the former may be enumerated leeches, cold astringent washes, astringent ointments, rest in the horizon- tal position, mild laxatives, general blood-letting. In seve- ral instances I have derived great benefit from a poultice made of the pulp of the green persimmon, and also from a de- coction of the bark of the persimmon tree. The extracts of stramonium, and belladonna, I have used for twenty years, and have found, in particular cases, extremely soothing, and useful. Internally administered, there is nothing better than the old remedy extolled by Benjamin Bell—the balsam co- paibae. When hemorrhoids become large and troublesome, or irredu- cible, an operation will be required. The knife, or ligature, will prove equally successful. The use of the former, however, is sometimes followed by profuse hemorrhage, violent inflam- mation, and even death. Three instances of fatal termination are related by Sir Astley Cooper. The first was that of a lady, who died in a week from peritoneal inflammation, induced by the removal of a single pile by the scissors; the second that of a gentleman who died from hemorrhage on the second day after the operation. In the third case, Sir Astley removed a large hemorrhoid by the scissors from the anus of a nobleman. " In about ten minutes after the operation, he said, ' I must relieve my bowels,' and he rose from his bed and discharged into the close stool what he thought to be faeces, but which proved to be blood. In twenty minutes he had the same sensation and evacuated more blood than before, in about the same lapse of time: he again rose, and soon became very faint from the free Hemorrhoids. 137 hemorrhage. I therefore opened the rectum with a speculum, and saw an artery throwing out its blood with freedom. I there- fore requested him to force down the intestine as much as he could, and raising the orifice of the bleeding vessel with a tenacu- lum, secured it in a ligature and also compressed the artery with a piece of sponge. His lordship bled no more. On the follow- ing day he was low, his pulse very quick, and he had a shiver- ing; on the next day he complained of pain in his abdomen; he had sickness and tenderness upon pressure, and in four days he died." Similar cases have been reported by other writers, both in this country and in Europe. When we recollect, indeed, that piles consist, in nine cases out of ten, of dilated veins, and that there are no valves from the anus to the liver, so that the whole column of blood must press upon the rectum, it is only sur- prising that surgeons, knowing these facts, should undertake to operate, as often as they do, with the knife, and scissors, and that a much greater number of accidents have not been met with. The latter circumstance can only be accounted for by the fact that tumours, which were originally varicose veins, have become obliterated by adhesive inflammation, or been con- verted into disorganized masses of cellular membrane, veins and skin, and that when, under these circumstances, clipped off by a cutting instrument, have shed little or no blood. Such being the case, it is important to draw a distinction between a cluster of dilated veins, within the sphincter, or projecting beyond the margin of the anus, and those lifeless indurated growths, which so often occupy the same situations. The latter may be safely cut away; but the former never can, without imminent risk of the patient's life. It is true that whilst most eminent surgeons are adverse to the removal of venous hemorrhoids by the knife, one or two others, equally eminent, have advocated the practice when con- joined with collateral means. Thus, Dupuytren, the magnus Apollo of French surgery, has boldly recommended and prac- tised not only the removal of piles by cutting instruments, but the application of the actual cautery, immediately afterwards, for stemming the torrents of blood. His own mouth has sufficient- ly condemned, we think, both the operator, and the operation. " I have seen you," says he in his Lectures, " shudder more than 138 Hemorrhoids. once at the sight of the red hot iron, and at the cloud of smoke which arises from the cauterized part: you may judge what an impression such a preparation would produce on the friends and relations of the patient, who are not, like you, accustomed to such scenes." Again: " It is also to avoid this disastrous occurrence— hemorrhage—that we make it a rule not to apply the dressings for some hours after the operation, because it is to be feared that the dressings would only hinder the blood from flowing out, and thus cause it to flow back into the superior intestines." What we apprehended happened the nextday: an internal hemor- rhage manifested itself; the pupil of the ward was not mistaken. He gave him (speaking of a particular patient,) an enema, which brought away a great quantity of blood; a second enema brought a considerable clot. He then made the patient strain first to ex- pel any blood that might remain, and, secondly, to cause relaxa- tion of the sphincter, and exhibit the surface of the divided ar- teries; then he applied to the bleeding parts two red hot iron instruments. The quantity of blood lost in this operation has been estimated to be three, four, and five pounds. It flows into the descending, the transverse, and the ascending colon, and as far as the caecum, but never beyond this. From the effects of the cauterization he experienced a retention of urine, and it was necessary to use the catheter. After the eva- cuation of a great quantity of urine, he felt violent pain, which did not cease until the organ returned to its usual state." Again: a very wealthy banker is attended by Dupuytren, who, with a pair of large forceps, pulls down the hemorrhoids and cuts them off. " At the end of a quarter of an hour, the patient became pale, fell into a state of extreme weakness, the pulse small and hard, a cold perspiration covered his body, and he felt a sensation of heat in the abdomen, continually ascending. The Professor immediate- ly recommended the patient to make expulsatory efforts, and a great quantity of scarcely coagulated blood was discharged. Cold injections were useless: the hemorrhage was not stopped: then a pig's bladder, stuffed with lint, was introduced. This succeeded completely: but it was not without great difficulty it could be kept in its place: involuntary expulsatory efforts tend- ed incessantly to displace it, and actually did so several times. This hemorrhage weakened the patient very much, and would undoubtedly have been fatal, if it had not been arrested so Hemorrhoids. 139 promptly." The banker's brother had a similar disease, is treat- ed in a similar manner, and would certainly have died, but for the presence of mind of another brother, who, in the absence of the surgeon, introduces the pig's bladder, and stops the blood. " But the loss of blood was so great that the patient was a long time before he recovered." In another instance, a Scotchman, an officer of dragoons, is subjected to excision. " There were three tumours not very voluminous, and as there was but a trifling ef- fusion of blood, M. Dupuytren thought that cauterization might be dispensed with. About five hours after the excision, all the characteristic symptoms of hemorrhage in the rectum were ma- nifested : anxiety,rigors, inclination to vomit, cold perspiration, sinking of the pulse, convulsive contraction of the limbs, inex- plicable agony, vertigo, syncope, tremors increasing, the pa- tient went to stool, and the expulsion of a considerable quantity of partly coagulated blood, gave him visible relief. At the ex- piration of about an hour the symptoms returned with in- creasing intensity: they produced complete collapse. The pa- tient requested a notary should be sent for, and hastened to ar- range his affairs, preferring death, which he thought inevitable, to cauterization. With the aid of a speculum, the place from whence the blood flowed was easily found, and the effusion stopped by the application of a bent cauterie en haricot heated to a white heat; a wick was kept in the rectum, and in a few days the patient was perfectly cured." Other cases are report- ed, in favour of excision, and the cautery; but the details, cor- respond so exactly with each other, that it is superfluous to state them. Besides, the disastrous effects of excision, and the cau- tery, already pointed out, it should be mentioned, (and the fact is admitted by Dupuytren,) that contraction of the anus, to such a degree as greatly to interfere with the patient having a stool, nt)t unfrequently follows. Under all these circumstances, may we not exclaim, Cui bono? Why subject an unfortunate indivi- dual to such torture? Why give rise to hemorrhage, merely for the sake, apparently, of showing our dexterity in stopping it? The ligature, then, in our estimation, is the only safe opera- tion, for the generality of hemorrhoidal tumours. As prac- tised by the older surgeons, and by most of the moderns, there can be no doubt that inconvenience, and sometimes very severe pain, and other unpleasant symptoms, follow its application; but Hemorrhoids. that any thing like the consequence spoken of by old Petit, and handed down from one generation to another,—symptoms of strangulated hernia, and death—ever follow from performing the operation, as it ought to be performed, or even when per- formed in the most bungling manner, I am very far from be- lieving. To Dr. Physick we are indebted for the best mode of per- forming this operation. A double cannula of the ordinary form, but only two inches long, is selected, and '• a piece of tough, flexible, pure iron wire, one twenty-fourth part of an inch, or rather less, in diameter, having firmness enough to allow of its being pushed backwards and forwards in the cannula," is passed through both barrels of that instrument, and whilst one end is secured at the wing of the cannula, the other remains loose. A loop being formed adapted to the size of the hemorrhoid, is passed around it, and then drawn as firmly as possible, by pull- ing upon the extremity of the wire projecting from the lower end of the cannula with a pair of flat pliers, and then securing its end to the opposite ^"ing. In twenty-four hours, or some- times twelve, the wire is loosened from the wing of the instru- ment, straightened by the pliers and cautiously pushed back, and its loop disengaged from the tumour, which by that time is commonly found black, shrivelled, and free from pain. A poultice is then applied, and in a few days the tumour is entire- ly separated. The peculiarity, it will be perceived, of the above operation, consists in the unusual firmness with which the wire is drawn, and its being removed in a few hours, instead of being suffered to remain for several days. " No one can pro- perly appreciate," says Dr. Physick, ,; the advantages result- ing from the above method of removing hemorrhoidal tu- mours, who has not seen them treated, by allowing the ligature to remain during the separation of the part Under that mode of operating, the patient is never at ease during the whole time; the discharge of the faeces is often excruciating, even moving in bed is dreaded, and in the last case in which I performed the operation in that manner, the convulsive twitchings of the lower extremities, which were induced, became so frequent and vio- lent that I was uneasy, through an apprehension of tetanus being the consequence. It seems to me probable, that one rea- son of the difference between the effect of the wire, and a com- Hemorrhoids. 242 mon ligature may be, that, however firmly the waxed ligature may be drawn and tied on the base of the tumour, before a se- cond knot can be tied to secure the first, the elasticity of the parts compressed opens the first knot a little, and of course the exclusion of blood, and nervous influence is not so complete as when the wire is used, which can be fastened on the arm of the instrument at the time when it is drawn round the swelling as tightly as possible. The pinch given by the wire is soon destructive, and any degree of restoration is rendered impossible. " It might be supposed, if a thread were used, it could be cut off after a short time; but the swelling comes on so speedily, the parts retract so much within the anus, and are so extremely tender to the touch, that it is difficult to find the noose: when found, the operation of dividing it either with knife or scissors, is productive of so much pain, that I have known some patients refuse to submit to it The removal of the wire occasions no pain. It may be proper to mention, that when the tumour hap- pens to be attached to the inside of the anus, anteriorly, some difficulty in voiding urine is often complained of; but this symptom, always, in my patients, has subsided immediately af- ter the removal of the wire. " Where," Dr. Physick further re- marks, " hemorrhoidal tumours are only protruded in the act of evacuating the faeces, then their excision would be attended with great risk of hemorrhage. This some have denied, but having twice witnessed the fact to a very alarming extent, I wish, on all such occasions, to guard against it." For many years I have practised the operation just described, both on small, and large hemorrhoidal tumours, and in a great many instances, and can positively declare, that, although I have often known very sharp, and severe pain to follow the tighten- ing of the ligature in some, that in others very little complaint has been made, and that in all very perfect and speedy cures have been accomplished. In proof of this, I shall relate a case which, I think, will be acknowledged to be equal in extent to any reported by Dupuytren. Mr. B., a respectable merchant of Danville, on the Susque- hannah, had suffered for fifteen years with internal hemorrhoids. His constitution was naturally very fine and vigorous, but from repeated hemorrhages from the rectum, he had become ema- Vol. II. 19 142 Hemorrhoids. ciated, and so debilitated, and suffered so much pain from the pro- trusion of the tumours, that he could scarcely attend to his busi- ness, and life had almost become a burden to him. When 1 saw him, his skin was of a pale yellowish hue and his whole aspect cadaverous. After resting a few days, to recover from the fatigue of his journey, he was directed to sit for half an hour over a buc- ket of warm water, and force down gradually the tumours. They came out, and as they descended became ravelled up into rolls, each as thick as the thumb, covered with blood and sero-puru- lent matter. There were two or three masses which complete- ly surrounded the verge of the anus, but which presented, when superficially examined, an irregular, tuberculated, dark purple, very vascular, highly sensitive tumour, as large as the fist. The patient was put to bed, a gentle aperient ordered, and the next day, immediately after the tumours, (by straining over warm water) had been forced down, was laid on his side over the edge of a bed, and the largest and most painful mass selected, included in the iron wire ligature, as near its base as possible, and the wire drawn with all the force I was master of. The pain, for an instant, was agonizing; but soon subsided—owing to the death of the tumour, thus so suddenly brought about. In fifteen or twenty hours, the wire was removed, and a warm poultice applied to the parts. In four days the remains of the tumour were completely separated, and the patient returned home in a fortnight, perfectly cured of the protrusion and of the hemorrhagies, and in a few months recovered his health. Seven or eight years have now elapsed since the operation; and I have never heard of his having had a return of this complaint. It may be asked what became of the remaining tumours. They were obliterated, by the supervention of the adhesive inflam- mation—a fact very important to be known, and an occurrence by no means uncommon. Aware of this, the surgeon should al- ways make it a rule never to include numerous hemorrhoids, or a very large mass, in a ligature, at a single operation, (in or- der to guard against violent symptoms,) but take his chance of curing all by one operation, and of repeating it, subsequent- ly, should the remaining tumour require it. A case, in some respects similar to that of Mr. B., I operated on, in presence of Dr. Physick, five years ago, and with the same happy result. The patient, Mr. W., long before and since the operation, a Hemorrhoids. 243 most valuable officer of the government at Washington, had de- termined to abandon his office, unless he could have obtained relief. I need hardly remark, that I have operated in a great many instances for small hemorrhoidal tumours, by the mode alrea- dy described, and peculiar to Dr. Physick, and invariably with success, and I am very sure that no surgeon can properly ap- preciate the value of the ligature unless he use it according to the principles pointed out, and unless he fulfil the most import- ant indication—to draw the wire with very great firmness. On Hemorrhoids, consult Abernethy, on Hemorrhoidal Diseases, in Surgical Works, vol. 2d—Earle on Hemorrhoidal Excrescences, 1807—Kirby on the Treat- ment of Hemorrhoidal Excrescence— Ware on the Treatment of Hemorrhoids—A Practical Treatise on Hemorrhoids, &c, by George Calvert—The double Cannula and Wire recommended in the Operation of Extirpating Scirrhous Tonsils, and Hemorrhoidal Tumours, by Philip Syng Physick, M. D., in Philadelphia Journal of Medical and Physical Sciences, vol 1, p. 17, 1820—Excision of Hemorrhoidal Tumours, in Clinical Lectures on Surgery, by Dupuytren, translated by Doane,p. 105, Phil. 1833—Observations on Injuries and Diseases of the Rectum, by Herbert Mayo, London, 1833, p. 53. 144 Fistula in Ano. Section IV. Fistula in Ano. When an abscess forms in the cellular membrane surround- ing the rectum, or about the verge of the anus, and leaves, after its contents are discharged, one or more small openings com- municating with its cavity, the disease is denominated fistula in ano. Other appellations have also been invented, expressive of the particular situation of the fistulous orifice, and the extent of the disease. If the fistula opens upon the surface of the in- teguments, it is called an incomplete fistula; if it communicates with the rectum, and not with the integuments, an internal fis- tula; and when there is an opening in the gut and another through the skin, a complete fistula. The formation of a fistula in ano is often denoted by rigors, a painful swelling about the ischium or perineum, difficulty of passing urine, and by irritation of the rectum and neck of the bladder. During the progress of the disease, the patient, in many instances, suffers immensely; at other times, the abscess forms and breaks almost without the patient being aware of its existence. Generally, the abscess communicates with the inte- guments by a single opening; occasionally, three or four are met with; and I once attended a case of long standing, in which there were no less than fifteen. In healthy constitutions the abscess does not differ from that of the common phlegmon, met with in other parts of the cellular tissue. In consumptive and scrofulous patients, however, the disease often assumes a different shape. The surface of the integuments is covered with an erysipelatous inflammation, the fever, sickness, and pain are very considera- ble, the matter is discharged in small quantity, and from a sloughy, ill-conditioned opening, or from a ragged unhealthy Fistula in Ano. 145 surface. The origin of fistula in ano cannot be always satisfac- torily traced. Sometimes it arises from irritation about the rectum, from local injury, from the lodgement of undissolved articles of food taken into the stomach, and passed through the intestines as far as the rectum, such as the bones of fish or fowls. Severe and long-continued exercise, on rough-going horses, I have sometimes known to lay the foundation of the complaint. Hemorrhoids, there is reason to believe, often contribute to the disease. The same may be said of severe colds and coughs. Treatment of Fistula in Ano. An opinion very generally prevails that every fistula in ano requires an operation. There cannot be a greater mistake. So far from it, almost every sinus, I am inclined to think, in a pa- tient tolerably healthy, might be healed, if attended to in the commencement, and judiciously managed. Nothing will con- tribute more to this end than absolute rest, simple dressings, moderate diet, and mild laxatives. I have known a fistula, (protracted and kept open for months while the patient walked about,) healed in a week by perfect quietude, and the horizontal position. It frequently happens, however, that the surgeon is not called until the disease is firmly established, and an operation urgently demanded. But, before he undertakes it, the operator would do well to sooth the parts, and reduce the inflammation and callosity about the sinus by emollient poultices, and after the irritation has subsided, gradually enlarge the fistulous orifice by bougies, (if necessary,) before an examination with the probe is entered upon. If these precautions are neglected, and the fistula probed at once, the patient will suffer, as I have often witnessed, immensely, and, indeed, will experience infinitely greater pain than from the operation itself. It will still remain to inquire concerning the patient's general health. If consump- tive, the operation can answer, generally, no good purpose; on 146 Fistula in Ano. the contrary, it will aggravate, if the fistula should be healed, all the pectoral symptoms. When determined upon, the operation may be performed by a common probe-pointed bistoury, by the sheathed bistoury of Dr. Physick, or by the knife of Cruikshank. The objection to the probe bistoury is, that it will sometimes be necessary, when there is no opening between the gut and sinus, to make one. For this purpose, an instrument with a sharp point will be re- quired. Dr. Physick's instrument was constructed with this view, and possesses the additional advantage, from being co- vered by a silver sheath, blunt on its edges, of not cutting the tract of the sinus whilst passing along, until the operator de- sires so to do. Cruikshank's bistoury is constructed with a moveable stilet that can be pushed forward or retracted at plea- sure, the point of which is intended to pierce the gut, and then to be withdrawn, that the surgeon's finger may rest on the blunt extremity of the knife. Previous to the operation, the rectum is emptied by a clyster, and the buttocks being turned towards the light, are held asun- der by assistants, while the patient stoops forward and rests his body and arms upon a table. The surgeon introduces a fore- finger, oiled, into the rectum, passes the probe into the sinus, examines carefully its situation and extent, and having satisfied himself thoroughly in this respect, carries the sheathed bistoury, (for example,) as high as the naked outer surface of the intes- tine, then disengages the sheath from the bistoury, and removes it from the sinus. The point of the bistoury is next pushed through the gut, and made to rest on the finger within the rec- tum. Both the finger and knife are next withdrawn, the latter dividing in its passage downwards the whole tract of the sinus, the intestine, sphincter ani muscle, and integuments, and leaving a chasm of considerable extent. A dossil of lint should be next introduced between the lips of the wound, and the patient put to bed. The cure is afterwards completed by mild dressings. When there is an opening in the gut and another at the mar- gin of the anus, or on the buttock, with an intermediate commu- nication by a sinus, constituting complete fistula, no other in- strument than the common probe-pointed bistoury will be re- quired for the operation. In performing the operation for fistula in ano, simple as it is Fistula in Ano. 147 considered, the operator must remember, that if he prolongs his incision too far upwards from an over anxiety to trace every ramification of the sinus, (a very unnecessary piece of work,) he may wound the peritoneum, lay open the cavity of the ab- domen, and also divide the internal hemorrhoidal artery. The ligature is frequently employed, instead of the knife, for the cure of fistula in ano. As it requires, however, a much longer time to effect its purpose, and is, withal, sometimes pain- ful and inconvenient, there are many patients unwilling to sub- mit to the operation. But cases present themselves now and then, in which the knife could not be employed without risk of hemorrhage, or in which from the number and depth of the si- nuses, it would be impossible to trace them, or if traced, diffi- culty would afterwards be experienced in making them heal from the bottom or in preventing the formation of new sinuses. Under these, and some other circumstances, it has been custo- mary, particularly among the French, from time immemorial, to resort to the ligature. The material of which it is made, as well as the instruments for conveying it, have varied exceeding- ly in different ages. Hippocrates used a linen thread wound upon a horse-hair, others employed silver or iron wire, and many preferred leaden wire to any other kind of ligature. Some con- veyed the ligature by means of a silver probe, others by a can- nula. Forceps for seizing the wire within the gut, and stilets for making an opening into the gut for the transmission of the ligature, have also been used. But, in many instances, it will only be necessary, when this operation is determined on, to pur- sue the following simple plan, one which has been practised for a great many years by Dr. Physick, and which experience has taught him to be almost always successful. A common pocket case probe, of the same thickness throughout, is slightly ragged at one end with a knife or file, and a piece of braid secured to it by thread, in the same way that the line is fastened to a fish- hook, is introduced into the fistulous orifice and conveyed along the sinus into the gut The probe is next bent upon a finger, (pre- viously passed into the rectum,) and brought out along with the ligature at the anus. The latter is then removed from the probe and its ends loosely tied. After the lapse of a few days the lig- ature is moderately tightened, and occasionally afterwards, (once a week, for example,) the constriction is repeated and increased, 148 Fistula in Ano. until the parts within its embrace are completely destroyed, and the cord, sua sponte, detached. The small ulcer left soon heals up. Sometimes the ligature comes away in four or five weeks; at other times, eight or ten months elapse before the loop sepa- rates. In the mean time, however, the patient is generally per- mitted to walk about and attend to his business. In cases where no communication exists between the rectum and fistula, Dr. Physick has been in the habit of making one, by means of a sharp-pointed sheathed knife, previously to the introduction of the probe and ligature. In peculiarly irritable patients, however, I have found it very difficult to carry the eyed-probe and ligature through the orifice in the gut without producing excessive pain in the act of bending the probe within the rectum, and which must al- ways be done before it can be brought out at the anus. To ob- viate this difficulty, I invented, four years ago, the following in- strument, which I have employed ever since, upon all occa- sions, where I have thought it necessary to use the ligature in preference to the knife, both in hospital and in private prac- tice, and with the greatest success and least possible inconve- nience to the patient A silver cannula, moderately curved, about five inches long, the eighth of an inch wide in its longest, and the sixteenth of an inch in its shortest diameter, is intend- ed to convey a narrow watch-spring, ten inches long, having at the extremitv next the handle of the cannula an eye. and at the other a small bulbous silver point An additional spring, dif- fering only from the first in the silver end being small enough to pass along with the spring through the cannula, and intend- ed for incomplete fistula, accompanies the instrument. A steel stilet. which fills up and traverses the cannula, and projects in the form of a small lancet, just beyond the extremity, com- pletes the contrivance. See Plate 3. If it be intended to operate on a case of incomplete fistula— that in which there is no opening in the gut—the cannula, armed with the stilet, and its point retracted, is entered at the fistulous orifice, conveyed carefully along the sinus until that portion of the side of the rectum is reached where it is intended to make the perforation. The stilet is then pushed through the walls of the gut, and is felt within by the finger, previously introduced into the rectum. Having withdrawn /y*t/,> ,;./;-/e Fistula in Ano. 149 the stilet, the spring with the flattened silver end, armed with very narrow braid, is conveyed through the cannula, and, guided by the finger in the rectum, brought out at the anus along with the ligature, which is then separated from the eye of the spring, and its ends loosely tied. In cases of complete fistula, the stilet will not be required, and the spring, with the bulbous end, previously placed in the cannula, and armed, as already described, with braid, may be- employed. In either case, it must be obvious that the pressure which gives the pa- tient so much pain when the probe is used, is taken off the fis- tulous orifice and borne by the cannula; and, besides, that the spring has a natural tendency, by forming a curve as it is pushed onwards, to avoid pressure, and to reach the anus with the greatest facility. The ligature is often adapted to those cases in which a fistula follows, or is conjoined with phthisis pulmonalis. Under an im- pression that the pulmonary affection is dependant upon, or aggravated by the fistula, many patients are extremely anx- ious to have an operation. I have invariably refused to em- ploy the knife upon such occasions, but have sometimes grati- fied them by operating with the ligature, which, by being worn for months together, is sometimes so far serviceable as to pre- vent the formation of other abscesses in the neighbourhood of the rectum, and by keeping up a steady drain throughout a sin- gle track, to relieve the cough, and other constitutional symp- toms. The worst case of fistula in ano I ever saw, I attended, along with Dr. Physick, about five years ago,—that of a Mr. W. from the neighbourhood of Lynchburg, Virginia. The pa- tient's whole family had been carried off by phthisis, and seve- ral of them had also laboured under fistula in ano. In Mr. W., the only remaining one of his race, there were strong premo- nitory symptoms of consumption, and for months he had suf- fered from profuse discharges of sanious, gleety, offensive mat- ter from the rectum, all the parts about wrhich I found indu- rated, covered with sinuses, and fistulous openings, with exten- sive ulcerations within the gut, destruction of all its coats in particular spots, and the whole rectum more or less insulated by the destruction of the surrounding cellular membrane, so that it might have been said to have floated loosely in a large bag of matter. I trimmed away many of the loose-hanging por- Vol. II. 20 150 Fistula in -bio. tions of the rectum and disorganized cellular tissue, and en- deavoured to reach by the finger and by probes the bottom of the sinuses; but found it impossible, owing to their great depth. In consultation, it was determined that there was every proba- bility of the patient sinking under his disease, and that all that could be done for his relief would be to introduce a large cord high up the gut, and let it remain for several months. This was accordingly done by Dr. Physick, and the patient returned home. The seton, thus left, had the effect of consolidating, through the medium of adhesive inflammation, all the loose parts, and, finally, contrary to our expectations, the external fis- tulous openings were obliterated, the sinuses healed up, and the patient now enjoys, comparatively, good health. When the knife is employed for the cure of fistula in ano, it effects its purpose by promoting the granulating process, by first dividing the sinus, which, so long as it remained lined by a secreting membrane, would never have been obliterated, and last- ly? by dividing the sphincters of the gut, thereby rendering them quiescent, and preventing that incessant motion about the anus, so well calculated to interfere with and to break up the granula- tions as soon as they are formed. Rest, then, so essential in the treatment of many other diseases, is peculiarly so in fistula in ano. Though the sphincters unite very readily, in most cases, after the operation by the knife, it sometimes happens that they remain separated, a deep fissure is left, and the patient cannot retain his faeces as perfectly as he had been accustomed to. It is extremely difficult, under these circumstances, to restore the use of the parts. In obstinate cases of the kind, I should think the surgeon justified in cutting away the edges of the chasm, as in hare-lip, and endeavouring to unite them by suture. On Fistula in Ano, consult Desauli's Works, by Smith, vol 1, p. 330—Potfs Works, by Earle, vol 3, p. 45—A Treatise on the Diseases of the Urethra, Vesica Urinaria, Prostate, and Rectum, by Charles Bell with Notes, &c. by John Shaw, Surgeon; Demonstrator of Anatomy, in the School of Great Windmill Street, Lon- don, 1820. 8vo. page 297—Copeland's Observations on some of the Principal Diseases of the Rectum and Anus, Philadelphia, 1811—Practical Observations on the Symptoms, Discrimination, and Treatment of some of the most Common Diseases of the Lower Intestines and Anus, by John Howship. London, 1820— Observations on Injuries and Diseases of the Rectum, by Herbert Mayo, p. 28, London, 1833—Sir Astley Cooper's Lectures, by Tyrrell, vol. 2d, p. 336. Encysted Rectum. 151 Section V. Encysted Rectum. Within the cavity of the rectum, between the internal and external sphincters, commencing at the margin of the former, are, naturally situated, a number of small sacs, or pockets, the orifices of which look upwards, while the bodies of the sacs de- scend towards the anus, perpendicularly, are about a quarter of an inch in length, and have a cul de sac termination. The num- ber of these minute pockets is in proportion to the number of grooves, situated between the columns of the rectum, and each groove terminates in its corresponding pocket. In general, from seven to thirteen sacs are found, all of which are covered and lined, by the mucous membrane of the gut. These sacs are filled, there is reason to believe, with mucus (poured out by the numerous adjoining follicles) which is pressed out of their cavi- ties during the passage of the faeces, and serves, probably, to lubricate that portion of the anus covered by cuticle. Accord- ing to Ribes, such sacs had been noticed by Ruysch, Morgag- ni, and Glisson, as being accidentally met with in the rectum upon certain occasions. Ribes himself was unable to find them, although he had made numerous dissections for the purpose, during the period of twenty-five years. Subsequently, he was more fortunate, and was able to find in one subject three, and, in another, four of these lacunas, but which he has not de- scribed with perfect accuracy. It remained for Dr. Horner to establish the fact, by numerous and most satisfactory examina- tions, that (what the anatomists, referred to, considered as acci- dental occurrences) these sacs exist invariably, and form a por- tion of the natural apparatus of the rectum. So far back as the year 1792, Dr. Physick met with a peculiar 152 Encysted Rectum. disease of the rectum, which had never been described or noticed by writers. It consisted of one or more sacs, of different di- mensions, which, by bending a probe upon itself, introducing it into the rectum, and hooking it into the mouth of the sac, could be drawn down and made to appear on the outside of the anus. From that period he was accustomed to speak of this case (and others, which he subsequently met with) in his surgical lectures in the University of Pennsylvania. From 1792 to the present time, 1835, his experience in the complaint has been very con- siderable, a great number of cases having occurred in his own practice, and in the practice of others by whom he has been consulted. From what has been said, it will be readily inferred that this disease, to which the attention of Dr. Physick was originally drawn, must consist in an expansion, or dilatation, of the small natural sacs of the rectum, described in the commencement of this section. Such, we have every reason to believe, to be the fact, though, strange as it may seem, no dissection has ever yet been made, so far as we are acquainted, calculated to demon- strate that the preternatural pouch is an"actual enlargement of the natural one. From the circumstance, however, of small portions of faeces, or foreign bodies, such as seeds, &c. having being found in the dilated sacs at the time of operation, it is more than probable that these articles, by finding their way occasionally into the natural pockets, may, by irritating them, cause their expansion and elongation, and produce the disease in question. Dr. Physick, himself, seems inclined to believe that " they commence in the same manner with one of the forms of hemorrhoidal tumour. The constriction of the sphincters which embarrasses the venous circulation of the part, aided by the pres- sure exerted in passing different stools, frequently give rise to ecchymosis beneath the integuments. The effused blood pro- duces no irritation of the cellular tissue in which it is placed, but forms for itself a simple inert receptacle. If the blood is neither absorbed nor discharged, but remains or becomes en- larged by successive ecchymoses, it constitutes (certain authori- ties to the contrary, notwithstanding,) one form of hemorrhoid. If, on the other hand, some accident, or the absorption of the integument, gives exit to the blood, after the cavity has become Encysted Rectum. 153 accustomed to its presence, the cellular tissue shows little dis- position to reunite, no obvious marks of inflammation appear, and a preternatural cavity is established. In support of this ex- planation, which is urged with characteristic caution, as an hypo- thesis, Dr. Physick states, that in the early part of his practice, he has, in several instances, operated on hemorrhoidal tumours of the same part, in which after the removal of the coagula, the part presented precisely the same aspect with the preternatural cavities, wanting only the orifice. He refers, also, to the existence of similar cavities after the discharge of ecchymoses of the scalp, such as most surgeons must have seen, particularly in children, and which often prove tedious and difficult of cure: he has also witnessed the same accident in other parts of the body. In most cases the first appearance of the cavities was preceded by troublesome piles."* It generally happens that patients troubled with sacculated rectum, have complained for weeks, or months, of uneasy, dis- agreeable, sensations, (resembling those created by the nestling of ascarides, within the gut,) or of extraordinary itching about the anus. Others complain of a sense of pressure or weight upon the extremity of the rectum. Pain is seldom felt until the disease has existed for some time, and even then, is not generally noticed until a short time after the passage of the faeces. It does not, however, follow every evacuation, and the patient may be free from it for whole days together. Some- times it is extremely severe. For the most part there is more or less smarting shortly after each stool—owing, in all proba- bility, to small portions of faeces finding their way into the pouches, and there exciting irritation. The secretion of mucus within the rectum is usually increased, but pus, except in the advanced stages of the complaint, or when inflammation has supervened, is rarely noticed. Upon the whole, it may be stated that this affection is often confounded with neuralgia of the rectum, and that, not unfrequently, even after examination, the patient's complaints have been pronounced, by practitioners, imaginary. * Hay's Cycloped. of Pract. Med. and Surg. Part 6, p. 125. 154 Encysted Rectum. Treatment of Encysted Rectum. When the surgeon has reason to believe, from the absence of inflammation, or of free discharge of mucus and pus, from the want of spasms about the sphincters, that there is no internal, or occult fistula, in the rectum, and no neuralgic affection, and, above all, when the symptoms enumerated have been strongly marked, especially uneasiness and pain, a short time after stool, he will naturally suspect enlargement of the rectal pouches, and proceed accordingly. The mere introduction of the finger into the rectum will not enable the surgeon to detect this disease. Dr. Physick, as al- ready mentioned, takes a probe wTith about half an inch of its extremity bent back upon itself, and by moving it upwards and downwards, throughout that portion of the circumference of the rectum situated between the two sphincters, is able by patience to explore successfully every part of the surface of the mucous membrane. When the dilated pouches exist, the reverted ex- tremity of the probe drops readily into them, and each cyst may be drawn down to the verge of the anus, and distinctly seen—though not without producing severe pain to the patient That the portion drawn down is really one of the rectal pouches may be known by its transparency, for the probe shines dis- tinctly through it—and by the exquisite pain which the bare admission of the probe into its cavity occasions. Several of the enlarged pouches often exist simultaneously; at other times, they enlarge in succession, and months may elapse before a complete cure can be accomplished. Having drawn the cyst down by the hooked probe, Dr. Physick then cuts off the whole of it, including the orifice where the probe entered, by a pair of scissors, so that its edges retract, and are soon obliterated and blended insensibly with the smooth surface of the rectum. Should other sacs exist, or form subsequently, they must be treated in a similar manner, until a radical cure is effected. In the hands of Dr. Physick, the practice has invariably proved successful, and the remark is confirmed by my own experience. So far Encysted Rectum. 155 back as 1812, I attended the late Dr. S. of Baltimore, with this complaint. It was the first case of the kind I ever saw. The nature of the disease, in this particular case, had been previously detected by Dr. Physick, and by operating in the manner he advised, I soon effected a perfect cure. I have operated subse- quently, and successfully, in numerous instances. For further observations on this subject, the reader is referred to an article by Dr. R. Coates, (drawn up under the superintendence of Dr. Physick,) in the seventh number of a recent valuable publication —the American Cyclopaedia of Practical Medicine and Surgery, by Dr. Hays. 156 Stricture of the Rectum. Section VI. Stricture of the Rectum. Simple stricture of the rectum, like that of the oesophagus and urethra, may be either spasmodic or permanent The former, however, is not very common, and, when it does occur, is the result, probably, of disordered action of the sphincter muscles, of the levator ani, and also, not unfrequently, of the muscles of the perinaeum and of those surrounding the urethra. But the permanent, or organic stricture of the rectum, if it be not so common as some other affections of that intestine, is nevertheless, by no means rare. It may occupy any part of the rectum, but is, commonly, met with at the upper margin of the internal sphincter; and consists of a fold of the mucous membrane or coat of the gut, which in the form of a tumid ring hangs, at first loose in the bowel, but in proportion as it acquires, from repeated straining, and irritation, firmness, projects horizontally towards the centre of the rectum, to a greater or less distance, so as to resemble in some cases a septum with a hole in its mid- dle. Sometimes there are two or three of these folds, or ridges, within a short distance of each other, which either continue separate or, in the course of time, approximate, and form an indurated tube, which diminishes the capacity of the bowel and subverts its texture. In either case, or in that of a single ridge protruded into the caliber of the gut from its walls, the effect must be a girding, or coarctation, well calculated to interfere with the passage of the faeces, or to produce wire-drawn-like stools. Hence, all patients complain of their excrement being contracted; and this, indeed, will be found to be an almost cer- tain accompaniment of the disease, though not an infallible diag- nostic, or criterion. As the stricture increases, other symptoms Stricture of the Rectum. 157 are developed; there is perpetual straining or nisus, sometimes followed by mucus, sometimes by blood, either from rupture of small vessels about the rectum or from superadded piles. The bladder, also, becomes involved, and great irritation and painful micturition ensue. Eventually, the rectum becomes extremely irritable, and so exquisitely sensitive, that the patient is often afraid to attempt the expulsion of the faeces; or, if they are passed at all, it is through the medium of purgatives, enemata, or diet, calculated to keep the contents of the bowels nearly in a fluid state. If not soon relieved, great distention of the bowels, from flatus and food, takes place, followed by more urgent symp- toms, and the patient dies. Not unfrequently, he has lived for years in a miserable condition, the real nature of his case un- known to himself or his attendant, and has, finally, recovered under the management of some more skilful surgeon. Strictures of the extremity of the rectum, or, rather, coarcta- tions of the orifice of the anus, are occasionally met with. This disease is often the result of operations, improperly performed, for hemorrhoids, prolapsus ani, fistula in ano, &c. Sometimes depositions of coagulable lymph are thrown out either on the outer or inner surfaces of the radiated folds of skin around the anus, or immediately within the termination of the rectum, where the mucous membrane and radiated folds meet. From any of these causes the opening of the anus may be so contract- ed as scarcely to admit the passage of a common-sized ure- thra bougie. Treatment of Stricture of the Rectum. Before attempting to overcome, by mechanical means, a stric- ture of the rectum, the causes of the disease should be carefully investigated, and, if possible, removed. Great attention should, in particular, be paid to the condition of the patient's stomach and bowels, through the medium of appropriate diet, gentle ape- Vol. II. 21 158 Stricture of the Rectum. rients, and enemata. Repeated ablutions of the rectum by tepid and cold water alone, or holding opium or other similar articles in solution, thrown to some distance up the .gut by a well con- trived syringe, will pave the way for bougies and other instru- ments, and sometimes, without the assistance of the latter, will effect perfect cures. But soft, well made, gum elastic, or waxen, bougies are more to be relied upon, in the majority of cases, than any other instruments or modes of treatment The surgeon should take care, however, not to promise to accomplish too speedy a cure; for if, under the impression that he has nothing to do but to break down by force the barrier opposed to him, he introduce at once a large bougie and drive it home, and follow it up shortly afterwards by another still larger, he may either destroy the patient at once by tearing the bowel, or re- motely by inducing peritoneal inflammation. Very instructive cases of the kind have been published by Sir Charles Bell, Mayo, and other surgeons. The utmost gentleness, therefore, should be employed during the introduction of such instruments, and caution observed in increasing their size. The more gradual the dilatation, the less will be the irritation; and when- ever it is found that the patient complains much of soreness or pain, the instrument should be diminished or withdrawn for a day or two. By prudence and discreet management, radical cures may be effected in a few months: by rash and intemperate measures, the disease will be aggravated, or the patient killed in a few weeks. The bougie acts either by dilating the stric- ture, gradatim, or by exciting the ulcerative process, and there- by removing, through the medium of absorption, the superfluous mass of which it consists. It has been proposed, and by high authority, to introduce a bistoury and cut through the stricture at several points of its circumference. But I am at a loss to conceive what benefit can result from such a measure. If merely divided, will not reunion take place, almost immediately, and the ridge or septum con- tinue as firm as ever? We cannot cut out the whole of the ridge from its base to its edge, by introducing the knife per anum, without great risk. But I have sometimes thought (should the urgency or peculiarity of the case require it,) that, by laying open the muscles of the perineum, as in the lateral operation for lithotomy, and then slitting the rectum, as is too often done Stricture of the Rectum. 159 by ignorant or careless lithotomists, that the strictured portion of the gut might be completely extirpated. This, however, is a mere speculation, and as such must be received. The other operation (notching the stricture) has been performed, and suc- cessfully, it is said. For coarctation of the orifice of the anus, the knife appears to be the best remedy. It must be followed up, however, by the bougie; though the cure is allowed, by all familiar with the disease, to be very difficult and uncertain. Consult Howship on some of the most important Diseases of the lower Intestines and Anus, p. 1. London, 1821—Observations on some of the principal Diseases of the Rectum and Anus, particularly Stricture of the Rectum, &c, by T. Copeland, p. 13. London, 1811—i Treatise on Diseases of Urethra, Vesica Urinaria, Pros- tate and Rectum, by Charles Bell. London, 1820, p. 311—A Practical Treatise on Hemorrhoids, Strictures of the Rectum, &c, by Calvert. London, 1824—Sal- mon's Practical Essay on Stricture of the Rectum. London, 1828—Two Clinical Lectures on Hernia and Strictures of the Rectum and Anus, in Lancet. London, 1827—Mayo on Injuries and Diseases of the Rectum. London, 1833—Hay's Ame- rican Cyclopaedia of Medicine and Surgery, Part 6, 1835. 160 Imperforate Anus. Section VII. Imperforate Jlnus. This congenital imperfection is occasionally met with, both in the human subject and among inferior animals. Sometimes it is complicated with other malformations. In my cabinet there is an interesting specimen of imperforate anus, spina bifida, and club feet; all in the same subject—a child nine months old. There are three or four varieties of imperforate anus—a mere closure by the common skin of the orifice of the rectum—a membranous septum occupying the same situation, or placed within the gut at a greater or less distance from its extremity—a cul de sac termination of the rectum—an entire oc- clusion of the sides of the rectum, or the conversion of the gut into a solid tumour. Along with these varieties, there is not un- frequently conjoined a communication between the rectum and vagina or between the rectum and urinary bladder, so that the faeces and urine are commingled. An uncommonly fine specimen, of the latter kind, I had an opportunity of witnessing some years ago in a thorough-bred colt, the property of the late Dr. Thornton of Washington. The animal was deficient in a tail. [Its rump terminating, as in the human subject, at the os coccygis,) and the anus was completely shut up by integuments, and beneath by an apparently fleshy membrane. Along with the urine were discharged quantities of thick greenish matter, evidently of the nature of faeces. At this time the animal was a week old. sucked freely of its dam, and in other respects was perfectlv healthy. Perceiving, at the natural site of the anus, a fluctu- ating tumour, 1 pushed a double-edged scalpel to the depth of an inch into the part, and immediately there was discharged about a gallon of greenish fluid, similar to that which had been Imperforate Anus. 161 accustomed to pass from the urethra. By means of plugs and tents, the orifice was kept open, by the owner of the colt, for a few weeks; and after that time, the use of them appeared un- necessary. The communication between the rectum and bladder closed of its own accord in a very short time. The animal, I believe, is now living and in perfect health. This statement is made for the twofold purpose—of recording an interesting fact, and of drawing the attention of students to the diseases of domestic animals, a subject in this country very much neglected and underrated. Country practitioners are often consulted, as friends, by their neighbours and patients, concern- ing epidemics, or local diseases, among their stock. Instead of considering their dignity insulted by such appeals to their feel- ings and humanity, (as too often the case,) they should furnish cheerfully all the information they possess, or prescribe in ob- scure and difficult cases, according to the principles that would guide them in the treatment of a human being—for between the two, as regards mere animal conformation, there is much great- er correspondence than generally imagined, and similarity of texture is commonly associated with similarity of disease. Mon- ro, Hunter, Jenner, Cline, and a host of other European phy- sicians and surgeons, and the late distinguished Dr. Rush, in this country, have not thought it beneath them to investigate the disorders of those domestic creatures, upon which so large a share of our comforts, convenience and pleasure depends, nor to recommend such studies to their pupils. Treatment of Imperforate Anus. From want of timely aid, from the nature of the disease being undiscovered or misunderstood, many infants have perished that might have been saved. It is incumbent, then, upon the practitioner to investigate, speedily, the variety of the complaint the child may labour under, and to decide, promptly, upon the 162 Imperforate Anus. treatment; for after the lapse of a few hours, meconium and other fluids may accumulate in such quantities as to produce great distention and distress, which may soon be followed by perito- neal inflammation and death. It is true, that a few cases have been reported where recoveries have taken place, although no operation has been performed until the tenth or twelfth day. In by far the greater number of instances, however, the child will not survive beyond the fourth or fifth day. When the anus is merely covered by a common skin, or where a membranous septum is visible, or felt, a short distance within the gut, a bistoury, (wrapped throughout the greater part of its edge,) may be pushed through the skin, or through the septum, guided, in the latter case, by a finger per anum, and the obstruction removed. But where the rectum is obliterated, to any extent, by closure of its sides, or filled up by a fleshy tumour, a more delicate and difficult operation will be demanded. Either a regular dissection in the natural course of the rectum should be made until the open portion of the bowel be reached, or a trocar of large size thrust through the obstruc- tion. Both operations have been performed, and with success in some instances; though in other cases they have failed—owing to the great extent of the obstruction, or the distance of it from the natural situation of the anus. Under such circumstances, it was proposed by Littre to cut through the parietes of the abdo- men, either in the right or left groin, open an intestine and estab- lish an artificial anus—by connecting the gut with sutures to the surrounding parts. The operation was afterwards per- formed, and with partial success, by Duret, a French naval sur- geon. It has since been repeated by Pring, an English surgeon, in the case of a lady, in whom the rectum was closed by a scir- rhous tumour. The operation was performed on the colon near its sigmoid flexure, and proved successful so far as the establish- ment of the artificial anus was concerned, though the patient died a few months afterwards from the scirrhous affection. If the surgeon, in any of the varieties of imperforate anus, should succeed, by the operation described, in making his way through the obstructed rectum, he will find it necessary, in or- der to preserve the track or passage of suitable dimensions, to introduce plugs of lint, sponge tents, gum elastic bougies and other similar instruments, and gradually increase their size, until Imperforate Anus. 163 the requisite degree of dilatation has been effected. This, how- ever, will be found, in many instances, the most difficult part of the treatment; as there will be great irritation from the long continued use of such instruments, and a perpetual tendency, in the artificial passage, to close up. On Imperforate Anus, consult Sabatier's Medecine Operatoire, torn. 4—Calli- sen's Systema Chirurgiae Hodiernae, torn. 2d, edit. 1815—Ford, in Medical Facts and Observations, vol 1—Richer and s Nosographie Chirurgieale, torn. 3d— Chamberlaine, in Memoirs of Medical Society of London, vol 5— Wayte in Edin- burgh Medical and Surgical Journal, vol 17—A. G. Hutchinson's Practical Ob- servations in Surgery, 1826. 164 Foreign Bodies in the Rectum. Section VIII. Foreign Bodies in the Rectum. Indigestible articles often pass from the stomach along the in- testines, and are arrested by the sphincters at the anus. Pieces of gristle, of bone, of sponge, of apple core, of toasted bread, and other similar substances, have been found within the rectum, and the cases reported. Still more numerous examples have been given of the lodgement of pins, needles, fish-bones, chicken- bones, all of which have excited more or less irritation, and, in some instances, laid the foundation of fistula in ano, of extensive ulcerations, and even death. Upon other occasions foreign ar- ticles have been forced into the rectum from without either by design, or by accident, sometimes producing death, at other times most violent symptoms—as exemplified in the case of the unfortunate Edward the Second of England, murdered by a red hot iron being thrust up the rectum, and in the celebrated case re- ported by Marchetti, where the but end of a pig's tail was forced up the rectum of a courtesan, and remaining for several days, had nearly destroyed her. " Des etudians avoient projette de jouer quelque mauvais tour a une fille publique; ils s'aviserent de lui mettre dans I'anus une queue de cochon qui etoit gelee; ils en couperent les poils un peu court, afin qu'ils fussent plus piquans et plus roides; ils la tremperent dans 1'huile, et l'in- troduiserent par l'extremite la plus grosse et a force dans le fondement de cette fille, a la reserve de la longeur d'environ trois doigts qui resta a I'exterieur de I'anus: on fit diverses tentatives pour I'oter; mais comme elle ne pouvoit etre tiree qu'a contre poils, les soyes entroient dans les membranes du rectum, et causoient a cette fille des douleurs inexprimables; pour les appaiser, on fit prendre a la malade divers remedes huileux par la bouche, et on-tacha de dilater I'anus avec un spe- Foreign Bodies in the Rectum. 165 culum, assez pour retirer cette queue sans violence, mais on ne reussir; il survint des accidens enormes, un vomissement vio- lent, une constipation opiniatre, une fievre, tres ardent, et des douleurs tres vive dans tout Pabdomen."* Although not to be classed, with strict propriety, under the head of foreign bodies, yet great irritation and even ex- treme distress are not unfrequently occasioned by the lodge- ment of the oxyurus vermicularis, or ascarides, within the rec- tum—especially in children and old people. These animals, (which probably find their way into the stomach and intestines, through the medium of fruits and unboiled vegetables, and have been found out of the body by Pallas in the waters of Siberia, and by Dr. Barry in certain springs in Ireland,) are so enveloped in mucus whilst in the rectum, which they sometimes almost choke up, as scarcely to be reached by medicine, or the most stimulating injections. That they may be gotten rid of, how- ever, or the irritation they produce very much alleviated, by means I shall presently point out, I have had frequent opportuni- ties of proving for the last twenty years, and on that account I notice them in this place. Removal of Foreign Bodies from the Rectum. When, from more or less irritation, difficulty of passing faeces, a peculiar pricking sensation, within the rectum, whilst at stool, and at other times, a discharge of purulent matter and blood, from the anus, &c, there is reason to believe, that some foreign body occupies the gut, an accurate search should be made both by the finger and by instruments. If discovered, the extraneous article may then be removed by a pair of forceps or scoop. The latter instrument, such as is used commonly for extraction • Memoires de l'Academie Royale de Chirurgie, torn. 3d., p. 78.—Edit. octav. Vol. II. 22 166 Foreign Bodies in the Rectum. of bullets, is peculiarly adapted to the removal of hardened faeces, which often accumulate in the rectum, and become so impacted that the patient is unable to force them out. But pins, needles, fish and chicken-bones, &c, may be removed with more facility by the forceps than any other instrument. In the extraordinary case reported by Marchetti, and detailed above, a most ingenious and successful expedient for the removal of the pig's tail, and the only one that could have been practised with probable suc- cess, was resorted to—the introduction of the end of the tail, hanging from the rectum into a reed, the reed carried up the gut, made to press down the bristles, that stood like a chevaux- de-frise, and then the removal of the reed with the tail enclosed in its cavity. " Le sixieme jour on eut recours a Marchettis: ce practicien instruit de tout ce qu'on avoit fait, inventa un pro- cede fort simple, mais fort ingenieux; il prit un roseau creux long d'environ deux pieds, il le prepara par une de ses extre mites de maniere qu'il put Pintroduire facilement dans I'anus, et enfermer entierement la queue de cochon dans ce roseau, pour la tirer ensuite sans causer de douleur; dans ce dessein il at- taeha a cette queue, par le bout qui etoit hors du fondement, un gros fil cire, et le passa dans le roseau; il poussa d'une main cette espece de canule dans le rectum, et il retenoit de l'autre, le fil, pour ne pas repousser la queue en enfoncant le roseau dans le fondement: il parvint a enfermer entierement cette queue dans la cavitie du roseau, et delivra promptement la ma- lade, tant du danger de la mort que de l'etat cruel ou. elle se trouvoit; elle rendit sur le champ une tres grande quantite de matieres stercorales qui avoient ete retenues pendant six jours par le corps etranger." In ancient times, when barbed arrows were U6ed instead of fire arms, an instrument somewhat similar to Marchetti's reed, was employed for removing them, in order to prevent the flesh from being torn during the extraction. There are many occasions, even now, when similar contrivances may prove useful. For the removal of ascarides from the rectum, I have em- ployed the bullet scoop, or a small instrument resembling a mustard spoon. I was first led to make the experiment by finding the disease to be exceedingly common, and sometimes productive of so much distress to the patient as to render life almost a burden. The scoop being oiled and introduced Foreign Bodies in the Rectum. 167 into the rectum, was found to bring away one or more of these animals enveloped in its appropriate nidus, and to relieve at once the intolerable itching so annoying to the patient. Adults can use the instrument themselves, with the greatest facility, and are always directed to the spot where the animal is situated, by the itching and pricking sensation which it creates. Chil- dren will require the assistance of a physician or skilful nurse. Incredible quantities of these troublesome insects may be taken away in a short time, by this simple expedient—where me- dicines might be employed for months, and at last fail. Consult Memoires de VAcademie Chirurgie, torn. 3d, Precis Observations sur les Corps Etranger, &c, par M. Hevin, Dictionnaire des Sciences Medicates, torn. 7th, p. 35—On Painful Constipation from indurated Faeces, in Lond. Med. Obs. and Inq. vol. 4ypr 123—Case of a Fork thrust up the Anus, and extracted, in Phi- losophical Transactions, abridged, 1725—Harrison's Case of Apple Core, forming a Fistula in Ano eight Months after being eaten, Memoirs of Medical Society of London, 1796—Blair's Case of hard Toast arrested in the Anus, in Medical Facts and Observations, vol 6—Gregory's Case in which Death followed from a Fish-bone- lodged for Years in the Rectumy in Monro's Morbid Anatomy of Stomach and Gul- let, p. 22, Ed. 1811, 168 Diseases of the Tunica Vaginalis and Testis. CHAPTER VII. DISEASES OF THE TUNICA VAGINALIS AND TESTIS. Having treated on a former occasion* of cancer and of fungus haematodes of the testicle, and described the treatment and ope- rations necessary for each, some other affections of these organs will be noticed. These are hydrocele, haematocele, chronic en- largement of the testis, irritable testis, encysted testicle, tumours of the scrotum, &c. Among surgical writers, accounts will be met with, of the cedematous hydrocele or dropsy of the scrotum, of hydrenterocele or hydrocele combined with intestinal her- nia, of encysted hydrocele of the spermatic cord, of the conge- nital hydrocele. These, however, are either the result of other diseases, or are so analagous, in many respects, to common hy- drocele, as not to require minute consideration. Section L Hydrocele. The tunica vaginalis is naturally bedewed with a thin serum, which, by lubricating its surface and that of the testicle, enables them to move freely upon each other. This fluid, when se- creted in undue quantity, constitutes hydrocele—a disease of frequent occurrence, and met with in patients of every age and constitution. If attended to in the commencement, the tumour •Vol. I. pages 191 and 197. Hydrocele. 169 will be found to occupy the lower part of the scrotum, and gra- dually to extend towards the abdominal ring. In shape it is pyriform, and to the touch elastic—feeling like a bladder dis- tended with water. When pressed upon, little or no pain is experienced by the patient, except at the posterior part of the swelling where the testis is situated. The rugae of the scro- tum generally remain unaltered, even in hydroceles of the greatest magnitude, and sometimes the tumour attains an enor- mous bulk. In ordinary cases, however, the tunica vaginalis seldom contains more than a pint of fluid. This fluid, in colour, is either perfectly limpid, or else yellowish. The disease is usually confined to one side. It is sometimes difficult to dis- tinguish between hydrocele and other complaints that bear a resemblance to it. Much may be learned from the history of the disease. The hydrocele invariably begins below, and very gradually ascends. The swelling in sarcocele, or scirrhous testicle, is uniform throughout, is accompanied with pain, is in- elastic, and heavier when handled than hydrocle. When re- cent, hydrocele is generally transparent, if examined by placing the tumour between a lamp and the surgeon. From hernia it differs materially—the one commencing above, the other below. In hernia, moreover, an impulse is communicated to the finger when the patient is directed to cough. This is not the case with hydrocele. The causes of hydrocele are very uncertain. By some the disease is attributed to urethral excitement, by others to varicose enlargement of the spermatic vessels, to blows upon the scrotum, to rheumatism, cold, &c. I have met with it in infants immediately after birth. Hydrocele is often conjoined with enlargement of the testicle—constituting the disease called hydro-sarcocele. It occasionally happens that the cavity of the tunica vagina- lis is occupied by one or more hydatids, or cysts filled with transparent fluid; and that the tumour bears so close a resem- blance to common hydrocele as to be mistaken for it readily. A few cases of the kind I have met with, both in young and old subjects. Sometimes the two diseases exist simultaneously, and occupy the same tunica vaginalis. In other instances the hydatids are connected with the epididymis, or substance of the testicle, and protrude when the tunica vaginalis is opened by a trocar or lancet. 170 Hydrocele. Hydrocele of the spermatic cord is now and then met with. It usually appears as a rounded, or oval tumour, in the site of the external abdominal ring; or it may be situated in the abdominal canal, between the internal and external rings. It is elastic to the touch, and retires in such a way, from the finger, as to give the idea of the existence of hernia, with which it is often confounded, even by experienced surgeons. A man forty years of age in the Aims-House Infirmary during the winter of 1833, had a tumour the size and shape of an egg, which occupied the left cord below the external ring. It was pronounced by some a hernia, by others, a varicocele. I was satisfied, however, by its not retiring with a guggling noise, by its being free from pain and by its transparency and bluish colour, that it was a hydrocele of the cord, and so it turned out to be; for, upon thrusting a lancet into it, nearly an ounce of limpid serum was discharged. Under the title of congenital hydrocele, a variety of that dis- ease was first described by Vigurie and Desault, and was as- certained by them to be owing to the communication being kept up between the abdomen and tunica vaginalis, so that wa- ter accumulating in either of those cavities, might pass freely from one to the other. This form of the complaint is by no means uncommon; but is not confined to children. Hence, the term congenital is not strictly correct It may be distinguished from common hydrocele by the fluid retiring into the abdomen when the patient is in the recumbent posture, and by its reap- pearing with more or less fluctuation in the erect position. The complaint is sometimes complicated with hernia. Treatment of Hydrocele. In very young subjects, and in recent cases, I have sometimes succeeded in removing the disease by purgatives, and by bath- Hydrocele. ]7| ing the tumour repeatedly with a mixture of sal ammoniac and vinegar. Sir Astley Cooper recommends, in similar cases, a sus- pensory bandage moistened with muriate of ammonia and liquor ammoniae acetatis, two drams of the former to six ounces of the latter; and, after using it for awhile, to add to the mixture tinc- tura lyttae, or to apply tincture of iodine, in case the fluid is not absorbed. In the majority of instances, however, an operation will be required. This is either palliative or radical. The former may prove necessary when there is any doubt respecting the nature of the disease, or it may be performed to diminish the size of the swelling, and thereby enable a patient to pursue a journey without interruption. In a short time the fluid accu- mulates again; and, if necessary, the operation may be repeated. A common lancet, or a small troear, answers equally well for the operation. The radical cure of hydrocele has been attempted in various ways—by laying open the tunica vaginalis, by passing a seton through it, by applying caustic to the surface of the tumour, by extirpating a part of the tunica vaginalis, by the introduction of a tent, and by the injection of the cavity of the sac, after having drawn off its contents. The latter operation is the one practised by most modern surgeons, and when properly per- formed, is generally successful. The patient being seated on the edge of a bed, or table, with his thighs separated, the operator sits before him, and grasps the tumour so firmly with one hand as to render it perfectly tense, while with the other he introduces a trocar of moderate size, covered by its cannula, obliquely upwards and inwards, into the front of the tumour, near its lower part.* The trocar, thus held, is made to penetrate the integuments of the scrotum, and the tunica vaginalis, to the depth of an inch and a half, and is then withdrawn, leaving the cannula behind, through which the fluid is immediately discharged. The nozle of a syringe, or gum * The opening is made in this situation, and the instrument directed obliquely with the vie w of avoiding the testicle, which is usually situated posteriorly. B ut it should be remembered that the testicle is sometimes placed in front, and will, there- fore, be wounded if the above direction is followed. To avoid so unpleasant a consequence, the operator must endeavour beforehand to ascertain, if possible, its exact position. 172 Hydrocele. elastic bag, is next adapted to the mouth of the cannula, and an injection, consisting of two parts of port wine, and one of water, thrown into the tunica vaginalis until it is distended to the size of the original tumour. The length of time the injection should be permitted to remain, must depend upon the patient's feelings. In general, a pain will be felt along the cord, extending into the abdomen; and when this becomes very severe, the wrine and water must be evacuated; on the contrary, if the patient, as I have sometimes noticed, should experience no pain whatever, the injection may be renewed, and its strength increased. It only remains to withdraw the cannula, and close the wound by a bit of lint. In a few hours the parts swell, sometimes enor- mously, and may require the application of a poultice, the anti- phlogistic system, and the recumbent posture. But the swell- ing usually subsides in four or five days, and a cure is accom- plished through the medium of adhesion—the tunica vaginalis being made to coalesce with the proper coat of the testicle. This operation, trifling as it is usually considered, is some- times, from inattention on the part of the surgeon, followed by serious consequences, owing to the end of the cannula being permitted to slip from the cavity of the tunica vaginalis, and rest among the cellular membrane of the scrotum, into which the vinous injection will pass, and, by exciting most violent inflammation, cause gangrene and sloughing of the scrotum, and denudation of the testicles. This has repeatedly happened to surgeons of the first eminence, and should be most carefully guarded against. Sir Astley Cooper mentions an instance in which a patient, from this cause, died in about a week after the operation, and I myself have known of one case of the kind, and heard of another in this country. If the operation of hydrocele, above described, should fail, as sometimes happens, it may be repeated; or the plan of Hun- ter may be pursued—which is simply to make an incision an inch long, into the upper and front part of the tunica vaginalis, evacuate the water, and sprinkle a little flour into the cavity. This generally excites the requisite degree of inflammation; and, after this purpose is accomplished, the flour may be washed out, or permitted to escape along with the pus. This operation, however, is followed, sometimes, by violent Hydrocele. 173 inflammation, and, in old people, by gangrene and death. In other cases the suppuration is so profuse that the tunica vagina- lis is filled with matter. But I have known the same to follow, in one instance, the operation by injection. I performed, No- vember 22d, 1835, the operation for hydrocele on a negro fifty years of age, at the Aims-House Infirmary. Nearly three pints of fluid were drawn off and the vinous injection thrown in. The wound made by the trocar healed up, but the swelling did not subside, and the patient's constitution was rapidly sinking. On the 22d of December, I pushed a lancet into it, and evacuated nearly a quart of thick offensive pus, and in a short time the man recovered perfectly. I have had occasion to repeat the operation by injection two or three times in the same individual, and, at last, only have succeeded by using spirits of wine, or turpentine, along with the port wine; and although no injurious consequences followed, yet I am not inclined to recommend the practice, but have pre- ferred, latterly, where the injection has failed, not to repeat it, but to resort to the seton, of which, under all circumstances, I entertain a very favourable opinion. The plan I pursue is very simple. The water being drawn off, in the usual way, by a tro- car, I permit the cannula to remain, and pass through its cavity a small narrow seton needle, six inches long, armed with French braid, and, pushing the needle through the tunica vaginalis and scrotum, introduce the braid, and remove the cannula and needle—leaving a space of two or three inches between the ori- fices where the ends of the braid emerge, and tie the ends loose- ly together. Perfect cures having invariably resulted from this practice, in my hands, I have resolved, in future, where I have reason to believe that the requisite degree of inflammation will not be excited by the injection, to employ the seton at once, and from the first. Indeed, I see no good reason why it should not supersede the injection in all cases; for in the hands of the celebrated Pott, and others, it scarcely ever failed; and was never followed, so far as I am acquainted, with serious conse- quences. In general, it will be sufficient to permit the seton to remain ten days, or a fortnight, and during that time no attempt should be made to draw it backwards and forwards, which would only create unnecessary pain and inflammation. Of the other methods of treating hydrocele—excision, caus- Vol. II. 23 174 Hydrocele. tic, and the tent, I do not speak, because they are acknowledged, by all modern surgeons, to be either very severe or else inert. Where hydatids occupy the tunica vaginalis, and fill it en- tirely, (a disease which cannot be distinguished, always, pre- vious to operation, from common hydrocele,) the surgeon will discover that very little fluid follows the push of the trocar, and that a membranous bag will protrude immediately afterwards from the opening. In such a case, he will find it necessary to enlarge the orifice an inch or two, and dissect away with the knife, or scissors, the different hydatids he may meet with. The operation is tedious and painful, but generally successful. In cases, however, where ordinary hydrocele is associated with two or three floating hydatids, the water must first be drawn off, and the injection, or seton, introduced, and each hydatid, afterwards pulled out as it shows itself, (which it generally does,) at the orifice, and cut off. Should any smaller hydatids remain, the inflammation that follows the injection or seton, will commonly obliterate them. If not, a small separate seton should, afterwards, be passed through them, and suffered to re- main for a few weeks. For hydrocele of the spermatic cord, either incision, or in- jection has been usually employed. The former is painful and apt to be followed by suppuration, and the latter almost sure to fail, even when repeated frequently. The seton is uniform- ly successful, and is decidedly, in every respect, the best reme- dy. Pott and other surgeons have reported cases where death has followed from laying open hydrocele of the cord. Congenital hydrocele, as improperly termed, may be cured, sometimes, by a well contrived truss, which, by obliterating through the medium of adhesion the sides of the tunica vagina- lis, shuts off the communication with the abdomen. Vigurie and Sir Astley Cooper report successful cases of the kind; but Desault, having tried the plan ineffectually, was induced to sub- stitute another proceeding, more complicated, painful, and fraught, I eoneeive, with considerable danger. He first drew off the water by a trocar, then directing an assistant to make firm pressure at the groin, injected the tunica vaginalis with warm wine, and having afterwards carefully removed every particle of wine, lest it should find its way into the abdomen, by firm compresses over the scrotum and groin, succeeded, in a short Hydrocele. 175 time, in obliterating the passage to the abdomen and in curing, at the same time, a hernia which happened to be conjoined with the hydrocele. This example, however, should not, I conceive, be imitated, on account of the risk of peritoneal inflammation from continuity of surfaces, and from the possibility of escape of the venous fluid into the abdomen. Should a truss effect a cure, by producing an hour-glass-like contraction between the belly and tunica vaginalis, it may afterwards become necessary to draw off the fluid from the latter by a trocar and perform some one of the operations for ordinary hydrocele. But expe- rience proves that the fluid is sometimes spontaneously absorbed after the communication between the two cavities has been cut off. In cases where ascites and hydrocele are conjoined, the scrotum will be found a convenient place for the operation of paracentesis. Hydrocele is removed, occasionally, by a blow upon the tu- mour, and, in other instances, by ulceration, or sloughing, from slow inflammation, or over-distention. I once performed the pal- liative operation upon a gentleman, and after the lapse of a few weeks, when the fluid accumulated again, ulceration took place at the spot pierced by the trocar, and left for a few days a fistulous orifice, from which the fluid drained off. In a few days the fistula closed and the fluid was again secreted, and again discharged, in a similar way; and after the process had been repeated several times, a cure was effected. Something similar occurred in a patient upon whom I operated for stone; for in twelve months after the operation the perineum ulcerated at the place of inci- sion and a lump of calculous matter was discharged from the bladder alonf with urine. The ulcer then healed up of its own accord, and the patient never had a return of his complaint. 176 Hematocele. Section II. Hcematocele. This disease, as its name implies, is a collection of blood—si- tuated either in the tunica vaginalis testis, within the tunica al- buginea, or in the cellular membrane of the scrotum. It may arise, according to writers, from several different causes—from wounding one or more of the large veins of the scrotum in per- forming the operation for hydrocele,—from wounds of the ves- sels of the scrotum, during the operations of lithotomy and castra- tion,—from rupture of branches of the spermatic vein,—from spontaneous rupture of a vessel within the tunica vaginalis, after the water of hydrocele has been drawn off,—from blows or inju- ries of the vessels of the testis, and, consequent extravasation of blood within the tunica albuginea. The disease may be distinguished, generally, from hydrocele, by its great weight and solid feel, by its want of fluctuation and transparency, by its often following the operation of hydrocele, or arising suddenly from a blow, and, sometimes, by the ap- pearance of extravasated blood in the cellular membrane of the scrotum. Treatment of Hematocele. Unless the extravasation of blood should be very considerable, it will probably be absorbed in a short time. If, in this respect, Hematocele. 177 however, the surgeon is disappointed, an incision may be made into the part that contains it, and the coagulum extracted; after which, the parts will granulate and fill up. If any particular vessel continue to pour out fresh blood, it must be searched for and secured by ligature. During the winter of 1830,1 attended a patient in the Alms-house Infirmary, whose scrotum was distend- ed to an enormous size. Upon opening the tumour, I found a large collection of blood mixed with serum. Three weeks previously, the patient had undergone the operation for hydrocele, and the surgeon who performed the operation had, in all probability, wounded with the trocar some large artery or vein. The man recovered perfectly in a short time. Effusion of blood under the tunica albuginea, is considered by Pott, and some other writers, as requiring castration; but, as I conceive, without foundation. There is, indeed, more reason to apprehend that the surgeon may be too prompt in performing this operation; for cases have been reported where the testicle has been extirpated and found upon examination perfectly sound. Sir A. Cooper, in particular, mentions an instance where a surgeon mistook a common haema- tocele for a diseased testis, and had so little curiosity, after cas- trating the patient, as not to examine the part. When dissected by Sir Astley, blood only was found in the tunica vaginalis, and the testicle in its natural situation and free from disease. On Hydrocele and Hematocele, consult Pott's Works, by Earle, vol. 3—A Treatise on Hydrocele, by Sir James Earle, 1803—Bell's Operative Surgery, vol 1, p. 193—Ramsden's Practical Observations on Sclerocele, 1811—Dorsey's Surge- ry, vol. 2__Richerands Nosographie Chirurgieale, torn. 4, p. 262 and 258—Scarpa on Hernia, by Wishart—Observations on the Structure and Diseases of the Testis, by Sir Astley Cooper, 4to. 1830. London. 178 Irritable Testis. Section III. Irritable Testis. This disease has been particularly described by Sir Astley Cooper, under the title of irritable testis. It is a most severe and distressing affection, but, fortunately, not very common. Sometimes it follows hernia humoralis, or common inflammation of the testicle induced by injuries, though not, perhaps, un- til the inflammatory symptoms have disappeared for months; at other times it comes on without evident cause, and may occur in persons of vigorous and healthy constitution. But, on the other hand, it is occasionally, preceded, or followed, by paralysis, or derives its origin from the brain or stomach. That one or more of the nerves of the spermatic cord may be materially im- plicated in this affection is not improbable. The symptoms are excessive pain in coitu, pain in the groin and back, exquisite tenderness in the whole testicle, particularly upon the slightest motion of the testicle or any pressure that may be made upon it, by the clothes in walking. There is scarcely any general swell- ing, or enlargement, of the testicle, nor is the uneasiness or pain diffused throughout the gland. On the contrary, there is some- times diminution of the testis, and the pain occupies a single spot or point and may shift from one part to the other in an instant. The cord is frequently the seat of suffering, and from it to the testicle, the pain darts backwards and forwards, like a flash of lightning. The recumbent posture, on the side opposite the disease, is the only one the patient can generally bear. Nausea, vomiting, mental dejection, and extreme bodily distress, are apt to follow long-continued attacks of the disease, and in some instances months and years wear away without any perceptible amendment or alleviation of the sufferings. When removed and examined by dissection, the testicle is found unaltered in structure, and apparently sound. In other cases, it is entirely Irritable Testis. 179 absorbed with the exception of the tunica albuginea, and tunica vaginalis. This atrophy, however, I have known to follow other affections of the testis, particularly hernia humeralis and that enlargement of the gland produced by cynanche parotidea, or mumps. In all the cases of the kind I have met with, one testis, or both have wasted away gradually, the pain has subsided and the patient recovered. Treatment of Irritable Testis. If the disease should reach the height I have described, it can seldom be removed except by the operation of castration. When only of afew weeks' duration,and the symptomsare moderate, be- nefit may be obtained, and a cure sometimes effected, by the in- ternal use of carbonate of iron, arsenic, ammonia, quinine, cam- phor, opium, cicuta, stramonium, belladonna, compound decoc- tion of sarsaparilla, and by the local application of blisters to the groin and thigh, and tincture of iodine, and pyroligneous acid, ice, &c, to the scrotum. Blood-letting, low diet, purga- tives, and other parts of the antiphlogistic system, generally ag- gravate the complaint. 180 Chronic Enlargement of the Testis. Section IV. Chronic Enlargement of the Testis. From inordinate indulgence in venery, or masturbation, from any urethral excitement, from exposure to cold, from fatigue or mental inquietude from intemperance, and from various constitutional causes, chronic inflammation is set up in one or both testicles, and is so insidious in its approach and so gradual in its advances, as often to escape the notice of the pa- * tient and to deceive the surgeon. In particular, even after the disease has existed for weeks, or months, the testicle may be handled roughly without exciting pain or any unpleasant sensa- tion. Indeed, in many instances, the testicle attains a consider- able magnitude, and yet is entirely devoid of uneasiness. The swelling commences in the epididymis, which slowly hardens and enlarges. From the epididymis it extends to the body of the gland, and both preserve their natural smoothness and shape. Both testes may be simultaneously affected, or the swelling may remain stationary in one and increase in the other. With the swelling, a hydrocele is often conjoined. The patient's ge- neral health is apparently good, and he is seldom debarred from exercise, or prevented from attending to his business. In this state of the disease, it often happens that a blow, or some other injury, is received, or that the patient has been drinking to ex- cess, or exposed to cold, and from that moment great pain, and swelling, take place in the testicle, which are soon followed by pain in the loins, febrile excitement, &c. By the use of appro- priate remedies these symptoms wholly subside, and for weeks, or months, the patient remains, apparently, well. He is very lia- ble, however, to a repetition of the attack, and should this occur Chronic Enlargement of the Testis. 181 frequently, suppuration is established in the body of the testicle or epidydimis, and the matter, of its own accord, at last dis- charged through the scrotum, or let out by the surgeon. A sinus ending in a fistulous orifice, soon follows, and from this a discharge of seminal fluid issues, sometimes, in consi- derable quantity, and is kept up, not unfrequently, for many months. From the mouth of the sinus, granulations in a fungous form, sprout forth, and often become very luxuriant Indeed, in this, and other respects, there is reason to believe that chro- nic enlargement of the testicle, corresponds with fungus of that organ, described in former editions of this work. Treatment of Chronic Enlargement of the Testis. In the commencement of this disease, or even after consider- able swelling of the testicle has taken place, strict confine- ment for several weeks, to the horizontal position, elevation of the testicle above the pubes, and retention there by a bag truss, the application of leeches, followed up by cold satur- nine solutions, or camphorated mixture, and vinegar, or the acetated liquor of ammonia, together with low diet, occasion- al purgatives, the internal use of mercury, and avoidance of ve- nereal excitement or indulgence, will often effect a perfect cure. But, should the patient afterwards neglect himself, and have repeated returns of the complaint, and suppuration of the testis, discharge of semen through fistulae, and fungous granulations follow, extirpation of the testicle, will, in many cases, be required, and, indeed, will often be insisted on by the patient. In other cases the fungous granulations may be re- pressed by caustic, or should be cut away with the knife, or kept down by pressure, whilst injections of solution of sul- phate of copper and other similar articles are thrown into the sinuses, to consolidate their sides and close the fistulae. It should Vol. II. 24 182 Chronic Enlargement of the Testis. be remarked, however, that the operation of castration has of- ten been performed, unnecessarily, for chronic enlargement of the testis, under the idea of its being a specific or malignant disease, which, in reality, it is not, as is proved by the circum- stance of the cord not being liable to contamination, as it al- ways is in the advanced stages of cancer of the testicle, &c. Encysted Testicle. 183 Section V. Encysted Testicle. Cysts, containing a yellow, transparent serum, or else a tur- bid gelatinous fluid, are found to occupy, occasionally, the sub- stance of the testicle within the tunica albuginea. They vary in size, some being not larger than a shot, and others equal in bulk to a pistol bullet The fluid contained in the larger ones is thick and muddy, and in the smaller transparent Both the tunica vaginalis and albuginea are thickened, and, in cases of long standing, the substance of the testicle in a great measure removed, and its place occupied by the cysts. According to Sir Astley Cooper, these cysts are probably enlargements of the seminiferous tubes, and not animal hydatids. Patients from eighteen to thirty-five years of age are most subject to the complaint, which, however, is rather uncommon than otherwise, and very liable to be confounded with other af- fections of the testicle, particularly with hydrocele. But the most striking symptoms of hydatid testicle are—conspicuous distention of the veins of the scrotum and spermatic cord, no tenderness, or pain, in the commencement of the disease, or even in the advanced stages, unless the part be forcibly squeezed, and then sickness of the stomach, pain in the groin, and that peculiar sensation which follows pressure on a sound testicle, arise. The testicle, too, retains its natural, or rounded shape, is heavier than usual, has a very obscure and limited sense of fluctuation, and the epidydimis preserves, generally, its natural line of demarcation. In the end the tumour becomes enormously large, but the cord and inguinal glands are never contaminated. Lastly, there is no transparency in the tumour. This, together with absence of distinct fluctuation, and the rounded, instead of 184 Encysted Testicle. pyriform, shape of the swelling will be sufficient, in most cases, to distinguish the disease from hydrocele. Nevertheless, the most experienced surgeons have been frequently deceived, and have confounded one with the other. Treatment of Encysted Testicle. Before giving a decided opinion, the surgeon should make it a rule to puncture with a lancet every tumour bearing a resem- blance to encysted testicle. In case a few drops of fluid issue mixed with blood, the nature of the disease will, generally, be made manifest. It will then become a question whether cas- tration should be performed or not. When the tumour is im- mensely large and is inconvenient, or so unsightly as to annoy the patient, it may be removed; but, on the contrary, when it remains stationary for years, and the patient's mind is not filled with apprehension as to the termination of the case, he should be advised to submit with Christian resignation to his misfortune and to palliate the complaint as long as possible. On the other hand, should he determine, after mature deliberation, to lose the testicle, the surgeon has it in his power to assure him of the safety of the operation, and that the disease (which is not of a malignant nature,) will not return. It may happen, however, to be conjoined with fungus hsematodes, and in that case an operation will prove fruitless. Tumours of the Scrotum. 185 Section VI. Tumours of the Scrotum. Sarcomatous, and other indurated, growths are met with, occasionally, in the cellular texture of the scrotum, which some- times are scattered about in the form of small tumours, which feel like a marble or piece of cartilage beneath the skin, being either firmly fixed or moveable; at other times the whole tex- ture of the scrotum seems to undergo a change, becomes unusual- ly corrugated, thickened, and finally converted into enormous indurated masses. Such are often seen in the West Indies and in Egypt, and interesting cases of the kind have been reported by Larrey, Titley and others, but are rarely met with in the United States. When a single sarcomatous, or adipose tu- mour occupies the scrotum, or the outer surface of the tunica vaginalis, or is imbedded in either of these textures, it often presents the appearance of a third testicle, and has been so con- sidered by ignorant persons. An interesting case of the kind occurred several years ago in the practice of Dr. Heister, an eminent physician of Reading, in this state. The tumour had existed for a long time, was of the shape of a testicle, but much larger, and was so situated between the testes as to inspire a be- lief on the part of the patient and his friends that it was really a third testis. Upon being removed, however, by Dr. Heister, it was found to be lodged in a cyst between the scrotum and tu- nica vaginalis, and to consist of adipose and fleshy matter. The preparation, obligingly presented to me by Dr. Heister, is still in my cabinet. 186 Tumours of the Scrotum. Treatment of Tumours of the Scrotum. Those enormous growths described by Larrey, Hendy, Tit- ley, Delonnes, &c, although supposed to derive their origin from an incurable disease—elephantiasis—have been extirpated, nevertheless, with success. In particular, Titley removed, ef- fectually, from a West Indian negro, a stupendous tumour, in the interior of which the genitals had long been buried, and which reached nearly to the ground, and weighed seventy pounds. Others of still greater weight and dimensions have been reported, and are said to have been successfully cut away. In performing such operations, the surgeon should endeavour, if possible, to ascertain the condition of the testes and penis, in order not to injure, or remove them unnecessarily. When small tumours occupy the scrotum or surface of the tunica vaginalis, they do not always require extirpation; but, when necessary, the operation is easily performed, and a cure soon effected. I have known, however, very large sarcomatous thickenings of the scrotum, and tunica vaginalis, and also enormous hydro-sarco- celes in West Indians removed in a short time by a change of re- sidence. In December, 1816, Captain D----was recommended to my care by Robert Harrison, Esq., United States consul for the Island of St. Thomas, on account of an immense scrotal tumour which involved each testicle and spermatic cord, and was com- plicated with hydrocele. The patient stated that from long re- sidence in Martinique and other islands, where he had been ex- posed from the nature of his occupation to hardships, and had drunk constantly of rain water, which was often in an impure state, his disease, as he believed, was to be attributed. Whilst the patient was arranging his affairs and recruiting his health, to enable him to undergo an operation, the tumour gradually subsided, and in the course of two or three months was entirely absorbed—and all the parts affected restored to their natural state. Tumours of the Scrotum. 187 Consult, on Diseases of the Tunica Vaginalis and Testis, Pott's Works, by Earle, vol 3d—A Treatise on Hydrocele, by Sir James Earle, 1803— Bell's Opera- tive Surgery, vol 1, p. 193—Cooper's Lectures by Tyrrel, vol 2d, p. 86—Obser- vations on the Structure and Diseases of the Testis, by Sir A. Cooper, p. 165— Ramsden's Practical Observations on Sclerocele, 1811—Richerand's Nosographie Chirurgieale, tom. 4th, p. 258 and 262—Observations on a peculiar Affection of the Testis, attended with the Growth of Fungus from that Organ, illustrated with Cases by W. Lawrence, in the Edinburgh Medical and Surgical Journal, vol 4, p. 257—Wadd's Cases of Diseased Prepuce and Scrotum, 4to. 1817—Larrey's Surgical Memoirs—Case of Extraordinary Enlargement of the Scrotum, by J. M. Titley, in Medico Chirurgical Transactions, vol. 6, p. 73—Delonnes' Case of Charles Delacroix, in Richerands Nosographie Chirurgieale, tom. 4th,p. 315. 188 Diseases of the Penis. CHAPTER VIII. Diseases of the Penis: A mistake into which writers, as well as practitioners, are extremely apt to fall,—that the penis, with one or two excep- tions, is subject only to specific disease—should be corrected. Possessing the same texture and organization, (modified by cer- tain peculiarities) as other soft parts, why should it not be lia- ble to the same infirmities? That it is so, experience, our safest guide, has, sufficiently, proved; for, wounds and other injuries, simple and erysipelatous inflammations,—excoriations—ab- scesses,—ulcers, simple, irritable, and indolent,—warts,—tu- bercles,—tumours, sarcomatous, encysted, steatomatous—her- petic and other eruptions, totally unconnected with syphilitic taint, or with other specific vitiation, sometimes the result of sexual intercourse, at other times entirely independent of it, the consequence often of abrasion, or mere mechanical injury, have been, always, more or less common, in every country and in every age. It is not my intention, however, to treat of all these affections, but chiefly of simple ulcerations, of phymosis, paraphymosis, &c. Chancre, or the true syphilitic sore, has been noticed on a former occasion.* * See vol. 1, p. 226. Wounds of the Penis. 189 Section I. Wounds of the Penis. The penis is liable to incised, lacerated, contused, gun-shot and other varieties of wounds. They may be the result either of design or accident, and numerous instances have been report- ed where maniacs, and persons under the influence of religious phrensy or hallucination, have removed both the penis and tes- ticles. An extraordinary instance where an attempt was made, under a different feeling, to inflict a punishment of this descrip- tion, occurred not long since, in the practice of an eminent sur- geon of New York. A woman who had long lived unhappily with her husband, and from whom she had been separated for a considerable time, became, apparently, reconciled to him, and through the intervention of friends the parties consented to re- new their nuptial intercourse. Prompted, however, by jealousy and a diabolic spirit, the virago, having provided herself with a razor, took it to her bed, and while her unfortunate Abelard was in the act of consummation, seized the penis, and with her weapon nearly severed it from his body. The penis has been shot off in duels, or swept away by can- non or musket balls or grape-shot, or so bruised and lacerated by these and other missiles, that it has afterwards sloughed and been lost. A severe bruise, or contusion, may likewise pro- duce a different effect or lay the foundation of a specific disease as in the following case. " I. Wallace," says Sir Everard Home, " a married man, thirty-seven years of age, stout-made, subject to no general or particular complaints, and by profession a sailor, was admitted into St George's Hospital, under my care, November ISth, 1803. About four years since, during a violent storm at sea, the main top-mast was shivered, and the upper portion was swinging backwards and forwards. It was Vol. II. 25 190 Wounds of the Penis. necessary to cut away the upper piece, and W allace was sent aloft for that purpose. He had on a pair of loose trousers at the time. The rolling of the ship was very great, which in- creased the motion of the mast, and while he was clinging to the standing part, his glans penis was caught between it, and the loose piece; he immediately fainted away and fell into the round top, from whence he was carried to the deck. On re- covering, he was informed by his companions that when they first took him up his glans penis was as flat as a half crown. The body of the penis and both testicles, as well as the glans, began to inflame and swell, and were extremely painful. He kept his bed for three weeks, at the end of which time the glans had recovered its natural size and figure, having only a small pimple on that part to which the fraenum is attached. This was considered of no consequence, and was not at all trouble- some until his arrival in England, six months afterwards, when it began to ulcerate and become very painful. It is proper to remark that he never had the venereal disease, and from the time of the accident never had intercourse with his wife or any other woman."* From that period the ulceration increased, assumed the cancerous form, involved the greater part of the penis and groin, and after the lapse of a year proved fatal. Treatment of Wounds of the Penis. In cases of incised or lacerated, wounds of the penis, the hemorrhage should be arrested by picking out the vessels with the tenaculum, or needle, and tying them, or by introducing a catheter into the urethra and making firm compression with a bandage on the penis. After the hemorrhage has ceased, the edges of the wound must be drawn together by the interrupted suture, and supported by adhesive straps. The bandage should * Home on Cancer. Wounds of the Penis. 191 then be slackened or removed, as, if long continued, it will be apt to cause swelling and to excite erections. When the urethra is divided and the penis nearly cut through, as in the New York case, the catheter must be continued until reunion is established; otherwise, effusion of urine and sloughing may follow. Con- tused wounds of the penis will require poultices and fomen- tations, and after full benefit has been derived from these, should ulcerations remain, mild dressings, such as are used in simple ulcers in other parts of the body, may be resorted to. But, in all injuries of the penis, an important indication is to repress erections—by the internal use of camphor, dulcamara, &c. 192 Ulcers of the Penis. Section II. Ulcers of the Penis. The loose skin covering the glans, as well as that on the body of the penis, is subject to phlegmonous inflammation and abscess, which seldom, however, forms a large tumour,but upon breaking, or being let out with a lancet, discharges freely, and leaves an ill- conditioned sore, with an indurated margin, and excavated edge. The whole aspect of the ulcer, indeed, is at first so unfavoura- ble as to cause it to be mistaken for chancre; though the rapid progress towards amendment, and the speedy filling up of the sore, will soon evince its true character. The Ulcus Erraticum is met with, almost invariably, in persons of bad constitution, in dram drinkers, and in those who have suffered from the abuse of mercury. It may follow sexual intercourse or not, and is distinguished, generally, by this pecu- liarity—that the sore, which usually occupies the body of the penis, ascends in a spiral form, and, while it heals below, breaks new ground above, and in this way may encircle the penis, reach the groin, and pubes, and devastate them. The edges of the ulcer are everted and indurated, the granulations foul, and the pain severe and burning. Psoriasis Preputialis is an affection almost peculiar to those individuals who have the prepuce unnaturally long, tender, and succulent It appears in the shape of deep fissures, or cracks, which pervade the edges of the prepuce, discharge at first a co- hesive, and afterwards a purulent matter, bleed freely upon being irritated, are excessively tender or painful, and difficult to heal. Herpes Preputialis differs from the foregoing affection in toto. It commences in the form of vesicles, which, upon breaking, leave, when situated on the inner surface of the prepuce, a small round yellowish white ulcer, and when it occupies the outer skin of the prepuce, forms a scab. Each vesicle has its corre- Ulcers of the Penis. 193 sponding sore, which often unites with those adjoining it, until one unbroken surface of ulceration is established. From expe- riments made by Mr. Evans, it appears that the sore is not con- tagious. The same writer imputes the disease to derangement of the digestive organs. Excoriatio, or abrasion of the cuticle of the glans penis or prepuce, may be the result of inordinate friction, of preternatu- ral tenderness of parts, of undue secretion of that whitish, cream- cheese like, sebaceous matter, which seems almost peculiar to certain persons, of filth, or want of accurate ablution, of connex- ion with foul and unwholesome women, particularly such as have laboured for years under flupr albus and other acrimoni- ous discharges, of extraordinary inequality of size between the male and female genitals, &c. From any of these causes, trou- blesome ulcerations may arise, and are often confounded with syphilitic sores. But their external characters are sufficiently marked, in general, to enable a careful surgeon to distinguish them from other ulcerations. In particular, these ulcers are su- perficial, irregular, in separate patches, of a yellowish hue, in the commencement, but surrounded, in the advanced stage, by a red areola. Extraordinary itching, together with undue serous or purulent secretion, followed, in some instances, by sympathe- tic enlargement of the inguinal glands, are the remaining symp- toms. Treatment of Ulcers of the Penis. Phlegmonous inflammation of the penis is rarely susceptible of resolution. The sooner, therefore, the matter is evacuated by a lancet, the better. An emollient poultice of bread and milk, ground flax seed, and particularly of the powdered bark of slippe- ry elm, may then be applied, and renewed frequently for a day or two. Afterwards, the mildest unctuous dressings and lotions may be employed. Should fungous granulations arise, the sul- phate of copper and lunar caustic will be required. 194 Ulcers of the Penis. Ulcus Erraticum, like the common irritable ulcer of other parts, frequently proves refractory. It should be coaxed and humoured by soothing and sedative lotions, such as the acetate of lead and sulphate of zinc blended with gum Arabic and opium. Very weak solutions of argentum nitratum, and nitric acid, ex- tremely diluted, will also prove useful. Acrid and stimulating applications generally fret and annoy it. The blue pill, as an alterative, and great attention to diet, with rigid observance, in plethoric patients, of other parts of the antiphlogistic system, will sometimes do more good than all the local remedies that can be thought of. In patients prostrated by intemperance, or other causes, a system of support, or nourishment, must be instituted, and corresponding applications to the sore, and in- ternal medicines employed. For Psoriasis Preputialis, various astringent lotions and ointments are generally used, and, according to Evans, the best application is the unguentum hydrargyri nitrati, reduced to one-half its ordinary strength. Herpes Preputialis is benefited by attention to diet, by the occasional use of gentle purgatives, and by the mildest local ap- plications. Keeping the parts perfectly clean, and suffering them, when disposed so to do, to form a scab, will effect a cure in a very short time. Simple Excoriations, unconnected with specific disease, may be removed speedily, by guarding against erections, by the use of simple ointments perfectly fresh, by moderately astringent lotions, and, when the sores become indolent, by gentle, occa- sional, touches of argentum nitratum, and weak solutions of cor- rosive sublimate mixed with spirit of lavender or alcohol. Phymosis. 195 Section III. Phymosis. There are two varieties of this disease—the natural and preternatural. The former exists at birth, and is therefore congenital; the latter may occur at any period of life. In both cases the prepuce is contracted in front, and cannot be drawn backwards over the glans penis. Natural phymosis is a very common complaint, and met with under two or three different forms. Sometimes, though rarely, the extremity of the prepuce is perfectly closed, and the urine cannot pass off, but collects between the glans and pre- puce, forming a large bag or tumour. The disease is of course discovered a short time after birth, but is often not understood, and from this cause several infants have perished that might have been saved by a trivial operation. Another form of natu- ral phymosis is that in which an opening exists at the extremity of the prepuce, but so small, as not to permit the urine to escape from it with the same rapidity it issues from the urethra. Con- sequently, it collects between the prepuce and glans, and dis- tending the former to a great size, is then forced off gradually in a very fine stream, and to a great distance. If the disease should continue in this state for several years, as I have known to happen, pus and calculi may collect within the cavity of the distended prepuce, and keep up a constant irritation. But in most instances, there is no impediment to the flow of urine, no extraordinary elongation of the prepuce; yet the skin is so closely contracted around, as to prevent the patient from unco- vering the glans penis. From this, other inconveniences result. A whitish sebaceous matter collects in large quantity between the glans and prepuce, and excites so much irritation, as to pro- duce a disease resembling gonorrhoea—with which it is often confounded. Besides this, the inflammation excited by this, 196 Phymosis. or any other cause, may produce an adhesion between the glans and prepuce, which can only be relieved, and that not always, by a most severe and tedious dissection. Preternatural phymosis is commonly the result of inflam- mation of the prepuce, by whatever cause induced. The dis- ease often accompanies severe gonorrhoea, extensive chancres, and venereal warts. Sometimes matter accumulates behind the corona glandis, and is followed by ulceration of the prepuce, and a protrusion of the glans through the opening. The in- flammation attending preternatural phymosis, is sometimes of the erysipelatous kind. Extensive sloughing of the prepuce is frequently the consequence, in bad constitutions, of the con- tinued exhibition of immoderate quantities of mercury. Treatment of Phymosis. Natural phymosis, if it exist at birth, and be complete, will re- quire an immediate operation, in order to save the infant's life. A puncture with a common lancet in the most prominent part of the tumour, may answer every purpose, as the stream of urine will afterwards prevent the opening from closing. When the prepuce has become distended, from repeated collections of urine, the small opening in its extremity may be either enlarged, or the superfluous bag amputated. The latter will prove the most effectual, and should be, generally, resorted to. A simple phymosis, when only inconvenient to the patient by impeding copulation, may be relieved by slitting up the prepuce at its middle as far as the corona glandis. The opera- tion can be performed with a sharp-pointed bistoury, or still better by the sheathed knife employed by Dr. Physick for fis- tula in ano. Hemorrhage sometimes follows the incision, but in general is easily suppressed by a dossil of lint. Before the parts are dressed, the surgeon must take care to tack the two layers of skin to each other by a single stitch of the interrupted Phymosis. 197 suture. The edges of the prepuce, thus divided, retire from each other, and after they are healed, become continuous, and resemble the borders of a prepuce naturally formed. This has been denied by some surgeons, who allege that two flaps or angles are left, which afterwards prove very inconvenient to the patient. I have performed the operation very frequently, and never experienced such a result. Preternatural phymosis, when complicated with gonorrhoea or chancres and attended with high inflammation, should never be touched with the knife. The best remedies, under such circumstances, are local blood-letting, emollient poultices, fo- mentations, and accurate ablution of the glans by means of a syringe. The continuance of mercury will prove immensely injurious. After the inflammation has entirely subsided, if ad- hesions should have formed between the glans and prepuce, uniting them firmly to each other, an attempt may be made to separate them by dissection, provided the patient is willing to encounter a most severe operation, (one compared by Petit " to the skinning of an eel,") rather than submit to his misfortune. Vol. II. 26 198 Paraphymosis. Section IV. Paraphymosis. Paraphymosis is the reverse of phymosis—the prepuce be- ing retracted behind the corona, leaving the glans uncovered. The disease may be either congenital or acquired, but the latter is the most common. Sometimes it is the result of the success- ful retraction of the prepuce in cases of phymosis; but generally it proceeds from inflammation induced by syphilis or gonorrhoea. So extensive is the swelling, in some instances, and so great the constriction produced by it, that the glans penis, or prepuce, occasionally mortifies and drops off. This termination, how- ever, must be considered as comparatively rare. Treatment of Paraphymosis. If called in time, or before the swelling attains a great height, the surgeon may often succeed in restoring, by steady pressure with the fingers, kept up for several minutes without intermis- sion, the prepuce to its natural situation. The application of very cold water to the parts wTill also contribute towards the same end. Punctures, too, when there is much oedema, as generally happens, afford great relief, by evacuating the serum and reducing the swelling. This treatment, together with an observance of the antiphlogistic system, will usually effect a Paraphymosis. 199 cure in a short time; should this not prove to be the case, and gangrene of the parts be likely to follow, the division of the stricture must be attempted. To accomplish this, a fold of the skin should be raised and cut through, a director pushed be- neath the stricture, and the latter divided by a bistoury. On Phymosis, Paraphymosis, and other Diseases of the Penis, consult Petit's Traiti des Maladies Chirurgicales, et des Operations qui leur Conviennent, tom. 2—Hunter on the Venereal—Cooper and Travers' Surgical Essays, part 1, p. 145 —Richerands Nosographie Chirurgieale, tom. 4, p. 328—S. Cooper's First Lines of the Practice of Surgery, vol 2, p. 176. Wadd's Cases of Diseased Prepuce and Scrotum, 4to. London, 1817—Pathological and Practical Remarks on Ulcerations of the Genital Organs, by James Evans, Surgeon to his Majesty's 57th Regiment. London, 1819. 200 Diseases of the Urethra and Bladder. CHAPTER IX. DISEASES OF THE URETHRA AND BLADDER. Volumes have been written on these subjects; and there is scarcely an eminent surgeon of any age who has not devoted some portion of his writings to their explanation. This will show the importance of these diseases, and the difficulties en- countered in their treatment. In a work professedly elemen- tary, it will not be expected that more than a very general sketch on such topics can be furnished. Ample scope, how- ever, must be taken in the lectures—such, I trust, as will abundantly supply any deficiency that may be here met with. The diseases of the urethra and bladder, that remain to be considered, are stricture, fistula in perinaeo, enlarged prostate, retention and incontinence of urine, and stone in the blad- der. Section I. Stricture of the Urethra. This is a very common complaint; more common, indeed, than is generally imagined. It may proceed from various Stricture of the Urethra. 201 causes—from gonorrhoea, or the remedies employed in the cure of that disease; from external violence; from irritation within the urethra, produced by the passage of calculi, or the applica- tion of blisters to the perineum or other parts of the body; from excessive indulgence in venery, or unnatural prolongation of the venereal act; from enlargement of the prostate gland; from stone in the bladder, &c. It is somewhat remarkable, however, that the disease seldom makes its appearance until years have elapsed, and the effect of the causes above enumerated has ap- peared to cease. Many surgeons question the propriety of re- ferring the origin of stricture to gonorrhoea, without, I conceive, sufficient foundation; though it must be acknowledged that the disease is sometimes met with in very young boys, and in adults who have led the most exemplary lives. Strictures have usually been divided into two kinds—the permanent and spasmodic. To these Mr. Hunter added a third variety—which is alleged to consist in a combination of the two. Permanent stricture may be said to consist of a thickening or change of structure in the urethra, induced by preceding inflam- mation. That spasmodic stricture frequently exists, there can- not be the smallest doubt, though it is still a question whether the spasm should be referred to the muscularity of the urethra itself, or to the muscles surrounding that canal; a question, however, in a practical point of view, of comparatively small importance. Yet I must confess my willingness, for various reasons, to subscribe to the latter doctrine. There is seldom much variation in the seat of a stricture; which is usually found behind the bulb of the urethra—about seven inches from the extremity of the glans. At the distance of four or five inches, also, and three inches and a half, mea- suring from the outer orifice of the urethra, strictures may be often discovered. Sometimes the orifice itself is the seat of stricture. Most patients have but one or two strictures, others four or five. Strictures differ from each other in extent and consistence. The most common form of the disease is that which resembles the effect of a thread tied round the canal; it is likewise the most simple variety of stricture. Sometimes the canal of the urethra is irregularly contracted or thickened, in one or more places, to the extent of an inch and upwards. The simple 202 Stricture of the Urethra. thread-like stricture, which does not always run in a circular direction, but sometimes splits and branches, may by irritation or bad treatment be converted into a callous induration. "W hen examined by dissection, most permanent strictures will be found to consist of a dense, pure white, fibrous substance, like gristle —the result of previous and repeated depositions of coagulable lymph. The symptoms of stricture of the urethra, are constitutional and local. Among the former may be enumerated, disorder of the digestive functions, general irritability of the system, va- rious mental emotions, severe chills followed by high fever and profuse perspiration. All patients, however, are not subject to the febrile paroxysm. The most common local symptoms are, a slight discharge of matter from the urethra; a frequent desire to evacuate the urine, which issues in drops, or in a forked, twisted, wiry or thread-like stream-, nocturnal emissions; scald- ing of the urine; uneasiness about the anus and perineum. Per- sons troubled with strictures, are extremely liable to cold, which greatly aggravates the symptoms. Excess in eating or drink- ing will produce the same result. During copulation, it fre- quently happens that a stricture, by interrupting the flow of se- men, occasions it to be forced backwards into the bladder, from which it is afterwards discharged the first time the patient makes water. Stricture is often confounded with other diseases; especially with gonorrhoea, gleet, stone in the urethra or bladder, enlarged prostate, spasm of the muscles of the perineum, irritation or inflammation of the lacunae, intermittent fever, &c. Treatment of Stricture of the Urethra. In the treatment of this disease, the first object of the surgeon should be to ascertain the situation and extent of the stricture. Stricture of the Urethra. 203 This may be done by a bougie, catheter, or urethra sound.* A soft white bougie of moderate size, well oiled, will excite as little irritation as any other instrument, and is well calculated, when softened by the heat of the urethra, to take an exact im- pression, with its point, of the form of the obstruction, and of its precise situation. Over the bougie, however, in many in- stances, the urethra sound possesses a decided advantage, since from its metallic nature, and the small size of the wire rod, it communicates a vibration to the surgeon's finger, and passes easily along the urethra, while the ball at its extremity catches readily upon any irregularity of the canal, and in this way de- tects the slightest obstacle. With this instrument, moreover, the situation of several strictures may at the same time be as- certained—an advantage which the bougie does not combine. Having satisfied himself of the nature of the stricture, its po- sition and extent, the surgeon must next determine upon the means to be employed for its removal. There are three or four methods in common use—dilatation of the stricture by waxen, metallic, or gum elastic bougies,t destruction of it by the lunar or vegetable caustics, and its division by a stilet. Each is adapted to particular cases. When the strictures are numerous and of considerable length, neither the caustic nor stilet can be employed to advantage, and dilatation by the bougie must be mainly depended upon. In using this, the surgeon should make it a rule to proceed as gradually and cautiously as possible, com- mencing with an instrument of moderate size, such as will pass readily through the strictures without giving pain or exciting • An instrument invented by Sir Charles Bell, made of silver wire, twelve or fourteen inches long, having at one end a ball, at the other a ring; the former in- tended for the stricture, the latter for the surgeon to hold by while the instru- ment is introduced. •j- The finest bougies I have ever seen, were prepared by the late Dr. Balfour, of Norfolk, Virginia; a gentleman remarkable for his intellectual endowments, amiable character, and mechanical ingenuity, and whose death will long be de- plored by the inhabitants of the district in which he resided. The wonderful dexterity which he possessed in the manufacture of instruments, of every de- scription, is evinced in the splendid collection of splints and bandages, presented to the museum of our university, in 1830, by his son, Dr. Eleazer Balfour, a most promising young practitioner of Norfolk. Many of the instruments referred to are of exquisite finish and workmanship, such as would puzzle, if not defy, the best regular mechanic in the country to imitate or equal. 204 Stricture of the Urethra. hemorrhage. It should be worn morning and evening, while the patient is in bed, or at regular intervals during the day, taking care not to continue it too long, but, on the contrary, to withdraw it when undue irritation is excited by its presence. Having derived full benefit from the use of one instrument, others should be introduced, proportioned in size to the extent of the dilatation—being gradually increased. In many instances, the constant use of these instruments for a few weeks will effect a perfect cure, in other cases, months or years will elapse, be- fore the patient derives the necessary relief. Silver bougies, when well made, are better adapted to the dilatation of a stric- ture than most others. Many patients, however, experience great benefit from the use of the flexible metallic bougie. For very long and narrow strictures, I have used, with much ad- vantage, for many years past, fine, highly polished, and very flexible whalebone bougies. Caustic has long been employed in the cure of strictures. It was a favourite practice with Mr. Hunter, and has since been highly extolled by his relation Sir Everard Home. I have em- ployed the remedy for many years, sometimes advantageously, at other times, with manifest aggravation of the symptoms. From all I have seen, I am disposed to conclude, that it is only adapted to strictures of small extent—such as the thread-like stricture. That much mischief has resulted from its indiscri- minate and injudicious application, I well know; but its strong- est advocates, also, confess, that in their own hands, false pas- sages, hemorrhage, great irritation, severe paroxysms of fever, and other ill consequences, have often been induced. These remarks will apply to the vegetable as well as lunar caustic, al- though the former has been considered by some writers to be milder in its operation, and to act upon a different principle from the lunar caustic. When a stricture is very small, and situated near the extremity of the urethra next to the glans penis, and there is reason to believe, that one or two applica- tions of the caustic will go through, it may be applied in the following way. The surgeon takes a common soft bougie, oils it, carries it nimbly down to the stricture, keeps it in contact with it a few seconds, and marks with his finger nail the bougie at the external orifice of the urethra before he withdraws it. Another bougie, composed of firmer materials, is next taken, Stricture of the Urethra. 205 a hole, about the eighth of an inch in depth, scooped from its extremity by a sharp penknife, and a portion of lunar caustic inserted into it, and secured by squeezing together the edges of the hole—leaving the central part of the caustic a little ex- posed. A mark corresponding to that on the soft bougie, (which is intended to designate the depth of the stricture from the external orifice,) is then made upon the caustic bougie, and the latter, at once oiled and carried down to the stricture, and kept in contact with it, for one or two minutes, or for a shorter period, should the patient complain of its severity. In two or three days' time the operation may be repeated, and occasional- ly within the same period until the stricture gives way, or is entirely removed. The stilet, although used by some of the older surgeons in the cure of stricture, was not practised in modern times, until recommended by Dr. Physick. In 1795, he first per- formed the operation, and has ever since continued to employ the same means, and oftentimes with the greatest success. I myself have likewise succeeded, in many instances, in effecting a perfect cure, after bougies, the caustic and other means, have entirely failed. Before the clinical class in the Aims-House Infirmary, some years ago, I perforated, with the stilet, a stric- ture of long standing, near the bulb, which had resisted for se- ven years the efforts of different surgeons, to introduce an in- strument of any description into the bladder. In three minutes after the division of the stricture, a catheter entered, and the patient experienced the greatest possible relief. What renders this plan of treating strictures the more valuable, is the circum- stance of the operation being attended with very little pain, and with no risk, provided the operator possess an accurate know- ledge of the structure of the parts. The instrument used by Dr. Physick, is a sort of lancet concealed in a cannula, that may be pushed forward or retracted at pleasure. When it becomes necessary to pierce a stricture situated near the bulb of the urethra, a curved instrument should be used.* Upon several occasions, I have used with success, in strictures seated near the anterior part of the urethra, a common couching needle, rendered blunt at the point, and sharpened at its edges. After * Drawings of these instruments may be seen in Dorsey's Surgery, vol. 2. Vol. II. 27 206 Stricture of the Urethra. the division of the stricture, a bougie or catheter must be worn for some time, to prevent the passage from closing again. From the use of bougies or the caustic, it very often happens that an unnatural route or false passage is created. This is owing, generally, to unskilfulness on the part of the surgeon, or patient himself, or to the use of instruments so small as to enter the lacunae of the urethra, instead of following the natural course of the passage. When once established, a false passage is ex- tremely difficult to remove, and, on this account, great pains should be taken to guard against its formation. To the patient the disease is inconvenient, chiefly by preventing the easy in- troduction of the bougie or catheter, and sometimes, on this ac- count, dangerous, in cases of retention of urine. The best plan, in general, of destroying the unnatural route, is to use a bougie larger than the one by which the disease was created, and to bend its point towards that part of the urethra opposite to the false passage. A large catheter, very much curved, will also pass, in many instances, where no other instrument can be made to follow the natural course of the urethra. Mr. Hunter was in the habit, sometimes, of performing an operation for the re- moval of this disease; fortunately, however, such an expe- dient can rarely, if ever, prove necessary. But in three or four instances, I have succeeded in establishing the natural course of the urethra, where the false passage depended upon the resistance of a stricture, by piercing the stricture with the stilet, and afterwards passing a catheter through it, and suffer- ing it to remain in the bladder for several days. Formerly, a few English surgeons of eminence were in the habit of forcing strictures, by driving bougies and catheters through them, and making an entrance by violence into the bladder. A similar practice for several years past has prevailed in France, where an instrument called sonde conique, is much in vogue. I will not condemn the proceeding, because I do not know it, from experience, to be hurtful; but I confess I have a feeling amounting to prejudice against it. Of Mr. Arnott's method of curing strictures, by the peculiar instruments named dilators, I have nothing to say—having never tried the plan. Fistula in Perineo. 207 Section II. Fistula in Perineo. From strictures of the urethra, from blows and other injuries, fistula in perinaeo is frequently produced. In proportion as a stricture increases, the urethra, at the diseased part, is dimi- nished; while that portion of the canal immediately behind the obstruction, by the efforts of the bladder and the continual pro- pulsion of the urine against it, is enlarged. The irritation thus kept up gives rise to inflammation and ulceration, and an open- ing is at last made through the urethra, and communicates with the cellular membrane surrounding it. Into this opening the urine finds its wa}^ and lodges, and by its acrimony increases the irritation until an abscess is formed; which gradually en- larges, and finally discharges itself externally. The urine then passes out mixed with matter, both from the opening in the perineum and from the external orifice of the urethra. In the course of time, however, it frequently happens that the stric- tured part of the canal, no longer feeling a'forcible impulse from the stream of urine, gradually closes, and is finally ob- literated, after which the whole of the urine is evacuated through the fistula. Sometimes, instead of the ulcerative process first commencing on the internal surface of the urethra, an abscess is formed from irritation in the cellular membrane exterior to the canal, into which the ulceration at last extends, and throws the two cavities into one. Fistula in perinaeo sometimes pro- ceeds from a rupture of the urethra, (produced by external vio- lence, or by the force of the urine upon the inflamed and tender part of the canal behind the stricture,) and the urine is instantly sent abroad into the loose cellular membrane of the perineum and scrotum, where it forms an enormous distention or tumour, and excites most violent inflammation, that terminates in a few 208 Fistula in Perineo. hours in gangrene, and sloughing of the scrotum—leaving in many instances, the testicles and urethra bare, and endangering the patient's life. There is seldom more than one fistulous open- ing communicating immediately with the urethra, but from it numerous sinuses generally extend in various directions; and in cases of long standing, it is not unusual to find the cellular membrane of the scrotum, and of all the other parts through which the urine meanders, greatly condensed and converted into indurated tumours, upon the surface of which may be found in- numerable small holes, that discharge offensive urine and mat- ter—rendering the patient disagreeable to himself and disgust- ing to his neighbours. Treatment of Fistula in Perineo. It will appear obvious, from what has been stated, that when fistula in perinaeo depends upon stricture, the first indication in the treatment of the disease should be to get rid of the obstruc- tion, and enable the stream of urine to regain its natural route. This, if the canal anterior to the fistula is obliterated, can be ac- complished only by an operation, and the one which I have usually performed, and frequently with success, is as follows. The urine being retained in as large quantity as possible, the patient is placed upon his back on a table, covered with a mat- tress or blankets, the thighs bent upon the pelvis, and the legs upon the thighs, separated and supported by an assistant on each side. A female catheter or sound is then carried down to the stricture, and there held firmly by another assistant, while the surgeon introduces a probe into the largest fistulous orifice he can find, and the one nearest to the stricture, and endeavours to feel with it the extremity of the sound, through the walls of the urethra. An incision, proportioned in length to the extent of the disease, is next made into the perineum, along the course of ihe probe, until the urethra or its remains are laid bare, when Fistula in Perineo. 209 the operator will be enabled to cut upon the extremity of the sound, and divide the stricture. The sound may be, afterwards, withdrawn, and a gum elastic catheter introduced at the glans penis, and carried along the urethra into the bladder, where it should be suffered to remain for several days. As soon as the natural route for the urine is thus re-established, the fistulae di- minish, the indurated cellular membrane contracts, the wound begins to fill up, and is finally closed, and, through the medium of granulations, which form around the catheter, a new urethra is created; after which, the sinuses all heal, and the patient re- covers. In many instances, the operation is extremely difficult, and very painful, especially in irritable patients, and those who have suffered a long time from the complaint. Cases, indeed, are reported of patients who have died under the operator's hands. When a fistula in perinaeo is complicated with pervious stric- ture, an attempt should be made by bougies, caustic, and other means, to destroy the stricture, or enlarge it, and afterwards to heal the fistulous opening by escharotics; the best of which, for this purpose, is the argentum nitratum. Sometimes a fistula in perinaeo will contract to the size of a hair, and in that state re- main for years, now and then shedding a few drops of urine. For this state of the disease, I have found a blister the best re- medy. Effusions of urine into the cellular texture of the scrotum, from rupture of the urethra, require very decisive measures. Aware of the nature of the disease, the surgeon should lose no time in making very free punctures and incisions into the skin and cellular membrane, from which he will soon find the urine to issue in considerable quantity. When performed in time, the operation may save the parts from sloughing. This, how- ever, is seldom the case. But it is astonishing how much na- ture does for the patient under these circumstances: for even after the testicles have been entirely divested of integument, a new scrotum is almost always formed out of the adjoining parts. The fistula, in general, heals spontaneously. 210 Enlarged Prostate. Section III. Enlarged Prostate. Although the prostate gland is subject to inflammation, ab- scess, scrofulous enlargement, and collections of urinary calculi within its substance, these affections are rare, compared with that commonly known under the name of scirrhus. To this disease old people are almost exclusively liable, and so frequent is it among them, that, according to Sir Everard Home, few subjects beyond the age of eighty are exempt from it. The middle lobe, as well as the two lateral, is often the seat of the disease; but the symptoms differ, in some respects, according as the former or latter happen to be affected. In proportion as the middle lobe enlarges, it pushes before it the internal membrane of the bladder, and by projecting into the cavity of that viscus, immediately behind the inner orifice of the urethra, obstructs the flow of urine; which, when the tumour, as it often does, at- tains considerable bulk, may be entirely suppressed. The en- larged lobe also, in many instances, becomes ulcerated, and gives rise to severe pain after passing urine, and to spasm about the neck of the bladder. When an enlargement of one, or both, of the lateral lobes of the prostate is conjoined with that of the middle lobe, the symp- toms are still more urgent. A discharge of a viscid, ropy mucus, is another attendant upon enlarged prostate, and a very com- mon symptom of disease of the lateral lobes. The left lateral lobe is more frequently enlarged than the right. When the la- teral lobes attain a considerable size, they project towards the rectum so as to diminish the capacity of that bowel, and may be distinctly felt by the finger per anum. Enlarged Prostate. 211 The causes of enlarged prostate are exceedingly obscure. By many the disease is attributed to syphilis, repeated at- tacks of gonorrhoea in early life, strictures of the urethra, inor- dinate indulgence with women, high living, intemperance, &c. But these inferences are rather gratuitous than founded upon any certain data. Treatment of Enlarged Prostate. The remedies for this disease are palliative only. Opium, internally administered, and in the form of enema, will prove highly serviceable in subduing spasm about the neck of the blad- der, and thus enabling the patient to pass urine. Frequently, however, every effort of the kind will be unavailing, and the catheter must be employed. One of elastic gum, without the stilet, very flexible at the point, and of large size, will be found to give less pain, and enter with greater facility than a metallic instrument. It should be kept in the bladder for several days in succession, and after the urgent symptoms have somewhat sub- sided, introduced occasionally. In addition to this treatment, the use of mild purgatives, and attention to diet, will be re- quired. 212 Retention and Incontinence of Urine. Section IV. Retention and Incontinence of Urine. From severe gonorrhoea, strictures in the urethra, enlarge- ment of the prostate gland, spasm at the neck of the bladder, stone in the bladder, hemorrhoids, fistula in ano, rupture of the urethra, blows upon the perineum, stimulating diuretics, the application of blisters, injuries of the spine, paralysis of the bladder, stones in the urethra, and some other causes, a reten- tion of urine frequently arises. The disease, when it occurs amongst old people from paraly- sis, is not often followed by serious consequences, unless it should be mistaken for an incontinence of urine; a mistake which is apt, among the inexperienced, to arise from the cir- cumstance of the urine constantly passing off by drops or in a small stream—one of the most decided symptoms of retention. Persons advanced in age are extremely apt to neglect the calls of nature, and suffer the urine to collect in the bladder in large quantity, or when they do make water are not particular enough in discharging the whole of it. From these and other causes, the bladder at last loses its power of expulsion, and the urine accumulates. As a part of it, however, is in general continually passing off by the urethra, that in the bladder seldom exceeds a certain quantity, and in this way the disease may be kept up for weeks together. The retention which takes place in young people, from go- norrhoea, strictures, or any inflammation or excitement about the urethra, neck of the bladder, or neighbouring parts, is very different in its character, and often in its result, from that just spoken of. The urine seldom escapes, even in the smallest quantity, by the urethra, and must of course accumulate, (unless Retention and Incontinence of Urine. 213 the patient be relieved,) until some part of the bladder gives way—either by ulceration or sloughing. It is astonishing, how- ever, to what an extent the bladder will yield in some cases be- fore its parietes are destroyed. Some years ago I was called to a child about two years of age, supposed to labour under ascites, and so strongly did the enlargement and feel of the belly resemble that disease, that I at first took it to be a case of the kind. But, upon inquiring into the history of the com- plaint I ascertained that its duration had not exceeded seven days, and that during this period the patient had passed no urine. This induced me to examine the urethra, in the mouth of which I discovered a calculus that blocked up the passage completely. Upon enlarging the orifice with a lancet, the stone was instant- ly pushed out, and followed, to the surprise of a medical attend- ant and myself, and to the great relief of the patient, in a little time by two quarts of urine. Many instances are related by writers, of the bladder becoming so distended by urine, as to rise above the umbilicus; and Sir Everard Home relates an in- stance in which the celebrated Mr. Hunter actually tapped the bladder, mistaking the swelling for a dropsy of the belly. But such cases are anomalous; and in most instances, long before the bladder is distended to a great size, it ulcerates, or sloughs at the fundus or neck, and the urine is sent abroad into the pe- ritoneum, or discharged through the rectum, or into the cellu- lar membrane of the scrotum or perineum. In either event, the patient generally dies. During the progress of the disten- tion the patient suffers exceedingly, grinds his teeth in ago- ny, tosses about the bed, or walks his room with his body al- most bent to the floor, is seized with chills, cold sweats and fainting, which are followed by fever, great restlessness, ex- treme thirst, intolerable anguish, swelling of the abdomen, hic- cup, delirium, and death. He seldom survives beyond the sixth or seventh day. Incontinence of urine is the reverse of retention. There are two or three varieties of the disease. Sometimes the urine passes off by the urethra as soon as it is secreted; at other times the patient can retain it for a certain period, and is then obliged suddenly to evacuate. In a third variety of the complaint, the discharge generally takes place during sleep. This is commonly confined to young children, while the other varieties are chief- Vol. II. 28 214 Retention and Incontinence of Urine. ly met with in adults, and are dependent for the most part upon general or local paralysis, general debility, injuries, malfor- mation of the urinary organs, hemorrhoids, stone in the blad- der, &c. Treatment of Retention and Incontinence of Urine. When retention of urine arises from stricture of the urethra, or from any inflammatory affection of the canal, or parts adja- cent, blood-letting, the warm bath, purgatives, and opiate en- emata, should have a full trial. If these fail, a gum elastic bou- gie may be carried down to the obstruction, and kept in contact with it a few seconds, after which, in many instances, the urine will flow. Should this, however, not produce the desired ef- fect, the surgeon will then endeavour to introduce a catheter into the bladder. Than this, there is not, in all surgery, a more im- portant, and, under certain circumstances, more difficult opera- tion—an operation requiring the utmost gentleness,patience,per- severance, and skill. Rudeness and force, indeed, independently of the unnecessary pain and punishment they inflict, seldom con- tribute towards the end in view. It is true that some eminent surgeons, in difficult cases, advise the forcible entry of the ca- theter; but it should be remembered that a great majority of others, not inferior to them in authority, condemn the practice in the most pointed terms. In general, the most favourable position for the easy introduc- tion of the catheter, is the recumbent But a good rule to ob- serve on such occasions, is, if the surgeon does not succeed readily while the patient is in one position, to change it for another. The curvature of the instrument is also a matter of importance; on this account, the operator should be provided with a number, varying in shape and size. Gum elastic cathe- ters, with or without the stilet, are better suited to most cases than metallic instruments. Sometimes, however, I have sue- Retention and Incontinence of Urine. 215 ceeded easily with a silver catheter, when a gum elastic would not enter. In using the latter, there is an advantage now and then obtained, especially when the middle lobe of the prostate is enlarged—in withdrawing the stilet an inch or two, so as to leave the extremity of the instrument more flexible than it other- wise would be. With the same view, Dr. Physick* has long been in the habit of using a gum elastic catheter, with a flexible wax bougie fixed upon its extremity. Stilets made of brass, in- stead of iron wire, are in many respects the most useful. Having oiled the catheter, the surgeon takes hold of the glans penis, on its sides, immediately behind the corona, enters the instrument, with its concavity towards the abdomen, at the urethra, carries it along steadily, and with one continued sweep, (the penis being drawn upwards at the same time upon the instrument, and laid nearly parallel with the abdomen,) un- til it reaches the bulb or triangular ligament of the urethra. Here the passage takes a sudden turn upwards, and it will be necessary to accommodate the point of the catheter to the curve. With this intention, the handle of the instrument is suddenly, but cautiously and without force, depressed. This manoeuvre elevates the point, and causes it to start over the edge of the triangular ligament, and enter the bladder. Should much dif- ficulty be experienced, however, in this stage of the operation, it may be often overcome by placing a finger in the rectum, and with it, lifting the end of the catheter. Whenever an obstruc- tion is met with in the urethra, which the catheter does not readily pass, instead of attempting to overcome it by force, it will be proper always to withdraw the instrument a little, elevate its point, and then push it on again. In retention of urine from paralysis, the introduction of the catheter is seldom attended with difficulty, and on this account the operation may be repeated two or three times a day, or as of- ten as may become necessary. But when the surgeon finds it in- convenient to attend for that purpose, a flexible catheter may be left in the bladder, for two or three days at a time, and the urine permitted to flow off, at stated periods, in place of dribbling away constantly. After the bladder has recovered its tone, the * For a description and drawings of this instrument, see Dorsey's Surgery, vol. 2. 216 Retention and Incontinence of Urine. catheter should be discontinued. Having experienced consi- derable difficulty in introducing the catheter, in some obstinate cases of retention of urine, it occurred to me, in 1811, that the resistance might, perhaps, be overcome by introducing the pipe of a syringe into the orifice of the urethra, and throwing in gently a stream of tepid water. Having accordingly tried the plan successfully, in a few cases, I was induced to recommend the practice for several years, in my lectures. Subsequent ex- perience, however, taught me that very little reliance could be placed upon the method, and I have since abandoned it alto- gether. Jlmusat, of Franee, has, within the last few years re- sorted to a similar expedient, and, according to his account, with great success. If, in spite of the efforts of the surgeon to relieve the patient by the remedies pointed out, and it is found impossible to in- troduce the catheter, it will become necessary to puncture the bladder. The operation may be performed above the pubes, or through the rectum. But it will be proper to premise that neither one nor the other are indispensably necessary once in a hundred times. The operation above the pubes is performed in the following way. The patient being laid upon a table, an incision, about an inch and a half long, is made in the linea alba, immediately above the pubes, through the integuments and fat, and between the pyramidales muscles, until the distended bladder is distinct- ly felt, when a curved trocar, six inches in length, covered by its cannula, is made to pierce the bladder as near the pubes as possible. A vessel being held between the patient's thighs to receive the urine, the stilet is withdrawn and the fluid evacuated. To prevent the cannula from slipping out, tapes are fastened to its wings, and secured to a bandage passed around the body. Its extremity is also plugged up, to prevent the perpetual flow of the urine. The greatest objection to this operation, is the liability of the urine to escape, (after the bladder becomes flac- cid,) into the cavity of the abdomen. Besides this, the constant presence of the silver cannula is apt to excite irritation, espe- cially when it is so long as to rest upon the back part of the bladder. The puncture of the bladder, through the rectum, I should prefer, in every instance, provided the prostate was not so much Retention and Incontinence of Urine. 217 enlarged as to require the instrument to be introduced high up the intestine. To perform this operation, (which is still more simple than that above the pubes,) to advantage, the patient should be placed in the position for lithotomy, and the fore-fin- ger of the left hand carried up the rectum, as a guide to the trocar, which is held in the right hand, introduced into the rec- tum, and made to perforate the anterior part of that intestine, at its centre, immediately above the prostate. The stilet being withdrawn, and the urine evacuated, the cannula is plugged, and secured in its situation by tapes. The patient's bowels should afterwards be kept in a soluble state, to prevent the can- nula from being disturbed during an evacuation of the faeces. After the natural route through the urethra is restored, the can- nula may be withdrawn, and the opening in the rectum allowed to heal. Whether the operation of puncturing the bladder be performed above the pubes, or through the rectum, it is very important that it should not be delayed beyond the third or fourth day; for it has been found by experience, that after this period, the case has usually terminated fatally. For incontinence of urine, when it occurs in adults, and de- pends upon general or local debility, the internal use of can- tharides, muriated tincture of iron, bark, and opium, conjoined with the cold bath, and blisters to the sacrum, will sometimes effect a cure. That variety of incontinence peculiar to children, gradually subsides spontaneously, as they advance in age. Pa- rents, and children themselves, to guard against this infirmity, have sometimes, most improperly, applied ligatures to the penis over night From this practice, there are numerous instances on record, of ulceration of the urethra, or of sloughing of the penis, at the part embraced by the ligature. On Diseases of the Urethra and Prostate Gland, consult Hunter on tfie Venere- al—Home on the Treatment of Strictures of the Urethra and Oesophagus, 3 vols. edit. 4—Whateley's Improved Method of Treating Strictures of the Urethra, edit. 2—Letters concerning the Diseases of the Urethra, by Charles Bell—Principles of Surgery, by John Bell, vol 2, p. 209—Howship's Practical Observations on Dis- eases of the Urinary Organs, 1816—Wilson's Lectures on the Structure and Phy- siology of the Male Urinary and Genital Organs, and their Diseases, 1821—Ds- sault's Works, by Smith—C. Bell's Surgical Observations, p. 86—C. Bell on the Diseases of the Urethra, &c. by J. Shaw—Bingham on Strictures of the Urethra, 218 Retention and Incontinence of Urine. 1821—Home on the Treatment of Diseases of the Prostate Gland—Hey's Practi- cal Observations in Surgery, article Retention of Urine, p. 388, edit. 3—Dorsey's Surgery, vol 2—C. Bell's Operative Surgery, vol. 1—Colles' Surgical Anatomy, p. 159, article Passing the Catheter—Abemethy on the Operation of Puncturing the Bladder, in Surgical Works, vol. 2, p. 189—Cooper's First Lines, vol. 2, p. 215. Urinary Calculus. 219 Section V. Urinary Calculus. Most calculous concretions are formed originally in the kid- ney, and thence find their way, along the ureters, to the blad- der, and when too large to pass off with the urine, remain in that viscus and serve as nuclei for other sabulous depositions. But any extraneous body, accidentally lodged in the bladder, may lay the foundation of a stone. A drop of blood, a portion of inspissated mucus, a pin, a piece of bougie or catheter, a musket ball, has often produced the disease. Many years ago, I operated on a boy four years old, and took from his bladder a stone, as large as a pullet's egg, in the centre of which was found the greater part of a needle. Urinary calculi vary exceedingly in form, size, colour, con- sistence, and chemical composition. Some are very rough on the surface, others perfectly smooth; in shape most of them are oval, a few quite round, whilst others are oblong or angular. The difference in magnitude is not less remarkable—being met with from the size of a pea to that of a cocoa-nut. Calculi dif- fer from each other in colour as much as in size and form; the most common variety is generally of a yellowish brown tint; some are nearly as white as chalk, and others, again, red or of a deep chocolate brown. In consistence, also, there is the ut- most variation; for, at the slightest touch some crumble into dust, whilst others almost resist the stroke of a hammer. Scheele and Wollaston were among the first to investigate the chemical composition of urinary calculi, and their discoveries have led others to pursue the same path. According to the latest and best writers, these substances are found to consist of the following materials: 1st, of lithic acid, 2d, of the lithate of 220 Urinary Calculus. ammonia; 3d, of the phosphate of magnesia and ammonia; 4th, of the phosphate of lime; 5th, of the oxalate of lime; 6th, of the triple phosphate of magnesia, ammonia and phosphate of lime; 7th, of the carbonate of lime. Of these the lithic acid calculi are by far the most numerous. A very uncommon variety of calculus has been met with, in this country, consisting of sabu- lous matter and hair, and resembling, closely, common plas- tering mortar. Only two instances of the kind have come to my knowledge. The first occurred about eighteen months ago, in the practice of Dr. Physick, and the second, within the same period, in that of my friend, Dr. Lemoyne, of Washington county, Pennsylvania. In both patients, the formation of this material was progressive, or kept up for months together. Urinary calculi may be contained in the kidney, ureter, blad- der, prostate gland, or urethra; but the bladder is their most common receptacle. Generally they lie loose within the cavity of that viscus, and at its most depending part. Sometimes they are contained in cysts, formed between the coats of the bladder at the termination of the ureters, or between the folds of a con- tracted bladder; at other times they are fixed upon a fungous excrescence, the granulations from which shoot into the inter- stices of a rough stone, and hold it fast. The bladder may con- tain a single stone, or a great number. Fifty-five were found in the bladder of the celebrated Buffon after death. Two hun- dred were taken by Desault, from the bladder of a priest. Sir Astley Cooper states that the greatest number he ever extracted, was one hundred and forty-two. Boerhaave and Beauchene, each record an instance of three hundred and upwards taken from different patients. Murat met with six hundred and se- venty-eight But the largest number ever removed, probably, from the human bladder, was taken by Dr. Physick, three or four years since, from Chief Justice Marshall. More than one thousand, varying from the size of a partridge shot to that of a bean, were counted, and many others were lost. They were all of an oval shape, and upon the end of each 1 examined, as it came out from the wound there was a black spot of the size of a pin's head. Notwithstanding the frequent introduction of the forceps and scoop, the patient recovered, perfectly, in a short time. When numerous, they are generally smooth upon their Urinary Calculus. 221 surface, and sometimes, in particular places, highly polished, from continued friction upon each other. The symptoms of stone must depend, in a great measure, upon the particular situation it happens to occupy. When de- tained in the pelvis or infundibulum of the kidney, the concre- tion sometimes attains a large size, without subjecting the pa- tient to much pain or inconvenience; on the other hand, its pre- sence is occasionally productive of so much irritation as to excite suppuration of that gland. During the passage of a calculus along the ureter, the patient suffers in most instances excruciating pain, has a frequent desire to make water, and can pass only a few drops at a time, and that very high-coloured and sometimes mixed with blood. So severe is the pain in some cases, that the patient finds it impossible to leave his bed, and is obliged, in order to obtain temporary relief, to bend himself almost dou- ble. Fever, eructation, nausea, vomiting, and spasmodic retraction of the testicle, are common accompaniments of the disease. As soon as the stone drops into the bladder, the symptoms subside. Sometimes, however, the patient becomes easy for a few hours, even before the stone leaves the ureter, and then has a relapse. This may occur repeatedly. An encysted, stone, so long as it continues encysted, seldom gives rise to any severe symptoms; but a stone that lies loose in the bladder, and is liable to move about, must always excite more or less uneasiness, whether it be rough or smooth, large or small. One of the first symptoms of stone in the bladder, is a frequent desire to pass urine, and severe pain upon voiding the last drops of it. About the same period, also, the patient com- plains of an itching at the glans penis, to relieve which, he soon gets into the habit of pulling or elongating the prepuce. An- other symptom, is the sudden stoppage of the urine while pass- ing in a full stream. This arises from the stone being carried, by the contraction of the bladder, or by the stream of urine, to the neck of the bladder, where it blocks up the inner orifice of the urethra; in proof of which, if the patient lie down or change his position, the water flows again. After these symptoms have continued for some time, the patient becomes troubled with tenesmus and prolapsus ani, induced by the constant straining and efforts to empty the bladder. When the stone is rough on its surface, there is often a good deal of mucus discharged Vol. II. 29 222 Urinary Calculus. along with the urine, which is now and then mixed with blood. Sometimes the patient is very sensible, when he turns upon his side, or suddenly changes his position, of something rolling in his bladder. The same sensation is experienced whilst on horseback, or in a carriage. Under the sufferings occasioned by the symptoms enumerated, the patient may live for a great number of years. Gradually, however, his health declines, the bladder contracts to a very small size, becomes thickened and diseased, and at last death takes place from long-continued ir- ritation and derangement of most of the bodily functions. When the prostate gland contains a number of stones, it may be possible to feel them through the coats of the rectum, by passing the finger within the gut. Dr. Marcet mentions a case in which Sir Astley Cooper was able, by this expedient, to de- tect a number of calculi moving in a cyst within the prostate, and to hear a distinct clashing as their surfaces were pressed to- gether.* Calculi, when detained in the urethra, generally stop behind the bulb, or at the external orifice of the passage. From being pressed upon by the stream of urine, they are sometimes imbedded in the substance of the penis, and afterwards do not obstruct the urethra. The causes of the formation of urinary calculi, although fre- quent attempts have been made to investigate them, have never been unravalled. We know, indeed, little beyond this,—that the disease prevails in certain countries and districts, more than in others, and that in some climates, especially very warm ones, it is never met with. Throughout the United States, which embrace a very extensive tract of country, fugitive cases may be every where seen; but, upon the whole, the complaint must be considered by no means common, if we except some portions of the western country, especially Kentucky, Alabama and Tennessee, where it is exceedingly frequent, and usually at- tributed, though, perhaps, erroneously, to the use of lime-stone water. • Marcet on Calculous Disorders, p. 19. Urinary Calculus. 223 Treatment of Urinary Calculus. When a patient is suffering from a fit of the gravel, as it is usually called, or in other words, from the passage of a calculus along the ureter, the most decisive treatment must be at once adopted. If robust and vigorous, several ounces of blood may be taken from the arm, and a brisk purge administered immediate- ly afterwards. These should be followed by immersion of the whole body in a warm bath. If, by these means, the pain is not diminished, ten or fifteen drops of spirit of turpentine may be given, three or four times a day. This remedy has been used by Dr. Physick, for many years, with the greatest success. A combination of turpentine and opium, according to Dr. Marcet, was formerly employed, as a quack medicine, in England, with great benefit in this complaint. By the advice of Dr. Physick, I prescribed, some years ago, the tincture of phytolaca (poke- berry) in an obstinate case of.lithiasis, and with the most decided relief to the patient. It should be administered in doses of a dessert spoonful two or three times a day. Sometimes I have known the patient much relieved by suddenly throwing up the rectum a stimulating enema. Opiate injections, also, in some cases, prove highly beneficial. The existence of a stone in the bladder, can only be deter- mined, positively, by sounding. This preliminary operation should, therefore, always be performed before the surgeon en- ters upon the treatment of the disease. By sounding is meant the introduction of a steel instrument, resembling a catheter, (but solid, instead of hollow,) into the bladder. The rules for- merly pointed out for the management of that instrument, in cases of retention of urine, should also be observed in the intro- duction of the sound. Very often the stone cannot be felt, in consequence of its lodging in a depending part of the bladder, below the reach of the instrument. In such cases the finger is put into the rectum and the lower part of the bladder pressed upwards, and the stone being carried by this manoeuvre along with it, rubs against the instrument. Or, the urine may be permitted to accumulate in large quantity, and the walls of 224 Lithotomy. the bladder being then distended, the stone will be raised from its lurking place and touched by the sound. But this expedient sometimes fails: in that event, the practice first pointed out by Dr. Physick should be pursued—by placing the patient " near- ly on his head," so as to render the fundus of the bladder the lowest part, and thus bring the stone in contact with the point of the sound. The surgeon should take care not to mistake a stone in the urethra, or prostate gland, for one in the bladder. He must particularly remember, moreover, never to sound a pa- tient during a fit of the stone, or immediately after his arrival from a journey. Having ascertained that the bladder contains a stone, its removal should next be determined upon. But, be- fore this is resorted to, the surgeon must endeavour to mitigate the symptoms as much as possible, or, in other words, to pre- pare the patient for the operation. Formerly, many attempts were made to destroy a stone, either by the use of internal me- dicines, or by the injection of fluids into the bladder. The practice, however, has long been abandoned—having been found ineffectual. But in another point of view it has proved highly useful—by relieving the symptoms, and thereby rendering the patient's chance of recovery after an operation more certain. The best medicines, for this purpose, in most cases, are the al- kalies, especially in the form of soda water, or the carbonate of soda. Magnesia, also, has often proved very serviceable. To- gether with this treatment, the patient should be obliged, for two or three weeks before the operation, to live on a low diet, and take occasional purgatives. The operation should not, if it can be avoided, be performed during very warm, or very cold weather. A few hours previous to the operation, the rectum should be emptied by an enema, the perineum shaved and a tape tied round the patient's penis to prevent him from making water. The latter is so important, that to ensure its observance, a careful attendant should watch the patient from the time the penis is tied, until the operation. Various modes of performing lithotomy have been practised from time immemorial; but it is merely my intention in this place to describe the lateral opera- tion as it is performed at the present day by the most eminent surgeons—With the gorget. The instruments are two or three scalpels, a curved probe- pointed bistoury, a straight sharp-pointed bistoury, a staff with Lithotomy. 225 a large deep grove, Physick's gorget,* several forceps, smaller than they are usually made, a scoop, tenacula, ligatures, sponges, a curved needle and forceps for the pudic artery, a large pewter injecting syringe with a pipe six inches long, tepid barley water carefully strained, strong bands of woollen or muslin, two inches broad and three or four yards long, and a bowl of warm oil. A narrow dining-table is selected and the leaves turned down. Over the table is placed a thick blanket, several times folded. On this the patient, dressed merely in a shirt and loose night gown, is laid—with a pillow under his head, his pelvis resting on the lower edge of the table, and his legs and thighs sup- ported by an assistant, on each side. The surgeon unties the penis, dips his staff in warm oil, introduces it into the bladder, and having satisfied himself, and the other medical attendants, of the presence of a stone, gives the staff to a third assistant, with an injunction not to let its point slip from the bladder. He then passes each wrist through loops formed at the extre- mities of the bands or fillets, directs the patient to grasp the soles of his feet, and fastens them and the hands together by numerous turns of the bandage. The assistant, holding the staff steadily with one hand, and standing on the side of the patient, is then directed to raise and support the scrotum and testicles with the other hand—taking especial care that the end of the staff is fairly within the bladder. The assistants, appointed to secure the patient's limbs, must each place a knee in their arm- pit, grasp a foot with their hands, and sustain the thighs nearly in a perpendicular position, separating them, at the same time, moderately. The surgeon then seats himself before the patient on a low stool, (having previously arranged his instruments in the order he will require them, on a small table placed within his reach, takes a scalpel of moderate size, makes an incision in the left side of the perineum, commencing a little below the arch of the pubes, extending downwards, with a slight obliquity, be- tween the rectum and tuberosity of the ischium, and terminating • This instrument differs from the common gorget in having a moveable blade, or one that can be separated from the back, for the purpose of sharpening it to greater advantage. For a particular description of it, see Dorsey's Surgery, vol. 2d. 220 Lithotomy. opposite the lower margin of the anus. This first cut is made, not with the point of the knife, but with its convex edge, through the integuments, fat, and perinaeal fascia. By repeated strokes of the knife, the transversales muscles are next unbridled, and the membranous part of the urethra and prostate gland laid bare. At this stage of the dissection, the operator will some- times find it necessary to stop and take up the transversalis pe- rinaei artery.* The membranous part of the urethra and staff being distinctly felt by the fore-finger of the left hand, the sur- geon next takes the sharp-pointed bistoury, carries it to the bot- tom of the wound, with its back towards the rectum, and opens the membranous part of the urethra, to the extent of half an inch or more, by cutting from behind forwards, or from the prostate towards the bulb. As soon as the urethra is opened, a stream of urine, (provided the patient has retained it,) issues through the wound. Without loss of time the surgeon next lifts the gorget, fixes its beak in the groove of the staff, takes the handle of the staff from the assistant, depresses it, balances for a moment the two instruments on each other, runs the beak of the gorget backwards and forwards, two or three times, to be certain that it is fairly in the gutter of the staff, then with a slow but steady and decided movement carries the instrument on- wards to the bladder through the prostate gland. A sudden and impetuous gush of urine announces the completion of this stage of the operation. The gorget being withdrawn, the left fore-finger of the operator is immediately introduced, the stone felt, and the staff taken away. Still keeping the finger in the bladder the surgeon then takes a small pair of forceps, and with the blades shut, carries the instrument through the opening in the prostate, alongside the finger, touches the stone, removes the finger, expands the blades of the forceps, seizes the stone, (gently, lest it break,) parallel, if possible, with its longest diameter, and gradually extracts it. As soon as it is removed, an accurate examination should be instituted, in order to dis- cover whether there be any other stones left behind. If so, the forceps must be again and again introduced, until the whole are extracted. To clear the bladder of any fragments, sand, or clotted blood, that may happen to remain, the pipe of the syringe * Usually this vessel does not require the ligature. Lithotomy. 227 should be introduced, and a quantity of tepid barley water thrown in, repeatedly, until the bladder is completely rinsed out Any vessel of importance, that may happen to have been cut will probably continue to bleed after the stone has been ex- tracted and should be secured by ligature without delay. If the pudic artery is divided by the knife or gorget, it will pour out blood copiously, and from this cause many patients have lost their lives. The forceps and needle* used by Dr. Physick, for deep-seated arteries, will be found the best instrument for taking it up.f As soon as the hemorrhage has stopped, a gum elastic catheter, of large size, should be carried through the wound into the bladder, the bandage removed from the hands and feet, and the patient laid in bed on his left side—the thighs being lightly bound to each other, by two or three turns of the roller. The gum elastic catheter, projecting from the wound serves to carry off the urine, which being received in a dish, the patient is kept constantly dry and com- fortable. For several days the urine continues to pass by the perineum; at length, however, it is discharged through the pe- nis, and very little runs through the wound. The catheter should then be removed, and, in a short time, the opening in the perineum will heal. In a few rare instances, indeed, the inci- sions have healed by the first intention; but in general, three or four weeks elapse before a cure is effected. * See vol. 1st, p. 55. \ It sometimes happens that after the stone has been removed, and the patient put to bed, secondary hemorrhage takes place, and that the blood finds its way into the bladder, where it excites so much irritation as to cause a contraction of that viscus, and a sudden discharge of urine and coagulated blood through the wound. In fifteen or twenty minutes the same accumulation and expulsion again take place, and may continue until the patient is exhausted, unless the surgeon understands the nature of the accident and the mode of treating it. In all such cases, I have reason to believe, from what I have seen, that the hemorrhage pro- ceeds from the venae vesicales, or from some of the arteries above the prostate. Under these circumstances, a very ingenious mode of arresting the flow of blood was executed many years ago by Dr. Physick, (in the case of a Dr. B.) by intro- ducing a large gum elastic catheter into the bladder through the urethra, and at the same time a long slip of lint between the lips of the prostate, so as to keep them in accurate apposition. The flow of blood being thus stopped, and the urine passing off by the catheter, instead of flowing through the wound, it follows that the hemorrhage will not return, so long as the lint retains its position, that it is important that it should be left for several days, or until suppuration takes place. By adopting this plan I have saved the lives of two patients, who otherwise, I am sure, must have perished. 228 Lithotomy. The operation of lithotomy, as I have described it, must be understood as adapted to the adult, and as calculated for cases unattended with difficulty. The same rules should be observed, in performing the operation on infants and children—the instru- ments and incisions, in such cases, being proportionally smaller. In such subjects, moreover, the surgeon may expect to expe- rience some trouble, from a frequent protrusion of the rectum, during the operation, inasmuch as most children, afflicted with the stone, are subject to prolapsus ani. Upon the whole, how- ever, the operation of lithotomy in children is, compared with that of the adult, attended with few difficulties. To guard against accidents, and to prepare the young surgeon for difficulties, which, at some period or other, he may expect to encounter, the following mementos should be carefully at- tended to. 1st. To examine minutely every instrument, before it is used, especially the gorget and staff. If the cutting edge of the former be not extremely sharp, it will not divide the prostate gland, but pushing it forward, will pass between the bladder and rectum, and deceive the surgeon, who, supposing that he has opened the bladder, thrusts the forceps into the wound, makes fruitless efforts to extract the stone, and, perhaps, may tear away, as has happened, the prostate and part of the bladder. If the gorget be not accurately fitted to the staff, it may be dis- covered, during the operation, (and at the critical moment of pushing the instrument into the bladder,) that the beak is too large for the groove. Under these circumstances, should the operator persevere in his attempts to thrust the gorget home, great mischief may ensue. The size of the gorget must always be proportioned to the age and size of the patient A gorget, for an adult, should never exceed in breadth three-quarters of an inch, and, for most patients, one five-eighths of an inch will answer. Children seldom require an instrument be}''ond three- eighths of an inch in width. An unusually wide gorget always endangers the pudic artery. The most experienced lithotomists, however, of modern times, have always inculcated, and, as I conceive, justly, a free incision of the prostate and neck of the bladder, rather than tear these parts, in attempting to get out a large stone. How then can this be accomplished unless a broad gorget be employed? The answer is very easy. The chief Piatt 4 V.Z. ?V Six&. Jh-.xmrtt "by Xltrayttm. . Lithotomy. 229 object of the gorget is to make an opening into the bladder; if this opening is sufficiently large to admit the finger of the sur- geon and enable him to touch the stone, this is all he can re- quire. Finding, by the feel, the stone too large to come away through the track made by the gorget, the curved probe-pointed bistoury is at hand, and with this the wound may be instantly enlarged to the requisite extent, and without exposing the pu- dic artery. In running the gorget along the staff, through the prostate and bladder, care should be taken to depress its handle, in order that the blade may be sufficiently elevated to pass in a line corresponding with the axis of the pelvis. This the ope- rator sometimes finds it difficult to accomplish, owing to the blade of the gorget being made as broad near the handle of the instrument as at its point, and, on this account, not calculated to rest in the lower angle of the incision. To obviate this diffi- culty, I have, for several years past, had the blades of gorgets so constructed, as gradually to taper from the outer corner of the cutting edge to the handle of the instrument. See Plate IV. fig. 1 and 2. 2d. If the surgeon, from timidity, or any other cause, does not make his incisions in the perineum ample, but leaves some of the fibres of the transversales perinaei muscles uncut, he will find, in attempting to extract the stone, great resistance, and a constant tendency in it to slip from the grasp of the forceps. This resistance usually arises from the fibres of the transversa- lis perinaei alter. In such a case the fore-finger of the left hand should be carried towards the bottom of the wound to depress the rectum, while the remaining obstruction is removed by the knife. A wound of the rectum will not prove so serious an ac- cident as some have represented; but, nevertheless, it should be carefully avoided. 3d. The lithotomy forceps are, in general, made unnecessari- ly large and clumsy; so large, indeed, as often of themselves to fill up the opening through the prostate. The teeth, too, on the inner surface of the blades, are often so large as to act like wedges, and break the stone the moment it is grasped. For a child, a forceps very little larger than the common pocket case instrument, will serve a better purpose than the one usually employed; and the smallest forceps contained in the lithotomy case, provided the handles be somewhat lengthened, will an- Vol. II. 30 230 Lithotomy. swer for an adult.* If a stone should be so large as to require breaking, a strong pair of forceps, with a screw in the handles, will prove more effectual than the complicated instrument of Mr. Henry Earle. Although I have had occasion, however, in three instances, to break large stones, I have never experienced any difficulty in effecting it with the common forceps. Frequently, a stone will break under very moderate pressure of the forceps, and when the surgeon is unwilling for it so to do. In this event, great patience and gentleness must be exercised in ex- tracting the fragments by the scoop, and by injections of barley water. It sometimes happens that one portion of a stone is im- bedded in a cyst in the coats of the bladder, while the other projects into its cavity. This happened in a case, upon which I operated, at Alexandria, under the care of two distinguished physicians of that place—Drs. Washington and Sims. Having seized the stone with the forceps, the projecting half broke off, and the remainder, with great difficulty, I was obliged to scoop out of the cyst with my finger. The patient had long suffered from the disease, was greatly exhausted before the operation, and died ten or twelve days after it. Some years ago, I ope- rated on a young man in the Aims-House Infirmary, and took from his bladder a stone about the size of a walnut, and after- wards introduced my finger to ascertain if there were any others left, when, to my great surprise, I discovered that the fundus of the bladder, for a considerable extent, was incrusted with cal- culous matter, which I pealed off in successive layers, some of which were nearly half an inch thick. This patient perfectly recovered. Under circumstances such as I have detailed, the surgeon should never, for a moment, lose his self-possession, but proceed cautiously and gently, but firmly, until he has ef- fected his purpose. In the common operation of lithotomy, too, it should never be necessary to pull violently with the forceps, but the instrument must be humoured, and its position changed, and twisted gently in a variety of directions. 4th. The after treatment of lithotomy is oftentimes more important than the operation itself; and the surgeon would do * Dr. John Rhea Barton, of this city, has invented a pair of lithotomy forceps, (with an oval hole in each blade, resembling the midwifery forceps, and not un- like the old polypus forceps of Heister,) well calculated, it appears to me, to hold a small stone, and prevent it from slipping. Lithotomy. 231 well never to operate, unless he could attend the patient through- out the whole course of his confinement. I have now per- formed the operation of lithotomy upwards of forty times, and have lost out of that number, only six patients. My success, I attribute, in a great measure, to ample incisions, and to ex- traordinary care during the after treatment. Three out of the six patients died at a distance where I could not attend them, and the other three were greatly exhausted by the disease be- fore the operation was performed. The shock communicated to the system by the severity of the operation, is sometimes such as greatly to endanger the patient's life, and, indeed, some have actually died on the table, or a few hours after—reaction having never been established. So long as this state of the system continues, stimulants, particularly ammonia, must be employed. After reaction takes place, then inflammation must be guarded against, and to prevent this, the antiphlogistic sys- tem, to the necessary extent, will be naturally resorted to. The high operation of lithotomy, or that above the pubes, an account of which, it is said, was first given by Franco, in 1556, was formerly much practised, particularly by Frere Cosme, Douglass, and Chesselden. The unfortunate termina- tion, however, of numerous cases, caused it to be abandoned al- most entirely. Still it has been revived at different periods, and latterly, by Souberbielle, of Paris, and Carpue, and Sir Everard Home, of London. But, even under the most favour- able circumstances, it is an operation greatly inferior to the la- teral, and, indeed, should only be practised, I conceive, in cases where the stone is ascertained to be of extraordinary mag- nitude, or where the prostate gland is very much enlarged. The principal objections to the operation arise from the diffi- culty of preventing the escape of the urine into the cavity of the pelvis, and the danger of wounding the peritoneum. If the operation be determined on, I should prefer the mode of exe- cuting it devised by Sir Everard Home, and as described by him in the following case. " An incision was made in the direction of the linea alba, be- tween the pyramidales muscles, beginning at the pubes, and ex- tending four inches in length: it was continued down to the tendon. The linea alba was then pierced close to the pubes, and divided by a probe-pointed bistoury to the extent of three 232 Lithotomy. inches. The pyramidales muscles had a portion of their origin at the symphisis pubis detached to make room. When the fin- ger was passed down under the linea alba, the fundus of the bladder was felt covered with loose, fatty, cellular membrane. A silver catheter, open at the end, was now passed along the urethra into the bladder, and, when the point was felt by the finger in the wound, pressing up the fundus, a stilet, that had been concealed, was forced through the coats of the bladder, and followed by the end of the catheter. The stilet was then withdrawn, and the opening, through the fundus of the bladder, enlarged towards the pubes, by a probe-pointed bistoury suffi- ciently to admit twTo fingers, and then the catheter was with- drawn. The fundus of the bladder was held up by one finger, and the stone examined by the fore-finger of the right hand. A pair of forceps, with a net attached, was passed down into the bladder, and the stone directed into it by the finger: the surface being very rough, the stone stuck upon the opening of the forceps, and being retained there by the finger, was ex- tracted. A slip of linen had one end introduced into the blad- der, and the other was left hanging out of the wound, the edges of which were brought together by adhesive plaster. A flexi- ble gum catheter, without the stilet, was passed into the bladder, by the urethra, and kept there by an elastic retainer surround- ing the penis. The patient was put to bed, and laid upon his side, in which position the urine escaped freely through the catheter." Some years ago, I was called to Virginia, to operate for li- thotomy. I found the patient very far advanced in years, and, labouring not only under stone, but morbid enlargement of the middle and lateral lobes of the prostate. Knowing the difficul- ties I should have to contend with under these circumstances, I determined, instead of performing the lateral operation, to open the bladder above the pubes. Accordingly, assisted by Drs. Withers and James, two eminent practitioners of the neigh- bourhood in which the patient resided, I performed the opera- tion after the manner of Sir Everard Home above described, and succeeded without difficulty in removing two calculi. The patient's chance of recovery, notwithstanding his age and the enlargement of the prostate was very favourable; so much so, that feeling himself, as he imagined, perfectly secure, and tired Lithotomy. 233 of restraint and confinement to bed, he insisted upon the cathe- ter being withdrawn, (contrary to very strict injunctions I had left with him,) and in consequence soon after perished from pe- ritoneal inflammation induced by effusion of urine into the ca- vity of the pelvis. This was the first instance, I believe, in which the high operation had been performed in America. It has since been done, successfully, by Dr. Carpenter, an eminent physician of Lancaster, and also, as I understand, by Dr. Van Volsy, of Lewisburg, Union county, Pennsylvania. Females are subject to calculus as well as males, though the disease in the former is by no means so frequent as in the latter —owing to the female urethra being so short and large as readily to permit the escape of the calculous particles before they be- come so large as to form a stone. The symptoms created by the presence of a stone in the female bladder resemble those which have already been pointed out as characterizing the dis- ease in males; in general, however, women suffer more than men from the disease. There are two modes of extracting the stone from the female bladder—by dilatation of the meatus urinarius, and by incision. The former was often practised by the older surgeons, and within the last twenty or thirty years, has been occasionally re- sorted to. It should be preferred, in general, to the knife, (especially when the stone is small,) inasmuch as it is not so liable to be followed by incontinence of urine. A bit of com- pressed sponge, or wax bougies gradually increased in size, will answer very well to dilate the passage with. When the stone is found to be very large, it will, perhaps, become necessary to divide the urethra, and the best mode of performing the opera- tion, is, I think, the following. The patient is placed in the ordinary position for lithotomy, and her hands secured to the feet by bandages. The surgeon then introduces into the urethra a straight staff, with its groove directed towards the left ischium, and holding it firmly by the handle, passes with the right hand a straight bistoury through the urethra and neck of the bladder, obliquely downwards. The finger being introduced and the stone felt, it may be readily removed with the straight or curved forceps. As incontinence of urine has followed in all the cases in which Sir Astley Cooper has performed or witnessed the 234 Lithotomy. operation, he has expressed his determination, in future, to try the effect of a suture upon the edges of the wound. Carpue's History of the High Operation, &c. 1819—Sanson des Moyens de Parvenir a la Vessie par le Rectum, 1817—Dictionnaire des Sciences Medicates, tom. 28, p. 422—Traite" Historique et Dogmatique de V Operation de la Taille,par J. F. L. Deschamps, Paris, 1796, 4 tomes, 8vo.—John Bell's Principles of Sur- gery, vol 2, part 1—Desault's Works, by Smith, vol. 3—C. BelVs Operative Surgery, vol 1, p. 329—EarVs Practical Observations on the Operation for the Stone, 1803—Roux's Journey to London—Allan's Treatise on Lithotomy, 1808— Colles' Treatise on Surgical Anatomy, p. 145 and 169—Cooper's First Lines of the Practice of Surgery, vol. 2, p. 320, edit. 4—Dorsey's Surgery, vol. 2—Dorsey's Inaugural Essay on the Lithontriptic Virtues of the Gastric Liquor, 1802—Mar- cel's Essay on the Chemical History and Medical Treatment of Calculous Disorders —Prout's Inquiry into the Nature and Treatment of Gravel, Calculous, &c.— Magendie on Gravel &c.— Wilson on the Urinary and Genital Organs, London, 1821, 8vo. Lithotrity. 235 Section VI. Lithotrity. Among the obsolete and musty records of ancient times, iso- lated scraps of valuable matter, plausible hints and specula- tions, ingenious instruments and operations are met with as "rari nantes in gurgite vasto." By the industry, however, of such men as Ploucquet, Sprengel, Good, Young, S. Cooper, and a host of German labourers, the golden sand has long been washed and picked from the rubbish which surrounded it, and whether dug from the caverns of Pompeii or Herculaneum, or collected from the deserts of Egypt or Arabia, or scraped from the ruins of Greece, has been preserved pure and unalloyed, and stored up for its rightful owners. But how few and unmerited are the claims of the ancients to those treasures which have been so un- sparingly showered for the last fifty years upon every department of the healing art. And yet, no sooner is a discovery made, or a new idea started, or a new operation performed, but the claim to priority is contested by a bold assertion that Hippocrates, Galen, or Celsus, or some other antediluvian, is entitled to the honour of the claim in question. This disposition to detract from well-merited fame, every where so prevalent, and inherent, perhaps, in human nature, was strikingly displayed a few years since in France, in relation to the operation of Lithotrity; for when Civiale, a poor and obscure, but most meritorious and ingenious individual, demonstrated that the stone could be de- stroyed in the human bladder, and removed, without the ope- ration of lithotomy, it was immediately proclaimed that there was nothing new about the affair, that he deserved no credit for the operation; for that a monk of Citeaux, and Martin, an English colonel, had both relieved themselves, long before, by 236 Lithotrity. nearly the same means; that Gruitheisen, a Bavarian physician, had made similar experiments, and that even Ammon of Alex- andria, Franco, Ambrose Parey, Hildanus, Sanctorius, Germa- nus, and Haller, were acquainted with lithotrity, that Amusat, Leroy and others, were all familiar, before Civiale, with the operation. But, in answer to all this, it may be said, (admitting that some obscure hints might have been thrown out, or nugatory experi- ments made by the individuals mentioned, or others,) that no brilliant discovery, or invention, ever was made, perhaps, that had not been previously imagined or thought of by some one, and that the man who, while struggling with poverty and almost overwhelmed with difficulties of every description, has energy enough to bear up and to persevere for years amidst privations and sufferings, and, finally, to bring triumphantly his experi- ments to successful issue, and adapt them to practice, is enti- tled fairly to the chief glory of a discoverer. To whom but Fulton are we really indebted for steam navigation? To whom but Civiale do we actually owe the operation of lithotrity? It is natural for us to look, in this age of project and trickery, with distrust towards proposals not sanctioned by long expe- rience, and there were many, accordingly, disposed to under- value the labours of Civiale. For myself, I candidly own, that for years I had no faith in the operation, as regards the full ad- vantage to be derived from it, and the facility of executing it, and believed, with many others, that it was adapted only to ex- traordinary cases. From the first, however, I never hesitated to speak of it, both in this work and my lectures, as a " most ingenious and beautiful idea," and to say, that the time would probably come, when the operation would be so modified and improved, as to deserve all the praises then so inconsiderately lavished upon it. At the same time, the young surgeon was cautioned how he ventured to undertake the operation, (which from trials, made by some of the most skilful surgeons in this country, was found to be extremely difficult, delicate and dan- gerous,) under the idea, then too prevalent, that any one of ordinary capacity and practice could perform it. That the ad- vice I then gave was just, and such as ought to have been fol- lowed, experience has since proved; for although there are now many successful operators in Europe, and a few in this country, Lithotrity. 237 every one of them, I am sure, will acknowledge that lithotrity requires a tact, an attention to minute circumstances, a discrimi- nation rarely possessed, and above all instruments which not one cutler in a thousand can manufacture. Upon the whole, then, it may be stated, that lithotrity has become an established operation, that it is adapted to a greater number of cases than was, originally, supposed possible, that in the hands of skilful operators it is generally safe, if not successful, and that when the patients are healthy, middle-aged, or advanced in years, the urethra large and free from disease, the stone small and soft, and when females are the subjects of it, the operation should always be attempted in preference to lithotomy. On the other hand, it must be remarked, that it is seldom adapted to children, or to very irritable and diseased patients, or to cases where the stone is large and extremely hard. Before describing lithotrity, it will be necessary to give an ac- count of the instruments employed in the operation. I have al- ready remarked that these are extremely difficult to make. Thoroughly convinced of this, I ordered a set from Paris, of the finest finish and construction, which, through the kindness of M. Civiale, were made under his own eye and direction, and every one examined by him and altered, until it met his approbation. Such of these, only, as are essential in the operation I shall de- scribe in this place. There are many instruments invented by Heurteloup, Leroy and other lithotritists, that possess no advan- tages, I conceive, over Civiale's, and which, therefore, need not be noticed in a work of this description. Civiale's apparatus,or lithontripteur, consists, lst,of a silver can- nula eleven inches long, and from two to four lines in diameter, open at its lower extremity and having at its upper a circular rim, connected with an oblong shoulder, intended to secure the can- nula in a corresponding handle, or lathe, to be afterwards de- scribed. Attached to this extremity, likewise, is a cylinder of leather enclosed in a circular box, to render the cannula water- tight. 2dly, of a steel cannula, longer than the silver one, made to fit and work on the inside of it, having at its lower end three elastic branches which curve inwards, are rounded at their extremities, are intended to seize the stone, and are so contrived as, when drawn within the outer cannula, to pack closely to- gether and form a smooth rounded end, well calculated to glide Vol. 11. 31 238 Lithotrity. along the urethra and enter the bladder. The upper extremity of this cannula is numbered, or graduated, to enable the opera- tor to ascertain the degree of expansion of the litholabe or claw, and is connected by a screw, to a rim or circular box filled with leather, somewhat similar to the one on the silver cannula, and in- tended for the same purpose—to prevent the escape of fluid during the operation. Sometimes four pincers, or claws, are used in- stead of three; and in certain cases, two only are employed. But Civiale has found three the most convenient, in the generality of cases. 3dly, of the lithotriteur, or perforator,—which is a steel rod, six inches longer than the litholabe, having upon one extre- mity a crown with a number of cutting edges, or teeth, calculated to pulverize, or grind the stone, or reduce it to fragments, and upon the other a graduated scale intended to denote the size of the stone within the grasp of the claw. This extremity is rounded, and, for half an inch beyond the scale, is slightly serrated, or ragged, in order that it may be securely held in the jaws of a grooved pulley designed to communicate to the lithotriteur a ro- tatory motion, when passed through the cannula of the litholabe. 4thly, of a brass frame, or lathe, somewhat similar to that used by watchmakers, the curved extremity of which has a square ca- vity, with lateral grooves on its interior, intended to receive the corresponding oblong shoulder of the silver cannula and to be secured in it by a screw; while the other extremity, or straight square shank of the lathe, is designed as a bar upon which a popet head slides backwards and forwards. Parallel with the bar, and fixed upon the superior extremity of the popet head, is a cylindrical brass tube, which encloses a spiral spring connected with a steel pivot, the cup-like extremity of which receives the rounded end of the lithotriteur, and, by the operation of the spring keeps its dentated crown in perpetual con- tact with the stone. This lathe, during the operation, is held by the hands of an assistant. 5thly, a steel drill bow, about twenty- five inches long, jointed in the centre, firm but elastic, and well tempered, fixed in an ivory handle, and mounted with catgut, is designed to play upon the pulley connected with the lithotriteur, and may be said to complete the apparatus. Three, or four, sets of the external cannula, and litholabe, of different sizes, and a proportionate number of the lithotriteur, (ten or fifteen,) should accompany each case of instruments. Lithotrity. 239 The patient having been sounded, the presence of a stone de- tected, the state of the health inquired into, the condition of the bladder, the size, consistence and situation, as far as practicable, of the stone ascertained, and lithotrity determined upon, the first step is to enlarge the urethra, gradually, by the introduction of bougies, sounds, or catheters, commencing with small in- struments, successively increasing their size, and suffering each to remain in the urethra ten or fifteen minutes at a time. This practice having been pursued for eight or ten days, the urethra, besides being dilated, becomes accustomed to instruments, and its natural sensibility thereby diminished. Some operators, how- ever, and among them Leroy and Bancal, deem the preparatory treatment unnecessary; but by Civiale it is considered, generally, indispensable. Immediately before commencing the operation, the bladder is explored by the sound, a second time, and the stone being felt and appearing not too large to be embraced by the litholabe, the patient is laid on a bed and his hips elevated by bolsters, in order to make the stone gravitate towards the fundus of the bladder. A common catheter is then carried into the bladder, and the pipe of a syringe being adapted to its extremity, pro- jecting from the urethra, tepid water, or strained barley water, is injected until the patient complains of a disposition to urinate. The catheter is then withdrawn and the lithontripteur, (with the branches of the litholabe retracted within the cannula, and all other partsof the instrument accurately adjusted,) well greased, is introduced into the urethra by the right hand—while the penis is depressed by the left, parallel with the thighs, which are slightly flexed. The instrument passes readily until it arrives at the bulb of the urethra; it then meets with resistance, which is only to be overcome by depressing the external portion of the lithontrip- teur, and elevating ils point, which starts forward, glides along the membranous portion of the urethra and prostate, and enters the bladder. The stone is then searched for, and, in general, may be felt distinctly. When found, and its exact position deter- mined, the blades of the litholabe are expanded by pushing downwards the rim attached to its upper extremity, taking espe- cial care to keep one blade directed upwards towards the linea alba, and parallel with the graduated scale, which should al- ways be uppermost, and correspond with the screw on the silver 240 Lithotrity. or external cannula, while the other blades lie along each side of the bladder, and in this position can hardly fail to enclose the stone. By attention to this rule, which is extremely import- ant, it is impossible for one of the branches to fall vertically upon the stone, and the surgeon, instead of enclosing it by chance or accident, seizes it to a certainty, by drawing the litholabe up- wards with the right hand, while the left is employed in pushing down the external cannula. To secure the stone firmly in the grasp of the claw, the screw, which traverses the rim of the external cannula, should be turned, and the two tubes rendered immovea- able or prevented from sliding upon each other. The next step is to attach the frame or lathe to the lithontripteur, to adjust the upper extremity of the perforator to the steel pivot projected by the spiral spring of the popet head, to apply the catgut to the pulley and rotate it by very slow and gentle movements. If the stone is found not to change its position by the action of the perforator upon it, and the patient does not complain of the mo- tion of the bow, the rapidity of the drilling may be increased and continued until the stone is perforated. When soft this is soon accomplished, but when hard requires some time, and is attended with a good deal of fatigue to the operator. In general, it is best not to attempt too much at the first operation. Having, therefore, succeeded in boring the stone at a single spot, the next step is to remove it from the claw of the instrument This is done by ex- panding the blades, pushing out the stone by the perforator, then closing them and removing the instrument from the blad- der. In doing this, however, great care must be taken that no fragments are interposed between the blades and drill, as often happens, but may be discovered by the difficulty of withdraw- ing the instrument. A few turns of the crown of the perforator, in such a case, will be sufficient to pulverize and remove them. After the operation the patient should take a warm bath, keep quiet for some hours, and attend to his diet. The urine first discharged is generally found slightly tinged with blood, and along with it pass off more or less sand and fragments of the stone. In three or four days the patient is ready, in most cases, for a second operation. In the details just given, I have followed closely the direc- tions of Civiale, and have reason to believe, that if pursued with minute attention to all the points enumerated, that much Lithotrity. 241 less difficulty will be experienced by operators in this country, who may now resort to the operation, than has been the case hitherto; for I am persuaded that most of the mishaps re- corded in former editions of this work, are imputable to want of attention to certain indispensable practical manipulations, the neglect of which must still eventuate in inevitable failure. But to guard, as much as possible, against ill consequences, I shall endeavour still further to inculcate such precepts, from the best authorities, as will be likely to prevent error and to facilitate the efforts of those who may feel disposed to engage in this branch of surgery, and may not have access to those European productions which have issued, latterly, in such numbers from the press. Notwithstanding the facility with which, in many cases, the stone is seized immediately upon expanding the branches of the litholabe in the bladder, yet it sometimes happens, that it pertina- ciously eludes their grasp. This is owing, generally, to the stone resting near the neck of the bladder, so that it comes in contact with the smallest diameter of the branches—that which is next to the extremity of the cannula. This will be understood, easily, when it is recollected that the branches, when opened into the bladder, represent a triangular pyramid, the base of which pre- sents to the sacrum, and the apex to the neck of the bladder. The course to pursue, under such circumstances, is either to withdraw the instrument and raise still higher the hips of the patient, in order to roll the stone towards the fundus of the bladder, or else to draw the instrument with its blades expand- ed towards the penis, which must have the effect of gaining room by expanding the neck of the bladder, (naturally elastic, and susceptible of dilatation,) and of bringing the claws at the point of their greatest divergence, over the sides of the stone. Still further to facilitate its enclosure, it may be necessary to raise the handle of the instrument, by which the two lateral blades must depress the prostate and embrace the sides of the stone, while the vertical blade descends and rests upon its summit. Having in this way succeeded in seizing the stone, the handle of the instrument should be depressed, by which manoeuvre the stone will be suspended, as it were, in the cen- tre of the bladder, and being sustained in that position while 242 Lithotrity. the drilling is going on, there will be no pressure or irritation on the walls of the bladder. If the stone, as often happens, should be too large to be em- braced by the litholabe, this may be easily known by its re- tiring from the instrument when its claws are expanded to the utmost, and may be proved by examination of the graduated scale. In such a case the lithontripteur is removed, and another of larger dimensions substituted. When the stone does not exceed in bulk a hen's egg, it may be destroyed by the opera- tion of lithotrity, but if larger, the surgeon will act wisely in not attempting the operation. The most delicate and difficult part, perhaps, of the operation of lithotrity is the turning of the stone, in order to perforate it in different directions; for after the first operation, and in all subsequent ones, this will become an important indication. The assistance of the lithotriteur, upon such occasions, is of the utmost importance. By moving this in different directions, sometimes pushing it forward, sometimes rotating it, and making it bear lightly upon the stone, the latter can be made to shift its position while still in the relaxed embrace of the claw, and as soon as the operator finds that the crown of the lithotriteur bears upon a surface not previously bored, the stone may be again seized and the drilling renewed. Having, in this way, perforated the calculus, in numerous directions, it becomes so hollowed out, and weakened, that it may often be crushed by the pressure of the claw. Soft and friable stones, indeed, as Civiale and others have proved, may be destroyed, sometimes, by the litholabe alone, and without the aid of the perforator. Before attempting lithotrity, it is of the utmost consequence to measure, exactly, by means of a catheter, (having on its side a graduated scale) the exact length of the urethra, which va- ries, as is well known, in different subjects. As soon as the urine begins to flow, the measurement may be taken. Know- ledge, thus obtained, will prevent the operator from attempting to open the blades of the litholabe whilst in the urethra, from which very serious mischief has ensued in several instances. Although the necessity of injecting the bladder, upon all oc- casions, whether for the purpose of exploring its contents, (which is sometimes done with the blades open as well as shut,) Lithotrity. 243 or for seizing the stone, has been mentioned, already, as essen- tial, yet it may be well to state, in this place, that without such preliminary measure, success can hardly be calculated upon. No difference of opinion exists among lithotritists upon this point, and, perhaps, it may be owing to attention in this re- spect, that Civiale has never, as he declared, some years ago, injured the sides of the bladder, although he had, at the time the declaration was made, introduced the lithontripteur upwards of five hundred times. Should the fluid then escape, upon any occasion, previous to operation, there can be no safety unless the bladder is again filled before the introduction of the instru- ments. As regards the number of applications of the lithontripteur, that may be required, before the cure is completed, it may be remarked, that this will depend upon the size and texture of the stone, upon the state of the patient's health, upon the condi- tion of the bladder, and a variety of other circumstances. In general, when the stone is soft and small, from one to three operations will be required, and a greater number when it is large and hard. In getting away the fragments, little difficulty is now experienced. They usually pass off along with the urine, from day to day, or are brought away by injections, or by the repeated introduction of the litholabe, or by forceps with two blades, and if too large to pass the urethra, may be easily crushed. Instruments, indeed, have been invented by Jacobson, Heurteloup, Weiss, and others, for crushing stones, or for break- ing them with a hammer, and have been found calculated, upon certain occasions, to supersede the lithontripteur. One of this description, admirably contrived for the purpose, either invented or modified by Civiale, was lately sent to me, by that distin- guished operator. Upon the whole, it may be stated that as lithotrity can ne- ver entirely supersede lithotomy, though it will undoubtedly greatly curtail it, the surgeon should strive to make himself so familiar with both operations, and with calculous disorders, as to be able to determine the kind of operation adapted to each parti- cular case, and prepared to perform either, as occasion may re- quire. Upon his judgment in this respect, I venture to predict, will his success, or failure, in a great measure depend. Death has followed both operations, in numerous instances, although per- 244 Lithotrity. formed by Civiale himself, less frequently, however, since the va- rious modifications of the instrument, and experience acquired in using them, than in the infancy of the art. Although Leroy, and some others, have performed lithotrity upon children of three and four years of age, and in a few cases with success, as a ge- neral rule it should not be attempted, on account of the sensibility of such subjects, and the difficulty of introducing instruments suf- ficiently large and strong to destroy the stone. In women, litho- trity is more difficult than might be imagined, owing to the very irritable condition in which the female bladder, when it contains a stone, is generally found, and to the difficulty of keeping it distended, during the operation, with fluids. On Lithotrity, consult de la Lithotritie ou Broiement de la Pierre dans la. Vessie, par le Docteur Civiale, 8vo. Paris, 1826—Expost? des divers procidis, emphyis jusqu'a ce jour, pour guerir de la Pierre sans avoir recours a V Operation de la taille,- par J. Leroy. Paris, 1825, 8vo.—Lettres sur la Lithotritie, ou Broiement de la Pierre dans la Vessie, park Docteur Civiale. Paris, 1827, 8vo.—Lettre sur la Lithotritie, &c, par le Docteur Civiale. Paris, 1828, 8vo.—Lettre sur la Lithotri- tie Uritrale suive'e d'une revue g£nirale, sur I'etat actuel de la methode Litho- tritique, par le Docteur Civiale, 8vo. Paris, 1831—Lettres sur la Lithotritie ou I'Art de broyer la Pierre, par le Docteur Civiale, 8vo. Paris, 1833—Manuel Pra- tique de la Lithotritie, par A. P. Bancal Paris, 1829, 8vo.—Description of the new Process of perforating and discharging the Stone in the Bladder, &c.,by James Atkinson, Esq., 8vo. London, 1831—Lithotrity and Lithotomy compared, being an analytical Examination of the present Method of treating Stone in the Bladder, &c, by Thomas King, M. D. London, 1832, 8vo.—Principles of Litho- trity, or a Treatise on the Art of extracting the Stone without Incision, by Ba- ron Heurteloup, 8vo. London, 1831—Case of Lithontripty, successfully per- formed by L. Deypere, in New York Med. Journal, for Nov. 1830—.5. G. Smith on Lithotrity, in North Amer. Med. and Surg. Journal, vol. 12th, p. 256—The Operation of Lithontripty, by Jacob Randolph, M D, in American Journal of Medical Sciences, No. 29, Nov. 1834—Spencer's Case of Lithotrity.—Ibid. Aus 1833. No. 24. S" Diseases of the Eye. 245 CHAPTER X. DISEASES OF THE EYE. The eye, from its delicate and complex structure, and the number and diversity of its diseases, was formerly much ne- glected, especially in Europe, by the regular members of the profession, and attended to almost exclusively by ignorant and itinerant oculists. Within the last twenty years, however, the value of this important branch of surgery has been duly estimated, in proof of which it need only be mentioned that Ware, Saun- ders, Gibson, Adams, Wardrop, Travers, Vetch, in Britain, and Scarpa, Beer, Schmidt, and others on the continent, have con- tributed largely by their writings and operations to elevate this department to a most respectable rank. Many of these gentle- men, indeed, forsaking the general practice of their profession, have devoted their whole attention to ophthalmic surgery, and with a result truly honourable to themselves, and glorious to their country. The most common affection, perhaps, of the eye, is ophthal- mia. Of this, therefore, it will be proper first to treat Oph- thalmia is employed by most modern writers as a generic phrase —denoting ocular inflammation. For the sake of precision and accurate discrimination, other terms have been invented, some of them simple and expressive enough, others formidable in the extreme, or altogether monstrous.* To elucidate the varieties * Nothing short of affectation or pedantry will enable us to tolerate, in many instances, the phraseology of Beer and Schmidt—such as opthalmo-blennorrhcea, blepharo-opthalmo-blennorrhoea, dacryoadenitis, blepharophalmitis idiopathica, Vol. II. 32 246 Diseases of the Eye. of the disease, I shall not follow the exact arrangement of any individual author, but endeavour to simplify as much as possi- ble, and oppose every distinction which is not perfectly clear and obvious. anchyloblepharon, symblepharon, and a hundred more, either of which surpasses in complexity the old anatomical mouthful, baseochondroceratoglossus, &c Conjunctival Ophthalmia. 247 Section I. Conjunctival Ophthalmia. Conjunctival inflammation, to denote which some writers employ the word ophthalmitis, is the most common form of ophthalmia, and is characterized by the following symptoms—a sense of uneasiness, or itching, an impatience of light, diffused redness of the conjunctiva, pain, heat, and swelling of the globe of the eye, and epiphora or increased secretion of tears, a pun- gentpain, proceeding apparently from the lodgement of a particle of sand or some other extraneous body, but in reality from one or more bundles of enlarged vessels. To these symptoms are superadded, if the inflammation continues to advance, deep-seat- ed, pulsatile and violent pain in the eye-ball, which extends to the forehead, accompanied by fever and other general indispo- sition. Very often, moreover, the conjunctiva becomes thick- ened, and projects in a fungous form beyond the margin of the cornea. At other times blood is extravasated between the con- junctiva and sclerotic coat In the still further advanced stages of the disease, suppuration is liable to ensue, followed by de- struction of the cornea, evacuation of the humours and abolition of sight. It is seldom, however, that a simple conjunctival oph- thalmia terminates so unfavourably; on the contrary,the symp- toms gradually decline, and the eye is restored to its natural state, though sometimes the disease assumes a chronic form, and is then very difficult to manage. The causes of conjunctival ophthalmia are, for the most part, exposure to extremes of cold and heat, sleeping in the open air without cover, too intense and vivid a light to the eye, whether direct or reflected, blows, wounds, irritation from the 248 Conjunctival Ophthalmia. lodgement of extraneous bodies upon the globe or between the eyelids, disorder of the digestive organs, &c. Catarrhal ophthalmia is a variety of conjunctival inflamma- tion exceedingly common on the continent of Europe, and sometimes met with in this country. It is frequently epidemic, and occasionally accompanies influenza. It is marked in the early stage, by a peculiar dryness of the eye and eyelids, and by a pungent pain near the caruncuTa lacrymalis. In a few days these symptoms diminish, and are followed by a copious flow of tears, and a mucous discharge, which is generally so acrid as to excoriate the eyelids and adjacent parts of the cheek. The patient is scarcely ever free from fever. In severe cases of the disease the whole conjunctiva is covered with small pustules, containing purulent matter or a yellowish serous fluid. Purulent ophthalmy differs from the catarrhal in many re- spects. It is a very formidable and destructive disease, and some- times destroys one or both eyes in the course of a few hours. Adults, as well as children, are liable to it, but especially the latter. It usually commences four or five days after birth, by a slight redness and tumefaction of the conjunctiva lining the eye- lids. This is speedily followed by the secretion of a thin ad- hesive matter, which glues the lids together. In a few hours the discharge becomes very copious, thicker in consistence, ac- quires a yellowish or greenish cast, and is so acrid as to exco- riate the cheeks. From the lids the inflammation extends to the conjunctiva covering the ball of the eye, and the whole membrane is converted into a thick fungous mass; which, when the eyes are opened, projects beyond the lids, and obscures the cornea. If the disease should continue to spread, the cornea is next involved, and either ulcerates or sloughs, the humours are discharged, and the eye lost A great deal of constitutional irrita- tion attends the early stage of the disease, but this subsides in three or four days, and the ophthalmia then assumes a chronic form. To assign any satisfactory explanation of the origin of puru- lent ophthalmia is very difficult. Some writers suppose it to be closely allied to the gonorrheal ophthalmia, others that it proceeds from leucorrhea; the matter of which, in both in- stances, is applied, it is imagined, to the eyes of the child during Conjunctival Ophthalmia. 249 its passage through the vagina. Mr. Saunders is inclined to believe that the inflammation is of the erysipelatous kind. Gonorrheal ophthalmia, another variety of conjunctival in- flammation, bears a striking similitude to purulent ophthalmy, that form of it especially which is so prevalent in Egypt and other eastern countries, and from which the British and French troops, a few years back, suffered so severely. The symptoms, however, are, in every respect, more vehement, and such as to terminate almost invariably in the loss of one or both eyes. That it follows, in many instances, the direct application of the gonorrhoeal virus, I have the strongest proofs; having had, at different times, patients under my care in whom the disease was produced by the practice, so common among the vulgar, of washing inflamed eyes with urine. There is reason to believe, also, that the disease is sometimes induced by sympathy or a metastasis, in consequence of suppressed gonorrhoea. Scrofulous ophthalmy, a disease very common amongst scro- fulous children, may be distinguished from other affections of the conjunctiva by a peculiar morbid irritability of the eye, or intolerance of light, unaccompanied with pain, which obliges the patient to keep the lids constantly in a half closed state, and confine himself altogether to a dark rooon. In addition to this, numerous distinct vessels may be seen running towards the cor- nea, some of which pass to the centre of that tunic, and termi- nate in a small pustule or ulcerated spot. This disease may continue for months together, without much alteration, and is very apt to be followed by corneal specks. Treatment of Conjunctival Ophthalmia. In the early stage or acute form of simple inflammation of the conjunctiva, the disease may be removed, in a short time, by general and local blood-letting, mild purgatives, nauseating doses of antimony, low diet, blisters behind the ears, or on the 250 Conjunctival Ophthalmia. back of the neck, lotions of tepid water, a solution of opium, or of the acetate of lead. If, in spite of this treatment, the inflam- mation should not terminate, but runs into the chronic stage, cold astringent washes and stimulating ointments may then be- come necessary, such as the vinous tincture of opium, the ci- trine ointment, the ointment of the red oxide of mercury, &c. For catarrhal ophthalmia the best remedies are moderate depletion, at first, and afterwards highly stimulating collyria and ointments. Purulent ophthalmia, in the commencement, should be treated upon common antiphlogistic principles, and by mode- rately astringent washes, introduced into the eye by means of a syringe. The best lotion for this purpose is the undiluted li- quor of the acetate of lead. In advanced stages of the disease, an infusion of two drams of the leaves of tobacco in eight ounces of water, was found highly serviceable by Mr. Vetch, in re- straining the discharge, relieving pain and removing watchful- ness. The aqua camphorata of Bates' Dispensatory has been praised as extremely efficacious in the chronic form of purulent ophthalmy. I have often tried it, however, without benefit, and sometimes with manifest aggravation of the symptoms. Gonorrhceal ophthalmia, unfortunately, admits of no relief; at least, in several instances of the kind which have fallen under my care, and in others which have occurred in the practice of Dr. Physick, no benefit whatever has resulted from any mode of treatment that could be devised. Mr. Vetch, however, with great confidence states, that the disease may be certainly cured by those remedies adapted to the treatment of Egyptian oph- thalmia. Scrofulous ophthalmy seldom requires antiphlogistic mea- sures; on the contrary, a tonic plan of treatment will generally be indicated. In the commencement of the disease, however, it may be necessary to purge the patient, regulate strictly his diet, order warm clothing, moderate exercise in the open air, &c. To alleviate the intolerance of light, which is so much complained of by all patients in this disease, a blister at the back of the neck, kept open by savin cerate, will be found the best remedy. Sometimes the internal use of mercury will be required. The best collyria are those composed of weak solu- tions of the argentum nitratum, of sulphate of zinc, alum, &c. Sclerotic Ophthalmia 251 Section II. Sclerotic Ophthalmia. An inflammation of the sclerotic coat described by many writers under the name of rheumatic ophthalmia, is often met with. That it is closely allied to rheumatism is exceedingly probable, both from the circumstance of its being a frequent concomitant of that disease, and from the nature of the texture which it occupies. The pain in the commencement of the dis- ease, is generally seated in the temple, and extends thence to the eyebrow, cheek and eye of the affected side. It is constant- ly present, but commonly most severe during the evening and late at night. The eyeball itself, when examined, does not pre- sent the common appearances of conjunctival inflammation. There is no purulent discharge, nor does the patient complain of intolerance of light. The vessels, moreover, instead of fol- lowing a tortuous course, run in parallel lines upon the sclero- tic coat, and terminate at the margin of the cornea. These ves- sels are small and very numerous, and from being distributed over the whole albuginea, give it a uniform red colour; the red- ness, however, is not of the bright scarlet or vermilion hue, but of a dingy, brick-dust tinge. More or less fever, and de- rangement of the digestive organs, generally accompany the disease; and in bad cases, the inflammation may run so high as to involve the cornea and destroy the eye. 252 Sclerotic Ophthalmia. Treatment of Sclerotic Ophthalmia. The chief indications in the treatment of this disease, are to restore, by means of emetics and purgatives, the functions of the stomach and biliary organs, or, if the inflammation has been in- duced by exposure, to excite the skin by antimonials. After- wards bark may, perhaps, be employed with advantage. The best local applications are a blister behind the ears, and the free use of the vinous tincture of opium as a collyrium. General, as well as local blood-letting, will, in certain cases of this disease, prove serviceable, but in others injurious. Hence, the variety of opinions entertained on the subject by different surgeons; some contending that the depleting system should never be pursued, others, that it is indispensable. When ac- companied by a full pulse, and met with in plethoric patients, general blood-letting, leeches to the temple, or forehead, or around the eye, will almost always relieve the pain and other urgent symptoms; but when the complaint occurs in thin, and debilitated subjects, has been of long standing, or connected with general rheumatism, little or no benefit may be expected from venesection. Opiate frictions to the temples are extolled by Beer and other oculists, and belladonna to the eyelids and superciliary ridges. Applications to the ball of the eye, with exception of wine of opium, so useful in other forms of ophthal- mia, are seldom of much service in this variety of the complaint Iritic Ophthalmia. 253 Section III. Iritic Ophthalmia. The term iritis was employed by Mr. Saunders to denote a variety of ophthalmic inflammation which previous to his time had been very little attended to. From the peculiarity and dis- tinctness of the symptoms, there can be no question as to the propriety of considering the disease purely an inflammation of the iris, and totally independent of every other species of oph- thalmia. These symptoms are severe lancinating pain extend- ing from the eyebrow to the orbit; and shooting thence through the globe of the eye towards the optic nerve, extreme impatience of light, and an extraordinary morbid sensibility of the eye. Unlike most other varieties of ophthalmia, iritis is unaccom- panied by redness of the conjunctiva, but the sclerotic coat is covered with numerous red vessels, which are particularly con- spicuous on that portion of it connected with the margin of the cornea. On the iris, also, at least on its anterior surface, red vessels may be distinctly seen; but the most remarkable change that this membrane undergoes, is the loss of its brilliancy, and a change from its natural colour to that of a reddish or greenish hue. At the same time the pupil becomes contracted and ir- regular, and its edge is turned backwards towards the crystalline lens. Instead of terminating in suppuration, the inflammation generally stops at the adhesive stage, and lymph is deposited upon the outer surface of the iris in one or more spots, and is sometimes secreted so copiously as to fill the anterior chamber. From this cause, incurable obliteration of the pupil often en- sues. The causes of iritic ophthalmia are various. Sometimes the disease is induced by exposure of the eye to intense or vivid light; sometimes it proceeds from wounds of the iris made by Vol. II. 33 254 Iritic Ophthalmia. the cornea knife or couching needle; at other times it appears to arise from some constitutional affection, such as gout In the greater number of instances, however, it is the result of sy- philis or of the abuse of mercury. Treatment of Iritic Ophthalmia. The antiphlogistic system, carried to its full extent, will barely prove sufficient, in many instances, to arrest the progress of this severe disease. Hence the propriety of resorting to it as speedily as possible after the inflammation has set in. To guard against obliteration of the pupil, by breaking up the bands of coagulable lymph which extend across it, the extracts of bella- donna or stramonium will be found immensely serviceable. They should be applied to the outer surface of the eyelids, or over the eyebrows two or three times a day, and kept on for half an hour at a time. Care should be taken, however, not to employ them during the height of the inflammation. For the removal of syphilitic iritis, the moderate use of mercury, fol- lowed up by sarsaparilla, will generally prove an efficient re- medy. Psorophthalmia. 255 Section IV. Psorophthalmia. Some of the German writers understand by psorophthalmia, a variety of inflammation of the eyelids, induced by psora or itch. In the usual acceptation of the term, however, nothing more is implied than simple inflammation or ulceration of the lids, whether induced by small-pox, measles, scrofula, erysipe- las, sties, or any other cause. Children, particularly those of scrofulous constitution, are very subject to this disease; adults, however, are not exempt from it. The inflammation first appears on the edges of the lids, and extends thence along the conjunctiva towards the globe of the eye. The pain is sometimes very severe, and the red- ness considerable, but the most distressing symptom is the in- tolerable itching, to relieve which the patient is obliged con- stantly to rub the affected part; and in this way only aggravates the disease. Sometimes the inflammation runs so high as to terminate in suppuration. This is followed by troublesome ul- ceration of the tarsi, and frequently by great deformity. The meibomian glands are always more or less affected in this com- plaint, and pour out an adhesive fluid, that glues the lids together during sleep. To open these, in the morning, some force is usually employed, and this keeps up constant irritation, and fre- quently renders the disease chronic, causing the formation of small crusts or scabs along the tarsi and the cilia to drop out. In bad and long-standing cases of the disease, the puncta lacrymalia are sometimes permanently obliterated, and an incurable epi- phora is produced. 256 Psorophthalmia. Treatment of Psorophthalmia. In the early stage of this disease, purgative medicines and a moderate diet will contribute very much towards a speedy cure. Weak solutions of the acetate of lead, of the sulphate of zinc, or sulphate of copper, will also be found useful as collyria. To prevent the lids from adhering, a very important indication in the treatment, a little fresh cream or butter should be placed between them every night before the patient retires to rest. After the inflammation has, in a measure, subsided, and is verging towards the chronic stage, the unguentum hydrargyri nitrati, applied to the edges of the lids, two or three times a day, will prove singularly useful in relieving the itching, and in healing the ulceration. With the same view, an infusion or decoction of the pith of the sassafras is sometimes used, and in many instances with decided advantage. Not unfrequently the disease resists, for a long time, every remedy, and, indeed, continues for years together. Under these circumstances, blis- ters behind the ears and neck, and a course of mercury may prove useful. Pterygium. 257 Section V. Pterygium. The pterygium, or eye wing, is a thin membranous expan- sion seated upon the conjunctiva. It commonly occupies the inner angle of the eye, in the shape of a triangle, the apex of which looks towards the cornea. The disease is very common, but in most instances productive of so little inconvenience, that many persons are subject to it for years together, without be- ing aware of its presence. In the early stages, it resembles a globule of fat, and appears to possess little vascularity; a slight cold, however, or an inflammation of the conjunctiva, renders its vessels very distinct. Although the disease may remain sta- tionary, or nearly so, for many years, it is always liable to in- crease, and in this case may extend over the surface of the cor- nea. But it is somewhat remarkable, that it seldom, if ever, passes beyond the semidiameter of the cornea. Sometimes a pterygium originates at each angle of the eye, and approaching the cornea in opposite directions, covers the whole of its sur- face. The disease is then called a pannus. There are two va- rieties of pterygium—the membranous and fleshy. Treatment of Pterygium. So long as this membranous excrescence continues small, and does not encroach upon the cornea, it will seldom be necessary 258 Pterygium. to resort to an operation for its removal. When, however, it has attained considerable bulk, and is a frequent source of irrita- tion, it should be dissected off either by a small scalpel or curved scissors. The scissors will generally be found the most con- venient. To perform the operation advantageously, an assistant should stand behind the patient and support his head firmly upon his breast, and with one or two fingers elevate the upper eyelid, whilst another assistant depresses the lower lid, and keeps it fixed. The surgeon then taking a pair of small forceps should elevate the pterygium from the conjunctiva, and by a few strokes of the scissors separate the whole of it from the globe. A smart and sometimes violent inflammation follows the operation, and this must be subdued by the usual remedies. Encanthis. 259 Section VI. Encanthis. The encanthis, an enlargement of the lacrymal caruncle and semilunar fold, is a very uncommon, but sometimes most malig- nant disease. It proceeds, in some instances, from obstinate and protraeted ophthalmia; at other times the gland assumes a can- cerous action, and terminates, like most diseases of this descrip- tion—unfavourably. In every disease of the kind, whether benign or inveterate, the caruncula lacrymalis presents a granu- lated and livid aspect. In proportion, however, as the tumour increases, its surface becomes less rugged, and is covered with varicose vessels. From the caruncle the disease extends some- times to the cornea, and along the inner surface of each eyelid. When the tumour attains a large size, the puncta lacrymalia are commonly compressed or obliterated, and a troublesome epiphora ensues. Treatment of Encanthis. Excision of the caruncula and of the valvula semilunaris is the only remedy for this disease; but the operation frequently fails either from the whole of the tumour not being taken away or from the malignant character of the complaint. In perform- ing the operation, the surgeon will find it most convenient to se- cure and control the tumour, by introducing a small hook into its substance, and then dissecting it out with a narrow scalpel. Care must be taken to avoid the puncta lacrymalia. If the tu- mour has taken on the cancerous action, is very large, and has involved the surrounding parts, it may become necessary to ex- tirpate the globe of the eye. 260 Opacity of the Cornea. Section VII. Opacity of the Cornea. There are three varieties of corneal speck, noticed by most writers under the names of nebula, albugo, and leucoma. By nebula is commonly understood a "superficial opacity of the cornea, preceded and accompanied by chronic ophthalmia, through which the iris and pupil are seen, and which does not, therefore, entirely take away from the patient the power of see- ing, but only causes the surrounding objects to be seen as if covered with a veil or cloud."* The whole cornea is sometimes covered by a nebula; in other instances, several distinct specks appear in spots upon its surface, each of which is generally sup- plied with one or more vessels from the conjunctiva, or other coats of the eye. These vessels, indeed, serve to nourish or keep up the disease. The albugo differs in several respects from the common nebula. It is more deeply seated, and occupies the lamella? or substance of the cornea; it is al?o of a white or pearl colour, is frequent- ly unaccompanied by ophthalmia or by red vessels, and is always the result of an abundant effusion of lymph. Leucoma is a dense callous speck of the cornea of a pure white or chalk colour, and polished aspect It is usually the re- sult of a cicatrix from a wound or ulcer. Sometimes it follows small-pox or measles. * Scarpa. Opacity of the Cornea. 261 Treatment of Opacity of the Cornea. A simple nebula or cloudiness of the cornea, may often be dispersed by slightly astringent collyria, such as are calculated to subdue the ophthalmia that usually accompanies the disease. But, in many instances, a division of the vessels supplying the speck is rendered necessary. If the trunks are large, they should be elevated by forceps, and a piece taken out of each by the curved scissors. The treatment of an albugo of long standing will always be found very difficult, and nothing short of highly stimulating ap- plications will effect a cure. One of the best for this purpose is the unguentum hydrargyri nitrati, applied by means of a camel hair pencil to the surface of the speck once or twice a day. A weak solution of argentum nitratum, will, in most cases, prove very serviceable. The same may be said of sul- phate of copper, and of corrosive sublimate. Red precipitate ointment, also, is a very useful remedy. Finely powdered loaf sugar, calomel, and other similar articles, are frequently blown into the eye, and produce most salutary effects. A drop of molasses, between the lids night and morning, has frequently dispersed both nebula and albugo. In several obstinate cases of the disease which have resisted all the usual remedies, I have known a speedy absorption of the speck accomplished by the repeated ablution of the eye and eyelids with diluted vine- gar. In addition to the local treatment, the internal use of calomel and other preparations of mercury should be resorted to. The leucoma is seldom, if ever, removed. Vol. II. 34 262 Ulcer of the Cornea. Section VIII. Ulcer of the Cornea. The cornea, as well as the fine lamina of conjunctiva cover- ing its surface, is liable to assume the ulcerative action. In either case, a very troublesome, and, perhaps, destructive disease may be induced. This ulcer is commonly the result of the different varieties of ophthalmia, or it may proceed from the introduc- tion of acrid or caustic substances into the eye. Sometimes the whole cornea is covered by the ulceration; at other times, a small dimple-like cavity, not larger than the head of a pin, occupies some particular part of the cornea, and instead of spreading towards its margin, penetrates the layers until it lays open the anterior chamber of the eye. An ash-coloured slough, resembling wet pasteboard, generally covers the surface of the corneal ulcer. The edges of the ulcer, also, are high and ser- rated. Treatment of Ulcer of the Cornea. To relieve the excessive pain that usually attends this dis- ease, and to promote healthy granulation, there is no application so effectual as the argentum nitratum. The sore should be lightly touched with the caustic, until an eschar forms on its surface, and when this drops off, which it generally does in Ulcer of the Cornea. 263 twelve or eighteen hours, the application should be renewed —taking care to wash away, with milk and water, any superflu- ous caustic that may happen to lodge about the eye or eye- lids. When the ulcer assumes a healthy aspect, the caustic may be discontinued, and mild collyria or ointments substi- tuted. " In all cases," says M'Kenzie, " we endeavour, of course, to check the ulcerative process, by those measures which are fitted for subduing the inflammation in which the ulcer took its origin. So long as there is an appearance of activity in the inflammatory disease, and much pain of the eye, local blood-letting must be employed. The bowels must be kept freely open, and opium administered in such a combination as shall be likely to operate on the skin. In strumous cases, sulphate of quinine operates very advantageously. In chronic superficial ulcer, calomel given so as to affect the mouth is sometimes necessary. In al- most all cases of ulcerated cornea, counter-irritation will be found useful. As the inflamed state of the eye abates, the pa- tient finds the pain greatly relieved, and we observe the ulcer clearing and beginning to contract" 264 Staphyloma. Section IX. Staphyloma. In the sense affixed to it by most modern writers, the term staphyloma implies a thickening and opacity of the layers of the cornea, together with a greater or less projection of the anterior surface of that tunic. Children, in whom the cornea is propor- tionably thicker than in adults, are most subject to the disease. One eye or both may be affected at the same time or in succes- sion. Small-pox, purulent ophthalmia, wounds of the eye by the couching needle or extracting knife, blows, and other in- juries, are among the most frequent causes of staphyloma. In the advanced stages of the disease, the tumour of the cornea is sometimes partially absorbed, and both the anterior and pos- terior chambers of the eye appear to be filled with a serous fluid. Two forms of the disease are met with—one in which more or less transparency of the cornea is preserved, and, along with it, a slight degree of vision, the other, in which the whole cornea is perfectly opaque. The former is denominated partial, the latter total staphyloma. Again; staphyloma has been di- vided into conical and spherical. Treatment of Staphyloma. There is no remedy, unfortunately, for this disease; at least the transparency of the cornea cannot be restored, and the patient, Staphyloma. 265 therefore, must for ever remain blind. But the surgeon, gene- rally, has it in his power to alleviate the severe pain and in- flammation (caused by dust and other extraneous bodies lodging upon the portion of the cornea projecting beyond the eyelids) by an operation. The object of this is to evacuate the humours, and permit the eye to collapse. To accomplish this purpose most effectually, and prevent a return of the disease, a section of the most prominent part of the cornea, by the knife used for extracting the cataract, should be made. The humours having escaped, the flap of the cornea may be removed with curved scissors. A circular opening will thus be made large enough for the contents of the eyeball gradually to drain away, whereas, if the surgeon were merely to puncture the cornea with a needle, as formerly practised, the opening would soon close, and the dis- ease return. However, it has been recommended, and practised, by many modern oculists, not to evacuate the contents of the eye, if it can be avoided, but suffer the humours to remain, and endeavour to produce cicatrization of the cornea, in order that the rotundi- ty of the eye may be preserved, and the deformity arising from the collapse of the organ obviated. With this view, all pres- sure upon the eye after the section of the corneal tumour must be avoided, the lids immediately closed by court plaster, and not opened for several days. In conical staphyloma it is more difficult to prevent the humours from draining off than in the spherical variety. 266 Hypopion. Section X. Hypopion. In consequence of violent deep-seated ophthalmia, it some- limes happens, that purulent matter is formed within the poste- rior or anterior chamber of the aqueous humour—constituting the disease known under the name of hypopion. Besides ex- treme redness of the conjunctiva, a yellowish crescent-shaped spot may also be observed at the bottom of the anterior chamber, which gradually increases in size until the whole of the cavity is filled. During the height of the inflammation, the pain, in- tolerance of light, &c, are intensely severe, and the matter co- pious ; but as these symptoms decline, the pus is proportionably absorbed and sometimes disappears in a few days without ma- terial injury to the eye. In other instances, it remains for weeks together, after the inflammation has entirely subsided, in the an- terior chamber, mixed with the aqueous humour, which it ren- ders turbid It is seldom, however, that the disease terminates so favourably. On the contrary, in bad cases of the kind, ulcera- tion and sloughing of the cornea are apt to ensue, followed by dis- charge of the humours and destruction of the whole eye. When the matter is lodged between the lamella? of the cornea, the dis- ease takes the name of onyx from its resemblance to the white spot at the root of the nails. Treatment of Hypopion. The proper mode of managing this disease is not to puncture the cornea and evacuate the matter, as some advise, but to sub- Hypopion. 267 due the accompanying inflammation, after which it will be found, commonly, that the matter is slowly absorbed, and will, in time, entirely disappear. When, however, the collection of pus is so large and the inflammation so violent, as to leave no hope of saving the eye, it may become expedient to open the cornea and discharge the matter, in order to relieve the patient from unnecessary pain and irritation. Nevertheless, cases have been reported by Wardrop, Mon- teith, and others, where, in the early stages of onyx and hypo- pion, the aqueous humour has been evacuated, and the purulent matter discharged, with speedy relief to the patient, and preser- vation of the eye. From statements made by Monteith, in par- ticular, it also appears, that what, in many instances, seems to be pus, is, in reality, lymph, as is proved by its consistence, and other properties, and that its removal checks the disposition to suppuration. Scarpa, long ago maintained, that the fluid poured out into the anterior chamber, in cases of hypopion, was, gene- rally, lymph, secreted by the choroid coat. 268 Hydrophthalmia. Section XI. Hydrophthalmia. Dropsy of the eye, a disease rarely met with, may originate either in the anterior or posterior chamber of the eye. It is, for the most part, dependent upon some constitutional affection, and is frequently connected with general dropsy. The most striking symptom of the disease is a gradual enlargement of the globe of the eye, without much pain or injury to vision. When the globe, however, begins to protrude from the socket, and the coats of the eye are rendered tense by the accumulation of se- rum within their cavities, a considerable degree of pain is ex- perienced, which extends in some instances to the head. At the same time the vision becomes impaired, the aqueous hu- mour acquires a turbid appearance, and the iris appears more deeply seated than usual, and trembles upon the slightest mo- tion of the patient's head. Finally, if not evacuated by an ope- ration, the humours accumulate in such quantity as to excite violent irritation and suppuration, and the eye is irrecoverably lost. Collections of serum between the sclerotic and choroid coats, and between the choroid and retina, are, occasionally, met with—the former termed sub-sclerotic, the latter sub-cho- roid dropsy. Conversion of the retina into a cord, and absorp- tion of the vitreous humour, may be the result, from pressure, of sub-choroid dropsy, which is much more common than the sub-sclerotic. Treatment of Hydrophthalmia. When hydrophthalmia depends upon general dropsy, and is attended to in the commencement of the disease, some benefit Hydrophthalmia. 269 may be derived, perhaps, from internal remedies—such as digita- lis, squill, volatile tincture of guiacum, calomel, cicuta, &c. But after vision has been materially injured, or destroyed and the eye projects beyond the lids, the operation of paracentesis is the only mode of treatment calculated to afford relief. This must be considered, however, as merely palliative. It may be performed with a common lancet or couching needle, and the operation occasionally repeated, or whenever the accumulation of water is such as to require its evacuation. When the disease proceeds from local causes, such as blows upon the eye or superciliary ridge, and the fluid is confined to the anterior chamber, friction with mercurial ointment around the eyelids, and blisters to the temples will now and then stop the progress of the complaint, and effect a cure. To relieve the violent pain accompanying sub-choroid dropsy, puncture of the eye with a grooved needle at the place where couching is usual- ly performed, should be resorted to. Ware and other oculists report interesting cases, where great benefit followed this mode of treatment. Vol. II. 35 270 Obliterated Pupil. Section XII. Obliterated Pupil. From common ophthalmia or from iritic inflammation, whe- ther induced by operations for cataract or by other causes, closure or obliteration of the pupil frequently takes place. The iris, under such circumstances, becomes wrinkled or puckered, and the pupil is either entirely effaced or contracted to a very small compass. If complicated with cataract, the opaque lens or its capsule may generally be seen behind the pupil of a whitish or bluish aspect; but if the lens and capsule remain transparent, the pupil, although contracted, still retains its na- tural black colour; and vision, perhaps, to a certain extent, is still preserved. Treatment of Obliterated Pupil. This disease can be relieved, or cured, only by an operation. Since the time of Chesselden, who was the first to resort to such an expedient, various methods have been practised. Chesselden's operation, in his own hands, proved eminently successful; with others it often failed, and was at last abandoned altogether. Recently, however, it has been revived by Sir William Adams, and as modified by him is better calculated, I conceive, for most cases of closed pupil, than any other operation. " The patient being seated as in the operation for cataract, and the eye ren- Obliterated Pupil. 271 dered steady by a gentle pressure with the concave speculum, placed under the upper eyelid, the artificial pupil knife should be introduced through the coats of the eye about a line behind' the iris, with its cutting edge turned backwards instead of down- wards. The point is next brought forward through the iris somewhat more than a line from its temporal ciliary attachment, and cautiously carried through the anterior chamber until it has nearly reached the inner edge of that membrane, when it should be almost withdrawn out of the eye, making a gentle pressure with the curved part of the cutting edge of the instrument against the iris in the line of its transverse diameter. If in the first attempt the division of the fibres of the iris is not sufficient- ly extensive, the point of the knife is to be again carried for- ward, and similarly withdrawn, until the incision is of proper length, when the radiated fibres will immediately contract, and an opening of a large size will be formed. After the operation is thus completed, the eye should be covered over with a plaster of simple ointment, spread on lint, and the patient put to bed with his head raised high."* If the obliterated pupil should be combined with an opaque lens or capsule, the surgeon should make it a point at the time he divides the iris, to cut up or la- cerate these textures, and thrust them forward through the pu- pil, which they will assist in keeping open. Wenzel, Gibson, of Manchester, and many other oculists, pre- fer in cases of closed pupil, a section of the cornea and the re- moval of a portion of the iris with scissors. Under particular circumstances, I should select this operation in preference to that of Chesselden. Several years ago, Dr. Physick invented a small instrument, resembling a saddler's punch, for cutting out a piece of the iris; but he has never, as he informs me, made use of it. It will, some- times, become necessary to make an artificial pupil (even al- though the natural one remain of its usual size) on account of corneal opacity. Beer, Schmidt, Reissinger, Maunoir, Flagani, Assalini, Scarpa, have all particular modes of operating for obliterated pupil; they possess no advantages, it appears to me, over those in common use. * Adams' Practical Observations, &c. p. 137. 272 Procidentia Iridis. Section XIII. Procidentia Iridis. A prolapsus, or projection of the iris through an ulcer or wound of the cornea, is by no means unfrequent The pain attending the disease is extremely severe, and the intolerance of light so excessive that the patient cannot bear the exposure of the eye for a moment. The pupil, in this disease, always assumes an unnatural shape; its particular form, however, will depend very much upon the situation of the opening in the cornea. General- ly, it is of an oval figure. Sometimes there are two or three projections of the iris, each of which passes through a distinct opening of the cornea. After the protrusion has continued for some time, an adhesion is apt to ensue between the cornea and iris, and the part of the iris that projects beyond the cornea be- comes dry and hard, and sometimes sloughs away. Treatment of Procidentia Iridis. When this disease follows a wound of the cornea, the iris may always be replaced at the time the edges of the wound are adjusted; but when it proceeds from an ulcerated opening, the surgeon will find it impossible to retain the iris in its natural situation so long as the ulcer exists. The great object, there- fore, in the treatment should be to heal the ulcer, and this will be most speedily accomplished by repeated touches of the ar- gentum nitratum. The caustic will serve the additional pur- pose of subduing the morbid sensibility of the iris, and of re- moving the superfluous portion of it projecting beyond the cornea. Cataract. 273 Section XIV. Cataract. The ancients entertained very erroneous notions respecting the nature and seat of cataract. They supposed it to be formed by an adventitious membrane in the posterior chamber of the aqueous humour. Dissection, and operations on the living sub- ject, afterwards proved that the disease was confined to the crystalline lens or its capsule, which becoming opaque prevented the rays of light from passing to the retina. Cataracts differ from each other as much in consistence as co- lour. Sometimes the lens is rendered perfectly fluid, and re- sembles milk, and on this account has been called the milky cata- ract. Sometimes it is found of the consistence of jelly or cheese, and hence the terms gelatinous and caseous cataracts. Not unfrequently the lens is perfectly hard, or ossified, so much so, that the sharpest instrument will make no impression upon it When the anterior or posterior capsule is rendered opaque, and the lens remains transparent, or is absorbed, the disease is called capsular cataract. When a cataract exists at birth, the appella- tion congenital is applied to it Most cataracts are of a bluish or pearl colour; some are gray or green; others white as snow. In a few rare instances the lens has been found of a brownish tint or perfectly black. The formation of cataract has never been satisfactorily ex- plained. By some the disease has been attributed to inflammation of the lens and its capsule, by others to hereditary transmission. That it may proceed from blows upon the eye and from wounds of that organ is very certain. In all cases of the kind there is reason to believe that the anterior capsule of the lens is either ruptured or cut, so that the lens itself is brought into immediate contact with the aqueous humour, which possesses the well 274 Cataract. known property of dissolving its texture as well as that of its capsule. It is remarkable, however, that an injury or destruc- tion of one eye, as I have several times witnessed, will frequent- ly give rise, at a subsequent period, to a cataract in the other. Old persons are most subject to cataract, though the disease may occur at any period of life; indeed, new-born infants are not exempt from it, and it has sometimes happened that all the chil- dren of a numerous family have been born with cataracts in both eyes. Persons whose eyes are much exposed to vivid and reflected lights are said to be peculiarly liable to cataract. The existence of cataract may be determined, generally, by the following symptoms. In the commencement, the patient is often sensible of a diminution of sight long before any opacity can be observed behind the pupil. Objects, moreover, especial- ly white ones, appear to him as if enveloped in mist or smoke, and when the eye is suddenly exposed to a strong light, vision is nearly destroyed. In a dull light, on the contrary, vision is more distinct, because the pupil being expanded, the rays of light, besides their increased quantity, pass through the thin margin of the lens. When the lens is completely opaque, its colour will commonly indicate the nature of the disease. The black cataract, however, is very liable to be mistaken for amau- rosis. Cataracts are said to have been formed very suddenly, or in the course of a night, without any obvious cause; but I am inclined to believe this to be erroneous, and that the disease has existed, at least in one eye, for some time, without the patient being aware of its presence, and that the discovery of it has been purely accidental. Treatment of Cataract. Although repeated attempts have been made, both by internal remedies and by local applications, to remove cataract, there is no well-attested instance, I believe, on record, of a cure having /•/-//< •' I'-i .! fyj )'. Cataract. 275 been effected, except by an operation. There are two or three different operations now in use, each of which it will be proper to describe. Couching or depression of the cataract, an operation prac- tised, there is reason to believe, long before the time of Celsus, is usually performed by the modern surgeon either with a curved or straight needle. The former is preferred by Scarpa —the latter by Hey. (See Plate V. figs. 1 and 2.) The patient being seated on a low stool, with an assistant behind to support his shoulders and head, the operator, sitting or standing before him, passes the speculum of Pellier (Plate V. fig. 3,) beneath the upper eyelid, and directs the assistant to hold it steadily, while with one or two of the fingers of his own hand he de- presses the lower lid. He then takes the needle, (and if Scarpa's be used, which I prefer to any other,) holds it in his fingers like a pen, and laying the handle of the instrument nearly pa- rallel with the patient's temple, directs its point backwards, and its convex surface forwards, and penetrates the coats of the eye, at its external angle, about two lines posterior to the iris. The needle is next pushed towards the superior margin of the crys- talline lens, and thence in the direction of the pupil, until its point is distinctly seen. It only remains to lacerate freely, but cau- tiously, with the point of the needle, the anterior capsule of the lens; which being done, the lens itself should be pressed down- wards and backwards by the needle, and lodged in the vitreous humour. Instead of withdrawing the needle immediately after from the eye, as is too often done, it should be suffered to re- main a few seconds, lest the lens reascend, in which case the surgeon should again depress it, and then carefully remove his instrument and close the eyelids. Extraction of the cataract is performed by a knife instead of a needle, and the opening made in the cornea in place of the sclerotic coat There are two knives in general use—the one invented by Wenzel and improved by Ware, straight and blunt on the back, convex on the edge, five-eighths of an inch in width, and in other respects shaped like a wedge, or gradually tapering from the handle to the point—the other invented by Beer, and differing from that of Wenzel chiefly in having a triangular shape. (See Plate V. figs. 5 and 6.) With either, the operation may be equally well performed. 276 Cataract. The necessary arrangements being made, the patient is placed on a low chair or stool, and his head committed to an intelligent assistant (one accustomed to the office and in the habit of perform- ing the operation,) who with his fingers, instead of a speculum, elevates the superior eyelid, and supports it against the super- ciliary arch. The surgeon himself taking charge of the lower lid, which he depresses with one or more fingers, and waiting until the patient rolls the eye towards the inner can thus and holds it steady, enters the knife above the semidiameter of the cornea and about a quarter of a line anterior to its junction with the sclerotica, with the edge downwards, passes it slowly and steadily along through the anterior chamber until its point emerges at the inner edge of the cornea. This completes what has been called the punctuation of the cornea, and to finish the section it is still necessary to push on the blade of the instru- ment until it cuts itself out. As soon as this is accomplished, the aqueous humour is discharged, the knife is withdrawn, and the lids are closed for a few moments. The next step of the operation, and the most important one, is to separate the lids, gently raise the flap of the cornea with the curette, (Plate VII. % 7>) Pass a g°ld or silver wire through the pupil, and cau- tiously lacerate the anterior capsule of the lens precisely in its centre. If this part of the operation be well managed, and care taken to avoid any thing like pressure upon the globe of the eye, the lens, after its capsule is broken, will gradually approach the surface and be discharged through the opening made in the cornea, without bringing with it any portion of the vitreous hu- mour. As soon as the lens is removed, the flap of the cornea should be adjusted, the lids closed, and a bandage applied lightly over both eyes. It sometimes happens, owing, principally, to the cornea knife being dull and ill-constructed, that the aqueous hu- mour flows before the section of the cornea is completed, and that the iris falls under the edge of the knife, and is liable to be wounded. To guard against this, Baron Wenzel suggested an expedient which has proved extremely important—friction of the cornea with the end of the finger during the passage of the knife. If this plan be adopted, the iris will immediately retire from the edge of the knife, and so remain as long as the friction is continued. The absorbent practice, as it is denominated by Sir William Hate 7 V2 i % i Cataract. 277 Adams, may be said, perhaps, to have originated with Mr. Pott; at least, that eminent surgeon was fully aware of the sol- vent power of the aqueous humour, and frequently took advan- tage of the circumstance, by pushing fragments of the lens which happened to be detached during the operation of couch- ing into the anterior chamber. Gleize, also, as well as Scarpa, Hey, and others, followed the same practice. But it is chiefly owing to Saunders, Conradi, and Adams, that this mode of re- moving the cataract has been brought to its present degree of perfection. There are two operations in use, each founded upon the ab- sorbent principle—the anterior and posterior. The first, or the operation of Conradi, as it is usually called, is chiefly adapt- ed to the soft or fluid cataract, and may be performed in the following way. The pupil being dilated by the application of the extract of belladonna or stramonium to the eyebrow, an hour or tsarian Section. 405 surgeons, two or three times in the United States, there is rea- son to believe; but in no instance has the life of mother and child, so far as my information extends, been saved except in the case I shall now relate. Mary R-----d, wife of Joshua M. R----d, Esq., of this city, 26 years of age, was married, the 16th of May, 1830, and on the fourteenth of June, 1831, was in labour with her first child. Dr. George Fox, being called to her assistance, found the os uteri sufficiently dilated to admit a finger, and feel the protruding membrane. Discovering, a few hours afterwards, great deformity of the pelvis, he was led to believe that Mrs. R. could not be delivered per vias naturales, and, therefore, requested the as- sistance of Professor James, and subsequently, that of Drs. Meigs, Lukins, Hewson and J. R. Barton. After repeated, and most accurate examination, it was concluded that the antero-posterior diameter of the pelvis did not exceed two inches; and it then be- came a question, whether the division of the symphisis pubis, the Caesarian operation, or embryotomy, should be performed. " The Caesarian operation was thought to be attended with so much risk to the mother as almost to be necessarily fatal, some of the most distinguished surgeons being decidedly opposed to its performance; and Dr. Physick, who was called upon for his opi- nion, on the propriety of this operation, was decided, and positive in his opposition to it. Under the weight of such authority, the idea of the Caesarian operation was abandoned."* It was then determined to perform cephalotomy, and Dr. Meigs agreed to undertake it. Before he commenced that operation, however, Dr. M., conceiving, after further examination, that " cephaloto- my would be attended with as much risk to the life of the mo- ther as the Caesarian operation, thought it better to call another consultation, to reconsider the propriety of performing the Caesa- rian operation."f During this consultation it was decided that the child was dead; there being, therefore, " no further hesitation as to the propriety of cephalotomy," that operation was com- menced immediately by Dr. Meigs, and performed in the most * Relation of a case of labour, in a female with deformed pelvis, by George Fox M. D., in North American Medical and Surgical Journal, No. xxiv. Octo- ber, 1831, p. 485. f Ibid. Vol. IL 52 406 Hysterotomy or Caesarian Section. skilful manner, and the patient, (notwithstanding the great dif- ficulties the operator had to encounter,) recovered in three week after delivery, though she had almost fallen a victim to exhaus- tion."* On the 22d of June, 1833, Mrs. R's. labour with her second child commenced. Dr. Meigs was again called to her assist- ance, and performed a second time the operation of cephalotomy —having previously ascertained that Caesarian section would not be submitted to. The patient again recovered, and with less difficulty than after the first operation. In June, 1834, Mrs. R----d became pregnant with her third child, and my friend Dr. Jos. G. Nancrede, now one of the oldest and most respectable accoucheurs of this city, was consulted, and after mature deliberation decided, that Caesarian section was the only appropriate operation in her case, inasmuch as it had been per- formed on the continent of Europe, in numerous instances, with success, and was considered by the most eminent accoucheurs not more hazardous, under certain circumstances, than embryotomy. Upon these and other grounds, Dr. Nancrede determined to use his influence with the patient, and her friends, to induce them to consent to the operation, and requested me to make every preparation for its performance—in case I approved of and was willing to undertake it. Coinciding with him in sentiment, and having considerable time for reflection, and opportunity for ex- amining authorities as to the best mode of performing the ope- ration, I made all the necessary arrangements. On Wednesday, 25th of March, 1835, I received notice that Mrs. R----was in labour; and at 3 o'clock, P. M., saw her, for the first time, with Drs. Nancrede and F. S. Beattie. Labour had commenced the night before, though the pains during that night, and the whole of Wednesday, were slight The os uteri, however, had dilated sufficiently to admit two or three fingers, but the membranes remained entire. In this state of affairs it was explained to Mrs. R----, by Dr. Nancrede, and the Rev. Mr. Hughes her pastor, that it was deemed improper, in every point of view, to destroy her child, and that it was her duty to risk her own life in the hope of saving that of her offspring. * Meigs on Deformed Pelvis, &c, in Baltimore Medical and Surgical Journal and Review, vol. 2nd, p. 30. Hysterotomy or Casarian Section. 407 After consulting for some time with her husband, and other friends, she consented to have the operation of Caesarian sec- tion performed.* A firm table was selected, and covered with a mattress and sheets, the patient placed upon it, on her back, and her pelvis and shoulders supported by pillows. In presence of Dr. Nancrede, Professor Dewees, Dr. Dove of Richmond, Professor Horner, Dr. Beattie, Dr. Wm. Coxe, Dr. Theodore Dewees, and my son, Charles Bell Gibson, I made an incision, at the centre of the linea alba, commencing about an inch be- low the umbilicus, through the integuments, and extending nearly to the pubes. To save the patient pain and to prevent this first, or perpendicular, cut from penetrating too deeply, I requested Dr. Horner to fold up the skin with his fingers, and while thus held I passed the knife through it with its back to- wards the abdomen. The superficial fascia being exposed was divided, then the tendons of the abdominal muscles, next the peritoneum, and lastly the body of the uterus, all to the extent of six inches. The uterus, however, at this stage of the opera- tion, was not cut entirely through, but a line or two in thick- ness, of the interior of its walls, left—with the view of draw- ing off the waters before I opened the womb, penetrated the membranes and exposed the child. At my request Dr. Nan- crede introduced a finger into the os uteri and endeavoured to rupture the membranes, but could not succeed. A similar at- tempt was made by Dr. Beattie, which also failed. Having re- sumed the knife, the remaining fibres of the uterus were divided, the membranes exposed, and cautiously opened by running Cooper's bistoury for strangulated hernia, upwards and down- wards, to the extent of six inches, while Dr. Horner held closely together the sides of the wound, to prevent protrusion of the intestines and the escape of any portion of the waters into the bag of the peritoneum. There was a right lateral obliquity of the uterus, and the po- sition of the child found to correspond with the third breech presentation of Baudelocque. Dr. Beattie then introduced his hand and drew out the feet, while Dr. Nancrede supported the hips and back, and removed the body, and lastly, the head * There are several modes of performing Cxsarian section, but I prefer the one L have here described. 408 Hysterotomy or Casarian Section. of the child, from the womb. It proved a girl of large size, and apparently healthy. For some seconds, however, it did not breathe, and, indeed, not until friction on the chest, blowing into the mouth, and the introduction of a few drops of brandy were resorted to. The cord being cut, the child was removed, and in a short time cried lustily. Whilst Dr. Horner still kept the sides of the wound together, Dr. Beattie extracted, without difficulty, the placenta and membranes, and, at the same time, pushed a finger from the interior of the uterus through the os tincae, to make a free communication with the vagina. During these manipulations, two portions of intestine, each the size of a pigeon's egg, protruded on the right side of the uterus, and near the upper corner of the wound. They were readily kept back, however, and did not again protrude; nor did any fluid, so far as could be observed, find its way into the peritoneal bag. No hemorrhage took place from the removal of the placenta, nor was it necessary to secure a single vessel with the ligature. There was a visible contraction of the womb, after the removal of its contents, and the incision in it had sensibly shortened in the course of a few seconds. My attention was next drawn towards closure of the wound. With great care, and the utmost nicety, the edges of the peri- toneum, muscles, and integuments were held together by assis- tants, while I passed, successively, three stout silk ligatures, in form of interrupted suture, through the integuments—avoiding the peritoneum and muscles—an inch and a half from each other, and supported the whole by adhesive straps, lint, a com- press and roller around the abdomen. To give vent to any se- cretion of serum, or pus, the lower angle of the wound was left open for the space of half an inch. The patient was then raised very carefully, by several assistants, and laid in bed upon her back, and great pains taken to render her position as comfortable as possible, and to prevent the slightest movement There was less difficulty in this respect than could have been anticipated, arising partly from the little pain, comparatively, during the operation, the natural firmness and equanimity of the patient, and her faithful reliance upon Providence for a happy issue out of her affliction. Under the cheering influence of such feelings, she slept soundly for several hours, and did not change her po- sition in the slightest degree. Hysterotomy or Casarian Section. 409 By Drs. Nancrede, Beattie and myself,* she was visited, for a week or ten days, three times a day; was kept entirely on barley water, during that time, under the influence of an occa- sional opiate at night, took, now and then, small doses of mag- nesia, or used enemata, had her diet gradually increased; on the twenty-fifth day after the operation, was enabled to sit up,— the wound, with exception of a single spot, the size of a pea, being entirely cicatrized—and, finally, recovered, and now en- joys, together with her child, perfect health. On Cesarian Section, consult Sabatier's Medecine Operatoire—Simon- in Mem. de TAcad. de Chirurg. tom. 3d, and 5th edit. 12mo.—Baudehcque Traite" des Ac- couchements—Hull's Defence of Caesarian Section, 8vo.—C. Bell in Med. Chir. Transact, vol. 4th—/. H. Green, ibid. vol. 12—Dictionnaire des Sciences Medi- cates, tom. 17—Plancton Traiti complet de V Operation Cesarienne. Paris, 1801 —AnsiauaPs Dissertation sur I'Operation Cesarienne, &?c. Paris, 1803—Dewees' Midwifery—Essays, Cases, &c by the folhwing writers, may be consulted with advantage:—Kaiserschnitt, Weinhart, Nettman, Rhode, Wigand, Flammant, Kulenthal, Meyer, Phderl, Huter, Kittel, Friedemann, Graefe, Bobertag, Wan- ner, Papius, Davidsohn, Michaelis, Siebold; an account of which may be found in Dictionnaire de Medecine, ou repertoire Generate des Sciences Medicates, tom. Septieme,p. 156. Paris, 1834—The 7th vol of Sprengel, Histoire de la Medecine, and Cooper's Surgical Dictionary, may also be referred to. But the most elabo- rate work ever published on the Caesarian section, is said to have been written lately by Mansfeldt, a German surgeon,- for an account of which, see Ryan's Manual of Midwifery. • After the operation the patient was kindly visited, repeatedly, by Drs. De- wees, William Coxe, Horner, Spackman and others. THE ENfD. MEDICINE, ; a scholar and a man of taste. 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BIOT, Member of the French Institute. ROBERT SOUTHEY, Esq. Poet Laureate. The Baron CHARLES DUPIN, Member of the Royal Institute and Chamber of Deputies. THOMAS CAMPBELL, Esq. T. B. MACAULEY, Esq. M. P. DAVID BREWSTER, LLD. J. C. L. SISMONDI, of Geneva. Capt. HENRY KATER, Vice President of the Royal Society. The ASTRONOMER ROYAL. DA VIES GILBERT, Esq. M. P. S. T. COLERIDGE, Esq. JAMES MONTGOMERY, Esq. The Right Hon. T. P. COURTENAY, M.P. J. J. BERZELIUS, of Stockholm, F. II. S.. &c The Rev. G. R. GLE1G. T. PHILLIPS. Esq. Prof of Painting R A Rev. C. THIRLWALL, Fellow of Trinity College Cambridge. ANDREW URE, M. D. F. R. S., rv respectfully, your obedient servant. " Mr. JohnVost." " LEVI FLETCHER. FRENCH. BY A. BOLMAR. A COLLECTION of COLLOQUIAL PHRASES on every Topic necessary to main- tain Conversation, arranged under different heads, with numerous remarks on the peculiar pronunciation and use of various words—the whole so disposed as considerably to facilitate the acquisition of a correct pronunciation of the French. By A. Bolmar. One vol. 18mo. A SELECTION of ONE HUNDRED PERRIN'S FABLES, accompanied by a Key, containing the text, a literal and free trans- lation, arranged in such a manner as to point out the difference between the French and the English idiom, also a figured pronunciation of the French, according to the best French works extant on the subject; the whole preceded by a short treatise on the sounds of the French language, compared with those of the English. I Les AVENTURES de TELEMAQUE par FENELON, accompanied by a Key to the first eight books; containing like the Fa- bles—the Text—a Literal—and Free Trans- lation ; intended as a Sequel to the Fables. The expression ' figured pronunciation,' is above em- ployed to express that the words in the Key to the French Fables are spelt and divided as they are pronounced. It is what Walker has done in his Critical Pronouncing Dic- tionary; for instance, he indicates the pronunciation of the word enough, by dividing and spelling it thus, e-nuf. In the same manner I indicate the pronunciation of the word comptaient thus, kon-te. As the understanding of the figured pronunciation of Walker requires the student to be acquainted with the primitive sounds of the English vow- els, he must likewise, before he can understand the figured pronunciation of the French, make himself acquainted with the 20 primitive sounds of the French vowels. This any intelligent person can get from a native, or from anybody who reads French well, in a few hours. A COMPLETE TREATISE on the GEN- DERS of FRENCH NOUNS; in a small pamphlet of fourteen pages. This little work, which is the most complete of the kind, is the fruit of great labor, and will prove of immense service to every learner. ALL THE FRENCH VERBS, both REG- ULAR and IRREGULAR, in a small volume. The verbs etre to be, avoir to have, parler to speak, finir to finish, recevoir to receive, vendre to sell, se lever to rise, se bien porter to be well, s'en aller to go away, are here all conjugated through—affirmatively —negatively—interrogatively—and negatively and in- terrogatively—an arrangement which will greatly fa- cilitate the scholar in his learning the French verbs, and which will save the master the trouble of explain- ing over and over again what may be much more easily learned from books, thus leaving him more time to give his pupil, during the lesson, that instruction which cannot be found in books, but which must be learned from a master. NEUMAN'S SPANISH and ENGLISH DICTIONARY. New Edition, in one vol. 16mo. (Eftemfctrg, Natural f^fstors, an* SPulosophg. THE CHEMISTRY OF THE ARTS, on the basis of Gray's Operative Chemist, being an Exhibition of the Arts and Manufac- tures dependent on Chemical Principles, with numerous Engravings, by ARTHUR li. PORTER, M. D. late Professor of Chemistry, &c. in tbe University of Ver" monti In 8vo. With numerous Plates. The popular and valuable English work of Mr. Gray, which forms the groundwork of the present volume, was published in London in 1829, and de- signed to exhibit a systematic and practical view of the numerous Arts and Manufactures which involve the application of Chemical Science. The author himself, a skilful, manufacturing, as well as an able, scientific chemist, enjoying the multiplied advantages afforded by the metropolis of the greatest manufacturing nation I on earth, was eminently qualified for so arduous an undertaking, and the popularity of the work in Eng- land, as well as its intrinsic merits, attest the fidelity and success with which it has been executed. In the work now offered to the American public, the practical character of the Operative Chemist has been preserved, and much extended by the addition of a great variety of original matter, by numerous correc- tions of the original text, and the adaptation of the whole to the state and wants of the Arts and Manu- factures of the United States. Among the most con- siderable additions will be found full and extended treatises on the Bleaching of Cotton and Linen, on the various branches of Calico Printing, on the Manufac- ture of the Chloride of Lime, or Bleaching Powder, and numerous Staple Articles used in the Arts of Dying, Calico Printing, and various other processes of Manufacture, such as the Salts of Tin, Lead, Man- ganese, and Antimony; the most recent Improve- ments on the Manufacture of the Muriatic, Nitric, and Sulphuric Acids, the Chromatf s of Potash, the latest information on the comparative Value of Dif- ferent Varieties of Fuel, on the Construction of Stoves, Fire-Places, and Stoving Rooms, on the Ven- tilation of Apartments, &c. &c. The leading object has been to improve and extend the practical charac- ter of the Operative Chemist, and to supply, as the publishers flatter themselves, a deficiency which is felt by every artist and manufacturer, whose processes involve the principles of chemical science, the want of a Systematic Work which should embody the most recent improvements in the chemical art3 and manu- factures, whether derived from the researches of sci- entific men, or the experiments and observations of the operative manufacturer and artisans themselves. CHEMICAL MANIPULATION. Instruction to Students on the Methods of perform- ing Experiments cf Demonstration or Research, with accuracy and success. By MICHAEL. FARADAY, F. R. S. First American, from the second London edi- tion, with Additions ^>y J, X. MITCHELL, M.D. " After a very careful perusal of this work, we strenu- ously recommend it, as containing the most complete and excellent instructions for conducting chemical experi ments. There are few persons, however great their ex- perience, who may not gain information in many impor- tant particulars; and for ourselves, we beg most unequiv- ocally to acknowledge that we have acquired many new and important hints on subjects of even every-day occur- rence."—Philosophical Mag. " A work hitherto exceedingly wanted in the labora- tory, equally useful to the proficient and to the student, 'and eminently creditable to the industry and skill of the author, and to the school whence it emanates."—Jour- nal of Science and Arts. GEOLOGICAL MANUAL, by H. T. De la Beche, F. R. S., F. G. S., Mem. Geol. Soc. of France. In 8vo. With 104 Wood Cuts. ELEMENTS of PHYSICS, or NATURAL PHILOSOPHY, GENERAL and MEDI- CAL, explained independently of TECH- NICAL MATHEMATICS, and containing* New Disquisitions and Practical Sugges- tions. By Neill Arnott, M. D. Second American from the fourth London edition, with Additions by Isaac Hays, M. D. " Dr. Arnott's work has done for Physics as much as Locke's Essay did for the science of mind."—London Uni- versity Magazine. " We may venture to predict that it will not be surpass- ed."—Times. "Dr. A. has not done less for Physics than Blackstone did for the Law."—Morning Herald. " Dr. A. has made Natural Philosophy as attractive as Buffon made Natural History."—French Critic. " A work of the highest class among the productions of mind."—Courier. CUVIER'S ANIMAL KINGDOM, arranged in conformity to its organization. Trans- lated by H. M'Murtrie, M. D. 4 vols. 8vo. Same work, abridged for the use of Schools, &c. 1 vol. 8vo. A FLORA of NORTH AMERICA, with 108 colored Plates. By W. P. C. Barton, M. D. In 3 vols. 4to. ARNOTT'S ELEMENTS of PHYSICS. Vol. II. Part I. Containing Light and Heat. "Dr. Arnott's previous volume has been so well receiv- ed, that it has almost banished all the flimsy productions called popular, which falsely pretend to strip science of its mysterious and repulsive aspect, and to exhibit a holy- day apparel. The success of such a work shows most clearly that it is plain, but sound knowledge which the public want."—Monthly Review. AMERICAN ORNITHOLOGY, or NATU- RAL HISTORY of BIRDS, inhabiting the UNITED STATES, by Charles Lv- cien Bonaparte; designed as a continua- tion of Wilson's Ornithology, Vols. I. II. Ill and IV. *** Gentlemen who possess Wilson, and are de- sirous of rendering the work complete, are informed that the edition of this work is very small, and that but a very limited number of copies remain unsold. A DISCOURSE on the REVOLUTIONS of the SURFACE of the GLOBE and the Changes thereby produced in the ANI- MAL KINGDOM. By Baron G. Cuvier. Translated from the French, with Illustra- tions and a Glossary. In 12mo. With Plates. ' One of the most, scientific and important, yet plain and lucid works, which adorn the age------Here is vast aid to the reader interested in the study of nature, and the lights which reason and investigation have thrown upon the formation of the universe."—Nex Monthly Mag. NLM041393933