ARMY MEDICAL LIBRARY WASHINGTON Founded 1836 Section^ . V^-' ■'' Number . A SYSTEM SURGERY. BENJAMIN BELL, MEMBER OF THE ROYAL COLLEGES OF SURGEONS OF IRELAND AND EDINBURGH, ONI OF THE SURGEONS TO THE ROYAL INFIRMARY, AND FELLOW OF THE ROYAL SOCIETX OF EDINBURGH. in FOUR VOLUMES. ILLUSTRATED with ONE HUNDRED COPPERPLATES. VOLUME I. the FIRST AMERICAN EDITION, corrected. MDCCXCI. c% 9>3l£yjL$£. IN an undertaking fo arduous and fo extenfive, as a General Syftem of Modern Surgery, it may be proper to explain the reafons which induced me to enter upon it, and to point out the plan upon which I have proceded. The learned and judicious Heifter publish- ed the laft edition of his Syftem of Surgery fo long ago as the year 1739. In this work, the author comprehends whatever the experience of former times had approved as ufeful; and adds fuch obfervations as his own knowledge in Anatomy and practice in Surgery fuggefted. This was the firft, and it ftill remains the only, complete Syftem of Surgery of which we are poffeffed. Since this publication of Heifter's, many valuable difcoveries and important improve- ments have been introduced ; and the Public has at different times been favoured with ac- * counts iv PREFACE. counts of them by their refpective authors. But thefe publications treat of various fub- jecls, and are all neceffarily unconnected with each other ; fo that the additional knowledge with which our art has been of late enriched, lies in a very diffufed, and to many perhaps in an iriacceffible, fituation. It is true, that fome attempts have been made towards a full fyftematic arrangement of chirurgical fubj^te. Platner publifhed his Inftitiites of Surgery in the year 1745 ; and Ludwig favoured the world with a fimilar pub- lication in 1767. But both thefe works may be properly confidered as heads of lectures which were read by thofe celebrated profeflbrs at Leipfic ; and although poffeffed of much mer- it, they are too concife to give a clear and dif- tinc^ idea of the various topics of which they treat. In confequence of this, the young ftudent in the art, as well as the intelligent practition- er who is defirous of information, is obliged to confult a great variety of publications, which he frequently finds much difficulty in procur- ing, and which his other occupations will not always allow him Sufficient time to perufe. Induced PREFACE. v \ Induced by thefe confederations, and having frequently experienced much inconvenience from the want of a well digefted Syftem of Surgery, I have been led to attempt the prefent work : Which, though it may not afford much new information to practitioners of experience and reflection, who are accuftomed to perufe every publication that appears; yet to the younger part of the profeffion, and to all thofe whofe opportunities of acquiring knowledge have not been considerable, I flatter myfelf it may prove fervkeable, I have exhibited a view of the art of Surge- ry, as it is at prefent practifed by the moft expert fargeons in Europe, as far at leaft as my own obfervaf ion in the courfe of attending different Hofpitals, joined to the advantages of reading and correspondence, have enabled me fo to do. It may be proper to remark, that a number of improvements fuggefted at different times in various parts of Surgery, are here purpofe- ly omitted. Within thefe laft thirty or forty years, fuch a rage -has prevailed for the inven- tion of new inftruments, that it has become faihionable to accompany every publication with vi PREFACE. with Something new and Singular of this kind. Some of thefe have undoubtedly been produc- tive of much advantage : But the greateft part of them tend more to evince the ingenu- ity of their authors, than to render the opera- tions for which they were intended, more eafi- ly accomplifhed ; for, although facility in performance is one great object in every fur- I . gical operation, yet the ends we have in view ! are in general attained by very fimple means. Indeed, one object of the prefent publica- tion is, an endeavour to diveft the art of all that ufelefs machinery with which it has been encumbered -, and to retain only what appears | evidently to reft upon the Solid bafis of ex- perience. I have therefore been particularly ' attentive, in admitting nothing which I have not myfelf found confirmed by trial, or which I have not known to prove ufeful in the hands of others. My connection with a large hofpital, the i Royal Infirmary of Edinburgh, to which the greateft part of the poor in Scotland requir- ing the affiftance of chirurgical operations, are accuftomed to refort, together with that private practice which has fallen to my fhare, have PREFACE. vii have given me opportunities both of re- peatedly performing every operation myfelf, and of being frequently prefent when they were performed by fome of the moft expert Surgeons of this place ; a circumftance which enables me to fpeak with fome degree of confi- dence, though, I hope with due caution, of each. Without fuch advantages, I fhould not have thought myfelf justifiable in under- taking the prefent Work ; for it is chiefly by hofpital practice that any individual can ac- quire fuch experience in the great variety of chirurgical operations, as to be able to form any accurate ideas concerning them. I have not in the courfe of the following Work, attempted a particular fyftematic ar- rangement of the fubjects of which it treats. Arrangements of this kind have indeed been employed with advantage in different branches of fcience: The ftudy of natural hiftory has been much facilitated by their means j and a knowledge of the more general difeafes to which the human body is liab}e, is perhaps acquired with more eafe by the comprehenfive views which a well digefted nosological Syftem gives of them. But, as diforders of every kind \^ requiring viii PREFACE. requiring the afliftance of the operative part of Surgery, are perfectly local and unconnect- ed with one another by means of fymptoms common to each; and as it feldom happens, that there is much Similarity in the means neceffary for the removal of fuch difeafes $ the parade of claflification under fuch circumftan- ces, although it may ferve to difplay the fancy of an author, can have no effect either in ren- dering the ftudy of Surgery more eafy, or the practice of it more attainable. Yet when one fubject is naturally connect- ed with another. I have not any where at- tempted to feparate them; and when the de- fcription of any operation can be more eafily underftood from what has been faid concern- ing another, I have considered them in imme- diate fucceSQon : But, in other inftances, where no connection can be traced between the different articles treated of, no methodical arrangement can be with advantage attempted. Were I to endeavour to trace the fucceflive improvements which have been made in fur- gery within thefe laft fifty or forty years, I fhpuld often find it difficult, and fometimes impoffible, to determine by whom the. prac- tice PRACTICE. ix dee, as it is now eftablifhed, was introduced ; and in order to give a fair account of the progrefsiof the different operations of furgery from their rude to their improved ftate, I fhould be under the neceffity of entering into a full chronological hiftory of each. While inquiries of this kind could ferve no ufeful purpofe, they would tend to render more pro- lix, a work which, from the variety of its Sub- jects, mult neceffarily extend to a great length. I fhall therefore in general decline them. On fome occafibns, however, when the author or any remarkable improvement is known with certainty, I fhall not fail to give him all the credit which his difcovery feems to merit. . Such of my readers as are fond of theoreti- cal difquifitions, will, I am afraid, be frequent- ly difappointed. When the Subject under consideration can be rendered more clear and intelligible by it, I have occasionally employ- ed fuch reafoning as experience and common fenfe feem evidently to fupport; but I have every where ftudioufly guarded againft enter- ing on the difcuflion of doubtful and Specu- lative opinions. In B X PREFACE. In considering the different Subjects, the appearance or fymptoms of the diforder—the ufual caufes known to induce it—its probable confequences—and the beft method of treat- ment—are particularly defcribed in fuccef- fion : And when an operation of importance is to take place, the parts which lie contigu- ous, but which the operator ought to avoid, are pointed out, as well as thofe which he is under a neceffity of dividing. In defcribing the different operations, I have uniformly adhered to the method at .pref- ent practifed by the beft Surgeons, excepting in fuch inftances where improvements of my own are propofed ; and none of thefe are any where recommended, the utility of which has not been afcertained by repeated trials^ In a work of this nature, it nruft unavoid- ably happen, that on feveral occafions; I differ in opinion from various refpectable authors,; but wherever I do fo, no other motive, I hope, will appear for it, than a wifli to .render; more perfect.an art which I am attempting to defcribe and illuftrate, I was fully aware of the difficulties to be encountered in carrying on and completing this PREFACE. xi this defign; and was fo diffident of my abili- ties to do juftice to the undertaking, that, even after a considerable part of the materials were prepared, I chofe the mode of pub- lifhing it in feparate volumes, that I might thereby have an opportunity of discovering the Sentiments of the public with regard to its merit and utility ; a circumftance, by which I was in a great meafure determined in the farther execution of my plan. CONTENTS, Xll CONTENTS, OF VOL. I. .v CHAPTER I. ■ P-age. (^SUTURES, 17 Sect. I. Of Sutures in general, 17 Sect. II. Of the Interrupted Suture, 18 Sect. III. Of the filled Suture, %i Sect. IV. Of the Glovers Suture, 22 Sect. V. Of the* Twifted Suture, 23 CHAPTER II. Of the Ligature of Arteries, and other means employed by Art for putting ajiop to Hemorrhages, 29 CHAPTER III. (^Bloodletting, 50 Sect. I. Of Bloodletting in general, 50 Sect. II. Of a Thrombus or Ecchymojis, 66 Sect. III. Of Wounds of the Arteries, 68 Sect. IV. Of Wounds or Pricks in the Nerves and Tendons, 72 Sect. V. Of Bloodletting in the Arm, 87 Sect. VI. Of Bloodletting in the 'Jugular Vein, 91 (Sect. VII. Of Bloodletting in the Ankles and Feet> 93 Sect. * CONTENTS. *iii Page, Sect. VIIL Of Artenotomy, 94 Sect. IX. Of Topical Bloodletting, 97 CHAPTER IV, 0/*Aneurisms, 104 Sect. I. General Remarks on Aneurifms, 104 Sect. II. Of the Treatment ofAneurifms\ 128 CHAPTER V. (yHERNIJE, 144 Sect. I. Of Hernia in general, 144 Sea. II. Of the Bubonocele, 174 Sea. HI. Of the Hernia Congenita, 195 Sea. IV. Of the Crural or Femoral Her- nia, 197 Sect. V. Of the Exomphalos, or Umbilical Hernia, 3°3 Sea. VI. Of Ventral Hernia, 206 Sea. VII. Of the Hernia of the foramen Ovale, 206 Se#. VIIL Of the Hernia Cyjica, ar Her- nia of the Urinary bladder, 208 CHAPTER VI. Of the Hydrocele, 212 Sea. I. General Remarks:on the Hydrocele, 212 Sea. II. Of the Anafarcous Hydrocele of the Scrotum, al7 Sea. IIL Of the Hydrocele of\the Tunica Vaginalis Tejlis, %**+. Sea. IV. Ofthe Hydrocele ofa Hernial Sac, 254 Sea. xiv CONTENTS. Sea. y. Of the Anafarcous Hydrocele of the Spermatic Cord, 258 Sea. VI. Of the Encyfled Hydrocele of the " Spermatic Cord, 260 CHAPTER VII. Of the Hematocele, 267, CHAPTER VIIL Of the Varicocele, Cirsocele, Sper- matocele, ^Pneumatocele, 273 CHAPTER IX. O/7&?SARCOCELE,0rSciRRHOUS TeS- TICLE, 277 CHAPTER X. Of the Diseases of the Penis, 293 Sea. I. Of the Phymqfis, 293 Sea. II. Of the Paraphymojts, 297 Sea. III. Of Amputation of the Penis, &c. 299 CHAPTER XL ^ Of the Stone, ' 304 Sea. I. General Remarks on Urinary Cal- o Cf\* 3°4 Sea. II. Of Sounding or Searching for the , Stone* 311 Sea. III. General Remarks on the operation of Lithotomy, w Sea. CONTENTS. xv Page Sea. IV. Of the Operation of Lithotomy by the Lejfer Apparatus, 325 Sea. V. Of Lithotomy by the Greater Ap- paratus, 330 Sea. VI. Of the High Operation for the Stone, ' 333 Sea. VII. Of the Lateral Operation, 340 Sea. VIIL Of Nephrotomy, 375 Sea. IX. Of Stones in the Urethra, 378 CHAPTER XII. (^Incontinence g/'Urine, 386 CHAPTER XIII. Of a Suppression o/'Urine, 390 CHAPTER XIV. Obstructions in the Urethra, 400 CHAPTER XV. Of the Fistula in Perineo, 420 Explanation of /^Plates, 433 a TREATISE ON THE THEORY and PRACTICE O F SURGERY. CHAPTER I. of SUTURES. SECTION I. Of Sutures in ^General. S futures of one kind or another are found neceflary, not only in every large wound, but in almoft every operation of importance, the consideration of, this Sub- ject feems firft to require our *jfenT3W#*" ■" attention. A variety of futures have been practifed by bur- geons, each of which has from long experience been applied to a particular purpofe, viz. The interrupt- C ed i3 Of Sutures. Chap I. ed future j the quilled future; the glover's and the twifted Suture. Many others are enumerated by ancient writers: But the four now mentioned are the only Species of futures at prefent in^ ordinary ufe j and even of thefe,. fome, we think, might with propriety be omitted. The intention of every future, is to unite parts, which either by accident or defign have been divid- ed. Another mode of effecting this, is through the intervention of adhefive platters : And this by fur- geons has been termed the falfe or dry future ■, in oppofition to the others performed by the needle, which are denominated the true or bloody future.— But as the consideration of this Subject, namely, the ufe of adhefive platters in wounds, will be more properly introduced in a fubfequent part of this work, we fhall not in this place enter upon its dif- cuffion. SECTION II. Of the Interrupted Suture. IN deep wounds, when a reunion of the. divided parts is intended, this is the Suture to which we gen- erally have recourfe j but from what will be after- wards more fully explained when treating of wounds, and from what will prefently farther appear, it does not feem to be fo well adapted to this purpofe as the twifted future. When it is determined, howev- er, to make trial of the interrupted Suture, the fol- lowing is the eafieft mode of doing it. In every wound where Sutures are found necefifa- ry for the retention of parts, it has commonly been confidered as good practice, to carry the needle and ligature to the bottom of the fore, fo as to give as little room as poflible for matter collecting under- neath ; and the ufual mode of effecting this, is by introducing the needle from without inwards, and again Sed. II. Of Sutures. 19 again from the bottom of the wound to the Same diftance on the oppofite fide. But this future, it may be remarked, is much more neatly, and at the fame time more eafily performed, by patting both ends of the thread from within outwards; which is readily done by ufing two needles upon each thread, inftead of one. A needle being put upon each end of the fame thread, and each needle being inSerted at the bottom of the fore, and puttied outwardly So as to paSs out at a proper diftance Srom the edge of the wound, the needles are then to be taken off, and the threads allowed to remain till all the ligatures are patted which the extent of fore Seems to require. The number of ligatures neceflary for any wound, muft in a great meafure depend upon the extent of divided parts. By authors in general it has been laid down as an eftablifhed rule, that one future is fully fufHcient for every inch of wound. It will frequently indeed happen, that this number is found fufHcient; but in ibme inftances, particular- ly where mufcular parts are deeply cut tranfverfe- ly, and where consequently a great degree of retrac- tion occurs, a greater number of flitches are necefla- ry : Whenever a number of angles, too, occurs in a wound, more ligatures are required than in a ftraight wound of the fame extent; for, at every angle, however inconfiderable it may be, there ought to be a future. In patting the ligatures, great care is neceflary to pierce the lkin at a fufHcient diftance from the edge of the wound: For if they do not comprehend a thicknefs of parts in fome meafure proportioned to the depth of the wound, and to the extent of retrac- tion which may be expected, they will very readily cut through the parts entirely.—By fome authors we are directed to enter the ligatures, at a diftance from the edges of the fore nearly equal to the depth of the wound. This rule, however, will by no jneans be found to anfwer in practice. Thus, in a very 20 Of Sutures. Chap. I. very deep wound, for inftance of about three inches, no neceffity can occur for carrying the ligatures •three inches from the edges of the fore ■, and again, in very fuperficial cuts, it fometimes happens that the ligature ought to be patted out at a diftance from the edges o( the wound greater than its depth. It ought not, in almoft any cafe, to be lef^ than half an inch-from the edge of the fore; and it will Sel- dom happen, even in the largeft wojonds, that an h*ch is not found to be a fufHcient difijance. It will be readily understood, that the ftrength of the ligature and Size of the needle ought always to be proportioned to the depth of the fore and re- traction of parts. The Several Sizes of needles rxprefented in Plate I, ajre fuch as have been found neceflary in practice; and the ligatures to be ufed along with them ought to be fuch as nearly, though not entirely, to fill the eyes of the different needles. In order to make the ligatures pafs "moHl eafily, to render them more durable, and at the fame time to make them more fufceptible of a flattened form, which does not fo readily Gut through the contained parts as a round one, they ought all to be well cover- ed with fine beefwax. As Soon as the threads are all paffed, the lips oS the wound ought to be preffed together and Sup- ported "by an afiiftant till all the ligatures-are firm- ly tied j beginning either in the middls. of the wound, or at one end, as the operator inclines. In tying the knots, it is ufual to pafs the ends of the threads twice -through the ftrft noofe, in order to prevent their yielding j andFkwhen this is done, it is alleged by fome that there is no neceffity for more than one knot upon each ligature ; but as two knots are very eafily made, and as every chance of their yielding is thereby effectually'prevented, this pre- caution ought never to be omitted. It is a practice with fome furgeons, to infert a piece of lint between the-fifft and Second knots, or between the firft knot and Plate 1 Sect. III. Of Sutures. 21 and the fkin below, in order to fave the parts un- derneath from the prefiure of the knots ; but as in reality all fuch means of protection afford no ad- vantage of importance, and as they prevent the knots from being made with exactnefs, they ought there- fore to be laid entirely afide. By fome writers on this fubject, we are defired not to bring the knots of ligatures immediately upon the edges of the wound, but rather to carry them to one fide, over upon the Sound teguments: But whoever has tried both methods, will at once be Sen- sible, that this is by no means an improvement; for in no way can both fides of the fore be equally fup- ported, but by the knots being paffed immediately above the lips of the divided parts. SECTION III. Of the Quilled Suture. AS the quilled future is ftill employed by fome practitioners, it is here thought neceflary to defcribe the mode of performing it. In deep wounds attended with much retraction, it is always a neceflary precaution, to aflift the ope- ration of the ligatures, by means of bandages fo applied as to afford as much fupport as pottible to the divided parts: But, even with every afliftance of this nature, it new and then happens, that the divided parts cannot be kept together, retraction oc- curs to a greater or lefler degree, and the ligatures of courfe cut afunder the foft parts they were at firft made to furround. With a view to prevent this receding of the tegu- ments and other parts, it was long ago propofed to add to the interrupted future what was Suppofed would afford an additional fupport j viz. quills, or pieces of plafter rolled up into the form of quills -, one of which being placed on each fide of the wound. 22 Of Sutures. Chap. I. wound, the doubling of the ligature is made to in- clude the one, and the knot to prefs direftly upon the other, inftead of being made immediately on the edges of the fore as was directed for interrupted Sutures. It is at once evident, however, that the ligatures muft here make the fame degree of preffure on the partes though which they pafs, as they do in the in- terrupted future -, and this being the cafe, it is equal- ly obvious, that the interpofition of thefe fubftances cannot be of any ufe. This future is accordingly now very rarely practifed, and it is probable that it will be foon laid entirely afide. SECTION IV. Of the Glover's Suture. THIS Suture receives its name from being that which the glovers commonly ufe. As it is exceed- ingly fimple, and very univerSally known, it does not here require a particular description: We fhall therefore juft fhortly obferve, that it confifts in a Series of flitches all connected with one another, and continued in an oblique Spiral direction along the courfe of the divided parts intended to be kept to- gether. This Suture has hitherto been univerfally employ- ed for reuniting fuch parts of the interlines as have been divided by wounds: But, when treating of ac- cidents of this kind, I fhall endeavour to fhow, that the Same end may be more perfedtly attained, and probably with lefs danger, by means of the interrupt- ed Suture; fo that as this future has almoft never been applied to any other purpofe, it will likewife in all probability Soon Sail into diSuSe. SECTION Sect. V. Of Sutures. 13 S E C' T I O N V. Of the Twisted Suture. BY the term Twifted Suture is -meant, that fpe- cies of ligature, by which parts, either naturally or artificially Separated, are united together, by means of Strong threads properly twifted round pins or needles puttied through the edges of the divided parts. This future is commonly employed for the pur- pofe of uniting the parts in cafes of harelip; and this indeed is almoft the only ufe to which it has been hitherto applied : But we may here remark, that it may with great advantage be put in practice in a variety of other cafes, particularly in all artificial or accidental divifions either of the lips or cheeks ; and, in every wound in other parts that does not run deep and in which futures are neceflary, this fu- ture is preferable to the interrupted or any' other. Jn very deep wounds, for inftance in all wounds extending to a greater depth than an inch and a half, the interrupted future is the only one that is admifilble -, for, in all fuch deep cuts, the pins nec- eflary in the twifted future cannot with propriety be employed, as they cannot be introduced to fuch a depth, and afterwards fo twifted with ligatures as to reunite the divided parts, without great pain to the patient. In fuch wounds, therefore, we muft of neceffity have recourfe to the interrupted future. But it may be here remarked, that wounds of this depth requiring the aid of futures, are very rarely met with : So that, in by much the greateft pro- portion of wounds where futures are advifable^ the twifted future will be found practicable; and whenever it is fo, it ought certainly to be preferred to every other, as* being obvioufly better calculated, even than the interrupted future, for the retention 24 Of Sutures. Chap. I. of divided parts. The pins made ufe of for twirl- ing the threads upon, ought to be made of a flat form, So as not to cut the parts through which they pafs, So readily as the ligatures employed in the in- terrupted future : And thus one great objection to the latter is very effectually obviated; for, every practitioner muft be fenfible of this being the great- eft inconvenience attending the interrupted Suture, that when mufcular parts are divided, So as to pro- duce much retraction, the ligatures employed for retaining them, almoft constantly cut them through before a reunion is accomplifhed; whereas, the flat- ncli of the pins ufed in the twifted future, and upon which, it may be remarked, the whole preffure pro- duced by the ligatures is made to reft, proves in gen- eral a very effectual preventative againft this occur- rence. The pins ufed in this operation have commonly been made of filver ; and, in order to make them pafs with greater eafe, fleel points have been added to them. As gold pins, however, are capable of receiving a fufHcient degree of fharpnefs, which renders the intervention of fteel points quite un- neceffary ; and as gold is more cleanly than Silver, from its not acquiring fo readily that kind of cruft which immerfion in fluids is apt to produce upon the other ; pins of this metal are therefore prefer- able. The form and Size of-pins reprefented in Plate II, are what experience has fhown to be the moft ufeful for every ordinary purpofe ; but, for par- ticular ufes, the fize muft no doubt be Subject to variations. The manner of performing this operation is as follows : The divided parts intended to be reunited, muft by the hands of an afliftant be brought near- ly into contact; leaving juft as much fpace be- tween the edges of the fore, as to allow the fur- geon to fee that the pins are carried to a proper depth. Hare II - v , 4 >7. .*. V r^zzsaQ Sect. V. Of Sutures. 25 depth. This being done, one of the pins muft be introduced through both fides of the wound, by en- tering it on one fide externally, pufhing it forwards and inwards to within a little of the bottom of the wound, and afterwards carrying it outwardly through the oppofite fide, to the fame diftance from the edge of the fore that it was made to enter at on the other. The diftance at which the needle ought to enter from the edge of the fore, muft be determined by the depth of the wound, and by the degree of retraction produced in the divided parts. In gen- eral, however, it is a proper rule in deep wounds, to carry the pins to a diftance from the edges of the fore, nearly the fame with the depth to which they penetrate : And it may be alfo remarked, that, whatever the deepnefs of the wound may be, the pins ought to pafs within a very little of its bottom j otherwife the parts which lie deep will run a rifk of not being united ; a circumftance which will fre- quently give rife to troublefome collections of mat- ter. In patting the pins through the different fides of the wound, if the fkin and other teguments are not more firm than ordinary, it may commonly be done by the fingers alone, and particularly if the pins are made with fmall heads or knobs for the fingers toprefs upon j but when firmnefs of parts and other circum- ftances render the entrance of the pins difficult, the inftrument termed Porteaiguille very effectually re- moves this inconvenience.—In Plate II. is repre- sented the moft convenient form of this inftrument that has yet been invented. The firft pin being patted in this manner very near to one end of the fore, and the parts being ftill fupported by an afliftant, the furgeon, by means of a firm waxed ligature patted three or four times round and acrofs the pin, fo as nearly to defcribe the figure of 8, is to draw the parts through which it has patted into clofe contact; and the thread be- D ing i6 Of Sutures. Chap. I. ing now fecured with a loofe knot, another pin muft be introduced in the fame manner at a proper dif- tance from the former ; and the thread with which the other was fixed, being loofed, and in the fame manner carried round this pin, others muft be in- troduced at proper diftances along the whole courfe of the wound, and the fame ligature ought to be of a fufHcient length for Securing the whole. The number of pins to be ufed, muft be deter- mined entirely by the extent of the wound. When- ever the future, however, is practifed, whether the wound be large or of very Small extent, a pin ought to be introduced very near to each end of it, other- wife the extremities of the fore are apt to Separate fo as not to be afterwards eafily reunited. In large wounds, if the pins be introduced at the diftance of three quarters of an inch from one another, it will in general be found fufHcient ; but, in cuts of Smaller extent, a greater number of pins become neceflary in proportion to the dimensions of the fores. Thus, in a wound of an inch and half in length, three pins are absolutely requifite ; one near to each end, and another in the middle of the fore : Where- as, five pins will always be found fully fufHcient for a wound of three inches and a half in extent, al- lowing one to be within a quarter of an inch of each extremity of the wound, and the others to be placed along the courfe of the fore at the diftance of three quarters of an inch from one another. The pins being all introduced and fecured in the manner directed, nothing remains to be done, but to apply a piece of lint wet with mucilage, all along the courfe of the wound, with a view to exclude the external air as effectually as poflible. In order to prevent the ends of the pins from prefling upon and hurting the fkin below, it is ufual to apply a fmall bolfter of linen or charpie under each of them ; but as this always does mifchief, by tending to prefs upon the pins, fo as to force them to Seft. V. Of Sutures. 27 to act upon the foft parts through which they have patted, every thing of this kind ought to be omitted. When, however, the patient happens to complain of being hurt by the ends of the pins, this may be eafily prevented by introducing between them and the fkin pieces of thin linen fpread with any ad- hefive plafter. In order to give every chance of fuccefs to this op- eration, it has been commonly advifed, immediate- ly after the pins are fecured, to apply the uniting bandage over the whole, fo as to afford as much fupport as pofljble to the contiguous parts. The leaft reflection, however, renders it evident, that every degree of preffure made in this manner muft domifchief; for, the bandage being made to reft immediately upon the pins, a confiderable degree of pain and confeojient inflammation muft of courfe be produced by it : And in fact this is fo much the cafe, that, in every inftance in which I have feen this bandage applied, it either did harm, by excit- ing inflammation in confequence of too much pref- fure upon the pins ; or, if that effect was not pro- duced, no advantage was received from it, from the bandage not being applied with fuch tightnefs as to afford any fupport whatever to the parts below. The next point to be determined, is, the time the pins fhould be allowed to remain. When they re- main long, they generally do harm, by the unnec- effary irritation and confequent retraction of parts with which they are always attended ; and again, if they are not continued for a fufHcient length of time, that degree of adhefion is not produced be- tween the divided parts that is neceflary for their future retention, fo that the effecl: of the operation comes to be in a great meafure, if not entirely, loft. In wounds of no great depth, for inftance of about three quarters of an inch, a fufHcient degree of adhefion always takes place in the Space of five days; and fix, or at mod feven days, will general- 2$ 6f Sutures. Chap. I. ly be found fufHcient for wounds of the greateft depth. But with refpect to this circumftance, it muft al- ways be underflood, that the patient's ftate of health will have a confiderable influence on the time nec- eflary for producing adhefion between divided parts. In Specifying the time required for this purpofe, the operation is fuppofed to have been done in a found and healthy ftate of the conftitution. When the patient labours under any diforder which affects the general Syftem, by cutaneous eruptions or other- wise, it is impoffible to. afcertain this circumftance with precision : In Such cafes we muft be determin- ed by the nature and ftate of the difeafe prefent at the time. As foon as the pins are withdrawn, the uniting bandage may be applied with great advantage in order to ferve as a fupport to the parts newly united ; but, as flips of leather fpread with ordinary glue, when applied to each fide of the cicatrix, may, by means of ligatures properly connected with them, be made to anfwer this purpofe in a more effectual manner, this mode of Supporting the parts ought of courfe to be preferred. As the twifted future when properly performed is a very neat operation, as its confequences are in general of importance, and as it may wkh much advantage be made to fuperfede the ufe of almoft every other future, a few inftances only excepted, I have therefore thought it proper to confider it with more attention than has hitherto been com- monly beftowed upon it. CHAP. Chap. II. Of the Ligature, Be. S9 CHAP. II. Of the LIGATURE of ARTERIES anb other MEANS EMPLOYED BY ART FOR. putting a STOP to HEMORRHAGES. xN every fpecies of wound, whether ac- cidentally produced, or affected by the hands of a Surgeon, the firft circumftance to be attended to, is the degree of hemorrhagy that takes place. In all fuch occurrences, the blood is difcharged, either from one or more large arteries ; or, is produced by a general oozing from the fmaller veffels over the Surface of the fore : To the former of thefe caufes we fhall firft attend, and fhall afterwards proceed to the consideration of the latter. A furgeon being called to a perfon Iofing much blood from the divifion of any of the larger veffels, the firft ftep to be taken, is, by means of Strong com- preflion, to effect a temporary floppage of the dis- charge, till by the application of ligatures a more effectual remedy is obtained. In the head, as well as in the trunk of the body, the eafieft method of applying preffure of this kind, is, by means of dof- fils of lint or of foft linen, held firmly upon the mouths of the bleeding veffels, either by the hands of an afliftant, or by the ufe of a proper bandage : Or, when preffure can be effectually applied to the fuperiour part of the artery, it anfwers better ; as it not only Secures the veffel equally well, but admits of the neceflary ligature being applied with greater freedom. When, again, accidents of this nature occur in any of the extremities, and where preffure can be made with eafe on the Superior parts of arteries, for fuch cafes we are in pofleflion of a remedy, which, when Skilfully applied, never fails to put an immediate 30 Of the Ligature Chap. II. immediate ftop to all farther lofs of blood. What is here meant, is, the Tourniquet. Till the invention of this inftrument, which was not known before the laft century, Surgery re- mained extremely defective indeed. No operation of importance could be undertaken on any of the extremities but with great hazard.to the patient; and the effects of large wounds muft frequently have proved mortal, from the want of this aflift- ance, which otherwife might not have been in any degree hazardous. As the invention of the tourniquet is claimed by different perfons, and even by different nations, we fhall not here pretend to fay from whence it orig- inally came : But whoever had the merit of it, the firft inftrument of this kind with which the world was made acquainted, was exceedingly fimple ; fo much fo, indeed, that it now appears very furprif- ing that the difcovery Should have been left for fuch a late period. A Small cufhion being placed upon the courfe of the principal artery of a limb, a cir- cular rope or bandage was made to pafs twice round it; and a fmall wooden handle being then intro- duced between one of the folds of the bandage, for the purpofe of twilling it, the cufhion by thefe means was preffed with fo much force upon the artery, as to put an effectual flop to the courSe of the blood through the under part of the limb. Mr. Petit, an eminent furgeon of Paris, was the firft who propofed a considerable improvement on this inftrument, by connecting the circular bandage with a fcrew, which was fo contrived as to produce the preffure chiefly on the principal arteries, with- out materially affecting the reft of the limb. It had this advantage over the other inftrument, that the operator himfelf could manage it, without be- ing under the neceffity of employing an afliftant; but it was liable to one great inconvenience from the very circumftance which by the inventor was eonfidered Hate III. >T a Chap. II. Of Arteries, (3c. 51 confidered as an improvement. This inftrument of Mr. Petit being made to aa upon the principal arteries only, the fmaller veffels communicating with thefe, by not being properly compreffed, difcharge blood freely from the inftant they are cut; and as this proves a very troublefome circumftance in the courfe of operations, different improvements have of late been made upon it. The pattern in Plate III. is the refult of all thefe. By means of this inftrument in its now improv- ed ftate, the blood in any limb is very eafily and ef- feaually commanded; and as it grafps the whole member equally, all the collateral branches as well as the principal arteries are equally compreffed by it. It has this material advantage, too, over every other inftrument of thiskind, that, when properly applied, a fingle turn, or even half a turn of the fcrew, is fufHcient for producing either a flow of blood, or for putting a total ftop to it.—The manner of ufing it is this. Let a cufhion of three inches in length by one inch and half in diameter, be prepared of a linen roller, and be made tolerably firm, but yet not fo hard as to render the preffure produced by it very painful : This being placed upon the courfe of the principal artery of the limb, is to be firmly fecured in that fituation by one or two turns of a circular roller, of the fame breadth with the cuftiion itfelf. The inftrument A, with the ftrap conneaed with it, being now placed upon the limb, with the han- dle of the fcrew B on the fide of the member op- pofite to the cufhion upon the artery, the ftrap C is to be carried round the limb direaiy over the cuftiion, and to be firmly conneaed on the other fide to the buckle D. In thus conneaing the ftrap and buckle together, particular attention is necefla- ry in doing it with great firmnefs, fo that the fcrew may afterwards operate with as much advantage as poflible, in producing a fufHcient degree of pref- fure. When proper attention is paid to this cir- eumftance, 5? Of the Ligature Chap. II. cumftance, a Single turn of the fcrew, as we have Said, proves Sufficient for putting an entire flop to the circulation of blood in the limb: But when the ftrap has not at firft been made very tight, Several turns oS the Screw become neceflary; an occurrence which may be always eafily prevented, and which, when not attended to, proves often very embarraff- ing in the courfe of an operation. Whenever it is determined, therefore, that any farther lofs of blood from a divided artery is to be prevented, preffure on the fuperior part of the veflel ought to be immediately applied by the hands of an afliftant, or a proper bandage, when the cut is on the head or trunk of the body ; and by means of the tourniquet, when any of the extremities are wounded. The patient being in this manner fecured from immediate danger, the praaitioner muft now pro- ceed to the eafieft and moft effeaual mode of pre- venting a return of hemorrhagy on the removal of the tourniquet. The ancients, as we have feen, were ignorant of the ufe and application of the tourniquet, and they were equally deficient in the employment of means for giving a permanent Security againft the flow of blood from divided veffels : It will therefore readily occur to every modern praaitioner, that in this im- perfect ftate of Chirurgical knowledge, when any capital operations were attempted, they muft have run a much greater rifk of doing mifchief, than of procuring any advantage to their patients. To the Smaller veffels they applied doflils of linen covered with aftringent powders; and for the larger arteries, fearing with hot irons was their only refource. Of this laft remedy, however, although it com- mands a temporary ftoppage of the blood in every cafe of hemorrhagy, the effects are by no means to be depended on : For, in general, the pulfa- tion of the larger arteries very Toon overcomes all the Chap. II. Of Arteries, (3c. 33 the refiftance produced by the application of the cautery. In ancient times, however, when this was the moft effeaual remedy with which the world was acquainted, praaitioners were under the neceffity of having recourfe to it ; and, at that period, it is not furprifing to find them exercifing their ge- nius in inventing a variety of ftyptic applications : But fince furgery became enriched with that mate- rial improvement of fecuring the larger arteries by means of ligatures, a praaice eafily effeaed, and with very little pain to the patient, it is furprifing to find that remedies of this kind are flill fearched after. If the ufe of ligatures were in itfelf attend- ed with much difficulty, if by experience it had been found to be produaive of many bad confe- quences, or, if it had been frequently known to fail in anfwering as a full fecurity againft the he- morrhagies of the larger arteries j in any of thefe events, it ought to be the bufinefs of praaitioners to endeavour to procure a more effeaual remedy. But, as the ligature of arteries is very fimple in its nature ; as the pain arifing from it is trifling; as few inftances occur of any thing bad being produc- ed by it; and efpecially as, when properly perform- ed, it never fails of proving a fure preventative againft all lofs of blood from the larger arteries ; there can be no good reafon for anxioufly feeking after other remedies. Agaric and other fungous fubftances have been much extolled for their ftyptic powers ; and cha- lybeate folutions, as well as all the variety of mine- ral acids, have in different forms been held forth to the publick as effeaual remedies of this nature; not only as noftrums by thofe of lefs liberal prin- ciples, but, what is more furprifing, in fome inftan- ces by praaitioners of charaaer. With the former clafs of men this happens as a •ommon occurrence in the courfe of their profeffion, E and 34 Of the Ligature Chap. II. and is therefore to be expeaed ; but a perfeverance in queft of any new remedy of this kind on the part of Surgeons of reputation, who are already well acquainted with the effeas of ligatures in cafes of hemorrhagy, and who alfo know that the praaice is feldom attended with bad confequences, muft proceed from a degree of nicety and refinement, which may create much trouble to themfelves, and which in all probability can never be produaive of any praaical advantage. We fhall therefore venture to lay it down as an eftablifhed maxim in furgery, That in every cafe of hemorrhagy from any of the larger arteries, no ftyptic application whatever ought to be trufted to, the ligature being the only remedy to be depended on. We now proceed therefore to the confideration of the eafieft and molt effeaual mode of carrying this application into execution. Various methods have been invented for fecuring arteries by means of ligatures. The praaice now in ordinary ufe, is, by means of a curved needle, to pafs a ligature of fufHcient ftrength round the mouth of the bleeding veffel, including a quarter of an inch all round of the contiguous parts*, and afterwards to form a knot of a proper tightnefs up- on the veffel and other parts comprehended in the noofe. One great objeaion, however, to this method is, that the nerves accompanying the blood veffels, to- gether with a considerable portion of the mulcular fubftance through which they pafs, muft always be Surrounded with every ligature formed in this manner. From this circumftance much more pain is produced than is neceflary, by the nerves and other parts being at the fame time compreffed with the arteries ; and, on fome occafions, the fame caufe has evidently given rife to violent convulfive affeaions, Sharp's Surgery—On Amputation. Chap. II. of Arteries, (3c. 33 affeaions, not only of the part chiefly affeaed, but of the whole fyftem. Spafmodic twitches are frequently found to oc- cur after the amputation of limbs, and are often the fource of much diftrefs. In fome inuances they are no doubt to be confidered as the effea of other caufes ; but in various cafes it has happened, that demonftrative proof has been obtained of their arifing from the ligatures of arteries applied in an improper manner. When fuch convulfive affec- tions occur after amputations, and the ufual means of preventing them are found to fail, effeaual re- lief may be frequently obtained by deftroying th« ligatures altogether, fo as to remove the compref- fion upon the nerves ; care being taken at the fame time to renew the ligatures upon the arteries imme- diately, without comprehending any of the contig- uous parts. Thus, it is not to the fimple ligature of veffels, but to the improper manner in which the operation is performed, that is, the including of nerves and other parts, inftead of tying the arteries alone, that the bad fymptoms occurring in fuch cafes are to be attributed. Praaitioners have commonly been afraid of ty- ing up blood veffels by themfelves without the in- tervention of fome of the furrounding parts, on this fuppofition, that the coats of arteries are not of fufHcient firmnefs to bear that degree of com- preffion neceflary for the prevention of hemorrha- gy. This, however, originates from an idea that the coats of arteries are not fo ftrong as they really are ; and that a great degree of force is neceflary for comprefling their fides into clofe contaa with one another. But it is now well known, that even very fmall arte- ries arepoffefledof much firmnefs ; and it is alfo cer- tain, that even in the largeft arteries of the arm or thigh, 36 Of the Ligature Chap. II. thigh, a very flight degree of compreffion is Sully Sufficient, not only Sor reftraining hemorrhagy, but for Securing the ligature on the very fpot to which it is firft applied : And in fmall veffels the force nec- eflary for this purpofe is trifling indeed j being far lefs than is commonly applied. Although the circumftance we are now infilling upon may not at firft fight feem to be of much importance, yet in faa it merits very particular at- tention. Even of itfelf it is a matter of no fmall confequence, but it is the more material when we confider it as conneaed in many inftances with circumftances on which the life of a patient may in a great meafure depend; and we know well too, that fuccefs in furgical operations depends more on a minute attention to every circumftance relating to them, than on particular dexterity in any one part of them. £ It has alfo been objeaed to this mode of fecur- ing blood veffels by themfelves, that the ligatures, although they Should not cut the arteries through, yet that they are more apt to flip than when fome of the furrounding parts are comprehended along with them ; and, in fome inftances, it is faid that ar- teries retraa fo far, that they cannot in any other way be laid hold of, than by means of the crooked * needle in the ordinary method. Long and repeated experience, however, of a few individuals, in regard to this mode of taking up ar- teries by themfelves, has put the faa beyond a doubt, that it is as fecure as any other yet invented*. —Fatal hemorrhagies after capital operations, either from inattention, or fome other caufe, do now and then indeed happen in the hands of the moft able \ praaitioners ; but occurrences of this nature have as frequently happened when the curved needle ! was employed, as when the blood veffels were fecur- ed * See an effay upon this fubjeft, by the ingenious Mr. Aitken, J furgeon in Warrington. .J Chap. II. of Arteries, (3c. 87 ed by themfelves without any of the contiguous parts being included. From the refult of my own experience, indeed, I ftiould be induced even from this confideration, to draw a conclufion in favour of the method we have been endeavouring to recommend. For, in the courfe of praaice, both among hofpital patients and in private, I have known different deaths occur from the bleeding of ftumps after the amputation of members : Whether this proceeded from the liga- tures having flipped from fome of the arteries ; or from this circumftance, that fome of the veffels which did not appear during the operation, had been of courfe paffed over without being obferved and had afterwards burft out, I fhall not pretend to determine : But in all of thefe, the crooked, needle only had been ufed during the operation ; and it has fo happened, that I never met with a fingle inftance of a fimilar occurrence where the arteries were fe- cured by themfelves by means of the tenaculum ; an inftrument to be afterwards taken notice of. In a few inftances it may happen, that a bleeding veffel, from lying at the bottom of a deep wound, cannot be laid hold of in any other manner than by the curved needle being made to pafs round it. Such occurrences, however, are exceedingly rare : Infomuch that I have feldom known an inftance in which hemorrhagy could not be as effeaually re- ftrained by the mode now to be pointed out, as by the ufe of the crooked needle. In all operations whatever, to fave unneceffary pain ought to be a very capital objea. In every bufinefs of this kind, the objea in view ought no doubt to be attained in the moft complete manner ; but that mode of operation, which is as complete as any other, at the fame time that it is the leaft pain- ful to the patient, is undoubtedly in every inftance to be preferred. Now, with refpea to the point in queftion, as we have already clearly fhown, that ar- teries 38 Of the Ligature Chap. II. teries may be tied with as much Safety in every re- Spea, by themfelves, as when conneaed with any of the neighbouring parts, the difference of pain produced by the two modes of operating, ought at once to determine in favour of the former. When any of the contiguous parts, particularly when the nerves which generally accompany the bloodveffels, are included in the fame ligature with an artery, which when the curved needle is employ- ed is a circumftance fcarcely to be avoided, every praaitioner knows that tying the knot in this man- ner is frequently complained of by the patient in very Severe terms. I have on many occafions known patients who have borne the amputation of limbs, and of cancerous breafts, without fhrinking, complain bitterly of the Severe pain produced by the method of fecuring arteries with the crooked needle. And on the contrary, the pain attending the method now propofed, is fo trifling, that, when properly done, even the mod timid patients very Seldom complain of it. For fome time after I firft began to ufe the tenac- ulum, curiofity induced me, on different occafions, to put the matter under consideration to the teft of experiment : And to render the trial as Sair and de- cifive as pottible, it was always made upon the Same Subjea, under the Same operation. Different veffels were fecured in the ordinary manner by the crook- ed needle ; whilft others were laid hold of by the tenaculum : But fo great was the difference in point. of pain, that the one was uniformly allowed to give very little u^eafinefs : Whereas it frequently hap- pened, that the other was complained of as the moft painful part of the whole operation. Among other advantages which the tying of ar- teries by means of the tenaculum has over the old mc le of operating, there is Mill one we have not yet taken notice of. It often happens after am- putations, and other operations where the larger arteries Chap. II. Of Arteries, (3c. 39 arteries have been tied, that the ligatures do not come eafily away, from being made to run fo deep as with the curved needle is commonly neceflary. In fome inftances much pain and trouble has oc- curred from this circumftance, the ligature remain- ing quite immoveable for a great many weeks: And after all, I have feen it neceflary for the furgeon, to put the patient to a great deal of pain, by being obliged to cut out the threads with a fcalpel. But when the tenaculum is ufed, every rifk of this kind is avoided, from the ligatures generally dropping of their own accord, in the courfe of the third or fourth drefling of the fore. From what has been faid, therefore, we fhall con- fider it as a praaice that ought to be eftablifhed, that in forming the ligature of arteries, the nerves and other contiguous parts fhould be carefully a- voided. For the purpofe of effeaing this with eaie and Safety, various kinds of the inftrument termed a Forceps have been invented ; with thefe, the arte- ries of a fore are laid hold of and pulled out, fo as to admit of the application of ligatures. For the larger blood veffels, the forceps has been found to anfwer conveniently enough ; but, in the fmaller arteries, they are by no means fo fit for the purpofe as the inftrument or hook I have been rec- ommending, termed a Tenaculum, and reprefented in Plate I. And as a hook of this form anfwers equally well in the larger arteries likewife the ufe of the forceps may therefore be laid entirely alide. The manner of ufing the tenaculum is this. In order to detea the arteries to be tied, the tourniquet with which they are fecured, muft be flackened a little by a turn or two of the fcrew ; and the moment the largeft artery of the fore is difcov- ered, the furgeon fixes his eye upon it, and imme- diately reftrains the blood again by means ot the tourniquet. An afliftant now forms a noofe on the 1 ligature 40 Of the Ligature Chap. II. ligature to be made ufe of ; and this noofe being placed immediately over the end of the artery, fo as to include it with certainty, the operator then pufhes the fharp point of the tenaculum through the fides of the veffel, and at the fame time pulls fo much of it out, over the furface of the furrounding parts, as he thinks is fufHcient to be included in the knot which the affiftant is now to make. In forming this ligature, the furgeon's knot, as it is termed, which con fills in patting the thread twice through the firft nooSe is certainly preferable to every other, from its being lefs liable to yield or flip. And as fome additional fecurity is obtained by forming a Second knot above the firft, this precaution ought never to be omitted. It is eafily done ; and on fe- curity in this point the patient's life may in a great meafure depend. The degree of ftrength of the ligature muft al- ways be proportioned to the fize of the veffels ; but this is a circumftance to be at all times determined by the judgment of the praaitioner, as muft alfo the force to be employed in forming the knots. To what was already Said upon this point I fhall juft add, that a very fmall force is fully fufHcient for fe- curing even the largeft arteries : And that, after fuch a force has been applied as evidently restrains the farther lofs of blood, a very trifling additional cora- preflion is all that is neceflary. The principal artery being in this manner fecur- ed, all the veffels of the part muft one after another be taken up in the fame manner, by firft loofening the tourniquet in order to difcover them, and after- wards applying the ligature to each in the manner direaed. It often happens, however, that the lofs of blood the patient has fuftained ; a tendency to delinquium tvhich may take place for the time ;. the fear he la- bours under ; and the degree of cold to which the fore is expofed, have altogether fuch an effect upon the Chap. II. Of Arteries, (3c. 41 the fmaller arteries, as to prevent them for the time from difcharging their contents ; and as arteries left in fuch a Slate without being fecured, generally burft out on the removal of thefe caufes, a circum- ftance which always occafions much trouble to the praaitioner, as well as a great deal of pain and rifle to the patient, every furgeon ought to pay the niceft attention to this point. The tourniquet fhould be made perfeaiy loofe ; any coagulated blood on the surface of the fore ought to be carefully wafhed off with a fponge and warm water ; and the patient, if faintifh, ought to get a glafs of wine, or fome other cordial; and after all, the furgeon ought to examine, with the moft minute attention, the ufual courfe which the veffels of the part are known to take. This being done, every artery of the part, even • the fmalleft that can be diftinguifhed, ought to be fecured with a ligature : For fuch veffels as appear exceedingly trifling while the part is yet expofed to the air, nay even the fmall branches of arteries that happen to be negkaed, will be capable of difcharg- ing very considerable quantities of blood after the patient becomes warm in bed, when the folids are thereby relaxed and the fluids -expanded ; and, as little or no injury can ever be done by the proper application of ligatures to all the arteries that pre- fent themfelves, the greateft attention ought at all times to be paid to this circumftance. I have inufted the more on this, from having fre- quently obferved much uneafinefs and diftrefs pro- duced by a want of proper attention to this part of an operation. When the principal arteries of a flump have been taken up, and a little blood continues to be dif- charged, but appears to come from a few fmall vef- fels only, the furgeon, unlefs he is much accuftomed to occurrences of this nature, is induced to think, that as they are very trifling to appearance, fo he-heed F 7 not 42 Of the Ligature Chap. II. not be at the trouble of tying them, as the neceffary compreflion of the bandages proper for the wound will in all probability effea a total ftoppage of the hemorrhagy. In a general oozing of a Small quan- tity of blood from the whole furface of .a fore, and when no particular veffel can be distinguished, there is a neceffity Sor trusting to this remedy • but, when- ever an artery can be discovered, of whatever Size it may be, it ought unquestionably to be fecured by a ligature. It very rarely happens that any inconve- nience occurs from ligatures when properly appli- ed ; but many lives have been loft from a remiflhefs in this article. I have known different inftances of this, and the fame muft have occurred to others. When, from the deepnefs of a wound, or from any other caufe, fome particular artery cannot be properly fecured by the tenaculum ; in this cafe we are under the neceffity of employing the crooked needle, and the following is the mode of ufing it. The operator ought to be provided with needles of various fizes, and of different forms. The needles in ordinary ufe, are for many purpofes quite too much crooked ; for, in general, they are more eafily managed when their curvatures are not fo consider- able. The fame kinds of needles that are found neceffa- ry for the interrupted future, as reprefented in Plate I, anfwer equally well for the ligature of arteries. The needles in common ufe are made triangular with three edges, one on each fide, and a third on the concave part of the needle. There is no real neceffity, however, for more than two : Indeed the needle enters more eafily with two than with three edges ; and as the third edge on the concave fide, renders them more liable to injure arteries and oth- er parts in the courfe of their introduaion, this ad- dition ought to be omitted. A needle of this fhape, armed with a ligature of a fize proportioned to itfelf and to the veflel to be taken Chap. II. of Arteries, (3c. 43 taken up, is to be introduced at the diftance of a fixth or eighth part of an inch from the artery, and puttied to a depth fufficient for retaining it, at the fame time that it is carried fully one half round the blood veffel. It muft now be drawn out ; and be- ing again pufhed forward till it has completely en- circled the mouth of the artery, it is then to be pul- led out, and a knot to be tied of a fufficient firm- nefs, as was already direaed when the tenaculum is ufed. In this manner, either by the ufe of the crooked needle, or of the tenaculum, every hemorrhagy de- pending upon a division of one or more large arte- ries, may in general be very eafily restrained ; but it frequently happens, that considerable quantities of blood are difcharged, not from any particular veffel, but from all the fmall arteries over the fur- face of the fore. In wounds of great extent, partic- ularly after the extirpation of cancerous breasts, and in other operations where extensive fores are left, this fpecies of hemorrhagy often proves very troub- lefome from being exceedingly difficult to fupprefs. Bleedings of this kind feem evidently to proceed from two very different and opposite caufes ; a cir- cumftance which, in the treatment of them, is a mat- ter requiring very particular attention. First, We now and then find effusions of this nature occurring in strong robuft people, where they evidently proceed, either from too great a quantity of blood contained in the veffels, or from an excefs of tone in the veffels them- felves ; or, perhaps, from a combination of both thefe caufes. But, Secondly, Such evacuations undoubtedly happen moft frequently in constitu- tions quite the reverfe of the former, viz. in fuch as are very relaxed and debilitated; either from a putrid diffolved ftate of the blood, or from a want of tone in the containing veffels, or in fome inftances from a concurrence of both. In 4 44 Of the Ligature Chap. II. In constitutions perfeaiy healthy, when the fluids are not tainted with any degree of putrefcency, and the folids are poffefled of their natural tonic powers, on the occurrence of wounds even of the most exten- five nature, as foon as the larger arteries are fecured, all the fmall veffels that have been divided, in confe- quence of that contraaile power with which in a Hate of health they are endowed, and from the Stim- ulus of the external air to which they are now ex, pofed, are diminiftied not only in their diameters, but alfo in their length ; in confequence of which, they recede considerably within the furface of the furrounding parts. This caufe of itfelf would probably in the great- eft number of inftances prove fufficient for restrain- ing all lofs of blood from the fmaller arteries ; but in the found ftate of constitution of which we have now been fpeaking, another very powerful agent is provided by nature for producing the fame effea. From the extremities of the divided veffels which at firft difcharged red blood only, there now, in their contraaed ftate, oozes out a more thin, though vifcid fluid, containing a certain proportion of the coagulable parts of tlie blood ; and this being equal- ly diftributed over the surface of the wound, by its balfamic agglutinating powers, has undoubtedly a very considerable influence in restraining all fuch hemorrhagies. In constitutions altogether healthy, where neither of the states of difeafe we have alluded to prepon- derates over the other, we find, that, as foon as the larger arteries of wounds are fecured, nature, in the manner already defcribed, generally puts a ftop to all farther difcharge. So that, whenever the contrary happens, by a tedious oozing continuing from the Sur- face of the fore, we ought then to pay particular at- tention to the habit of body with which it is conneaed. When fuch an occurrence happens in a patient, young and vigorous, and where the tone of the muf- cular Qhap. II. of Arteries, (3c. 4$ cular fibres is evidently great, the moft effectual means of putting a ftop to the difcharge, is to relax the vafcular fyftem, either by opening a vein in fome other part, or, wh^t gives Still more immediate relief, by untying the ligature on one of the principal ar* teries of the part, fo as to allow it to bleed freely : Thofe violent fpafmodic twitchings too, fo frequent after operations on any of the extremities, when they do not depend' on a nerve being included in the ligature with the artery, are in this manner more effeaually relieved than by any other means. By the fame means, the patient, from being in a Afebrile heat and much confufed, foon becomes very tranquil : The violent pulfaiion of the heart and larger arteries abates, and the blood not being pro- pelled with fuch impetuosity into the fmaller veffels of the part, they are thereby left at more liberty to retraa ; and as in this ftate they do not pour Sorth red blood fo freely, they are the more readily cover- ed with that vifcid glutinous fluid which we have al- ready Shown to be one of the moft importapt means intended by nature for the prevention of fuch hem- orrhagies. At the fame time that by the means recommended we endeavour to allay the commo- tion produced in the fyftem, the patient ought to be kept exceedingly cool; wine and other cordials fhould be rigidly avoided; cold water, acidulated either with the mineral or vegetable acids, ought to be the only drink ; motion of every kind, particu- larly of the part affetted, fhould be guarded againft; and the wound being gently cbvered with lint or Soft charpie, ought to be tied up with a bandage fo applied as to produce a moderate degree of preffure on the extremities of the divided parts. In every extensive wound attended with hemor- rhagies of this kind, and particularly when violent fpafmodic affeaions of the mufcles fupervene to- gether With the means already recommended, large dofes of opiates are found highly beneficial ; for whatever 46 r Of the Ligature Chap. IL whatever hurtful effeas may have been apprehend- ed from opiates in fome inflammatory affeaions, ev- ery praaitioner who has ventured on a free ufe of them muft admit, that in all occurrences of this na- ture their influence far furpaffes that of any other remedy. As foon therefore as a fufficient quantity of blood has been difcharged, and the wound is drefled and the patient laid to reft, a doSe oSopium proportion- ed to the violence of the fymptoms ought to be ex- hibited. It fhould be remarked, however, that, in all fuch circumfiances, much larger dofes of the remedy are neceflary, than in ordinary cafes requir- ing the ufe of opiates?* Small dofes, inftead of an- fwering any good purpofe, feem frequently rather to aggravate the various fymptoms ; fo that, when- ever they are here employed, they ought always to be given in quantities fufficient for the intended ef- fea. Although hemorrhagies of this nature do now and then occur in firm vigorous constitutions j yet they undoubtedly happen much more frequently in re- laxed enfeebled habits, where the folids have loft part of their natural firmnefs, and the fluids have acquired fome degree of putrefcency. As the vef- fels in this situation are fuppofed to have been de- prived of that degree of tone of which we wifh them to be poffeffed, inftead of restraining the patient from the ufe of cordials, as is done usually in every cafe of hemorrhagy, a moderate ufe of generous wine ought to be immediately prefcribed ; for nothing, it may be obferved, tends fo much in fuch circum- ftances to restrain hemorrhagies, as a well direaed ufe of proper cordials. By intending to invigorate and brace the folids, they thereby enable the arte- rial fyftem to give a due resistance to the contained fluids ; and the fame caufe, it may be obferved, has a confiderable influence in restoring to the fluids that Chap. II. Of Arteries, (3c. 47 that vifcidity of which in all fuch inftances we fup- pofe them to be deprived. Whenever, therefore, fuch tedious hemorrhagies occur in relaxed debilitated habits, a free ufe of Port, Madeira, or any other wine whofe strength and goodnefs can be depended on, ought to be im- mediately allowed ; a nourishing diet alfo becomes proper ; the patient ought to be kept cool ; and the mineral acids, from their known utility in every fpecies of hemorrhagy, ought alfo to be prefcribed. Reft of body is here proper too ; and opiates, when indicated either by pain or fpafmodic affeaions of the mufcles, ought never to be omitted. Together with thefe remedies adapted to the gen- eral fyftem, particular dreffings, appropriated to the ftate of the parts to which they are to be applied, have been found very beneficial. We have already remarked, that in firm healthy constitutions, as foon as the difcharge of blood which naturally occurs in every large wound is over, the parts come foon to be covered with a vifcid coagulable effufion from the mouths of the now retraaed arteries; but in constitutions of an oppofite nature, where the folids are much relaxed, the blood in general is found in fuch a diffolved ftate as to afford no Secretion of this nature. In order therefore to supply as much as poffible the deficiency of this natural balfam, different arti- ficial applications have been invented. Dusting the parts with starch or wheat flour has fometimes been found of ufe ; and I have known gum arabic in fine powder to anfwer when thefe have failed. Applications of this kind, indeed, have been ufed with fuccefs in all fuch hemorrhagies, with what- ever habit of body they happen to be conneaed; but they have always proved more particularly fer- viceable in relaxed constitutions, attended with a diffolved ftate of the blood and an enfeebled mufcu- lar fyftem. We may here ufe with freedom too, a remedy 4& Of the Ligature Chap. II. remedy which in fuch circumstances generally proves Serviceable, but which in constitutions of an oppb^ lite nature ought never to be employed. The rem- edy alluded to is alcohol, or any other ardent Spirits, impregnated with as great a quantity as they can diffoive of myrrh or any other of the heating viScid gums. The balfamum traumaticum of the fhopS, a remedy 6f this nature, has long been famous for its influence in Such cafes : But that indiscriminate ufe of this and Similar applications which has long pre- vailed with Some praaitioners, I am confident has done much harm ; for, as they are all poffeffed of very Stimulating powers, they of courfe tend to ag- gravate every Symptom in wounds conneaed with a tenfe ftate of fibres, when much pain, and efpecial- \y when fpafmodic mufcular affeaions, prevail. But, in constitutions of an opposite nature, where the blood appears to be in a diffolved ftate, and where the arterial fyftem feems evidently to require a Stim- ulus, remedies of this clafs Come to be very ufeful: Infomuch that, in every constitution of this kind where hemorrhagies prove trouble fome, no applica- tion whatever is found to anfwer better, than char- pie immerfed in an agglutinating Spirituous balfam of this nature. By a due perfeverance in one or other of the plans here pointed out, it will Seldom happen that hemorrhagies of this nature are not at lafl restrain- ed : But when the contrary does occur ; when, not- withstanding the ufe of the remedies recommended, a difcharge of blood ftill continues ; together with the means already advifed, an equal moderate pref- fure ought to be applied over the whole furface of the fore, to be continued as long as the neceffity of the cafe feems to indicate. In finifhing the dreffings of fuch wounds, after the charpie and compreffes have been applied, a bandage ought to be adapted to the part in fuch a manner as to produce as equal a degree of preffure over Chap. II. Of Arteries, (3c. 45 over the furface of the fore as possible. But it fome- times happens, that no bandage whatever can be fo applied as to produce the defired effea ; and in fuch cafes, the hand of an affiftant is the only refource. In fuch inftances, a perfon's hand being firmly ap- plied over the dreflings, fo as to produce a very equal degree of preffure, will commonly fucceed when no other remedy is found to have mwch influence. Having thus endeavoured to point out the moft effeaual means of putting a ftop to morbid hemor- rhagies, we fhall now proceed to confider the dif- ferent modes employed by art, for effeaing a dif- charge of blood wh*zn indicated by the prefence of fome diforder in the constitution. Q GHAP. 5o Of Bloodletting. Chap. III. CHAP. III. of BLOODLETTING. SECTION I. Of Bloodletting in General. Bloodletting, whether we confider it as to its influence on the fyftem, or with refpea to the nieenefs and even difficulty of the mode ufually employed for effeaing it, is perhaps one of the moft important operations in furgery. From its being fo frequently put in praaice, and from every pretender to any knowledge in the heal- ing art being able to perform it without any appa- rent difficulty, the publickhave been induced to con- fider it as trivial with refpea to its execution ; but every praaitioner of charaaer muft acknowledge, that, in order to perform this operation properly, the greateft nicety, fteadinefs, and exaanefs, are neceffary. All the other operations in furgery I have frequently feen well performed ; but I can with freedom fay, that I have feldom feen bloodlet- ting with the lancet done very correaiy : When properly performed, it is really a neat operation ; but when not done with exaanefs, it is the very reverfe. It is not here meant to enter into the considera- tion of the various caufes which in different circum- stances point out the propriety of abftraaing blood from the fyftem ; nor is it intended to enter upon a particular difcuffion of the different effeas produc- ed by general and topical bloodletting : Thefe con- fiderations, as being highly important, would of themfelves Sea. I. Of Bloodletting. 51 themfelves extend to a very great length ; and be- fides, are of fuch a nature as renders it impoffible to enter minutely upon their difcuffion in any fyftem of furgery. All that is here intended, is to defcribe as clearly as poffible the various modes of perform- ing the operation of bloodletting. In all inflammatory affeaions producing a gene- ral diforder of the fyftem, the method of taking a- way blood as now eltablifhed by immemorial prac- tice, is, by fuch means as difcharge the quantity to be taken in a fhort fpace of time, by an opening made with a lancet, either in an artery or in a vein. Whether there is any real difference in the effeas produced by thefe two modes of difcharging blood, it may be difficult to determine with any precifion ; but there is reafon to fuppofe, that, independent of the quantity taken, the difference is of lefs import- ance than is commonly imagined. The latter of thefe termed Phlebotomy, and the former Arteriot- omy, are the means employed for what we term general bloodletting ; the particular confideration of which we fhall prefently attend to. But it often happens, in diforders of an inflam- matory nature, where there is evidently a fixed lo- cal affeaion, and where no great degree of fever takes place, that general bloodletting has not much influence in mitigating the fymptoms ; and in fuch circumstances confiderable advantage is frequently obtained by difcharging blood from the part imme- diately affeaed, by dividing a number of the fmall veffels which fupply it ; and this we term Topical or Local bloodletting. The means employed by art for difcharging blood in this manner fhall be afterwards treated of, and we now return to the particular confideration of phlebotomy. Wherever a vein of a tolerable fize can be reach- ed with fafety, an opening for the difcharge of blood may be made in it with a lancet ; but the follow- ing are the parts from whence blood is ufually tak- en 52 Of Bloodletting. Chap. III. en in this manner j viz. from the veins of the arm at the flexure of the cubitus ; from the jugular veins; and from the veins of the ankles and feet. On particular occafions, too, blood is advifed to be taken from the veins of the hand, of the tongue, &c. There are fome general rules and obfervation* which relate equally to this operation in whatever part of the body it is praaifed ; thefe we fhall in the firft place point out with as much accuracy as pof- fible, and fhall afterwards proceed to treat particu- larly of bloodletting in the arm and other parts. I. In this as in every other operation, the Situa- tion of the patient, and of the operator likewife, ought to be precifely fixed. As the fituation of a patient during the operation of bloodletting, has a considerable influence on the effeas produced by the evacuation upon the fyftem, this circumftance therefore merits our particular attention. In fome diforders, it is the objea of this remedy, to evacu- ate a considerable quantity of blood without induc- ing fainting : When this is the cafe, and when from former experience it is known that the patient to be operated upon is liable during the evacuation to fall into a faintifh ftate, a horizontal poflure, either upon a bed or on a couch, ought to be preferred to every other ; for every praaitioner is now well ac- quainted with this faa, that fainting does not fo readily occur in a horizontal as in an erea pofture. It now and then happens, however, that one ma- terial advantage expected from the operation of bloodletting, is the inducing a ftate of deliquium ; as for inftance, in cafes of strangulated hernia, where a general relaxation of the fyftem is fometimes de- finable. In all fuch circumftances, inftead of a hori- zontal pofture, the more erea the patient is kept, the more readily will a ftate of fainting be induced : So that the particular objea in view from the ope- ration, muft at all times determine this matter. While we thus attend particularly to the pofture of Sea. I. Of Bloodletting. 53 of the body at large, the particular pofition of the limb or part to be operated upon muft not be neg- leaed. In every operation, it is a matter of much importance to have the patient Seated in a proper light, but in none is it more material than in blood- letting. The beft general rule that can be given upon this point is, that the patient ought to be fo placed, as that the principal light of the apartment fhall fall direaiy upon the part to be operated up- on, fo that the vein to be opened may be made as- apparent as poffible. When clear day light can be obtained, it ought to be preferred ; but when this cannot be procured, one or more candles fhould be ufed. But, whatever may be the pofition of the part it- felf, and whether the patient is to be placed on a bed or on a chair, the furgeon ought always to be feated. The operation may, no doubt, be done while the furgeon is ftanding; and it is moft fre- quently indeed performed in this manner: But it can never be done either with fuch fteadinefs or neatnefs, as when the operator is firmly feated on a chair. II. From the coats of veins being more flaccid than thofe of arteries, and from the blood not circu- lating with fuch rapidity in the former as in the lat- ter, an opening made in one of thefe will Seldom difcharge blood freely, unlefs the vein be either cut entirely acrofs, which in general would be produc- tive of difagreeable confequences, or unlefs the blood be prevented from returning to the heart, by means of a ligature placed between the heart and that part of the vein in which the opening is to be made. The patient being properly feated, the next Step muft therefore be, by means of a proper bandage fo to comprefs the vein intended to be opened, as to prevent the blood from returning to the heart; and for the fame reafon, an equal degree of preffure, it is 54> 9f Bloodletting. Chap. III. is obvious, ought to be applied to all the other veins of the part ; for, if this circumftance fhould not be attended to, the communication preferved by the collateral corresponding branches would render the preffure upon any one particular vein of very little importance. But, independently of its producing a more free difcharge of blood than could be other- wife obtained, this preffure upon the veins, by cauf- ing an accumulation of their contents, tends to bring them more evidently into view, and confequently renders it eafier for the operator to affea a proper opening than he would otherwife find it. Although compreffion, however, to a certain ex- tent, is neceffary for this purpofe of accumulating a quantity of blood in the veins, and for afterwards difcharging it at an opening made by the lancet, it is at the fame time perfeaiy evident that any con- fiderable degree of preffure, inftead of forwarding thefe purpofes, muft obftrua them entirely ; for, if the preffure intended to be applied to the veins only, fhould accidentally be carried fo far as to reft mate- rially upon the arteries conneaed with them, all farther accefs of blood to the veins would be there- by cut off, fo that no evacuation of importance could take place at any opening to be made in them. Whenever it is intended, therefore, to evacuate blood in this manner, a good deal of nicety is requisite in applying this preffure upon the veins : It ought al- ways to be carried fo far as effeaually to comprefs the veins of the part, but never to fuch a length as to obftrua the circulation in the correfponding arte- ries. When we fee that the preffure has the effea of raifing the veins, and if at the fame time the pul- fation of the artery is diftinaiy felt in the inferiour part of the member, we may then be certain that it is applied to a very proper degree, and that it ought pot to be carried farther : For by the fwelling of the veins, we are fure that they are fufficiently compreff- ed ; and by the arteries continuing to beat, it is ev- ident Sea. I. Of Bloodletting. 55 ident that a continued flow of blood may be ex- pected. III. The reflux of blood to the heart being in this manner prevented, the next point to be deter- mined, is, the beft method of making an opening into the vein. Different inftruments have been in- vented for this purpofe ; but there are two only which have been retained in ufe, and which are all, • therefore, that here require to be mentioned. Thefe are, the Lancet and the Phleme. This last, on be- ing placed immediately on the part to be cut, is by means of a fpring struck fuddenly into the vein, and produces an opening of the exact fize of the inftru- ment employed. The phleme, in many parts of Germany, has ac- quired fome reputation, particularly in taking blood from the jugular vein : But there are various ob- jeaions to this inftrument, which will probably prevent it from ever coming into general ufe ; and thefe particularly are, that we are obliged, from the nature of the inftrument, to regulate the deep- nefs to which it is to go, before it is applied : Now we know well, that in bloodletting this is a cir- cumftance of which we are never by any means cer- tain ; for we frequently, after the introduaion of a lancet, find it neceffary to go much deeper than was at firft expeaed ; fo that when a phleme is ufed, un- lefs we employ one on every occasion of a length which cannot be frequently required, we muft often meet with difappointments. But the moft material objeaion to this inftru- ment is, that where there are arteries or other parts lying below the veins, and in any danger of being hurt by the operation of bloodletting, the rifk is much greater with the phleme than with the lancet: For when the lancet is ufed, after the vein is once opened, the orifice may be enlarged at pleasure without any additional rifk, merely by carrying the inftrument forward along the courfe of the vein at 56 Of Bloodletting. Chap. III. the fame depth to which it was at firft introduced ; whereas the phleme, as Soon as it enters the vein, muft for certain paSs direaiy downwards as Sar as its length will permit it to go ; a circumftance which adds greatly to the rifk of wounding the part* underneath. Independently of this too, by the ufe of the lan- cet, we have it much more in our power to com- mand an orifice of a determined Size than when the phleme is uSed : So that without hefitation, we may venture to pronounce the phleme to be an inftru- ment in no degree neceflary ; but for fuch as incline to ufe it, the moft convenient form of one is repre- sented in Plate III, fig. 2. The manner of ufing the phleme is as follows. The bandage for producing the turgefcency of the veins being applied in the manner already di- reaed, the point of the inftrument A, with the Spring properly bent, muft be So placed upon the part of the vein to be opened, that an orifice of an oblique direaion may be made in it on the Spring B being let looSe. The Subfequent management is the fame here as when the lancet is ufed, and will be prefently pointed out. When it is determined to employ the lancet, the form of the inftrument is evidently the firft circum- ftance requiring our attention ; although we may here remark, that this point is feldom fo particularly attended to as it ought to be. The form of the lancet in oi/Iinary ufe, as reprefent- ed in Plate IV, fig. 5. is an inftrument which ought * to be laid entirely aside. For opening abfeefles it is very well calculated, but for the operation of blood- letting it ought never to be ufed. The capital objeaion to this form of lancet, is, that the broadnefs of its fhoulders produces always a wound in the external teguments of perhaps three times the fize of the opening made in the vein ; a circumftance which adds no advantage whatever to the v I'lAfe IV A Sea. I. Of Bloodletting. 57 the operation : On the contrary, it produces much unneceffary pain in the firft inftance ; it renders it frequently a very difficult matter to command a ftoppage of the blood ; and the wounds produced by it are Commonly fo extenfive as to render them very liable to terminate in partial suppurations ; an occurrence which always proves painful and difa- greeable to the patient. The fpearpointed lancet, on the contrary, as rep- refented in Plate IV, fig. 3 and 4, is an inftrument in every refpea well calculated for the purpofe of venaefeaion. From the acutenefs of its point, it en- ters the teguments and vein with very little pain; which we may here obferve, is with many patients a circumftance of no fmall importance : We are fure of making the opening in the vein equal, or nearly fo, to the orifice in the external teguments : And the difcharge of blood produced by an opening made with one of the lancets, is commonly put a flop to with great eafe, immediately on removing the liga- ture upon the vein. For thefe reafons, therefore, the fpearpointed lan- cet is highly preferable to every other : And al- though, with timid praaitioners, the acute point of this inftrument may appear to require more dexter- ity in ufing it than the broad fhouldered lancet; yet the difference in this refpea is fo inconsiderable, that very little experience muft, with every praaitioner who gives it a fair trial, very foon counterbalance all fuch objeaions. Indeed no furgeon ought to be trusted in letting blood with the one, whofe fteadi- nefs and dexterity would be in any degree doubted with the other. IV. The form of lancet being thus fixed up- on, we come now to fpeak of the method of ufing it. The furgeon and patient being both properly feated, and the ligature having been applied for a fhort fpace of time in order to produce fome degree of fwelling in the veins, that vein is to be made choice of, which, H at 5* Of Bloodletting. Chap. III. at the fame time that it appears confpicuoufly e- nough, is found to roll lefs than the others on being preffed upon by the fingers. There are fome veins which roll fo much, from being loofe and uncon- neaed with the cellular fubftance of the part, that although they may rife Sufficiently, yet are much worSe to operate upon than others which lie at a much greater depth. That vein therefore is to be preferred which not only rifes fo as to become per- feaiy evident, but which appears to be conneaed with fome degree of firmnefs to the contiguous parts. It is fcarcely thought neceflary to obferve here, that when a vein appears to be fo immediately connea- ed with a contiguous artery or tendon, as evidently to produce fome rifk of wounding thefe parts in the operation, if another vein not liable to fuch hazard can be procured, it ought undoubtedly to be prefer- red. Veins may lie direaiy above both arteries and tendons, and yet no manner of rifk be incurred by opening them, provided the operator is Sufficiently Steady and attentive ; but it does now and then hap- pen, that veins are So nearly and intimately connect- ed with thefe parts, as to render it hazardous even for the moft dexterous furgeon to attempt this op- eration. The vein being at laft made choice of, the fur- geon, if he is to ufe his right hand in the operation, takes a firm hold of the member from whence the blood is to be drawn, with his left, and, with the thumb of the fame hand, he is now to make fuch a degree of preffure upon the vein, about an inch and half below the ligature, as not only to render the fkin and teguments fomewhat tenfe, but at the fame time to interrupt for a little all communication be- tween the under part of the vein, and that portion of it lying between the ligature and the thumb plac- ed as thus direaed. The Sea. I. Of Bloodletting. 59 The lancet being bent to fomewhat more than right angles, the operator now takes it between the finger and thumb of his right hand ; and, leaving at leaft one half of the blade uncovered, he refts his hand on the middle finger, ring finger, and little finger, all placed as conveniently as poflible in the neighbourhood of the vein from whence the blood is to be taken ; and having puttied the point of the inftrument freely through the (kin and teguments into the vein, he now carries it forward in an oblique direaion, till the orifice is of the fize he inclines to have it ; taking care, during the time of pufhing on the lancet, that its point be kept in as straight a di- reaion as poflible, for fear of dipping into the parts below. The inftrument is now to be withdrawn, and the furgeon removing the thumb of his left hand, is to allow the vein to empty itfelf freely into the cups provided for the purpofe. It is here of importance to obferve, that, during the time the blood is difcharging, the member ought to be kept in exaaiy the fame pofture it was in when the lancet was firft introduced: Otherwife, the ori- fice in the fkin is apt to flip over the opening in the vein ; a circumftance which always proves inconve- nient, and on fome occafions produces a good deal of trouble by the blood from the vein infinuating itfelf into the furrounding cellular fubftance. In taking hold of the lancet, we have direaed the fcales to form rather an acute angle with the blade of the inftrument. It will even anfwer when they are at right angles ; but a farther feparation proves always troublefome, by throwing the fcales too much back upon the operator's hand. The length of inftrument left out from between the finger and thumb is another circumftance requiring our at- tention ; for unlefs a fufficient quantity of it is left uncovered, the operator cannot aa with free- dom. In lancets of an ordinary length, one half of 60 Of Bloodletting. Chap. III. the blade, as I have already remarked, or very near- ly that quantity, ought always to be left out. The entry of the lancet into the vein is the next circumftance we have defired to be attended to. By very little attention the entrance of the inftrumsat into the vein may be diftinaiy perceived ; Sor as Soon as its point has entered the cavity of the veffel, the refiftance to its farther progrefis is evidently found to be much diminiftied ; and immediately on the opening being in any degree enlarged, the blood be- gins to rufh out, which is the cleareft proof of the operation being fo far complete. On being thus rendered fure that the lancet has got into the vein, we have alio defired that it may be carried forward in an oblique direaion, taking care to keep the point of the inftrument in the fame degree of elevation from the inftant it has paffed fairly through the coats of the vein j and to this part of the operation we would beg the moft particular attention. To the want of neceflary caution in this matter, or rather to the improper regulations held forth upon it by. eve- ry writer on this fubjea, much of the rifk attending this operation ought to be attributed. The propriety of an oblique direaion for the courfe of the orifice is very obvious : For, when made altogether longitudinal, the fides of the wound. are apt to fall immediately together, fo as not to ad- mit of a free difcharge of blood; and, on the other hand, when the vein is cut entirely acrofs, trouble- fome confequences commonly enfue from the wound being very difficult to heal : An orifice Somewhat oblique with refpea to the courfe of the vein, is therefore preferable to either. But the material cir- cumftance to be kept in view is the direaion of the point of the lancet after it has got fairly into the vein. By almoft every author who has written up* on bloodletting, as foon as the lancet is known to have got into the vein, in order to extend the orifice to a fufficient length, we are direaed, very; properly, to Sea. I. Of, BloodkUing. 6i to carry the inftrument forward : But in what man. ner are we defired to do fo ? By raifing the heel of the lancet, as it is termed, at the fame time that the point and edge of it is in fome degree pufhed for- ward, fo as to make the point of the inftrument the centre of motion. The reafon of this laft precaution is, that the in- ternal orifice of the vein may not be farther extend- ed upwards than the external wound in the flcin and other integuments ; as ecehymofes, or effufions of blood into the cellular fubftance, have with the broad fhouldered lancet been found frequently to occur from a contrary management. But when the fpearpointed lancet is ufed, this is an occurrence which may be always avoided ; as, from the narrow point of the inftrument, it may with fafety be car- ried on in the cavity of the vein as far as is necefla- ry. The orifice produced by it in the vein, muft, when the operation is properly done, be always of very nearly the fame extent as the external wound in the teguments : And by the fame management we avoid that capital rifk which it is evident muft always occur from an implicit obedience to the di- rection alluded to ; for one certain effea of raifing the heel, or back part of the lancet, is, that the point of the inftrument muft in the fame proportion be depreflfed; and the confequence of lowering the point of the lancet, already perhaps Aiding along the under fide of the vein, muft at once appear to be very, hazardous. For in fuch circumftances, if the point of the inftrument be depreffed, which muft undoubtedly happen if the back part of it be elevat- ed, it muft for certain pafs through the back part of the vein ; fo that if either an artery, nerve, or ten- don, lie contiguous, they muft of neceffity be wound- ed ; and* I am perfeaiy convinced, that this caufe a- lone has frequently been the origin both of wound- ed arteries, and of pricks in the nerves and tendons. So that as the hazard of the praaice, whenever it 62 Of Bloodletting. Chap. IIL is attentively confidered, muft at once appear evi- dent, and as the fuppofed inconvenience arifingfrom a contrary mode of operating is effeaually prevent- ed by the ufe of the fpearpointed lancet, all fuch rifks therefore fhould be carefully avoided. With refpea to the fize of orifice in cafes of bloodletting, this circumftance muft at all times be determined by the nature of the diforder for which the evacuation is prefcribed. When a hidden lofs of a considerable quantity of blood is intended, ei- ther, with a view to produce a Slate of fainting, or for any other reafon, a free large orifice is abfolutely neceflary ; but in ordinary praaice, no neceffity oc- curs for this. In ufing a fpearpointed lancet, an orifice of about an eighth part of, an inch in length will in general anfwer every purpofe ; but when a lancet with broad Shoulders is ufed, an opening of twice that fize is little enough ; for with fuch an inftrument the orifice in the vein can Seldom be above half the ex- tent of the external opening. After withdrawing the lancet from the orifice, we have direaed the thumb of the left hand to be re- moved from the place it was made to occupy. Many circumftances may appear to be related here- with uifneceffary minutenefs, and this among others! may poffibly be confidered as one ; but in an ope- ration of importance, every particular requires much attention. Now, one material ufe of the thumb placed below the part where the lancet was direaed to enter, is, to keep the teguments and vein firm, fo as to prevent the latter from rolling. But another advantage occurring from it is, that by making a fumcient degree of preffure upon the vein, it there- by prevents any confiderable quantity of blood from efcaping between the time of removing the lancet, and the application of one of the cups for receiving the blood from the orifice in the vein. During this period it frequently happens, that a good Sea. I. Of Bloodletting. 63 good deal of blood is difcharged, to the great an- noyance both of the patient, the operator, and by- ftanders ; a circumftance which, with a little atten- tion, may be always effeaually prevented. V. When the vein is properly cut, and the ori- fice is made sufficiently large, it rarely occurs that any difficulty is experienced in procuring all the blood that is Wanted. But it now and then happens otherwife, either from the orifice of the fkin and other parts having receded from the opening in the vein, or from the patient having become faintifh ; a fituation always unfavourable to a free difcharge of blood. When this laft circumftance occurs, a stream of frefh air ought to be admitted to the apartment, wine or fome other cordial fhould be administered, and the patient ought to be laid into a horizontal pofture. By thefe means the faintifhnefs will in general be foon removed; but if Still the *blood fhould not flow freely, the member ought to be put into all the variety of positions that can probably affift in bringing the opening of the fkin and other teguments to correspond with that of the vein, which will foon be known to have happened by the blood beginning instantly to flow. Throwing the mufcles of the part into conftant aaion, by giving the pa- tient a cane or any other firm fubftance, to turn frequently round in his hand when the operation is done in the arm, will often anfwer in producing a conftant flow of blood from a vein, when every other means has failed : And lastly, when the pulfe in the inferior part of the member is felt very feeble, or especially if it cannot be diftinguifhed at all, we may be thereby rendered certain that the ligature is too tight, and may in general have it in our power to produce an immediate flow of blood by removing the compreffion thus improperly made upon the ar- teries of the part. VI. A quantity of blood proportioned to the circumftanccs of the diforder, being thus difcharged, the 64 Of Bloodletting. Cha£. III. the preffure upon the fuperior part of the vein fhould be immediately removed ; and this being done, if the fpearpointed lancet has been ufed, all farther difcharge of blood will in general flop im- mediately. The contrary, however, fometimes oc- curs, and blood continues to flow freely even after trie ligature is removed. WThen this is the cafe, the operator ought to comprefs the vein both above and below the orifice by means of the finger and thumb of one hand, So as to prevent any farther loSs of Wood : And this being done, the limb ought to be wafhed and entirely cleared of any blood that may have fallen upon it; and the orifice being alfo clear- ed of every particle of blood, the fides of it fhould be laid as exaaiy together as poflible, and a piece of what is named courtplafter, or any other that is Sufficiently adhefive, being fo applied as to retain them, it will feldom happen that any kind of band- age is neceffary : But when the blood has iffued with uncommon violence during the operation, and has been difficult to command after the removal of the ligature, in fuch inftances it will be prudent to apply a fmall comprefs of linen over the piaster, and to fecure the whole with a linen roller properly ap- plied round the member. Before applying the plaster, we have direaed the orifice to be perfeaiy cleared of every particle of blood ; and this, it may be obferved, is a circum- ftance of more importance than is commonly imag- ined ; for, by not attending particularly to this point, and from want of exaanefs in clofing the lips of the orifice, painful fwellings and confequent Sup- purations are often induced, which a very little at- tention would have eafily prevented. In every in- ftance when the operation is properly done, the wound ought to heal by what furgeons call the Firft Intention, that is, by the parts adhering to one another without the formation of matter ; but this can feldom happen if the lips of the fore have not been Sea. I. Of Bloodletting. 65 been very neatly laid together after all the blood has been perfeaiy cleared away. Another argument of importance, too, occurs for neatnefs in this matter. Among other troublefome confequences arifing now and then from bloodlet- ting, inflammation produced in the cavity of the vein has in fome inftances been known to occafion much mifchief ; and as nothing tends more to pro- duce it thanjhe^admiffion of air to the part, by the orifice in the vein not "being properly clofed, this circumftance of itfelf strongly points out the propri- ety of the caution here given : For although fuch inflammatory affeaions in the internal furfaces of veins are not by any means to be confidered as fre- quent, yet it is certain they do now and then occur ; and as the confequences arifing from them, especial- ly if fuppuration is induced, muft commonly ter- minate fatally, they ought certainly, by every means in our power, to be ftriaiy guarded againft. VII. We come now to fpeak of fome troublefome confequences which on fome occafions are found to occur from bloodletting, and which every operator ought to be as much as poflible prepared to remedy. The moft material of thefe are, fmall tumors occa- fioned by effusions of blood from the orifice of the vein into the furrounding cellular fubftance ; wounds of the artery lying contiguous to the vein ; pricks of the nerves and tendons ; and lastly, inflammation, induced in the internal cavity of the vein, as we have juft now mentioned. Thefe we fhall now, under feparate heads, proceed to treat of particu- larly* ' ' I SECTION * Among other reaions which we have given for preferring a fpear- pointed lancet, it was obferved, that by means of it the operation of bloodletting is attended with much lefs pain than when the broad mouldered lancet is uied: And the prevent.on of pain is a matter of luch importance, that nothing fhould be omitted that can in any deeree contribute to it. ., , In every operation it is of much confeq.ience to have all the nee- effary inftruments in the molt complete order ; but in no mftance is it of uch imoortance to attend to this circumltanceas in bloodletting. 66 Of Bloodletting. Chap. III. SECTION II. Of a Thrombus, or Ecchymosis. WE have already defired, that in the operation of bloodletting, the member fhould be retained in the very fame pofture it was in when the lancet was introduced, till the whole quantity of blood intended to be taken is evacuated. When this direaion is not duly attended to, it commonly happens, that a fmall tumor is raifed immediately above the orifice. in the vein, by the blood insinuating itfelf into the cellular fubftance of the neighbouring parts. Such a tumor, when round and fmall, is termed a Throfn^ bus ; and when more diffufed, an Ecchymofis. Immediately on the appearance of fuch fwellings, the ligature ought to be removed from the Superior part of the vein ; and the member being brought into that pofture which it was in when the lancet was firft introduced, the ligature may be again re- newed ; and it will thus be frequently found that a free return of blood will be induced, which com- monly carries off the fwelling altogether, or at leaft prevents it from producing any further obftruaipn to the difcharge of blood. But it does now and then happen, that thefe fwellings come at once to fuch a fize, as entirely to preclude every possibility of fin- ifhing the operation at the orifice firft made in the vein. Even here, however, the ligature ought to be Well tempered lancets will no doubt anfwer tolerably well, even after they have been frequently ufed ; infomuch that I have heard even well employed furgeons aflert, that they have ufed one or two ancets only during the courfe of many years practice, without ever having them touched by a cutler. But it is verv certain that eveiy time a lancet is ufed, it muft be injured more or lefs ; fo that, as the prevention of pain is with moft patients a matter ot no fmall confe- quence, I think it ought to be laid down as a fixed rule never to ufe t£e fame ianoet twice, without putting: it into the hands of a cutler. This 1 have ong been in the praftice of doing, not only with lan- cets, but with every cutting inftrument; and the trouble and ex- tenfe attendinr: -<■ is very irconfiderable, when compared with the advantage rdulung Irom it. Sea. II. Of Bloodletting. 67 be immediately removed, as the moft effeaual meth- od of preventing an increafe of the tumor. By con- tinuing the bandage on the Vein, the blood ftill con- tinues to be forced in great quantities into the fur- rounding cellular substance ; and by the fame means fuch i'vvellings are induced, as now and then give a great deal of trouble, which by a contrary man- agement might eafily have been prevented from com- ing to any considerable height. In luch occurrences, as it is in vain to expea any considerable quantity of blood from the orifice firft made, the next step to be taken, is, to finifh the op- eration, not by another opening in • the fame vein, which in fuch circumstances would f^dom be found to bleed freely, but in any other that lies moft con- venient. When tumors of this kind do not arrive at any great fize, very little is neceffary to be done for their difperfion, as the effufed blood is commonly foon abforbed. When it is found neceffary, however, to have recourfe to difcutient remedies, thofe of the aftringent kind are by far the moft effeaual ; and of this clafs brandy or any other ardent fpirits are perhaps as ufeful as any. Compreffes wet in a weak folution of crude fal ammoniac in vinegar, and applied with a very moderate degree of preffure, have likewife been found very effectual in difcuif- ing fuch fwellings. * "' Inftances, however, do now and then occur, though by no means very frequently, of the blood collected in fwellings of this nature being in too great quantities to be all abforbed : And when this happens to be the cafe, as no good fuppuration can be induced where there is nothing but red blood contained in the tun,or, it ought to be immediately laid open as foon as there is reafon to fuppofe that no farther diminution of fize will probably occur from aBforption. This being done, and the coagu- lated 68 Of Bloodletting. Chap. III. lated blood being evacuated, the fore falls to be treated like any ordinary wound. But occurrences of this nature, are in general of very little importance when compared with other accidents which now and then proceed from bloodlet- ting. The firft of thefe we are to treat of are wounds of arteries. SECTION III. Of Wounds df the Arteries. • IN the fmajler arteries, as for inftance in any branch of th|? temporal artery, openings may be made without much rifk ; but we know from long and repeated experience, that wounds in the larger arteries often prove hazardous, and very feldom heal without a great deal of trouble. When in bloodletting we have reafon to fufpea that an artery has been wounded through the orifice made in the vein, and that blood is difcharging at the fame orifice both from the artery and the vein, it becomes a matter of importance for an operator %o know with precision whether it is fo or not. There is only one method by'which a complete de- gree of certainty can be obtained on this point ; and it is this : WThen the blood is difcharged from the vein only, if a degree of preffure be applied both immediately above and below the orifice fufficient for compreff- ing the fides of the vein together, all farther evacu- ation of blood fhould inftantly ftop, even though the preffure is not fo confiderable as to affea the artery below ; but on the contrary, if part of the blood be thrown out from the wounded artery, this preffure upon the vein, inftead of putting a ftop to the difcharge, fhould rather tend to make it more' confiderable. When at the fame time the blood is difcharged per Jahum, this will no doubt ferve as a corroborating Sea. III. Of Bloodletting. 69 corroborating circumftance : But this teft of itfelf, we may remark, is by no means fo decifive as is commonly imagined % for, an orifice made in a vein lying direaiy above and immediately contiguous to a confiderable artery, receives the influence of the arterial pulfation to Such a degree, as to difcharge blood very nearly in the fame manner as if the arte- ry itfelf was cut. No other proof however, is nec- effary of the artery being wounded, than the one we have already mentioned } for, if after the vein is thoroughly compreffed both above and below the orifice, blood ftill continues to be difcharged in great quantities and with any confiderableforce, our fuf- picions of the artery being wounded' ar,e then reduc- ed to the utmost degree of certainty. Allowing this to be the cafe, that in fuch circum- stances we are rendered certain of the lancet having pierced the artery, What remedy ought we to have recourfe to ? Not the means usually advifed, but the very reverfe. In all fuch occurrences, we are conftantly direa- ed to tie up the part with as much firmnefs as pofli- ble, in the firft place with different compreffes placed over the orifice of the vein; and left thefe fhould not produce a fufficient degree of preffure, a piece of money or other hard fubftance is defired to be add- ed, and the whole to be fecured with a Toller very tightly applied. But what effea ought we reafona- bly to expea from much preffure applied in this manner ? We cannot fuppofe it was ever intended that any preffure of this kind fhould be fo confider- able as to comprefs the artery itfelf; for by that means when the principal artery of a part is wound- ed a total ftop would be put to the circulation in the whole limb : And if the preffure, on the contra- ry is to be applied in fuch a degree as to comprefs • the fides of the veins only, one certain effea of this muft be, to occasion a confiderable refinance to the flow of blood from the artery j and that fluid being thus 70 Of Bloodletting. Chap. III. thus obftruaed in its natural courfe, will neceffarily be much more readily effufed at the opening in the" artery, than if the veins had been all left free and pervious to receive and tranfmit it. In all fuch cafes, therefore, inftead of applying much preffure, we ought to attempt every means of relaxing the veins to the utmoft ; and in order to command the blood, the lips of the wound fhould be laid together, and retained by Straps of adhefive plaf- ter only, without any bandage whatever. And as there is not a more effectual method of relaxing the fyftem at lasge, and the vafcular fyftem in particu- lar, than by difcharging large quantities of blood very quickly, fo fi^pn as it is known that an artery has been accidently opened, it ought to be immedi- ately determined to evacuate by the orifice newly made, as much blood as the patient can eafily bear to lofe. By thefe means, and by enjoining ftsia at- tention to reft of body, in order to prevent as much as poflible the undue aaion of the arterial fyftem, and by keeping the body cool, with the ufe of gentle purgatives, a low diet, and farther bloodlettings When neceffary, there may always be at leaft fome chance of fuch wounds in arteries being brought to reunite : W'hereas a contrary management, in which much preffure upon the veins is advifed, muft uni- verfally do mifchief, by forcing the artery to emp- ty itfelf at the only paffage the blood in fuch cir- cumstances can be difcharged at, viz. the opening newly made by the lancet; and by fuch treatment many aneurifmal fwellings, I am confident, have been produced, which by the management now pointed out might eafily have been prevented. In cafes of wounded arteries, however, it will fre- quently happen, that no treatment v. hatever will fuc- ceed ; the orifice in the artery will not reunite, and blood in confiderable quantities is effufed into the" contiguous parts. Even in this ftate of the com- plaint, Strong preffure is advifed, with a view to dif- fipate Sea. III. Of Bloodletting. 71 fipate the tumor: But unlefs the fwelling is of a very foft nature, and unlefs the blood contained in it flill remains in a ftate of fluidity, no preffure whatever can have any influence in difcuffing it ; for, whenever the accumulated blood has acquired any moderate degree of firmnefs, we cannot fuppofe that preffure will have any effea in driving it back by the paffage from whence it originally came. Nor does it appear, that in fuch circumstances, compref- fion is of any ufe in forwarding the abforption of extravafated blood. From theory alone we might readily be induced to draw this conclusion ; but in faa we do not know a fingle inftance in which pref- fure in fuch cafes appeared to be produaive of any advantage. There is indeed a particular fpecies of fwelling, which now and then occurs on an arfeery being in this manner wounded by a lancet that has previouf- ly paffed through a neighbouring vein, and in which moderate preffure has proved ferviceable. When an artery thus wounded, lies quite contiguous to the correfponding vein, the opening between the two veffels on fome occafions continues pervious after the external orifice in the vein is clofed, fo as to produce a direa communication between the one and the other ; and the vein in this manner receiving the full force of the arterial pulfation, at the fame time that its coats are not poffeffed of a firmnefs fufficient to refift it, a fwelling of the vein comes of courfe to be produced. In all fuch inftances, moderate preffure, we may readily fuppofe, muft be of very great ufe, by ferving as a'fupport to the diftended vein, and by thus preventing any farther increafe of its bulk ; but in no other fwelling arifing from blood effufed from an artery can preffure be of any ufe; on the contra- ry indeed, for the restfons already enumerated, there is great caufe for fufpeaing that it has frequently done much mifchief. When we are rendered quite certain that an arterv has been opened, and that the tumor 72 Of Bloodletting. Chap. III. tumor produced by it is owing to blood colleaed in the cellular membrane around it, if keeping the limb in an eafy relaxed pofture, and the veins per- feaiy free from preffure, together with the other means formerly pointed out, do not prevent a far- ther increafe of the fwelling, no other mode of treat- ment with which we are acquainted will have much influence. The tumor ftill continuing, by the communica- tion between it and the artery being constantly kept up, and none of the means employed for its difper- fion having any influence, the diforder in that ftate is to be confidered as forming a fpecies of aneurifm, an ailment of which we will treat more particularly afterwards. SECTION IV. 0/"Wounds or Pricks in the Nerves and Ten- dons. THE diforder we have now been defcribing, viz. wounds of the arteries, as well as Similar affeaions of the tendons, ought never to happen in the hands of a furgeon who pretends to any tolerable degree of fteadinefs ; for, as the arteries and tendons are both parts which previous to the operation may be eafily diftinguifhed by the finger, fo as that their fituation may be afcertained with exaanefs, it muft always be the fault of the furgeon, if the point of his lancet is not fo direaed as to avoid them. One principal caufe of fuch accidents occurring in bloodletting, is, as we have already fhown, the ordinary praaice of depressing the point of the lancet, after it has entered the cavity of the vein. This, however, we have demonstrated to be always unneceffary, and in many inftances to be. produaive of very pernicious effeas. But although, by proper attention to this part of the operation, we may always with certainty avoid the arteries Sea. IV. Of Bloodletting. 73 arteries and tendons ; yet it may be faid, that the nerves, which in general are fo fmall as not to be previoufly diftinguifhed, run at all times a great rifk of being wounded, and that the accidents which now and then occur from wounded nerves, are well known to be produaive of as dreadful confequences as have ever fucceeded to the operation of blood- letting. But although the nerves from the fmallnefs of their fize cannot previoufly be diftinguifhed by the fingers ; yet, if fufficient attention be given to the direaion of the point of the lancet, fo as to avoid with certainty carrying the instrument through the back part of the vein, the fame means which tend to fecure the arteries and tendons, will with almoft equal furenefs prove a fafeguard to the nerves : For, if the operator enters his lancet, as he ought always to do, on the fuperiour part of the vein, and if he does not cut the vein entirely acrofs by pufhing the lancet through to the opposite fide of it, he can never run any rifk of wounding the contiguous nerves : For thefe, though they run fo near to the veins, yet either lie immediately below them, or at leaft are situated fo far down upon their fides as to be out of all rifk of being wounded, if the lancet is made to enter where it ought to do ; and it muft always be the furgeon's fault if the inftrument is pufhed out at the opposite fide of a vein. I may venture to affert, that no inconvenience of this kind ever happens, from the wound made by a lancet in entering the anteriour part of a vein : It is always on the oppofite fide of the vein that any mifchief of this kind is produced, when the lancet, as we have al- ready obferved, is pufhed entirely through ; which it never ought to be, and which every furgeon ought to have fteadinefs enough to prevent. But although a very ordinary degree of caution would eafily prevent every occurrence of this na- ture j and although, when accidents of this kind do K happen, 74 Of Bloodletting. Chap. III. happen, the furgeon is almoft in every inftance to blame ; yet experience has on different occafions evinced, that, either from the want of attention, or from the operator not being poffeffed of a fufficient degree of fteadinefs, however eafily fuch inconve- niences ought to be prevented, yet Still they do fre- quently occur. Nerves, and even tendons, are Some- times pricked ; and the dreadful train of fymptoms which fuch accidents commonly produce is almoft inevitable. It fometimes happens immediately on the intro- duaion of the lancet, that the patient complains of a moft exquifite degree of pain ; and when this oc- curs, we may reft allured that either a nerve or ten- don has been wounded. On fome occafions, by proper management, Such as evacuating a confidera- ble quantity of blood at the orifice newly made, by keeping the part at perfea reft, and preferving the patient in as co61 a ftate as poflible, the pain at firft complained of will gradually abate, and at laft go off entirely without any bad confequence whatever. At other times, however, this pain which occurs inftantaneoufly on the introduction of the lancet, inftead of abating, begins foon to increafe ; a fullnefs, or fmall degree of fwelling, takes place in the parts contiguous to the wound ; the lips of the fore be- come Somewhat hard and inflamed ; and in the courfe of about twenty four hours from the opera- tion, a thin watery Serum begins to be discharged at the orifice. If, by the means employed, relief is not foon ob- tained, thefe fymptoms generally continue in nearly the fame ftate, for two, or perhaps three days long- er. At this time the violent pain which at firft took place becomes Hill more diftreffing ; but inftead of being fharp and acute as before, it is now attended with the fenfation of a burning heat, which flill goes on to increafe, and proves during the whole courfe of the ailment a fource of conftant diftrefs to the patient. Sea. IV. Of Bloodletting. 75 patient. The fullnefs and hardnefs in the lips of the wound begin to increafe, and the fwelling in the neighbouring parts gradually extends over the whole member ; from the foot upwards over the thigh, when the operation has been done in the lower ex- tremity ; and from the elbow down the forearm, and along the humerus over to the peaoral mufcle and other contiguous parts, when the accident has oc- curred at the ufual place of bloodletting in the arm. The parts at last become exceedingly tenfe and hard ; an erysipelatous inflammatory colour fre- quently appears over the whole member ; the pulfe by this time has generally become very hard and quick ; the pain is now intenfe, the patient exceed- ingly reftlefs ; twitchings of the tendons occur to a greater or leffer degree ; on fome occafions, a locked jaw and other convulfive affeaions fupervene ; and, all thefe fymptoms continuing to increafe, it moft frequently happens, that the fufferings of the unfor- tunate patient are terminated by death only. Bloodletting, from being fo very generally prac- tifed, may by many be confidered as an operation by no means either fo difficult in execution, or fo dreadful in its confequences, as is here reprefented. Such inftances indeed are not to be confidered as frequent occurrences ; but they happen often enough to convince us of the neceffity of very great caution in this operation. In the courfe of my experience I have known feveral inftances where the confe- quences of bloodletting have proved fatal, and the dreadful train of fymptoms we have already enu- merated uniformly occurred in all of them. Different opinions have prevailed refpeaing the caufe of thefe fymptoms : By fome they have been imputed to wounds of the tendons ; and by others the tendons are fuppofed to be fo entirely deftitute of fenfibilitv, as to be quite incapable of producing fo much diftrefs ; fo that wounds of the nerves they confider 76 Of Bloodletting. Chap. III. confider in all fuch occafions as the true caufe of the various fymptoms we have mentioned. On one or the other of thefe fuppafitions the va- rious phenomena which occur in this diforder have been explained, till a different opinion was at laft fuggefted by the ingenious Mr. John Hunter of London. Mr. Hunter fuppofes, that all the fymp- toms thus induced by the operation of bloodletting, may be more readily accounted for, from an inflam- ed state of the internal furface of the vein, than from any other caufe. Such a ftate of the vein he has often traced in horfes that have died of fuch fymp- toms from venaefeaion, where the internal coat of the vein was always found much inflamed, not only in the neighbourhood of the part where the orifice was made; but on fome occafions the inflammation extended along the whole courfe of the vein, and Seemed at laft to reach the heart itfelf. Some in- ftances too have occurred, of the fame appearances in the human body, where the veins after death were found in a ftate of high inflammation. And on other occafions, inflammation having in this manner been once excited, has been known to terminate in fuppuration ; and the matter thus produced, being in the courfe of circulation carried to the heart, Mr. Hunter fuppofes that in fuch cafes death may have been induced by that caufe alone. There can be no reafon to doubt the faa held forth by Mr. Hunter, that in fuch inftances, the vein in which the orifice has been made, has frequently after death been found greatly inflamed : But however ingenious his arguments may be, for concluding that this ftate of the vein is the original caufe of all the bad fymptoms enumerated ; and although we muft allow, that fuch an inflammatory affeaion of a vein muft have a confiderable influence in aggravating the various fymptoms previoufly induced by other caufes; yet I think we may very fairly conclude, that it could not probably in any one inftance be able to account Sea. IV. Of Bloodletting. ff account in a fatisfaaory manner for their firft pro* duaion. In all the inftances of this dreadful complaint which I have had an opportunity of feeing, the pa<- tient at the very inftant of the operation felt a very unusual degree of pain. In fome cafes, the vio- lence of the pain was almoft infupportable. Now this we can never fuppofe to have been produced by the mere punaure of a vein ; for although the coats of veins are not perhaps entirely deftitute of feeling, vet we know well, that they are not endowed with fuch a degree of lenfibility as to render it probable fuch intenfe pain could ever be induced by their be- ing punaured in any way whatever. This inflam- ed ftate of the veins therefore, as deteaed by Mr. Hunter after death, muft be confidered rather as be- ing produced by, than as being produaive of, fuch affeaions ; and that fuch ailments fhould frequently produce an inflammation of the contiguous veins, is a very probable conjeaure. In the courfe of about forty eight hours from the Operation, when the fe- brile fymptoms are juft commencing, fuch a degree of hardnefs and evident inflammation is induced over all the parts contiguous to the orifice, that it would be furprifing indeed, if the vein, which is thus per- haps entirely furrounded with parts highly inflam- ed, fhould not be inflamed likewife. We fhall therefore proceed upon the fuppofition of this inflamed ftate of the veins being a confe- quence, rather than the caufe, of fuch ailments ; and of courfe we now revert to one or other of the opinions long ago adopted on this fubjea, that all the train of bad fymptoms found on fome occafiorts to fucceed to venasfeaion, proceed either from the wound of a nerve or of a tendon. That a partial wound of a nerve will now and then produce very diftreffing fymptoms, no prac- titioner will deny : But it has been attempted to be fhown, as we have already remarked, that tendons are 78 Of Bloodletting. Chap. III. are almoft totally deftitute of Sensibility; and it has therefore been fuppofed, that their being wounded, can never account for the various fymptoms known to occur in fuch cafes. There is great reafon, however, to think, that in different inftances the fame train of fymptoms have been induced by different caufes ; that in one in- ftance a wounded nerve, and in others pricks of the tendons, have given rife to them. Being decidedly of this opinion myfelf, I think every perfonmuflbe fo, who has paid much attention to the fubjea; but as the fame method of treatment proves equally ap- plicable, whether the difeafe has originated from the wound of a nerve or of a tendon, we do not think it neceffary to enter here into a more minute difcuffion of the question. Having already in a former feaion fhown how fuch accidents may be al- moft always avoided, we fhall now proceed to con- fider the means beft calculated for preventing the fymptoms coming to a great'height, when it is dis- covered that either from inadvertence or any other caufe the mifchief has aaually happened. Whenever a patient at the time of the operation complains of a very exquisite degree of pain, we may always be certain that fome parts have been wound- ed which ought not to have been touched. When this unfortunately happens, if proper attention be given immediately, much may be done to obviate the acceffion of thofe fymptoms which fuch a caufe will otherwife certainly induce. In order therefore to prevent as much as poflible the confequent inflammation and other fymptoms which ufually enfue, a confiderable quantity of blood fhould be immediately difcharged at the orifice juft made; the limb, for feveral days at leaft, ought to be kept in a ftate of perfea reft, care being at the fame time taken that the mufcles of the part be all pre- served in as relaxed a ftate as poflible ; the patient fhould Sea. IV. Of Bloodletting. 79 fhould be kept cool; on a low diet; and, if neceffa- ry, gentle laxatives ought to be adminiftered. By fuch management alone, the fatal fymptoms we have enumerated may frequently be prevented; and when they do occur in cafes where the above precautions have not been taken, they may be con- fidered to be as much the confequence of negligence in the fubfequent treatment, as of any thing pecu- liarly bad in the nature of the original accident. When notwithstanding, however, of the means recommended, the fymptoms, inftead of diminifhing, rather become more violent, if the lips of the ori- fice turn hard and more inflamed, if the pain be- comes more confiderable, and especially if the fwelling begins to Spread, other remedies come then to be indicated. In this ftate of the com- plaint, topical bloodletting, by means of leeches applied as near as poflible to the lips of the wound, frequently affords much relief; and when the pulfe is full and quick, it even becomes neceffary to eva- cuate large quantities of blood by opening a vein in fome other part. The external applications usually employed in this ftate of the complaint, are, warm emollient fomentations and poultices, and in similar affeaions of other parts no remedies with which we are ac- quainted would probably be found more fuccefsfulj for as warm fomentations and cataplafms tend in general very powerfully to promote the formation of pus, and as nothing would fo certainly relieve the fymptoms which ufually occur here as a free fuppuration, applications of this nature were made therefore with fome apparent propriety : But from all the experience I have had in affections of this kind fucceeding to bloodletting, I am now perfea- ly convinced, that little or no advantage is ever to be expeaed from remedies of this clafs. On the idea of being able to induce a free and kindly fuppuration on the wound, and having great rea- $o Of Bloodletting. Chap. III. fon to think, from its effeas in fimilar cafes, that all the fymptoms would be thereby rendered more mild, I muft own that in Several cafes I went into the ufe of applications of this kind to the greateft poflible degree. Unfortunately, however, the ad- vantages refulting from them never anfwered my expeaations ; fo that at laft I was induced to make trial of a very different fet of remedies. Although, at the time of thus ufing applications $f the warm emollient kind, I did not attend par- ticularly, to the caufe of their failure, yet I now think that this circumftance may be very eafily ac- counted for. The parts here principally concerned being almoft entirely membranous, and being there- fore, as we have elfewhere fhown*, incapable of yielding purulent matter, a continued courfe of warm applications, inftead of producing the wifhed for effect, muft in all probability rather tend to ag- ' gravate all the fymptoms ; for when fuch remedies do not induce a free fuppuration, the heat they convey to the parts, by aaing as a perpetual stimu- lus, muft rather tend to increafe the inflammation : And in faa we find, in the complaint now under Consideration, that all fuch applications, inftead of being produaive of any advantage, rather do harm. The heat of the part is here one of the moft diftreff- ing fymptoms ; fo that, inftead of affording relief, warm emollient applications rather tend to augment this very tormenting Source of uneafinefs. The lips of the wound, from not being capable of producing a good fuppuration, are, by the additional heat ap- plied to them through the medium of fuch appli- cations, rendered Mill more hard, fwelled, and of courfe more painful, and the fwelling of the con- tiguous parts alfo becomes more diffufed over the reft of the member. By Ambrofe Pare, Dionis, Heifter, and others, inftead of emollient remedies, oil of turpentine, tinaure * Vide Trsatife on Inflammation and its confequences. Sea. IV. Of Bloodletting. 81 tinaure of myrrh, and other heating applications, are recommended. That thefe would not prove effeaual, I cannot from experience pretend to fay ; for, fufpeaing their powerful ftimulating effeas might in cafes of this nature prove too irritating, for parts already by difeafe rendered exquisitely fenfi- ble, I have never ventured to ufe them : But I can from repeated experience affert, that cooling astrin- gent applications afford much more eafe, and, upon the whole, in all fuch ailments, prove much more effeaual, than warm emollients ; and of this clafs, the moft effeaual I have ever ufed are the faturnine applications. The parts chiefly affeaed being al- ternately covered with cloths wet with a folution of faccharum faturni, and pledgits Spread with Goulard's Cerate, are kept more cool and eafy than by any other remedy I have ever happened to ufe. In all fuch cafes, therefore, as foon as a number of leeches proportioned to the violence of the fymp- toms have been applied to the parts chiefly affeaed, and have difcharged a fufHcient quantity of blood, the fwelling ought to be covered with pieces of foft linen wet in the fatUrnine folution ; and thefe being kept constantly moift for the fpace of a few hours, fhould be fucceeded by Goulard's cerate ; and thus every part in any degree affeaed, ought to be al- ternately covered with one or other of thefe appli- cations, as long as any degree of fwelling remains. The febrile fymptoms which occur, muft at the fame time be attended to, by keeping the patient cool ; on a low diet ; preferving a lax ftate of the bowels ; and, if neceffary, farther quantities of blood ought to be evacuated. For the violence of the pain, which is fometimes fo excessive as to destroy the patient's reft entirely, opiates ought to be freely exhibited ; and when twitchings of the tendons and other convulsive Sympt ms fupervene, medicines of this kind become (till more particularly neceflary. In order, howev- L er, 82 Of Bloodletting. Chap. III. it, to have a proper influence in this ftate of the complaint, opiates ought to be given in very full dofes; otherwife, inftead of anfwering any good pur- pofe, they conftantly tend to aggravate the different fymptoms, not only by increasing the heat and reft- leffnefs, but by having an evident influence in ren- dering the fyftem more fufceptible than it was be- fore of the pain and other distressing effeas produc* ed upon it by the wound : Whenever opiates there- fore are in fuch circumftances employed, the dofes ought always to be confiderable. It often happens, however, in this very alarming diforder, either from negleaing the matter altogeth- er on the accident firft happening, as is too fre- quently the cafe, or from an improper fubfequent treatment by warm emollient applications, that opiates and all the other remedies enumerated are afterwards ufed without any advantage whatever : The fever, pain, and fwelling of the parts continu- ing, convulsive affeaions of the mufcles at laft oc- cur ; all tending to indicate the moft imminent dan- ger. In this fituation, if we have not immediate re- courfe to fome effeaual means, the patient will foon fall a viaim to the diforder ; and the only remedy from which much real advantage is to be expected, is a free and extcnfive divifion of the parts in which the orifice producing all the mifchief was at firft made. We know well from the repeated experi- ence of ages, that much more pain and diftrefs of every kind is commonly produced by the partial divifion either of a nerve or of a tendon, than from any of thefe parts being at once cut entirely acrofs. Now the intention of the operation here recom- mended, is, to produce a complete divifion of the nerve or tendon we fuppofe to have been wounded by the point of the lancet, and which we confider as the fole caufe of all the fubfequent diftrefs. The operation now recommended being amended with a good deal of pain, and being put in praaice for Sea. IV. Of Bloodletting. 83 for the removal of fymptoms from which it is per- haps difficult to persuade the patient that much danger is to be apprehended, all the remedies we have mentioned fhould be firft made trial of before it is propofed : But at the fame time, care ought to be taken, that the diforder be not allowed to proceed too far before we have recourfe to it ; for if the patient fhould be previoufly much weakened by the fevei ifh fymptoms having continued violent for any length of time, neither the remedy now propof- ed nor any other with which we are acquainted, would probably have much influence. As foon therefore as the courfe already prefcribed has been fairly tried, and is found to be inadequate to the ef- feas expeaed from it, we ought immediately to have recourfe to a free divifion of the parts chiefly affeaed ; and the manner of doing it is this : As all the contiguous parts are now fuppofed to be much fwelled and in a ftate of high inflamma- tion, it is impoffible to get proper accefs either to the nerve or tendon, cut by means of a large and extensive incision; and as this cannot be affeaed without fome rifk, of opening at leaft fome large branches of arteries, the firft ftep to be taken in this operation is, to fecure the parts, againft the effeas of fuch an occurrence, by the application of the tourniquet on the fuperior part of the member. This precaution is neceffary, not only for guarding againft the lofs of blood which would enfue from a divifion of any of the large arteries, but for prevent- ing that interruption which would otherwife be oc- casioned by a conftant difcharge of blood from the fmaller veffels during the operation. The tourni- quet indeed is more particularly requisite with a view to the prevention of this laft inconvenience, than for any other reafon ; for although it is proper by means of it to guard againft the effeas to be ex- peaed from a divifion of any of the large arteries, V 84 Of Bloodletting. Chap. III. yet with proper caution fuch an occurrence may in moft cafes be very eafily avoided. The tourniquet then, being properly applied, a tranfverfe inciiion Should be made with a common Scalpel*, upon the parts chiefly affeaed, and it ought to run in a direaion exaaiy acrofs the orig- inal orifice in the vein. In every Surgical operation, rafhnefs is undoubt- edly improper, and is often produaive of difagreea- ble confequences ; but unneceffary caution, which almoft conftantly proceeds from the operator being inaccurate and confufed in his ideas of the anatomy of the parts, generally produces fuch a degree of timidity, as ultimately proves more hurtful to the patient, than even an unufual degree of boldnefs ; for in every operation where an incifion is neceffary, if the firft cut is not made fully fufficient for the in- tended purpofe, all the fubfequent Steps of it are commonly either much retarded, or perhaps ren- dered entirely ineffeaual. In no operation whatever, is it more neceffary than in this, to aa with proper freedom in laying the parts fufficiently open by the external incifion. A fmall incifion puts the patient to nearly the fame degree of pain as a larger cut ; and it has this mate- rial inconvenience, that the furgeon cannot go on with the future fteps of the operation with fo much eafe and expedition as when an extensive opening is made at firft. The external teguments being thus freely divid- ed, the operator is now to proceed in a gradual manner, making one flight incifion after another, taking care, if poflible, to avoid wounding either the larger arteries or veins ; and he is to go on in this way,*to endeavour to detea the wounded nerve ; or if there is no poffibility of doing fo, even by great caution and nicety in wiping away with a fponge every particle of blood as he goes along, he muft flill * For the moft proper form of a 'ca!pc', fee Plate IV. Sea. IV. Of Bloodletting. 85 ftill continue to proceed in this flow gradual man- ner, till he has divided every part between the fkin and periosteum ; the tendons, larger arteries, and veins excepted. At this time the tourniquet fhould be loofened ; and in all probability the patient will be found to exprefs much Satisfaction at what has been done : For, if the part is thus divided which originally had been pricked by the lancet, and from whence all the fubfequent diftrefs proceeded, an immediate relief will now be obtained; but, on the contrary, if the pain ftill continues violent, we are thereby rendered almoft certain that the mifchief lies altogether in one or other of the tendons. An accurate exam- ination, therefore, muft now be made, by clearing the parts effeaually with a fponge ; and that ten- don lying moft contiguous to the vein in which the orifice was made, will in all probability be found either wounded, or in an evident ftate of inflam- mation ; but at all events, whether any fuch ap- pearances are deteaed or not, no hesitation what- ever fhould occur as to the propriety of dividing that tendon which lies moft contiguous to the vein ; or if two or even three tendinous extremities fhould happen to lie in the way, and to be all therefore equally liable to fufpicion, they ought all un- doubtedly to be cut entirely acrofs; and this be- ing properly effeaed, it will feldom happen that re- lief is not immediately derived from it: And at any rate, this being done, every attempt will have been made from which we could expea any benefit. The parts having been thus freely divided, the tourniquet muft now be made as flack as poflible ; and fuch arteries as have been wounded muft be properly fecured. The parts are then to be cover- ed with foft eafy dreffings, and to be afterwards treated in the fame manner as a. wound from any other caufe. The 86 Of Bloodletting. Chap. III. The remedy here recommended, if every circum- ftance is not duly attended to, may probably be confidered as fevere ; for fuch an'incifion carried to fuch a depth, muft no doubt be attended with much pain ; and the divifion of one or more tendons runs a considerable rifk of producing at leaft a partial lamenefs, and that too probably for life, of the whole member : But if we confider for a momenf the importance of the objea in view, every confid- eration of this kind muft immediately lofe all weight. It is not a trifling advantage we are in purluit of, nor can fuch a painful operation be ever , with propriety recommended except in very urgent circumftances. In the prefent inftance, however, it is clear that the patient's life is in all probability to depend on the event of this operation j fo that the moft timid operator, if he is at all capable of re- fleaion, muft admit the propriety of putting it in praaice ; and from the event of almoft every cafe of this nature, that has once advanced to the length for which we have recommended the operation in question, it may with great certainty be pronounc- ed, that every patient in fuch circumftances is in the utmoft hazard of his life ; fo that in fuch a def- perate situation, no remedy that affords any tolera- ble chance of a recovery, however painful it may be, can with propriety be condemned. From reafoning alone, we would readily con- clude, that in all fuch circumftances no remedy whatever would more probably prove fuccefsful than the operation we have now advifed ; but when the propriety of the meafure is enforced by the fuc- cefsful iflue of repeated trials, no argument adduced againft it ought to meet with much attention. In different occurrences of this kind, of lefs import- ance, I have feen much advantage enfue from the praaice here recommended ; but in one inftance, where the patient had been blooded in the median cephalic vein of the arm, the diforder had got to fuch Sea. V. Of Bloodletting. ■ 8; fuch a height, and had fo obstinately refilled every other remedy, that there was every reafon to fup- pofe death muft have enfued, had it not been for the effeas of a free and very deep incifion made into the parts affeaed. The patient, from being evidently in very great hazard, and in exquifite pain, experienced almoft instantaneous relief ; and the fwelling, which had previoufly refilled the ef- feas of every other remedy, and had even contin- ued to fpread, began foon to abate, and a perfea recovery was obtained in a much Shorter fpace of time than could have been expeaed. There is not therefore a point in furgery that I am more fatisfied of, than the propriety of fuch an operation in all fuch defperate cafes as the one we have been treating of ; but to fuch as have not hap- pened to meet with occurrences of this nature, the remedy propofed will not only appear to be too vi- olent for the difeafe, but they will alfo be induced to confider the length of difcuffion here gone into to be much more prolix than is neceffary : A An- gle inftance, however,'of the dreadful fymptoms now and then induced by accidents of this kind, will be fully fufficient to convince any man, that the fubjea now under confideration is perhaps one of the moft important in the .department of furgery. All that has hitherto been faid on bloodletting relates to the operation in general : We fhall now proceed to confider the operation as it is put in praaice in particular parts ; and firft of bloodletting in the arm. SECTION V. Of Bloodletting in the Arm* BLOODLETTING is more frequently prac- tifed on the forepart of the arm at the joint of the elbow, than in any other part of the body. The veins 88 Of Bloodletting. Chap, llh veins are in general more confpicuous in this place; but no other reafon can be affigned for this prefer-. ence: On the contrary, the near contiguity of nerves, tendons, and of large arteries, to thefe veins, makes the operation more hazardous here than in any other part. From this circumftance, therefore, I have often been induced to confider the fixing on this part for the ordinary operation of bloodletting, as a very capital error ; and the more efpecially as blood may be drawn from veins in other parts with the fame eafe as from thofe of the arm, and with much lefs danger ; particularly Srom the veins of the neck, from thofe of the under part of the legs, ankles, and feet. Bloodletting in the lower extremities has indeed in general been confined to a particular fet of dif- orders ; chiefly to thofe of females : But no good reafon, I imagine, can be affigned for this ; for it is now well known, that, in general bloodletting, the place from whence the blood is drawn, is of little importance, and that the effeas of the operation de- pend almoft folely upon the quantity of blood that is difcharged in a longer or Shorter fpace of time. Bloodletting at the arm may be fafely performed by a furgeon of fteadinefs and attention, as in the hands of fuch a man there can be little or no rifk of the lancet going deeper than the vein, and in this cafe nothing bad can enfue : But, in ordinary prac- tice, I fhould at all times rather incline to have the operation done in fome other part. It may almoft always be done with eafe in the feet and ankles ; and if the operation is properly performed, the fame quantity of blood may be drawn from the veins of thefe parts, as from veins of an equal fize in any other part of the body. But whether the idea now fuggefted fhould ever be generally adopted or not, this is fo far evident, that if the cautions we have pointed out are proper on every occafion when venaefeaion is praaifed, they Seft. V. Of Bloodletting. 89 they are neceffarily much more fo when the operation is done in the arm, where the veins lie fo very contig- uous to parts which cannot be wounded without pro- ducing very alarming fymptoms. Having already confidered with minuteriefs the various fteps of the operation of bloodletting, fo far as they relate to it in a general way; in order to avoid repetitions, nothing will now be pointed out but what is particularly required in performing this operation in the arm. In applying the ligature for the ftoppage of the cir- culation, it ought to be placed about an inch or an inch and half above the joint of the elbow : and, in order to prevent the ends of it from interfering with the lancet, the knot fhould be made on the outfide of the arm. In general, one knot might anfwer •, but a flipknot being made above the firft, renders it more fecure, and it is very eafily done. In making choice of a vein from whence blood is to be taken, the general rules we have already laid down upon this point muft be here particularly at- tended to. That vein which appears moft conspicu- ous, at the fame time that it rolls leaft under the fkin, fhould in general be fixed upon; but when an artery is found to lie immediately below, and quite contigu- ous to fuch a vein, the operator, if he is not perfectly fatisfied with his own fteadinefs, ought rather to take fome other. In general, however, the artery lies fo low in this place, that the median basilic vein, under which it commonly runs, may be opened with perfeft fafety; and as this vein in general appears more con- spicuous than any of the others, probably from the continued puliation of the artery below obftruaing in fome meafure the paflage of its contents, it is for this reafon therefore to be made choice of rather than any of the reft. % Other circumftances occur too, which render the median basilic preferable to the cephalic or median cephalic veins for the operation of blood- M letting. 9o Of Bloodletting. Chap. HI. lettmg. The former, viz. the median bafilic, is lefs deeply covered with cellular fubftance, and by lying towards the inner part of the arm it is more thinly covered with the tendinous expansion of the biceps mufcle, than either of the others. From thefe cir- cumftances the operation is always attended with lefs pain when done in this vein than in any of the others; and that confideration alone ought to have a good deal of influence in determining the choice of an op- erator. In bloodletting at this part of the arm, although the operation may be done with the right hand either upon the right or left arm of die patient •, yet it is much more neatly done by performing with the right hand upon the right arm, and with the left hand upon the left arm of the patient; and whoever attempts die contrary, muft find that it cannot be done but in a very awkward manner, as the operator can never in any other way apply his hand properly to the patient's veins. In very corpulent people, it fometimes happens, that all the larger veins lie fo deep as not to be dis- covered by the eye ; but when they are fenfibly felt by the fingers, even although they cannot be feen, they may be always opened with freedom. In a few inftances,'however, it is the cafe, that they can neither be diftinguifhed by the eye, nor by the finger : In fuch a Situation, as they may in general be met with about the wrifl, or on the back part of the hand, the ligature fhould be removed from the upper part of the arm ; and being applied about halfway between the elbow and wrifl, the veins below will thereby be brought into view ; and wherever a vein can be evi- dently obferved, there can be no danger in having re- coune:tQ the operation. SECTION. £e&. VI. Of Bloodletting. 9* SECTION VI. Of Bloodletting in the Jucular Vein. FOR inflammation of the throat, diforders of the eyes, and other affeaions of the head, when it li wifhed to evacuate blood from veflfels near to the parts af- feded, it is frequently judged proper to open the ex- ternal jugular veins -, and the manner of doing the operation is this : There is only one ramification of this vein, viz. its principal posterior branch, which can eafily ^ be brought fo much into view, as to be with propriety opened j and even this lies deeply covered with parts, not only with the fkin and cellular fubftance, but with the fibres of the platifma myoides mufcle, fo that a confiderable degree of preffure becomes neceflary in order to raife it to any height. With a view to pro- duce this, the operator's thumb is commonly advifed to be placed upon the vein, fo as to comprefs it ef- feaually about an inch or inch and half below where the opening is to be made. This, however, /eldom proves fufHcient for the purpofe, as the blood, on being flopped in its progrefs through this branch, eafily finds a paffage to the other veins j fo that un- lefs the principal vein on the other fide of the neck be alfo compreffed, the vein to be opened can never be fully diftended. In order to distend it sufficiently, a firm comprefs of linen fhould be applied on the larg- est vein on the opposite fide of the neck j and an or- dinary garter, or any other proper Hgature, being hid diredly over it, fhould be tied with a firm knot below the oppofite armpit -, taking care to make fuch a de- gree of preffure, as to put an entire ftop to the circu- lation in die vein, which in this way it is eafy to do without producing any obftruaion to the patient's breathing. 92 Of Bloodletting. Chap. III. This being done, and the patient's head being prop- erly Supported, the operator, with the thumb of his left hand, is now to make a fufHcient preffure upon the vein to be opened, and with the lancet in his right hand is to penetrate at once into the vein -, and, be- fore withdrawing the instrument, an orifice fhould be made large enough for the intended evacuation. It may be proper to obferve, that a more extenfive opening ought always to be made here than is necef- fary in the arm, otherwife the quantity of blood is generally procured with difficulty : And befides, there is not the fame neceffity for caution on this point here that there is in the arm : For it feldom or never hap- pens, that any difficulty occurs in this situation, in put- ting a ftop to the blood after the preffure is removed from the veins j all that is commonly neceffary for this purpofe being a flip of adhefive platter, without any bandage whatever. In order to bring the vein more clearly into view, fo as afterwards to be able to open it with more ex- aanefs, it has been direded, that the fkin, cellular fubftance, and mufcular fibres covering the vein, fhould be previoufly divided with a fcalpel before at- tempting to pufh the lancet into it. There is not, however,' any neceffity for this precaution, as it rarely happens that any difficulty is experienced in procur- ing a free difcharge of blood by opening the vein and teguments at once in the manner direaed : And it is here, as in every inftance where it is neceffary to take blood by a lancet, if it be not done at once, the pa~ tient is much difappointed, and is fure to attribute the failure entirely to a fault in the operator. SECTION/ Sea. VII. Of Bloodletting. 93 SECTION VII. Of Bloodletting in the Ankles and Feet. WHAT has already been faid on the operation of bloodletting, renders it quite unneceffary to be here in any degree minute. When blood is to be difcharg- ed from the veins of thefe parts, it will be readily un- derflood, that the firft ftep to be taken is a proper compreflion of the veins, fo as to produce an accumula- tion of their contents. .The ligature for this purpofe being applied with a fufficient degree of tightnefs a little above the ankle joint, all the branches of the vena faphena, both in the infide and outfide of the foot, come at once into view ; and as this vein lies every where very fuperficial, being in general covered with flcin only, wherever a proper vein appears con- fpicuoufly it may with fafety be opened. With a view to encourage the difcharge of blood, it has been a conftant praaice in bloodletting in thefe Veins, to dip the feet into warm water immediately on the orifice being made. But this is a very inaccu- rate method of proceeding, as the quantity of blood taken in this manner can never be afcertained with precision ; for the blood being all mixed with the wa- ter, the operator can never be in any degree certain as to this point: And befides, there does not appear to be any neceffity for this affiitance ; for, when the compreflion of the fuperior part of the veins is made effeaual, and the orifice is of a proper fize, I never found more difficulty in obtaining a full difcharge of blood from the veins of thefe parts, than from any other veins of the body. On removing the ligature, the difcharge is gener- ally flopped at once ; fo that a piece of adhefive plaf- ter applied over the orifice, aniwers all the purpoics of a bandage. 94 Of Bloodletting. Chap. III. Thefe are die feveral parts from whence blood is usually taken by venaefeaion ; but on fome occafions, where the contiguous parts have been particularly af- feaed, it has been diought advifable to open the veins of other parts, viz. thofe of the tongue, of the penis, the external hemorrhoidal veins, &c. When it is found neceflary to difcharge blood in this manner from the penis, the veins can be eafily brought into view by producing an accumulation of their contents in the fame manner as in other parts of the body, through the intervention of a ligature : But, in the tongue, iri the hemorrhoidal veins about the anus, and other parts where compreflion cannot be applied, all that the Surgeon can do, is, to make an orifice of a proper fize in that part of the vein which fhows itfelf moft evidently j and if a fufficient difcharge of blood is not thus produced, as there is no other method of effed- ing it, immersing the parts/ in warm water may in fuch circumftances be a ver^ neceffary meafure. Having thus confidered the various modes of dif- charging blood by venasfedion, we now proceed t©> arteriotomy. SECTION VIIL Of Arteriotomy. WHATEVER particular advantages may in the- ory have been expected from arteriotomy, and how- ever fome of its fupporters may in their clolets have recommended it, not only as being in many inftances preferable to venasiedion, but as an operation perfed- ly fafe even in veffels of confiderable fize j yet the moft strenuous friends to the pradice, have fhrunk from attempting it on the larger arteries. Inftances have no doubt occurred of large arteries having been opened without any danger enfuing ; but thefe are fo exceedingly rare, that no praditioner of experience will Sed. VIIL Of Bloodletting. 95 will be induced by them, deliberately, or from choice, to open any confiderable artery. The fmaller branch- es of arteries may indeed be opened with great fafety when they are not deeply covered, and efpecially when they lie contiguous to bones, as in fuch fituations, fo foon as the quantity of blood intended to be taken is difcharged, all farther lofs of blood may be very eafily prevented by compreflion ; but the opening of any of the larger arteries muft be always attended with fo much hazard, and the advantages to be expeded from it in preference to venasfedion are apparently fo trifl- ing, as muft in all probability prevent it from ever being carried into execution. There are very few arteries, therefore, which with any propriety can be opened ; the different branches of the temporal are the only arteries indeed from whence blood in ordinary pradice is ever taken : But, if a fanciful praditioner fhould at any time in- cline to take blood in this manner from a different part, it may be done with great fafety from one of die arteries running on each fide of the fingers. About the middle of the laft phalanx, this artery is fufficient- ly large for difcharging a confiderable quantity of blood ; in moft cafes it lies very fuperficial, and in this situation there can feldom much difficulty occur in putting a ftop to the evacuation. In performing this operation on any of the temporal branches, if the artery lies fuperficial, it may be done with one pufli of the lancet, in the fame manner as was direded for venaefedion ; but, when the artery lies deeply cov- ered with cellular fubftance, it is always neceffary to lay it fairly open to view, before making the orifice with the lancet: For in all the fmaller arteries, when they are cut entirely acrofs, there is little chance of being able to procure any confiderable quantity of blood from them : As, when divided in this manner, they retrad considerably within the Surrounding parts, which commonly puts a Hop to all further evacuation. Some 96 Of Bloodletting. Chap. Ill, Some degree of nicety is alfo neceflary in making the opening into the artery, of a proper oblique direc- tion, neither quite acrofs, nor diredly longitudinal -, for a longitudinal opening never bleeds fo freely, ei- ther in an artery or in a vein, as v/hen its diredion is fbmewhat oblique. If the opening has been properly made, and if the artery is of any tolerable fize, it will at once difcharge very freely without any compreflion •> but when the evacuation does not go on fo well as could be wifhed, the difcharge may be always affifted by comprefling the artery immediately above the orifice, between it and the correfponding veins. The quantity of blood being thus difcharged, it will commonly happen, that a very flight compreflion on thefe fmaller arteries will Suffice for putting a ftop to the evacuation. But any degree of preffure that is found neceffary may be ap- pfied he|| as in vensefedion, by means of a linen com- prefs anjjfroller •, the orifice being firft entirely clear- ed of blood, and properly covered with a bit of ad- hefive platter. If that fhould not be found to anfwer, a comprefs of linen fhould be applied over it, the whole being then to be fecured with a roller. It happens, however, in fome instances, that this does not fucceed, the orifice continuing to burft out from time to time, fo as to be produdive of much diftrefs and inconvenience. In this fituation there are three different methods by which we may with tolerable certainty put a ftop to the farther difcharge of blood, ifl. If the artery is fmall, as all the branches of the temporal arteries commonly are, the cutting it entirely acrofs, exadly at the orifice made with the lancet, by allowing it to retrad within the furrounding parts, generally puts an immediate ftop to the difcharge. id. When that is riot confented to, we have it always in our power to fecure the bleeding vefTel with a ligature, as we would do an artery -accidentally divided in any part of the body. Sea. IX. Of Bloodletting. 97 body. And, laftly, if neither of thefe methods is a- greed to by the patient, we can, by means of a con- ftant regular pressure, obliterate the cavity of the ar- tery at the place where the operation has been per- fcnv.wd, by producing an accretion of its fides. Differ- ent bandages have been contrived for comprefling the temporal artery ; but none of them anfwer the pur- pofe fo eafily and fo effedually as the one reprefented in Plate VI. fig. 3. As fome time, however, is required to obliterate the cavity of the artery, this method is accordingly more tedious : But to timid patients it generally proves more acceptable than either of the other two. Having thus finifhed the confideration of the va- rious methods employed for evacuating blood from the larger arteries and veins, we now proceed to the confideration of topical bloodletting. SECTION IX. Of Topical Bloodletting. WHEN, either from the feverity of a local fixed pain, or from any other caufe, it is wifhed to evacu- ate blood diredly from the fmall veffels of the part affeded inftead of opening any of the larger arteries or veins, the following are the different methods employ- ed for affeding it, viz. By means of leeches ; by (light icarifications with the fhoulder or edge of a lan- cet ; and, laftly, by means of an inftrument termed a Scarificator, containing from one to twenty lancets or more, fixed in fuch a manner, that when" the inftru- ment is applied to the part affeded, the whole num- ber is by means of a spring driven suddenly into it, and to a greater or leffer depth at pleafure. This being done, as it is the fmaller blood veffels only that by this operation are ever intended to be cut, and as thefe do not commonly difcharge freely, fome means N ■ or 98 Of Bloodletting. Chap. III. or other become neceffary for promoting the evacua- tion. Various methods have been propofed for this pur- pofe. Glaffes fitted to the form of the affeded parts, with a fmall hole in the bottom of each, were long ago contrived; and thefe being placed upon the fcar- ified parts, a degree of fudion was produced by a per- fon's mouth fufficient for nearly exhausting the air contained in the glafs: And this accordingly was a ftire enough method of increafing the evacuation of blood1 to a certain extent*. But, as this was attended with a good deal of trouble, and besides did not on every occasion prove altogether effedual, an exhaust- ing syringe was at laft adapted to the glafs, which did indeed anfwer as a very certain method of extrading the air contained in it: But the application of this in- ftrument for any length of time is very troublefome; and it is difficult to preferve the syringe always air tight. The application of heat to the Cupping Glafles, as they are termed, has been found to rarify the air con- tained in them to a degree fufficient for producing a very confiderable fudion. And as the inftrument in the fimple form answers the purpofe in view, with very little trouble to the operator, and as it is at all times eafily obtained, the ufe of the Syringe has therefore been laid afide. The glaffes for this pur- pofe, it is evident, muft be entire; for if there is the leaft communication allowed between their cavities and the furrounding atmofphere, no effed whatever will be produced by them. There are different methods employed for thus ap- plying heat to the cavity of the glafs. By fupporting the mouth of it for a few feconds above the flame of a taper, the air may be fufficiently rarified; but if the flame is not kept exadly in the middle, but is allow- ed to touch either the fides or bottom of the glafs, it is * Celfus, lib, 2. cap. ix. Sed. IX. Of Bloodletting. 99 is very apt to make it crack and fly in pieces. _ A more certain, as well as an eafier'method of applying the heat, is to dip a piece of foft bibulous paper in fpirit of wine, and having fet it on fire, to put it into the bottom of the glafs, and, on its being nearly ex- tinguifhed, to apply the mouth of the instrument di- redly upon the fcarified part. This, degree of heat, which may be always regulated by the fize of the piece of paper, and which it is evident ought to be always in proportion to the fize of the glafs, if long enough applied proves always fufficient for ratifying the air very effedually, and at the fame time, if done with any manner of caution, never injures the glafs in the leaft. The glafs having been thus applied, if the Gratifi- cations have been properly made, they instantly begin to difcharge freely j and as foon as the inftrument is nearly fulfof blood, it fhould be taken away, which may be always eafily done by raifing one fide of it, fo as to give accefs to the external air. When more blood is wifhed to be taken, the parts fhould be bath- ed with warm water; and, being made perfedly dry, another glafs exadly of the fize of the former fhould be inftai tly applied in the very fame manner; and thus, if the fearificator has been made to penetrate co a fuf- ficient depth, fo as to have cut all the cutaneous vef- fels of the part, almoft any neceffary quantity of blood may be obtained. It fometimes happens, however, that the full quantity intended to be difcharged can- not be got at one place: In fuch a cafe, the fcarifica- tor muft be again applied on a part as contiguous to the other as poflible ; and this being done, the appli- cation of the glaffes muft alfo be renewed as before. When it is wifhed to difcharge the quantity of blood as quickly as poflible, two or more glaffes may be applied at once on contiguous parts previoufly fcarified ; and on fome occafions, the quantity of blood is more quickly obtained when the cupping glaffes are too Of Bloodletting. Chap. III. are applied for a few feconds upon the parts to be af- terwards fcarified. The fudion produced by the glaffes may possibly have fome influence in bringing the more deep feated veffels into nearer contad with the fkin, fo that more of them will be cut by the fcar- ificator. A fufficient quantity of blood being procured, the wounds made by the different lancets fhould be all perfectly cleared of blood; and a bit of foft linen or charpie dipped in a little milk or cream, applied over the whole, is the only drefling that is neceflary. When dry linen is applied, it not only creates more uneafinefs to the patient, but renders the wounds more apt to fetter than when it has been previoufly wetted in the manner direded. Although this operation is by no means difficult in the execution, yet a good deal of pradice is neceffary to perform it in a neat and fuccefsful manner; but with a little attention, any operator may foon become fo expert, as to be able to take any quantity of blood by it that can ever be neceffary. In fome cafes of local pains, and in others where fuppuration of the part has been wifhed for, an opera- tion termed dry cupping has been propofed, and in fome inftances its advantages are faid to have proved confiderable. This consists in the application of the cupping glaffes diredly to the parts affeded, without the ufe of the fcarificator. By this means a tumor is produced upon the part; and where any advantage is to be expeded from a determination of blood to a particular fpot, it may probably be more eafily accom- plifhed by this means than by any other. In Plate VI. are reprefented a fcarificator, and dif- ferent fizes and figures of cupping glaffes, with which every operator ought to be amply fupplied, fo as to be able to adapt a glafs to every part from whence it may be proper to difcharge blood in this manner. When the part from which it is intended to produce a local Plate V. \ /, evidendy suffer more from the effeds of this kind of pressure, than either membranes, mufcles, or liga- ments. Even the bones frequently undergo a very great degree of derangement, hy the pulfation and distension of contiguous aneurifms : Sometimes they are Separated entirely from one another at the differ- ent joints : On fome occafions they are elevated much out of their natural Situations ; and in many inftances they have btjen found entirely diffolved. Occurrences Sea. I. Of Aneurifms. to? Occurrences of this kind are not common in -any of the extremities, as it is'the Strong pulfation of the aorta only, or of fome of the larger arteries at no great diftance from the heart, that we can ever fup- pofe fhould be followed by fuch confecmences. Now and then, however, fimilar effeds of an aneurifm have been obferved in the thigh, and fuperior parts of the arm ; even the bones ofthefe parts having been found much affeded by aneurifmal fwellings of the neigh- bouring arteries. The appearance and termination of encyfled aneu- rifms, are in general Very nearly as is here reprefent- ed : One exception, however, occurs in a particular fpecies of the diforder, which will afterwards be more accurately defcribed. Various caufes may be fuppofed neceffary to the produdion of encyfled aneurifms. i. We know from daily experience, that partial debility frequently oc- curs in different parts of the fyftem : Thus, there is nothing more common than cedematous fwellings of the extremities, even in constitutions otherwife healthy; and fwellings of this nature, we justly fuppofe to de- pend moft frequently on a local weaknefs of the parts in which they occur. Now, why may not a debility of a fimilar kind fall upon part of the arterial fyftem ? And, if it fhould ever do fo, we can eafily fee how in almoft every inftance it muft neceffarily terminate in aneurifmal fwellings : For the force of the heart con- tinuing the fame, if any particular part, of an artery has loft its tone, as it is thereby rendered incapable of refitting the pulfations of the heart, a yielding or dilatation of its coats, muft at thefe weakened parts naturally enfue ; and as foon as a morbid enlargement of its cavity is thus fairly commenced, as its power of resistance will of courfe proportionally diminifh, while at the fame time the vis a tergp ftill continues equally powerful, the farther increafe of the fwelling is a con- fequence that muft neceffaruy enfue. 7 This io& Of Aneurifms. Chap. IV. This caufe of the difeafe may be confidered as the moil frequent origin of aneurifms that do not evident^ ly depend upon external injuries: All fuch fwellings as occur in the courfe of the aorta, feem clearly to depend on this caufe j as is in general the cafe, indeed, with all fuch as happen internally, in whatever part of the body they may be Situated. i. The external coats of an artery being destroyed by a wound with any kind of inftrument, a partial weaknefs of the part will be thus produced; and this muft render it liable to be aded upon to advantage, by the heart and other parts of the arterial fyftem, in the fame manner as if it had been previoufly debili- tated by difeafe. In dilatations of an artery produced by this caufe} the diforder proceeds in the manner we have already defcribed. The blood, from being ftill confined; within the coats of the artery, continues to form a cir- cumfcribed tumor. In die beginning of the difeafe, the fwelfing is eafily made to disappear upon prefiure $ but on advancing farther, part of its contents become fo firm by coagulation, as to render it impoffible to diScufs it by any degree of preffure that can with pro-, priety be applied. This fpecies of the diforder rnay now and then occur from other caufes, but it is moft frequently produced by bloodletting in the arm; by the lancet, after having paffed through the vein, going fo deep as to divide the external coats of the artery. " 3. A fimilar effed has been fometimes produced, by the matter contained in neighbouring fores and aij- fcefles, proving fo corrofive as to destroy the external coverings of the contiguous arteries: When this hap- pens to occur, the fame train of fymptoms, it is evi- dent, muft Succeed as if the outer coats of the veffej had been destroyed by a lancet or any other fharp in- ftrument. 4. The bones, mufcles, ligaments, &c. with which fcrtenes are furrounded, all ferve as a fupport to thefe veffels, Sed. I. Of Aneurifms. 109 veffels, fo that it is not surprising, that the deftrudion of any of thefe parr, fhould tend to the produdion of aneurifms; and accordingly inftances have occurred, where affedions of this kind feemed evidently to de- pend on fuch a caufe; Indeed the firmnefs and fta^ bility of any fet of parts naturally connected together, depends fo much upon a found ftate of the whole, that any one of them becoming weak and difeafed, gener- ally terminates in a difeafed ftate of all or part of the remainder. In the thigh of a patient where part of the mufcles and other foft parts had been destroyed by an extenfive mortification, different aneurifmal Swell- ings occurred m the courfe of the femoral artery which had thus loft part of its fupport; and no other caufe appeared to be concerned in their produdion. ^ 5. In bloodletting at the ufual place in the arm, it was already remarked, that arteries are fometimes wounded, by the lancet pasting quite through the vein into the artery below; and when the artery namww to be diredly in contad with the vein, the blood dis- charged from the orifice made in the artery, by pair- ing directly into the vein, ferves to keep up a com- munication between the trunk of the one, and a prin- cipal branch of the other. m In this manner, a dired pafiage being produce^ between the artery and vein, and the coats of the lau ter not being sufficiently firm for refilling the smpulfe of the former, a preternatural dilatation of the vein is a confequence that muft neceffarily follow: A tumor accordingly is very foon produced, which is at nrft fmall and circumfcribed, but by degrees it extends confiderably both above and below the orifice; not only along the courfe of the vein originally wounded, but, on fome occafions, all the veins lying contiguous come to be equally diftended. . This fpecies of the difeafe was fiift accurately de- scribed by that celebrated anatomist Dodor William Hunter j and may with great propriety be termed the no Of Aneurifms. Chap. IV. Varicofe Aneurifm. Since that period it has been frequendy obferved by different praditioners; fo that tts nature is now very generally underflood. Although the coats of the artery are here fuppofed to be all cut fairly open, fb as to produce an imme- diate diffcharge of blood; yet by the blood being con- tained within the cavity of the veins, this Species of the difeafe may with equal propriety be confidered as encyfled as any of the preceding ; and as the treat- ment of it coincides much with that of other encyfled ^leurifins, the farther confideration of the fubjed could not, it was imagined, be any where more prop- erly introduced. In this fpecies of aneurifm, the fwelling is confined entirely to the veins. Soon after the injury produc- ing it has been received, the vein communicating im- mediately with the artery begins to fwell: In a gradu- al manner, this enlargement becomes more remarkar ble -y and when any confiderable anastomosis occurs near to the part affeded, between it and the contigu* oris veins, thefe alfo become much enlarged. By preff- ing upon this swelling of the veins, it may be made to difappear entirely, the blood contained in them being in part pufhed forward in its courfe towards the heart, while part of it may poflibly be forced into the artery itfelf; and, when the tumor happens to be of a con- fiderable fize, the blood, when it is thus forced out of it, is heard to make a very Singular hiffmg kind of noife. This, when it occurs, is a very charaderiftic fymptom of the difeafe ; but as it is not met with in every cafe, it becomes neceffary to point out particu- larly, Such circumftances as more certainly Serve to diftinguifh this fpecies of aneurifm. In the varicofe aneurifm there is a very singular tremulous motion diflv ^ered in the dilated vein, aN tended with a perpetual hiffing noife as if air was park ing into it through a fmall aperture.. If a firm liga- ture be appfied upon the under part of the limb, im- mediately Sed. I. Of Aneurifms. in mediately below the fwelling, and be tied fo tight* as even to slop the pulfe in the under part of the mem- ber, the fwelling in the veins, on being removed by preffure, returns inflantaneoufly on the preffure being taken off, and does not appear to be in any degree a£ feded by the ligature below ; which it undoubtedly would be, was it not for the dired communication be- tween the trunk of the artery and correfponding vein. The fwelling being removed by prefling the blood forward to the heart, and a flight preffure being made with the point of the finger on the orifice in the artery, the veins remain perfedly flaccid, without any fwelling whatever being produced, until the preffure is remov- ed from the orifice, when they fill again immediately j and this even happens, although the preflure on die artery is not fo firm as to ftop the circulation in the under part of the limb. In the fame manner, too, if the trunk of the artery be comprefied above the orifice, fo as to flop the cir- culation effedually, that tremulous motion and hiffing noife in the fwelling of the veins ceafes instantly ; and, if the veins are'now emptied by preffure., they will certainly remain fo till the compreflion upon the ar- tery is removed. On fome occafions, too, it happens, that if two Hgatures be applied, one an inch or two a- bove, and the other as much below the fwelling, and are made fo tight, as to ftop entirely the circulation of the blood in the tumor lying between them ; if die fwelling is now compreffed, all the blood contained in it is made to pafs into the opening in the artery, from whence it inftandy returns again on the preflure be- ing removed. This, however, does not always hap- pen ; and its not doing fo, is no proof whatever of that fpecies of aneurifm now under confideration "not actually existing ; for if all or feveral of the leading circumftances of the difeafe which we have juft enu7 merated ever take place, the nature of the diforder is /thereby rendered clear and evident. 112 Of jfaeurifms. Chap. IV. In addition to the other charaderiftic fymptoms of the varicofe aneurifm, it may be remarked, that when - it has continued for any length of time, fo as to have produced a coiiflderable dilatation of the veins, the trunk of the artery above the orifice generally be- comes preternaturally large, while the branches below become proportionally fmall; and of confequence, the pulfe in the under part of the member is always more feeble than in the found limb of the oppofite fide* The reafon of this laft circumstance is obvioufly this ; that the blood, by finding a dired paffage be- tween die trunk of the artery and the principal branch of the corresponding vein, paffes more readily in that Way, than by the common courfe of circulation along the uhder part of the member ; fo that the quantity of blood fent to the inferior extremities of the artery being thus much diminifhed, the pulfation produced by it must of courfe become proportionally feeble : But Why the fuperior part of the artery fhould be en- larged, by the blood pafling thus f b diredly and eafily from it into the vein, is a circumftance not fo ea- fily accounted for. The resistance to the blood pair- ing through the artery, is by this dired communica- tion between it and die vein very much diminifhed ; and this has been fuggefted as the caufe of the phe- nomenon. But this circumftance, of the resistance to the paffage of the blood being thus diminifhed, we might more readily cxped to have a very contrary effed. In other parts of the circulating fyftem, we frequently find, that refiftance to the paffage of the fluids terminates in a dilatation of the containing vef- fels ; and that fwellings thus produced, can be remov- ed by no other means than the removal of that refift- ance which firft gave riSe to them. Nothing that can be foid upon this fubjed, however, will afford much fatisfadion, as it is merely a fpeculative point; and as it can have no great influence on the pradical treat- ment Sed. I. Of Aneurifms. 113 ment of the diforder, we fhall not here attempt a far- ther investigation of it. Having thus enumerated the ordinary appearances of the different fpecies of encyfled aneurifm, together with the various caufes which are found to produce them, we fhall now proceed to defcribe the fymptoms and caufes of the cfifrufed aneurifm, and fhall conclude with the treatment of the various fpecies of the difeafe. The Diffufed, or what is commonly termed the Falfe Aneurifm, confifts in a wound or rupture of an artery, producing, by the blood thrown out from it, a Swelling, more or lefs diffufed, in the contiguous parts. Great bodily exertion has frequently proved an evident means of inducing a rupture of very confid- erable arteries feated internally : This we know to be particularly frequent in thofe of the lungs, probably from their being in that organ Surrounded with fuch foft contiguous parts as do not afford them much fup- port ; and probably from the contrary reafon, that here the arteries are more firmly supported, fuch ac- cidents feldom or never occur in the external parts, where alone they could ever become the objed of a surgeon's attention. We fhall therefore confine our defcription of this diforder, entirely to that kind of it which we know to be moft frequendy produced by a wound made directly into an artery, and which it is commonly in the power of art to relieve. When treating of the confequences of vensefedtion in the arm, wounding the contiguous artery was par- ticularly mentioned as one : In a few inftances, by the treatment then pointed out, any bad effeds which might otherwife occur from this circumftance, will be entirely prevented by the wound in the artery healing without any of the ufual confequences being produced by it. Such happy terminations, however, of this ac- cident, are exceedingly rare, and can never with any degree of certainty be depended on. P When 114 Of Aneurifms. Chap. IV. When a punctured artery refills the means em- ployed for preventing the ordinary effeds known to refult from it, it will then for certain terminate in a fwelling of the aneurifmal kind ; and the following is the ufual progrefs of the diforder. A fmall tumor, of about the fize of a horfe bean, generally rifes juft at the orifice in the artery, foon af- ter the difcharge of blood has been ftopt by compres- sion : At firft the tumor is foft, has a ftrong degree of pulfation, and yields a little upon preffure. It is never, however, fo compreffible as the fwelling of an encyfled aneurifm : For in the latter, except in the more advanced Stages of the difeafe, the blood re- mains perfedly fluid, and there is a regular circula- tion of it through the whole cyfl j whereas, in the diffufed aneurifin, the blood forming the tumor is at once extravafated ; and as in that ftate it Soon begins to coagulate, it is nqt long in acquiring a very firm degree of consistence. In this ftate of the diforder, if the Swelling be not improperly treated by the application of much pref- fure, it generally remains nearly of the fame Size for feveral weeks, when it begins gradually to increafe; and if feated in the ufual place of bloodletting in the arm, it proceeds rather farther up than the orifice, and extends rather more inwardly than towards the outer part of the arm, probably from the expansion of die biceps mufcle not being there fo firm and compad as in the external and under part of the arm. This enlargement of die tumor, too, proceeds with much more quicknefs in fome inftances than in others, and on fome occafions the fwelling is much more diffufed and extended than in others. Both thefe circumftances, it is probable, depend upon the Same cauSe. If the blood poured out by an artery, is thrown into a very lax cellular fubftance, we can eafily fuppofe, that its increafe will not only be more rapid, but that the diffufion of the tumor muft for Sea. I. Of Aneurifms. tt$ for the fame reafon be much more confiderable, than when the artery is immediately enveloped by firrn membranous or ligamentous parts, which do not fo readily yield to the impulfe of the blood. There is,| from this circumstance alone indeed, fuch a remark-' able difference in the progrefs of the diforder, that in fome inftances fwellings of this kind have been many months, nay even years, in arriving at any confidera- ble fize ; and on the contrary, fome instances have occurred of the blood from the orifice in the artery, being diffufed over the whole arm from the elbow up to the fhoulder in the Space of a few hours from the operation. A particular laxity of cellular fubftance, has un- doubtedly, in all fuch inftances, a great influence in promoting this rapid chfrufion of the extravafated blood ; but the ordinary pradice in every cafe of a wounded artery, of applying very tight compreffion, I am convinced, has alfo a very great influence in producing the fame effed. In addition to what was faid upon this point in the chapter on Bloodletting, I fhall here just obferve, that if it was poflible to pro- duce a moderate degree of preflure upon the orifice in the artery alone, fome advantage might now and then perhaps be derived from it; but in order to ap- ply a degree of compreffion fufficient for producing any influence upon the artery, the principal veins in the limb muft by the fame means be all fo much ad- ed upon, as to occasion much obftrudion to the re- turn of blood from the corresponding artery. And whatever tends in any degree to obftrud the refluent blocd, muft in an equal proportion distend the wound- ed artery, and increafe the quantity of blood which ef- capes by the orifice. Many machines have indeed been contrived for producing a partial compreflion upon the artery without affecting the reft of the limb: But however much thefe may have been extolled by their feveral inventors, yet none hitherto difcovered aniwers j 16" Of Aneurifms* Chap. IV. anfwers the purpofe of compreffing the artery, with- out at the feme time tending gready to obftrud the circulation in the veins ; infomuch that a great dea] of mifchief has on different occafions been produced by all of them. Whoever indines to have recourfe to the ufe of thefe inftruments, will find a variety of them deline- ated in Heifter's Syftem of Surgery, and in Dionis and Platner's works. Mr. Dionis, an eminent French furgeon, although in cafes of wounded arteries he recommends the ufual pra&ice of compreflion, yet relates a cafe which happened to a furgeon of his acquaintance, in which the bad effeds produced by it were fo strongly mark- ed, as muft convince any perfon of the general im-» propriety of fuch a remedy, A furgeon having in bloodletting opened an artery, the ufual method of tight compression was immedi- ately employed. By this means the difcharge of blood externally was very foon flopped : But Some blood continuing to efcape from the orifice in the ar- tery, paffed up towards the fuperior part of the arm, which it filled to fuch a degree, that on the operation for the aneurifm, which was foon found neceffary, being performed, upwards of four pounds of coagu- lated blood was difcharged from it; and for this pur- pofe it became neceffary to lay the parts open, along the whole courfe of the arm.* When, again, compreflion has not been applied to fuch tumors, unlefs there is a very unufual degree of foftnefg and laxity in the Surrounding parts, the fwek ling proceeds to increaSe in a more gradual manner : As it becomes larger, it does not, like die true aneu- rifin, become much more prominent, but rather {breads and diffufes itfelf into the Surrounding parts : By degrees it acquires a very firm consistence; and the pulfation, which was at firft confiderable, always di-, minifhes • Vid. Piohis's Cowrie of Chirurgical Operations, Sed. I, Of Aneurifms. 117 minifhes in proportion to this difference of confiftence, and to the increafe which the tumor receives in point of fize; infomuch, that in large aneurifmal Swells jngs of this kind, it fometimes happens, that the puh- fation of the artery is fcarcely perceptible. In the firft flages oSthe tumor, if the blood thrown out Srom the artery lies very deep, the fkin preferves its natural appearance, and does not change its colour till the diforder is much advanced. It frequendy hap- pens, however, that the blood is at firft thrown out with So much violence, as to get into immediate con- tad with the fkin; and when this occurs, the colour of the parts becomes instantly livid, as if tending to a ftate of mortification. A real fphacelus, indeed, has on fome occafions been induced where the extravafation of blood has been confiderable, and where the means beft Suited for its removal have either failed or have been entirely neglected, It muft be confidered, however, as a piece of un- pardonable negligence, in any practitioner, to allow a patient, from this caufe, to run that degree of rifk which always attends mortification; for the hazard at- tending the operation of the aneurifm, is in general trifling when compared with the danger accruing from an extenfive gangrene, As the tumor in this species of the difeafe proceeds to increaSe, the patient, who during the first flages oS it did not complain of much uneaiinefs, is now much diftreffed not only with fevere pains, but with fliff- nefs, want of feeling, and immobility of the whole member: And thefe fymptoms, continuing to aug- ment, if the tumor is not previoufly operated upon, the teguments at laft burft j and if die artery is of any confiderable fize, and if v/e have not immediate recourfe to effectual means for preventing it, death muft for certain enfue, in confequence of the very profufe hemorrhagy which muft thus be produced. Yarious tiS Of Aneurifms. Chap. IV. Various caufes were enumerated, as being frequently under certain circumftances productive of the encysted aneurifm ; fome variety occufs too of caufes which terminate in the diffufed species of aneurifm. I. Violent bodily exertions may be confidered as the moft frequent caufe of the rupture of arteries Situated internally -, but as thefe do not properly belong to a work of furgery, we fhall not here enter at any length into their confideration. II. The corrosive matter of fores and abfceffes, by entirely destroying the coats of a contiguous artery, may in this manner be produdive of the diffufed an- eurifm. III. The fharp fpiculae of a fradured bone being pufhed into a neighbouring artery, have, on different occafions, produced aneurifm. IV. Violent blows have been known to produce aneurifmal fwellings of this kind. This, however, can fcarcely happen in any other Situation than on the head, where the arteries He more expoSed than in other parts to the effeds of fuch injuries, by their being here very thinly covered, and from a blow in this fituation ad- ing with great advantage, by falling on the artery ly- ing almost in clofe contad with a firm hard body, the cranium. V. If the arterial covering of an encyfled aneurifm, fhould ever burft before the external teguments of the tumor, in that cafe the blood contained in it would dif- fufe itfelf into the contiguous parts; and in fuch an event, the difeafe would no doubt become a real diffufed an- eurifm. Such an occurrence, however, we have rea- fon to think, very rarely, if ever happens ; for, inftead of the internal coverings of fuch tumors firft breaking; fo far at leaft as I have had opportunities of obferving, it is the very reverfe. The fwelfing going on to in- creafe in a gradual manner, the teguments at laft be- come fo tenfe and overstretched, that they lofe their tone entirely ; the fkin becomes foft and cedematous; on Sed. I. Of Aneurifms. 119 on fome occafions, it comes into a gangrenous ftate $ and on others, although it retains its natural white colour, yet its ufual powers are as evidently destroyed as they ever are in the laft ftage of mortification. In this State it generally remains for a longer or fhorter fpace of time, according to the Strength of the arterial pulfation below. At laft, however, the fkin begins to crack, and a thin ferum oozes out; the edges of this fmall fiffure in the teguments gradually feparate from one another ; and the contents of the tumor having loft a confiderable part of their fupport, the force with which they are impelled, by degrees becomes too powerful for the remaining coverings, which accord- ingly foon burft, So as to difcharge their contents ex- ternally, without producing any effusion among the neighbouring parts. I fhould therefore Sufped, that authors in general have all along been under fome mistake on this point: The Encyfled, or True Aneurifm, as it is termed, has been always SuppoSed in its laft Stages to burft inter- nally, and fo to produce the diffufed or falfe fpecies of the difeafe ; from what has been faid, however, there is good reafon to prefume, if ever it does happen, that it is at leaft a very rare occurrence. The progrefs and termination of the encyfled aneurifm, in every cafe I have either feen, or known well authenticated, has been very nearly as we havejuft defcribed ; not by the arterial fac firft bursting, but by a rupture being pro- duced in the external teguments after they have been gready overstretched ; the blood being foon thereafter difcharged outwardly, without producing any effusion into the furrounding parts. As it has been alleged, however, by very refpedable authors, that the contra- ry does now and then happen, and as there is a pofli- bifity of this being the cafe, I could not here avoid confidering it as one of the caufes of diffufed aneurifm. VI. The moft frequent caufe, however, of this fpe- cies of aneurifm, are punctures with fharp inftruments, fuch 12a Of AneuAfrns. Chap. IV. , fuch as Swords* cudaffes, and particularly the lancet; which laft may be confidered as having been produc- i tive of at leaft nine tenths of all the aneurifmal fwell- ings that ever occurred. ; Under one or other of thefe heads, almoft every cir- cumstance may be comprehended, that can ever tend to the produdion of fitch affedions. On many occafions, it has unfortunately happened/ ] that tumors of the aneuriSmal kind having been mifc taken for abfceffes and other colledions of matter* their contents of courfe have been laid open by incif- ion. The confequences of fuch. pradice, may be more readily conceived than defcribed. With a view to prevent fuch dreadful occurrences, it would be a matter of very great importance to praditioners, to have fuch a fet of diagnostic fymptoms of aneurifm pointed out, as would with certainty determine the nature of the complaint. In the commencement of the diforder, there is in general no great difficulty in determining, as the pulfation in the tumor is com- monly fo strong, and other concomitant circumftances tend fo obvioufly to point out the nature of the difeafe, that litde or no doubt refpeding it can ever occur ; but, in the more advanced Stages of the difeafe, when the fwelling has become very large, and has loft its pulfation entirely, nothing but a very minute atten- tion to the previous history of the cafe can enable us to form a judgment of its nature. Thofe fwellings, with which aneurifms are moft likely to be confounded, are, foft encyfled tumors, fcrophulous fwellings, and abfcefles containing either purulent or other matter, Situated either immediately above, or So nearly in contad with an artery, as to re- ceive the influence of its pulfation; and when any fuch tumor happens to be nearly conneded with an artery of confiderable fize, the pulfation communicat- ed to it is frequently found to be fo very ilrong and diftind, as to render it impoffible from this circum- ftance S>ed. I. Of Aneurifms. C2i ftance alone, to form any juft idea as to the nature of its contents. But there is one Symptom which, when prefent, and when conneded with a strong pulSation in the tumor, may always lead us to determine with a great degree of certainty, that the fwelling is of the aneurifmal kind ; and it is this; the contents of the tumor being made eafily to difappear upon preffure, at the fame time that they return inftantaneoufly on the compreffion being removed. But although the prefence of this circumftance, when conneded with other charaderifc- tic fymptoms of aneurifm, may lead us to conclude, that every tumor is of that nature in which thefe hap- pen to be combined, yet the want of it ought by no means to convince us that it is not of that kind; for it very frequently happens, particularly in the advanced flages of aneurifms, that their contents become fo firm and compad that no effed whatever is produced upon them by preffure. Upon the whole, therefore, as in many inftances of this difeafe, no certainty what- ever can be obtained as to its real nature, in all fuch cafes where there is any confiderable degree of doubt, praditioners ought to lay it down as an eftabUfhed rule, to proceed as if the tumor was in reality of the aneurifmal kind. By adhering to this rule, they may perhaps in a few inftances be deterred from opening tumors of an ordinary nature, which they may after- wards find might have been laid open with fafety ; but any leffer inconvenience that may thus be occa- sioned, will be much more than compenfated, if, even in a fingle instance, a furgeon be Saved from thofe dis- agreeable reflections which he muft experience if he fhould have the misfortune to open an aneurifm in- ftead of a colledion of matter. But it is in the trunk of the body only, it muft be obferved, or in the neck, axilla, upper part of the thigh, or groin, that fo much caution in the treatment of tumors of this doubtful nature can be ever necef- Ct fary% 122 Of Aneurifms. Chap. IV. fcry. For when fituated on the under part of any of the extremities, or even on any acceflible part of the head, as in fuch cafes, when the fwellings have pro- ceeded to any confiderable fize, the operation for the aneurifrn-ought always to be performed, fo there can never in fiich circumftances be any impropriety, in having recourfe to it; for if, on laying the tumor open, it is found to be of the aneurifmal kind, we are poffeffed of a very certain method of faving the pa- tient from immediate danger, namely, the application M of the tourniquet. In forming a prognofis in cafes of aneurifm, three t important circumftances chiefly require our attention. The manner in which the difeafe appears to have been produced : The part of the body in which the fwel- ling is fituated : And laftly, the age, and habit of body, of the patient. If an aneurifm has come forward in a gradual man- ner, without any apparent injury having been done to the part, and without having Succeeded to any violent bodily exertion ; there will then be great reaSon to fuppofe, that the difeaSe depends upon fome paralytic j or other general affedion either of the trunk of the ,q veffel in which it occurs, or perhaps of the whole ar- terial fyftem ; fo that no great foccefs is to be exped- ed from any means to be attempted for the patient's relief; for the operation of the aneurifm being per- formed on the part affeded, there would be much reafon to fufped that the Same caufe which originally produced it here will have the effed of producing { fimilar dilatations in other parts of the artery : Where- as, there is great reafon to exped, if the tumor has evidendy Succeeded to a bruife, puncture, or other ex- ternal accident, that the operation will be attended with complete fuccefs, provided the circulation of the part is not altogether destroyed by the ligature to be put upon the artery. la Jed. I. Of Aneurifms. 1^5 In that fpecies of the diforder we have termed the Varicofe Aneurifm, we may generally venture on a more favourable prognosis than in any other kind of aneurifm : For it has been found in different inftances, that the aneurifmal tumor does not here proceed fo rapidly as in other cafes ; that as foon as it gets to- a* certain length, it does not afterwards acquire much additional fize ; and that any inconvenience proffucetf by it may be sustained with tolerable eafe for a great number of years. It is in this circumftance alone, We muft obferve, mat any advantage occurs in the treatment of aneu- rifms from Dr. Hunter's difcovery of this fpecies of the difeafe : And a very important difcovery it is; for by means of it, a patient may be Saved; not only from a very painful operation, but from that great degree of rifk which muft always attend* the destruc- tion of the principal artery of a limb. In the event of a fwelling of this nature arriving at fiich a Size as to produce much real diftreSs, the operation ought no doubt to be had recourfe to; but, So long as any inconvenience arifing from it can be eafily submitted to, the hazard which almoft always attends this opera- tion, and which nothing but neceffity ought to indi- cate, fhould certainly be avoided*. The * In Volume II. Art. XXXVI, of London Medical Obfervatiolis* two cafes are related of the varicofe aneurifm, by Dr. Hunto One of them at that time was of fourteen yeans ftapding, and tne other had fubfifted for five years, without being1 productive ot any neceffity for having recourfe to the operation. And in Vol. ill, ot the fame work, Art. XIII, a Similar cafe of five years duration is related by Dr. Cleghorn. , , - As it has been alleged by fome praftitioners, that no advantage refults from the difcovery of this fpecies of. aneurifm, from their fuppofing that the ufual operation is as neceflary in it as in any.oth- er variety of the difeafe ; and as in different inftances the operation lias been put in praftice even in the incipientstages of the diforder, where no real neceftity we think could occur for it ; it therefore be- comes a matter of fuch importance as to merit a very attentive ex- amination ; and it is with much fatisfaCbon that I communicate the fallowing fadts, as they tend to eftablifb as a certainty, that in the varicofe aneurifm, the ufual operation of obliterating the cavity ot the artery, is feidoro, if ever, neceflary. 124 Of Aneurifms. Chap. IV. The Situation of the tumor is the next circumftance of importance requiring our attention. When an aneurifmal fwelling is So fituated, that no ligature or effectual compreffion can be appfied for putting a ftop to the circulation in the part, if the artery be large, there would be the utmost hazard in opening it; as the patient, in all probability, would loSe more blood than his ftrength could bear, before the artery could be fecured. In aneurifms fo fituated, therefore, par- ticularly on any part of the trunk of the body, on the neck, axilla, or groin, there can never be any good foundation for a favourable prognosis. On the con- trary, indeed, in Such Situations, the greatest danger is always to be apprehended: For the force of the arte- rial pulSation will at laft certainly overcome the resist- ance of the coats with which the tumor is Surround- ed; and'in fuch an event, the moft fatal confequen- ces are to be apprehended. In the upper parts of any of the extremities, too, where In a letter I am favoured with from Dr. Hunter, he fays, " The Lady in whom I firft obferved the varicole aneurifm is now living at Bath in good health ; and the arm is in no fenfe worfe, although it is now thirty five years fince ftie received the injury." And the Doclor farther obferves, that he never heard of the operation being performed for the varicofe aneurifm that was known to be fuch. In a letter from Dr. William Cleghorn of Dublin, I am informed, that the cafe of varicofe aneurifm abovementioned, as related in the 3d Volume of London Medical Obfervations, remains nearly in the fame ftate as at the time that account of it was made out, which was at leafttwenty years ago ; only that the veins are rather more en- larged. The patient recovered, and the limb became nearly as ftrong and ferviceable as the other. The man has all along contin- ued his bufinefs of ftioemaker, and has lately recovered from a fprain in the affected arm, which he received in lifting a heavy burden. In a letter from Mr. Pott, whofe opportunities for obfervation are great, he fays that he has met with three different inftances of this fpecies of aneurifm, and that the operation never became nec- effary in any of them. Among other inftances of varicofe aneurifm which have appeared here, a young, man from Paifley, who had the misfortune to meet with it feveral years agojwas examined by different furgeonsof this place. The difeafe was very clearly marked, and no operation was advifed. In a letter from Mr. Hamilton profeffor of Anatomy in Glafgow, I am informed, that this man is now ferving in the Navy. where he undergoes great fatigue without any inconvenience from the aneurifm, although it is now of thirteen yearsitanding. Sed. I. Of Aneurifms. 125 where all the arteries of the limb are centred in one common trunk, the fuccefs of the operation for the aneurifm muft always be doubtful. But although this is undoubtedly the cafe in the fuperior parts of the extremities, yet in lower situations of the fame parts, even the principal artery of the limb may be operated upon widi a very fair profped of fuccefs; for after the great artery of a member has crept along the upper part of it, a number of fmall branches are always fent out, which anaftomozing not only with fimilar branches below, but by their means with the under part of the large artery itfelf, thefe, in the event of the common trunk from whence they Sprung being destroyed, come to dilate to Such an extent as to car- ry on the circulation in the inferior part of the Hmb much more completely than could a priori be expected. We would not naturally fuppofe, after the principal artery of a part has been obliterated, that the circula- tion would there be afterwards carried on with any tolerable degree of force ; and yet numberlefs in- stances have occurred of the large brachial arteiy be- ing completely destroyed by ligature, without be- ing produdive of much inconvenience to the parts below ; and the fame circumftance has alio happened, where the operation for the aneurifm has been per- formed on the trunk of the great femoral artery*. From * In one cafe, the operation for the aneurifm was performed with tbe moft complete fuccefs, on the trunk of the femoral artery, about two hand breadths from the groin, by the late Mr. Hamilton pro- fefror of Anatomy in Glalgow. And what rendered this cale more remarkable, was, that after the trunk of the large artery was iecui - ed by the lieatun-s, it was neceffarv to perform the operation again upon a fmall branch of an artery which had been wounded, even farther up than the principal trunk. . For fome tune after the operation the hmb remained colder than the oOier, and it was upwards of a week before any puliation could be felt in the artery at the ankle. In two months from the opera- tion, the wound was completely healed, and the circulation and heat returned : and in a fhort time thereafter the patient had lo tar re- covered the ufe of his limb, as to be able to take very violent exercile. Thefe particulars I thought it right to communicate, as the cale Of this patient is one of aver) few well authenticated mttances of 12$ Of Aneurifms* Chap. IV. From what has been faid, therefore, it muft ap- pear, that when an aneurifm is fo fituated, that com- preffion cannot be applied fo as to fecure the patient from the lofs of much blood when the artery is laid open, the operation fhould not be attempted ; and in foch cafes the prognofis ought certainly to be very unfavourable. And on the contrary, whenever an aneurifm, produced by external violence, is feated on any of the extremities, where we are fure of com- manding the circulation, the operation ought always to be undertaken, as foon as, from appearances, there is .the leaft reafon to fufped that the tumor if left to itfelf might burst fo as to endanger the Ufe of the pa- tient. The fuccefs of this operation, depending in a great degree upon the probable chance there is for the cir- culation afterwards going on in the under part of the member, our prognofis, in every cafe of aneurifm, ought tateris paribus, to be more or lefs favourable, accord- ing as the diforder is feated higher or lower on the different extremities : For the rifk of the circulation being hurt by it, is always in proportion to the height of the tumor ; according as it is higher or lower, this rifk is always increafed or diminifhed. But lastly, whether an aneurifm has been produced' by an external injury, or by the effeds of internal dif-^ ^eafe, and whatever may be its fituation, the habit of body and age of the patient ought to have a confider- able influence, in determining the opinion of practi- tioners this operation having been attempted on the femoral artery fo near to its origin ; anf Aneurifms. 119 In the diffufed or falfe aneurifm preflure has been univerfally advifed, not only with a view to diffipate the fwelling already induced, but in order to produce a reunion of the wound in the artery: We have al- ready made it appear, however, as preflure in such cafes cannot be applied to the artery alone, without at the fame time affeding the veins; and as this cir- cumstance} by producing an increafed resistance to the arterial pulfations, muft undoubtedly force an ad- ditional quantity of blood to the orifice in the artery* that therefore no advantage is to be expeded from it; but, on the contrary, that on many occafions there is reafon to fuppofe it has been produdive of bad con- fequences* But although preflure ought never to be attempted in any period of the diffufed aneurifm, yet in fome Stages of the other fpecies of the difeafe, it may be oft- en applied with advantage* In the early flages of encysted aneurifm, while the blood can be yet preffed entirely out of the fac into the artery, it often happens; by the ufe of a bandage of foft and fomewhat elaftick materials, properly fitted to the part, that much may be done in preventing the fwelling from receiving any degree of increafe ; and on fome occafions, by the continued fupport thus giv- t en to the weakened artery, complete cures have been %• at laft obtained. In aU Such cafes, therefore, particu- larly in every inftance of the varicofe aneurifm, which we have already endeavoured to fhow can very feldom require the ufual operation, much advantage may be expected from moderate preffure. But although preffure to a certain degree has fre- quendy in cafes of encyfled aneurifm proved very ufe- ful, it ought never to be carried to any great length; for tight bandages in all fuch affedions, by producing an immoderate degree of readion in the containing parts to which they are applied, inftead of anfwering the purpofe for which they were intended, have evidently R the I JO Of Aneurifms, Chap. IV. the contraryfffed. Moderate compreflion, therefore, is more eligible than a great degree of it; and indeed the gleateft length to which preflure in Such cafes ought to go, fhould be, to Serve as an eaSy Support to the parts affeded, and no farther. While at the fame time we have recourfe to this ^remedy of compreflion, other means ought not to be omitted : The patient fhould be kept upon a low diet; when neceffary, fome blood fhould be evacuated; the bowels fhould be kept lax ; and all violent exer- cife, particularly of the part affeded, fhould be care- fully guarded againft. In the latter stages of aneurifm. when much tension and pain are induced, opiates are found very ufefbl; and in many fuch ailments they are the only clafs of remedies from which any relief is ob- tained,. The treatment here recommended applies to every aneurifm not intended to be operated upon ; but it is particularly proper in all fwellings of this kind fituated on the trunk of the body and other parts where the operation is inadmiffible. In fuch fituations, indeed, an eafy fupport by means of gentle compression; a low diet in order to prevent a plethorick ftate of the vef- fels ; repeated bloodlettings when plethora adualry exifts ; a total abstinence from exercife ; and the ufe 'j0 of opiates when indicated by pain ; are the only rem- edies from which much benefit is to be expeded. Having thus pointed out the different remedies to be employed where the operation is either not confidered as proper, or where it is rendered inadmiffible by the fituation of the Swelling, we fhall now proceed to de- scribe the operation "itfelf, on the fuppofition of its having become neceffary, either when the means re- - commended for the previous treatment of the difor- der have failed, or when the tumor has made too great progrefs before proper afliftance was procured. The first ftep in this operation ought to be, to ob- tain a full command of the circulation in the inferior part Sed. 11. Of Aneurifms. 131 part of the member by means of the tourniquet ap- plied above. This being effeded, the patient fhould be fo placed, that the difeafed limb, on being stretched . on a table, is found to be of a proper height for the furgeon, who, as die operation is generally tedious, ought to be feat- ed. The limb being in this situation properly fecur- ed by an affiftant, the operator is now with a fcalpel to make an incifion through the fkin and cellular fub- ftance, along the whole courfe of the tumor, and as it is a matter of much importance to have a fufficient command of fpace for the remaining parts of the op- eration, it is even of ufe to carry this external incifion about half an inch both above and below the extrem- ities of the fwelling : No mifchief can occur from the firft incifion being made very free and extenfive ; and I have feen different inftances of the operator being much embarraffed in the fubfequent fteps of the op- eration, by too much timidity or perhaps ill judged lenity in this part of it. This being done, the ordinary method is, to pro- ceed in a very flow, cautious manner, diffeding away one layer of the membrane after another, till the ar- tery itfelf is laid bare. In this manner the operation is always rendered exceedingly tedious, as the thicknefs of parts with which the artery is found covered, is often re- aUy aftonifhing,by one layer of a membranous fobftance having been formed after another, from the coagqR- ble lymph of the blood contained in the tumor. In reality, however, there is no necessity for this degree of caution, as the operation may in the following man- ner be equally well performed, in a much fhorter fpace of time, and with much lefs pain to the patient. As foon as the external incifion has been made in the manner direded, fo as to divide the fkin and cel- lular fubftance, all the effufed blood ought to be wip- ed off by means of a fponge; and the fofteft part of the tumor being difcovered, an opening ought there to be made t3* Of Aneurifm. Chap. IV made into it with a lancet, large enough for admit* ting a finger of the operator's left hand. This being done, and the finger introduced into the cavity of the tumor, it is now to be laid open from one extremity to the other, by running a blunt pointed bistoury a- long the finger from below upwards, and afterwards from above downwards, fo as to lay the whole cavity fairly open. In Plate VII, fig. i, there is an exact ■ reprefentation of this bistoury, with a curve much lefs than ufual, as a very flight concavity anfwers every purpofe, and cuts more eafily than a greater degree of curvature. The cavity of the tumor being thus laid freely open, all the coagulated blood is now to be taken out: For which purpofe, a number of instruments, partic- ularly fcoops, have been invented by different opera- tors ; but no inftrument anfwers this intention fo ef- fedually, and with fo much eafe to the patient as the ringers of the operator ; who having in this manner removed all the coagulated blood, together with thofe tough membranous filaments commonly found here, the cavity or the tumor is now to be made quite dry, and cleared of the blood which on the firft opening of the fwelling is difcharged into it from the veins in the inferior part of the member ; and this being ef- fectually accomplifhed, the tourniquet muft be made perfedly flack and eafy, in order to difcover not only tljfartery itfelf, but the opening into it from whence fhe blood colleded in the tumor has been all along difcharged. This being done, the next point to be determined, is, the manner of preventing any farther effusion of blood into the aneurifmal fac. Various means have been propofed for accomplishing this; but the effeds of all of them may be comprehended under the three following heads. I. The effeds of ligature upon a large artery, hav- ing in fome inftances occafioned the lofs of the infe-, flor part of the member, it was long ago propofed, riwt Sed. II. Of Aneurifms. 13$ ■ « that fo foon as the opening into the artery has been difcovered, inftead of applying a hgature round it, which for certain is to obliterate its cavity entirely, a piece of agaric, vitriol, alum, or any other astringent fubftance, fhould be applied to the orifice, in order if poflible to produce a reunion of its fides. II. Upon the fame principle with the preceding, viz. that of still preferving the circulation in the ar- tery, it was feveral years ago propofed by an eminent furgeon of Newcastle, Mr. Lambert, that the orifice in the artery fhould be fecured by means of the twifted future, A fmall needle being pufhed dirough the edges of the wound, they are then direded to be drawn together by a thread properly twifted round the needle, in the manner formerly advifed when treating of fu- tures*. Strong objedions, however, occur to both of thefe methods. In the firft place, no aftringent application with which we are acquainted, is poffeffed of fuch powers as to deferve much confidence ; for, although different articles of this kind have on various occa- fions proved a means of putting a temporary ftop to hemorrhagies, yet there are very few inftances prop- erly authenticated, of their having produced any per- manent advantage. In almoft every inftance in which they have been ufed, the hemorrhagy has recurred again and again, fo as to prove very diftreffing, not only to the patient, but to the praditioner in attend- ance ; fo that from this want of fuccefs, little or no attention is now paid to remedies of this kind in ordi- nary pradice. With regard to Mr. Lambert's method of Stitch- ing the orifice in the artery, it is certainly a very in- genious propofal, and would in aU probabifity, at leaft in moft inftances, prove an effectual ftop to all farther difcharge of blood ; but as it has hitherto, at Jeaft fo far as I haye heard, been only attempted in one » yide London Medical Obfervations, Vol. II, Article XXX. 134 Cf Aneurifms. Chap. IV. one inftance, farther experience of its effeds is neceffary before it can with propriety be either rejeded or ap- proved. Butifinfucha matter reafoning may be indulged, we would beg leave to obferve, that two material objedions occur to this practice. One is, that in the operation for the aneurifm, in almoft ev- ery inftance, a very few only excepted, the artery lies at the back part of the tumor ; fo that when all the coUeded blood is removed, there is fuch a depth of wound, that it muft be always a very difficult matter, and on many occafions quite impradicable, to per- form this nice operation upon the artery, with that ,; attention and exadnefs which, in order to insure fuc- cefs, it certainly requires. It has now and then hap- ; ■pened indeed, that in this operation the artery has been found to be on the anterior part of the tumor, and in fuch a fituation the wound in it would no doubt prove acceflible enough. This, however, is a very rare occurrence, as in almoft every inftance of diffuf- ed aneurifm the artery lies at the very bottom of the tumor, the blood being colleded between it and the common teguments ; and accordingly I have feen feveral instances of this diforder, in which, after the tumor was laid freely open, the artery was found to lie fo deep as would have rendered it quite impoffible to perform this operation. But there is another very material objedion which a priori evidendy occurs to the pradice recommend- ! ed by Mr. Lambert. By introducing a needle through the fides of the orifice, and drawing thefe to- gether by a ligature, the cavity of the artery muft un- -doubtedly be at that point much diminifhed. In- deed Mr. Lambert, in his account of the cafe in -which this operation was performed, acknowledges that the diameter-of the artery was thereby diminifh- ed. .Now, the paffage of the blood being thus con- sraded at one point, the impulfe upon that particular part muft be very confiderable : So that the very "•' >* - remedy Sed. II. Of Aneurifms* 135 remedy employed for the cure of one species of aneu- rifm, will in all probability prove a very powerful ag?nt in inducing another ; for the blood being thus obftruded in its ufual courfe, there wfll be no fmall danger incurred, of a dilatation being produced im- mediately above this preternatural ftridure. I mult fairly acknowledge, however, that aU I hav» advanced, proceeds from reafoning alone, and is not as yet Supported by experience. But, if farther trials of this operation tend to fhow that the objedions now ftated againft it are not well founded, no perfon what- ever will be more ready than I fhall be in adopting it; for, if thefe objedions were removed, this operation, as propofed by Mr. Lambert, I fhould confider as deferring to be ranked among the moft important improvements which in modern times furgery has acquired. In the treatment of aneurifm by die com- mon operation, if the principal artery of a limb is concerned, fome rifk is always incurred, not only of injuring the parts below in a moft material manner, but even of destroying them entirely, by depriving them of the quantity of blood neceffary for their fup- port. Now, by Mr. Lambert's improvement, an ef- fedual ftop is put to the farther evacuation of blood, while at the fame time the circulation in the difeafed artery is ftill preferved; fo that if farther experience of its effects fhall fhow that the objedions we have ven- tured to bring againft it are not well founded, it will defervedly be admitted as a very material improve- ment in the treatment of this fpecies of aneurifm. III. Neither of the methods we have yet been con- sidering, being found eligible for fecuring the orifice in the artery, we fhall now proceed to defcribe the or- dinary manner of performing this operation, which consists in obliterating the arterial cavity entirely, by means of ligatures ; and the method of doing it is this. The artery being laid bare in the manner direded, and all the coagulated blood being carefully removed from K6 Of Aneurifms, Chap. IV, from the cavity of the tumor, on the tourniquet being How flackened fo as to bring the orifice in the artery into view, a fmall probe is to be introduced at the opening, with a view to raife the artery from the neighbouring parts, fo as that the furgeon may be en- abled with certainty to pafs a ligature round it witiV out comprehending the contiguous nerves, which in general run very near to the large blood veffels of a limb. By this precaution, the nerves may be always avoided ; and by doing fo, a great deal of mifchief may be prevented, which otherwife in all probability! might fupervene. When the diforder is fituated ei- ther in the ham, or in the ufual place of bloodletting in the arm, bending the joints of the knee or of the elbow, as it relaxes the artery a little, renders this part of the operation more eafily effeded, than when the limbs are kept fully extended. The artery being thus gently feparated from the contiguous parts, a firm, broad, waxed ligature muft be paffed round it, about the eighth part of an inch above the orifice, and another muft in the fame man- ner be introduced at the fame diftance below it. Much harm, I am convinced, has been done by paf- fing the ligature fo far distant from the orifice as is commonly pradifed ; for the rifk of losing the bene- fit of anaftomofing branches will be always increafed in proportion to the extent of artery included between the Ugatures. The eafieft method of introducing the ligatures, is by means of a blunt curved needle; and the form reprefented in PI. V, fig. 2, will be found more con- venient for this purpofe than any other. An ordina- ry fharp needle is commonly made ufe of for this pur- |K)fe; but it does not anfwer the intention fo well as the one here recommended: By the fharpnefs of its •points it is apt to injure the contiguous parts; and when the common crooked needle is ufed with a fharp *dge on its concave fide, diere muft even be fome rifk Sed. II. Of Aneurifms. m rifk of its wounding the under part of the artery, as in this situation it cannot be introduced without mak- ing part of the needle pafs quite in contad with the • coats of the artery. The blunt needle is not Uable to either of thefe objedions; and befideSj when of the form here reprefented, it is more eafily introduced than any of the needles commonly ufed in this op- eration. The ligatures being both paffed in the manner di- reded, the upper one is now to be tied with a firm- nefs fufficient for comprefling the fides of the artery. The directions formerly given for forming the knot upon bleeding veffels in other parts, will apply with equal propriety here: The ends of the Ugature ought by aU means to be twice paffed through the firft noofe, and this fhould again be farther fecured by a Angle knot made above it. By many writers on this fub- jed, a fmall bolfter of Unen is ordered to be inferted between the artery and the knot, in order to prevent the artery from being cut by it. This, however, is a very unneceffary precaution; for if the whole artery is not furrounded with the bolfter, it will be juft as liable to be cut by the ligature at any other part as where the knot is fixed: And besides, as we have al- ready very fully remarked, there is no occasion what- ever for making the Ugature fo tight on arteries as to run any rifk of dividing them; a much lefs degree of preflure than is either commonly applied, or could have any influence in hurting them, being fuUy fuffi- cient for comprefling them in the moft effectual manner. The upper ligature being thus finifhed, before the knot is paffed upon the other below the orifice, the tourniquet ought to be untwisted, in order to fee whether any blood is now difcharged by the wound in the ar- tery or not. If blood flows in any confiderable quan- tity, it affords a pleafant profped of the fuccefs with which the operation will in all probabiUty be attended, S as t3i. Of Aneurifms. Chap. IV. as it clearly fhows, that the anaftomofing branches from the fuperior part of the artery are confiderable . enough for carrying on at least a tolerable degree of circulation in the under part of the member. At the fame time, however, although blood fhould not be difcharged at this time by the orifice, we are by no means, from this circumftance alone, to defpair of fuccefs ; for it frequently happens that the operation succeeds in a very effedual manner, although no blood whatever is difcharged on the trial now recommended. But whether any blood fhould be difcharged by this trial or not, we are not to reft Satisfied with one ligature ; for unlefs the ligature below the orifice be alfo tied, there is always a rifle, on the return of cir- culation to the under part of the artery, of blood pair- ing out at the orifice : This precaution, therefore, fhould never be omitted ; it is eafily done, and it renders the patient quite fecure againft all farther evacuation of blood by the orifice. After the knots have been put upon the ligatures, thefe fhould be cut of fuch a length that their ends may lie fully out over the edges of the wound, fo that when neceffary they may be more eafily withdrawn. By way of greater fecurity in this operation, it has been advifed to infert other two ligatures quite con- tiguous to the former, and to leave them untied, fo that if any of the others fhould happen to fail its place may be immediately fupplied. There is not, however, any neceffity for this pre- caution, for, if the firft ligatures are properly applied, there can be no doubt of their anfwering the purpofe; and in cafe either one or both of them fhould give way, they can be very eafily renewed : In the mean time, too, the patient is rendered fafe against any fud- den lofs of blood by the tourniquet being left loofe upon the upper part of the member, which it ought by all means to be for feveral days after the operation, fo that, in the event of blood burfting from the wound, it Bed. II. Of Aneurifms. *39 it may be fecured by means of it, much more readily than if it depended on the tying of a ligature. The ligatures being both finifhed in the manner direded, the tourniquet is now to be made quite loofe; and if no blood is difcharged at the orifice in the ar- tery, we may then reft fatisfied that the operation is fo far properly completed. The wound is now to be lightly covered with foft lint, with a pledget of any emollient ointment over the whole ; and a comprefs of linen being applied over the dreflings, all the bandage in any degree re- quifite, is, two or three turns of a roller above, and as many below the centre of the wound, making it prefs with no more tightnefs than is abfolutely neceffary for retaining the applications we have juft now mentioned. The patient being now put into bed, the member fhould be laid in a relaxed pofture upon a pillow, and ought to be fo placed as to create the least poflible uneafinefs from the posture in which it is laid. As the operation for the aneurifm is always tedious, and produces much pain and irritation, a full dofe of laudanum fhould be given immediately on the patient being got into bed. In order to diminifh fenfibility during fome of the more capital operations, I have made different trials of opiates given about an hour before the operation : On fome occafions, this prov- ed evidently very ufeful; but on others, it feemed to do harm ; particularly in weak, nervous constitutions, in which with any dofes I ever ventured upon, the pa- tients appeared to be rendered more irritable and more foSceptible of pain, than if no opiate had been given. Immediately after this operation, however, an opiate ought to be exhibited, and repeated occasionally ac- cording to the degrees of pain and reftleflhefs. In fome few cafes of aneurifm it has happened, that the pulfe in the under part of the member has been perceptible immediately after the operation. This, however, is a very rare occurrence : For as this dif- order 140 Of Aneurifms. Chap. IV, order is feldom met with in any other part than at the joint of the elbow as a confequence of bloodlettings and as it rarely happens that the brachial artery di- vides till it paffes an inch or two below that place, the trunk of this artery is therefore moft frequendy wounded ; and when accordingly the ligature in this operation is made to obftrud the paffage of almoft me whole blood that went to the under part of the arm, there cannot be the leaft reaSon to exped any pulSation at the wrifl, till in a gradual manner the a- naftomofing branches of the artery have become fo much enlarged, as to tranfmit Such a quantity oS blood to the inferior part of the member, as is fufficient for ading as a Stimulus to the larger branches of the artery. Immediately after the operation, the patient com- plains of an unufual numbnefs or want of feeling in the whole member; and as it generally for a few hours becomes cold, it is therefore right to keep it properly covered with warm foft flannel; and in or- der to ferve as a gende ftimulus to the parts below, moderate fridions appear to be of ufe. In the fpace often or twelve hours from the operation, although the numbnefs ftill continues, the heat of the parts gen- erally begins to return; and it frequendy happens in the courfe of a few hours more, that all the inferior part of the member becomes even preternaturaUy warm. Although physiological difcuffions are not immedi- ately conneded with our fubjed, and although for that reafon we fhaU not often enter into them ; yet we can- not here avoid remarking the very clear proof which after this operation always occurs, of the great depen- dence one part of the human frame has upon another. The nerves we know to be the instruments of fenfe and motion; but on being deprived of their ufual fupport from the fanguiferous fyftem, their influence immediately diniinifhes, Immediately Sect. II. Of Aneurifms. 141 Immediately after this operation, the want of feel- ing in the parts is often very great; and in proportion as the circulation in the under part of the member be- comes more confiderable, the degree of feeUng alfo augments. If we could fuppofe the nerves of the parts below to be always included in the ligature with the artery, that numbnefs which fucceeds immediately to the operation, might be eafily accounted for ; but I have known it happen, when I was certain that nothing but the artery was fecured by the Ugature : And be- fides, although the knot upon the nerves would ac- count for the immediate lofs of fenfibility which fuc> ceeds to the operation, it would not in any degree ferve to explain the return of feeling on the circula- tion being again reftored ; for the nerve having been destroyed by the effeds of the ligature, if the want of feeUng produced here originated entirely from that circumstance, it could not be expededtobe much in- fluenced by the return of blood to the part. In die mean time the patient being properly attend- ed to as to regimen, by giving him cordials and nour- Hhing diet when low and reduced, and confining him to a low diet if his constitution is plethoric, the limb being ftill kept in an eaSy relaxed pofture, towards the end of the fourth or fifth day, Sometimes I have known it much Sooner, a very weak Seeble pulfe is discovered in the under part oS the member, which becoming stronger in a gradual manner, the patient in the Same proportion recovers the uSe and Seeling of the parts. As foon as there is an appearance of matter having formed freely about the fore, which wifl feldom hap- pen before the fifth or fixth day, an emollient poultice fhould be applied over it Sor a few hours, in order to Soften the dreffings, which may.be then removed. At this time, too, the ligaturei might be taken away; but as their continuance for a day or two longer can do no harm, it is better to aUow them to remain till I42 Of Aneurifms. Chap. IV. the fecond or third dreffing, when they either drop off of themfelves, or may be taken away with perfed fafety. The dreffings, which fhould always be of the fofteft materials, being renewed every fecond or third day according to the quantity of matter produced, the fore is in general found to heal very eafily; and al- though the patient may for a confiderable time com- plain of a great degree of numbnefs and want of ftrength in the whole courfe of the difeafed limb, yet in moft inftances a very free ufe of it is at laft obtained. It will be readily fuppofed, that the termination of this operation as we have here defcribed it, is the moft favourable that can possibly happen. In fome in- ftances, the fuccefs attending it is far from being fo complete : Inftead of a return of circulation, and of » the feeUng and ufe of the parts, they remain cold and infenfible, and no marks of returning life are perceiv- ed. From a mere want of blood, therefore, morti- fication at laft commences ; and as nature is here de- prived of one of her principal agents for the removal or feparation of gangrenous parts, I mean the efforts of the fanguiferous fyftem, whenever the parts in fuch circumftances begin to mortify, nothing can prevent their progrefs to the ultimate ftage of that malady. Whenever mortification erju'es, therefore, as a con- fequence of this operation, if the patient survives the immediate effeds of it till a feparation occurs between the healthy and difeafed parts, amputation of the member will then be the only refource. That this operation when pradifed upon the prin- cipal artery of the fuperior part of a member, does now and then terminate in this manner, no practition- er of experience will deny; but its doing fo in fome inftances, is not a fufficient reafon for rejeding it in every cafe. The event of every capital operation we know to be very uncertain; and in this, as in every other of equal importance, as we cannot in any cafe fay with precision how it is to anfwer, fo we are never to Sed. II. Of Aneurifms. 143 to put it in pradice where means of a lefs hazardous nature wUl fucceed: And on the contrary, whenever thefe are found to fail, and the patient's life comes to be in danger, it ought undoubtedly to be performed without farther hefitation. CHAP, 144 Of Herni*. Chap. V. CHAP. V. HERNIA. SECTION I. Of Hernia in General. J. HE term Hernias might with pro- priety be applied, to every fweUing occafioned by the diflodgment of parts from thofe boundaries within which in a ftate of health they are contained ; but the term in its general acceptation, impUes, a tumor pro- duced by the protrufion of fome part or parts from the cavity of the abdomen. The parts in which thefe SweUings usually appear, are the groin, fcrotum, labia pudendi, the upper and fore part of the thigh, the umbilicus, and different points between the interstices of the abdominal mufcles, If the fituation of fuch tumors be various, the vifcera which they contain are ftiU more fo ; inftances having occurred of the Stomach, uterus, liver, Spleen, and bladder, being Sound to form their contents^ But a part of the intestinal canal, or a portion of the omentum, are from experience known to be the moft frequent caufe of their formation. From thefe circumftances of fituation and contents, all the different appellations are derived by which hernias are diftinguifhed. Thus they are termed In- guinal, Scrotal, Femoral, UmbiUcal, and Ventral ■, m from Sed. I. Of Hernia. 145 from their appearing in the groin, fcrotum, thigh; navel, or beUy. When the tumor is confined to the groin, the hernia is faid to be incomplete, and is term- ed Bubonocele ; but, when the fwelling reaches down to the bottom of the fcrotum, the rupture is then fup- pofed to be complete, and the difeafe obtains the name of Scrotal Rupture* or Ofchiocele. When a portion of gut alone forms the tumor, it is called an Enterocele, or Intestinal Hernia ; when a piece of omentum only has got down, it is termed Epiplocele, or Omental Hernia ; and if both intef- tine and omentum are down, it is called an Entero- epiplocele, or Compound Rupture. As all the abdominal vifcera are apparently con- tained within the cavity of the peritonaeum, and as it was thought impoffible for that membrane to admit of fuch a degree of distention, as to furrouhd tumors containing fuch large portions of the different vifcera as are at times protruded, it was therefore commonly fuppofed, that in at leaft the greateft number of cafes of hernia, the peritonseum muft certainly be burft or ruptured ; and from this the term Rupture was in all fuch inftances fuppofed to be applied with propriety enough. The idea was farther confirmed too, from its having been obferved, that in cafes of fcrotal hernia, the protruded vifcera were in fome inftances found in contad with the testicle ; a circumftance, which it was fuppofed could not poffibly happen, if the peritonaeum had not been previoufly ruptured. Since the anatomy of thefe parts, however, was better underflood, this circumftance, of parts protrud- ed from the abdomen being on fome occafions found in contad with the testicle, is explained in a more fat- isfadory manner than on the fuppofition of a rupture of the peritonseum ; an occurrence which we fuppofe will very rarely happen, in any other manner than from external violence : But as the nature of thefe diforders cannot be properly underflood without a T previous 146 Of IlernU. Chap. V. previous knowledge of the anatomy of the parts con- cerned, it will be proper, before proceeding farther, to defcribe fuch as here become the more immediate fubjeds of operation ; and thefe are, a part of the ab- dominal mufcles ; the peritonaeum ; testicles ; and spermatic veffels. 'fhe fides and other flefhy boundaries of the ab- domen are formed by five pairs of mufcles ; viz. the redi, pyramidales, tranfverfales, obliqui interne, and obliqui externi. In fome fubjeds, the pyramidales are wanting ; and as the obliqui externi are in general thofe which in cafes of hernia come to be moft conneded with the difor- der, we fhall here confine our defcription to the anat- omy of thefe only. The obhqui externi are two thin, broad mufcles: On their posterior and upper parts they are flefhy; and tendinous on their anterior and lower parts. They originate from the eighth, ninth, and inferior ribs, by flefhy portions which intermix in a ferrated manner with corresponding parts of the latiffimus dorfi> ferratus major anticus, pedorales major, and in- tercoftales : And afterwards becoming tendinous, they form the greateft part of all the anterior Surface of the abdomen, and are inferted into the linea alba, the fpine of the os ilium, and into the os pubis. On each fide of the under part of the abdomen immedi- ately above the pubes, two openings are met with in thefe tendons, intended for the paffage of the Spermatic veffels in men, and Sor the ligaments of the womb in women. Thefe openings, or rings as they are term- ed, which feem to be formed merely by a feparation of the fibres of the tendon from one another, are of an oval figure, and have an oblique diredion from the fpine of the ileum downwards ; they are fomewhat wider above than below, and are rather of a larger fize in men than in women. Although Sed. I. Of Hernia. 147 Although thefe rings or openings have been com- monly defcribed as paffing through not only the ex- ternal oblique, but the tranfverfales and internal ob- lique mufcles alfo ; yet it is now certainly known, that it is in the tendinous parts of the external oblique mufcle only, that any fuch opening exifts. It is of fome importance to the student to be thoroughly ac- quainted with this circumftance : For, by the accounts received of it from books, one is led to fuppofe, that, inftead of one diftind paffage, there are always three to be met with here. Thefe mufcles are likewife perforated in the middle by the umbilicus, which af- fords a paffage for the conneding veffels between the mother and uterine foetus, and which is continued through life, being filled up by cellular fubftance only. From the inferior border of the tendinous part of the external oblique mufcle, a detachment of fibres is fent off, which, after affording a firm covering to the inguinal glands, are loft in the fafcia lata of the thigh: And the under edge of this tendon being folded in- wards, obtains the appearance of a ligament, which stretches from the fore part of the os ileum to the pubes, forming a kind of arch, through which pafs the great blood veffels of the lower extremity. It is this ligamentous like portion of the external oblique mufcle, which is known by the appeUation of Pou- part's or Fallopius's ligament. This paffage for the blood veffels of the thigh, being larger in women than in men, owing to the greater fize of the pelvis in the former, by which the arch formed by Poupart's ligament is rendered both long- er and wider ; fo in them the crural hernia, or that fpecies of the difeafe formed by a protrufion of parts' through this paffage, is found to occur much more frequently than in men. The internal furface of the mufcles of the abdomen, together with every other part of that cavity, is lined with a fmooth fomewhat elastic membrane, termed Peritonaeum, I Art Of Hernia. Chap. V. Peritonasum. This membrane, befides lining the cavity of the belly, furnifhes the external covering to almoft every vifcus contained in it; but, in fo fingur lar a manner are thefe coverings produced, that al- though at firft fight the different vifcera appear all to be contained within the cavity of the peritonasum, yet on a minute examination they are in reality found to lie behind it. The peritonasum, after having completely lined the cavity of the abdomen, is continued or refleded over all the vifcera, fo as to give an external covering to each. After furrounding one vifcus, it stretches a- long to the moft contiguous, forming in its courfe the Supporting membranous ligament of the liver and other vifcera ; and affording in its duplicature a kind of fupport or connedion to the various blood veffels, as they stretch along to their destined Situations in the intestinal canal and other organs. Behind the peritonasum lies a quantity of loofe cel- lular fubftance, by authors commonly termed its Ap- pendix. In fome parts this fubftance is filled with fat; and in others it is empty, and can eafily be filled with air. The testes in the foetus are, till near the period of delivery, lodged in the cavity of the abdomen, in the fame manner with the reft of the abdominal vifcera. They are fituated immediately below the kidneys, on the fore part of the pfoas mufcles, near to the upper end and by the fide of the redum, where their exter- nal covering adheres by its posterior SurSace to thoSe parts of the peritonasum on which they reft, while aU their anterior and lateral furfaces fie loofe in the ab- dominal cavity in contad with the other vifcera. Even in this fituation, however, a connedion takes place between the testes and fcrotum. This is form- ed by means of a fubftance, which runs down from the under end of the testis to the fcrotum, forming a kind of pyramidal fhaped ligament; its large bul- bous . Sed. I. Of Hernia. 149 bous head being fixed to the lower end of the teftis and epididymis and its under extremity, after having paffed through the ring i.\ the external obUqsae muf- cle, being loft in the ceUular membrane of'the fcro- tum. This ligament is evidently vafcular and fibrous, and feems in part to be compofed of the cremafler mufcle turned inwards*. All that portion of the ligament contained within the parietes of the abdomen paffes behind the perito- neum, and receives a covering from it in the fame manner with the testes and other vifcera; and the pe- ritonasum even gives a coat to a portion of the liga- ment after it has got into the groin, by pafling down along with it from the abdomen into the upper part of the inguen. At this place, viz. at the annular opening of the external oblique mufcle, the peritonasum is very loofe; and when the ligament and fcrotum are drawn downwards, an aperture is obferved from the cavity of the abdomen all around the fore part of the liga- ment, which feems ready to receive the teftis; and this aperture gradually becomes larger as the teftis de- fcends behind the peritonasum in its way to the fcro- tum. While the testicle is ready to defcend, it does not faU down, as has been commonly imagined, along the fore part of the peritonasum, between it and the other vifcera; but this ligament we have now defcribed as lying behind the peritonasum, and which is conneded with the teftis at its under and posterior parts, by di- reding or pulling it down as it were from behind, brings it in this manner along the pfoas mufcle be- tween it and the peritonasum; and that part of this membrane to which we have Shown that the testicle adheres, being neceffarily drawn along with it, a kind of pouch or bag, fomewhat refembling the finger of a glove, is thus formed by this elongation of the per- itonasum * See a very accurate account of the Anatomy of thefe paits by Mr. J, Hunter, in Dr. Hunter's Medical Cemmentarifs. 150 Of Hernia. Chap. V. konasum; the under extremity of which ftill contin- ues to fur round the teftis as it goes along, in the fame manner as it did when that vifcus rested upon the pfoas mufcle; and the entrance from the abdomen to the cavity of this procefs, is exadly at that point where the teftis was originally fituated; for it is there that this procefs commences when the teftis begins to idefcend. The peritonasum being in a foetus remarkably lax *nd dilatable at this part, and being conneded poste- riorly, as we have feen, with a quantity of very loofe cellular fubftance, its elongation produced by the de- fcent of the testicle is in this manner provided for by nature, and of courfe is eafily admitted of. It muft not, however, be fuppofed, that the teftis and peritonasum in coming down fall loofely and without connedion ; for, as they Aide down very gradually, they ftill continue to adhere to the parts lying behind them as they did when in the abdomen. The precife time at which the teftis paffes down from its original fituation in the abdomen, cannot be exactly determined; but in general, this change takes place about the eighth month. About this period, the testis furrounded with the peritoneal procefs, moves downwards till its under extremity comes into contad with the moft inferior point of the abdominal parietes; and by this time the paffage through the tendon of the external oblique mufcle is found a good deal enlarged, by the ligament of the teftis having funk downwards fo as to produce a confiderable dila- tation of it. After the teftis has paffed the tendon of the mufcle, it commonly remains for fome time by the fide of the penis, and by degrees only defcends to the bottom of the fcrotum; and even when it has got entire- ly into the fcrotum, its ligament is ftill conneded with it, and Ues immediately under it, but is fhorten- cd and compreffed. The Sfid. I. Of Hernia. t$i The procefs of the peritonasum, which we have fhown to defcend with the testicle, continues to cover it when it has reached the fcrotum : And it is this loofe covering or bag which is afterwards converted into what Anatomists term the Tunica Vaginalis Teftis ; and from the defcription we have given of it, it is evident, that the cavity of this bag muft at firft communicate with the great peritoneal cavity of the abdomen. This it accordingly does, as a probe may be paffed readily and eafily along this procefs or bag, from the belly down to the bottom of the fcrotum ; and if it be laid open through its whole length on the fore part, it will be plainly feen to be a continuation of the peritonasum ; the teftis and epididymis will be found at the lower part of it without their loofe coat the tunica vaginalis ; and as the Spermatic veffels and vas deferens, while the testicle remained in the ab- domen, entered the body of it behind, and between the refleded lamina of the peritonasum, fo here when in the fcrotum they will be found covered by the pof- terior part of the bag, in their whole courfe from the commencement of that procefs down the groin to the testicle. This paffage from the cavity of the abdomen to the fcrotum is in general very foon cut off, by a firm ad- hefion being produced between the fides of the perito- neal procefs at its upper extremity where it defcends from the abdomen. What the caufe of this adhefion may be, is uncertain ; perhaps it may proceed from fome flight degree of inflammation being excited up- on the contiguous parts by the forcible paffage of the teftis ; but whatever the caufe may be, the fad is, that at the time of birth this paffage in general is com- pletely obliterated.* • The defcent of the teftes from the abdomen is a phenomenon very difficult to account for, and its immediate caufe may probably always remain a myftery ; but their being in almoft every inftance found in the fcrotum before birth, is a clear proof of their not being forced down by the effects ot rcfpiration, as has been commonly fuppofed. 152 Of Hernia. Chap. V, It is in the neck only, however, or fuperior part of this procefs, that fuch an adhefion takes place ; as the lower extremity of the fac remains open and loofe through life, and forms, as we have already faid, the tunica vaginalis testes : The common feat of a hy- drocele. If thefmalleft attention be given to this defcription, it muft appear evident, that if immediately upon the testicle defcending from the abdomen, and before the paffage is fufficientiy contraded, any portion of the alimentary canal or omentum fhould like wife fail into the opening, fuch parts muft for certain lodge in the fame bag or covering with the teftis itfelf; and that as long as they remain there, they muft effedually pre- vent the ufual obliteration of the paffage from being accomplifhed. It is this occurrence, of a portion of fome of the abdominal vifcera getting into the tunica vaginalis "testes, which forms that fpecies of hernia to which '< new born infants are liable, termed by 1 -idler the ; Hernia Congenita. The teiftcle and protruded in- ! teftine being here in contad with one another, the tunica vaginalis teftis forms the hernial fac. . If the gut, or other parts which have fallen down, be again pufhed into the abdomen, and are retained there by proper bandages or any other means, in that cafe the paffage is foon clofed up, and no return of the diforder is obferved. But this being negleded, - and the gut being allowed to remain long down, the parts forming the paffage feem thereby in a great meafure to lofe that power of adhefion which natural- ly they are known to poflbfs; inftances of fuch cafes having occurred where no art has been able to pro- duce this wifhed for obliteration of the opening. The hernia congenita is ufually produced in the manner now defcribed ; it is probable, however, that the fame diforder may, and frequently does, occur, from this paffage between the abdomen and testicle, after Sed. I. Of Hernia. 153 after having been once clofed, being again rendered pervious, in confequence of the parts being over stretched by thofe violent fits of coughing, crying, and other convulsive affedions to which children foon after birth are now and then liable. The intestinal canal and other vifcera, being on fuch occafions pufh- ed v/ith violence againft all the containing parts, thefe will moft eafily give way where the leaft degree of firmnefs occurs; and this we may readily fuppofe will moft probably happen in fuch parts as have been moft recendy united. In this manner it is probable that the crreateft proportion of thofe cafes of hernia are produced which occur in the early months of infancy ; and I am even inclined to think, that on fome occa- fions in more advanced periods of life, the fame fpe- cies of hernia may likewife occur from the fame caufe. It is evident, then, in what manner the hernia con- genita is produced; we fhall now inquire into the caufes which tend to the produdion of hernia in its more ufual form. I. The containing parts of the abdomen we know to be elastic and compreflible; whatever, therefore, tends to produce a diminution of capacity in the cav- ity of the abdomen, muft occafion a proportional de- cree of rifle, of fome of the contained parts being pufh- ed from their natural situations. Violent coughing, crying, laughter, or great bodUy exertion, are attend- ed with more or lefs contraction of the abdominal mufcles, and particularly of the diaphragm ; and as the contradion of thefe mufcles, muft always dimin- ifh the abdominal cavity, thefe caufes therefore are frequently found to be produdive of hernia. II. Falls, in confequence of the derangement they produce in the abdominal vifcera, from the fudden and violent fhock with which they are often attended, are not unfrequently the immediate caufes of hernia. III. Perfons of a preternatural laxity of frame, are very liable to hernia. The containing parts of the 1 U abdomen 154 Of Hernia. Chap. V. abdomen, from the want of a fufficient tone and firm- j nefs, are unable in Such people to resist on all occa- sions the weight of the different vifcera; and they are therefore more particularly expofed to diforders of this kind on the flighteft application oS any of the caufes already mentioned. IV. Sprains are apt to induce a laxity of the part injured; and have therefore a fimilar influence in in- ducing hernias, with general laxity. i V. It has been obferved, that the people of thofe , countries where oil is much ufed as an article of diet, ) are .particularly liable to herniae. In whatever parts the parietes of the abdomen hap- pen to be weakest, thefe various caufes will moft read- ily operate in producing hernias; and accordingly we find, that defcents of the bowels usually occur only in fuch parts. The parts which from anatomy we would a priori fufped to be mofl liable to fuch protrusions, are, the j openings already defcribed in the external oblique . mufcles; the arch formed by Poupart's ligament for . j ' the paffage of the great blood veffels of the thigh; and the umbilicus, where the fame degree of firmnefs does • not take place as is met with in the reft of the tendi- ! nous expanfion of the abdominal mufcles. Thefe, as we have already faid, are the ufual feats of hernia; but it fometimes happens that parts of the vifcera are protruded between the interstices of the different mufcles of the abdomen: Thefe, however, are not frequent occurrences. , In whichever of thefe Situations a protrufion of any , portion of the intestines occurs, except in the cafe of the hernia congenita, as all the vifcera are contained in the manner already defcribed within the peritonas- um, a portion of that membrane, it is evident, muft be carried down together with the parts protruded; and in every fuch inftance, it is this portion of the peritonasum which goes down along with the gut that is Sed. I. Of Hernia. 155 is termed the Hernial Sac. • The fize of this fac is various in different fubjeds, and in different flages of the fame diforder. On the firft appearance of the difeafe, the fac is commonly of no very confiderable fize, as fuch fweUings feldom acquire any great bulk at once : But by re- peated defcents of the bowels, the fac comes to be pufhed lower and lower, till in fome inftances its bulk becomes very confiderable indeed ; and when in this advanced period of the diforder the fac happens to be laid open, it is found to contain either large quantities of omentum or intestine, and frequendy large portions of each. As the peritonasum has this property in com- mon with many' other parts of the body, of thicken- ing according to the degree of any gradual extenfion applied to it, fo in many inftances the thicknefs and firmnefs of the hernial fac are often really aftonifhing. Although every instance of a bowel protruded from its natural fituation is to be confidered as a derange- ment, and as fuch demands our attention, yet daily in- ftances occur, both of recent hernias, and of thofe of longer standing, in which no bad fymptoms are pro- duced by fuch protrusions of the vifcera. Thus it is well known, that hernial fwelUngs of every kind very frequendy happen, without the patient suffering in any other manner, than from the inconvenience arifingfrom the bulk of the tumors. But in general this is otherwife ; troublefome fymptoms moft fre- quendy occur ; and at all events, when the redudion of a hernia can be accomplifhed with any kind of propriety, it ought always to be effeded as quickly as poflible. All the bad fymptoms which are found to occur in herAias, proceed, as may be readily fuppofed, either from obstruction to the paffage of the feces when the intestinal canal forms the tumor, or from a ftoppage of circulation occafioned by Stricture on the prolapfed parts; 156 Of Hernia. # Chap. V. parts; fo that the attending fymptoms, it is evident, wiU be always more or lefs hazardous, according to the nature of the parts fo protruded. Thus, when a portion of the omentum alone forms the fobftance of hernial fwellings, as that organ does not appear to be fo immediately neceffary to life as many of the other vifcera, fuch tumors accordingly are not fo frequently produdive of bad confequences, at leaft they are feldom in any degree fo hazardous, as when a part of the alimentary canal is either protrud- ed by itfelf, or along with omentum. Although this, however, is in general the cafe ; yet it does fometimes happen, that even an omental rup- ture is produdive of no fmall degree of danger. When a flridure So complete upon it occurs, as to occafion a ftoppage of circulation in the protruded part, mortification with all its bad confequences muft be the certain event: And befides, the connedion be- tween the omentum, stomach, and other vifcera, is fuch, that a, fudden defcent of any confiderable portion of the former fometimes brings on vomiting, hickup, and other troublefome fymptoms : And laftly, al- though a rupture containing omentum only, might not of itfelf produce any thing bad ; yet as the paf- fage through which the omentum has flipped, muft of neceffity continue open as long as that yifcus remains protruded, and as that circumftance alone* muft as long as it continues render it more eafy for a portion of gut likewife to get down, this of itfelf is a fufficierit* reafon for bellowing even upon this fpecies of hernia our ferious attention. But whatever the contents of fuch fwellings may be, as their remaining in fome inftances for a confide erable length of time without being produdive of any bad fymptoms, muft proceed entirely from the cir- culation continuing to go freely on, notwithstanding the derangement of parts ; fo, whenever a flridure occurs upon the protruded vifcera, fufficient to pr6- * duce Sed. I. Of Hernia. «57 duce either a ftoppage of the circulation, or of the fascal contents of the alimentary canal when a portion of gut forms the difeafe, the following in general are the fymptoms which accrue. An elastic colourlefs fwelling is obferved at the part affedted ; a flight pain is felt not only in the Swelling itSelS, but, if part of the alimentary canal is down, an univerfal uneafinefs is perceived over the whole abdo- men ; and this pain is always rendered worfe by coughing, freezing, or any violent exertion. The patient complains of naufea ; frequent retching ; can get no difcharge by ftool; becomes hot and reftlefs; and the pulfe is commonly found quick and hard. If the fwelling is entirely formed by a portion of gut, and if no feces are contained in it, it has a smooth, equal surface ; and is eafily compreflible, but instant- ly returns to its former fize on the preflure being re- moved. But, in gut ruptures of long Handing, where hard feces have coUeded in the protruded bowels, con- fiderable inequalities are deteded. When again the tumor is compofed both of gut and omentum, its appearance is always unequal, it feels foft and fomewhat like dough, and of courfe is not fo elastic as when part of the intestinal tube only is down ; for although like the other it is comprefli- ble, it does not fo readily regain its former dimenfions on the preffure being taken off. It has been a received opinion, that in cafes of strangulated hernia, the fymptoms fhould be lefs vi- olent when the interline is accompanied by a portion of omentum, than when gut alone is down. Little or no difference, however, is produced by this cir- cumftance ; for when a gut becomes obftruded and inflamed, the fymptoms thereby induced are nearly the fame whether the omentum be down with it or not. It will be readily fuppofed, however, that the fymp- toms we have defcribed never can happen from the prefence of omentum only : For although flridure produced 158 Of Hernia. Chap. V* j produced on a portion of omentum, even when no « part of the intestinal tube is down, does now and then occafion a good deal of diftrefs, fuch as pain in the part, ficknefs, vomiting, and twitching pains through the whole belly ; yet no obftrudion of the gut ever occurs from this, and of courfe none of the fymptoms, \ ever prove fo alarming as when any part of the gut is concerned. If thefe fymptoms we have defcribed as being pro- duced by a Strangulated gut, are not now obviated by a removal of the flridure which produced them, the naufea and retching terminate in frequent vomitings, | firft of a bilious, and afterwards of a more fetid mat- ter ; the" belly becomes tenfe ; the pain turns more violent; a diftreffing convulfive hickup comes on; and the fever, which before was not apparendy of much confequence, now becomes very formidable, and a total want of reft with a very difagreeable ftate i of anxiety continues through the whole courfe of the complaint. Thefe fymptoms having gone on with violence for 1 fome time, the patient is at laft for the moil part Sud- denly relieved from all manner of pain, when he flat- ters himfelf every rifk is for certain over. But inftead ' of that, the pulfe, from having been hard and fre- quent, becomes languid and interrupted ; cold fweats break out over the whole body, but efpecially on the extremities ; the eyes acquire a kind of languor ; the tenfenefs of the abdomen fubfides, and the fweUing of the part affeded difappears ; the teguments covering the parts, which before were either of a natural ap- pearance, or had fomewhat of a reddifh inflamed cast, • now acquire a livid hue, and a windy crepitous feel is diftinguifhed ail over the fwelling. If the protruded parts have not of themfelves gone entirely up, their return is now in general eafily efT feded by a fmall degree of preffure ; and the patient then difcharges freely by stool; but the cold fweats increafing, Sed. I. Of Hernia. *59 increafing, the hickup turns more violent, and death itfelf is at laft ufhered in by its ufual forerunners, fub- fultus tendinum and other convulfive switchings. TheSe are the ordinary Symptoms of what is term- ed a strangulated or incarcerated gut hernia ; that is, ' when the parts protruded become fo affeded by ftric- mre, as to produce pain ; and do not either return to their natural fituations on the patient getting into a horizontal pofture, or cannot even be immediately re- placed by the hands of a praditioner. In whatever fituation a strangulated hernia occurs, the only rational method of cure, it is evident, muft confift in the removal of that flridure which prevents the return of the protruded parts. It is that which ought to be confidered as the caufe of all the mifchief ; and unlefs it be removed, nothing effedual can be done for the relief of the patient. Various methods have been attempted by pradi- tioners for the removal of flridure in thefe diforders; all-of them, however, may be comprehended under two general heads. I. Such as effed a redudion of the protruded parts, without the interpofition of incifion or any chirurgi- cal operation properly fo caUed ; and, II. A divifion of the parts producing the stricture, fo as to admit of a replacement of the deranged vif- cera, constituting what is termed the Operation for the Hernia. The remedies to be employed for accomplifhing the firft of thefe, are, a proper posture of the patient, with the manual afliftance of a praditioner ; bloodlet- ting ; ftimulating glyfters ; opiates ; the warm bath; and proper applications to the tumor itfelf As foon as the affiftance of a praditioner is defired for the removal of fymptoms in cafes of hernia, the firft circumftance requiring his attention, is, the plac - ing his patient in Such a pofture as will moft probably favour the return of the protruded parts. Thus, when i6b Of Hernia. Chap. V. the tumor is in the groin, or in the fore part of the thigh, the patient ought to be fo placed, as to raife his thighs and legs confiderably higher than his head and trunk ; that is, he fhould be placed almoft perpen- dicularly upon his head. This pofition caufes almoft the whole quantity of intestines to hang or Swing by the protruded parts, which frequently proves a means of effeding their re-' dudion. Placing the patient's feet over the fhoulders of another perfon, while at the fame time his body is aUowed'to hang downwards, and causing him in this pofture to be a good deal jolted about, has on fome occafions been known to anfwer when every other ' means has been tried in vain. For the fame reafon that in the inguinal and femor- al hernia the pofition now mentioned is more advifa- ble than any other, the ufual ered pofture of the body becomes moft proper in cafes of exomphalus or um- ' bilical rupture ; and again, a horizontal pofture is moft likely to prove ferviceable in cafes of ventral hernia. While the patient thus remains in the moft fuitable pofture according to the feat of the diforder, the fur- geon fhould at the fame time endeavour to affift the return of the gut or other parts, by means of gentle pressure with his hands and fingers. In the inguinal or fcrotal hernia, this preffure fhould be made ob- liquely upwards towards the os ileum, fo as to corref- pond as nearly as poflible with the opening in the ex- ternal oblique mufcle. In the femoral hernia, the preffure ought to be made diredly upwards ; in the umbilical hernia, downwards and backwards ; and in the ventral hernia, diredly backwards. When tumors of this nature are of any confidera- ble fize, preffure, as we have here recommended, is moil conveniently made, by grafping the fwelling with one hand from the bottom Upwards, while with the fingers of die other hand we endeavour to pufh forward Sed. I. Of Hernia. 161 forward the contents at the fuperior part of the tu- mor. Some furgeons, in pufhing forward the intef- tine, employ the fingers of both hands at the upper part of the tumor ; but the fame purpofe is anfwdred equaUy well with the index and middle finger of one hand, while the other hand is employed to great ad- vantage in pressing the under part of the tumor up- wards fo as to cooperate in this manner in the reduc- tion of the parts. It is this operation which by au- thors is termed the taxis. No defcription, however, can convey an adequate idea of the manner of per- forming it properly : for, like many other circum- ftances in the art of furgery, the knowledge of it can only be acquired by repeated experience and attentive observation : But this muft always be had in view, that any preflure that is applied, muft be of the moft # gentle kind; for every thing of this nature that cre- ates much pain, is very prejudicial, and ought by all means to be avoided. If a very moderate degree of preffure applied in the manner defcribed, does not effed a redudion of the tumor, other means muft be immediately em- ployed. Bloodletting is here a principal remedy. In no diforder is it either more indicated from appear- ances, or affords more relief in reality. . The quantity to be taken away ought in a great meafure to. be de- termined by the ftrength of the patient: But if in any cafe we can with propriety venture upon abftrad- ing large quantities" of blood from weak people, it is here ; and it is often aftonifhing to what length this evacuation is carried in cafes of hernia without being produdive of any prejudice to the fyftem. A ftate of deliquium being known to produce a more effectual relaxation of the various mufcular parts of the body, than Can be obtained by any other means, it has fometimes been advifed, in cafes of hernia, to take off fuch large quantities of blood, and in fuch a fud- X den 162 Of Hernia. Chap. V. den manner, as to produce fainting; and the pradice has now and then been attended with advantage. As an obstinate coftivenefs is commonly one of the molt alarming fymptoms of hernia, it has been a com- mon pradice to prefcribe not only a variety of ftim- ulating purgatives by the mouth, but injedions com- pofed of the moft acrid materials. From all the ex- perience, however, which I have had in diforders of this nature, I am convinced that purgatives are very feldom produdive of much good; and when they do not prove ufeful, they almost univerfally do mifchief, by increafing not only the ficknefs- at Stomach which always prevails here, but even by adding to the pain and tenfion of the tumor. I am clear, therefore, that remedies of this kind fhould not be pufhed fo far as 4 they commonly are ; and when they are applied, in- ftead of purgatives by the mouth, which always prove very naufeating, and in this ftate are ufuaUy rejeded by the stomach, I would recommend tobacco smoke thrown up in the form of injedions, as preferable to every other remedy. A variety of machines have been contrived for injeding fmoke by the anus; but none of them I have met with anfwer the purpofe ei- ther fo eafily or fo effeduaUy as the inftruments rep- refented in Plates VI, and VII. They are eafily pro- cured ; and by means of either of them, fmoke may be injeded with any neceffary degree of force. I would not have it fuppofed, however, that I rec- ommend tobacco fmoke ufed in this manner as an infallible purgative, as many have done. For the .contrary is certainly the cafe ; I have known it ufed in a great number of cafes both of hernia and ileus, and feldom with any advantage. I only advife it aa the moft effedual remedy of this kind with which I am acquainted ; and I know that the method here recommended of injeding it, is the moft effectual hitherto invented. It has been objeded to thefe in- flrumen'.s we have delineated, that we cannot when they Plate VI. I'lafp vn. *«/. 2 /V//. / Sed. I. Of Hernia. 1S3 they are employed afcertain the quantity of fmoke in- jeded. But this is a nicety of little importance ; as the rule in aU fuch cafes fhould be, to continue to throw up the fmoke, either till it has produced the wifhed for effed, till a confiderable degree of ficknefs is induced, or till the abdomen is found to be fome- what diftended by it, as in fome patients a third or even a half more may be neceffary for this purpofe than is found to anfwer in others. But although this remedy does not frequently an- fwer as a purgative, it often, both in cafes of hernia and ileus, proves a very effedual anodyne. And as we are frequently in Such cafes deprived of the advan- tage of opium, by its being rejected by the Stomach, in fuch inftances, when the pain is very fevere, it may be always employed as one of the beft means of pro- curing eafe. With the fame view as the remedy laft mentioned, acrid Suppositories, compofed of foap, aloes, and other ftimulating materials, have been recommended; and when remedies of this clafs are to be ufed, thefe may be confidered as a neceflary addition to the other pur- gatives ; but no great dependence ought ever to be placed upon them. I know, we are told that in fome cafes of hernia, the ufe of drastic purgatives has been of advantage ; but I have fo frequendy known them do harm, by increafing the naufea, pain, and inflammation of the strangulated gut, that I am under no difficulty in fay- ing that they ought feldom, if ever, to be ufed in any cafe of hernia. Opiates are here often of fervice, not only by re- Ueving pain, but as tending to relax thofe parts which, by being preternaturally conftrided, we confider as the principal caufe of the diforder. We have already obferved, however, that the conftant retching which occurs in moft cafes of hernia, prevents the exhibition of opiates by the moudi; but in fuch inftances they may > 164 Of Hernia. Chap. V. may be applied with fome advantage in the form of injedion, and their ufe may be alternated with that of tobacco fmoke as we have above recommended. ; _ Warm bathing is another remedy from which ,/.<-' as-ur much advantage has been received in diforders of this w a V\ Qt-r* nature. It is not the local application of heat, how- , , h ever, in the form of poultices and fomentations, &c. ^we mean to recommend, but the univerfal warm bath, "' in which the whole body is immerfed, and which"we know to be poffeflkLof very relaxing powers. The latter, viz. the general warm bath, by tending to relax the conftridion on the protruded inteftines,has fre- quently had a confiderable influence in promoting their replacement; but the former, viz. poultices and other ' means of applying local heat to the fwellecr parts, al- «L^> A/m though commonly employed, are undoubtedly very prejudicial. On the conflrided tendon thejTcan have no influence, for it always lies fo deep as to be out of the reach of every local application of this nature: And as the heat conveyed by fuch remedies, muft for certain tend to rarefy the contents of fuch fwellings, by their thus producing an increafe of fize in the tu- mors to which they are applied, inftead of anfwering any good purpofe/en this principle it is evident they muft do harm ; and accordingly, whoever will atten- tively obferve their effeds, will find this to be the cafe. When the external teguments are much in- flamed and painful, by their emollient properties they now and then afford fome relief; but the eafe fo ob- tained is only momentary, as the pain commonly foon becomes more violent than before they were em- ployed. Whoever attentively confiders the nature of thefe diforders, and the means generally found moft effec- tual in relieving them, wiU probably coincide with us, in imputing the bad fymptoms which occur in cafes of hernia, to a ftri£ture induced upon the protruded parts. By many, however, a contrary opinion has been Sed. I. Of Hernia. 165 been inculcated ; and the principal caufe of the vari- ous fymptoms which occur here, has been fuppofed to be, inflammation, or fome fpafmodic affedion of the protruded parts, independent of any flridure of die parts through whicji thefe have paffed. That inflammation of the prolapfed bowels, what- ever may originaUy have produced it, will m general terminate in all the fymptoms of strangulated hernia, no perfon will deny; but that flridure of the forrounding tendons is by much the moft frequent caufe of them, we think is So very obvious, as to render it quite un- neceffary here to adduce any arguments in fupport ot the opinion : This, however, we muft remark, that even on the fuppofition of the origin of aU the mil- chief lying in the protruded parts themfe ves, and not in any flridure of thofe through which they pafs, ftill the impropriety of warm applications muft be equally obvious, as by the rarefadion they induce, they muft always tend to produce an additional degree of fwell- ing in the contents of the hernial tumor. Independent, however, of any theoretical reafoning,^ I can with certainty aver, that in pradice, much more advantage is obtained in diforders of this kind, from cooling applications, than from thofe of an opposite nature?/ Indifferent inftances I have ventured onthe/ application of ice and fnow, fometimes with evioent advantage, and I never faw them do harm J But in general, the remedies I depend moft on here, are, cold saturnine folutions, and cloths kept conftantly moift with a mixture of cold water and vinegar. ^ By a proper application of one or other of the rem- edies now mentioned, or by a due combination of al of them, many cafes of hernia are relieved without anv farther affiftance : But it frequently happens, not- withstanding every endeavour, that the protruded & parts P- 559- .-45* V i66 Of Hernia. Chap. V. parts cannot be returned ; the fymptoms, inftead of abating, become more violent; and die event of the (Uieafe is of courfe rendered more doubtful. In this fituation, when no probability remains of fuccefs from the employment of the means already mentioned, the division of the parts producing the flridure is then our only refource. This, it may be remarked, is one of the nicest points in practice that a furgeon has ever to determine upon: I mean the exad period at which, in cafes of hernia, the more gehde means fhould be' laid afide, and die operation be put in pradice. If a furgeon, without having given a full trial to all the ufual remedies, fhould early in the diforder proceed to the operation, and if unfortunately it fhould not fucceed, he would probably be blamed by the friends of the patient as the principal caufe of his death ; and again, even al- lowing a recovery to be obtained, he is apt" to be blamed, not only by his brethren of the profeffion, but by the patient himfel£ for having made him suf- fer an unneceffary degree of pain. In fuch a fituation a praditioner often finds himfelf much embarraffed. But we ought to be direded here, as in every critical cafe we are employed in, by the refult of experience only ; and if this rule is, ad- hered to, inftead of tedious delays ufual in every cafe of strangulated hernia, we wiU have recourfe to the operation much earlier than is" usually done. This operation, as is the cafe indeed with every other of equal importance, is no doubt attended with , fome hazard; but the danger accruing from it has by moft praditioners been more magnified than it ought to be : For although no perfon of charader can in any cafe of hernia be fuppofed to have recourfe to it before other means have been tried; yet fo far as from experience I am able to judge, the rifle attending the diforder itfdif when the operation is long delayed, is infinitely Sed. I. Of Hernia. 167 4 infinitely greater than is commonly experienced from the effeds of the operation confidered abftradedly. Were we able from the attending fymptoms to de- termine the exad period at which the operation ought to be performed, no kind of difficulty would occur from it; but diis is fo far from being the cafe, that the moft experienced praditioner cannot with any cer- tainty decide upon it. In fome inftances, hernias with ., every fymptom of strangulation, continue for fix, eight, or ten days; and after all, the protruded parts are at length replaced, and the patient does well; and in many fimilar cafes when the operation has been the means of relief, although the very worst fymptoms have subsisted for feveral days, yet on laying the parts open, no appearances either of inflammation or gan- grene have been deteded. On other occafions, again, the fame fet of fymp- toms, with perhaps no greater degree of fwelling or tension in the parts affeded, end fatally in a very fhort fpace of time. In fome fuch inftances, the rapid progrefs of the diforder is very furprifing j the fpace of eight and forty hours hardly intervening, from its firft attack till the patient's death : I have even known the intestines become perfedly gangrenous in the courfe of one day from the time of their firft ex- pulsion. Every praditioner muft be Sensible, tiiat this is the real Slate of the question ; and if it is So, it muft at once become evident, that confiderable delays muft in fuch critical circumftances be always attended with great hazard ; and as the real danger to be appre- hended from the operation itfelf, is trifling when com- pared to the rifk which long delays usually produce, it ought therefore, I think, to be laid down as an eftab- Hfhed maxim, Always to proceed to the operation, if, in the fpace of a very few hours bloodletting and the; odier remedies pointed out, do not prove effedual. Two or three hours at farthest, even when the affift- ance i68 Of Hernia. Chap. V. ance of praditioners is early applied for, is perhaps the greatest length of time that fhould ever be con- fumed in trials of this nature. In the treatment of hernias, it is certain, that French furgeons are ufually more successful than the generali- ty either of German or Britifh praditioners ;' and So far as I know, no reafon can be affigned Sor the differ- ence, but that the French in almoft every inftance proceed more early to the operation than the Surgeons of almoft any other nation. They will thereby, no doubt, perform it frequently on patients who might have recovered by more gentle means; but any in- convenience arifing from this circumftance to a few, is fully compenfated by the number of lives which muft be faved by having recourfe to the operation in due time, and which in all probability would other- wise have been loft. Although for very obvious reafons the redudion of every cafe of hernia ought to be attempted when that can be done with propriety, yet it frequendy happens that particular circumftances occur which effectually debar us from every refource of this nature. When once a hernial fwelling has been properly reduced, it is in general in the patient's power to pre- vent any return in future, by keeping a proper ban- dage constantly applied to the opening from whence the parts were, protruded. But it often happens from inattention to this circumstance, that ruptures which might at firft have been eafily cured, come at laft by repeated defcents, and by the great quantity of parts that fall down, to form tumors of fo great a magni- tude, in proportion to the opening through which they were protruded, that no art can replace them by the more fimple means of redudion. Independently, too, of the great degree of bulk to which tumors of this kind fometimes arrive, fuch ad- hesions frequently take place, betv/een the vifcera forming the fwelling and the surrounding parts, as render Sed. I. Of Hernia. • 169 render their return altogether impradicable by any other means than by the operation. By this laft mode, indeed, almoft every cafe of hernia may be reduced ; but however neceffary this operation may be when a patient's life is in danger, as it is always at- tended with fome degree of rifk, it ought never to be put in pradice where fymptoms of strangulation do not adually exist. In that chronic State of hernia we have been juft defcribing, although by interested and ignorant prac- titioners the operation has been often propofed as a radical cure, yet no furgeon of character would in fuch circumftances ever think of advising it: He would reft fatisfied with preventing any accumulation of feces in the inteftines, by prescribing a proper diet and the occasional uSe of gentle laxatives ; and with obviating any inconvenience which might arife from the weight of the tumor, by the application of a prop- er fofpenfory bandage. By thefe means alone, large tumors of this kind are often rendered very fupportable for a great length of time ; the circulation of the parts contained in the fwelling goes freely and regularly on, as weU as the peristaltic motion of fuch parts of the alimentary ca- nal as have been protruded ; and hence it is that we have many inftances of large portions of the gut faU- ing down even to the bottom of the fcrotum, and continuing there for a great number of years without producing any interruption whatever to the ufual dif- charge by flool. In this fituation, therefore, of the difeafe, the opera- tion can never become admiflible. But although people labouring under this Slate of the complaint, do frequently enjoy very good health, and fometimes feel little or no inconvenience from the fweUing,. yet it muft not be fuppofed that their fituation is altogether free from danger : On the contrary, it is very certain, that en many occafions, fwellings of this kind which Y have 170 Of Hernia. Chap. V. have fubfifted for a great length of time without being productive of much trouble, do at laft inflame and turn painful, fo as to produce every bad symptom commonly obferved from the real strangulation of a gut. As long, too, as a fweUing of this nature re- mains, as the opening through which the parts have been protruded is thereby ^effeduaUy prevented from clofing, fo the patient is always liable to defcents of other portions of intestine which have not formerly been down, and which may be produdive of the most fatal fymptoms. But what we here wifh to eftablifh is, that till once theSe bad Symptoms do actually occur, either from an affedion of that part of the gut which has been long down, or of a portion more recently protruded,, no fuch operation as the one in question ought to be employed. All that can be done with propriety in Such caSes, is, to fit the patients with proper fufpenfory bandages; to warn them of the rifk they are conftantly liable to ; and to caution them against violent exercife, particularly leaping, and every Sudden exertion. Although with regular praditioners this circum- ftance cannot require much diScuffion, yet the public at large is much interested in it. The former know well, that the operation fhould not be performed in any cafe of hernia where violent fymptoms do not render it neceffary ; but the latter, by not being'able to judge of the various circumftances which ought to be taken into confideration, are too frequently impofed upon by that numerous fet of Itinerants with which every country abounds. By thefe a variety of opera- tions are put in pradice for performing what they call a radical cure of thefe diforders ; by which they mean to fay, a prevention of future defcents. But as no remedy with which we are acquainted, a well adapted trufs only excepted, can be depended on for this purpofe ; and as all the other means put in pradice for it, are not only painful, but in general are Sed. I. Of Hernia. 171 are produdive of much danger; the magistracy of ev- ery community ought to interfere in fuppreffing them. The objed in view by every attempt of this nature, is, either to effeduate the entire deftrudion of the her- nial fac, or at leaft to procure an accretion of its fides; , which, by fuch as are ignorant of the anatomy of the * parts concerned, has been confidered as capable of preventing any returns of the diforder in future ; and for the produdion of which, various methods have been invented. In order to effed a total deftrudion of the fac, our forefathers employed not only the knife, but the po- tential and even adual cauteries ; and with a view to produce a firm union of its fides, which was confider- ed as equaUy effedual, it was afterwards propofed by praditioners of more tender feelings, to employ the needle and ligature, or what was termed the Royal Stitch : And for the fame purpofe was invented the famous punffum aureum, which was performed-in the foUowing manner. After reducing-the inteftines into the abdomen, the fac was laid bare with a fcalpel; and a pieee of gold wire being paffed round its up- per end, the wire being likewife made to include the fpermatic cord, it was then ordered to be twifted with a pair of forceps to fuch a degree of tightnefs as to prevent the defcent of the gut, but not to inter- rupt the circulation in the fpermatic cord.* But none of thefe methods being found to anfwer, for even the adual cautery, when carried perhaps to the depth of the bone itfelf, did not fecure the pa- tient againft a return of the diforder, our modern pre- tenders have therefore ventured to improve upon the ignorance of ancient praditioners, and adually go the length of destroying not only the hernial fac, but even the teftis alfo: Without any knowledge of the anatomy of * For a more particular account of thefe various modes of prac- tice in the different kinds of hernia as employed in former times, fee the writings of Albucafis, Paulus ;*Egineta, Fab. ab AquapencHptc, Hildanus,' Parey, &c. 172 Of Hernia. Chap. V. of the parts, and having no charaders to fuffer from whatever confequences may enfue, they proceed with- out fear; and, by promifing all that patients can hope for, they are fore to be every where well received. In confequence of this, in every large town, many op- erations are performed by them; numbers according- ly are for certain mutilated, and many thereby even lofe their lives. Their method of proceeding 1$ fhortly this : They lay bare the hernial fac, and hav- \ ing reduced the prolapfed parts, a Strong ligature is paffed round both the fac and fpermatic cord, and is drawn fo tight as to destroy effedually, not only the paflage along the fac, but the cord itfelf, and of courfe the testicle. On fome occafions matters go no far- ther ; but on others, fuch a degree of inflammation has been induced, as to terminate in the patient's de- ftrudion. If any of thefe means, however, was to be produc- tive of the effed propofed, viz. the prevention of eve- ry future defcentof intestine, the rifk incurred would be in fome measure* oompenfated by the advantage received : But the fad is much otherwife ; for unlefs a trufs be kept conftantly applied, the patient contin- ues liable to a return of the diforder in nearly the fame degree as if no operation had been performed. Even the operation for the hernia itfelf does not, as has been fuppofed, fortify the parts againft a return of the diforder, the continued ufe of a trufs being juft as neceffary after that operation as if it had not taken place.' I have dwelt longer on this circumftance than may be thought neceffary by thofe who are much conver- fant in this part of practice ; but as it is certain, that even of late years much mifchief has been done by Itinerants in the various species of hernia, and as they StiU continue to impoSe upon the public, I thought it neceflary to put the unwary on their guard againft the effects of their knavery and ignorance. In Plate Vffl. 999999 Sed. I. Of Hernia. »73 In plate VIIL are reprefented a variety of trufies for different fpecies of hernia. Thofe here delineated are intended for the more usual kinds of hernia, viz. the inguinal, crural, and umbilical. When others are wanted for particular parts, fome ingenious tradefman in that line of bufinefs fhould be applied to, with di- redions to fit the inftrument with the nicest exadnefs to the parts for which it is intended. Indeed, the good effeds of every bandage for this complaint, depend fo much upon the exadnefs with which it is made to fit, that without the utmost nicety in this refped, it muft always do more harm than good; for the fole purpofe of a bandage in cafes of hernia, is to prevent effec-* tuafly the falling down of fuch parts as have been newly replaced : If therefore the pad or bolfter of the bandage does not bear properly againft the opening upon which it is placed, a portion of gut may flip out, and be thus materially injured by the preffure of the pad. I have met with different inftances of this kind, where bandages by not being exadly fitted did much mifchief; and every praditioner muft have ob- ferved them: It is therefore a matter of the firft im- portance, that tradefmen be ordered to pay much at- tention to this circumftance. Every bandage ufed for this purpofe ought to be of the fteel Spring kind; for thofe compofed of linen and other foft materials, can never be kept properly appUed. Even in infancy the fteel bandages, when properly made, are in general ufed with eafe and fafety: But at any rate, when they cannot be got to apply exadly, which in early child- hood is fometimes the cafe, no dependence ought to be placed upon any other ; for they always fret and gall the parts to which they are applied, and I nev- er knew them in any one inftance to anfwer the purpofe. Having premifed thefe general obfervations, which relate equally to every variety of the diforder, and by which frequent repetitions will be rendered unnecef- fary, 174 Of Hernia. Chap.V. fary, we fhaU now proceed to the more particular confideration of the different fpecies of hernia ; and firft of the Bubonocele. SECTION II. Of the Bubonocele. TOGETHER with the general fymptoms of Strangulated hernia which we have lately enumerated, and to which we muft here refer, the particular ap- pearances of. the bubonocele, or inguinal hernia, are, a foft fomewhat elastic fwelling, beginning in the groin, and defcending by degrees into the forotum in men, and into the labia pudendi, in women. When a portion of gut forms the tumor, it commonly feels terffe, and this always in proportion to the degree of flridure that occurs in the opening of"the~~feiicI6n ; and when any inflammation takes place, the leaft de- gree of handling or preffure always gives pain. When the hernia contains omentum only, the fweU- ing is both more foft, compreffible, and more un- equal, than when gut alone is down; the fcrotum be- comes more oblong, and of courfe lefs round, than in an intestinal hernia; and when the quantity of omen- tum is large, it is alfo much more weighty than a gut rupture of the fame fize : But in many cafes, perhaps in the greateft proportion of all hernial fwellings, the tumor is compofed of both gut and omentum ; and then the diftinguifhing fymptoms of each can never be fo clearly marked. In books, various fymptoms are enumerated, for diftinguifhing the contents of ev- ery species of hernia ; but whenever the cafe is any degree complicated, every candid praditioner muft acknowledge, that no certainty as to this point can be obtained till the tumor is fairly laid open. As there are fome diforders with which the ingui- nal and lcrotal hernia may be confounded, pradition- ers Sed. II. Of Hernia. 175 ers ought to be as much acquainted with their charac- j teriftic marks as poflible. Thefe complaints are, <~ glandular or other fwellings in the groin, whether from the venereal difeafe or any other caufe ; that fpecies of Swelling termed Hernia Humoralis; and all the different kinds of hydrocele. The venereal bubo and other fwellings in the groin, are readily diftinguifhed from hernia, not only by the abfence of aU the general fymptoms of hernia, but by that incompreffible hardnefs with which all fuch fwell- ings are aTfirst?attended, and byjthe fluduation of matter which in their Suppurated State is always ob- fervable. In the hernia humoralis, or fwelling of the testicle, the hardened and enlarged ftate of the testicle itfelf,as well as of the epididymis; their being exquifitely pain- ful to the touch; the tumor being remarkably heavy in proportion to its bulk ; and the fpermatic procefs being commonly veryTree from fwelling; are in gen- eral pretty certain marks of diftindion. In the her- nia humoralis, too, the inteftines are free and unob- ftruded, and the other general fymptoms of hernia as formerly pointed out are wanting. In the hydrocele of the tunica vaginalis testis, the tumor in general is more equal to the feel than in her- nia : In the former the fwelling always begins in the under part of the fcrotum, "anct "proceeds upwards: Whereas the very reverfe occurs in hernias. Except in cafes of very enlarged hydrocele, the fpermatic procefs is always perfedly free and diftind ; whereas in every cafe of hernia where the tumor defcends to the fcrotum, the fpermatic cord cannot in any part of its courfe be diftinguifhed.""Tn a hydrocele, a flue-. tuation of a fluid is diftinguifhable ; in a hernia it is | otherwife. From the anafarcous fwelling of the fcrotum, or hydrocele of the dartos as it is termed, hernia is very readily diftinguifhed ; and indeed the means of diftinc- \ J non 176 Of Hernia. Chap. V. tion are fo obvious, that they need not be here enu- merated ; but there is another fpecies of hydrocele* viz. the hydrocele of the fpermatic cord, which on fome occafions it is no eaSy matter to diftinguifh from hernia, and which therefore requires particular atten- tion. The fpecies of hydrocele, where the water is col- leded in one or more ceUs of the fpermatic procefs, now and then begins in the under part of the cord, and proceeds upwards; and in fuch cafes, this circumftance alone is a fufficient means of diftindion between it and hernia, in which the fwelling always proceeds from a- bove downwards ; but it fometimes happens, that the fwelling in this kind of hydrocele begins even within the opening in the abdominal mufcle, and by degrees fells downwards. In fuch inftances, it is altogether' impoffible from the ftate of the tumor merely, to fay whether it is the one difeafe or the other. The gen- eral fymptoms of hernia, fuch as pain and tension of the abdomen, obftruded inteftines, &c. muft be par- ticularly attended to: And as thefe do not occur in any fpecies of hydrocele, when they happen to take place they will commonly throw much light on the real nature of the difeafe. In fome cafes, however, thefe and every other means of diftindion are want- ing ; but even in fuch circumftances a prudent prac- titioner will never run any rifk, either of hurting his patient, or of affeding his own reputation ; which the mistaking a Hernia for a Hydrocele, and treating it as fuch, muft always do ; and which, to the diSgrace of Surgery, has on fome occafions adually happened. In all fuch cafes, where any degree of doubt occurs, as well as in every cafe of tumor in the testicle where the most perfed certainty is not obtained, and when it k neceflary to have recourfe to an operation, the furgeon ought to proceed as if the diforder was a real hernia : By doing fo, every rifk will be avoided; and on the tumor being laid cautioufly open, the true nature Sta. II. Of Hernia. ijf nature of the difeafe will be then rendered evident, and the praditioner accordingly will be at liberty to apply ^. , the means beft suited for its removal. Whereas by *" 1 adopting a contrary method, and by treating as a Hy- , I drocele what afterward turns out to be a true Hernia j ^ independent of any injury to his own reputation, he runs a very great rifk of destroying his patient. In the treatment of the Bubonocele, when the vari- ous means we have recommended when treating of hernia in general are employed without fuccefs, the furgeon is then under the neceffity of proceeding to * the operation ; and the method of doing it is this. .■. _7 J.J A table of a convenient height being placed in a CyU'1 *7 P proper light, the patient muft be laid upon it with his ao 0Jt^iC head and body almoft horizontal, whilst at the fame time his buttocks are fomewhat elevated by pillows laid beneath them. The legs hanging over the edge of the table ought to be feparated fo as to admit the operator between them ; and fhould in that fituation be firmly fecured by an affiftant on each fide, who fhould take care to keep the thighs fo far raifed, as to relax aU the abdominal mufcles. .a In order to afford as much empty Space as poffible U/wula- L for the return of the protruded parts, the patient fhould £ c ^ c£\, be advifed to empty his bladder entirely; and the £± parts having^been previoufly fhaved, an incifion muft now be made with a common round edged fcalpel through the fkin and part of the cellular fubftance,; *. beginning at kaft an inch above the fuperior end of ,fh the tumor, and continuing it down to the moft de- % (r pending part of the fcrotum. Even although the tu- mor does not extend to the bottom of the fcrotum, the parts fhould be laid open in this manner. By a free external incifion we are enabled to finifh the ope- ration with more eafe and freedom than when the firft opening is not fo large ; it does not produce much more pain than a fmall incifion; and by being contin- ued to the bottom of the fcrotum, the matter produc- Z ed kx< i73 Of Hernia. Chap. V. ed in the upper part of the fore is prevented from col- leding below, which it is otherwife ready to do. The operator now goes on to divide flowly the reft of the cellular fubftance, together with fome tendinous kiiicLoLbands, which, unlefs the diforder is very re- cent, are univerfally met with, either loofe upon the furface of the hernial fac, or, on fome occafions, pair- ing as it were into its fubftance. Even this external incifion of the teguments ought to be made with great caution : For although in by much the greateft pro- portion of hernial fwelUngs, the fpermatic veffels lie behind the protruded parts, yet on fome occafionti they have been found on the anterior part of the tu- mor ; fo that in order to avoid the rifk of wounding them, as foon as the fkin is divided the remainder of the operation ought to be done in the moft cautious manner, care being taken to avoid every large blood veffel that makes its appearance. This circumftance of the prolapfed parts getting \down behind the spermatic veffels, has never, So far as I know, been taken notice of in books; it muft there- fore be a very rare occurrence. As I met with it, however, in one cafe, where the fad was exceedingly evident, the poffibility of its happening I have there- fore no reafon to doubt. If we attend only to the ufual conformation of thefe parts, the hernial fac, we would fay, ought never to get behind the fpermatic cord : But we know weU, that in no part of the hu- ' man body is nature more apt to defert her ordinary \ courfe, than in fome circumftances relating to the tef- C^ ticks and their blood veffels. We have already ob- 'ferved, that till near the period of delivery, the testicles continue in the abdomen ; and about that time, fall down in a gradual manner to the fcrotum. Many in- ftances, however, occur, of both testes remaining in the abdomen through life : Sometimes one remains, and the other falls into the fcrotum. On other occa- fions, one or both fall into the groin, and never pro- ceed Sed.lL Of Hernia. 17$ ceed farther; a circumftance which every young prac- (- titioner fhould be aware of, as inftances have occurred y / of a testicle remaining in the groin being mistaken for ' a hernia, and of much pain and diftrefs being pro- duced by different attempts made for their redudion. Now, if fuch varieties as thefe occur in the mechanifm of thefe parts, why may not nature in fome inftances produce fuch a conformation as may, in the event of a hernial fac falUng into the fcrotum, bring the fper- matic cord, and even the testicle itfelf, into a fituation anterior to the protruded parts ? I fhall not here enter into the difcuffion of the manner in which fuch a cir- cumftance may be produced ; but, as I am certain that the fad has happened, and as it may therefore occur again, I confider it as an additional argument for the propriety of dividing the hernial fac in the cau- tious manner here direded*. # ; In making this first incifion of the fkin, it is ufual 1 to do it by pinching up the teguments, and then di- viding them with a fcalpel; but no furgeon of fteadi- nefs and dexterity wiU ever think it neceflary to pro- ceed in this manner: For this incifion of the fkin is done with much more neatnefs, and with equal fafety, by the operator grafping the tumor with his left hand, in fuch a manner as to render the teguments on the anterior part of it as tenfe as poflible, while with the fcalpel in his right hand he divides the fkin from one end of the fwelling to the other. The divifion of the fkin and cellular lubftance be- ing continued in the manner direded till the fac is laid bare, an opening muft be made in it fo as to bring its contents into view; and die moft fafe place ; £ for fuch ah opening is, not about the middle of the tumor, as is commonly aTreded, but as near to the under * Since this went to the prefs, I find that a fimilar inftance is re- corded by Le Dran, in his Treatifc on Ruptures of the fpermatic vef- fels having been found on the anterior part of a bubonocele.-S ch a fituation, therefore, of thefe veffels, is perhaps more frequent than is commonly imagined. i8o Of Hernia. Chap.V, under point of it^as poflible: It is here done with as much eafe as Tn any other p*rt; and befides, the gut is feldom if ever found juft at the bottom of the fac, which is commonly occupied with a quantity of bloody ferum ; fo that the rifk of wounding it there is much lefs than in any other part of the fwellingl . In making this perforation into the fac consists the great* eft nicety in the operation, the utmost caution being neceffary to avoid wounding the parts protruded from the abdomen. Good eyes and a Steady hand are in no operation more requisite than in this : With thefc^ any praditioner acquainted with the anatomy of the parts may be fore of doing the operation properly, and without them the beft anatomist muft undoubt- edly go wrong. With the fame fcalpel that divided the fkin and cel- lular fubftance, the operator muft proceed flowly, di- viding one fibre of the fac after another, till there is reafon to think that the whole fubftance of it is cue through. This may he always difcovered by means of the blunt end of a probe : If it paffes in eafily, we may conclude with certainty that the fac is divided j and if it does not, the incifion muft be continued in the fame gradual manner fomewhat farther, when the fame trial with the probe muft be again made. In profecuting this divifion of the fac, a good deal of affiftance is obtained from the ufe of a fmaU fharp pointed diredory, open at the extremity, as is repre- sented in Plate IX, fig. 3. By pufhing the end of this inftrument below fome of the fibres of the fac, they are thereby feparated from the parts underneath, and may be thus divided with more fafety than in any other manner ; and in the fame way the remaining parts of the fac muft be divided, till this part of the operation is finifhed*. In * In the 4th Volume of Memoirs of the Paris Academy of Sur- gery, there is a very ingenious paper on Hernia? by Monfieur Louis. iiMt although there are many ufeful obfervations communicated in this Seft. II. Of Hernia. 181 In almoft every cafe of hernia where the tumor is confined to the groin, and even where the fwelling ex- tends to the fcrotum if the parts are recently protrud- ed, the hernial fac is found very thin, and in fuch cafes is always foori'cutlhrough ; but it is neceffary for the information of young praditioners, to obferve, that in hernial fweUings of long Standing, the fac frequently becomes fo very thick, as to require much more dif- fedion than beginners commonly exped : By going on, however, in the cautious manner we have direded, every rifk of wounding any material part may be a- voided, . As foon as an opening is made quite through the fac, a circumftance of which we are made certain, as was already remarked, by a probe paffing eafily in, it ought then to be farther enlarged, tiU it is of fuch a fize as to admit the fore finger of the operator's left hand. * r. The finger being now introduced, is to be uled as a diredor for entering the narrow blunt pointed bif-, toury, reprefented in Plate VII, with which the fur- geon is to divide the hernial fac along its whole length from below up to the opening in the external oblique' mufcle. By means of the finger as a diredor for the bistoury, this part of the operation is performed with perfed fafety ; and the bistoury here delineated, ren- ders the many complex inftruments formerly employ- this treatifc, Mr. Louis in one point I think has gone•*» """& ™ ridiculingthat degree of caution fhown by fome ^r^n» ^•"'g the hernial fac : The divifion of the fac, hefays,,»i tended with fo little difficulty, that he does not confider it as different in that re lpect tram the firft external incifion of the fkin «»« words are . •'Jamais le fac ne m'a donne n, plus de peine, m plusd embarras que la peau ; ondivife, pour ainfi dire celle-ci *»P""™r™'' "le fac d* heand " In the hands of fuch an expert operator as Mr. Lout the fcalpel even in this manner may be.fo managed as to do no harm but with the general run of.R^y^^^'fo would be produced by proceeding in this part of ^e operation 10 rapidly as^is here direaed. A nd when we reflccthat the= d^erence of a tew feconds in the courfe of the opera tion, "all that wuWbe eaineTbv OTc ereatelt difpatch we can employ, little doubt, 1 thiiiK, Sn remain as fo the propriety of proceeding through every part of it in the molt deliberate manner. 182 Of Hernia. Chap. V. ed not only for this part of the operation, but for the fubfequent divifion of the tendon, quite unneceffary. On laying the fac open at the bottom, a quantity of coloured fluid always ruflies out, and the protruded parts now come fully into view: If a portion of gut is down, and is not much entangled with omentum, by being now fet at liberty it pufhes out immediately on the fac being opened ; thereby giving the appearance of having been coUeded in a larger quantity, than the Nfize of the tumor gave reafon to exped. The portion of gut found in hernial fwellings is very various, no part of the intestinal canal being en- tirely exempted from falling down. Hitherto the jjg^ um has been commonly fuppofed to form the fub- ftance of the greatest proportion of fuch tumors; later and more accurate obfervation, however, renders it probable, that the cascum, appendix vermiformis, and part of the colon, are perhaps as frequently contained .in herniary facs as any other portion of the gut. The fac being laid fully open, the parts contained in it ought now to be examined with the nicest atten- tion, in order to difcover whether they are aU found or not; and if upon an attentive infpedion they are found to be found, that is, if they are not evidently in a gangrenous ftate, even although they do feem to be confiderably inflamed, every endeavour fhould be ufed to get them immediately returned into the abdomen. In making the reduction, whether intestine or omen- tum, or a portion of each, have been found contained in the fwelling, thofe parts of them which appear to have corne laft out, ought to be firftjaifhed back ; the difficultjTahd trouble of returning them being thereby much leffened: And in making the redudion, , / it both anfwers the purpofe better, and is lefs likely to j\ y do mifchief, to apply the fingers to that part of the in- S teftine connected with the mefentary than to the con- vex part of the gut. While the redudion is going on, -s \ the patient's thighs and loins, fhould be ftiU more ele- vated Sed.II. Of Hernia. 183 vated than they were during the preceding fteps of the operation ; as this pofture of thefe parts tends much to facilitate the return of the protruded inteftines to the abdomen. When the difeafe is recent, and the parts have not been frequently down, it fometimes happens, that by pulling out a litde more of the gut than was former- ^p K_ ly in the fac, any obstruction which occurred to its be- ing replaced is thereby removed; and if the protruded parts are not of great bulk, they may thus be fome- times reduced, without any neceffity for enlarging the opening through which they have paffed from the ab- domen : But when upon trial this cannot be done . . with great eafe, it fhould never be attempted ; much U ^ more danger being to be dreaded from any degree of force ufed for the redudion of the gut, than can ever occur from finifhing the operation by an enlargement of the opening in the tendon of the external oblique mufcle. As die tendon of this mufcle runs in an oblique di- redion from above downwards, and as meopening through which'the contents of a hernia protrude, is __-, formed merely by a feparation of the tendinous fibres « vac,/_| from one another, the diredion of this opening is of *^ courfe the fame with that of the tendon ; that is, it runs fomewhat obliquely from the fpine of the ileum to the os pubis. In enlarging this paffage, then, for the redudion of fuch parts as have paffed through it, as a tranfverfe £ .j fedion of the tendon is by no means neceflary, the knife fhould be carried obliquely upwards, fo as mere- ly to continue the natunuHfeparation of the tendinous fibres. The finger was recommended as the belt director for the knife in opening the fac, and in dividing the tendon it is equally neceffary. By infinuating the fin- ger into the aperture in the tendon immediately above the protruded parts, the point of the blunt bistoury is r eafilv 184 Of Hernia. Chap. V. eafily introduced upon it; and in this manner, by keeping the end of the finger always a little before the bistoury, the opening may be enlarged to any necef- fary extent without any rifk of wounding the con- tiguous parts. In general, a very fmall enlargement of the natural opening in the tendon is found fufficient for the reduc- tion of the gut and other parts : But the fize of the opening ought by all means to be fully fufficient for the end propofed ; for it is better to exceed in making it fomewhat too large, than to run any rifk of hurting die parts by forcing them through a very fmaU aper- ture. If upon introducing the finger any adhesions of the gut to the contiguous parts are difcovered, the in- cifion in the tendon ought to be larger than might otherwiSe be neceffary, in order that the finger may be freely admitted fo as to destroy Such adhesions as it can reach ; for unlefs they are removed, complete fuccefs from the operation cannot be expeded. Independently of fuch adhefions internally, it fre- quendy happens, by long confinement in the fcrotum; preffure ; and perhaps other caufes ; that Strong ad- hefions are formed among the parts contained in the fac itfelf; and before they can be with propriety re- duced, it is always neceffary to attempt to feparatse them. When adhefions of this kind occur, as they fome- times do, between different parts of the protruded gut, the greateft caution is neceffary in feparating them : But connedions of this nature between one portion of the intestinal canal and another, are feldom / very firm, and are commonly eafily feparated by the fingers alone ; and when the connedion is formed by means of long filaments, which is fometimes the cafe, the eafieft method of removing them is to cut them, either with a pair of fciffors or the bistoury: But when it is found,, that one part of a gui adheres fo firmly to another Sed. It. Of Hernia. 185 another as not to be feparated but with difficulty, it is much better to return the whole even in that ftate in- to the abdomen, than to run the rifk of hurting the intestine mateiiaUy by ufing much force. When, again, adhefions occur between the gut and the hernial fac, or between the gut and omentum, if the filaments producing the connection cannot be oth- erwife removed, as there is no great hazard in wound- ing the omentum, and ftill lefs in hurting the fac, a Very fmall portion of thefe may be diffeded off, and returned with the gut into the abdomen ; and in the fame manner, when the omentum adheres fo firmly . to die fac as not to be feparated in any other manner, no danger can ever accrue from the fac being fome- what encroached upon. The rifk and trouble attending the pradice now recommended is nothing, at leaft it is very tfltfiing, when compared to the inconveniences that woUld en- fue from leaving^either the omentum or gut adhering externaUy to the hernial fac, as is advifed by fome Writers when fuch adhefions Cannot be very eafily di- vided. The fmaUeft portion of gut being left down, would run a great rifk of Suffering by exposure to ah unufual degree of cold, arid to the effeds of the exter- nal air at the different dreffings; and by leaving part of the omentum to protrude through the opening from the abdomen, one great advantage to be ex- peded from the operation would be loft, viz. the pre- vention in future of that rifk which a patient with a portion of protruded omentum is always liable to, of a piece of gut flipping down, and perhaps of becom- ing strangulated. After returning the contents of the fac into the cavity of the abdomen, it has been propofed by fome authors, to pafs a ligature round the upper part of the fee juft at its neck, with a view, as we are told, of procuring a reunion of its fides, in order that it may A a ferve 186 Of Hernia. Chap. V. ferve as a means of preventing future defcents of the bowels. But as Such a ligature cannot be applied without much rifk of injuring, or even of destroying the fper- matic veffels, with which the posterior lamella of the fac is immediately conneded, the pradice from that confideration alone ought to be laid aside ; but in re- ality it does not appear to be in any degree neceffary, as this very union of the fides of the fac is univerfally produced merely by that degree of inflammation 'which always fucceeds to the divifion of it by this operation. Hitherto we have recommended the immediate re- dudion of the contents of hernial tumors upon the fuppofition that they have been only difplaced ; that they have been adhering to one another or to the neighbouring parts ; or perhaps that they have been more or lefs in a ftate of inflammation. But when it appears that this inflammation has already termi- nated in gangrene, as the return of fuch mortified parts, whether of omentum or interline, might be ex- ceedingly hazardous, a greater degree of caution be- comes neceflary. (sAJ\\t vv When the omentum is found in a mortified ftate, as the excifion of a portion of this membrane is not attended with much rifk, it has been the common pradice to cut away the difeafed parts ; and in order to obviate any inconvenience from the hemorrhagy which might enfue, we are advifed to make a ligature on the found parts previous to the removal of thofe that are mortified; whilst the ends of the ligature be- ing left hanging out of the wound, the furgeon has it in his power to remove them when circumftances ap- pear to render it proper. TheSe ligatures on the omentum, however, having frequently been produdive of bad confequences, fuch as naufea, vomiting, cough, fever, pains in the belly, and inability to fit ered ; and it having been found by Sed. II. Of Hernia. 187 by the experience of many individuals, that no hem- orrhagy of any importance ever occurs frorrTa~di- vifion of this membrane even in a found unmortified ftate; fuch parts as have become gangrenous may therefore be freely cut off, and the remaining found parts be afterwards without the intervention of liga- tures introduced into the abdomen with no rifk what- ever. This is now the opinion of different pradi- tioners *: But if it fhould ever happen, on cutting off part of the omentum, that a veffel of any fize is di- vided, a ligature may with great fafety be paffed a- , bout the veffel itfelf, without including any of the membrane ; and the ends of it being left long enough to hang out at the wound, the threads may be after- wards pulled away at pleafure. Another circumftance fometimes occurs, too, which renders the removal of part of the omentum neceflary; when a rupture has been of long duration, and a confiderable portion of caul has remained long down, from the preffure made by the ufual fufpenfory bandage and other circumftances, it frequently hap- pens that confiderable quantities of the protruded parts' become much thickened, very hard, and col- leded into lumps. When thefe lumps are not very large, there is no neceffity for removing them, as when fmall they may be returned into the abdomen without producing any inconvenience; but whenever it appears to the operator, that by their bulk and hardnefs they might probably do mifchief if reduced into the belly, they ought as certainly to be cut off as if in a ftate of real mortification. When it is determined to remove any part of the-. omentum, the eafieft and fafeft method of doing it is' this. The membrane ought to be carefully expand- ed * A very accurate paper upon this fubjecl may be feen in the 3d Vol. of Memoires de SAcademie Royalle de Chirurgie of Paris, by Monfieur Pipelet, in which feveral cafes are related of the bad ef- fects produced by ligatures on the omentum, Mr, Pott is alfo of this opinion.—Vide Treatife on Ruptures. i88 Of Hernia. Chap. V. ed at the part intended to be cut; and in this ftate it is very eafily divided by a pair of thin edged fciffors, much more fo indeed than by any other inftrument. When folly Spread out, any turn of the intestine that happens to be enveloped in it, is at once brought iota view, which without this precaution we would run a great rifk of dividing by the fciffors. . - When, again, a portion of gut is found to be mor- js/ tified, if it fhould be returned in that ftate, a diSchargft' ; / of feces would certainly take place into the cavity of the abdomen, as foon as the mortified fpot fhould fep- arate from the found. In order to prevent fuch an occurrence, which would foon terminate in the pa- tient's death, if it is a fmall fpot only that is diSeaSed, we ought to endeavour by means oS a needle and lig- ature, to conned the Sound part of the gut immediate^ ly .above the mortified spot^ to the wound in the ab~ dominal parietes. By this means, when the mortified part Separates, or on its being immediately cut out, Which is perhaps better, the feces are difcharged by the wound ; and different inftances have occurred, where the lofs of fubftance produced by the mortifiea-^ tion was not extenfive, of the opening into the gut becoming gradually lefs, and at laft healing entirely: But whether the event fhould prove So fortunate or , not, whenever a portion of gut is obferved to be com- 'pletely mortified, it ought by aU means' to be Secured by a ligature to the parts moft contiguous" to the wound. And farther, when the mortified portion of gut is of great extent, and includes, fo far as it goes, the whole circumference of the intestine, the gangrenous parts of it ought to be cut out at once ; and if the quantity thus taken away is not fo confiderable as to prevent the ends of the gut from being brought into contad with one another, it ought to be immediately effeded in the manner we fhall direct in another chapter when treating of Gaflroraphy. This at leaft affords * cjiance Sed. II. Of Hernia. 189 chance of the ends of the gut being brought to re- unite ; and if unfortunately that event fhould not take place, as the gut ought here alfo to be conneded to the parts contiguous to the wound in the abdomen, a . paffage for the feces will ftill be fecured by die groin, ' Although in cafes of hernia, attended with a morti- fication of the inteftines, many have recovered by the method we have recommended who otherwife muft have died ; yet it will be readily fuppofed, that the rifk attending patients in fuch a ftate muft be very great: But although a fmall proportion only of fuch as are unfortunately in this fituation fhould recover, yet ftill no praditioner would be excusable for omit- ting thofe means which afford the greateft probable chance of a recovery. A patient of my own is now' living, and in good health, voiding his feces by the ) anus, who loft at leaft one foot of the intestinal canal by mortification in a cafiTof crural hernia; and we are told by different authors, of fimUar recoveries equaUy remarkable. % It is to the moderns chiefly, we muft remark, that this very material improvement in the treatment of hernials to be attributed. It is even recorded of Rau, who lived in a very late period, that on opening a hernial fac, where a gangrenous ftate of the parts was deteded, as the cafe was confidered as defperate, he laid down his knife and proceeded no farther in the operation. This patient, who died next day, would in modern pradice have had at least fome chance for life. , . , When it is therefore difcovered, that part of the contents of the fac are mortified, all fuch portions as are to be removed ought to be cut off; and the re- maining found intestine being retained till properly Se- cured by a ligature, the opening in the external ob- lique muScle may then be dilated with Safety: Where- as, if it fhould be enlarged before the difeafed part of the gut is taken awav, the gangrenous portion might very I-OO Of Hernia. Chap.V.. very probably flip up together with the found; but by the precaution now recommended, every rifk of this nature is prevented. The parts forming a hernia being aU completely replaced, when the fac in which they were contained is found thick, hard, and much enlarged, as in fuch a state no good fuppuration can take place, and as its prefervation cannot be in any degree ufeful, fuch parts of it as can be cut away widi propriety ought to be removed : All the lateral and fore parts of the fac may be cut off with fafety; but as it is commonly firmly conneded with the fpermatic veffels behind, this part of it ought not to be touched. The operation being now finifhed, by the protrud- ed, parts being replaced, and thofe intended to be re- moved being cut off in the manner direded, the re- maining fore muft be dreffed as lightly as poflible with charpee of the fofteft kind; and the beft bandage for retaining the dreffings, is the ufual fufpenfory bag properly fluffed with Soft lint. The patient on being carried to bed fhould be fo placed as to have his loins fomewhat elevated above the reft of his body, and fhould in that Situation be immediately laid to reft: Opiates are here particularly ufeful: To prevent, or at leaft to moderate, the Sever which commonly Succeeds, the patient fhould be kept cool; in plethoric habits, bloodletting fhould be pre- scribed, together with a rigid low diet; and lastly, a frequent ufe of gentle laxatives, fo as to keep the beUy moderately open, is particularly proper. When however the constitution has been previoufly much reduced, either by long ficknefs or any other caufe, inftead of bloodletting and a low diet, a nour- ifhing regimen fhould be prefcribed ; for if a patient in fuch circumftances be not properly Supported, he will not So readily recover Srom the effeds of the difor- der : And it is proper to remark, that in ordinary pradice, the indiscriminate ufe of bloodletting, and an Sed. II. Of Hernia. ,191^ an abstemious regimen; in every cafe of hernia, ap- pears to be too rigidly adhered to ; for although this pra6tice proves always more effectual than any other means in every cafe of rupture attended with inflamma- tion, yet daily experience convinces us of its being highly pernicious where the fyftem has been already much reduced by evacuations, and where no inflam- matory fymptoms take place. The fore being regularly dreffed as often as it ap- pears neceffary • in the fame eafy manner as at firft, . and the fame degree of caution being continued both v-*v^ winVrefped to diet and other circumstances, if the pa- -^ tient survives the firft three or four days he wiU iiv >^ff" general recover : And as foon as the fore is firmly cicatrized, a trufs ought to be properly fitted to the parts, and fhould never in any future period of life be laid aside. By many it has been recommended, and it is ftill a very common pradice, to ftitch up the wound with two or three futures; but as no real advantage can be obtained from this, and as it has been on fome occa- fions produdive of mifchief, it ought not to be at- tempted. No perfon will probably fay, that fuch lig- atures ought to be carried fo deep as the tendon of the oblique mufcle; and if they are only made to pafs through the external teguments, they can have no ef- fed in preventing a protrufion of inteftines : On the contrary, it does now and then happen, during the cure of the wound after this operation, that fmaU por- tions of gut pafs out at the opening in the tendon, which are always readily feen and eafily reduced when the external parts have not been drawn together ; buto' on the fkin being by ligatures made to cover the great- ^ C ;. eft part of the wound, I have known it more than once . happen, that portions of inteftines have paffed out at the opening in the tendon, and remain protruded for a confiderable time without being noticed ; fo that the pradice ought not to be encouraged. * * After 194 Of Hernia, Chap. Vj After laying'the fac bare, it was fome time ago rec- ommended by Mr. Petit and other French practi-;> tioners, to endeavour to reduce the protruded intef- ; tine without dividing the fac. One great advantage expeded from this, was, the prevention of thofe bad ( confequences which are fuppofed will moft likely en- / foe from the external air finding accefs to the contents / of the abdomen. 1 It ought to be remembered, however, that unlefs ^ the hernial fac is laid open, we cannot poffibly khow in what ftate the protruded bowels are ; fo that parts might be returned into the abdomen in fuch ablate of difeafe as would add greatly to the patient's rifk. Not only the intestines are liable to mortification, but colkdions are apt to occur in the hernial fac, of a .very fetid putrid ferum, which, on being pufhed into \the abdomen, might be produdive of much mifchief. , y And befides, it has fometimes happened, that, on lay- ing open a hernial fac, the caufe of strangulation has v been deteded, either in the entrance to the fac itfelf, / or among the parts protruded along with it : For al- ' though, in a great proportion of all the inftances of hernia that occur, a flridure of the paffage in the ex- ternal oblique mufcle is to be confidered as the caufe of all the bad symptoms, yet now and then inftances of the contrary are obferved ; one of which I met with fome years ago, and I have heard of others of the fame kind.—'In a cafe of fcrotal hernia of long standing, fymptoms of strangulation at laft supervened; and on laying open the fac, the appendix yenmformis was found fo tightly twisted round a portion of gut, as left / no reafon to doubt of that circumftance alone having " been the caufe of all the mifchief. If the parts had here been returned into the abdomen without dividing the fac, no advantage whatever would have occurred from the operation ; and, after death, the praditioner would have had the mortification to find, that, in all probability, Sod. II. Of Hernia. *93 probability, the patient's life might have been saved, if this very neceffary meafure had not been omitted. Inftances of the protruded parts being returned into the abdomen without opening the fac, are enumerated by different French authors ; and in fome of thefe which ended fatally, it was found on diffedion, that ftrangulation of the gut had been occafioned by stric- ture formed by the parts contained within the fac, and not by the tendon of the external oblique mufcles^ Difafters of a nature fimilar to thefe we have men- tioned, having on different occafions occurred to Mr. Petit and others who had adopted the pradice of re- turning the parts contained in the fac without divid- ing the fac itfelf, it has now accordingly been very generaUy laid afide. Even Mr. Petit himfelf was at laft fo convinced of the inconveniences refulting fromj it, that he is faidto have joined keenly with thofe who' hadoppofed it from the time of its being firft introduced. By fome authors again, it is advifed, to reduce not only the protruded bowels, but even the hernial fac itfelf, without opening it; whilst, by others, it is al-^ . leged, that the fac can never be reduced. Mr. Louis, in the paper we have already quoted, is clearly of this laft opinion, as Mr. Pott alfo is. But we have the testimony of different authors of credit, and particu- larly of Mr. Le Dran, to the contrary ; and I have myfelf met with one inftance of this, where the appear- ances were fo unequivocal as to leave no doubt with me refpeding it. In cafes of hernia where the parts have been long and repeatedly down, fuch firm adhefions are ufually formed between the fac and the contiguous parts, as to reduce them apparently into one infeparable mafs ; fo that, in fuch circumftances, reduction of the fac be- comes altogether impradicable. But although this is perhaps in every inftance found to be the cafe in ruptures of long continuance, we are by no means warranted in supposing that it is fo in ever)' cafe of re- B b cent 194 Of Hernia. Chap. V. cent hernia. We know that the adhefion of one part of the body to another, cannot any where be inftanta^ i neoufly produced. Even where recent divifion has taken place, and when the divided parts are kept in cloSe contad, the Space of feveral days is commonly required to effed a firm reunion. Now in the cafe of a portion of membrane being forced into a natural opening, where the parts are neither rendered raw by art, nor are as yet affeded with inflammation, a ftill longer period we may fuppofe wiU be neceffary for this effed ; and in fad, although I fuppofe there is Scarce an inftance of a hernial fac of long duration being re- duced, yet there are sundry indifputable fads which fhow, that in recent ruptures the fac may be returned. ) The one above alluded to, which occurred in an ope- ration at which I was prefent feveral years ago had been down five or fix days, and Sormed a tumor in the groin of the fize of an egg : The fac did not in any point feem to adhere ; the operator therefore found no difficulty in reducing it; and on diffedion after death, which happened in about two days from the operation, the paffage through the external oblique mufcle was found dilated, but no existence of a fac could be traced into it. It is not, however, my own opinion, that this is a matter of much importance in pradice, I mean the pradicability of reducing the hernial fac or not; for, the various reafons we have al* ready given, againft the propriety of returning the con- tents of a fac. without opening.it, occur with equal force againft the propofed pradice of returning the fac itfelf unopened. But as there is a poffibility of fu- ture experience deriving fome advantage from this cir- cumftance, it is certainly right to have the fad as clearly eftablifhed as poffible. Hitherto we have been supposing the diSorder to exist in a male Subjed only ; but as the Same open- ings in the external oblique muSck are met with in females, Sea. III. Of Hernia. *95 females, fo they are alfo liable to the fpecies of rup- ture we have juft been defcribing. In males, however, the bubonocele is obferved to occur more frequently than in women, and as in them too the ceUular membrane furrounding the fpermatic veffels is very lax and dilatable, fo hernial fweUings of this kind are commonly much larger in men than in women. But inftances do now and then occur of fuch tumors even in women becoming very large ; in fuch cafes, the protruded parts faU down to the very bottom almoft of the labia pudendi. As the openings in the external oblique mufcles of females are exceedingly fimilar to thofe in male sub- jects, fo the treatment of this fpecies of hernia is in them very fimilar to what is found to anfwer in men. In cafes of strangulated gut, when glyfters, bloodlet- ting, and the other remedies formerly enumerated, happen to fail, the fame operation of laying open the hernial fac, and of enlarging the opening in the ten- don of the oblique mufcle, is here equaUy proper as in the other fex. With modeft women, diforders of this kind often take place without the praditioner in attendance be- ing made acquainted with them ; whenever therefore fuch fymptoms of colic occur as give reafon to fuf- ped the existence oS hernia, a particular examination ought always to be made, in order if poffible to deted the caufe or the mifchief, from the removal of which a cure can alone be expeded. SECTION III. Of the Hernial Congenita. B Y attending to the anatomical defcription given in the firft fedion, of the parts chiefly concerned in cafes of hernia, it muft evidently appear, that in the ordinary fpecies of fcrotal hernia, the parts protruded from 196 Of Hernia. Chap. V, from the abdomen muft of neceffity be contained in a bag; or fac perfedly diftind from the testicle; which in that' kind of rupture is always found in its ufual fituation in the fcrotum, unrounded by its own proper mem- brane the tunica vaginalis, and not in contad with any other part whatever. We then made it appear too, that if in early infan- cy a portion of gut fhould flip down by the fame paf- fage with the tefticie, that the parts fo protruded muft be in immediate contad with the teftis, and muft thus be furrounded with the tunica vaginalis ; fo that in this fpecies of rupture, very properly by Haller term- ed Hernia Congenita, the., tunica vaginalisJieftis forms the hernial fac. The difcovery of this fpecies of hernia, which was referved for modern times, enables us to account for a number of cafes recorded in books of furgery, of the contents of ruptures having been found in the fame bag with the tefticie : A circumftance which, till this difcovery, was always confidered as a clear proof of the peritonaeum being frequently ruptured in thofe difor- ders ; as there was not otherwife a poflibility of ac- counting for the phenomenon. But we now know,, that the peritonaeum in thefe cafes of hernia is never ruptured ; and that the parts forming a hernial tumor being found in contad with the testicle, is a circum- ftance eafily explained from our more accurate ana- tomical knowledge of thofe parts. In the treatment of ruptures of the congenital kind, little difference occurs from the management of the bubonocele in its more ordinary form. When the parts can be replaced without any operation, it ought always to be done, a trufs being at the fame time rec- ommended as a preventative of future defcents.; and when fymptoms of strangulation take place, which can-* not be otherwife removed than by the operation, it here becomes equally neceflary as in any other species of rupture. When Bed, IV. Of Hernia. 197 When from the circumftance of the parts having been protruded in early infancy, and from their having at times continued to fall into the fcrotum from that period downwards, there is reafon to fufped that the hernia to be operated upon is of the congenital kind, the furgeon in fuch a cafe, in laying open the contents of the tumor, muft proceed with ftiU more caution than in cafes of ordinary rupture ; for the tunica vag- inalis which here forms the fac, is commonly much thinner than the ufual fac of hernias. On the parts being returned, more attention is neceffary too in dreff- ing the wound than in other cafes of hernia ; for the tefticie being here laid bare by its vaginal coat being cut open, if it is not treated with much delicacy it wiU very probably inflame, and may thereby be produc- tive of much diftrefs. The teftis therefore ought to be immediately enveloped with its own proper covering, the loofe tunica vaginalis ; and at every dreffing, care fhould be taken to prevent as effectually as poffible every accefs to the external air. In other refpeds the management of the hernia con- genita is perfedly fimilar to that of any other rupture. SECTION IV. Of the Crural or Femoral Hernia. THE feat of this fpecies of hernia, as we have elfe- where remarked, is on the upper and anterior part of the thigh ; the protruded parts passing out at the fame opening through which the large blood veffels of the thigh are traniinitted from the abdomen. In the defcription given in a former fedion, of the external oblique mufcles of the abdomen, the under edge of thefe mufcles, it was remarked, by doubling backwards, forms, a kind of ligament, which extends in an oblique diredion from the fpine of the ileum near to the Symphisis pubis. It is this under border 198 Of Hernia. Chap. V. ^ of thefe mufcles which is commonly known by the ; name of Poupart's or Fallopius's iigament. Excepting at its two extremities where this liga- ment is attached to the pubes and ileum, it is not in any other part conneded with bone. By the particu- lar fhape of the ileum at this part, a kind of arch is formed by the ligament paffing over a hoUow in that bone through which the large artery and veins of the thigh find a paffage, the reft of the cavity being I fined up with cellular fubftance, glands, and fat; and all thefe parts again are covered and tied down by a firm tendinous aponeurofis of the fafcia lata of the thigh. It is under the tendon or ligament juft now defcrib- ed, that the parts composing a crural hernia defcend. On fome occafions they pafs immediately over die femoral artery and vein; on others, they are found on the outfide of thefe veffels; but more frequently they Ue on the infide, between them and the os pubis. As the" protrusion of any of the abdominal contents produces in this fituation nearly the fame fet of fymp- toms as occur in cafes of inguinal hernia, the method of treatment recommended in that fpecies of the dif- eafe is alfo applicable here. When, therefore, in the femoral hernia, fymptoms of strangulation occur, we muft put all the remedies in pradice already advifed for the inguinal rupture : Only here, in attempting to reduce the parts by the hand, the preffure fhould be made diredly up- j wards, inftead of obliquely outwards, as we direded '\ in the other; and when thefe means are unfortunately found to fail, the operation itfelf muft then be em- i ployed. A free external incifion was inculcated in cafes of inguinal hernia ; and it is here equally neceffary, or ' even more fo, from the parts concerned being more deeply feated than in the other. By too much timid- ity in making the external incifion, the operator is frequently Sed. IV. Of Hernia. 199 frequently much incommoded in all the fubfequent j> r-^,. J fteps of the operation. The external cut fhould ex- , ^ . M tend at kaft Srom an inch above the upper end of the'S J/"^'•-* <^l tumor to the fame fpace below the moft depending J part of it. The membrana_adipofa, tendinousexpansion of the^e^M fy* fafcia lata, and hemiaTfac,being all cautioufly divided, '%0 if the protruded parts are found in a situation proper for redudion, we fhould immediately attempt to re- place them ; and as the fpace below the ligament through which they have paffed is confiderable, this may frequently be done without dividing the ligament, merely by preffure properly applied with the hand, while the patient's body is placed in the pofture we have already direded in the bubonocele as being beft fuited for favouring a return of the bowels, When in this manner the contents of the tumor can be reduced without the neceffity of dividing the liga- ment, the patient is thereby faved from a great deal of hazard, as from the particular fituation of the fper- £ ^^ matic veffels and epigastric artery with reSped to this ligament, any cut made into the Substance of the lat- ter, runs a very great rifk of dividing one or other of them. The fpermatic veffels as they go along to pafs out at the opening in the external oblique mufcle, run nearly upon the very edge or border of Poupart's lig- ament almoft through its whole length, fo that I con- q c^>Jt, fider it as impoffible to make a free divifion of the . ligament without cutting them acrofs. We have been advifed indeed by fome, in order to avoid wounding the fpermatic veffels, which they ac- knowledge would certainly happen if the incifion fhould be carried dire£tty_jspwards, to cut in an ob- - ^ lique diredion outw^ds. In this method, they al- & j <- low, that the epigastric artery, from the courfe it usu- ally takes, may very probably be divided : But the rifk attending the divifion of that artery they do not confider 2oo Of Hernia. Chap.-V; confider as of much importance; and if the djfchargM of blood occafioned by any wound that may be made in it fhoulcfhappen to be confiderable, they fpeak of it as a very eafy matter to take it up by a needle and ligature, and needles of various fhapes have been in-, „ vented for this purpofe. Even in emaciated people,- 1 { however, it is a matter of much difficulty to reach the \ epigastric artery, and in corpulent patients it will be / found altogether impoffible to furround it with a lig- ature ; fo that the younger part of the profeffion ought . to be very cautious in receiving the diredions ufually, % given on this fubjed. On reading the remarks of the late Mr. Sharpe upon this point*, to fecure the epi- gastric artery by means of a ligature, one would ex- ped to be the eafieft of all operations ; but the diffi- culty which in reality attends it, is fuch as muft con- . vince every one who has tried it, that Mr. Sharpe himfelf had never put it in pradice. ■ ^ But even although this accident of wounding the epigaflric artery could be guarded againft in the moft eafy and effedual manner, yet I will venture to fay, when a femoral hernia is of any confiderable fize, the distention of the ligament thereby produced muft bring the Spermatic,veffels So nearly on.a.line with the under border of the ligament, as to render it altogether im- poffible to divide the one without the other ; and whoever will examine thefe parts in the ftate we have now defcribed, will fee that this cannot be avoided, \ whether the incifion be__carried diredly upwards, or even obliquely outwards or inwards. Some authors, from being fenfible of the danger attending this part of the operation, have propofed merely to dilate the paffage, inftead of dividing the ligament ; and Mr. Arnaud, a French writer on this fubjed, delineates a curved levator for the purpofe of fopporting the ligament till the protruded parts are re- duced : But as we are to fuppofe in every cafe of stran- gulated * Critical Inquiry into the prefent ftate of Surgery. I Sed. IV. Of Hernia. loi gulated hernia,> that the paffage through which the Oarts have fallen down is already dilated to nearly its' utmoft poffible extent, in fuch a fituation to attempt a farther dilatation without the afliftance of the knife, would feldom, it is probable, be produdive of any ad- vantage. A confiderable time ago it occurred to me, that in r\ p g^ this part of the operation fome afliftance might be de- '" rived from performing it in the following manner ; S-ia£J> "h and having fin'ce had occafion to make trial of it in one cafe where it answered moft effedually, I can now therefore recommend it with fome certainty. Inftead oS dividing the ligament in the ordinary way, I only ^ made an incifion into part of its thicknefs : In order*) to proted the parts below, I firft insinuated the fore- finger of my left hand between the gut and the liga- ment; and then with a common fcalpel made a cut of about an inch in length, beginningaboye and pro- ceeding to the under border of the ligament. The firft fcratch with the fcalpel was very flight; but by repeated touches, it was made to penetrate al- moft through the whole diicknefs of the ligament, till at laft a very thin lamella only of it remained : The finger being now withdrawn, the protruded parts were returned with great eafe, the ligament at its weakened part yielding gradually as the neceffary preffure was applied for the redudion of the' intestines. As in this manner the opening may be enlarged to any neceflary extent, and as the fpermatic veffels and epigastric arteiy are thus effedually avoided, the ope- ration for this fpecies of hernia may not only be done with equal certainty, but with the fame degree of safe- ty, as for any other kind of rupture. For, by not penetrating with the fcalpel through the whole thick- neis of the ligament under which thefe blood veffels lie, they are thereby kept free from all kind of danger during this part of the operation ; and, the preffure to be afterwards ufed for the redudion of the protruded C c parts, ao2 . Of Hernia. Chap. V. parts, if done in an eafy gradual manner, as it ought always to be, can never injure them materially; as blood veffels of the fize and ftrength of which thefe are, eafily admit of a degree of extenfion much more confiderable than can be here required. p The femoral hernia being in other refpeds perfed- ly fimilar to the inguinal, and the mode of treatment applicable to the one, being in every other circum- ftance equally So to the other, it is not neceffary to Say any thing farther here concerning it: Only we may remark with refped to bandages for retaining the dreffings, both in this and every other fpecies of hernia, except in the bubonocele, as laft defcribed, in which the ordinary fufpenSory bandage of the Scrotum an- swers the purpoSe in a very eaSy effedual manner, that in no other fituation can a bandage be applied, without being produdive of much inconvenience. For inftance, the Spica, as it is termed, which after the operation of the crural hernia, ufed always to be' employed, can never be applied but with much dif- ficulty ; nor does it anfwer the purpofe properly: Inftead of this or any other bandage, a piece of thin \ leather Spread with any plaster moderately adhefive, being applied over the dreffings, retains them more effedually, and with much more eafe. We have elfewhere remarked, that from the partic- ular conformation of the parts concerned in this dif- eafe, which is found to take place in females, that women are more liable to it than men. In them the fame means of relief, and the fame mode of operating, ought to be employed as we have already advifed for male fubjeds. For, as the fame rifk occurs here of / wounding the epigaftric artery, the fame precautions , are neceffary for avoiding it; and by attending to the cliredions we have given upon this point, this may be always done with certainty. SECTION Sed. V. Of Hernia. aoj SECTION V. Of the Exomphalos, or Umbilical Rupture. IN this fpecies of hernia, the parts protruded from the abdomen pafs out at the umbilicus ; and the con- tents of the hernial fac are here, as in every other kind of rupture, exceedingly various. On fome occafions they confift of inteftines only ; fometimes of omentum only ; and frequently of both. At other times, again, part of the stomach, the liver, and even the fpleen, have been found in the fac of an umbilical rupture. As all the parts we have now mentioned, are, while in the abdomen, contained in the peritoneum, the her- nial fac, it is evident, muft be here formed as well as in other ruptures, by that membrane being carried along with fuch parts as are protruded. Accordingly, in every recent inftance of umbilical hernia, this fac is in general very evident; but when the tumor has become confiderable in fize, by a long continu- ance, and the great weight of its contents, the fac, by the preffure thus produced, becomes fo conneded with the neighbouring parts, that by many it has been doubted whether this fpecies of hernia has a fac or not. In ruptures of this kind the fwelUngs fometimes increafe to fuch a degree, as actually to burft the fur- rounding parts ; not only the fac, and cellular fub- ftance, but even the fkin itfelf. This diforder occurs moft frequendy in infancy, foon after birth ; and corpulent people are more Ua- ble to it than thofe of a contrary habit, from this evi- dent reafon, that in the former, by the great bulk of contained parts, the furrounding mufcles are kept con- ftantly diftended, and the opening at the umbilicus through which the parts are protruded, is thereby made more pervious : For the fame reafon too, worn-. 204 Of Hernia. Chap. y. en in the laft months of pregnancy are particularly lia- ble to umbilical rupture. If the diforder is attended to in due time, a bandage properly fitted to the parts will commonly effed a a cure ; and, in fuch fwellings as occur in pregnancy, a removal of the diforder, is, in general, a certain confequence of delivery. But even in cafes' of um- bilical hernia in pregnant women, by employing a bandage on the firft appearance of the difeafe, and by perfevering in the ufe of it for a proper length of time, although a cure may not be obtained till delivery, the diforder will at leaft be prevented from receiving' any farther increafe. Both in male and female*'patients, due attention to the ufe of a trufs is abfolutely necef- ^ fary in every cafe of hernia ; but as in this fpecies of the difeafe the fwelling and different fymptoms are al- ways greatly aggravated by pregnancy, women in that ftate ought to be particularly attentive to the XmaUefl appearance of every fweUing of this nature. Although in fome inftances of umbilical ruptures, different portions of the alimentary canal are found to be protruded ; yet by experience we know, that the omentum alone is much more frequently protruded than any of the other vifcera: And hence umbilical hernias in general, are not produdive of Such bad Symptoms as uSually occur in the other kinds of rup- ture. It happens, however, as we have already obServed, that in Some caSes a portion oS gut alone is pufhed out, hy which the uSual Symptoms of a Strangulated hernia are apt to be induced. In which event, when the means usually employed for returning the gut in- to the abdomen do not succeed, as a flridure of the paffage through Which the gut has fallen, is to be confidered as the Caufe of the diforder; fo a cure, it is evident, muft depend entirely on a thorough remov- al of that flridure. In performing this operation, a free external incifion along the courfe of die tumor, is the ' Sed. V. Of Hernia. 205 the firft ftep to be taken; and on laying the protrud- ed parts bare by a cautious divifion of the fac, if they are found in a state proper to be returned, and if that cannot be effeded without making an enlargement of the paffage into the abdomen, this may be done with great fafety by introducing^the finger, and enlarging the opening as far as is neceflary with the blunt point- ed bistoury. This incifion, we may remark, may be made with almoft equal fafety in any diredion; but left the ligament formed by the umbilical veffels lhould be wounded, which, however, would not prob- " ably occafion much injury, yet if any perfon is ap- ijprehenfive of danger "from that circumftance, it may be always avoided by making the incifion on the left ' fide of the umbilicus, and carrying it a litde obliquely upwards and outwards. When, again, the prolapfed parts, on being laid open, are found to be fo far difeafed as to render their reduction improper, the diredions formerly given for the treatment of fimilar occurrences in other cafes of * hernia, apply with equal propriety here, fo that diey need not now be repeated. By Albucafis, Guido, Aquapendens, and other authors, it has been propofed, widi a view to obtain a radical cure without having recourfe to the operation, to'lift up the fkin covering the tumor, with the finger and thumb, fo asjo^feparate it from the gut under- neath ; when a ligature is ordered to be applied round the parts fo held up, and to be made of fuch a tight- nefs as to induce a mortification of all the parts that lie anterior to it. In other inftances again, when the form of the fwelling did not admit of this, the fame precaution be- ing taken as we have direded above for avoiding the gut, a needle containing a double ligature was intro- duced at the bafis of the tumor, near to its centre, and e ligatures were afterwards tied one above and the other 2o6 Of Hernia. Chap. V. other below, of fuch a degree of tightnefs as to induce the wifhed for effed. But as the pradice thus recommended was not ad- equate to the defign propofed, as it did not prevent a return of the diforder, and as the deftrudion of fkin produced by it rendered every future defcent more dangerous; fo it is now, at leaft by regular pradition- ers, very univerfally exploded. SECTION VI. Of Ventral Hernia. IN this fpecies of hernia the parts forming die fweUing are protruded between the interstices of the abdominal mufcles. No part of the abdomen is al- together exempted from the occurrence of fuch tu- mors, but they are moft frequently obferved in fome of the parts moft contiguous to the linea alba; and when the Stomach alone happens to form the tumor, the fweUing is fituated juft under, or immediately to one fide of the xiphoid cartilage. The treatment of this kind of rupture correfponds exadly with that of exomphalos. When the parts are reducible by the hand merely, a cure may be fre- quendy obtained by the conftant ufe of a trufs; and, again, when fymptoms of strangulation occur, which cannot be otherwife removed than by an incifion through the flridure, this muft be done in the man- ner direded in the laft Sedion, fo as to admit of the parts being replaced. The after treatment of the parts concerned in the operation, is the fame here as in other kinds of rupture. SECTION VII. Of the Hernia of the Foramen Ovale. I N this variety of rupture, the vifcera protrude through the foramen ovale of the pubis and ifchium. It ;»Sed. VII. Of Hernia. 207 Jt is not by any means a frequent diforder; but, as it does fometimes occur, it is neceffary here to defcribe it. The fymptoms in this kind of hernia being very fimilar to thofe produced by the strangulation of in- testines in other parts, it is not neceffary to enume- rate them: Only it is proper to remark, that in this rupture the tumor is in men formed near to theup- per part of the perinaeum ; and in women, near to the under part of one of the labia pudendi. In both fexe* it lies upon the obturator externus, between the pedinseus mufcfe-and the firft head of the triceps fem- oris. The foramen ovale being partly filled up by a membranous or ligamentous fubftance, and in part by the obturatores mufcles, it was commonly fuppofed that this fpecies of hernia arofe from a relaxation of one or other of thefe ; but as an opening is left in the foramen for the tranfmiffion of different blood veffels and nerves, it is now known, that in this diforder the vifcera pafs out at that opening, by gliding down in the courfe of thefe veffels. The general mode of treatment as we formerly rec- ommended for other Species of hernia, muft be here attended to; and when the parts are reduced, a trufs properly adapted to the parts, muft be trusted to for their retention. But as it will fometimes happen in this, as in every other cafe of hernia, that redudion cannot be effeded by the hand alone, in that event the operation of dilating the paffage through which the inteftines protrude, is the only refource. The tumor, however, that occurs in this diforder, being in general fo fmall as fcarcely to be noticed but by the moft minute examination, unlefs a local pain, with the ufu- al fymptoms of a strangulated gut lead to its detec- tion, it is feldom difcovered from its fize, untU it is too late to exped much affutance from art. But whenever the operation becomes neceffary, as it muft always be when fymptoms of ftrangulation are difcovered 20# Of Hernia. Chap. V; ' difcovered to have arifen from a portion of gut beir^ ] protruded, and which cannot by any other means be removed ; in fuch an event, after carefully laying the prolapfed parts freely bare, if they cannot then be re- duced but by dilating the paffage, and as death muft be the certain confequence if that fhould not be effeded; it ought at all events to be attempted : But as here it is almoft impoffible to enlarge the opening by means of any fharp inftrument, without dividing fome of the' blood veffels which pafs out at the foramen ; and as ! fuch an occurrence, from thefe veffels being of a confid- j erabk fize, would of itfelf, in all probability, end in , the patient's death, the depth and fituation of the parts rendering the application of a ligature impradicable"; it is more advisable, by means of fuch a flat hook as is reprefented in Plate IX, fig. 2, to dilate the paf- fage to a fufficient fize by gentle gradual Stretching. By insinuating the end of the hook between the intel- tine and ligament, and pulling it gradually from with- out inwards, a degree of dilatation may be obtained fufficient for the redudion of the gut, without incur-- ring that hazard which the divifion of the ligarhent with the knife or any fharp inftrument muft always occafion. SECTION VIII. Of the Hernia Cystica, or Hernia of the Urina- ry Bladder. I N this fpecies of rupture, the urinary bladder is the organ protruded ; and the fituations in which it occurs, either in the groin and fcrotum, through the opening in the external oblique mufcle of the abdo- men ; in the fore part of the thigh, under Poupatt's '* ligament; or in the perineum, through fome of the mufcular interstices of that part.* Inftances have oc- curred, * An inftance of this is recorded in Vol, IV. of Memoires de PAcademie Royale de Chirurgie, by Monf. Pipelet le Jeune, p. 181. Sed. VIIL Of Hernia. 209 cijrred, too, of the bladder being pufhed into the vag* ina, fo as to form hernial tumors of no inconsiderable degrees of magnitude. As only a part of the bladder is covered with the peritonaeum ; and as the bladder; in order to get in- to the opening in the external obUque mufcle, or un- der the Ugament of Fallopius, muft infinuate itfelf between that membrane and the abdominal mufcles ; it is evident; that the hernia cystica cannot be Covered with a fac, as intestinal ruptures usually are. In the perinaeum, again, that portion of the bladder moft liable to fall into it, is in no way conneded with the peritonaeum. On /ome occafions, this fpecies of rup- ture occurs by itfelf, without any complication ; and on others it is found to be accompanied with intef- tines and omentum, both in inguinal and femoral hernias : When complicated with a bubonocele, that portion of the bladder which is protruded lies between the hernial fac and fpermatic cord ; that is, the intef- tinal hernia lies anterior to it. The ufual fymptoms of this fpecies of hernia are, A tumor, attended with fluduation, either in the groin, in the fore part of the thigh, or perinaeum, which gen- erally fubfides when the patient voids urine. When the fwelling is large, before water can be made with freedom, it is commonly neceffary to have recourfe to preffure, at the fame time that the tumor, when in die <*roin or thigh, is as much elevated as poflible ; but when the fwelling is fmall, and efpecially when no flridure is as yet produced, the patient generally makes water with great eafe, and without any aflift- ance from external preffure. When a hernia of the bladder occurs without any complication, it is commonly found to proceed from a foppreflion of urine. In the treatment, therefore, every caufe of foppreflion ought as far as poflible to be guarded againft ; and when no adhefions take place, and iSthe protruded portion of bladder can be r ' Dd reduced ft!0 Of Hernia. Chap.V. reduced, a trufs properly fitted to the part, fhould be wore for a confiderable length of time : And, again, when the parts cannot be reduced as long as no fymp- toms occur to render the operation neceffary, a fuf- penfory bag, fo fitted as effedually to fupport the pro- lapfed parts, while at the fame time it does not pro- duce fevere preffure; is the only probable means of relief. When, again, a portion of bladder happens to protrude into the vagina, after reducing the parts, which is done by laying the patient on. her back with her loins fomewhat .elevated, and pressing with "the fingers from the vagina, defcents in future may in general be effedually prevented by the ufe of the preffary reprefented in Plate IX, fig. i. And the fame means, we may remark, are employed with fuc- cefs in preventing a falling down of part of the intef- tinal canal into the vagina ; a fpecies of rupture which now and then occurs. It may happen, however, that the prolapfed parts, by being attacked with inflammation and pain in con- fequence of flridure, may render the divifion of the parts producing thefe fymptoms as neceffary in this as in any other cafe of hernia ; in which event, the diredions given in the preceding fedions for the treat- ment of intestinal hernia?, will be equaUy applicable here.—Only it muft be remembered, that as in the her- nia cystica without any complication, the protruded parts are not covered with a fac ; fo a ftill greater de- gree of caution is neceffary in laying them bare, than in the ordinary kinds of rupture. It fometimes happens; that ftones are produced in that portion of the bladder which remains protrud- ed ; in which event, if it fhould ever become necef- fary to cut into them, if the bladder can be eafily re- tained in its prolapfed ftate till the wound is healed, it ought always to be attempted, in order to prevent that extravafation of urine internally which would otherwife occur, and which in all probability would do mifchief. Plate IX y^a 3. I Scd.VIII. Of Hernia. 311 mifchief. The fame precaution, too, becomes necef- fary, if, either by accident in the operation for the hernial cyftica, the bladder fhould be cut into ; or if any part of it has been found mortified, fo as to ren- der it improper to return it into its ufual fituation*. CHAP. ♦The beft accounts to be obtained of the various fpecies of her- nia may be had in the works of Le Dran, Heifter, and of Mauchart * • in a treatife De Hernia Inearcerata ; in the different volumes of Memoires de VAcademie Rojale de Cbirurtie of Paris, in the Medical EfTays of Edinburgh; in the works of the late Dr. Monro ; in Haller De Hernia Congenita, in his Opufcula Patbologica; In Mr. lohn Hunter's very accurate account of the ftate of the Teftis in the . Foetus in Dr. Hunter's Medical Commentaries ; and in Mr. Pott's valuable Treatife on niptures. Thefe are thcbeft modern authors on this fubje£t; and very little fatisfaction is to be got from any of the ancient writers upon it. 21Z Of the Hydrocele. Chap. VI.' CHAP. VI. OF the HYDROCELE. ^ SECTION I. General Remarks on the Hydrocele. ' j EVERY tumor formed by a col- ledion of water, might, from the import of the word", 1 be with propriety denominated a Hydrocele ; but the , chirurgical acceptation of the term, implies a watery fwelling fituated in the fcrotum or fpermatic cord, j Swellings of this kind, as well as every other fpecies of tumor in the fcrotum or groin not immediately ] produced by the protrufion of parts from the abdo-* men, are by ancient writers termed Falfe or Spurious Hernia?, in oppofition to thofe defcribed in the laft Chapter, which they diftinguifhed by the appellation of True Hernia. No real utility, however, is derived from this dif- tindion ; and as it arofe from a very erroneous no- tion which prevailed of the origin of thefe diforders, j we fhould not have thought it neceflary to mention it here, but with a view to render intelligible the ideas of ancient writers upon this fubjed. Indeed, the opinions concerning thefe difeafes, as handed down to us by aU the older writers, by which I mean thofe of the laft and former centuries, are in general fo confufed and perplexed, that few of them are worth much attention ; For, as they were very ignorant Sed. I. Of the Hydrocele. 213 ignorant of the anatomy of the parts concerned, the ideas they formed of the fituation of the difeafes to which they are liable, were fo erroneous, that the pradice built upon them came to be very pernicious. So little were they acquainted with the strudure of thefe parts, that they proceeded with much unnecefla- ry dread in the treatment of their diforders; for, by iiippofing an immediate Connedion to fubfift between the coats of the tefticie, the cavity of the abdomen, liver, kidneys, and other vifcera, they were induced to confider the colkdions of water that occur in the hy- drocele, as depofitions from thefe parts, and as tend- ing to free them, and perhaps the fyftem at large, from fome important diforders. Different paflages in Hildanus, Lanfranc, Fabricius, ab Aquapendente, and even in Dionis's works, fhow this to have been the idea of praditioners in the times of thefe authors. In confequence of this, their pradice became timid and undecided; fo that every chirurgical operation, in which thofe parts were concerned, became a mat- ter of great importance to refolye upon, and very te- dious, painful, and uncertain in the execution. From the time of Celfus to the middle of the laft century, very little progrefs feems to have been made in reducing the knowledge of thefe difeafes to greater certainty. Indeed, from Celfus downwards, authors feem to have copied almoft exadly from one another, till Wifeman, Le Dran, Garengeot, and Heilter, grad- UaUy elucidated the fubjed: But they were never clearly and accurately defcribed, till the difcoveries of Monro, Haller, Hunter, and Pott, rendered the anat- omy of the parts concerned plain and intelligible. So much attention, however, is ftill given to the con- fufed accounts of thefe parts handed down by ancient writers, that the real nature of the diforders of the tef- ticie and its appendages is lefs underflood than it oth- erwife would be. There is no part, indeed, of chi- ■ furgical pathology, of which ftudents in general are fo ignorant 214 Of the Hydrocele. Chap. VL> j | ^lorant as of this; and hence their notions of thefe c&Teafes, and of the anatomy of the parts in which \. they are feated, are commonly very indistind.—NouV' I ing but a ftrid attention to the difcoveries of late an- atomists can convey clear and diftind ideas concern- ing them; and whoever will make himfelf thorough- ^ Jy acquainted with thefe, wiU find, that the hydrocele, ' send other diforders to which thefe parts are liable, are explained with as much clearnefs and Simplicity as any other diSeaSe incident to the human body. We have already, in the beginning of the preced- ing Chapter on Hernise, given a description of thefe * parts, fo far as related to that clafs of difeafes. To what was then faid, we muft now beg leave to refer j but before proceeding to treat farther of the diforders, ' now under confideration, we fhaU firft enumerate fuch particulars relating to the ftrudure of the parts con- cerned as were not formerly neceffary to be men- tioned. In the anatomical defcription already given of thefe parts, we made it appear, that on the testes with their blood veffels defeending to the groin and fcrotum, as they were while in the abdomen Surrounded by the peritonaeum in the fame manner with the other vif- cera, and as in their deScent they bring a procefs of the peritonasum along with them, So when in the Scro- tum, that they ftill remain in the cavity of that mem- brane. At the time of their faffing down, and for a fhort while thereafter, a dired communication fubfifts along this procefs of the peritonaeum between the teftes and vifcera in the abdomen; but foon after this, ex- cept, as we formerly obferved, in the cafe of a con- genital hernia, the fuperior part of the paftage begins to contrad, and in a fhort time is entirely obliterated, from the opening in the external oblique mufcle down along the Spermatic cord, to the upper part of the ep- ididymis i the under part of the procefs continuing loofe Sed. I. Of the Hydrocele. 11$ looSe and open. In this manner the inferior extrem- ity of the procefs is converted into a kind of bag, the tunica vaginalis testes. From the defcription formerly given of thefe parts it appears, that the teftis while in the abdomen is at its back part firmly conneded to the peritonasum, at which part the blood veffels, nerves, and vas deferens, communicate with it; fo when in the fcrotum, as die vaginal coat with which it is there furrounded is evi- dently a procefs or continuation of the peritonaeum, it muft of neceffity be ftiU conneded with that mem- brane in the fame manner as while it remained in the abdomen. And accordingly we find, that although the tefticie lies loofe in this fac or vaginal coat in every other part, yet aU along its pofterior part it is firmly attached to it. At this part the different veffels of the testis ftill enter ; and at this part the peritonaeum, or what is now the tunica vaginalis, is reflected over it, thereby forming the tunica albuginea, or immedi- ate covering of the tefticie ; fo that the latter, viz. the tunica albuginea, is demonstrably a mere continuation of the former or vaginal coat. The inferior part of the peritonaeal procefs being Somewhat wider below than above, leaves the tunica vaginalis of a pyramidal form ; and it is alfo fome- what longer than the teftis, reaching from the fuperi- or part of the epididymis, where it begins, to a little below the inferior point of the tefticie where it ter- minates. It is altogether of fuch a fize as to allow the testis to roU eafily within it; its principal ufe ap- pearing to be, to retain a fmall quantity of a fine ex- fcalation, which is conftantly fecreting, either from its own furface, or from the furface of the testis itfelf, for the purpofe of keeping the latter moist and eafy. This vaginal coat which we have now defcribed is the only loofe covering belonging either to the fper- matic cord or to the teftis : For although, by many writers on this fubjed, a vaginal coat of the cord is 4i 6 Of the Hydrocele. Chip. \% alfo defcribed, together with a fuppofed feptum be- tween it and the vaginal coat of the teftis; yet no fuch covering is, on dilfedion, found to exist. The fuperi-. or part of the peritonaeal fpermatic procefs, we have already feen, is entirely clofed up very foon after the defcent of the testicle; and a firm adhefion being pro- duced between the fides of the fac all along the courfe of the cord, no vestige whatever can be traced, either of a vaginal coat of the fpermatic cord, or of any par* ticular feptum between that and the tefticie : This it is of] fome importance to attend to, as the difeafes of thefe parts cannot otherwife be properly underflood. As the difeafes we are now to treat of are chiefly feated in the coverings of the teftis, we have been more particular in rendering their ftrudure clear and obvious, than is neceffary in defcribing the tefticie it- felf ; with refped to whkh we fhall only obferve, that it is evidently very vafcular, being eompofed almoft entirely of different convolutions of blood veffels. Befides the vaginal coat proper to each tefticie, the two testes have for their farther protedion a more ex- ternal covering, the fcrotum : A bag formed almoft entirely of fkin and cellular fubftance ; for that body the dartos, which has commonly been fuppofed to be mufcular, is now clearly proved to be altogether cel- lular. Even the feptum fcroti, or that membrane which divides one teftis from another, is eompofed of cellu- lar fubftance in a more condenfed ftate. By air it is eafily inflated, and it is equally pervious to water : So of courfe it partakes of all thofe watery effufions, to which the more external parts of the fcrotum arc liable. It is very neceffary to be acquainted with this struc- ture of the fcrotum, as from the defcriptions which till of late have been given of it, young praditioners are induced to confider it as mufcular, and to fuppofe the feptum with its rapha to be ligamentous ; and hence Seel. II. Of the Hydrocele. di'j hence they are led to be more cautious than they need be in performing operations upon it. We have thus entered with as much minutenefs into the anatomy of thefe parts as is neceflary for un- derstanding their difeafes ; and the nature of this un- dertaking not admitting of a more particular difcuffion, we fhall now proceed to confider the different fpecies of the hydrocele; the immediate objed of this chapter. All the varieties of the hydrocele which have been mentioned by authors, may; I think, be comprehend- ed under the two following fpecies, viz. the anafarcous^ and encyfled. In the former, the water is diffufed over all the fubftance of the part in which it is feated; the fweUing is not coUeded in any particular cavity, but occupies equally aU the cells of the part: In the lat- ter, viz. the encyfled; the water is coUeded in one diftind bag ; and a fluctuation of a fluid is in general perceptible to the touch. . The fcrotum, with its contents the tefticie and its appendages, are liable to both fpecies of the diforder j and the fpermatic cord with its coverings are alfo liable to both. We fhaU firft treat of the fcrotal affedions of this kind. SECTION II. Of the Anasarcous Hydrocele of the Scrotum. THE fcrotum from being entirely ceUular, and conneded immediately with the trunk of the body, is rendered liable to partake of every difrufable fwel- Hng with which the general constitution is attacked : And accordingly we find, that anafarcous fweUings of other parts of the body, feldom fobfift for any length of time, without producing a fimflar affedion of ths fcrotum. A local anafarcous fullnefs of the fcrotum unattended with any general affedion has on fome occafions Ee ai8 Of the Hydrocele. Chap. VL opcafions indeed been produced by a local caufe; viz. by the accidental preffure of a tumor on the lym- phatics of the part; by external injury ; and by an effusion of urine from a rupture of the urethra : But fuch occurrences are very rare, a general difeafe of the constitution being the ufual forerunner of fuch tumors. As foon as water is coUeded in any confiderable quantity in the fcrotum, a foft, inelastic, colourlefi tumor, is obferved over the whole of it; preflure of the finger or of any hard body is eafily received, and the mark of fuch preffure is for fome time retained by it: The fkin at firft preferves its natural appear- ance ; and the rugae of the fcrotum, which in a ftate of health are always remarkable, are not for fome time much altered ; but as the fwelling advances they graduaUy difappear, till at laft they are totaUy obUter- ated : The fweUing, from being at firft foft and of a doughy feel, by degrees -turns more firm ; and the colour of the fkin from being for fome time very lit- tle altered, at laft acquires an unnatural white, fhining appearance. As the diforder increafes, the tumor by degrees becomes larger; and from being originally confined to the ufual boundaries of the fcrotum, it at laft Spreads up the groin ; and the penis bein$ likewile affeded, becomes fo fwelled and distort- ed, as to be produdtive of much inconvenience and diftrefs : And although the fcrotum is eompofed of parts which readily admit of extenfive dilatation, yet in fome inftances the fwelling here becomes fo enor- mous as to burft the surrounding parts entirely. The various appearances we have enumerated 3re fo charaderiftic of the difeafe as to render it almost impoffible to confound this fpecies of fwelling with any other tumor to which the fcrotum is liable. We have already obferved, that inftances now and then occur of the fcrotal anafarca being produced by a local caufe, but by much the greatest proportion of aU gecl:. II. Of the Hydrocele. 21$ all fuch cafes depend upon a general hydropic tenden- cy ; fo that, the cure of this kind of hydrocele muft depend almoft entirely on the removal of that habit of body which originally produced it. The treatment of the general diforder of the con- stitution falls to the province of the phyfician, fo we fliall not here enter into the confideration of it; but the afliftance of Surgery is frequently required for re- lieving that great diftrefs which thefe tumors always produce when they arrive at any confiderable degree of magnitude. In fuch circumftances, the objed of Surgery is, by drawing off the water from the tumor, to diminifh the fize of it as much as poffible ; which not only af- fords much immediate relief, but is a means of the diftended parts recovering their tone more readily than they otherwife would do. Different methods have been propofed for evacuat- ing the water, viz. by the introdudion of a feton, by the trocar, by incisions, and by pundures. All thefe methods, that by the trocar excepted, ferve very effedually to evacuate the diffufed water j and therefore we are to adopt that mode which not only creates kaft pain, but which is leaft liable to be produdive of troublefome confequences ; and this unquestionably is the method by pundures. The feton and long fcarifications may evacuate the water fomewhat more quickly than punctures ; but in dropfical constitutions, fuch as this fpecies of hy^ drocele is commonly conneded with, they almoft conftantly go wrong. . For the firft twenty four hours or fo, fcarifications give the patient much fatisfadion; the water is al- moft entirely evacuated, the tumor is of courfe great- ly diminifhed, and much relief is thereby obtained. About this time, however the fcarified parts com- monly begin to fret, their edges turn hard and m- ■ * 5 flamed, 0.2O Of the Ifyarocek. Chap. VI. flamed, and by degrees an erysipelatous kind of red- nefs fpreads over the neighbouring parts. That fretful uneafinefs which was at firft complain- ed of, by degrees turns into what the patient terms, a, burning kind of pain, which frequently becomes fo tormenting as to destroy reft entirely ; and it but too commonly happens, that all the applications employ- ed for relief, have no manner of influence in prevent- ing the acceffion of gangrene, by which the patient is at laft in general carried off. I wiU not fay that fuch fymptoms are always in- duced by fcarifications, but I have in many instances obServed them ; and on the contrary, although punc- tures do now and then terminate in the Same manner, yet they are by no means So ready to do So.* As Scarifications are So apt to produce mifchief here, there is much reafon to fufpect that either the trocar or Seton, which both give ftill more irritation, would commonly prove more hurtful. They are now accordingly in this species of the hydrocele very generally laid afide. When fcarifications are to be employed, the meth- od of doing it is, with the fhoulder of a lancet to make two or three incifions on the moft depend- ing part of the fcrotum, each of an inch in length, and extending no deeper than the cutis vera : Ancj when pundures are to be depended on, they are like- wife to be made of this depth with the point of a fpear pointed lancet; and five or Jix on the moft prominent part of the tumor will commonly prove fufficient. This number will in general evacuate the Water very quickly ; but when they do not prove ful- ly adequate to the effed propofed, or when in the courfe of a day or two, thefe now made are found to heal, they may be renewed from time to time as pften as is neceffary. Preferving * Vide Le Dran's operations, with Chefclden's notes, p, 116 ; and Treatife on Hydrocele by Mr. Pott, p. 40. 3ect, II, Of the Hydrocele. ti % PreServing the parts as dry as poffible, by a frer quent renewal of dry foft linen cloths, in order to im- bibe the moifture, is here a very neceffary piece of attention; the want of it, I am convinced, is the caufe of much of the mifchief that frequently enfues from operations of this kind. When either fcarifications or pundures go wrong, by beginning to inflame and turn painful in the man- ner we have defcribed; inftead of the warm emollient poultices and fomentations usually employed, a cold folution of faccharum faturni, appUed upon foft linen, not only proves more effedual in putting a ftop to the Sarther progrefs of the inflammation, but affords more immediate relief to the prefent diftrefs. Aqua calcis employed in the fame manner proves alfo a very ufeful application. When, however, the diforder proceeds to gain ground, by a real mortification coming on, we fhould immediately have recourfe to bark and other reme- dies usually employed in fuch affedions. But as we have elfewhere treated fully upon this fubjed, it is unneceffary to enter into a more particular confidera- tion of it here.* It may only be proper to obferve, that although in general, when the fcrotum in this difeafe happens to mortify, the greateft danger is to be dreaded; yet now and then yery unexpeded cures are obtained, af- ter all the teguments have been destroyed by morti- fication. A remarkable cafe of this kind occurred fome years ago in the Royal Infirmary here : The whole fcrotum feparated, and left the testicles quite bare. During the time that the fore remained open, all the water colkded in other parts of the body was evacuated, and by the ufe of large quantities of bark and mild dreffings to the fore, the patient got well. Jn the courfe of the cure, the teftis became enveloped with a kind of cellular fubftance, which ferved as a very * Vide Treatife on Ulcers, &c. Seftion IV\ On Mortification. £22 Of the Hydrocele. Chap. VI, very good means of protedion. It muft have been fome production of this kind, I fuppofe which Hil- danus fpeaks of as a regenerated fcrotum.* We have already obferved, that although this fpe- cies of hydrocele for the moft part depends upon a general dropfical tendency, that fome inftances, how- ever, occur, of a local caufe producing a mere local dropfy of the fcrotum. Thus it has been known to happen, from fwellings in the groin and in the abdo- men obftruding the paffage of the refluent lymphat- ics. When this is the cafe, if the tumors producing fuch obftrudions can be extirpated, no other means will afford foch effedual relief; but when they are fo deeply feated as to render any attempt for removing them improper, the pradice we have already pointed out, of punctures in the moft depending part of the tumor, muft be employed with a view to paUiate foch fymptoms as occur. It fometimes happens in cafes of foppreflion of u- rine, either from caruncles in the urethra, from Stones impaded in it, or from colkdions of matter, that the urethra bursts, and the urine in this manner finding a paffage into the Scrotum, an anaSarcous Swelling of it is thus fuddenly produced, which ftill continues to increafe till the caufe giving rife to it is removed.f In order to prevent the formation of finufes, which in fuch circumftances will otherwife be apt to occur, an incifion fhould be made into the moft depending part of the fcrotum, and carried to fuch a depth as is fufficient for reaching the wound in the urethra. In this manner a free yent will not only be given to the urine already diffufed, but the farther colkdion of it may very probably be prevented. If a flone impad- ed in the urethra is found to be the caufe of this ef- fusion, it ought to be cut out; if a colkdion of mat- ter is difcovered, the abfcefs fhould be opened ; and if * Obfervat, Chirurg. cent 5. obf. 76. f The works of the late Dr. Alex, Monro, p. ,569, Sed. II. Of the Hydrocele. i1% ]£ the obftrudion is produced by caruncles in the u- rethra, bougies fhould be employed for their removal. The caufe being thus removed, if the patient's hab- it of body is good and untainted with any veneral or other general affedion, by dreffing the fore properly with foft eafy applications, the opening into the urethra will probably be brought to heal, and a complete cure will be in this manner obtained. But when fuch ail- ments are complicated with any general diforder of the fyftem, particularly with old venereal complaints, it frequently happens, that neither mercury nor any other medicine has much influence in removing them. Every praditioner muft have met with inftances of this kind. Both in the hofpital and in private I have met with fuch cafes, where, notwithftanding all the means employed for relief, the paffage from the ure- thra remained open, and continued to difcharge con- fiderable quantities of urine. Inftances of the fcrotal anafarca of a local nature, have alfo occurred, from the rupture of a hydrocele of the tunica vaginaUs teftis: When this fpecies of hy- drocele arrives at a great fize, jumping from a height, or a violent blow or bruife of any kind, will readily burft it; and the water not finding a paffage outward- ly, muft neceffarily diffufe itfelf over the whole fcro- tum. Different inftances of this kind have been met with ; two of which are related by Douglafs.* And the fame kind of fwelling has been produced by the water of a hydrocele of the vaginal coat being improp- erly drawn off by the operation of tapping. When the orifice in the fkin is aUowed to recede from the opening into the vaginal coat before the water is all difcharged, the remainder of the colkdion is very apt to diffufe itfelf through aU the ceUular fubftance of the fcrotum. In whichever of thefe ways the fweUing is produc- ed, the cure ought to confift in laying the tumor fuffi- cientiy • Treatife on the Hydrocele, by John Douglafs, p. *. £^4 Of the Hydrocele. Chap. VI. ckntly open, not only for evacuating the diffufed wa-, ter, but for.effeding a radical cure of the hydrocele of the tunica vaginalis. We have thus enumerated aU the varieties of anafar- cous fwellings to which the fcrotum is liable, together with the modes of treatment adapted to each : For with refped to the hydrocele of the dartos,* a difeafe particularly defcribed by ancient writers, as that part of the fcrotum is now known to be altogether cellular, fo any water coUeded in it muft tend to form that very difeafe we have now been defcribing, an anafar- cous fwelling of the whole fcrotum. We now proceed to the confideration of that fpecies of the diforder, which, from its being feated within the cavity of the fcrotum, we have termed the encyfled hydrocele of the fcrotum. Of this there are two varie- ties, viz. the hydrocele of the tunica vaginalis testis; and that species of tumor formed by water coUeded in the fac of a hernia. SECTION III. Of the Hydrocele of the Tunica Vaginalis Testis. WHEN treating of the anatomy of thefe parts* we remarked, that in a ftate of health an aqueous fecre- tion is always found in the tunica vaginalis ; the prin- cipal uSe of which feems to be, to lubricate and keep tiie furface of the testicle foft and eafy. In a healthy ftate, this fluid is abforbed by the lym- phatics of the part; its place being as conftantly fup- plied by a frefh fecretion : But in difeafe, it frequent- ly happens, either that the fecretion of this fluid is morbidly increafed, or that the powers of the abforb- ing veffels of the part are diminifhed. The effed of either of thefe caufes muft be, to induce a preternat- ural colkdion of water in the cavity of the vaginal coat j Sed. III. Of the Hydrocele. 11$ coat; and by a gradual accumulation of this fluid, the fpecies of hydrocele which we are now consider- ing will be at laft produced. The fymptoms and ap- pearances of the diforder are as follow. A fulnefs is at firft obferved about the inferior part of one of the testicles, which is at this time foft and compreffible ; but as the tumor increafes in fize, it alfo becomes more tenfe : No degree of preflure can make the fwelling difappear either at this or any oth- er period of the difeafe : The teguments at first pre- ferve their natural appearance, both as to colour and rugofity ; but as the water accumulates, the fkin grad- ually becomes more tenfe, although feldom or never to fuch a degree as to obliterate the rugse of the fcro- tum entirely. The fhape of the tumor, which was at firft nearly globular, becomes gradually more pyramidal, being larger below than above : In the first flages of the diforder, the fwelling does not extend farther than the ufual boundaries of the fcrotum ; but in procefs of time, it advances by degrees up to the abdominal mufcles; fo that although in the early period of the difeafe, if it be not combined with hernia, or with a hydrocele of the cord itfelf, the fpermatic proc- efs may be always diftindly felt; in its more ad- vanced ftate it cannot poffibly be diftinguifhed.— The weight of the tumor being now very great, the fkin of the neighbouring parts is dragged fo much along with it as to caufe the penis to fhrink confider- ably, and fometimes to difappear almoft entirely: And in this advanced ftate of the difeafe, the tefticie, which ufually lies at the back part of the tumor, and which for fome time after the commencement of the diforder could be diftindly felt, cannot now be evi- dently difcovered. On a minute examination, how- ever, a hardnefs is always to be felt along that part of the fcrotum where the teftis is fituated : And a fluc- tuation Ff 226 Of the Hydrocele. Chap. VI. • tuation of a fluid may in general be diftinguifhed through the whole courfe of the difeafe. It fometimes happens, however, in that very tenfe ftate of the tumor, which a long continuance of the difeafe ufually occafions, that the fluid contained in it cannot be evidently diftinguifhed : Nor in this fitua- tion is the ordinary characteristic mask of hydrocele more to be depended on ; I mean, the transparency of the tumor when expofed to the light of a candle or of the fun. In the early flages of the difeafe, when the contents of the tumor have not become difcolour- ed, and when the vaginal coat has not yet acquired much thicknefs, the contained fluid, on being expofed to this trial, always appears tranfparent; and'when it does fo, it always affords a corroborating proof of the cxiftence of water : Yet its abfence is by no means a proof of the contrary.;, for as the tranfparency of the tumor depends entirely on the nature of its contents, and on the thicknefs of its coverings, whatever tends to render the one lefs clear, and the other of a more firm texture, muft in proportion to this effed invali- date the certainty of the test. During the whole courfe of the diforder the patient does not complain of pain in the tumor itfelf; but fome uneafinefs is commonly produced in the back, by the weight oS the Swelling on the Spermatic cord : This, however, is generally either prevented altogeth- er, or is at kaft much alleviated, by the ufe of a prop- er fufpenfory bandage. Thefe are the ufual appearances of a hydrocele when the difeafe is confined to one fide of the fcro- tum, which is generally the cafe. But on fome oc- cafions a double hydrocele is met with, in which both testicles are affeded in the fame manner ; and in which the tumor, inftead of being confined to one fide of the fcrotum, occupies the whole of it equally. As there are fome diforders with which this fpecies of hydrocele is apt to be confounded, it is particula rly neceffary Sedl III. Of the Hydrocele. • 227 neceffary to attend to fuch circumftances" as moft readily charaderife it. Thefe diforders are, All the variety of fcrotal herniae ; the anafarcous hydrocele of the fcrotum ; the encyfled hydrocele of the fper- matic cord ; thefarcocek, or fcirrhous tefticie ; and the hernia humoralis, or inflamed teftis. When treating of hernias, we enumerated fuch circumftances as, when properly confidered, will al- moft always ferve to diftinguifh this fpecies of hydro- cele from every variety of thefe diforders : To what was then faid, we muft here therefore refer* It has on fome occafions, we are told, been con- founded with the anafarcous tumor of the fcrotum; but the means of diftinguifhing the two difeafes are fo evidently pointed out in the histories we have given of their appearances, as to render it quite un- neceffary to enter farther into their confideration. In- deed it must be grofs inattention only, which _ can ever render the anafarcous fpecies of hydrocele liable to any degree of doubt. From the encyfled hydrocele of the fpermatic cord, it may commonly be eafily diftinguifhed, by the tef- ticie in the latter being plainly felt at the under part of the tumor ; whereas in this difeafe, when the teftis is perceptible, it is always at the back part of it: And in this fpecies of hydrocele, the fwelling begins in the under part of the fcrotum, and proceeds upwards : Whereas in the encyfled hydrocele of the cord, it makes its firft appearance above the epididymis, and by degrees falls down to the inferior parts of the fcro- tum. By this difference alone thefe two fpecies of hydrocele may be always diftinguifhed from one an- other. The circumftances which moft clearly diftinguifh this kind of tumor from a fcirrhous tefticie are thefe: In the latter the fwelling is hard and firm ; it does not yield in any degree to preffure j the furface of the * See p. 313, 228 Of the Hydrocele. Chap. Vt the tumor is rough and unequal; it is in general at- tended with a good deal of pain, and is always heavy in proportion to its fize. Whereas in the hydrocele, the fweUing commonly yields to preflure ; its furface is fmooth ; little or no pain takes place ; and the tumor is fight in proportion to its bulk. Thefe differences will always ferve as a fufficient means of diftindion between this fpecies of hydrocele and a pure unmixed farcocek. But when a fcirrhous tefticie is combined with an effufion oS water into the tunica vaginalis, forming what has very properly been termed a hydro farcocele, the means of diftindion are not fo obvious. In the incipient ftate of fuch effu- fions, the difference between the two difeafes is fuffi- cientiy apparent; but in the latter Stages of it, the. moft attentive obServer commonly finds it difficult, and Sometimes impoffible, to mark the diftindion. In fuch doubtful cafes, however, by proceeding in the cautious manner to be afterwards pointed out, no det- riment will occur to the patient from any uncertainty of this nature. From the hernia humoralis this fpecies of hydro- cele is eafily diftinguifhed. In the former, the tumor fucceeds either immediately to fome external bruife ; or it is evidently the confequence of a gonorrhoea, or of fome other inflammatory affedion of the urethra.* The fkin is more or lefs affeded with an imflamma- tory rednefs ; it is attended with a confiderable degree of pain, efpecially on handling, and the fwelling is hard and firm ; fo of courfe no fluduation can be diftin- guifhed in it, unlefs in its more advanced ftate, when Suppuration Sometimes takes place, and when the uSual fymptoms of abfcefs, particularly the pointing of the * The operation of,lithotomy is frequently attended with an irr- flammation of one, and fometimes of both, of the tefticles ; proba- bly from the inflammation induced by the operation in the neigh- bourhood of the caput gallinaginis, being communicated along th- V3S differens to the teftes, Sed. III. Of the Hydrocele. 22£ the tumor, and its being much difcoloured, ferve to distinguish it fufficientiy. In forming a prognofis of this difeafe, we muft be direded almoft entirely by the habit of body of the patient. In general, v/e are to confider it as a local affedtion ; and in that ftate the moft favourable ex- pedations may be formed of the event; for, whatever may have been alleged by fome writers as to the haz- ard of every operation for a radical cure of the difor- der, in a Ample unmixed hydrocele, and in a found healthy constitution, it may at any time be advifed with a very fair profped of fuccefs. In the radical cure of the hydrocele, in whatever way it is attempted/ fome pain will be occafioned ; rhe parts will inflame, and of courfe fome degree of fever muft be expeded. In fome inftances, thefe fymptoms have gone rather farther than was juft nec- effary ; but under the limitations I have already men- tioned, of an unmixed ftate of the diforder in a con- stitution otherwife healthy, whenever the operation has been properly performed, I can fafely aver, that of a very confiderable number I have operated upon my- felf, as well as of many I have been conneded with, I never knew one inftance of any thing bad occurring. But on the contrary, in constitutions otherwife dif- eafed ; in old people ; and in infirm habits of body ; we are by no means to exped fuch certain fuccefs : Even in fuch circumstances, the operation very fre- quently fucceeds ; but it muft be acknowledged that it now and then fails. The fymptomatic fever is apt to run too high for the ftrength of the patient; and the fuppuration produced by a high degree of inflam- mation tends afterwards to destroy entirely the remains of a constitution already much impaired. This, how- ever, ought not to be laid to the account of the opera- tion, but to the real difeafed ftate of die patient. When, therefore, this diforder occurs in a healthy Constitution, I would conclude, from aU the experience I have 230 Of the Hydrocele. Chap. VI. I have had in it, that little or no danger is to be dreaded from any neceffary operation : And on the contrary, in a difeafed ftate of body, that fome rifk is always incurred by every operation that takes place ; and the degree of rifk we may fuppofe will be always in proportion to the nature and extent of that difeafe with which the constitution is affeded. As long as a fwelling of this nature keeps within moderate limits, patients in general rather fubmit to the inconvenience produced by it, than undergo the pain of an operation ; at least this is commonly the cafe among people of better rank, who can more readily put up with any diftrefs which it occafions, than the poorer fet of patients, whole daily labour is frequently impeded by large tumors in the fcrotum. Among thofe of the former clafs, inftances occur of the diforder having existed for a great length of time without being productive of much inconvenience : But even among thefe it commonly happens that they become anxious ; fatigued with uncertainty ; and are at laft induced to fubmit to the operation.—In all fuch inftances, when the constitution is" otherwife found, this may be undertaken, as we have already re- marked, with an almoft certain profped of fuccefs ; but when the fyftem is materially difeafed, a patient had better fubmit to any inconvenience produced by the diforder, than undergo an operation for a radical cure : And this may be the more eafily agreed to from the relief which people with tumors of this kind always experience from tapping, which is termed the Palliative Cure ; and which when it is properly done, if the conftitution is not greatly impaired indeed, may be always submitted to without any dread of its prov- ing hazardous. Various methods are propofed by authors for the treatment of this diforder. All of them, however, may be reduced to two general heads ; viz. fuch as have in view only a temporary relief, and which, as we Sed. III. Of the Hydrocele. 231 we have juft now obferved, is termed the Palliative Cure ; and fuch as are intended for effeding a Radi- cal Cure, or a final removal of the diforder. Whatever advantages may be experienced, from the ufe of internal medicines, in dropsical affedions of the conftitution, no praditioner, I beUeve, has fo much confidence in remedies of this kind, as to ex- ped much benefit from them in any partial hydropic colledions of the encyfled kind: We have daily proofs of their general failure in almoft every affection of this nature; and in no fpecies of dropfy do they prove more ineffedual than in the hydrocele.—We are told, in- deed, of cures having been performed by different medicines, particularly by the ufe of strong drastic purgatives: I have known them employed, but never with advantage; and when pufhed to any extent, they are fore to hurt the conftitution.—As it is always nec- effary, however, to confine the patient to bed for fome time af^er any operation that takes place, in order to prevent his being afterwards disturbed, it is proper to empty his bowels by a laxative immediately before I he operation; but this is almoft the only medicine that can be requifite. Internal medicines, therefore, being found ineffedual, as well as external applica- tions, we are to feek for that relief from Surgery which experience fhows it is capable of affording. When the tumor in the fcrotum has acquired fuch a fize as to become inconvenient, if the patient either sefufes to fubmit to the operation for the radical cure, or if his ftate of health renders that operation improp- er, in fuch circumftances, the palliative treatment, or a mere evacuation of the water by pundure, is the only means we can employ. There are two methods propofed for drawing off the water in this manner, viz. by the pundure of a lancet, or with a trocar—It is aUeged by fome, that by the mere puncture of a lancet the water can nei- ther be fo completely or fo properly drawn off as when the 1& Of the Hydrocele. Chap. VI, the trocar is employed; for the orifice in the fkin be- ing apt to recede from the opening in the vaginal coat, die water is thereby either ftopt altogether, or is apt to infinuate itfelf into the furrounding parts. By others again it is faid, that the difficulty of intro- ducing the trocar is fuch as to render it hazardous from the contiguity of the tefticie ; and inftances are not wanting to fhow, that even in the hands of expert furgeons the teftis has been very materially injured by a trocar reaching it in this operation. Indeed, the ordinary form of this inftrument, which is triangular, renders its introdudion both difficult and unfafe; but the trocar of a flat form which I propofed fome years ago, enters with as much eafe as a lancet.—In Plate X, different inftruments of this kind are reprefented, of a proper fize for this operation.—And as with a trocar of this kind an opening may be made into the tunica vaginalis with perfed fafety, and the water with this instrument being much more freely evacuated than by a mere pundure with a lancet, which is apt to produce an effufion into the cellular fubftance of the fcrotum, the mode of effeding it by the lancet ought therefore to be laid afide. The inftrument being fixed upon, the next point of importance is the part of the tumor moft proper for the operation. Even in this fimple operation, an ac- quaintance with the anatomy of the parts will appear to be very neceffary. We have already Shown, that the testis does not hang altogether loofe in the vagi- nal coat; but on the contrary, that its pofterior part is firmly conneded to the body of the testicle; fo of confequence at this part there is no water to be met with between the fcrotum and teftis; and according- ly it would be highly improper to attempt an opening at this place : For if through ignorance the trocar fhould be inferted here, one inftance of which I have feen, the inftrument would for certain pierce the body y«/. 2 Plate X Ov. 3. 'A r>*, kA/,0/ ~Af. h » Sed. III; tfihe Hydrocele* 233 of the tefticie, and would not, after all, evacuate the water. The moft proper part for introducing the inftru- ment is the moft anterior point of the under part of the tumor; The patient being feated on a chair* with the tumor hanging over the edge of it, the ope- rator with his left hand fhould grafp the tumor on its back part, fo as to pufh the contained fluid as much as poflible into the anterior and under part of the fwelling. Having done fb, he then makes an open- ing through the fkin and cellular fubftance, of about half an inch in length, with the fhoulder of a com- mon lancet, on that point where the trocar is to en- ter. This gives very litde pain to the patient; it is done in the fpace of a fecond or two, and it enfores an eafy paffage to the point of the inftrument; a cir- cumftance which divefts this operation of all kind of hazard. The operator now takes the trocar in his right hand, and having fixed the head of the inftrument in the palm of the hand, he places the fore finger along the courfe of it, leaving juft as much of the point of the inftrument uncovered as he thinks ought to penetrate the tunica vaginalis, and this being introduced in a gradual eafy manner, the ftilette is to be withdrawn immediately on the end of the canula having entered the cyft. The water will now run off; and if the tumor be not of a great fize, it may be all evacuated at once : But when the fwelling is large, as the fud- den difcharge of the fluid, by taking away too quick- ly the fupport which it afforded to the veffels of the testes and vaginal coat, might endanger the rupture of fome of them, it is better every now and then to ftop the flow of it for a few feconds; and when the whole is thus evacuated, and the canula withdrawn, a piece of adhefive plafter fhould be immediately applie^So the orifice, and a comprefs of foft linen beingpnd over Gg 234 Of the Jfydrccele. chap, vr; over the fcrotum, the whole fhould be firmly fop- ported by a proper application of the T bandage.* The patient being- in this ftate laid in bed, it com- monly happens, that in a few hours all manner of uneafinefs is gone, and he goes about his ordinary bufinefs without farther interruption : Now and then, however, the fore produced by the trocar fetters; and the inflammation thus produced, in fome in- ftances, has been known to terminate in a radical cure of the diforder. Such occurrences, however, are rare, and are by no means to be depended on. This operation, when done with attention, is eafily performed, and is feldom produdive of any mifchief; but when not performed with caution, and1 efpecially when the patient is allowed to go about immediately after the water is evacuated, it fometimes terminates in very troublefome fymptoms. Even when done with every poffible attention, if the patient's habit of body is bad, it fometimes goes wrong. Of this eve- ry praditioner may have feen fome inftances more or lefs remarkable : And two cafes are related by Mr. Pott; one of which terminated fatally ; and in the ofiher a mortification ehfued, which in the fpace of a few days destroyed not only a good deal of the fcrotum, but ev.:i a confiderable portion of the tunica vag- inalis, -j- Both of thefe indeed occured in very un- healthy constitutions ; but it is proper to have it known, that this operation may in fuch habits of body be produdive of thefe confequences. In found healthy people, it feldom or never ends in any thing bad; but the event of thefe cafes of Mr. Pott and others, ought to convince us that it fhould not be attempted where the fyftem is evidently much difeafed. Drawing the water off in this manner in order to relieve the patient from the bulk it produced, was the 9fi± firft *-£ome very judicious remarks on the importance of a due degree of compreflion in fuch cafes may be met within Dr. Monro's ob» (ervations on this fubject, loco citato. f Cafes xxi and xxii, Treatife on the Hydrocele, Sed. III. Of the Hydrocele. 235 firft idea that occurred to praditioners in the treat- ment of the Hydrocele ; but this being found inef- fedual for the complete removal of the difeafe, various other methods were afterwards introduced. The adual cautery and the ligature were both propofed as means of preventing farther defcents of water from the abdomen, which in former times was confidered as the origin of this diforder. Celfus orders a cyft of a hydrocele to be cut away, and many of his follow- ers do the fame. Tents, both foUd and hollow, were afterwards employed ; as was likewife the ufe^ of the feton, which we find recommended by Fabricius ab Aquapendente, and other writers even of a more early period. The ufe of various applications of the cauf- tic kind has at different times been in vogue : Injed- ing wine, diluted ardent fpirits, and other irritating liquids, into an opening in the vaginal coat, has been propofed as a means of inducing a degree of inflamma- tion fufficient for effeding a radical cure; and a sim- ple incifion of the cyft containing the water has been pradifed for the fame purpofe. Thefe, I think, comprehend all the variety of means which at different periods, have been employed - for the cure of the hydrocele. Ancient praditioners feem to have been acquainted with all of them ; but having very inaccurate ideas of the anatomy of the parts concerned, they could not have any fixed or clear opinion of the manner in which any of their rem- edies operated in effeding a cure. In confequence of this they were applied very much at random ; and no method proving at aU times fuccefsful, the igno- rance they laboured under in the theory of the dif- order rendered changes of remedies very frequent in the treatment of it. One material advantage obtained by the moderns in this point is, that by knowing the water" to be con- r rained in a particsilar cyft with which no part of jhe *'- jbody communicates, they are thereby left at Uberty f 36 Of the Hydrocele. Chap. VI. to apply their remedies without any dread of injuring parts which were formerly fuppofed to be conneded with the testicle ; and by finding that the water col- leded in this difeafe, is in many refpeds in a fimilar fituation to the contents of other tumors, with the means of curing which they are well acquainted, they have ventured from analogy to transfer the method of treatment found to fucceed in thefe diforders, to this fpecies of the hydrocele. Matter coUeded in a particular cavity or cyft, we fuppofe to be in circumftances very fimilar to water coUeded in the tunica vaginalis testis. In both Situ- ations, the contents of the tumor are fecluded from accefs to the external air; and neither of them have any communication with any other part of the body. And although the bag containing the matter of an en- cyfled tumor is in Some meafure a new formation, yet in many inftances it is found to be equally firm and elastic with the tunica vaginalis testis. In the treatment of encyfled tumors, praditioners are now agreed, that, befides evacuating the matter, means muft be employed for destroying the cavity which contained it, otherwife a return of the diforder may in general be expeded. To accomplifh this, different methods have been propofed ; fome with a view to destroy entirely the cyft which contained the matter ; and others, as it is faid, to fill up the cavity of the cyft with a formation of new parts. But we now know, that unlefs the coats of a cyft are much extended, and greatly thickened indeed, that there is no reafon whatever for removing any part of it. It is alfo known, that to fill up the cavities of tumors with a creation of new parts, is a mere imag- inary matter, being what neither art or nature ever effects to any extent: And we likewife know, that the cavity of almoft every tumor may be more effecT tually destroyed by producing an adhefion of its fides than by any other means. Sed. Ill, Of the Hydrocele, %$f Parts of the human body in a ftate of infkrmtiation very readily adhere to one another. Indeed fo eafily do they do fo that fome art is required to prevent the adhefion of contiguous inflamed parts. By attempt- ing the cure of abfceffes and of encyfled tumors, on principles analogous to this, the fame phenomena were found to happen; for, after difcharging their" contents, it has been found, that cures are commonly" obtained v/ith more eafe and certainty by inducing a fufficient degree of innan*nation on their internal Surfaces, than by any other means. And in like man* ner it is now known, that the hydrocele of the tunica vaginalis, may be treated upon the fame principles, and with the fame general effeds. This is the moft fimpk idea that can be given, of the prefent views of praditioners in the treatment of this diforder ; and I hope it will ferve to render their ideas refpeding it fufficientiy clear. The intention, then, of every means now in ufe for the radical cure of this Species of the hydrocele, is, to induce foch a degree of inflammation on the parts, as may tend to obliterate entirely the cavity of the tuni- ca vaginalis, by making it adhere firmly to the tunica albuginea or furface of the testicle. Some individuals, indeed, ftill proceed upon the fuppofition of a total deftrudion of the fac being nec- effary for a pomplete cure, But the extenfive expe- rience of many of the beft employed furgeons makes it appear very clear that this is never neceffary. When the fac has become very thick, and has been diftend- ed to Such a degree as entirely to have loft its tone, removing a fmall part of it fometimes proves ufeful, by allowing the fcrotum to contrad more readily; but in no other point of view is it in any degree requisite. We know well, that in this, as in every Species of encyfled. tumor, a cure may be, and frequent- ly is, obtained, by removing the fac entirely; for, the contiguous parts from whence the. Sacs have been »38 Of the Hydrocele. Chap. VI. been dtffeded, adhere very readily together, fo as to destroy effectually the cavities in which the matter was contained.* But we alfo know that this is never neceffary, as the fame end may be always obtained by much more gentle means. We fhaU now proceed to the particular confidera- tion of the feveral means at prefent employed by dif- ferent practitioners for effeding a cure, and fhall treat with moft minuteneSs thoSe which are now^ in moft general uSe. TheSe are, - xcifion of the tunica vagi- nalis; the application of caustic; the ufe of a feton j and a fimple incifion of the fac. By Mr. Douglas it is recommended f to destroy the vaginal coat entirely; and his method of doing it, is, first to diffed out an oval piece of the fcrotum, which he confiders as always neceffary; and having dien laid the vaginal coat open, to cut it away by dif- ferent fnips of a pair of fciffors. But if there is, any praditioner who ftill continues to prefer this excifion of the fac, he will find that it may be more eafily dif- feded away by the fcalpel than with fciffors, and it is rarely neceffary to remove any portion of the fcro- tum. The method of cure with caustic is commonly de- fired to be conduded in the following manner: The fcrotum being fhaved, a piece of common paste cauf- tic properly fecured with adhefive plafter is to be ap- pUed, of about the breadth "'of a finger, the whole length of the tumor; and if, on removing the caustic, it has not penetrated the tunica vaginalis, this is or- dered to be done with a fcalpel, fo as to evacuate the contents, lay bare the tefticie, and admit of proper dreffings.^ But * Mr. Elfe afTer,ts, that in the method he recommend* of curing this fpecies of Hydrocele by cauflic, the tunica vaginalis floughs eHT tirely off. t Loco citato. % Douglas on the Hydrocele, pag. 3. Pott, loc, cit. pag. 15$. Sed. III. Of the Hydrocele. 13$ But Mr. Elfe, one of the latest writers in favour of the method by caustic, fays, that there is no neceffi- ty for fuch an extenfive application of caustic as has been recommended by authors : That an efchar of the fize of a Shilling anfwers the-purpofe fufficiendy ; That this may be always fully obtained by the appli- cation of caustic paste of the fize of a fixpence ; which he direds to be laid upon the anteriour and under •s point of the fcrotum, and to be properly fecured by adhefive plafter in order to prevent it from fpreading.f- The cauftic commonly produces all its effeds in the fpace of five or fix hours, and may then be re- ryoved. At this time digestives, or an emollient poultice, muft be applied over the fcrotum ; and the whole properly fufpended with a bandage. Inflammation, we are told, is foon induced over the whole tunica vaginalis; and the febrile fymptoms which fucceed, are directed to be kept moderate by bloodletting, injedions, Sec. In a few days the efchar of the fcrotum feparates and comes away ; and in a gradual manner, in the courfe of four, five, or fix weeks, the whole tunica vaginalis comes off, when the wound immediately cicatrizes, and a complete cure is obtained. When the feton is to be ufed, the following is©the method of applying it, as is recommended by Mr. Pott, Who has wrote a very ingenious treatife on this fubjed: He ufes a trocar ; a silver canula, five inches in length, and of fuch a diameter as to pafs eafily through the canula of the trocar ; and a probe, fix inches and a half long, having at one end a fine fteel trocar point, and at the other an eye which carries a cord ofcoarfe white fewing filk, of fuch a thicknefs as will pafs eafily through the long canula. With the trocar, the inferior and anterior point of the tumor is to be pierced ; and as foon as the perforator is with- drawn t Vid. AnEfTay on the cure of the Hydrocele of the tunica vagi* Aalis teffis, 2d edition, p. 33, $43 Of the tiyclncelt. £hap. VI; drawn, and the water difcharged, the feton canula is paffed through that of the trocar, till it reaches the Upper part of the tunica vaginalis, and can be felt in the very fuperior part of the fcrotum. This being cjone, the probe armed with its feton is to be convey- ed through the latter canula, the vaginal coat and teg- uments to be pierced by its point, and the feton to be drawn through the canula till a fufficient quantity is brought out at the upper orifice, when both the canu- las are to be withdrawn, and the operation is finifhed. About the end of the third day, the parts begin to inflame ; when fomentations, poultices^ a fufpenfory bandage, a temperate regimen, and a lax beUy, are or- dered, to keep the fymptoms moderate : As foon as the parts become eafy by the inflammation kffening, which is generally about the tenth or twelfth day, the feton is begun to be diminifhed, when fix or eight threads are withdrawn at every drefling; the dreffings confifting of nothing more than a fuperficial pledgit upon each orifice, and a difcutient cerate, fuch as the feratum faturninum, to cover the fcrotum. In ufing the feton, I fhould wifli to follow the method here defcribed, in every other point except in the mode of introducing it; an eafier method or do- ing^it being now difcovered. In a former publica- tion, I have defcribed the manner of opening abfcefles by a feton ; and the diredions then given, prove equally applicable here. Let an opening be made, either with a fcalpel or a lancet, in the fuperior part of the tumor, large enough to admit with eafe a cord of white fewing filk of a proper fize. The curved diredor with an eye at one end, * in which the cord is' inferted, is to be introduced at this opening ; and its farther extremity being carried down to the moft depending part of the tumor, an opening is there to be made of about half an inch or fo in. length, by cut- ting * Delineated in the Treatife on the Theory and Management of Ulcers, &c. Sed. lit. Of the Hydrocele. 24! ting upon the end of the diredor with a fcalpel. The diredor being now drawn down till a fufficient quanti- ty of filk is left hanging out below, the operation is then finilhed. In every other refped the management of the feton ought to be the fame with the method we have defcribed from Mr. Pott. By making tlje firft opening in the fuperior part of the tumor, the inftrument conduding the feton is more eafily introduced to the farther extremity of the fwelling, than when the firft opening is made below ; for in this cafe, the tumor remains diftended to the laft: Whereas, when opened below, the water rufhes cut immediately; and the vaginal coat Collapfes fo much about the teftick, that I have feen a good deal of difficulty in getting the instrument insinuated be- tween them, by which I have been fenfible of the tef- ris being confiderably injured. Before entering farther into the consideration of this method of cure by the feton, we fhall proceed fo de- fcribe the operation for a radical cure by incifion. The patient being placed upon a table of a conve- nient height, and being properly fecured by two affifl> ants, with the fcrotum lying nearly upon the edge of the table, the operator with one hand fhould grasp the tumor fo as to hold it firm and make it fomewhat tenfe on its anterior part; and with a common round edged fcalpel in the other, he fhould now divide the ex- ternal teguments by one continued incifion from the fuperior extremity of the tumor all along its anterior furface down to the moft depending point of the fwelling.' By this means, as the divided fcrotum retrads a little, the tunica vaginalis is laid perfedly bare, for the breadth of about half an inch from one extremity to the other. An opening is now to be made with a lancet into the vaginal coat, juft at its upper extremi- ty where the firft incifion commenced. This opening fhould be of fuch a fize as to receive the finger of the H h operator; 242 Of the Hydrocele. Chap. VI. operator ; which being inferted, the probe pointed biftoury is to be conducted upon it, and by means of it the fac is to be divided to the very bottom, all along the courfe of the firft incifion. By the previous divi- fion of the flcin with the fcalpel inftead of the biftoury, the operation is done with much more accuracy, and with lefs pain ; for the fcalpel from its convexity ad- mits of a much finer edge than an inftrument of any other form is capable of receiving, and hence it cuts with more eafe. By making the firft opening in the upper end of the fac, much trouble and inconvenience is prevented, which making the first orifice below is fore to occa- fion : For, as we have before remarked, when the tu- mor is first opened below, the water is instantly evac- uated ; and as this produces an immediate collapfe of the tunica vaginalis, the paffage through it is not af- terwards eafily difcovered. Whereas, by making the firft opening above, as the water is thereby evacuated gradually as the excifion is extended downwards, the vaginal coat continues diftended to the bottom till the incifion is completely finifhed. We have not thought it neceffary to fay any thing here of the probe pointed fciffors, an instrument which fome time ago was very generally employed in this operation : For wherever the knife can with proprie- ty be ufed, no furgeon of thefe times will hefitate in preferring it. We have direded the incifion into the vaginal coat to be carried from one extremity of the tumor to the other. Many furgeons, with a view to faye fome pain to the patient, advife the incifion both of the fcrotum and tunica vaginalis to be only two thirds of the length of the tumor. But the difference of pain thus produced is very little ; being indeed nothing when compared with the uncertainty of a radical cure not being obtained by it. When the incifion is car- ried the whole length of the tumor it is rarely found to Sed. III. Of the Hydrocele. 243 to fail; and I have known fundry inftances of thefe partial openings being followed with a return of the difeafe. * The incifion being completed in the manner we have direded, the tefticie covered with its tunica al- buginea comes into view. Sometimes the teftis pro- trudes from the wound altogether; in which cafe it fhould be replaced with great caution, and ought by all means to be covered as quickly as poffible from the external air; and provided none of the tunica vaginalis is to be removed, this may be always done inimediately by finifhing the dreffing diredly on the fac being opened. When the fac is not much thickened, there is no neceffity for removing any part of it; but when it is difcovered to be otherwife; to be thick and very hard; the removal of a portion of it on each fide of the incifion, makes the cure of the remaining fore more eafy and expeditious. As in this hardened ftate, the fac generally feparates with great eafe from the furrounding teguments, any quantity of it may be eafily taken away with the fcalpel without the leaft danger of wounding the fcrotum. Some writers in- deed advife part of the fcrotum itfelf to be cut away on every occafion ;f but even in the moft enlarged cafe of hydrocele I ever met with, no neceffity ever appeared for removing any part of it. On examining the tefticie after the divifion of the vaginal coat, it is generally found to be of a foft tex- ture, and of a more pale complexion than in a healthy ftate: On fome occafions it is confiderably enlarged; and on others, I have feen it reduced to a very fmall fize, confifting of the tunica albuginea almost quite empty. As the cure of the fore, however, advances, the tefticie in a gradual manner commonly regains its ufual bulk; of mis I have feen different inftances, and a very • Mr. Pott is clearly of this opinion, hoc, iit. p. 163* t Vide Douglas on the Hydrocele, 136, &44 Of the Hydrocele. Chap. VL a very remarkable cafe of the fame kind is recorded by Douglas.* We have hitherto foppofed that the diforder is con- fined to one fide of the fcrotum ; but now and then, as we have elfewhere remarked, a double hydrocele^ met with. The ordinary pradice in fuch a cafe, is, to do the operation twice in all its parts, both in the fcrotum and tunica vaginalis; to lay each colkdion open from top to bottom, by a double incifion. Some- , times both operations are done at the fame time; but in general praditioners are afraid of too much inflam- mation being thus induced, fb that one is commonly allowed to heal before the other is attempted. In this manner the patient is expofed to delay, uncertain- ty, and to the hazard of two complete operations. It may be done, however, in a much eafier man- ner, with much lefs pain, and in lefs time, than in the ordinary method,- After finifhing the operation on one fide, by mak- ing an opening into the vaginal coat of the oppofite tefticie at its upper extremity through the feptum fcroti, and continuing the incifion down to the bottom of the tumor, the cyft is thus equally well laid open, the wa- ter is as completely evacuated, and the patient is liable to as little hazard of a return of the diforder, as if the operation had been done in the ufual manner. From the account we gav.e of the anatomy of the fcrotum, no danger, it is evident, can occur from any divifion of the feptum, which we have fhown to be entirely eompofed of cellular fubftance; and in fad I have twice had an opportunity of performing this op- eration in the manner here direded upon a double hy- drocele, and in both inftances with moft complete fucceSs. Whether the hydrocele be double or confined to one tefticie, as foon as the water is aU evacuated, and any part of the vaginal coat removed that may be nec- effary, * Loc, cit, p, 194, Cafe JI, Scd. III. Of the Hydrocele. 245 effary, the wound ought then to be dreffed; and on this it may obferved, much of the fuccefs to be ex^- peded from the operation depends. If the vaginal coat be juft wrapped about the testi- cle without the interposition of any kind of dressings partial adhefions are apt to occur, before a degree of inflammation is produced fufficient for rendering the cure complete. By this means cavities are kft, which either fill with pus during the progrefs of the cure, or afterwards afford an opportunity for colkdions of wa- ter, and thus occafion a return of the diforder; differ- ent inftances of which I have met with. And again, a defire for fluffing the cavity of the fore too much with dreffings has alfo been a frequent caufe of mifchief. By their rubbing or preffing too much upon the. furface of the tunica albuginea, a part which nature never intended to be much expofed, fuch a degree of inflammation is fometimes induced as to be produdive of much pain, inflammation, and fever: But it is commonly the fault of the operator when this is the cafe ; for in a found healthy conftitu- tion, it feldom happens that either of the occurrences we have mentioned take place when the dreffings are properly managed. The method I haye uniformly found to fucceed, is this : The tefticie, if it has pufhed forwards, as it fometimes does, out of the fcrotum entirely, being cautioufly replaced, a piece of foft lint fhould be in- ferted between it and the divided vaginal coat, firft on one fide of the divided fac, and then on the other, reaching from the fuperior part of the tumor to the moft depending point of it. One end of each piece of lint ought to be left out of the fore, to fold over the edges of the wound ; and the other ought to be gently pufhed in between the teftis and the vaginal #coat, about halfway between the external incifion and the bottom of the fac : If lefs is inferted, it does not with certainty anfwer the purpofe ; and I have com- monly %tfi Of the Hydrocele. Chap. VI- monly found that a fingle ply of fine lint may be in- introduced this length without any difficulty, and ex- perience fhows it to be fufficient. A comprefs of foft linen being now applied over the tumor, the whole fhould be properly fufpended with a bandage ; and for this purpofe, either the T bandage, or the com- mon fufpenfory bag, may be employed. The patient is now to be carried to bed ; an anodyne fhould be preScribed ; and he ought to be enjoined to remain as much in the Same pofture as poffible, for much mo- tion in this ftate of the fore certainly does mifchief. The intention of this operation being to induce a moderate degree of inflammation in the parts chiefly affeded, viz. the tunica vaginalis and tunica albugin- ea, if the pain, inflammation, and fwelling, which in fome degree always fucceed to the operation, do not run to a great height, nothing is to be done for the firft two or three days after the operation : But, when thefe fymp- toms become violent, and efpecially when any confid- erable degree of fever is induced, it muft then be the bufinefs of art to prevent their going too far. The remedies to be ufed for this purpofe, are, bloodletting, according to the ftrength of the patient; gentle laxa- tives, So as to preServe an eafy ftate of the bowels ; a low cooling diet; and warm emollient poultices and fomentations to the part, in order to forward a plenti- ful fuppuration, which commonly tends to moderate every bad fymptom more effedually than any other remedy. By thefe means the inflammation may in almoft every inftance be kept within proper bounds : From all the experience, indeed, which I have had in this diforder, I might fay that it may be done in every in- ftance ; for I never yet Saw any thing to the contrary, where the operation was properly perSormed, in a Sound healthy conftitution. When, again, the pain, inflammation, and tumefac- tion of the parts, do not come to a great height, the cataplafms. Sed. III. Of the Hydrocele. 247 cataplafms and fomentations need never be employed before the fourth day : About this time, by foment- ino- the parts, and applying a large emollient poultice over the whole, the external dresfings are commonly eafily removed about the fifth or fixth day. At this. time, on taking them away, the edges of the lore are obferved to be hard, and confiderably swelled ; and the matter difcharged is thin and difcoloured : If the lint inferted between the teftis and the vaginal coat can be eafily taken out, it may at this time be remov- ed ; but in general, it does not come away with free- dom till the third or fourth dreffing, when the fweU- inc of the parts is fomewhat diminifhed. The fore ought to be dreffed once every day or two, according to the quantity of matter produced; and the poultices fhould be continued till a plentiful fuppuration is eftab- liihed. • In twelve or fourteen days from the operation, the fuppuration is in general very freely formed ; and the fwelling of the parts is now fo much reduced as to give the whole a fine healing appearance : The only dreffing neceffary in this ftate of the fore, is a little foft lint, covered with a pledgit of any emoUient oint- ment. The fwelling of the fcrotum now graduaUy fubfides; and the fore continuing to leffen daily, a complete cure is commonly obtained in the fpace of four, five, or fix weeks, according to the fize of the wound and other circumftances. Having thus given an account of the manner of performing every operation at prefent in ufe for the radical cure of the hydrocele, we fhall now make a few obfervations on the comparative advantages of the three laft, viz. the caustic, feton, and the Ample incifion ; thefe being almoft the only means now pradifed for the removal of this diforder. From the teftimonv of many refpedable authors concerning the efficacy of each of thefe, there is no reafon to doubt, but that colkdions of this kind may in general be cured tL$ Of the Hydrocele. Chap. VL cured by any of them. That the caustic, when prop- erly managed, will feldom fail of producing a cure, We have every reafon to believe ; and the fame may be fafely afferted both of the feton and the fimpk in-» eifion. But, it commonly happens, that a practition- er, from being prejudiced in favour of a particular method, continues to pradife that mode and no oth- er ; and finding it in general fucceed, he by degrees conies to persuade himfelf, that other methods of cure with which he has not had fuch opportunities of be- coming acquainted, are liable to objedions, which thofe who have pradifed them do not find to be the cafe. I attended the hofpitals in London about the time that Mr. Pott's publication on the Seton, and Mr. Elfe's Treatife on the. Cure of the Hydrocele by Cauftic, were publifhed ; when of courfe the various means of curing the diforder were frequently the fub- jed of medical converfation. I was thereby induced to pay particular attention to the fobjed ; and having the advantage of feeing the pradice of different hofpi- tals, and not being particularly biaffed in favour of any one method, I was thus furniihed with an excel- lent oppof timity of forming an opinion : And the re- folt of all the obfervation I was either at that time a- ble to make, or fince that period, both in the hofpi- tal here, and in private practice, is, That although all the three modes of operating, by cauftic, the feton, and fimpk incifion, are perhaps equally capable of producing a radical cure; yet that of the three, the lat- ter, viz. the fimpk incifion, is liable to fewer objec- tions, and effeds a cure both with lefs trouble to the operator, and with lefs rifk to the patient : And of the other two, the treatment by cauftic appears to me to be the moft eligible. I have feen all the three methods produce trouble- fome fymptoms, foch as great pain and tenfion of the abdomen, inflammation, and fever* but from much ob- fervation, Sed. IH. Of the Hydrocele. £4$ fervation, 1 can without hesitation fay, that the feton is more frequently produdive of thefe confequences than either of the others: And we need not wonder at this being the cafe; for the cord which is here introduced^ lying in clofe cohtad with the body of the teftis, muft neceffarily occafion a confiderable and continued irri- tation, as long as it remains applied to it. The feton is likewife attended With other inconve- niences, to which neither of the others, when properly hnanaged, are liable. When the inflammation which fucceeds to the introduction of the cord runs very high, as it frequently does, it commonly terminates in fuch a plentiful fuppuration, that the matter pro- duced by it cannot be readily difcharged at the open- ing made for the feton: In confequence of this, it in- finuates itfelf into the neighbouring parts; arid differ- ent abfceffes are accordingly formed, Which muft all be difcharged by as many openings. Even when the operation has been done with much nicety and atten- tion, I have feen it terminate in this manner. Another objedion to this operation, which I think of importance, is this: It does not admit of a free ex- amination, either of the state of the tefticie, or of the fluid contained in the fac. I know; that in a Ample uncomplicated hydrocele, there is no reafon whatever for examining the tefticie; nor would we think of re- moving it either on account of a mere enlargement or diminution of its fize; provided it be not otherwife difeafed. But we know well that cafes do fometimes occur; which elude the utmoft fkill arid penetration oPthe furgeoh; no diagnostic fymptoms with which We are yet acquainted being sufficient to dired us with abfolute certainty. . The moft experienced praditioner muft be fenfi- ble, that at times he has been mistaken in his opinion refpeding the nature of fuch tumors; a real farcocele, or fcirrhous tefticie, attended with fome effufion of a fluid, being now and then mistaken for a pure unmix- Ii ed 350 Of the fydmele. Chap. Vi- ed hydrocele; and, vice verfa, a fimpk uncompUcat- ed cafe of hydrocele has been frequendy mistaken for, and treated as, a fcirrhous tefticie. Such occurrences every praditioner must have met with: And among other writers who confefs their having been deceived in fuch cafes, a very candid acknowledgment of this kind is made by Mr. Pottj* and Mr. Elfe takes no- tice of a fimilar occurrence in which he was con- cerned.f I have myfelf been concerned in different cafesj where the moft experienced Surgeons were at a loSs to determine the real nature of the diforder ; that is, whether the swelling in the Scrotum was a fimpk hy- drocele of the vaginal coat, or an effufion ora fluid into that bag produced by a fcirrhous tefticie. In all fuch cafes where any doubt occurs, the furgeon ought to proceed as if the tumor was a real hydrocele. If, on laying open the fweUing, the tefticie fhould be found difeafed, that is, if it fhould be in fuch a ftate as to require extirpation, it ought to be removed imme- diately ; and on the contrary, if it fhould appear to be perfectly found, the cafe fhould undoubtedly be treat- ed altogether as a fimpk hydrocele. In feveral inftances of this kind, where, by differ- ent praditioners, a mere colkdion of water was ex- peded without any other affedion, the tefticie has been found to be fo much difeafed with a real farco- cek, as to render extirpation highly proper. Now, if in fuch circumftances a cure had been attempted by the feton, the tefticie would have been allowed to re- main expofed to the irritation produced by the cord, which * Treatife on the Hydrocele, p. 288. In this cafe, which from every circumftance had been confidered as a Sarcocele, the teftis, after being removed, was found to be perfectly found ; the difeafe being a real Hydrocele of the tunica vaginalis. There being even a pojjlbility only offuch an occurrence with fuch an attentive obferver as Mr. Pott, ought to ferve as a moft convinc- ing argument with practitioners in general, of the neceffity of pro- ceeding with the utmoft caution in all fuch cafes where there is the leaft caufe for doubt. \ Loc, cit. p. -\. Se&. III. Of the Hydrocele. $5* which in all probability would have induced very troublefome and even alarming fymptoms ; for we know that every Symptom of a Scirrhous or cancerous tumor is uniformly rendered work by irritation. It has been alleged, that the real ftate of the teftis may be always known, by drawing the water off from the tunica vaginalis by a trocar; and this has accord- ingly been recommended as a previous ftep to the in- trodudion of the feton, with a view to afcertain the fituation of the testicle. But it often happens, even after aU the water is drawn off, that the thicknefs pro- duced by the vaginal coat and fcrotum, collapsing in large folds about the teftis, precludes effedually every accurate examination of this kind. We obferved above too, that when the feton is uf- ed, the contents of the vaginal coat cannot be proper- ly afcertained. It frequendy happens, that the water of a hydrocele is contained in a number of hydatids; a circumftance which cannot be difcovered previous to the opening of the tumor: And as it will be read- ily admitted that the method of cure by feton is ill fuited for evacuating hydatids, this of itfelf is a very material objedion to the practice. So that, upon the whole, although the feton in every other refped fhould be equally eligible with the Simple incifion, which for the reafons formerly given I think it is not, yet the two laft objedions we have adduced againft it are fufficient reafons for fetting it entirely aside. With refped to the mode of treatment by cauftic, I have only to obferve, in addition to what was al- ready laid upon this fubjed, that where patients are naturally timid, and do not incline to fubmit to the operation by the knife, this will in general be pref- erable. But the treatment by cauftic is liable to one very material objedion, which never attends the cure by incifion, viz. that of being produdive of iinufes, and collections of matter, in the fcrotum and cellular fubr fiance z$z Of the Hydrocele. Chap. VI, ftance conneding that hag to the tunica vaginalis, One inftance of this I have feen, where it was necef- fary to evacuate different colkdions of matter by dif- ferent openings; and a remarkable cafe of the fame Hind is related by Douglas, where an extenfive incifion was neceffary for removing the coUedions which oc- curred.* For this reafon, therefore, and as the mode by incifion brings the State of the tefticie more evi- dently into view; and eSpecially as, from all the expe- rience I have had of the two Sifferent methods of cure, that by incifion feems in general to be produc- tive of the leaft troublefome fymptoms, \ am clear that it ought to be preferred. In different publications, we read of many dreadful fymptoms induced by this operation for the hydro- cele ; but the fame objedions have been adduced a- gainft every mode of operating hitherto propofed, and the fame will ftill be continued by fuch as judge from partial information. In old, infirm, or difeafed con^ ftitutions, this and every other mode of operating will on forne occafions be productive of troublefome "and perhaps fatal confequences; On. the contrary, aU the three methods of cure of which we have been treating, viz. thofe by cauftic, the feton, and Simple incifion, will in general be found to anfwer the pur- pofe very effedually, of producing a. radical cure of the diforder. What I have been here endeavouring to fhow, and what the importance of the Subject makes me again repeat, is, that this end will com- monly be obtained with more eafe both to the ope- rator and patient by the fimpk incifion than by any other means. In a matter of this kind no perfon ought to form an opinion hastily. Nothing but a variety of opporr (unities of putting the different operations in practice, can enable any praditioner to judge with propriety of the merits of each. In the writings of the late cele- brated * Loc. cit. p. 105. Se&. III. Of the Hydrocele. 253 brated Mr. Sharpe, we have a very remarkable in- ftance of this. In his treatife on the Operations of Surgery,* he fpeaks of the treatment of the hydrocele by incifion as a very dangerous operation, and thinks that it wiU probably be difearded altogether. At that time, it is evident, Mr. Sharpe's experience in this diSorder had not been Sufficient for warranting fuch a decifive opinion. It proved to be very con- trary to the dired experience of fome of our beft Sur- geons ; and Mr. Sharpe himfelf feems afterwards to be convinced that his firft ideas refpeding this operation had been very ill founded.-)- I will not positively Say, that the experience of an- other praditioner wiU not lead him to make a differ- ent conclufion refpeding the fuccefs of thefe three modes of operating, Confequences which I havo not met with, may follow each of thefe methods. My opinion is chiefly founded on my own obferya- tion ; and as the opportunities I have had of treating this diforder, and of being concerned with others in the management of it, in aU the variety of ways we have mentioned, have been frequent and ample, I have deUvered it without referve or difficulty. To thofe who are not thoroughly acquainted with the importance of the fubjed, it may perhaps appear that it has been here treated with more minutenefs than is neceffary; but I khow I will not be confidered as blamable in this particular by praditioners of ex- perience. . . We now proceed to confider the third fpecies of fcrotal hydrocele, viz. that variety of the diforder in which the water is coUeded in the cavity of a hernial fac* SECTION » Tenth Edition, Chap. IX. t Vide Critical Inquiry, Firft Edition, p. 86. 254 Qf the Hydrocele. Chap. VI. SECTION IV. Of the Hydrocele of a Hernial Sac. IN every fpecies of hernia, when the parts have been long protruded, a quantity of a ferous fluid col- leds in the bottom of the fac; and if any obstacle oc- curs to the abforption of this, if the diforder is feated in the fcrotum, we can eafily conceive the poffibiUty of the tumor augmenting to fuch a Size as to afford all the uSual marks of a hydrocele: And accordingly, on consulting the various authors who have written upon hernia and hydrocek, I find a number of cafes enumerated, which fufficientiy warrant the infertion of this as a real, and perhaps not an unfrequent, variety of the diforder. It was well known to the ancients, that a consider- able quantity of a fluid is frequendy contained in the fac of a hernia, along with the parts protruded from the abdomen ; but Saviard feems to have been the firft who entered into a particular confideration of this occurrence. Le Dran relates different cafes of it: Heifter fpeaks of it under the title of Hydroentreo- cele : And the late Dr. Monro defcribes it with his ufual accuracy, and mentions a cafe of this kind where fix pounds of water were evacuated from the tumor by an opening made with the trocar.* A cafe of it is alSo related by Douglas,f and two caSes of a fimilar nature are mentioned by Mr. Pott* The water is in this diforder confined in a cyft formed by a procefs of the peritonaeum, and as it oc- cupies nearly the fame fituation in the fcrotum with the hydrocele of the tunica vaginalis, fo we cannot, by the feel alone, on every occafion, mark the differ- ence between them. For although the tefticie in this fpe«ies * Monro's Works, p. 579. ■\ I.oc. cit. p. 182. % Treatife on the Hydrocele, p. zi. Sea. IV. Of the Hydrocele. 155 fpecies of hydrocele is commonly diftinguifhed more evidfendy at the lower and pofterior part of the fweU- ing than in the hydrocek of the vaginal coat, yet the difference in this particular between the two difeafes is not always fo evident as to prove a fufficient mark of distinction. When a portion of gut and other parts forming the hernia are down, the fulnefs they produce along the fpermatic cord, ferves in fome meafure to diftinguifh the diforder from a fimpk hydrocele. And when, along with this and other fymptoms of hernia, we evidently difcover in the tumor of the fcrotum a fluctuation of a fluid, if this fluid can by preffure be made to dif- appear either entirely or in part, the nature of the dif- order is thus rendered obvious. This fpecies of hydrocele may occur as readily in the hernia congenita as in any other variety, of rup- ture, and in that event, the water muft for certain be contained in the fame fac both with the tefticie and protruded inteftines. Indeed, as all the fluid naturally fecreted for keeping the furface of the different ab- dominal vifcera moift, muft in the cafe of a congeni- tal rupture fall into the hernial fac, we would be in- duced to fuppofe that almoft every cafe of this kind of hernia ought to be complicated with the diforder we are now defcribing. The two cafes of this fpecies ofhydrocele related by Mr. Pott, we find to have been conneded with a hernia congenita ; and I have my- felf feen two inftances of the fame kind. But whether this commonly happens or not, farther obfervation will difcover. Whatever fpecies of hernia this kind of hydrocele may be conneded with, if the water can by preffure be made to pafs into the abdomen, this will always prove a certain charaderiftic of the difeafe 5 for in no other fpecies of encyfled hydrocek is it poffible to make the water difappear by preflure. It may hap- pen, however, in this kind of hydrocek, that this dii- tinguifhing a $ 6" Of the Hydrocelet Chap; Vti tinguifhing Symptom of the difeafe does -not exist * for if by the preflure of a trufs, or from any other caufe, an adhesion is produced in the groin between the fides of the hernial fac, if the under part of the fac continues open with water colkded in it, the tu- mor which it occafions wfll afford all the ufual ap- pearances of a hydrocele, While no part of its contents can be made to pafs into the abdomen by preffure : A cafe of this kind We find related by Le Dran, where the neck of the hernial fac was fhut compktely, and a hydrocele formed in the under part of it. In fuch a cafe, the only means of distinction will be^ an acquaintance with the previous history of the difor- der. Whenever in an ambiguous cafe of this kind it is found, that, before the water began to colled in the fcrotum, the patient had been Uable to a hernia of the fame fide, this circumftance alone will tend much to determine the nature of the difeafe. But even although a mistake fhould occur here, and although this Spe- cies of hydrocele fhould be confidered by a pradition* er as a fimpk hydrocele of the tunica vaginalis, noth- ing bad could enfoe from it j for the treatment adapts ed to one fpecies of the difeafe, would apply with "near- ly equal propriety to the other. But when the protruded parts ftill remain down* unlefs the operation for the bubonocele is at the fame time fubmitted to, no other operation fhould be at- tempted than that of difcharging the water by a punc- ture with a fmall trocar, when the fize of the tumor renders fuch a Step neceffary* For unlefs it was in- tended to perform the operation for the hernia at the fame time, much mifchief might enfue from expofing the bowels to the external air, by laying the tumor open for a radical cure of the hydrocele. Whenever in this fpecies of hydrocele it is refolv- ed to have recourfe to the radical cure, the Simple in- cifion ought unquestionably to be employed ; as from the rifk of injuring the bowels or other parts protrud- ed Sect. IV. Of the Hydrocele. "ft ed from the abdomen, neither the feton nor cauftic are here admiffible. Indeed this confideration of itfelf af- fords a very strong argument in favour of the method of treating the hydrocek in every inftance by incifion, which lays all the parts concerned in the diforder open to view : The very poflibUity of a patient being kill- ed by a feton paffing through a portion of intestine contained in a hydrocek, is a weighty objedion againft the feton being ever ufed ; and every praditioner muft acknowledge, that when the Spermatic procefs along the groin is much diftended, and when the vaginal coat of the teftis is much thickened, Such uncertainty often occurs as to render it impossible for the moft lkilfol furgeons to determine with precision what the contents of fuch fwellings reaUy are. In the two in- stances above alluded to, of a hydrocele conneded with a congenital hernia, and which I met with fome years ago, there had not been previoufly in either of them any caufe to fufped the real nature of the cale. They were both by fkilftrl practitioners taken to be Colledions of water in the tunica vaginalis without any complication whatever ; and in each of them, on the tumor being laid open, together with water in contad with the testicle, a piece of intestine was found protrud- ed into the upper part of the fcrotum : In one of the cafes, too, a fmall portion of omentum accompanied the gut. In this laft, it was propofed, at a confultation of different furgeons, to employ the feton. For fome reafon or other, this was fortunately rejeded; for, on laying the tumor open by incifion it evidently appear- ed, that if a cord had been introduced, it muft in all probability have paffed through the protruded gut. The mere poffibiUty, thereSore, of fuch an occurence, I would confider as a very material objedion to the method of treating any cafe of encysted hydrocele by the feton. K k SECTION 2$8 Of the Hydrocele. Ghap,VX SECTION V. Of the Anasarcous Hydrocele of the Spermatic' Cord. IN the anatomical defcription we gave of thefe parts, it was obferved, that, foon after the defcent of the teftis, the paffage along the Spermatic proceSs of the peritonaeum is completely obliterated, by the fides of the paffage adhering to one another through the intervention of cellular fubftance. By external pressure, and perhaps from other cauf- es, this adhefion of the Sides of the peritonaeal procefs in general is very firm in that part of it. which paffes along the groin ; but the fuperior and more internal part of the procefs, is not only more loofe in itfelf^ but is conneded with and enveloped in a very loofe cel- lular fubftance. From this cellular ftrudure of diefe parts we might a priori fuppofe them to be liable to cedematous fwellings, which other parts of the body of a fimilar Stru6ture are frequently attacked with : And accord- ingly we find this procefs of the peritonaeum liable to partake of every anafarcous fwelling with which the reft of the body is attacked : It fometimes accompa- nies afcites ; and it now and then appears as a local diforder, without being combined with either of thefe. The caufes of this diforder in general are, obstruc- tions produced in the lymphatics of the part, by fcir- rhous affedions of the liver, fpleen, and odier abdom- inal vifcera : I have likewife known it induced by the preflure of a trufs applied for the cure of a hernia.* When a fwelling of this kind is conneded with a general anafarcous affedion, the nature of the diforder is fo diftindly marked as to render a particular de- fcription * An inftanee of this kind is alfo mentioned by Douglas, Treatife on the Hydrocele* Sed. V, Of the Hydrocele. 259 fcription of it unneceffary. When it occurs as a local difeafe its appearances are thefe : A colourlefs tumor in the courfe of the fpermatic cord ; foft and inelastic to the feel, and not attended with fluduation. In an ered pofture, it is of an oblong figure; but in a re- cumbent pofture of the body, it becomes more flat, and fome what round. It does not commonly occupy more than the ufual stretch of the cord along the groin; but on fome occafions, it extends down the length of the tefticie, and even stretches the fcrotum to an enormous fize.* By preffure the fwelling can be always made to recede, if not entirely, at leaft in great part, into the cavity of the abdomen; but it in- ftantly returns to occupy its former fituation on the preffure being withdrawn. When a tumor of this kind depends upon a general anafarcous fwelling of the body, unlefs the caufe which gave rife to the original difeafe of the constitution be removed, it would be a vain attempt to endeavour to cure this particular fymptom: And it commonly hap- pens, that thefe fwellings in the groin which occur in the anafarca difappear, when the difeafe of the fyftem at. large is carried off. But when a fwelling of this nature occurs as an original diforder ; produced perhaps by fome local caufe ; a local remedy is then the only means neceffary to be employed. In fuch a cafe, as we have not the general bad habit of body to encounter, which com- monly occurs in cafes of fcrotal anafarca, we need not be fo much afraid of making a free large incifion into the tumor ; and accordingly all that is neceffary to be done here, is this : As foon as the fwelling has ac- quired foch a fize as to become inconvenient, an in- cifion fhould be made with a fcalpel from one end of it to the other, taking care to go fo deep as effedually to evacuate all the water contained in the cells of the part; * A remarkable inftance of this is related by Mr. Pott, who from a fwelling of this kind difcharged eleven Enghfh pints at once. Treatife on the Hydrocele, Cafe X. 26o • Of the hydrocele. Chap. VT part; and as the water is now and then found to have acquired a viScid consistence, this circumftance ren- ders a deep incifion more neceflary than it otherwiSo would be. The contents of the fwelling being aU removed* fome foft lint fhould be inferted between, the lips of' the fore, which muft afterwards be treated in every refped as a fimpk wound from any other caufe; by poultices and fomentations, if much pain and a fcanty fuppuration render thefe remedies neceffary i and by a due attention to djefling fo as to induce the forma- tion of firm granulations from the bottom. SECTION VI. Of the Encysted Hyprqcele of the Spermatic Cord. THE forrounding fubftance of the fpermatic cord being altogether cellular, the formation of encyfted tumors, we may conclude, ought here to be as fre- quent as in other parts of the body; and accordingly we find in fome inftances, that water, inftead of dif- fusing itfelf over the whole fpermatic procefs, is coU leded in one or more diftind cells or cyfls. This kind of hydrocele being on its firft appear- ance very Small, gives little or no trouble, and is therefore feldom much noticed till it .has acquired a larger Size. On fome occafions, the fwelling begins in the fuperior part of the procefs ; but in general, it is firft obferved towards its lower extremity a Uttle above the epididymis. By degrees, however, it Stretches upwards, and on fome occafions So far down- wards as to reach from the abdominal mufcles to the very bottom of the fcrotum; in which cafe, a perfon not verf&nt in diSorders of this nature, may very prob- ably mistake this fpecies of hydrocele for a colkdion in the tunica vaginalis teftis: But we have here a verv charaderiftic Sed. VI. Of the Hydrocele. if>\ charaderiftic diftindion between the two difeafes. In the commencement of this fpecies of fweUing, the tumor is always above the tefticie, which is diftindly felt below it; and even in the moft advanced stages of the diforder, the teftis is found lying at the back part of it, perfedtly unconneded with the fwelling : Whereas, in the advanced ftate of a hydrocele of the tunica vaginalis, although fome degree of hardnefs is always difcovered at that part where the vaginal coat adheres to the tefticie; yet in the latter period of that diforder, when the fwelling is confiderable, the testis itfelf can never be distinctly felt. In the lpecies of hydrocele we are now defcribing, the figure and fize of the penis is not commonly fo much altered, as when the water is colleded in the tunica vaginalis, when the penis is frequently made to difappear almoft entirely. In other particulars, the encyfted dropSy oS the fpermatic cord is very fimilar to the hydrocele of the tunica vaginalis testis. A fluduation of a fluid is ev- idently difcovered on preffure : The tumor is com- monly of a pyramidal form, as is generally too the cafe with the other, with its bafe or largest extremity downwards :* And no preffure has any influence in making it difappear either altogether or in part. This is the appearance of the diforder when the water is contained in one cyft; when it is feparated into two diftind cells, the line of divifion is common- ly evident, by the tumor being at that part fomewhat puckered, or fometimes a little diminifhed in its di- ameter. A fimilar appearance, we may obferve too, takes place when this fpecies of fwelling is combined with a real hydrocek of the tunica vaginalis testis, which * A Hydrocele of the tunica vaginalis teftis is fo frequently of a pyramidal form, with its bale downwards, that this fhape may be confidered as one of the characterise appearances of the difeafe $ every other tumor to which the teftis and its coats are liable, being either more round, or of a more irregular fhape. 0.62 Of the Hydrocele. Chap. VI. which on fome occafions it is : And in that cafe a line of feparation is obferved at that part where the upper extremity of the tunica vaginalis terminates. We have already mentioned the means of distinc- tion between this fpecies of hydrocele and that of the vaginal coat of the teftis. The only other affedions with which it is in danger of being confounded, are the anafarcous hydrocek of the fpermatic cord ; and a real hernia, either of the omentum, or of a portion of gut. From the former, however, as alfo from an omental hernia, it may in general be diftinguifhed bv the feel. Iff neither of diefe can the fluduation of a fluid be in the leaft perceived, and to the touch they are both foft and inelastic; whereas, in this fpe- cies of hydrocek, the tumor has a fpringy kind of feel, and a fluduation is evidently found in it. And in both the other?, the fwelling recedes more or lefs upon preffure, which it never does in this fpecies of encyfted hydrocele. , From a gut rupture it is chiefly diftinguifhed by the tumor beginning, not at the ring in the external ob- lique mufcle, as is the cafe in hernia, but farther down the cord : In the latter, too, the fwelling commonly turns lefs on the patient getting into a horizontal pof- ture ; and it is always confiderably affeded both by coughing and fneezing ; but no pofture, no preffure, nor any accident whatever, alters the fize of this va- riety of hydrocele. The abience of other fymptoms of hernia, too, is here material in the diftindion: For there is'neither pain in the tumor, nor in the abdo- men ; nor ficknefs, vomiting, nor any interruption to the paffage by ftool, as there very commonly are in hernia. Althougii all the aneient writers were quite unac- quainted with the anatomy of the parts concerned-in this diforder, it is evident they were well aware of its existence. We find it particularly defcribed by iEgin- eta. Sed. VI. Of the Hydrocele. 263 eta, Albucafis, and afterwards by Fallopius, Wifeman, &c. Arnaud, in his treatife on hernia, alfo takes notice of it, though not with much accuracy ; and we find it more lately defcribed with exadnefs, by the late Doc- tor Monro, by Douglas, and by Mr. Pott. This species of hydrocek, as alfo the anafarcous fwelling of the cord, and the cedematous tumor of the fcrotum, are all very frequent in infancy. In that ten- der age, however, they generally foon diffipate, and in this they are much affifted by the application of cloths dipped in Spirit of wine ; and I have foen much ad- vantage produced by an application of a strong infu- sion of red rofe leaves, combined with a confiderable proportion of alum. The late Dodor Monro advifes the application of cloths warmed with the fumes of burning benzoin. But in adults, the cyft confining the water gener- aUy becomes fo firm as not to be affeded by any of thefe remedies. So that when it arrives at any confid- erable fize, which it frequently does, either the means for the palliative or radical cure may be employed, as was recommended in the hydrocele of the tunica vag- inalis teftis. When it is intended merely to avacuate the water by pundure, it ought to be done with a trocar, in the fame manner as was direded for a hydrocele of the tunica vaginalis ; taking care to introduce the inftru- ment at the moft depending part of the tumor. And again, when it is intended to effed a radical cure, the fame means are to be employed which we formerly recommended in the other fpecies of the difeafe. There do not here, indeed, occur the fame objedions to the ufe of the feton, as in the hydrocele of the tunica vag- inalis from the prefence of the tefticie : And if we could in every fpecies of hydrocele afcertain with cer- tainty the exad contents of the tumor, the feton might no doubt be employed h«re with fafety and advantage: But as it is clear from what we have already faid upon 264 Of the Hydrocele. Chap. VL this point, that no certainty of this kind c« n be obtain- ed j and as a hydrocele of a hernial fac i which a portion of gut is contained, may be as rcaJdy con- founded with this as with any other fpecies of the dif- eafe ; I would therefore without heiitation -ay this method of cure entirely afide. A material objedion occurs to the method of cure by Cauftic in this fpecies of hydrocek, which is not ap- plicable in the hydrocele of the tunica vaginalis, viz. the water being in fome inftances of this diforder col- leded in two or more diftind cyfts ; different cafes of which I have met with, and fimilar occurrences are related both by Garengeot and Douglas.—Now in fuch an event, if cauftic fhould be applied in the meth- od recommended by Mr. Elfe, upon a fmall fpot on- ly, all the water would not be evacuated ; and in or- der to obtain a complete removal of the diforder, it would be neceffary to repeat the application of the cauftic. This, I think, is an additional reafon for employing in all fuch inftances the method of cure by incifion -, «*» which by laying the tumor open from one end to the other, divides at once all the different cyfts of which it may be eompofed, and faves the patient from that diftrefs and disappointment which muft always be ex- perienced, on a complete cure not being obtained when good reaSons had been previoufly given for ex- Eeding it. We would therefore advife the treatment y incifion in this fpecies of hydrocele, in the fame manner as was recommended in the hydrocele of the tunica vaginaUs; the mode of performing the opera- tion, and the after treatment of the patient, being near- ly the fame in each. We have thus enumerated all the kinds of hydro- cele which can properly be confidered as forming dif- tind varieties of the diforder. In doing fo, as no dif- eafe is defcribed but fuch as every practitioner of ex- perience muft have met with, and of which the fymp- toms 4 Sed. VI. Of the Hydrocele. 26$ toms are clearly and distinctly marked; fo it will not, I hope, be confidered as an unneceflary degree of mi- nutenefs that I have particularly taken notice of them all. I can by no means agree with fome authors, par- ticularly with Mr. Sharpe* and Mr. Elfe,f who think it might be better to confine the defcription of this diforder to two fpecies. We need not indeed wonder at Mr. Sharpe Speaking in this manner : For even at the late period in which he wrote, although the exift- ence of all the varieties of the difeafe we have men- tioned had been defcribed by different authors, yet they were not till of late years understood with much accuracy; and it is very evident from Mr. Sharpe's writings on this fubjed, that his ideas of thefe diforders were in many refpeds more confufed than could have been expeded in one of his ufjual accuracy and pene- tration. But whatever was the cafe with Mr. Sharpe* it is truly furprifing, that thofe who are unquestion- ably well informed in every circumftance relating to this diforder, and who muft be convinced, from their acquaintance with diffedion, of the existence of aU the varieties of the difeafe that have been mentioned, fhould objed to their being retained. Where no evi- dent or marked diftindion occurs between one tumor and another, an attempt to eftablifh a difference would be ufelefs, and therefore improper; but where ap- pearances point out an obvious variety, it would sure- ly be confidered as an unpardonable negled in an au- thor to omit the detail of them. In our defcription of the five different fpecies of hydrocele, viz. the anafarcous fwelling of the fcrotum; the hydrocele of the tunica vaginaUs teftis; the hy- drocele of the hernial fac ; the anafarcous fwelling of the fpermatic cord ; and the encyfted coUedion in that part ; it was neceffary in going along to enume- Ll rate • Treatife on the Operations of Surgery. f Loco citato. 266 Of the Hydrocele. Chap.Vl. . rate the fymptoms of each as they occur feparately and uncombined. It fometimes happens, however, that one, two, or more of the different fpecies occur at the fame time in the fame patient: On fome occafions I have met with three, and not unfrequently with two, varieties in the fame perfon : The late Dodor Monro mentions an inftance of four fpecies of hydrocele being all combined in one cafe.* In fuch occurrences fome difficulty and confusion is, no doubt, to be expeded j but praditioners in form- ing a judgment of their nature, muft be entirely di- reded by a due attention to the various fymptoms which ufually occur in a feparate ftate in each variety of the difeafe. We now proceed to the confideration of the other varieties of falfe hernia $ and firft of the Hematocele. • See his works, p. 57$. CHAP. Chap. VIL Of the Hematocele, t6y CHAP. VII. of the HEMATOCELE. 1HE Haematocele is a tumor in the. fcrotum or fpermatic cord, produced by extrav- afated blood. The ufual feat of fuch tumors is in the tunica vag- inalis of the teftis; but on fome occafions they are feated in the fpermatic procefs, and now and then they are met with in the dartos. Tumors of this kind are in general produced by the rupture of one or more blood veffels, in confe- quence of external violence. Blows upon the fcrotum have produced ruptures of veins, not only in the cel- lular fubftance of the fcrotum, but in the vaginal coat of the tefticie; and accidents of a fimilar nature have produced fimilar affedions in the courfe of the sper- matic cord: And as the parts in this fituation are very lax and cellular, the rupture either of an artery, or of a vein of any confiderable fize, will always be attended with a plentiful extravaSation of their contents. In the tunica vaginalis teftis, this diforder is fre- quently induced by the point of" a trocar or of a lancet in tapping for a hydrocele, wounding Some of the blood veffels of the fac, which in fuch cafes are always much enlarged. In fuch an occurrence, we are com- monly rendered certain of what has happened, by the water drawn off being foddenjy tinged with blood; but on other occafions if;, does not appear till the water is all evacuated, and then a tumor of a confidr erable 26d Of the Hematocele. Chap. VII. erabk fize is frequently produced in the courfe of a very fhort fpace of time. In fome of thefe cafes where the bulk of water has been remarkable, the fudden difcharge of it, by tak- ing away the fupport which the veffels of the part have been for fome time accuftomed to receive from it, has undoubtedly been the caufe of the rupture of fome of them ; and from repeated obfervation I think it may be confidered as a certainty, whenever a tumor is produced either in the fcrotum or fpermatic cord, fuddenly after the water of a hydrocele has been evacu- ated by tapping, that it is entirely the confequence of art extravafation of blood ; for colledions of water are never known to arrive fo quickly at a confiderable fize. In the fpermatic procefs, injuries of the fame kind will be attended with a fimilar effed upon the fmaUer veins of the fac containing the water; and more con- fiderable violence has On fonie occafions produced a rupture of the fpermatic artery and vein. But, in whatever way the tumor has been produc- ed, the appearances are nearly fimilar to thofe of wa- tery colledions in the fame parts, fo that we do not confider it as neceffary to repeat them here : Only it may be obferved, that when blood is extravafated in the fcrotum, it is eafily difcovered from a colkdion of Water by the colour, it being in every refped a real Ecchy moils. When the fweUing is feated in the tu- nica vaginalis, the means of diftinguifhing between blood and water, is, that a tumor produced by the former, feels to be more heavy than water in propor- tion to its bulk ; and they Who are much accuftomed to handle foch diforders, are on many occafions fenfi- ble of a difference of confiftence. The treatment here is nearly the fame that we have already recommended in cafes of hydrocele. In the commencement of the anafarcous or diffufed fpecies of hasmatocek, when produced by a flight external vio- lence, Chap. VII. Of the Hematocele. S6§ knee, whether in the fcrotum or fpermatic pr6cefs, the application.of ardent fpirits, or of a folution of alum, will on fome occafions effect its difcuflion: But when this, upon trial, is not found to fucceed, the tumor is to be laid open, and in every refped treated in the fame manner as was direded for the hydrocele; only, if a ruptured blood veffel is difcovered, the only ef- fedual means of preventing a return of the diforder is to fecure it by ligature. In the fame manner, all colledions of blood, either in the vaginal coat, of the teftis, or in the Cyft of a former hydrocele of the fpermatic cord, are to be laid open by an incifion extending the whole length of the tumor, and are to be treated as we formerly direded for hydrocele. And, as we have already advifed in the diffufed fpecies of hematocele, if any ruptured veffel comes into view in the courfe of the operation, it ought to be immediately fecured by ligature. It fome- times happens, however, in affections of this kind, both of the fpermatic procefs arid tunica Vaginalis tef- tis, that the veffels from whence the blood is difcharg- ed cannot be detected; a very confiderable oozing continuing from day to day, notwithstanding the ufe of bark, vitriolic acid, and every other means com- monly employed in fuch cafes. If, after a proper trial of all the ordinary remedies ufed in cafes of haemorrhagks, the veffels from whence the blood is difcharged cannot be otherwife fecured, the end in view may frequendy be obtained*by extir- pation of the tefticie; which, in fuch occurrences, is the only remedy from which any advantage is to be expeded. Another fpecies of haematocek is taken notice of by Mr. Pott, in which the blood is contained within the tunica albuginea of the teftis. It proceeds, he thinks, from a relaxation or diffolution of part of the vafcular ftrudure of the tefticie ; and when the quan-, tity of blood coUeded is confiderable, it produces, 27© Of the Hamatocele. Chap. VII. Mr. Pott remarks, a fluduation fomewhat like to that of an hydrocele of the tunica vaginalis. When this happens to be mistaken for a hydrocele, as it has fometimes been, and an opening with a trocar is made into it, a difcharge is produced, of a dark dufky coloured blood, nearly of the confiftence of thin chocolate ; but although fome diminution may be made in the fize of the tumor, by the evacuation thus obtained, yet no confiderable alteration is effeded by it. Any perforation that is made into it, accordingly does no good; and as the testicle is commonly fo far Jpoiled by the difeafe as to be rendered quite ufelefs, castration is advifed as the only effectual remedy.* . I have different times met with a difeafe very fim- ilar to this deScribed by Mr. Pott: But as the blood in Such inftances did not appear to be extravafatedi but to be ftill contained in the veffels of the teftis in an enlarged varicofe ftate, I would not incline, there- fore, to refer this kind of tumor to any fpecies of ha> matocek. I have even feen this diforder mistaken for a hydrocele, and treated as foch, by a trocar being plunged into it, when the effeds were juft fuch as are defcribed by Mr. Pott. But, if the blood had been extravafated, a more copious difcharge ought to have taken place, in confequence of the operation, than was procured by it in.any of the cafes I have met with : Even where the tumor has been of a confiderable fize, I never found it poffible to evacuate in this man- ner more than a fpoonful or two of blood ; and al- though in fuch cafes the blood appears evidently to be thicker than it ought to be, yet it is by no means fo much fo as fhould prevent it from being freely dif- charged by the canula of a trocar if it was lodged in a ftate of extravafation. But in all the inftances I have ever feen of this diforder, the blood appeared to he #ill contained within its proper veffels in an enlarged varicofe * Mr. Pott's Treatife on the Hydrocele, Chap. VII. Of the Hematocele. 271 varicofe ftate ; So that, inftead of considering fuch a tumor as a variety of haematocek, I would rather re- fer it to a'species of Varix. In any cafes of this kind that have occurred to me, when the tumors were not opened, but were entirely trusted to the fupport afforded by a fuSpenSory, they have in Some inftances remained for many years with- out being produdive of any mifchief: And they are commonly attended with this peculiarity, that when effedually Supported by a bandage, they remain sta- tionary for a great length of time, without acquiring any additional fize ; a circumftance which no fupport will prevent either in a hydrocek or in the real hae- matocek. But as foon as the tumor, by being mif- taken for a hydrocele, is touched with an inftrument with a view to evacuate its contents, it is from that moment fore to go wrong. The patient, from being previoufly liable to litde or no pain, immediately en the tumor being opened becomes very much diftreff- ed; the Swelling then begins to increaSe, and in a gradual manner to prove fo troubleSome by Srequent difcharges of blood, as to render caftration abfolutely neceffary. Even diis difagreeabk reSource does not always prove a certain relief; for it fometimes happens, that fuch a Spongy relaxed ftate of the veffels occurs along the whole courfe of the cord, that although they are fecured by Ugature today, the blood bursts out from different parts of the fore tomorrow. I happened once to be concerned in a very melancholy inftance of this kind : After the ufual operation of caftration, frefh haemorrhagies occurred at every dreffing ; the veffels were at different times fecured by ligature, but to no purpofe ; the blood burft out again and again; and the patient, after fuffering much diftrefs, at laft died. The only difference which, before laying the parts ©pen, can be obferved between this fpecies of tumor and %Ti Of the Hatnatocele. Chap. VIT. and a real hydrocele of the tunica vaginalis, is, that in this, the fluctuation in the fwelling is never fo evident as in the other; the tumor is heavy in pro*portion to its fize ; and if properly Supported by a bandage, it does not receive any additional increaSe. Whenever theSe circumftances, therefore, occur in the fame cafe, it ought to afford much reafon to fiifped that the fweUing is of this nature, and that accordingly it ought not to be meddled with. As I confider this diforder to be entirely of the varicofe kind, I would not have thought of introduc- ing the confideration of it here; but as it was proper to mention its having been taken notice of by others as a fpecies of hematocele, I thought it better to fin- ifh the difcuflion of it at once, than to be under the neceffity of bringing it in again in a fubfequent chapter. CHAP. Chap. VIII. Of the Varicocele, &o VJ3 CHAP. VIIL of the VARICOCELE, CIRSOCELE, SPER* MATOCELE, and PNEUMATOCELE. By the firft of thefe terms is meant, a varicofe diftention of the veins of the fcrotum ; which in this ftate form a tumor of hard knotty in- equalities, feldom attended with pain, and in general produdive of no inconvenience except what arifes from its bulk. The Cirfocele is a tumor of a nature fimilar to the former, in the courfe of the fpermatic cord, extending from the Superior part of the fcrotum to the abdom- inal mufcles, and produced by a varicofe diftention of the fpermatic vein. Both thefe affedions are now and then produced,. by obftrudion of one kind or another in the veins of thefe parts: But moft frequendy they depend on a de- bilitated relaxed Slate of the veins. When tumors in the courfe of the veins are deted- ed as the caufe of fuch fweUings, or when the preffure of a hernial trufs upon the fpermatic procefs is dif- covered to be their origin ; the removal of this evi- dent caufe of the difeafe ought to be the firft attempt towards a cure. If the preflure of a trufs has been the caufe of the fwelling, an alteration in the bandage may probably remove it. If tumors of a hard fcirrhous nature have produced it, their extirpation," when that is found to Mm be 274 Spermatocele, GV. Chap. VIIIv be pradicabk, wUl be the moft effedual means that can be employed ; and if the tumors have any ten- dency to Suppurate, warm emollient applications will be more ufeful than any other remedy. But when a general relaxed ftate of the veins is fuf- peded to give riSe to the complaint, Such remedies ought to be employed as will moft effedually recover that tone, of which they have been deprived by being long overdiftended. For this purpofe nothing com- monly anfwers fo wen as the ufe of a proper fufpen- Sory bandage ; a horizontal pofture ; the cold bath ; and the application of a folution of alum and other astringents, to the parts affeded. By a due continuation of thefe means every affec- tion of this kind may be always prevented from in- creafing, and wiU commonly be fo far relieved as to render tie harfh means by the knife, the cautery, and ligature, recommended by ancient writers for the re- moval of foch tumors,, unneceflary. By the term Spermatocele,, is meant, a morbid diftention of the epididymis and vas deferens, produc- ed by a Stagnation of femen. This maybe produced by tumors, ftridure, or inflammation, about the caput gallmagmis, or in the courfe oS the vas deferens ; but there is reafon to think, that it is more frequently in- duced by the laft, viz. by inflammation, than by either of the other two. When an inflammatory affedion of the parts is difcovered to be the caufe of the difeafe, general and topical bloodletting, gentle laxatives, a low cooling diet* and reft of body, will commonly be found the moft effedual remedies. And again, when tumors are difcovered to prefs upon the vas deferens, they ought either to be brought to suppurate, or their ex- tirpation fhould be attempted when that can be done with propriety. At other times, thefe tumors are found to depend on a venereal caufe j and in fuch in- ftances Chap. VIIL Of the Pneumatocele. 27 5 dances a weft direded courfe of mercury has been known to remove them. On fome occafions we are told, that all the other means having failed, caftration has at laft been found requisite. This, however, we cannot fuppofe to be ever a very neceffary meafure. The term Pneumatocele, is applied to signify a dif- tention of the fcrotum by a colkdion of air. This has been defcribed by moft of the ancient writers as a very frequent occurrence; but there is much reafon to think, that a great proportion of all the tu- mors they take notice of as containing air, were either formed by coUedions of water, or by a protrufion of fome of the bowels. That fpecies of hernia to which young children are liable, is to this day by our com- mon people termed a Wind Rupture ; as are all thofe coUedions of water in the fcrotum with which new born infants are affeded: But we know well, that none of thefe tumors are formed merely by wind ; their contents being of a very different nature. In wounds of the lungs, air is fometimes thrown into die Surrounding cellular fubftance, and in that way paffes into the fcrotum, as it does in particular inftances over the whole body ; and in high degrees of putrid difeafes, fo much air may be feparated from the blood, as to distend the ceUular fubftance of the fcrotum, as weU as of other parts : But a real pneu- matocele has never, probably, existed as a mere lo- cal affedion of the fcrotum ; at leaft I have never feen it. In the cafe of air diffufed into the cellular fubftance of thefe parts, in confequence of a wound or any other affedion of the lungs producing an extravafation of it, the fame method of cure will anfwer for its removal that we recommended for anafarcous fwellings formed by water, viz. fmall pundures with the point of a lan- cet, which are found to be fully fufficient for evacuat- ing great quantities of air. But whenever the difeafe 27 ^ Of the Pneumatocele. Chap. VIIL is induced by fuch a great degree of putrefcency in the fyftem as is neceffary for effeding a feparation of air from the blood, there can be litde reafon to exped any advantage to refult from whatever means may be employed for refief. CHAP, Chap. IX. Of the Sarcocele. 277 CHAP. IX. of the SARCOCELE, or SCIRRHOUS TES- TICLE. BY the term Sarcocele, is under- flood, a firm flefhy kind of enlargement of the testi- cle : A fimpk inflammatory affedion of die testis af- fords a tumor of fome degree of firmnefs; but the true farcocele, or fcirrhous teftick, is attended with a hard- nefs never to be met with in the real hernia humoralis or inflamed tefticie. A fcirrhous tefticie, in the courSe of its progrefs, puts on fuch a variety of appearances, as renders it difficult by defcription to give an adequate idea of it: In general, however, the acceffion and progrefs of the difeafe is as follows. m An unufual degree of hardnefs, attended with a trifling enlargement of the whole teftis, proves in gen- eral to be the firft indication of the difeafe : In the beginning no difcolouration is obferved, nor is there any material pain : In a gradual manner the tumor acquires a larger fize : As yet it remains smooth and equal on its furface; but with the fize of the fwelling, the hardnefs alfo becomes more remarkable: SUght pains are at times felt through the fubftance of the tumor ; and if it be not Suspended the patient com- plains of fome uneafinefs in his back. When there is nothing particularly bad in the con- ftitution, the diforder will on fome occafions remain in this fituation for a great length of time ; and in a few inftances, by a moderate diet, keeping an open belly, Suspending the tumor properly, and avoiding 1 r violent «78 Of the Sarcocele* Chap. IX. violent exercife, the diforder has not only been pre- j vented from increafing, but has in a gradual manner diffipated : Such favourable occurrences, however, it must be owned, are exceedingly rare; for the fwelling, inftead of difcuffing, or remaining stationary, in gen- eral proceeds with more or lefs rapidity to turn worfe. The tumor acquires a larger fize ; becomes ragged and unequal on its furface ; and the pain, which at firft was trifling, becomes more fevere, darting, in fmart flings, through the fobftance of the tumor. The inequalities on the furface of the tumor by de- grees increafe, and continue to retain the fame kind of hardnefs with the fweUing from which they originate: On fome occafions, a confiderable quantity of ferum is extravafated into the tunica vaginalis, which, to thofe not acquainted with the nature of foch diforders, gives the tumor the appearance of a common hydrocele: And at other times, inftead of fuch depositions into the vaginal, coat, partial collections of matter are formed through the whole body of the tumor: Thefe by degrees increafe; and the fcrotum, which has hith- erto been gradually distending, at laft bursts, and a discharge takes place from the various coUedions in the body of the tumor, of a thin, fetid, bloody matter. On fome occafions, the fpermatic cord becomes hard and enlarged foon after the commencement of the difeafe ; but in general the cord does not become affeded till the tumor has acquired a confiderable fize, .and moft frequently, I have obferved, not till matter has formed in fome part or other of the fweUing. As the diforder of the tefticie advances, this affec- tion of the cord alfo becomes worfe : From being at firft only flightly tumefied, it gradually turns more hard and fwelkd ; it becomes very painful, and knot- ty or unequal through the whole extent of it. The difcharge from the openings in the fcrotum ftiU continues : But although the matter increaSes in quan- tity, the fize of the tumor is not thereby diminifhed; on Chap. IX. Of the Sarcocele* 279 on the contrary, it Still continues to increaSe : The edges of the fore become hard, livid, and retorted ; and fungous excrefcences pufh out from different parts of it. Whatever was the ftate of the patient's conftitution on the firft attack of the difeafe, in this advanced ftate of it, it is always greatly impaired: He now becomes emaciated j of a pale, wan complexion ; and the dif- order, which in this ftage of it is a real cancer of the moft malignant nature, turning ftill more virulent, by the pain becoming more tormenting, the patient is at lall carried off in very great mifery. Such, in general, is the progress and event of this dreadful diforder, if it be not interrupted by extirpa- tion of the tefticie before the fweUing has proceeded too far. We have already faid .that it exhibits a great variety of fymptoms : Thofe here enumerated occur moft frequendy ; but no defcription can convey a clear idea of all the appearances it affumes. On fome occafions, we have already obferved, it remains ap- parently in an indolent, inactive ftate, for a great length of time, even for years ; and in others, it proceeds fo rapidly, that in the fpace of a few months it has been known to pafs through all the various changes we have enumerated. In by much the greateft proportion of fuch affec- tions the diforder begins in the body of the teftis, af- fecting the whole of it equally ; but now and then it makes its firft appearance in the epididymis, and fome- times even in the fpermatic cord. It has been a pre- vailing opinion, indeed, that a fcirrhous hardnefs tend- ing to cancer, never does begin in the epididymis; but that the tefticie is always first affeded. This is cer- tainly the cafe in general; but every praditioner muft at times have met with cafes of a real cancerous na- ture beginning in the epididymis, and fometimes even in the fpermatic cord, and fpreading from thence to the neighbouring parts.—I might here ir.fert different cafes 22o Of the Sarcocele. Chap. IX. cafes of this nature, which have faUen within my own obfervation ; but Mr. Pott's colkdion furnifhes a fuf- ficient number of weU marked examples of the fad.* In almoft every cafe of a fweUed tefticie from a gonorrhoea, the epididymis is not only affeded before the tefticie, by the inflammation in fuch cafes fpread- ing from the urethra along the vas deferens, when of courfe it muft firft reach the epididymis; but the dis- order in Such caSes, when it begins to yield, always firft removes from the tefticie, leaving in general a Scirrhous hardneSs in the epididymis, which on Some occafions in the courSe of time dissipates entirely, and in others remains of the fame degree of hardnefs for a confiderable time, and now and then even for Ufe. But as the hardnefs produced in this manner is mere- ly the confequence of inflammation upon a membran- ous or vafcular part; fo here as in other parts of the body of a fimilar texture, we feldom find, that hard- nefs thus induced terminates in any thing bad. The contrary, however, of this has been too much inculcated. It has been faid, that the hernia humora- lis produced by a venereal infedion, is a frequent caufe of the worst kind of fcirrhous tefticie ; which, as the fad is very much otherwife, has this improper ten- dency, that it prevents the ufe of, and a proper perfever- ance in, fuch courfes of medicine, as might, without the neceffity of extirpation, have removed it: There have even been inftances of this idea being fo improp- erly applied, as to be the means of different teftes be- ing extirpated, which were evidently diSeafed from a venereal caufe, and which by proper courfes of mer- cury might in all probability have been removed. But although I have faid that affedions of this na- ture, I mean a fwelling of the teftis from a venereal caufe, are very feldom known to end in any thing bad ; yet I will not go fo far as to fay that they never do fo: For I know, that a hardened ftate of the teftis and • Treatife on the Hydrocele, Cafes 42. 48. and 49. Chap. IX* tfthe Sarcocele. 281 and epididymis, produced originally by a Venereal taint, does in fome inftances degenerate into the worst fpecies offarcocek ; that is, that though affedions of this kind do moft frequently terminate eafily, yet that now and then in particular constitutions, whofe pecu- liarities, however, we are not acquainted with, they do certainly produce fcirrhofities of the very worst kind, when fuch ailments would never probably have ap- peared if the original venereal taint had not occurred as an exciting caufe of the diforder. We, know well, that a predifpofition to different diforders will remain long in a latent ftate in the fyftem, without being pro- dudive of any evident affedion, till the application of fome particular stimulus brings it into adion : In the fame manner, a venereal inflammatory affedion of the teftis, will in fome constitutions terminate in much mifehief, although in general its effeds in this way are by no means to be dreaded. I have dwelt longer upon this point than 1 other- wife fhould have done, from a contrary dodrine hav- ing been ftrenuoufly inculcated by one whofe authori- ty is defervedly great, and whofe obfervation in this difeafe has led to the conclufion he endeavours to eS- r.abUfh :* But as all the experience I have had in thefe matters, has led me to form the opinion here delivered, I could not avoid Slating it in the manner I have done. In the treatife aUuded to, we are told, that a hernia humoralis is never, in any one inftance, produdive of this difeafe. If on this fubjed Mr. Pott's idea is juft, it ought undoubtedly to be received : But if it is not, it may very certainly do mifchief, by rendering both patients and practitioners more remifs in cafes offar- cocek proceeding from this caufe than they otherwife would be ; as, by continuing ftill in hopes of a mercu- rial courfe being able to effed a cure, they may there- by allow the difeafe to go too far even for extirpation to be advifabk. Nn In 5 Mr, Pott, Treatife tn the Hydrocele, &c. p. tin, 282 Of the Sarcocele. Chap. IX, In every doubtful cafe of this kind, when a venereal infection is fufpeded as the caufe of the difeafe, blood- letting when ths pulfe is full; an open belly ; a cool- ing- diet; a horizontal pofture ; with a proper fuf- penfory bandage; and a well direded mercurial courfe, will very commonly remove it. But when in fuch inftances the means recommended are put in pradice without any evident advantage; and efpecial- i. ly if, during their application, the diforder, inftead of mending, turns gradually worfe ; as foon as from its increafe in fize there appears to be any rifk of its ad- vancing beyond the reach of operation, it ought then at aU events to be extirpated, whatever the caufe which \ originaUy produced it may have been. Among other caufes mentioned by authors as being produdive of a fcirrhous ftate of the testicles, is the \ hydrocele of the tunica vaginalis. From quantities of a watery fluid being frequently found in the vaginal > coat of a fcirrhous tefticie, it has been suppofed, that .1 the water in fuch cafes was the original caufe of the , difeafe in the teftis, and not the confequence of it.- 1 There is every reafon, however, to think, that in thefe > colledions of water in the vaginal coat, in which the teftis is found difeafed, that the hardened ftate of that organ ought to be confidered as the original diforder, and not the quantity of water which surrounds it. CoUedions of water are no doubt often met with, even in the real Sarcocele ; but this- ought to be con- , fidered only as a different ftage of the fame difeafe: For although the true Scirrhous tefticie is never at firft attended with any collection of this nature, it is natur- al to fuppofe, that a hard difeafed ftate of that viScus muft have Some influence in producing an alteration "j in the quantity of fluid with which the tunica vaginalis 1 is always provided in a found healthy ftate. If it ei- ther produces an augmented fecretion, or a diminifh- 1 ed abforption of that fluid, a dropfical fweUing muft be the certain confequence -, and every fuch coUedion, j combined Chap. IX. Of the Sarcocele* 28$ combined with a fcirrhous tefticie, has been very properly termed a hydrofarcocele. That the teftis, by remaining long immerfed in th» water even of a true hydrocele, does frequently be- come fomewhat altered in its texture, there is no reafon to doubt. Thus, as we have elfewhere obferv- ed, on laying open the tunica vaginalis, the teftis in that diforder is always found to be of a more pale ap- pearance than it naturally ought to be ; On fome oc- cafions it is very much diminifhed, and on others con- fiderably enlarged ; but all fuch enlargements, when conneded with a real hydrocele, are of a foft harmkfs nature, fuch as never give any pain 5 and in this ftate the testis ought never to be extirpated. This is a point, we may remark, which it is of fome importance to afcertain.: For on the idea of thefe en- largements of the testes, frequently conneded with, and perhaps produced by, their immersion in the wa- ter of a hydrocele, being of a real fcirrhous nature, their extirpation has been often advifed, and unfortu- nately too often pradifed. In circumftances of this kind the means of diftinc- tion between the mild and malignant fpecies of en- larged tefticie, by which we fhould in general be di- rected, are the following. When the body of the teftis becomes hard and en- larged, previous to any colkdion of water in the tu- nica vaginalis, fuch colledions as afterwards occur ought not to be confidered as constituting a simple hydrocele; and if, upon evacuating the water by in- cifion, the teftis, befides being enlarged, is found in a r hardened ftate, and especially if it is attended with pain, and is ulcerated on the surface, extirpation ought undoubtedly to be advifed immediately : And, on the contrary, when the water of a hydrocele is known to have been coUeded while the testicle remained found and of its natural fize, whatever enlargement it may- be found to have acquired on laying the fac open, if 2 S4 Of the Sarcocele. Chap, IX. the teftis is neither of a fcirrhous hardnefs, nor affed- . ed with pain or ulceration, we ought unquestionably J to proceed as in a caSe of Simple hydrocele j for any l enlargement of this kind will be rarely found to oc- cafion future uneafineSs, and conSequendy will Seldom or never render extirpation neceffary. In forming a prognofis of this diforder, different circumftances are to be attended to; the age, and habit of body, of the patient; the duration of the dif- eafe, and the ftate it is in at the time. j Thus, whatever treatment is to be adopted, more fuccefs may be reafonably expeded in a young healthy • conftitution than in the reverfe ; particularly if extir- pation of the testis is to be advifed. In the former, the chance of fuccefs from the operation is commonly j confiderable, provided the diforder be not too far ad- \ vanced ; whereas in old, infirm people; and in habits attended with pale, wan complexions ; with indigef- tion ; and other Symptoms of obftruded vifcera j whatever ftate the diSeaSe may be in, little or no ad- vantage can be expeded to accrue from any operation, ' With refped to the duration of the difeafe, if it has already fubfifted for a confiderable time without mak- ing much progreSs, there will be great reaSon to think that it is of a mfld nature; and that the fyftem, in general, is not fo much affeded by it as if its progrefs had been great and rapid ; and laftly, the ftate of the diforder for the time is of much importance in form- ing an opinion of its final event. As long as the tef- ticie is only fomewhat hard and enlarged, without the formation of matter, and without any difeafe of the cord, if the constitution is otherwife healthy, there will be much reafon to exped a favourable event from any operation that ought to take place. But on the contrary, when the diforder is fo far ad- vanced that coUedions of matter have formed, either upon the furface of the tefticie, or in its more internal parts, as in that ftate the conftitution will probably have ' Chap. IX. Of the Sarcocele. 285 have fuffered from abforption, fo there is lefs chance of the operation in thefe circumftances proving fo SucceSsful as in the more early period of the difeafe : ' And this is ftill more remarkably the cafe when the tumor has become ulcerated externally; for we know well, that in all fuch cafes, the fyftem is much more apt to suffer from abforbed matter on the parts being laid open, than while they remained excluded from the external air. In whatever ftate, however, the tumor may be, there is always reafon to exped more fuccefs from the operation while the fpermatic cord is yet found, than when it has become much difeafed ; for, as foon as the cord is materially affeded, the chance of fuccefs from any means to be attempted is always propor- tionably leffened. The cord, indeed, may towards its under extremity be difeafed, even in the fame manner with the teftis itfelf, without kffening the chance of benefit from the operation ; but whenever the diforder has spread fo far up the fpermatic procefs as to render it doubtful whether the parts affeded can be all re- moved by the knife or not, and efpecially when it is once rendered clear that the cord is difeafed within the boundaries of the abdomen, inftead of there being in fuch circumftances any advantage to be expeded from the operation, every attempt towards the remov- al of the parts below, will for certain tend to aggra- vate every fymptom, and wiU be a means therefore of forwarding the patient's death. Whenever a fcirrhous or cancerous tumor is fo fit- uated as to render its total removal by the knife quite pradicabk, it ought always to be advifed ; but when the difeafe has advanced fo far as to render this im- poffible, in whatever part of the body it may be fitu- ated, no attempt of this kind ought to be made, the fad being now clearly afcertained, that cancerous af- fedions are always rendered worfe by extirpation, when aU the difeafed parts cannot be removed. 286 Of the Sarcocele. Chap. IX, It is of much importance, however, to obferve, that the fpermatic cord is in this diforder frequently affeded with a fulnefs and thicknefs of its parts, pro- duced merely by the weight of the tumor, without being in any other refped difeafed. A fulnefs of this kind, when no pain occurs in the cord itfelf, and when there are no knots or inequalities upon its furface, ought never to prevent the operation, when in other refpeds it appears to be neceffary; as a mere enlarge- ment of it very frequently occurs, either from a vari- cofe ftate of the veffels, or from a watery deposition in the ceUular fubftance of the part, when the procefs is not in any other manner difeafed.* But on the contrary, when the cord, at the fame time that it has become confiderably enlarged, hard, and knotty, ad- heres to the neighbouring parts, is painful to the touch, and efpecially if it is already ulcerated ; thefe, if the diforder extends over the whole procefs up to the ab- dominal mufcles, are circumftances which, with every prudent praditioner, will at aU times forbid the ope- ration of caftration.. It has indeed been propofed, in fuch a State of the cord, to enlarge the opening in the external oblique mufcle, fo as by diffedion to trace the difeafed parts even into the cavity of the abdomen, with a view to extirpate them entirely. But although theoretical writers may attempt to amufe their readers with fuch propofals, they will never be ferioufly thought of by praditioners whofe opportunities for obfervation ena- ble them to think and ad for themfelves. We do not think it neceffary to fay any thing, either of the effed of internal medicines, or of external ap- plications, in the removal of this difeafe ; for in the real farcocek, or fcirrhous tefticie, no remedy with which we are acquainted has any kind of influence. Even * Of what is here inculcated we have fome Angular proofs in Mr, Pott's Colletlion of Cafes, which we have fo often referred to as a riepofitary of ufeful fads. See Cafes xxxix. xl, xlix. and 1, Trea- tife oa the Hydrocele, Chap. IX. Of the Sarcocele. 28/ Even cicuta, the powers of which .are fo much extol- led, does not appear to be in any degree ufeful, either in carrying off the diforder entirely, or in mitigating any of its fymptoms. The only remedy, therefore, from which we at prefent reafonably exped any ad- vantage, is the removal of the difeafed parts by extir- pation ; fo that the moft important matter to be here determined, is that period of the difeafe in which the operation is moft advifabk. We have already obferved, that cafes of fcirrhous tefticie do now and then occur with which patients go about for a great kngth of time with litde or no in- convenience : Such inftances, however, are exceeding- ly rare ; for, by much the greateft proportion of all fuch affedions, prove to be of a dangerous malignant nature. With refped to this point, therefore, we may fhort- ly determine, that, whenever a fcirrhous or hardened ftate of the tefticie does not yield to the means com- monly employed, fuch as moderate evacuations of blood when thefe are indicated ; a fbft eafy diet; a lax beUy; the ufe of a fufpenfory bandage; and efpec- iaUy when mercury, which, on the chance of the dif- order being venereal, is very commonly tried, all are ufed without any effed; we may in fuch circum- ftances always have great caufe to SufpeCt that the dif- eafe is of a truly bad nature. When more inveterate fymptoms appear ; when the tumor, which till now was in a hard indolent ftate, becomes painful, and is evidently going on to acquire an additional bulk; no farther delay ought then to be advifed : For however improper it would be to remove a hardened teftis, which for a confiderable time had remained indolent, without pain or any increafe in bulk, yet it would be equally unpardonable in any praditioner to recom- mend a delay of the operation when matters are fo far changed that the tumor is become painful, and is daily becoming larger. In fuch circumftances, the fooner ^38 Of the Sarcocele. £hap. IX. fooner the difeafed parts are removed, the greater will be the chance of a recovery, and not a day therefore lhould be loft. For whatever may have been the opinion of a few individuals on this point, it has long been a fixed maxim with the moft experienced fur- geons, that, in all fcirrhous or cancerous affedions, the rifk of a relapfe after the operation is commonly in proportion to the duration of the original difeafe.* The extirpation of the tefticie being at laft deter-* mined upon, the method of performing the operation is this ; The patient muft be placed in a horizontal pofture on a table of a convenient height, with his legs hanging down, to be firmly fecured by an affiftant on each fide. The parts being previoufly Shaved, if the tumor is very large, an affiftant muft be employed to fecure it properly ; if only, however, of a moderate fize, it is better for the furgeon to do it himfelf. With one hand, therefore, he ought to grafp the fwelling fo as to keep it firm; and with a fcalpel in the other fhould make an incifion along the whole courfe of it; beginning at leaft an inch above the part where the cord is to be cut, and continuing it through the fkin and cellular Substance to die inferior point of the fcro- tum. The eafieft method of doing this, we may ob- ferve, both for the furgeon and patient, is by one con- tinued Stroke of the knife ; as it is both more quickly and more neatly performed in this manner, than in the ufual way of pinching up the fkin between the finger and thumb before cutting it; and there is.no kind of difficulty or rifk in doing it in the manner we have here direded. The fpermatic cord being thus laid bare, the fur- geon is now with the finger and thumb of one hand to endeavour to feparate the fpermatic arteries and veins * The opinion of the late Mr. Sharpe on this point was lingular in a man of fuch extenfive experience. He confidered the rifk of a re- lapfe after extirpation in cancerous tumors to be greater in the mo^e early periods of thefe difeafes than in their more advanced ftates,, Critical Inquiry, 4th edit. p. 108. Chap. IX, Of the Sarcocele. 289 veins from the vas deferens ; which is for the moft part eafily done, and which ought never to be omit- ted, for it is in no degree neceflary to include the nerve in the ligature : And this being done, a firm, waxed, flat cord, eompofed of a number of fmall threads, is by means of the curved needle, Plate V, fig. 4, to be carried round the blood veffels, which are thus to be fecured by a running knot about a quarter of an inch above that part of the cord which is to be divided. The cord being at this part cut acrofs, the tefticie is then to be entirely removed by diffeding the cord and it from above downwards, fo as to feparate them as eafily as poffible from the furrounding parts. Dif- ferent contrivances have been propofed for facilitating the feparation of the teftis from the contiguous parts ; but no invention with which we are acquainted an- fwers this"purpofe fo well as a fcalpel. When the difeafed parts are all removed, the knot upon the cord fhould be united, in order to difcover the fpermatic artery and vein, which by means of the tenaculum may generally be feparated from the nerve with which they are in contad ; and whenever this can be done, they^pught unqueftionably to be fecured in this manner ; for, by including the nerve, no ad- vantage whatever is obtained, and it always renders this a very painful part of the operation. I have feen more pain, indeed, complained of in tying the sper- matic cord in the ufual way, than I was ever witnefs to in any part of almost any operation; fo that when- ever the nerve can be feparated from the other parts, as it very commonly with a little attention may be, it ought always to be left out of the ligature.* When it fo happens, however, that this cannot be done, the ligature muft then be applied in the ordinary manner, and be made to furround the blood veffels and nerves indifcriminately; care being taken to make no more O o preffure * Vide Chirtirgical Cafes and Obfervations, by Mr. Bromfield, Vol, I. P. 33*. 290 Of the Sarcocele. Chap. IX. preffure with the knot than is juft neceffary for the preventing any difcharge of blood. We have defired, that in fecuring the divided blood veffels, both the artery and veins, ought to be.tied ; for if the veins are not included in the ligature, a good deal of blood may be difcharged from them, as they are not furnifhed with fo many valves as the veins of other parts of the body. The cord paffed at the upper part of the procefs is to be left entirely loofe, and to ferve only as a tour- niquet for fecuring the blood veffels more readily in cafe the ligatures paffed upon them fhould accidentally flip. There is in fad no more neceffity for allowing this ligature to remain tied, than there is for leav- ing a tourniquet firmly applied upon any of the ex- tremities after the operation of amputation ; and yet, inftead of one ligature of this kind, it has been the pradice with many,- to apply two, about half an inch distant from one another, by way of very great fecu- rity ; and thefe they leave firmly tied upon the whole fobftance of the cord during the cure of the fore.* There is, however, no kind of neceffity for this precaution, as all manner of rifk may be entirely pre- vented by fecuring the blood veffels in the manner we have here directed. I have often done the opera- tion in this way, and I never faw any inconvenience produced by it. By leaving the ligature at the up- per part of the wound untied, it may be made ufe of to comprefs the cord in the event of the blood veffels bursting out again : But when the operation it prop- erly done, this is an occurrence that will be very fel- dom met with ; and at any rate, when it does unfor- tunately happen, it may be always prevented from producing much mifchief by the ligature left for that purpofe, and which may with fafety be removed at the fecond or third dreffing of the fore. In * Even the late Mr. Sharpe gives thefe direttions. Treatife on the Operation of Surgery, 10th edit. p. SS* Chap. IX. Of the Sarcocele. 291 In making the ligature of the blood veffels at the extremity oS the cord, if it is neceffary to divide the procefs near to the abdominal mufcles, as there is a poffibiUty, of its retrading for a fmall fpace fo as to get it within the ring, die ligature ought to be cut of fuch a length as to admit ofthis; a few inches of it, therefore, fhould be always left hanging over the fore, fo that it may be pulled away at a proper time, in the event of any retradion taking place. But we may here obferve, that this retradion never happens, when the cord has not been too much feparated from the surrounding parts in endeavouring to introduce the ligature below it. Indeed, no farther feparation fhould be attempted than merely to raife the cord fo far as to get the point of the needle introduced be- tween it and the bone. In profecuting the removal of the tefticie, the fcro- tal artery is neceffarily divided, and it is fometimes of fuch a fize as to difcharge a great deal of blood ; in which cafe it fhould always, before going farther, be fecured by a Ugature. The parts being all removed, and the different blood veffels all fecured as we have here direded, a quantity of foft lint fhould be gently laid into the bot- tom of the fore; and a comprefs of linen being ap- plied over it, the whole fhould be fecured either with the T bandage, or with the fufpenfory bag ufuaUy em- ployed in affedions of the fcrotum. The patient be- ing now laid to reft, and an opiate administered, the Tore oUght not to be touched till a free fuppuration takes place, which will commonly be about the fifth or fixth day ; and then the dressings fhould be re- moved, and renewed^from time to time, once every two days or oftener, according as the quantity'of mat- ter renders it neceffary. Now and then, after this operation, the patient complains of much pain in the fore, and of tenfion and uneafinefs in the belly; in which event, warm fomentations fhould be applied to, 2$1 Of the Sarcocele. Chap, IX. to the abdomen, and the fore itfelf fhould be covered with an emollient poultice, to be repeated as often as snt-y be neceffary. In defcribing the manner of performing this opera- tion, we fuppofe it to be done in a cafe where the testicle has not arrived at any great bulk : In fuch a fituation there is never any good reafon for removing any part of the fcrotum, as has been commonly ad- vifed ; * for if the teguments are not difeafed, or ren- dered very thin by being much overstretched, they al- ways recover their tone very foon, and fhould not therefore be removed. But, when the fkin has become very thin and in- flamed, and efpecially if any of it is aduaUy in a ftate of ulceration, all fuch parts of it ought to be removed along with the tefticie. In fuch circumftances the beft method of doing it is this : Inftead of a longitu- dinal incifion along the courfe of the tefticie, the firft incifion ought to be carried in a Straight line to the . under extremity of the fpermatic cord; from whence i two femilunar incisions ought to be continued to the under part of the fcrotum, and fhould be made to in- clude all the parts of the fkin that are in any degree difeafed. In this fituation the remainder of the operation ought to be exadly the fame as we have already de- ! fcribed : The fkin included by the two femilunar I cuts is not to be diffeded off, but ought to be remov- ed at once with the difeafed tefticie. CHAP. * Mr. Sharpe in fuch cafes advifes a portion of the fcrotum al- ways to be removed, p. 55. Loc, cit. $ed. L Of the Thymojts. 2?j| CHAP. X. PF the DISEASES ofthe PENIS. . o»»»; SECTION I. Ofthe Phymosis. , _»• ji 1HE glan the application ofthe found to a fcirrhus or any other tumor. There being the kaft hazard, however, of foch a misfortune occurring as the one we have mentioned, namely, that of a patient being made to undergo all the pain and rifk attending the operation of lithotomy^ when no ftone has existed, is a matter of fuch a feri- ous nature, as ought to render every praditioner ex- ceedingly attentive to this part of the operation. SECTION III. General Remarks on the Operation of Lithot- omy. THE prefence of a ftone in the bladder being af- certained in the manner we have mentioned, the means to be employed for the patient's relief" is the next objed of confideration. At a certain period, the publick were much amuf- ed with high encomiums oh the lithontriptic powers of different articks, particularly of Ume water, and of cauftic alkali in a diluted State. But although fome human calculi are folubk in either of thefe liquids, particularly in the latter when directly immerfed in it, yet neither of theirs can be conveyed in foch a ftate to the bladder as to be much depended on. Many patients, indeed, have experienced fome reUef from the ufe of thefe remedies: The pain has, by their means, been rendere4 fomewhat lefs fevere, and the paroxyfms have apparently been rendered lefs frequent; but we have not one authenticated inftance of a ftone jn the bladder being diflblved by the ufe of thefe, or of any remedy whatever. As the constituent principles of thefe and other li- thontriptic medicines, render them liable to very ma- terial changes in their pafiage through the circulation fcom the Stomach to the bladder, it has been propof- Ss ed 322 Of the Stone. Chap. XL . ed to convey remedies of this clafs diredly into the bladder itfelf, in order to bring them into immediate contad with the ftone ; and machines have, accord- ingly, been invented for' injeding with facility fuch medicines of this kind as are fuppofed to prove moft effedual: But, after a great many trials have been made of remedies of this nature, it feems now to be univerfally allowed among praditioners, that no ibl- vent, powerful enough to have any effed upon a ftone can be injeCted into the bladder, but with the greateft hazard of injuring that organ in a very material man- ner. But as fome praditioners Still continue to thinj< favorably of this pradice, we have given a delineation, in Plate XX, of a machine by which liquids may with great eafe be injeded into the bladder. Every attempt, however, of this kind is now in general laid aside; and as no dependence is to be placed upon the lithontriptic powers of any medicine taken by the mouth, the only refource we have, is, the removal of the stone by a chirurgical operation. By this means, if the patient's constitution is not much impaired, he may again enjoy as good health as he did previous to the appearance of the diforder. And unlefs the ope- ration be Submitted to, it is almoft certain that the re- mainder of a miserable life will be cut fhort by the frequent returns of pain and fever to which people in this fituation are conftantly liable. It is to be remembered, however, that although a great proportion of thofe who are cut for the ftone recover and do well, yet a confiderable degree of dan- ger always attends the operation ; fo that, before ad- vising any perfon to fubmit to it, fuch circumftances ought to be confidered with attention as can beft en- able us to form a juft prognofis ofthe event. By experience it it found, that children more reatj- ily recover from this operation than adults; and it is likewife obferved, that old people, from the fifty fifth to the feventieth year, whofe, constitutions have nor. been Sed. IIL Ofthe Stone. 3^3 been much broke, run lefs rifk from it than men in the full vigour of life. This difference may poffibly arife from the inflammatory fymptoms, which ufually foe- % ceed to this operation,' being more apt to proceed to. a dangerous length in young plethoric people than in older patients; and we know from experience, that more danger is to be dreaded from the effeds of in- flammation after this operation, than from any other caufe. But at whatever period of life the patient may be, if he is otherwife in good health, more fuccefs is to be expected from the operation, than if his consti- tution had been previoufly impaired by frequent re- turns of the diforder ; and this efpecially if the dif- eafe fhould have continued fo long as to produce ul- ceration in any part of the bladder. In fuch a difeafed ftate ofthe bladder as ulceration commonly induces, if the patient is far advanced in years, he could not exped much enjoyment of life, even although he fhould recover from the operation : In thefe circumftances, therefore,' a prudent pradi- tioner would rather decline to operate; and inftead of this, he would advife a plentiful ufe of mucilagi- nous drinks ; the ufe of the warm bath ; together with dofes of opiates proportioned to the degree of pain. By thefe means the violence of the diforder is fometimes mitigated, and the patient Is thereby faved from the diftrefs of a fevere operation, the effeds of which, in a conftitution foch as we have mentioned, are frequently found to prove.fatal. But, even in thefe circumftances, if the patient is" at an early period of life ; if he is Suffering much from the diforder ; and if he is riot fo weak as to render it probable that the quantity of blood ufually loft in the operation may prove deftrudive to him ; I would be clear and decided in advifing the operation. His jchance of recovery will, undoubtedly, be lefs than if his health had been otherwife unimpaired ; but, if he is 324 Of the Stone. Chap. XL- is lucky enough to forvive the operation, he may en- joy life with comfort and eafe. When it is once determined to have recourfe to the operation of extrading the ftone, the next point of irrrpbrtance is the beft method of effecting it. From the anatomical defcription we have given of the parts with which the human bladder is furrounded, it is evident, that there are only two parts of it which calf with any propriety be laid open for this purpofe. A confiderable part of the fundus of the bladder we have fhown to oe covered with the peritonaeum ; fo that to open it here would be attended with immi- nent danger, from the certainty of exposing the ab- dominal vifcera, not only to the effeds of the exter- nal atmofphere, but to the irritation of the urine evac- uated into the cavity of the peritonaeum from the wound in the bladder. The pofterior part of the bladder we have fhown to be either immediately cov- ered with bbne, or internally conneded with parts ■which it would be highly improper to injure ; and thefe particularly are, the redum, the veficulae fern-' fnafes, with the vala deferentia and ureters. The only" parts of the bladder, therefore, which we tin with propriety cut into, are, that portion of the an- terior part of it, which lies immediately below the peritonaeum, and which, when in a ftate of distention, is raifed Somewhat above the pubes; where an inci- fion diredly above the brim oS the pelvis will lay that part of it bare where it is not covered by the perito- naeum, and where accordingly an opening into it is commonly pradicabk : And, again, that portion of the bladder we have termed its neck, which may be opened laterally by an incifion in the perinaeum, with- out afiy danger of wounding other parts of importance. It is in one or other of thefe parts that any opening into the bladder can be made with fafety. Some praditioners, indeed, have attempted to cut into it at the pofterior part of its neck, or even into the body of Seft. IV. Ofthe Stone. 325 of it at once ; but the hazard of wounding parts of much importance is here fo great, that for this and other reafons which we fhall afterwards mention, ev- ery operation of this kind is now laid aside. We fhall prefendy, however, enter more fully into the diff- cuffion of this point, by giving a detail of the various means which have been propofed from the time of Celfus downwards, for the purpofe of extrading ftones from the bladder ; and this we fhall do in the order of time thefe different operations were introduced in- to pradice. The diftrefs and mifery occafioned by urinary cal- culi were probably experienced in the early ages of the world. Relief, we may therefore fuppofe, would be fought for by the removal of the ftones, as foon as fuch a fufficient knowledge of anatomy was obtained as could render attempts of this kind pradicabk. Accordingly we find, from the writings of Hippoc- rates, that, even at this early period, the operation for the ftone was frequently performed; but as this branch of bufinefs was then folely pradifed by a particular fet of men termed Lithotomifts, no account is trans- mitted to us by this author of their method of per- forming it. Celfus is the firft who defcribes the method of operating at the time when he lived ; and it confifted in an opening being made in the body of the bladder, diredly upon the ftone itfelf. From the fmall number of inftrnments ufed in this method of cutting, it has been termed the operation by the Leffer Apparatus. SECTION IV. Of the Operation of Lithotomy by the Lesser Apparatus. THE perfon to be cut being properly fecured, the eafieft and beft method of effecting which we fhall $26 Of the Stew, Chap. XI; fhall defcribe when fpcaking of the lateral operation* the furgeon is then to dip the fore and middle fingers of his left hand in oil ; and having introduced them* into the anus of the patient, he is to Search for the ftone, and to pufh it forward towards the perinasum, diredly below the pubes. In order to facilitate this part ofthe operation fo as to get the ftone properly fixed, the furgeon ought to prefs with his right hand upon the under part of the abdomen, at the fame time that he is pufhing the ftone forward by his fin- gers in die redum. By this means the ftone is to be preffed forward below the pubes, and is to be fecured upon one fide ofthe perinaeum, between thefe bones and the anus. This being done, we are direded by Celfus to make a femilunar cut through* the fkin, cel- lular fubftance, and mufcles ; beginning on one fide ofthe anus, and carrying the cut diredly over the centre of the tumor formed by the .projediori of the Stone. Trie bladder being thus laid bare, a tranfverfe incifion is ordered to be made through the coats of it diredly upon the ftone ; when tfre ftone,- if it is a fmall one, may probably be turned out by the fingers in the redum prefling upon it from behind ; but if jt is large,- and if it does not come away eafily, we are defired by Celfus to take the afnftance of a hook for fco.oping it out. This operation, with a few variations, continued,' fo far as we know, to be the only method of cutting for the ftone, till the beginning of the fifteenth cen- tury, when- another method of operating was intro- duced, which we fhall afterwards relate particularly! Long after this period, however, this operation of Celfus was ftill continued by many regular pradi- tioner.* ; and the eafe with which it is accomplifhed^ not only from-the fmall number of inftruments nec- effary for doing it, but from little or no anatomical' knowledge being abfolutely requifite, preferved it in conftanrufe with Itinerants, who continued, even to a ' " very Sect. IV. Of the Stone. 327 yery late period, to pradife ic in different parts, of Eu- rope, under the name ofthe operation upon the Gripe. This method of cutting for the ftone is indeed fp eafily effeded, particularly in young fubjeds, that, even in thefe times, many of our well informed prac- titioners have a ftrong partiality towards it. At fo late a period as the time of Heifter we find it was much in repute, that praditioner himfelf having been in the habit of performing it frequently. But fur- geons in general have been much deceived with re- fped to the parts injured by this operation : For it has been commonly fuppofed, that by cutting diredly upon the ftone, the bladder itfelf muft alone be wound- ed, while ah\ the neighbouring parts of importance are imagined to efcape unhurt; a circumftance which would undoubtedly prove a strong recommendation of it, if on experience this was found to be the cafe : This, . however, is far from being fo, as any perfon who will make the experiment will readily perceive. A ftriCt attention to the anatomy of the parts might at once indeed convince us of the difficulty, if not of the abfolute impoffibility, of cutting from the perinaeum diredly upon a ftone of the bladder, without destroy- ing either the vafa deferentia, the veficulae feminaks, or the excretory duds of thofe receptacles; the de- ftrudion of any of which would accomplifh the effeds of caftration with as much certainty as a total extir- pation ofthe teftes themfelves. Thefe parts we have fhown to be all placed upon the under and back part ofthe bladder ; and as they, as well as the ureters, are immediately conneded with that part of it which is cut in this operation, it is perhaps impoffible to per- form it without dividing one or other of them. As I had once a favorable opinion of this operation, . I thought that on many occafions it might be ufefully employed, if on experience it fhould be found that thefe pasts could be avoided by the fcalpel. I accord- ingly put it frequently in practice on dead fubjeds ; 32$ Ofthe Stone. Chap. XL but although in all of them it was done with every pof- fible attention, it was conftantly found either that the veficulae feminaks were divided, or that their excre- tory duds were cut acrofs. This, however, was not all; for although in fome instances the urethra was not touched, yet in others it was found to be com- pletely laid open before the fcalpel reached the blad- der. In every instance where the operation is per- formed in the manner direded by Celfus, this circum- ftance of injuring the urethra before opening the blad- der, is what muft unavoidably happen : For it is al- together impracticable to make a tranfverfe incifion here into the bladder, as is advifed by that author, without previoufly paffing through part Of the urethra j that canal at its farther extremity being always pu/hed forward by the fingers in the redum, in fuch a man- ner as to render it impoffible to avoid it in this meth- od of performing the operation. But in moft of the trials of this kind which I had occasion to make upon dead fubjeds, I attempted what I fhould confider as a very material improve- ment of Ceffus's method. A tranfverfe or femilunar incifion through the teguments and mufcles I believe to be better adapted than any other for giving a free paffage to the ftone ; but as the bladder is compofetj of a very dilatable membranous fobftance, there is no fieceffity for a tranfverfe incifion being made into it. After laying the bladder bare, thereforep by a femidr- cular cut along the courfe ofthe ftone, inftead of con- tinuing the fame kind of incifion with which the operation commenced, a longitudinal wound was made diredly on the centre of the ftone, in order to avoid with as much certainty as poffible all thofe parts which ought not to be injured. Even with this precaution, however, although the urethra was avoid- ed, fome ofthe other parts we have mentioned were always found to be divicfed ; fo that although they may by accident, perhrps, be avoided once in a great number Sed. IV; 'Ofthe Stone.' 329 number of inftances; I am confident that evCn the moft expert anatomift would very feldom be able to make an opening into, this part of the bladder fuffi- cient for extrading a ftone even of a very moderate fize, without dividing either the veficula? feminaks, the vafa deferentia, or their excretory duds. In fome inftances, too, the entrance of the ureters into the blad- der is fo low down as to render them liable to be injured by this operation: This, however, is a rare occurrence 5 but it has on fome occafions been known to happem Another very material objedion to this operation is, that the bladder when cut, being pufhed forward and divided at a part which muft afterwards recede from the external wound in the teguments, confidera- ble rifk muft be thereby incurred of finufes formingj by the urine insinuating itfelf into the neighbour- ing parts ; and we have to add to all this, that in general this operation muft be confined to the early periods of infancy. The readings of Celfus with which we are furnifhed, limits the performance of this operation to the age of ten, or from that to the four- teenth year ; but this muft furely be confidered as an error in the late editions of that work, as the opera- tion of which we are now fpcaking is unquestionably better calculated for the earliest periods of infancy tiian for the more advanced flages of it, infomuch that it is always practicable with more or lefs eafe, in proportion to the thicknefs of parts about the redum and bladder ; and this, again, we know depends in a great meafure upon the age of the patient. We are told, indeed, of fome praditioners who performed this operation on people of every age, of every habit of body, and whether corpulent or not: Such ac- counts, hov/ever, have never been well authenticated. Among other improvements of this operation of Celfus, the ufe ofthe forceps for extrading the ftone was none of the moft inconsiderable ; but neither this, nor any other advantage it can receive, is capable of T t obviating 330 Of the Stone. Chap. XL obviating the difficulties we have mentioned. We find accordingly, that, about the beginning ofthe 16th century, fome time between the year 1500 and 1520, a new method of operating for the ftone was propof- ed at Rome, by Johannes de Romanis, as we are af- terwards informed by one of his pupils, Marianus, and whofe name has been commonly given to it; mis being termed the Methodus Mariana, or Lithot- omy by the Greater Apparatus, from the great number of inftruments which on its firft introdudion were employed in it. SECTION V. Of Lithotomy by the Greater Apparatus. BY this operation a paffage is made into the blad- der, by cutting into the urethra immediately at the bulb; and at this opening a variety of inftruments were by ancient writers propofed to be introduced, for the purpofe of dilating the paffage to fuch a fize as might eafily admit of the extradion of the ftone. From the period at which this operation was in- troduced, a number of inventions were propofed at different times, for the fole purpofe of rendering the dilatation of the urethra and adjacent parts more eafy. Thefe it is unneceflary to enumerate, as an account of the operation as it was laft pradifed in its moft improved ftate, will ferve to communicate all that is neceflary to be known concerning it. The patient being properly fecured, and placed up- on a table in the manner we fhall defcribe more par- ticularly when treating ofthe lateral operation, a groov- ed ftaff was then introduced through the urethra into the bladder; the handle of the inftrument being car- ried over the right groin, while its convex part was made to pufh out the urethra on the left fide of the perinaeum. In this pofition the ftaff was preferved by an Sed. V. Ofthe Stone. 331 an affiftant, who likewife fufpended the fcrotum; whik the operator, v.ith a fcalpel in his right hand, made an incifion from the very bottom ofthe fcrotum to within a finger's breadth ofthe anus, carrying it aU along the left fide of the perinaeum, within a very lit- de of the rapha. The fkin, cellular fobftance, and mufcles, being thus divided, the urethra itfelf was now opened at its bulb, by turning the back part of the knife towards the redum, and cutting with the edge of it diredly into the groove ofthe ftaff; and the incifion was then completed by carrying it along to the extremity of the urethra, at die commencement of the proftate gland. Various inftruments were at one period in ufe, termed Dilators, Male and Female Conductors, &c. &c. for the purpofe of finifhing the operation, by di- lating fuch parts as we have not here direded to be cut; and the timidity of fome operators was even fo great as to caufe them to dilate almoft all that part of the urethra which lies between the bulb and the proftate gland: A degree of caution by no means neceflary, and which, by the violence done to the parts, was fore to be productive of many difagreeable con- fequences. Other praditioners, however, performing the operation fo far in the manner we have mentioned, finifhed the remainder of it, firft, by introducing a blunt gorget into the bladder by running its beak a- long the groove of the ftaff, and afterwards pufhing it forward fo as to force a paffage through the proftate gland; and this being accomplifhed, the fore finger of the left hand was introduced along the gorget, and with it the paffage was farther dilated, till the opera- tor thought the opening was fufficientiy large for the ftone to pafs through it. The opening being in this manner finifhed, the ftone was extraded in the manner we fhall afterwards dired when treating of the lateral operation, by the ufe of different forceps adapted to the fize of the parts: And 332 Ofthe Stone. Chap. XI, And in the extradion of the ftone, all thoSe parts which were not cut in the previous fteps oS the ope- ration, were of neceffity very much lacerated. Although this operation was long pradifed, it is li- able to many objedions. The number of instru- ments ufed in it is mentioned as one of thefe : But in the improved ftate ofthe operation we have defcribed, this objedion is entirely removed, no more inftru- ments being ufed in it than are neceffary in the moft fimpk method of performing the lateral operation ; namely, a fcalpel, gorget, and forceps for extrading the ftone. But the material objedions to which it is liable, are, that by beginning the incifion So near to the fcrotum, much more of the urethra is cut than is neceffary : By not dividing the proftate gland with a cutting inftrument, Such laceration is produced, first by the Sorcible introdudion of the blunt gorget, and then by the extradion of the ftone, as muft be the caufe of much irreparable mifchief; And laftly, by the parts not being fo freely divided as they ought to be, it muft frequently be impoffible to extrad large ftones by this operation, which, in the lateral method as it is now pradifed, would pafs with tolerable eafe. In other refpeds, howeyer, this operation was poffeffed of much merit, and it required only to be improved in a few circumftances tp become the real lateral op- eration of modern praditioners. Thefe, however, it is unneceffary to dwell longer upon at prefent, as they will be afterwards particularly taken notice of when we come to treat of that operation. After this operation had been pradifed for thirty or forty years, fome of the inconveniences attending it suggested the idea of what was afterwards termed the High Operation; an appellation it received from the bladder in it being cut into above the offa pubis. About the year 1561, Franco, a French furgeon pf this name, publifhed a treatife on hernias*; and here f Traite tres ample des Hernies, par Pierre Franco. fled. VI. Of the Stone. 333 here we find the firft account of the high operation that is to be met with in books. It was accident which fuggefted it to Franco; for having, as he in- forms us, met with a large ftone in a child of two years of age, which he could not poffibly extrad by the operation as then pradifed in the perineum, he was induced to open the bladder above the pubes: But although the ftone was extraded and the child recovered, Franco never performed the operation a- gain himfelf; and he even advifes it never to be at- tempted by others, from the great danger which he thinks will attend it. The next account which we find given of it is by Roffer, in a publication on this and fome other fub- jeds, publiffied at Paris in the year 1590. But it does not appear that he ever performed the operation himfelf; nor was it any where much pradifed till fome time after the commencement of the prefent century, when it was adopted and keenly patronized at London by Mr. Chefelden and Mr. Douglas. During the twelve or fifteen years immediately fub- fequent to the year 1720, the high operation was fre- quently performed both in London, Edinburgh, and other parts of Europe: But the lateral operation, with the improvements upon it by Rau, being then more generally known, the fuperior advantages it was found to poffefs very quickly procured it a preference; and fince this period the high operation has never been generally pradifed, either in this or in any other country. But we fhall now proceed to defcribe the method of performing it. SECTION VI. Of the High Operation for the Stone. WE have already fhown, that the bladder, at its fundus, or that part of it which lies highest in the pel- vis. 334 Ofthe Stone. Chap. XI. vis, is covered with the peritonaeum ; fo that at this part no opening, it is evident, can be made into \ with fafety, as the operator would not only run the rifk of wounding the inteftines, but the urine would be apt to efcape into the cavity ofthe abdomen. It is the anterior part of the bladder, viz. that fpace ly- ing between the middle of this vifcus and its neck, which ought to be opened in this operation : But this part of the bladder is feldom fufficientiy elevated for this purpofe, unlefs when it is confiderably diftend- ed ; and as one common effed of the ftone in the bladder is to produce a diminifhed contraded ftate of it, this circumftance of itfelf is not an unfrequent ob- jedion to this operation ; for unlefs the bladder is capable of containing a confiderable quantity, at kaft a pound and a half in an adult, it ought feldom, if ever, to be attempted. Various methods have been contrived for the pur- pofe of distending the bladder. It has been propofed to effect it by means of air thrown into it from a pair of bellows ; and others have recommended a quanti- ty of water to be injeded into it immediately before the operation, and to retain it there by making a lig- ature upon the penis, Both of thefe methods, how- ever, will incur fome rifk of hurting the bladder by too fudden diftention ; and we are even told by fome writers, that the bladder has been burft by attempts of this kind. Means, therefore, of a more harmlefs nature fhould be attempted ; and it may be done, I think, without running any rifk of injuring the blad- der, merely by defiring the patient to accuftom him- felf for a confiderable time before the operation, to retain his urine as long as poffible ; and as foon as it is found that he can retain the quantity that is thought neceffary, viz. a pound and an half in an adult, and fo in proportion according to the age, by paffing a ligature upon the penis ten or twelve hours before the operation, and ordering him to drink plentifully of any Sed. VI. Ofthe Stone. 33$ any diluent drink, we may be almoft certain of pro- ducing a fufficient degree of diftention. This being done, the patient muft be laid upon a firm table about three feet four inches in height; at the fame time that his legs and arms muft be proper- ly fecured, not by ligatures, but by the hands of af- fiftants. In order to guard as much as poffible againft any injury being done to the bowels, the patient ought to be laid with his head confiderably lower than his body, and his thighs and buttocks a good deal elevat- ed. By this fituation, too, the ftone, which would otherwife fall into the neck of the bladder, where it could not be very acceffible, will be brought more contiguous to the intended opening, and will hence be more eafily laid hold of, either by a pair of forceps or by the fingers. The patient being thus properly fecured, an incifion is to be made with a roundedged fcalpel, diredly up- on one fide of the linea alba, beginning about four inches above the offa pubis, and continuing it down to the fymphyfis of thefe bones : Even the linea alba itfelf may be divided with perfed fafety ; but it is bet- ter to avoid it, as the incifion is much more eafily made in foft parts than in tendinous ligamentous Sub- stances. The fkin and cellular fubftance being freely divided, the redi and pyramidales mufcles come fuc- ceflively into view : In general, the incifion may be carried on merely by feparating thefe mufcles from one another ; but no detriment could enfue from fome oS their fibres being cut by the Scalpel. A Sufficient opening of the external parts being thus obtained, the operator is now to fearch with his fingers for the bladder ; which he will commonly be fure to difcover immediately above the pubes. With the fingers of his left hand he ought now to prefs back the peritonaeum, with the intestines contained in it, and with the fame fcalpel with which the preceding fteps ofthe operation were effeded, he is to penetrate the 336 Ofthe Stone. Chap. XL the bladder itfelf at its moft'prominent part. This opening into the bladder ought at once to be made fb large as to receive the two fore fingers of the opera- tor's left hand ; which being introduced, the incifion is to be enlarged to the length of about three inches, by running a probe pointed biftoury along one ofthe fingers down towards one fide of the neck of the bladder. The inftant that the fingers are introduced into the bladder, the ligature upon the penis fhould be taken off; fo as to admit of the water contained in it being evacuated by the urethra, otherwife the whole of it will be immediately difcharged by the ' wound. The incifion being completed in the manner we' have direded, the operator ought to fearch with his fingers for the ftone, and, if poflible, he fhould extract it without the afliftance of any instrument: But if* this is found to be impradicable, the forceps muft, no doubt, be employed. One great advantage at- tending this operation is, that as very little force is neceffary for extrading the Stone, So it is here rarely known to break : But when this misfortune occurs, the pieces will be more eafily removed by the fingers alone, than with any of the fcoops commonly employ- ed. The ftones being semoved, the fuperior part of the wound in the teguments ought to be drawn to- gether, either by the means of ftrong adhefive plasters, or by the twifted future, care being taken to leave at leaft an inch and half in the under part of it open, in order to evacuate any urine that may be thrown out from the wound in the bladder into the contiguous parts. It might even be proper to keep the whole external incifion open till the wound in the bladder is reunited ; but as the bowels, fupported now by the peritonaeum only, would be apt to protrude at this opening, and as fuch an occurrence would prove not only troublefome, but even dangerous, it ought to be guarded againft as much as poffible. WTith Sed. VI. Ofthe Stone. 33J With this view the bowels fhould be kept open by the ufe of gentle laxatives, and the patient during the whole cure ought to be kept with his head and Upper part ofthe body confiderably lower than the pelvis. The parts cut in this operation are hot any where nearly furroUnded by bone; on this account large ftones can be extraded with more eafe by this than by any other method : And as the wound in the bladder Is made at a diftance from its neck* fistulous openings are not fo apt to enfue from it as from incifions made in the perinaeum. Thefe are two advantages which attend this mode of operating; but the objedions to it are various. 1. When it is found that the bladder cannot admit of fuch diftention as to be elevated above the offa pu- bis, it is almoft impoffible to make an opening into it without dividing the peritonaeum. Much danger muft undoubtedly be the confequence of this, from the protrufion of the bowels which will probably oc- cur, from the accefs which is given to the external air, and from the urine efcaping into the cavity ofthe abdomen. We are informed, indeed; by writers on this fub- jed; of a protrufion of part of the bowels having fometimes happened in the high operation, without any bad confequences being induced by it ; the woifnds being found to cure, and the patients after- wards to do as well as if no foch occurrence had hap- pened. Such favorable terminations, however, of accidents of this kind could not probably be frequent; and this is, accordingly a very ftrong objedion to the high operation. 2. After the high operation, and during the whole courfe ofthe cure, the urine, in many inftances, paffes readily by the urethra ; but it happens not unfre- quently, in confequence of inflammation about the neck of the bladder or fome other caufe, that the nat- ural courfe of the urine is obftruded. In thefe in- U u ftances, 33* Ofthe Stone. Chap. XI. ftances, from the wound in this operation being made in the anterior part of the bladder, the urine is very apt to be diffufed in the cellular fubftance between the peritonaeum and abdominal mufcles, and between the bladder and pubes * and as no proper vent can be procured for it, finufes are frequently produced, which always terminate in much diftrefs. 3. It has been obferved,. whenever the patient's habit of body is not altogether good, that it is almoft impoffible to obtain a cure either of the wound of the bladder, or of the external teguments. This, it will be faid, may be alleged as an objedion to every op- eration of importance : But although, in every other method of performing the operation of lithotomy, the wound both of the bladder and of the more ex- ternal parts heals more eafily in fome constitutions than in others; yet from all the writings we have on this fubjed it is clear, that any depravity of con- ftitution is, in this refped, always produdive of much more diftreSs after the high operation than what com- monly occurs from the fame caufe in the ufual meth- od of operating in perinoco. 4. This operation is confined almoft folely to pa- tients below thirty years of age : For although it was frequently pradifed on older people, and although no particular reafon can be given why it ought not to Succeed in more advanced ages ; yet we learn from almoft every author who has wrote upon it, particu- larly from Middleton, Smith, Douglas, and Heifter, that a very fmall proportion only recovered of fuch as were above their thirtieth year. It is perhaps for one or other of thefe reafons that the high operation has faUen fo generally into difufe, and that it has not been much pradifed for a great length of time in almoft any part of Europe. But although this method of operating is attended with hazard, and is frequently foUowed with inconveni- ences ; Sed. VI. Of the Stone. 335 ences; yet there is reafon to think, that, on fome oc- cafions, it might be pradifed with advantage. The moft material objedion to the modern, or lateral method of cutting for the ftone, arifes from the bruifing of the foft parts againft the contiguous bones in the extradion of a large ftone ; which is fo much the cafe, that we may confider the rifk from the lat- eral operation to be almost in proportion to the fize ofthe ftone. When a ftone is fmaU and is eafily ex- traded, the proportion of deaths in the lateral opera- tion is very Small: But whenever a ftone is of fuch a fize as to weigh feven, eight, or ten ounces, this ope-. ration perhaps is one »of the moft dangerous to which a patient can fobmit. Different inftances have occur- red, too, where the ftone has been fb very large, as to render its extradion by the lateral operation impracti- cable, by all the force that could be applied; and fome cafes are on record in which there was a necef- fity of having recourfe to the high operation, after the operator had failed in extrajding the ftone by the ufu- #1 method of cutting in the perinaeum.* When, therefore, from the long continuance ofthe difeaSe ; Srom the Senfe of weight about the neck of the bladder ; and particularly from the touch by the finger in ano, we have reafon to fufpeCt the ftone to be oS a large Size, it ought to be an objed of consid- eration, how far it may be proper to avoid the lateral, and, in (certain circumftances, to employ the high op- eration. The circumftances we allude to refped the age of the patient, the foundnefs of his conftitution, and the poffibiUty of. diftending the bladder fo as to raife it above the brim of the pelvis. Thefe circum- ftances may be favorable where the ftone is of a large fize ; and when it is found to be fo, the high opera- tion, although perhaps lefs advantageous in the gen-r eral run of calculous cafes than the lateral method of cutting, * This difagreeable occurrence, we find, happened, to HetfterV yid. Hcifter's Surgery, P, II, S«&f V. c|»P» cxli^ 349 Ofthe Stone. Chap. XL cutting, may be pradifed with greater probability of fuccefs than any other with which we are acquainted. Having how faid all that is neceffary refpeding the Apparatus Alius, we fhall proceed to the confidera- tion of what has ufually been termed the Lateral Op- eration. SECTION VII. Of the Lateral Operation. IN the operation of lithotomy, as it was formerly pradifed by the great apparatus, the external incifion was made in nearly the fame part that it is now in the lateral operation; but the two methods of operating jdiff-r materially in every Other circumftance. The original invention of the lateral operation \i due to a French Ecclesiastic commonly known by the name of Frere Jacques. This operator firft appeared at Paris in the year 1697, when, by the fuccefsfol event of a few cafes, he was allowed to operate upon a great number. But it foon appeared to pradition- ers of difcernment, that the fame he had acquired would not probably be of long duration. For, witfy a very imperfed knowkdge of the anatomy of the parts concerned in the operation, a bad affortment of inftruments, and a total negled of his patknts after the operation, it was almoft impoffible that much fuccefs could refult from his method. His manner of operating; was as foUows. The patient being properly fecured either upon a table or on a bed, a common folid ftaff was introduc- ed into the bladder by the urethra, and the handle of it being carried over the right groin, the convex part of it was made to elevate the teguments and other parts on the kft fide of the perineum. With a straight biftoury he now made an incifion through the fkin and cellular fubftance, beginning be- tween, Sed. VII. Of the Stone. 34I tween the anus and the tuberofity of the ifchium, and continuing it upwards along the left fide of the perin- aeum, at a fmali diftance from the rapha, till it ex- tended at leaft one half of the courfe of the perinaeum. With the fame knife he now went on along the di- redion of the ftaff, to divide the parts between the external incifion and the bladder ; which he alfo opened with the point of this very knife with which the other fteps of the operation had been executed. At this opening in the bladder he firft introduced the index of his left hand, in order to difcoyer the fitua- tion of the ftone ; and having withdrawn the ftaff, he laid hold oS the ftone with a pair of forceps, and ex- traded it in the ufual manner. The patient was now carried to bed ; and no farther attention was paid to him by the operator, who never applied any dreffings, as he trufted the Subsequent management of every Cafe to the nurfe or other attendants. In confequence of this unpardonable negligence, and by his frequently cutting parts in the courfe of the operation which ought to have been avoided, a great proportion of thofe he operated upon died ; no lefs, we are informed, than twenty five of Sixty.* Hence Jacques Soon Sell into diSrepute; and although he afterwards introduced confiderable improvements in his method of proceeding, particularly in being more attentive to the fubfequent management of his patknts, and in ufing a grooved ftaff inftead of a fol- id one, yet his reputetion in Paris never again gained ground; nor do we find that his method was ever attended with much fuccefs, either in Holland, or in the various parts of Germany where he afterwards pradifed. For with fo much inattention did he proceed, that although he profeffed to cut diredly into the body of the bladder, without injuring either the urethra or proftate gland; yet in the diffedion of fuch bodies as * Vide Morand Opufcules de Chirurgit, part ii. p. 54. 342 Ofthe Stone. Chap. XL as died of the operation, it was found that on many occafions the proftate gland was divided, together with the veficute feminaks. In fome inftances, the bladder was cut in two or three different parts ; in others the redum was divided ; and it frequently happened that the bladder was found to be entirety feparated from the urethra.* We need not wonder, therefore, that this praditioner, as well as his method of operating, foon fell into difcredit. But although this was a confequence which neceffarily enfued from the ill fuccefs that attended his practice; yet the world, it muft be acknowledged, is much indebted to Jacques, for having laid the foundation of the lateral method of cutting for the ftone, which, in its preSent improved ftate, is pradiSed with So much SucceSs oyer all Europe. The famous Rau was the firft who endeavoured to improve this operation oS Frere Jacques, which he did by ufing a Staff with a very deep groove, which enabled him to continue his incifion into the bladder with more certainty than it was poflible to do without this afliftance. But Rau, afraid of wounding the proftate gland, introduced a refinement into his meth- od of cutting, which, in the event, proved extremely prejudicial, and was probably the caufe of its being afterwards laid afide. For, inftead of dividing the urethra and proftate gland, by which means the ex- tradion of the ftone would have been much facilitat- ed, he diffeded with much caution by the ficje of the proftate, till the convex extremity ofthe ftaff was dif- covered in the bladder itfelf. At this part an incif- ion was made into it, and the ftone was afterwards extraded, in the manner then pradifed for cutting with the great apparatus. By this method of operating, the rectum and vefic- ulae feminaks were in great danger of being injured; the * For a particular account of Frere Jacques's method of operat- ing, fee Dr. Lifter's journey to Paris ; the works of Dionis. Meri, Collet, Sa.viard, and Morand. ? Sed. VII. Of the Stone. 343 the ftone was extraded with difficulty; and from the depth of the incifion the urine did not pafs eafily off by the wound, fo that troublefome finufes were very frequendy forming.* Thefe inconveniences prevented this operation of Rau's from ever being generally received, and sug- gested to the celebrated Cheielden the lateral method of cutting, as it is now, with a few alterations, very univerfally pradifed. As this operation of Mr. Chefelden's is defcribed by~many writers in Surgery, it is not here neceffary to enter into a detail of it: We fhaU, therefore, now proceed to defcribe the lateral operation in its prefent improved ftate. In order to prevent the patient from being under the neceffity of going foon to Stool after the operation, the bowels ought to be thoroughly emptied by a laxa- tive given on the preceding day ; and with a view to evacuate the contents of the redum entirely, an in- jedion fhould be given a few hours before the opera- tion is performed. When the bladder is in a collapfed ftate, it is lia- ble in this operation to be cut in different parts; the patient ought therefore to be defired to drink plenti- fully of fome diluent liquor, and to retain his urine for feveral hours before he is laid upon the table: And when the irritation produced by the difeafe is found to render a voluntary retention of the urine im- pradicable, it ought to be effeded by a flight com- preffion upon the penis. Thefe circumftances being attended to, and the perinaeum and parts about the anus being fhaved, the patient is now to be laid upon a table for the op- eration. The moft convenient height for this ta- ble • Rau himfelf kept his method of operating as much concealed as poflible. But an account of it was publifhed after his death by Albi- nus; who, by aflifhng frequently at his operations, became perfectly mafler of his manner of performing, fide Index fuppellcttihs anatomic*, &c, J-ug. Batavorum, 344 Ofthe Stone. Chap. XL bk is three feet two inches. It ought to be made perfedly firm : And in order to afford fufficient fpace for the patient to lie upon, it ought to be about three feet eight inches long, and at kaft two feet and a half wide. As it is of much importance to have the patient properly fecured, it becomes neceffary to attend par- ticularly to this circumstance. The moft certain method of effeding it is as follows: Let a rioofe be formed in the double of a piece of broad firm tape about three feet in length ; the patient's wrifts being introduced at this noofe, he ought then to take a firm hold of the outfide of the ankle of the fame fide, when, by different turns of the tape round the hand, ankley and foot, his hand is to be effedually fecured in this pofition; and this being done on one fide, the hand and foot of the oppofite fide are to be firmly tied to- gether in a fimilar manner; The operator ought now to introduce a grooved ftaff, of a fize proportioned to the parts through which it is to pafs. Thefe staffs are reprefented in Plate XII ; the artift who makes them ought to be very attentive in rounding off the edges of the grooves/ otherwife they are apt to injure the urethra ; and the further extremity of the groove ought to be perfedly free and open, otherwife it is difficult to difengage the gorget from it after it has been introduced into the bladder. As the groove is only neceffary in the con- vex part of the ftaff, and from that to its point, the handle ofthe inftrument down to the commencement of the convexity, ought to be entirely folid, fo as to ad- mit of the penis being preffed upon it, without being hurt either by the hand ofthe affiftant, or by a piece of tape, which may be fometimes neceffary, as we have already advifed, for preferving the urine from being evacuated. It is neceffary to remark, that more attention ought to be paid to the length ofthe ftaff than is common- ly Sed. VII. Of the Stone* 345 ly done. Thefe instruments are generafly fhortef than they fhould be; fo that when, in the courfe of the operation, the handle of the ftaff happens to be preffed down upon the groin by the affiftant, the point of it is very apt to flip out of the bladder alto- gether ; a circumftance which muft always be pro- dudive of much hazard and inconvenience* Care* therefore, fhould be taken to have the ftaff always ot a fufficient length. The ftone being again diftindly felt, not only by thfe furgeon himfelf, but by his affiftants, the patient muft be then put into that pofture in which he ought to be kept during the remainder of the operation;. The table intended to be ufed ought to be perfedly kvel; but, that the patient may lie with as much eafe as poffible during the operation, a pillow may be put under his head, and, in order to raife the pelvis confiderably higher than the abdomen, two piUows at kaft ought to be laid under the buttocks, which fhould be made to projed an inch or two over the end of the table* This diredion we have given for elevating the but- tocks, is a matter of much importance, although it is feldom attended to by operators ; indeed, the very reverfe is commonly pradifed, the head and upper part of the body being generally kept a good deal higher than the pelvis. This, however, muft pro- ceed entirely from inattention on the part of the fur- geon : For the kaft refledion may convince us, that the more ered the body is kept, the greater preffure muft be produced by the inteftines upon the bladder; and if by fiich preflure the fundus of the bladder is preffed down upon its neck, the rifk of its being wounded muft be very great. Of fuch patients as have died of this operation, I nave in two different inftances found on diffedion, that the bladder was wounded in three different parts: In its cervix, as is always the cafe when the gorget is Xx of 34$ Of the Stone. Chap. XL of a fufficient length j in its fide confiderably above the cervix j and, again, very near to its moft fuperior part. Now this is an accident which can never hap- pen, if the diredions we have given are attended to ; for when the bowels are prevented from falling upon the bladder, by keeping the buttocks elevated above the reft of die body, and if at the fame time the blad- der is properly diftended with urine, it muft be alto- gether impoffible, in the ufual lateral operation, to in- jure it in an improper part. But if this precaution. of having the bladder diftended during the operation is neglected, at the fame time that the bowels are, by an elevated pofture of the upper part of the body, allowed to fall into the pelvis, the bladder muft be fo completely coUapfed, and its fundus pufhed fo much down upon its neck, as muft frequently be the caufe of much unneceffary hazard. Befides thefe two cafes I have mentioned, in which the bladder was after death found to be wounded in different parts, we find a very candid acknowledg- ment made by a celebrated Uthotomift, of his being once fo unfortunate in the lateral operation, as to have an immediate protrufion of a confiderable portion of the fmall guts at the wound.* Such an occurrence would have difconcerted many operators : But, fortunately for the patient, the ope- ration was in this cafe completely finifhed ; the bow- els were reduced, and a perfed cure was obtained. Mr. Bromfield attempts to account for this protru- fion ofthe boWels in a different manner : But we are much inclined to think, that it muft have been owing to the pelvis not having been fufficientiy raifed above the reft of the body, and to the bladder having been in a coUapfed ftate at the time the incifion was made into it. For this author, it muft be remarked, inftead of ordering the bladder to be diftended at the time » Vid. Mr. Bromfield'* ChirujglcJil Obfervations and CafcM Vol. II. p. 364. Sed. VIL Ofthe Stone. 347 time of operating, desires exprefsly that it may be emp- tied immediately before the operation.* Matters being adjusted in the manner we have di- reded with refped to the patient, an affiftant on each fide is to fecure his legs and arms : One muft pre- vent him from moving the upper part of his body ; another muft lay hold of the ftaff; and a fifth wiU be required to hand the neceffary inftruments to the op- erator. The furgeon, after having again felt the ftone with the ftaff, is now to make the hand of it pafs over the right groin of the patient, fo as that the convex part ofthe inftrument may be diftinguifhed on the left fide oS the perinaeum : And in this pofition it ought to be preserved by the affiftant, who with his right hand fhould lay hold oS the handle of the ftaff, while with his left he elevates and Supports the fcrotum. The thighs of the patient being fufficientiy Separat- ed by the afliftants, and the furgeon being feated be- tween the patient and the window, in fuch a manner as to make the light faU diredly upon the parts to be cut, an incifion is now to be made through the fkin and cellular fobftance, at kaft four inches in length in a fuU grown perfon, and fo in proportion in fmall- er fized people ; beginning a litde to the left fide of the rapha, about an inch from the termination of the fcrotum, and proceeding in an oblique diredion along the perinaeum, tiU it is made to run at an equal dif- tance between the tuberofity of the ifchium and the anus, which laft it ought to pafs at leaft an inch- As the fuccefs of the operation depends in a great meafure on this part of it being properly executed, the attention of beginners ought to be particularly fixed upon it. From timidity or inattention, which always proves prejudicial to the patient, this external jncifion is frequently made much fhorter than it fhould be} in many inftances, inftead of four inches, I have ? Page nS, Vol. II. 34& Of the Stone. Chap. XL feen it, even in the largeft adult, Scarcely two. The conSequence of this is, that the mufcles, and other* parts below, cannot be properly divickd ; the opera- tor has no freedom in profecuting the other fteps of the operation ; and if the ftone is large, the parts through which it has to pafs muft be much more bruifed and lacerated than if they had been freely' di- ' vided by the knife ; and as there is no rifk whatever in making the external incifion free and ample, it ought, in every inftance, to be done. Much hazard may occur from a fmall incifion ofthe teguments and mufcles ; but no detriment can enfue from their being largely laid open. By this first Stroke of the fcalpel, the fkin and cel- lular fubftance fhould be freely divided, fo as to bring the fubjacent mufcles completely into view ; when, by a continuation of the incifion, the eredor penis, accelerator urinae, and tranSverSalis perinaei, are alSo to be divided ; and as Some part oS the levator ani is in- termixed with theSe muScks, it will likewiSe be cut. As there is no danger Sound to occur Srom a Sree divifion of thefe parts, and as a large opening not on- ly facilitates the extradion of the ftone, but admits of any blood veffel that happens to be cut being eafily fecured by a ligature, which can never be done when the incifion is fmall, every* operator, as we have faid, ought to be particularly attentive to this cirumftance. In general, the arteries with which theSe muScks arc ftjpplied are not So large as to render this precaution neceffary ; but whenever it is found to be otherwife, and that a confiderable veffel has been cut, and ef- pecially if the patient is weak and emaciated, a liga- ture ought to be immediately applied before the fur-; geon proceeds to the other fteps ofthe operation. In the ordinary method of performing this operar tion, the furgeon now proceeds to lay open the ure- thra, and enters the point ofthe knife into the fub- #anc« ofthe bulb itfelf, Bur, this adds greatly to the hazard Sed. VII. Ofthe Stone. 349 hazard of the operation : For, independendy of the blood veffels ofthe bulb being frequently pretty large, but which indeed may, when the external incifion is extenfive, be fecured, finufes are much more apt to form ; and the cure of the wound is therefore much more tedious when this part is divided, than when no injury is done to it; and as a divifion of the bulb is not by any means neceffary, it ought on every occa- fion to be avoided. When, therefore, the incifion of the mufcles is completed, the operator ought to fearch for the ftaff with the index of his left hand ; and hav- ing found it, he is now to pufh the point of his finger along the courfe of it till he paffes the bulb, when, with the edge of his knife turned towards the groove ofthe staff, he is to divide the membranous part ofthe ure- thra in its whole courfe, from the bulb to die proftate gland; and as the finger is made ufe of as a diredor, and as by means of it the redum is effedually preferved from being injured, this incifion of the urethra may be made with perfed fafety. Indeed, there is in gen- eral fuch a quantity of cellular fobftance between the urethra and redum, as renders it impoffible, in this part of the operation, to cut into the gut, if the fur- geon is not either very unsteady or inattentive : And by means of the precaution we have recommended, of keeping the fore finger of the left hand always be- tween the knife and the intestine, it may in this man- ner be on every occafion very certainly avoided. The incifion ofthe urethra being now completed, the proftate gland, which may be evidently difcover- ed by the finger, is next to be divided. In the hands of an expert furgeon, a patient would be equaUy fafe by having the operation finifhed with the fcalpel as with any'other inftrument: For, by continuing the incifion ofthe urethra, and carrying on the fcalpel fo as to divide the proftate gland laterally, if the finger is ftiU continued between the knife and the redum, no pSk whatever eould occur from it: But as this part 3$o Ofthe Stone. Chap. XL ofthe operation is performed entirely by feeUng, with- out the afliftance of the eye fight; and as many ope- rators are notfo much accuftomed to this kind of buf- inefs as, in fuch circumftances, to have a fufficient de- gree of fteadineSs, it is probable the redum would be frequendy wounded if the fcalpel was ufually employ- ed for finifhing the operation. This inconvenience, however, of wounding the redum, may be effedually avoided by ufing' a cut- ting diredor, or Gorget, as it is termed, instead of a fcalpel: This inftrument was originaUy the invention of Mr. Hawkins at London. It is reprefented in Plate XIV; and in Plate XIII different views of an inftrument are delineated, which I confider as a very material improvement of Mr. Hawkins's gor- get. The gorget of Mr. Hawkins is contraded too much at the cutting part of it, which prevents it from dividing the proftate gland fufficientiy. If we were to ufe a gorget much wider in the cutting part of it than is ufually done, the opening through the proftate gland might indeed pe made extenfive enough : But the gorget in common ufe will by no means effect this; the divifion of this gland being in general quite too fmall, either for the extradion of a ftone, or even for the introdudion of the forceps, without much lac- eration; a circumftance which we ought to guard againft as much as poffible. The gorget in ordinary ufe is made to expand gready behind; the diameter of the blunt part of it being at leaft twice the extent of that of the cutting point. This will appear to be very unnecessary, when we confider, that the only ufe ofthe gorget, af- ter it has cut through the proftate gland, is to ferve as a condudor to the forceps; and as this purpofe may be answered equally well by a diredor that does not expand to near the extent that the gorget does, it is obvioufly improper to have this inftrument fo wide as it is commonly made. But farther, the improprj* ety Plate JXITI Sed. VII. Of the Stone. 35 * ety of this construction is ftill more evident, when we compare the fize of the common gorget with the parts through which it has to pafs: For it is perfed- ly evident, that the latter, and particularly the ure- thra, muft be greatly injured by the forcible introduc- tion ofthe former; the back part ofthe gorget being fo wide and deep, as to render its paffage through the urethra quite impradicable, without much laceration. The cutting diredor we have mentioned above, will be found to poffefs all the advantages ofthe gor- get, without any of its inconveniences: The cutting part of it expands more than that of the gorget, it therefore divides the proftate gland more freely; and as the blunt part of it is much contraded, no injury is done to the urethra on its being pufhed into it. To thofe who have never ufed this inftrument, and who thereby may have a partiality for the gorget, it may perhaps appear that it is not fufficientiy wide for ferving as a diredor to the forceps: This, however, is not the cafe; and it will foon be found, that it is not only more eafily introduced than the gorget, but that it anfwers equally weU for conduding either the finger or the forceps. It has been objeded to this inftrument, that it will not probably make fuch a free divifion of the muf- cles as is obtained by the gorget. This obfervation, however, proceeds fokly from prejudice in favour of an inftrument with which praditioners are as yet bet- ter acquainted, and which has indeed been defervedly much employed; but it is thrown out without due refledion on its import. We have already endeav- oured to inculcate the neceffity of a free divifion of the teguments and mufcles in this operation; but whoever confiders this point with attention will fee, that this ought to be effeded by the fcalpel alone, and that it fhould not depend in any degree upon the gor- get. AU that fhould be left for the gorget or cutting director to do, is to divide the proftate gland with a fmall 35* Of the Stone; Chap. XL fmall portion of the neck of the bladder. Some prac- titioners have indeed recommended instruments for j carrying the incifion into the body of the bladder j but this is a very hazardous attempt, and it is not in any refped neceffary : For as foon as the proftate and neck of the bladder are divided, the forceps are admitted with much eafe; and the bladder itfelf is fo . eafily dilated, that it very readily yields to the paffage ' of the ftone, however large it may be, We Would i wifh to have it underflood, that it is not the fize ofthe wound in the bladder which renders the extradion of ftones eafy or difficult; and that it is the previous free incifion ofthe mufcles and proftate gland upon which this entirely depends, . \ The membranous part of the urethra being dividU , ed by the fcalpel in the manner we have direded, the nail of the index of the left hand ought to be intro- duced into the groove of the ftaff, in order to ferve as a condudor to the point or beak of the cutting direct- or. And the furgeon having no further occafion for the fcalpel, muft now lay it afide j and having introduc- j ed the point of the diredor into the groove of the ftaff, he is now to take the handle of that inftrument from the affiftant; and having raiSed it considerably from the groin ofthe patient in which it lay, he must with his left hand preferve it firm in this Situation* while with his right .he pufhes on the director till it has paffed freely into dag; bladder, a circumftance which is rendered evident at once by the urine rufhing plentifully out at the wound. In executing the firft part of the operation, the furgeon ought by all means to be feated.; but in paffing the gorget or diredor into the bladder, as likewife in the extradion of the ftone, he ought to ftand immediately before the pa- tient, as in.this pofture thefe fteps of it are more eafi- ly performed; Much attention is neceffary, in this part ofthe op- eration, in raifing the ftaff to a proper height before pufhing Sect. VII. Ofthe Stone. 353 pufhing on the gorget. The ftaff ought to form nearly a right angle with the body of the patient j and if it be kept fufficientiy firm in this pofition, the gorget or diredor may be pufhed on with great fefety, as the beak ofthe instrument, if this diredion is attended to, can fcarcely efcape from the groove of the ftaff. But if the elevation of the ftaff is either much greater or much lefs than this when the gorget is pufhed forward, its point inftead of getting into the bladder muft be forced out of the groove, arid paff- ing between the redum and bladder, or between the bladder and pubes, it muft here run the rifk of doing much mifchief. I have known even expert fur- geons, from an unpardonable degree of inattention, fall into this error with regard to the height of the ftaff. Younger praditioners, therefore, cannot be too much on their guard againft it. While attention is thus given to the elevation of the ftaff, care ought alfo to be had that the beak of the diredor or gorget be exadly fitted to the groove intended to receive it; for if thefe are not properly a- dapted to one another, the gorget cannot run fo eafily as it ought to do. Befides, if the beak ofthe instru- ment is turned a little inwards, as is reprefented in Plates XIII and XIV, it is pufhed forward with more fafety than when the point of it is either in a dired line with the inftrument, or, perhaps, fomewhat turned back, as is too frequently the cafe. In order to render this part of the operation per- fedly fafe, different inventions have been piopofed for fixing the beak ofthe cutting gorget fo effedual- ly in the groove of the ftaff, as to prevent it from cutting out of it till it has paffed into the bladder : But every contrivance of this kind produces fome difficulty in paffing the instrument; and befides, there is not the leaft neceffity for it, as no operator can poffibly go wrong if he attends fufficientiy to the di- redions we have given, Yy As 354 Ofthe Stone. Chap. XL As foon as the gorget has freely entered the blad- der, the ftaff ought to be withdrawn; and this being done, the next ftep in ordinary pradice is, to intro- duce the forceps immediately ; but as theJtone may be frequently felt by the finger, and as no other meth- od ferves fo effedually to difcover its real fituation, this precaution of introducing the finger into the bladder ought never to be omitted. If the ftone cannot be felt by the finger, the pain of thelpatient is not increafed by its introdudibn ;: and if the opera- tor is lucky enough to difcover* it,, he is thereby in- structed with fome certainty of the beft direction for the forceps. The fituaiion of the ftone being in this manner difcovered, or if, upon trial, it is'found that the finger cannot reach it, a pair of forceps, proportioned to the Size of the patient, are to be introduced alohg the courfe of the diredor or gorget,' whik the latter is to be immediately withdrawn. In an operation of fuch importance as tiiis, the moft trifling circumftance is worthy of attention ; for the more obvious and leading parts of it may be per- formed in the moft masterly manner, and the whole be rendered unfuccefsful by the operator not attending fo accurately as he ought to do to the more minute Steps of it. Even the method of withdrawing the cutting diredor or gorget, is a matter which requires attention, much more, indeed, than is commonly giv- en to it. After the forceps are introduced, the gorget ought to be floWly withdrawn in the very exad di- redion by which it is entered i For if it be turned in any degree either to one fide or another, it muft of neceffity make another incifion,. not only in the prof- tate gland, but in all the other parts through which it is made to pafs ; the impropriety of which is too ob- vious to require any further animadverfion. If the ftone has been previoufly difcovered by the finger, it i$ commonly eafily laid hold of with the forceps | 0^. 3 I %> 2 Plate XVI Sed.VIL Ofthe Stone. 3SS forceps; but when the finger has not been able to reach it, it is on fome occafions with much difficulty met with. The forceps muft neceffarily be introduc- ed fhut, that is, with their blades as near to one an- other as their form admits of; for, with a view to pre- vent them from laying hold of the bladder, they fhould be fo conftruded as not to meet at any part except at their axis, by at leaft the tenth part of an inch. But as foon as they have entered the bladder, they fhould be gradually opened. ; and in this expanded ftate ought to be eafily moved about, with their handles fometimes depreffed and fometimes elevated, till the ftone is difcovered, when it is to be immediately laid hold of. It frequently happens, however, even with very expert furgeons, efpecially when the ftone is fmaU, that it is not readily difcovered by the forceps. In fuch inftances it is fometimes met with near to the fundus of the bladder; but it is moft frequendy found concealed in the under and back part of it, near to its neck, in that bag which we have mentioned as be- ing formed by the natural preffure of the u rine. When it is found to be in this fituation, nothing wiU bring it fo readily into contad with the forceps, as elevating this part of the bladder by introducing the finger into the redum. In general, straight forceps, fuch as are reprefent- ,ed in Plate XVI, fig. i. and 2. are preferable to thofe that are much crooked, delineated in fig. 3. For they not only prove more effectual for extracting the ftone, but ferve equally well with the others for difcovering it. Every operator, however, ought to be provided with all the varieties of forceps that are now in ordi- nary ufe. When much difficulty occurs in difcovering the ftone, it is frequently aUeged by operators*, that this proceeds from its being contained in fome preternat- ural bag or cyft ; and when it is laid hold of by the forceps, and requires an unufual degree of ftrength1 to extrad 356 . Ofthe Stone. Chap. XL extrad it, this is commonly faid to arife from the ftone adhering to the coats of the bladder. That the weight of a ftone will fometimes form a partial cavity for it- felf, by prefling that part of the bladder on which it lies into the neighbouring foft parts, there is no rea- fon to doubt; and in fome inftances the bladder is found to have been fo much contraded round a ftone, as to form almost two diftind bags. Such occurrences, however, are exceedingly rare : And the adhefion of ftones to the bladder, we believe to be ftill more fo, if it ever takes place. Stones have indeed been fre- quently found covered with the coagulabk part of the blood, which on fome occafions becomes fo firm and tough, as to have the appearance of an organifed membrane ; but we are perfedly unacquainted with any procefs of nature by which an adhefion can be produced between the bladder and a ftone contained in it. It is very improbable that it can take place in confe- quence of a communication of blood veffels betwixt the bladder and ftone : And it is equally improbable that it can be produced merely by agglutination ; for, by the intervention of the urine, with which the blad- der is conftantly moistened, fuch an effeCt muft be very certainly prevented. But it is not reafoning alone that militates againft this opinion. For although fuch an occurrence has been frequently mentioned by authors, yet we do not meet with one authenticated inftance of any firm adhe- fions betwixt the bladder and ftones contained in it be- ing difcovered after death : We are therefore kcj to conclude, that this idea is entirely void of foundation; and that it has probably originated from the mif- condud of operators, who, by making the external incifion too fmall, or by not dividing the mufcles and proftate gland fufficientiy, have.* experienced much difficulty in extrading a ftone of even a mod- erate fize, and who, to efcape cenfure, have fug-geft- ed Sed. VIL Ofthe Stone. 357 ed the poffibiUty of ftones adhering to the internal coat of the bladder. When the ftone is laid hold of by the forceps, the operator, before he proceeds to extrad it, ought to introduce his finger into the bladder, in order to dif- cover whether it is properly iixed in the forceps or not. In many instances, this is of much advantage ; for, when it is difcovered that a ftone of any confider- able length is laid hold of in fuch a manner as to have its longest diameter made to prefs in a tranfverfe di- redion with refped to the opening in the bladder, much pain and laceration, which would undoubtedly occur from extrading it in this diredion, may be ea- fily prevented, either by turning the ftone with the point of the finger when this is found to be pradica- bk, or by letting it flip altogether out of the forceps, and again endeavouring to lay hold of it in a more favourable pofition. When the operator is certain that this is properly accomplifhed, he is then to pro- ceed to the extradion of the ftone, which ought to be done in a very flow and gradual manner : He ought to hold the forceps firmly in both hands, his right be- ing applied towards the extremity of the handles, and his left near to the common axis. In ordinary pradice, if the ftone does not come readily away, the force made ufe of is commonly ap- plied fo as to dilate the parts equally in every direc- tion. The ftone is made to move not only upwards and downwards, but laterally ; and, on fome occa- fions, even a rotatory motion is given to it. Noth- ing, however, can be more deftrudive to the parts through which the ftone muft pafs than fuch a prac- tice, while at the fame time it is evidendy iU calculat- ed for facilitating the extradion of it. Inftead of moving the ftone in this manner, the preffure ought to be made almoft entirely downwards; not directly from the fymphyfis of the pubes towards tlie anus, but in the courfe of the external wound, which 35% Ofthe Stone. Chap. XL which ought, as we have already faid, to run between the anus and the tuberofity of the ifchium. As it wiU be readily admitted, that the force employed in ex- trading a ftone will prove more ufeful when exerted upon foft yielding parts, than when applied immedi- ately upon a bone ; fo, whoever attentively considers - the anatomy of the parts concerned in this operation, will fee the propriety of the advice we have now giv- en. The opening into the pelvis is at this place fo extremely narrow, that a very flight examination muft convince any one, that in the extradion of a ftone no advantage can be derived from lateral preffure. If a- gain the ftone is preffed upwards, it muft prefs againft the bones of the pubes ; for in this diredion nothing intervenes between thefe bones and it, except the ure- thra, and a fmall quantity of cellular fubftance : And if it be direded towards the anus, it muft prefs the redum againft the point of the coccyx; a circum- ftance which muft not only produce much immedi- ate diftrefs to the patient, but which muft even add to the hazard of the operation. The rotatory motion which in this operation is fometimes given to a ftone unites all thefe difadvan- tages ; but by carrying the preflure downwards in the courfe ofthe wound fo as to fall between the anus and ifchium, every inconvenience of this kind is avoided, and a more extenfive dilatation is obtained than can poffibly be procured in any other diredion. By a proper and gradual application of preffure in this diredion, the ftone, if it is not very large, will be at laft extraded: In the courfe of the extradion, how- ever, if the operator finds confiderable refiftanee to the paffage of the ftone, he ought to examine the Slate of the divided parts ; and if any part of the mufcles •which ought to have been cut are ftill found to be en- tire, they fhould be immediately laid freely open ; and the eafieft method of doing this, is, to fecure the ftone in Sed. VII. Ofthe Stone. 359 in the forceps with the left hand, while a fcalpel is em- ployed in the other for effeding what is neceffary. In order to prevent the forceps from prefling fo much upon the ftone as to be in danger of breaking it, fome inventions have been propofed for rendering the degree of preffure employed by them fleady and certain. Of thofe the beft feems to be what is repre- fented in Plate XVIII, fig. 3- *n which» as foon as a ftone is laid hold of, it is preferved in the fame pofi- tion by means of a fcrew which paffes from one ofthe handles into the other. During an operation, howev- er, every incumbrance of this kind proves trouble- fome, and there is not in fad the leaft occafion for fuch an improvement : For, when a ftone is fmall, no furgeon of experience will apply great force in the extradion of it; and when it is very large, it will be more for the patient's advantage that it fhould be broke than extraded entire. We have already had occafion to fpeak ofthe great rifk which occurs from the extradion of ftones of a large fize : Indeed, this, as we have faid, is fo consid- erable, as to warrant this conclusion, that caeteris par- ibus, the hazard attending the operation of lithotomy may be considered as correfponding to the fize ofthe ftone to be extraded. In healthy fubjeds, when the ftone is fmaU, and when the operation is properly per- formed, there does not above one die in twenty : But, although a few inftances have occurred of patients re- covering from whom ftones have been extraded of a large fize, yet whenever the ftone exceeds feyen or eight ounces in weight, fo far as I am able to judge, not above one in ten recovers. This, therefore, is a moft material circumftance, and worthy of our moft ferious attention; and although the breaking of a ftone, in the courfe of extradion, is in other refpeds rather difagreeable, yet, with a view to obviate the dreadful confequences which com- monly enfue from Waring out a very large ftone, when 360 Ofthe Stone. Chap. XL in the courfe of an operation it is found that the ftone is of an uncommon magnitude, and that it cannot be extraded but with great hazard to the patient, Might it not be more eligible, either to endeavour to break the ftone with the forceps already introduced, or to withdraw thefe and to introduce an inftrument repre- fented in Plate XVII, fig. 1. originally inventedfj^ this purpofe by Andreas a Cruce, and fince improvedT by Le Cat and others ? By means of the long and ftrong teeth with which thefe forceps are furnifhed, and efpeciaUy by the intervention of the fcrew for comprefling their handles, almoft any ftone may be broken into very fmall pieces ; and as foon as this is effeded, the different pieces may be extraded with- the common forceps. J In fuch circumftances, however, or when a ftone! has broke by accident in the courfe of any operation, * the utmost care is neceffary in order to extrad every fragment of it ; for, if the fmallefl particle be left, f if it be not afterwards wafhed off with the urine, it may prove very prejudicial, by ferving as a nucleus for the formation of another ftone. After all the lar- ger pieces have been extraded by the forceps, a fcoop, fuch as is reprefented in Plate XVII, fig. 2. is fome- times found ferviqjabje for taking out the fmaller par- ticks ; but for this laft purpofe nothing ever proves fo effedual as injeding, either with a syringe or a bag and pipe, large quantities of warm water, which, when a proper heat and a due degree of force are attend- ed to/may be thrown in without injury, and it com- monly proves very effedual for the purpofe for which it is employed. * •When a ftone is extraded with a fmocfh polifhed furface, it is commonly fuppofed that there will be others remaining in the bladder, as this-fmoothrtefs is* \ imagined to be owing to the fridioh produced by other ftones ; and, on the contrary, a rough unequal furface is fuppofed to denote the existence of one ftone only. Plate ATJI ■-# Sect. VII. Ofthe Stone. 361 only. No dependence, however, ought to be placed upon thefe circumftances; for every praditioner muft have met with inftances of a Single ftone with a fmooth furface ; and, on the contrary, a ftone of a rough un- equal furSace has been Sound where there have been more than one in the bladder. As Soon, thereSore, as one ftone is extraded, the operator, inftead oS trusting to any appearances of the ftone, ought firft to fearch with his finger, and then, either with the forceps, or with the thick curved inftrument reprefented in Plate XV, fig. 3. which may be termed a fearcher, and which anfwers the purpofe better ; and as long as any •ftones are difcovered, the forceps are to be repeatedly introduced tiU the whole are entirely extraded. In the courfe of this operation, fome blood veffels are unavoidably divided ; but when the incifion is kept as low down in the perinaeum as we have dired- ed, and when therefore the bulb of the urethra is a- voided, there is feldom much rifk to be apprehended from any hemorrhagy that enfues. It now and then happens, however, that thofe branches of the internal iliac artery which fupply the parts lying anterior to the proftate gland, are fo confiderable as, when divid- ed, to pour out a good deal of blood : But as a free difcharge during the operation has a confiderable in- fluence in preventing inflammation, a fymptom which is more to be dreaded than any other occurrence fub- fequent to lithotomy, nothing in general fhould be done to put a ftop to the hemorrhagy till the ftones are all extraded ; when, if the difcharge ftill contin- ues, any divided artery that appears ought to be fe- cured by ligatures ; and if the external incifion has been made large and free in the manner we have di- reded, this is a part of the operation by no means fo difficult as is commonly imagined. On different oc- cafions, I have paffed a ligature upon an artery almoft as deep as the proftate gland ; and when a large vef- fel has been cut, the advantage derived from this ef- Z z fedual 362 Of the Stcne. Chap. XL fedual method of fecuring it, is of itfelf a very iu>^| portant argument for making the external incifion in every inftance very free and extenfive. When, however, the divided, veffel cannot be fe- cured by ligature, we are then to endeavour to ftop the hemorrhagy by preffure ; and for this purpofe a firm roller introduced at the wound would anfwer very ef- fedually : But in order to avoid any ftoppage to the flow of urine, inftead of a folid roller a filver canula covered with foft linen may be employed with advan- tage ; a figure of fuch an inftrument is reprefented in Plate XVIII, fig. 3. Notwithstanding, however, ev- ery precaution, fome of the deep feated arteries, which have been divided hy the operation, continue fome- times to pour out a great deal of blood, and which, inftead of paffing off by the wound, is, on .fome occa- fions, coUeded in great quantities in the cavity ofthe bladder. As foon as this is perceived, fome means ought to be attempted for its removal; and the moft effedual of thefe are, to extrad as much ofthe coag- ulated blood as poflible, by a proper ufe of the^ fcoop already mentioned, and afterwards by the fre- quent injeding of warm water by the wound, to wafh off the remainder. In this manner very large collec- tions of blood have been evacuated ; and when, as has fometimes happened, means of this kind have not been employed, the coagulum in the bladder has at laft become fo firm, and has filled up the cavity of that vifcus fo effectually, as to prevent entirely all further depofition of urine. In fuch inftances the abdomen becomes pained and much tumefied ; the fever gradually increales ; and death itfelf very com- monly fucceeds: With a view to prevent .fuch an unfortunate occur- rence with as much certainty as poffible, every pa- tient fhould, immediately after the operation of li- thotomy, be placed in fuch a pofture as moft effedu- aUy to evacuate any blood that may be difcharged : Inftead Sed. VII. Of the Stone. 36 3 Inftead of laying the head low, and the buttocks high, as is commonly done, the pelvis fhould be confidera- bly lower than the reft of the body; by which means the wound is kept in a depending pofture, which ferves to affift the evacuation of any blood that the divided arteries may throw out. As foon as any flow of blood that has occurred is ftopt, the patient fhould be untied, and a piece of foft lint being inferted be- tween the lips of the wound, the thighs fhould be laid together, and in this pofition he fhould be carried to bed ; and a confiderable dofe of laudanum being ad- ministered, he ought for fome time to be left entirely to the charge of the nurfe in attendance. No dreff- ing whatever anfwers fo well as a piece of dry foft lint: For as the urine is conftantly running off by the wound, and as the parts are thereby kept very wet and are apt to fret, it becomes neceffary to renew the dreffings very frequently; and nothing is either more eafily applied or removed than a piece of dry lint. When the ftone has not been difficult to extrad, the patient generally remains eaSy, and Sree from much pain ; and he frequently falls into reft, and procures Some fleep during the firft three or four hours after the operation: But when the ftone is large, and when much violence has been done to the parts in extrad- ing it, a fevere pain in the under part of the abdo- men often supervenes in the fpace of an hour or two from the operation; and this, we muft obferve, when it does not foon yield, is one of the moft alarming fymptoms which occur. If it is merely of a fpaf- modic nature, however, which in fome inftances it appears to be, it is commonly foon removed by the ufe of warm fomentations to the belly, or by emolli- ent and efpeciaUy by anodyne injedions thrown up by the redum. When by a continuation of thefe remedies the pain is found to abate, little or no anxiety need be enter- tained en account of it; but when, inftead of becom- ing 3°4 Of the Stone. Chap. XL ing lefs violent, it proceeds to increafe, and efpecially ♦ when the abdomen becomes hard and tumefied, and the pulfe full and quick, and when thefe fymptoms continue to be aggravated, much danger is to be dreaded. As they almoft conftantly originate from inflammation, blood ought to be taken in quantities _ proportioned to the violence of the diforder ; emoUi- ent injedions ought to be continued ; and if the local application of heat to the abdomen, either by warm flannels, or by warm water contained in a bladder, is not found to anfwer, the patient fhould be immedif ately put into the femicupium. Indeed, in fuch cir- cumftances, I have experienced more advantages from this than from any other remedy; for the heat is not only applied with more effeCt diredly to the parts affeded, but a free difcharge of urine by the wound is alfo more commonly procured by this than by any other means, and accordingly much relief is often obtained from it. A due continuation of thefe means, with a proper ufe of opiates, a low diet, and a free ufe of diluent drinks, will frequently remove very alarming fymp- toms. But, in fome inftances, all our efforts prove ineffedual; the pain and tenfion of the abdomen continue to increafe ; the wound, inftead of putting on a kindly healthy appearance, remains floughy and illconditioned ; the quicknefs of pulfe, and other fymptoms of fever, increafe ; and death clofes the fcene. But, when matters terminate happily; the wound by degrees acquires a healthy afped : The urine, in fome inftances, paffes by the urethra from the beginning ; but in moft cafes it comes away by the wound for the firft two or three weeks : The pain in the abdomen gradually abates ; and any fymptoms of fever which at firft prevailed, are in a fhort time entirely removed. The period at which a compkte cure ofthe wound is effeded, is exceedingly various, and depends much on Sect. VII. Of the Stone. 36 5' on the ftate of health the patient is in: In fome few cafes of young healthy boys, I have known the wound completely cicatriied in kSs than three weeks; but in others this is not accomplifhed till the fixth, feventh, or eighth week. Unfortunately, in fome instances, a- gain, although a great part of the fore heals perhaps quickly enough, yet a fmall opening is left at which die urine continues to be difcharged, and, the edges of the paffage becoming callous, a real fistulous open- ing is produced, which cannot be cured but by anoth- er operation ; the manner of performing which we fhall prefently have occafion to mention. Indeed the prevention of fistulous openings depends much on proper attention in dreffing the wound. If care be taken to introduce the lint fufficientiy within the lips j of the wound till granulations fill up the bottom ofthe j fore, there wiU feldom be any rifk of fistulous fores: At the fame time, however, the wound ought not to be much crammed, either with Unt or with any other dreffing; for in this cafe the edges muft either in- flame, or acquire a morbid degree of hardnefs. In other refpeds the treatment here ought to be nearly fuch as is known to anfwer in fimilar wounds in other J] parts. It is proper, however, to obferve, that noth- ing removes fo effedually that excoriation ofthe but- tocks, which fometimes proves very troublefome af- ter the operation, from their being kept conftantly i wet with the urine, as their being frequently wafhed f either with brandy or any other ardent fpirit, or with J lime water. In patients of a weak, feeble conftitution, an incon- tinence of urine frequently occurs after the operation of lithotomy. In general, however, this is removed upon the patient recovering, his former degree of , ftrength; and the uSe of the cold bath, Peruvian bark, and a nourifhing diet, contribute much to this effed. ►.'• But, in order to obviate the immediate difagfeeabk ijjf effects of a conftant difcharge of urine, different in- ftruments 366 Of the Stone. Chap. XL ftruments have been contrived: Some of thefe have in view the compreflion of the penis, in order to pre- vent the urine from being difcharged; and others are intended to be concealed within the patient's breeches, and to ferve as receptacles for the urine on its paffing from the urethra. In Plate XIX, fig. i. is reprefented the moft con- venient form of the former of thefe ; and in fig. 2, is delineated a receiver, which by experience has been found to anfwer the purpofe of the latter both eafily and effedually. And thefe instruments, it is obvi- ous, may be ufed in all cafes of incontinence of urine, whether originating from this operation or from any Other caufe. Hitherto we have been Suppofing the operation to take place in a male fubjed only ; but although the fhortnefs and width of the urethra in women renders them much lefs liable to ftone in the bladder than men, yet inftances Srequently occur oS this diforder in females; and whenever it does fo, and when the Symp- toms produced by it are violent, Some means muft be employed for relief. While from the fhortnefs of the urethra women are lefs liable to the ftone than men, the operation of lithotomy with reSped to them, is, on the Same ac- count, much more fimpk, and of courfe more eafily performed. It cannot be done by cutting from the perinseum, in the fame manner as in male fubjeds; for, as the urethra and bladder lie immediately above the vagina, any opening made into them from the perinaeum muft of neceffity pafs through the vagina, fo as to wound it both above and below: And this was confidered as a very material objedion to the lat- eral method of cutting, upon its firft introdudion. There is not here, however, the leaft neceffity Sor do- ing any injury to the vagina, as the urethra may be di- vided from one extremity to the other, without any rifk of touching it. The Sed. VII. Ofthe Stone. 367 The patient being placed upon a table, and fecured in the manner we have already direded, a grooved ftaff, fuch as is reprefented in Plate XIV, fig. 3. is to be introduced into the bladder, by paffing it through the urethra which lies between the nymphae immedi- ately below the clitoris ; and the operator, keeping it firm with his left hand, is with his right to introduce the beak of the cutting diredor into the groove, and to run it eafily along till it has fairly entered the bladder. He ought now, as in male fubjeds, to in- troduce his finger along the diredor; and having dif- covered the ftone, fhould proceed to extrad it in the manner we have already recommended. By the old method of cutting in females with the greater apparatus, no incifion was made into the ure- thra, but different inftruments were ufed for the pur- pofe of dilating it; and when this was fuppofed to be fufficientiy effeded, the forceps were employed for extrading the ftone. In this manner, however, much laceration was produced; the patient fuffered a great deal of unnecessary pain, and the bladder was com- monly deprived of all power of retention. We have no difficulty, therefore, when operating on female fub- jeds, in preferring the method we have recommend- ed, of laying the urethra open through its whole length. As the bladder in females lies immediately above, and quite contiguous to, the vagina, it has been pro- pofed, that, inftead of laying open the urethra j as we have direded, an opening fhould be made directly in- to the bladder from the vagina, at which the forceps are to be introduced for extracting the ftone. One cafe of this kind we find recorded by Buffiere* ; and, more lately, other three are related by the ingenious Mr. Gooch, in which this method of extradion was fuccefsfoUy employedf. It has never, however, been generally • Philofophical Tranfaftions for the year 1669, p. ,ig6.. f Vide Cafes and Remarks in Surgery, vol. ii. p. 18a. by Ber.ja. min Gooch. 368 Ofthe Stone. Chap. XL generaUy adopted; and as various objedions occur to it, we do not think it will ever be frequendy put in pradice. By cutting into the bladder through the vagina, parts are injured, which by the other method may be avoided: The ftone, when it does not lie diredly up- on the vagina, is with difficulty laid hold of; it can- not be fo eafily extraded as when drawn along in the courfe of the urethra; fistulous openings muft in all probability occur more frequently after this than after the other method of operating ; and if the woman fhould afterwards become pregnant, the cicatrix form- ed in the vagina would produce pain, obstruction, and perhaps laceration in the time of delivery. One great advantage which the lateral operation, in its improved prefent ftate, poffeffes over the others, both in males and females, is, that no laceration whatever is produced by it unlefs the ftone is remarkably large; in which cafe, no precaution with which we are ac- quainted has any influence in preventing it: But, in ordinary caSes, where the ftone is not large, if the parts are divided in the free manner we have recom- mended, all the rifk attending laceration, and which we have endeavoured to point out as the moft haz- ardous part of this operation, is very effectually avoided. We have thus defcribed the various means, hither- to employed by praditioners, for extrading ftones from the bladder; and from what has been faid, it muft readily appear, that the lateral operation is, in ordinary cafes, greatly preferable to every other. In- deed it stands fo eminently fuperior to the others for general ufe, that we do not confider it as neceffary to draw any farther comparifon between them; but, as we have already obferved, particular cafes do fome- times occur * in which the high operation may with great propriety be employed inftead of it. We have already in ftrong terms pointed out the rifk which oc- curs Sed. VII. Ofthe Stone. 369 curs from extrading a large ftone by the lateral meth- od of cutting; and we have fhown, that ftones of any magnitude which the bladder can contain may be ex- tracted by the high operation. Whenever, therefore, it is known with any tolerable certainty, that a ftone is of an uncommon fize, and when the high operation is in other refpeds admiffible, it ought certainly in every foch inftance to be preferred : For although in cafes of large ftones it may be better to break them into Small pieces in the manner we have direded, than to lacerate the parts by extrading them entire ; yet this pradice is only adviSable when the operator unexpededly meets with a large ftone aSter the bladder has been cut into : And whenever it happens other- wise, and the ftone is previoufly known to be very large, much advantage may accrue to the patient from a judicious choice, on the part ofthe operator, of his method of operating. In the diredions here laid down for performing the lateral operation, the didates of experience are ftridly adhered to, and nothing is recommended that is not either at prefent very generally adopted, or that I have not myfelf put in pradice. Many ingenious propofals have been made by in- dividuals for the improvement of the operation of lithotomy, particularly of the lateral method of cut- ting : But a minute detail of all that has been sug- gested upon this fubjed, is incompatible with the na- ture of this work ; nor could it ferve any purpofe, but to bring into view fome particular modes of prac- tice, which were either never generally followed; or which, if adopted, have fallen again into difufe. The moft remarkable of thefe propofed improve- ments ofthe lateral operation are, thofe of three French furgeons, Monfieur Foubert, Monfieur Thomas, and Frere Cofme. The two first of thefe gendemen in- vented inftruments for penetrating the body of the bladder without interfering with die urethra. The A a a bladder 37© Of the Stone. Cfha^p. XL bladder being distended with urine, and an incifion be* N ing made through the fkin and cellular fubftance, a cutting inflTurnent of a particular cohftrudion is then direded to be pufhed paftthe urethra into the fide of j the bladder ; and an opening being made of a fiiffi- J cient fize, the ftone is to be extracted in the ufual manner. One material advantage propofed from this improvement is, that by the urethra and prostate gland being avoided, that inability to retain the urine and other troublefome confequences, which fome- times enfue from injuries done to thefe parts, are hot ' fo apt to occur when the body of the bladder alone is wounded. But, independent of any other objedion to which this method of operating is liable, this of it- t felf muft ferve effedually to prevent it from being *l ever very generally received, namely, the wound in the bladder being fore to recede from the Wound in the teguments as foon as all the Water contained in it is evacuated: And the confequences refulting from fuch an occurrence muft frequently, it is obvious, J J prove very diftreffing ; as the urine, by not finding *-| 1 free paffage by the Wound, WiU readily infinuate mi felf into the contiguous parts, where it muft of confe?|^| quence be produdive of veiy troublefome fistulous ,<. openings. '. is So that although this method of cutting dircctlyXlfl into the neck or body ofthe bladder^ is, at firft view, wk extremely plausible, yet the kaft reflection on thefe p •confequences which frequently refult from it, muft at T! once convince every praditioner of the rifk attending w it being confiderable. 3 The operation of Frere Cofme, is, in effed, the J fame with the real lateral operation, as it is now common-Jll ly pradifed. The parts cut in it are exadly the fame/ 1 only they are divided in a different manner. After J the ftaff is laid bare in the ufual manner, the beak of J the inftrument, fig. i. Plate XVIII, is introduced in-, j to the groove ; and being pufhed forward till it reach- *■ es Plate Will SeCtVIL QftheStw. 371 es the bladder, the frring.C is then to be prqfted down, fo as to raife the knife from its fheath, when the ope- ration is to pe finiihed by witi^awing the irtftrument in fuch a diredion as may divide the neck of the blad- der and proftate gland in the fame manner as is done by the common gorget: After this, the other fteps of the operation are to be completed in the manner we have already direded, by the forceps a)qne. Moft of the other deviations from the eftabliihed mode of pradice, hitherto propofed by furgeons, con- sist, either in fome improvement of the cutting gor- get of Mr. Hawkins, or in a preference which fome practitioners ftill continue to give to the knife. Wc have already obferved, that Mr. Hawkins's gorget does not fpread foffickntly at the cutting part of it ; and that it is much wider and deeper backwards than it ought to be, by which it is liable to tear and otherwife injure the urethra more than is neceffary : This in- convenience, however, we think is effedually remov- ed, by the cutting diredor we have ventured to rec- ommend. With refped to the fcalpel being preferred by fome operators both to the cutting gorget and dired- or, we have only to obferve, that an expert forgeon of fteadinefs, and poflefling a minute knowkdge of the anatomy of the parts, may with eafe and fafety perform the operation of lithotomy with the knife a- lone; but we muft alfo remark, that, with the gener- aUty of furgeons, the danger of wounding the redum is fo great when the fcalpel is employed, that the ufe ofthe gorget or cutting diredor, by either of which the intestine is effedually defended, ought to be com- monly preferred. In the courfe of this Sedion we haye endeavoured to deliver all that is worth recording, of modern prac- tice in the operation of lithotomy : We are not con- fcious of having omitted any improvements of im- portance ; and fome, we hope, are propofed, which are not 37« Of the Stone. Chap. XLv not generally known, or which, if known, are not commonly pradifed. As the fubjed we are treating of is one ofthe moft material in the department of Surgery, we have been induced to extend the confideration of it to a very confiderable length : It may therefore prove fervicea- ble, to ftudents efpeciaUy, to have fuch circumftances enumerated in a more concife manner as particularly merit their attention. i. We have already in ftrong terms pointed out the propriety of an abfolute certainty being attained, of a ftone existing in the bladder, before the operation of lithotomy is propofed: And we have endeavour- ed to fhow, that no fymptoms, however Strongly marked, afford Sufficient evidence of the prefence of calculus; the operation of founding, or touching the ftone with a ftaff, being the only certain means we have of judging of this matter. 2. In performing this operation, a confiderable quantity of urine ought to be previoufly allowed to colled in the bladder ; the redum fhould be emptied by an injedion; the buttocks ought to be confiderably elevated above the reft of the body ; and the external incifion ought to be more extenfive than is commonly advifed. In full grown adults, inftead of an inch and a half, or two inches, as it is generally made, it fhould be at leaft three inches and a half long ; care being taken to commence the cut at the inferior edge of the pubes, and to continue it in an oblique direction till it has pafled the anus, at an equal diftance be- tween the extremity of the redum and the tuberofity ofthe ifchium. 3. As the great refiftance frequently experienced in this operation to the extradion of the ftone, pro- ceeds moft commonly from the mufcles covering the urethra, thefe ought to be, freely divided : No danger can enfue from this, and much advantage may be de- rived from it. 4. But Sed. VII. Ofthe Stone. 373 4. But although a free divifion of the mufcles is of much importance, there is no neceffity for cutting fo much of the urethra as is very commonly done : It does not render the extradion of the ftone in any de- gree eafier; and it makes the operation more hazard- ous than when the membranous part of the urethra only is divided. When the incifion is carried through the teguments and mufcles fo as to leave the ftaff covered by the urethra only, the operator ought to in- fert the index and middle finger of his left hand into the bottom of the wound, by which means the redum will be effedually proteded; and this being done, an opening fhould be made into the urethra by piercing it with the point of the fcalpel very near to the prof- tate gland, and extending the incifion to the bulb, but no farther. This, we may remark, fhould be done by one stroke of the knife ; and not by repeated ap- plications of it as is the common pradice, for by this means a rugged unequal wound muft for certain be produced. In the first part of the operation, the point and edge of the knife ought to be fo applied as to cut from above downwards, as in this manner the incifion is very eafily and fafely accomplifhed ; but in dividing the urethra, the back of the knife ought for certain to be turned down, while the edge of it is made to penetrate the urethra, and to run along the fulcus ofthe ftaff. By this means the redum cannot poffi- bly be injured ; an occurrence, which, in the ufual method of operating, is too frequently met with. 5. The next ftep in this operation is to divide the proftate gland, with a very Small portion of the neck of the bladder. This, we have obferved, may be done with much fafety and eafe with the fcalpel alone, by a good anatomift, whofe hand is perfedly steady ; but as there is a neceffity for dividing the proftate gland in fuch a diredion as to ayoid the redum, with which it is posteriorly conneded, and Ukewife the ex- cretory duds ofthe veficula? feminaks which termin- ate 374 Of the Stone. Chap. XL ate here, much exadnefs is required to get this ac- complifhed, and it can only be done with fafety to thefe parts by a lateral cut through this gland, A very fmall variation, it is evident, in the direction of the "fcalpel, might here be productive of much danger; and few praditioners being poffeflH of fuch equal fteadinefs as at all times to be able to avoid this, fop ordinary pradice, a knife, conftruded in fuch a man^ ner as to proted the redum and other parts behind, at the fame time that it effeds a lateral divifion of the gland, ought certainly to be preferred. The gor- get of Mr. Hawkins is attended with all thefe advan- tages ; but we have formerly fhown, that it is likewife attended with a very material inconvenience. This, we think, is effedually obviated by the cutting dired- or we have already defcribed, which makes a more ckan and ample cut than the gorget, at the fame time that ic does not tear the urethra, as the gorget always does by being made to expand more behind than is neceffary. 6. After the ftone is laid hold of by the forceps, it ought to be extraded in a very flow and gradual manner ; not by a rotatory motion, or by preffure applied equally in all diredions; but by endeavouring to dilate the parts along the courfe of the wound in a iine diredly between the anus and the tuberofity ofthe ifchium. Moderate preflure laterally, may likewife have fome influence: But nq force ought ever to be appli- ed towards the upper part of the wound ; for nothing can be gained by doing fo, and it muft for certain do raifchief by prefling the urethra with violence againft the pubes. When in the courfe of extradion it is found, that the paffage of the ftone is impeded by fome of the mufcles not having been fufficientiy di- vided, this ought ftill to be done, by the operator keeping the ftone firm in the forceps with one hand, whik with a fcalpel in the other he effeds what is neceffary. 7. The Sed. VIIL Of the Stone. 31$ J. The ftone being extraded, foft eafy dreffings fhould be applied to the wound: And the patient fhould be laid in bed with his head and upper part of the body elevated, in order to facilitate the evacna- ation of any blood that may be difcharged from any arteries that have been cut; and which, by a contrary pofture, with the buttocks raifed above the reft of the body, is often made to lodge in the bladder, to the great detriment and even hazard ofthe patient. Having thus enumerated thofe points in this ope- ration which deferve moft attention, we fhall now proceed to confider the operation of Nephrotomy. SECTION VIIL Of Nephrotomy. WHEN one or more ftones are impaded in the kidneys, in fuch a manner as to be prevented from paffing off with the urine, they give rife to a train of fymptoms which occafion the moft complete mifery during the life of the patient, and which at laft almoft conftantly terminate in his death. The feverity of the pain produced by ftones in the kidney, is frequently fo great, as to have induced practitioners to fuggeft an operation for extrading them. This confifts in a cut being made through the common teguments and mufcles immediately a- bove the kidney, with an opening into the kidney it- felf of a fufficient fize to afford a free paffage for the ftone. But we are to remember, that, however marked the fymptoms of a ftone in the kidney may appear to be, it is impoffible to obtain an abfolute certainty on this point. We know that a ftone in the kidney oc- cafions pain in the region of the kidneys together with ficknefs and vomiting, and a difcharge of urine fometimes mixed with blood, and on other occafions with 376 Ofthe Stone. Chap. XL with mucus, and even with purulent matter. We alfo know, however, that the fame fymptoms are not unfrequently induced by other caufes, particularly by inflammation and confequent fuppuration of the kid- ney. Many inftances have occurred of the moft vi- olent nephritic complaints fubfifting for a great length of time, where ftones were fufpeded as the caufe of them ; but where, upon diffedion, inftead of this the kidney has been found to be completely fuppurated, and as it were entirely diffolved, a quantity of purulent matter being contained within its external covering. Even in the cafe of calculus of the bladder, a dif- order lefs ambiguous than the nephritis calculofa, the fymptoms are never So diftind and charaderifttc as to render the operation of lithotomy advifable, unlefs a ftone is difcovered upon the introdudion of a found. But in affedions ofthe kidney, fufpeded to originate from ftone, we are deprived of this means of afcertain- ing its prefence ; fo that it might not unfrequently^ happen, that, after laying open the kidney, no ftone would be difcovered. This is, therefore, an objec- tion, and a very important one to the operation in question. But it is to be farther obferved, that the kidneys do not lie near the furface of the body ; that although they are not altogether covered by the inferior falfe ribs, yet thefe ribs projed fo much over them, as to prove a confiderable obstacle to an operation ; and that, in people who are corpulent, the kidneys are very thickly covered indeed. For thefe reafons, it is impoffible to make an o- pening into the kidney with fo much accuracy and precision, as the near contiguity of the neighbouring. large blood veffels would require ; and whoever at- tempts the operation of nephrotomy, even on the dead body, wtfl find it a difficult matter to cut into the pelvis of the kidney without opening fome of the large blood veffels belonging to it: The very °reat and Sed. VIIL Of the Stone. 377 and immediate danger from fuch an accident is too manifest to require to be farther mentioned. When, indeed, the inflammation, frequently induc- ed by a ftone in the kidney, terminates in an abfcefs, and when the matter thus coUeded forms a tumor in which a fluduation is diftinguifhed, little or no dan- ger can enfue from opening it: And in fuch an event the ftone which produced the tumor will either be dif- charged along with the matr "t may, if it can be laid hold of, be afterwards extracted with fafety. The ftone being thus taken out, the opening through which it paffed, will either heal by the ufual means employed in the treatment of abfceffes in other parts; or the moft unfavourable termination that can proba- bly happen, will be a fistulous fore, through which a mixture of pUs and urine will continue to be difcharg- ed. Upon the whole we may conclude, that when we are not direded by the apppearance of a tumor to the part which ought to be opened, the uncertainty of the ground upon which we proceed when we un- dertake this operation—the difficulty of performing it—and the very imminent danger which attends it, will more than counterbalance any advantage which can ever be expeded to be derived from it; and that for this reafon the operation of nephrotomy wUl nev- er probably be received into general pradice, howev- er much it may be recommended by fome writers, and warmly Supported by others, who, in order to raiSe a reputation which they might not otherwife obtain, will fometimes ftep forward and propofe with confidence what no praditioner of charader would think right to attempt*. B b b SECTION * For farther information on the fubjeft of Nephrotomy, fee Rofletus de partu Cjelareo, cap. vii. fett. 4. Philofophical Tranfao tions for the year 1696. Schenkius Obfervat. Med. lib.iii. Jump- er's Confpect. Chirurg. tab. 93. Edinburgh Medical Eflays. Me- moires de PAcademie RoyalledeChirurgie of Paris,—And Mery's Observations fur UManiere de Taillcr. 37 a Of the Stone. Chap. XL SECTION IX. Of Stones in the Urethra. IT is not an unfrequent occurrence for patients li- able to calculus complaints, to pafs fmall ftones along \ with their urine. When the ftones, in Such inftances, j are Smooth and not very large, they uSually come off '■< with little or no difficulty ; and in fome cafes ftones of a very confiderable Size have been paffed without being produdive of much pain. But when an an- gular or rough ftone is pufhed-into the urethra, if it ■ is not So Small as to paSs eafily off with the firft flow of :i urine, it is fore to create a great deal of diftrefs. ; Pain is the firft fymptom produced by a ftone lodg- ■ ed in the urethra ; and to this fucceed inflammation, ;- tumefadion of the parts, and always a partial and fre- quently a total fuppreffion of urine. In fome inftan- , ces, when the diforder is long negkded, this fuppref- fion and confequent tumefaction terminate in a rup- * ture of the urethra ; in confequence of which, the u- rine efcapes into the contiguous cellular fubftance, and very troublefome fwellings are produced not only in the body of the penis, but frequently in the fcrotum, and through the whole courfe ofthe perinseum. The treatment fuited to fuch tumors will be pointed out when we come to treat of fiftulous fores in thefe parts ;. we have now only to relate the eafieft and moft effedual means of difcharging the ftones which are lodged in the urethra. As foon as it is known that an obftrudion is formed in the urethra by the ftoppage of a ftone, the nicest attention be- comes requifite in order to procure its removal. When a ftone has been long fixed at one particu- lar part without yielding in any degree, and when the pain and inflammation produced by it are confidera- ble, a chirurgical operation ought to be immediately employed Sed. IX. Of she Stone. 379 ' employed for removing it; but in the incipient Stag- es of this diforder, other means of a more gentk na- ture fhould be firft put in pradice. Whether or not the urethra itfelf is poffeffed of any contradile power, is a point not eafily to be deter- mined : But the mufcles with which it is immediately conneded, are in common with other mufcular parts fubjed to the influence of stimuli; and as nothing with which we are acquainted, can be fuppofed to give a more powerful stimulus to a fenfible part than . the irritation of a rough or angular ftone, fo we may fairly conclude, that when once a ftone is impaded in the urethra, its farther paffage along that canal may very poffibly be impeded by a fpafmodic contraction of fome of the contiguous mufcles. One very im- 1 portant indication, therefore, in the treatment of this % malady, is, the removal of SpaSm ; and when we keep f this idea in view, and continue to perfift in the ufe of proper remedies, we feldom fail to bring off fuch ftones as have been lodged in the urethra, without the aid of any chirurgical operation. But, inftead of the appUcation of means calculated for the removal of ~ fpafm, the ordinary pradice of furgeons is the dired reverfe of this, and muft frequently be attended with a very oppofite effed. An attempt is commonly made to pufh the ftone forward at once with the fingers. It is obvious, how- ever, that until the fpafm which in part produces the obftrudion, is removed, every trial of this kind will rather tend to increafe the complaint. For this rea- fon, therefore, no preffure ought to be ufed till the moft effedual means have been employed for remov- ing the fpafm produced by the ftone. With this . view, the patient, if he is plethoric, ought to lofe a ' confiderable quantity of blood by the lancet; or if he is thin and emaciated, a proportionable quantity fhould be difcharged by leeches, diredly from the part affeded. • A quantity of warm oU fhould be re- r peatedly 380 Of the Stone. Chap. XL : peatedly injeded into the urethra, in order to lubri- cate the paffage as much as poffible.—The patient j fhould be immerfed in a warm bath—and a full dofe j of laudanum fhould be at the fame time exhibited. Together with thefe remedies, a plentiful ufe of diuretic medicines, and of diluent drinks, is common- \ ly prefcribed ; but, inftead of being produdive of any advantages, they almoft conftantly do harm. , For, when the urine nifties out with violence, if it . does not carry the ftone freely out of the urethra, it will tend to fix it more firmly than before ; and the pain thus produced, will always increafe the inflam- mation, tenfion and fpafm of the parts affeded : So that whatever has much effed in increafing the quan- 1 tity of urine Should be carefully avoided. A proper quantity of blood having been difcharg- ed ; the patient having remained for a fufficient length of time in the warm bath ; and the opiate having be-. .-*! gun to operate ; the parts will thus be as completely -:' relaxed as poffible : And this is the period when fome attempt fhould be made for extrading the ftone. Various inftruments have been contrived for this pur^ '| pofe, particularly long fmall pliers or forceps con- cealed in a canula of a fize correfponding to that of the urethra ; but as none of thefe have ever proved' ' in any degree ufeful, and as they often do much harm by producing an increafed irritation in the urethra, we do not think it neceffary to delineate them. In place of ufing inftruments of this kind, a furgeon ought at firft to-eadeavour by very gentle preffure to pufli the ftone forward along the courfe of the ure- thra. In this manner large ftones may be brought off", for the removal of which a very painful operation might otherwife be neceffary. Indeed, ftones of fo very confiderable a fize have been fometimes paffed by the urethra, as ought always to induce pradition^ ers to perfevere for a confiderable time in the employ- ment Sed. IX. Ofthe Stone. 38i ment of the more gentle remedies we have recom- mended, before advifing any other means of relief. It frequently happens, however, that ftones of fuch a fize and figure get into the urethra, as cannot by any means be made to pafs to the extremity of that canal. When a ftone, thus fixed in the paffage, is of foch a form as to admit of the difcharge of the urine, a pa- tient, rather than fubmit to an operation, is fometimes induced to allow it to remain; and when he does fo, the ftone, in a fhort time, commonly obtains an in- creafe oS Size by a deposition of earthy matter from the urine : I have known different inftances of this in which the ftones have become very large, and in which the urethra was So dilated as to Sorm an extenfive pouch or cavity correfponding to the Size and figure of the ftone. But when the ftone, inftead of allowing any of the urine to pafs, fills up the urethra entirely, it then becomes neceffary to have immediate recourfe to an operation as foon as the means we have already recommended are found to prove ineffedual. This operation consists in cutting diredly upon the ftone, and extrading it either with a fcoop or with a pair of fmall forceps; but the methods of effeding this vary according to, and depend upon, the part of the urethra in which the ftone is fixed. When a ftone is fituated near to the beginning of the urethra, and very contiguous to the bladder, it has been advif- ed to pufh it again into the bladder by means of a ftaff: But as it might there probably acquire a much larger fize, and would confequently render the patient liable to all the diftrefs ufuaUy produced by a ftone in the bladder, this is a pradice which ought by no means to be admitted, as the ftone may be extraded with much more eafe from any part of the urethra, and with much lefs hazard to the patient, than is commonly incurred by the more formidable operation of cutting into the bladder. WThen 39-z Ofthe Stone. Chap. XL , When therefore, an operation is neceffary for ex- . trading a ftone fixed in the urethra near the neck of I the bladder, the method of performing it is this. 1 The patient ought to be laid upon a table, and fe- 1 cured in the manner we have direded for the opera- J tion of lithotomy: And an affiftant fufpending the j fcrotum and penis, the furgeon, after oiling the firft J and Second fingers of his left hand, fhould introduce ,1 them into the anus, and by means of them ought to , prefs firmly upon the parts immediately behind the j ftone ; which will not only enable him to lay it bare I with more eafe, but will be the forest method of pre- ] venting it from being pufhed into the bladder by the \ neceffary preffure of the knife. This being done, an " incifion fhould be made through the common tegu- ments and urethra, fo as to lay the ftone completely J bare ; which mi y now be either turned out by a due degree of preffure applied with the fingers in the rec- •■ turn; or, if this is not found to be fufficient, it may be taken out either with a fcoop or with a pair of for- ceps, i The after treatment is the fame here as we have ) direded in the operation of lithotomy. When, again, a ftone has paffed farther into the urethra, in order to extrad it the fkin ought to be drawn as much as poffible pafl it, either in a back- ward or forward diredion; and the ftone being now fecured in its fituatiol* by preffure, a longitudinal cut is to be made diredly upon it through the urethra, of a fufficient fize to admit of its eafy extradion either with the fcoop or forceps. The edges of the wound are now to be completely cleared of fabulous particles, and the fkin aUowed to regain its natural fituation ; by which means, if the operation has been properly done, the wound in the urethra will be entirely cov- ered by flcin that has not been injured: A circum- ' ftance which tends to render this operation much lefs formidable than it otherwife would be ; for the wound in Sed. IX. Ofthe Stone. 33j in the urethra is thus fo weU proteded, that it com- monly heal* bythe firft intention. It Sometimes indeed happens, that in voiding urine, part of it efcapes at the wound, and infinuates itSelf in- to the contiguous cellular fubftance. This is, how- ever, a rare occurrence, and the inconveniences arif- ing from it are eafily obviated by laying open any colkdion of urine which may take place during the cure. When a ftone fixes near to the point of the yard, as it fometimes does ; if it is fo near as to be obferv- ed by the eye, it may frequently be taken out with a pair of fmall diffeding forceps : And in order to fa- cilitate the extradion, when it cannot be otherwife ef- feded, the urethra may be fomewhat dilated from its extremity with the point of a fcalpel. But when we fail of fuccefs in this way, an incifion muft be made upon the ftone in the manner we have direded where the urethra is covered with fkin. Soft dreffings fhould be applied to the wound; and when the cure is near- ly Completed, a hollow bougie, a fhort filver tube, or a fmall catheter of the elastic gum, fhould be intro- duced into the urethra, in order to preferve it of a proper fize. The moft perplexing fituation in which a ftone can be fixed in the urethra, is juft below the fcrotum; for if the ftone eitter makes its way into the fcrotum, or if it is neceffary^to make an opening into it with a fcalpel, fuch large coUedions of urine are apt to oc- cur, as commonly occafion much diftrefs. In order, therefore, to obviate this inconvenience, as foon as a ftone is discovered in this fituation, the greateft attention ought to be given, either to get it carried farther into the urethra, or, if this cannot be ef- feded, to pufh it back into the perinasum by means of a staff. By a due perfeverance in the means we have recommended, this will very commonly be ef- feded : But when it is found to be impradicable, and that 384 Of the Stone. Chap. XL that there is a neceffity for extrading the ftone, an in- cifion muft be made into the urethra, by beginning the cut at the under part ofthe fcrotum immediately J to one fide of the feptum, and continuing it upwards till the ftone is diftindly felt, when it is to be laid bare and extraded in the manner we have already direded. By making the incifion from below upwards, any urine that efcapes from the urethra finds a very free paffage; and if the opening is made fufficientiy large, the ftone may be in this manner eafily extraded. During the operation, care muft be taken to have the teftis of that fide on which the cut is made, as much proteded as poflible, by an affiftant pulling it away from the knife; and when this is properly done, there is no danger of the tefticie being injured. Some at- tention is neceffary after the operation in applying the , dreffings in fuch a manner, that the fore may heal firft at the bottom ; for if this circumftance be not kept in view, and if the teguments are allowed to heal before every vacancy in the parts beneath is 'filled up, purulent matter, and perhaps urine, will very proba- bly be coUeded, and may thus give rife to trouble- fome finufes. When urine continues to be difcharged for any length of time at a preternatural opening of the ure- thra, whether the confequence of the operation of li- thotomy or of any other caufe, if ttye calculous dia- thesis prevails, ftones of a large fize will frequently form in the cellular fubftance contiguous to the open- ing. I have met with feveral inftances of this : In fome of them, the ftones were fmall and eafily ex- traded ; but in others they were found to occupy a confiderable portion of the cellular membrane, and to occafion a good deal of trouble in taking them entire- ly out*. The treatment here consists fokly in mak- ing * A very remarkable cafe of this nature is recorded by Gooch. See Cafes and praftiCdJ Rrrmuks in Surgery, Vol. ii, p, 174, by Benjamin Goc:h. ' Sed. IX. Of the Stone. 3*S ing a free incifion along the courfe ofthe calculous concretions; in turning them out, either with a fcoop or a pair of forceps ; and in dreffing the wound prop- erly, fb as to induce a firm adhefion of the parts be- neath, before the external teguments are allowed to heal. In females, the urethra is fo fhort, and dilates fo readily, that fmall ftones feldom ftop in it: They are moft commonly carried off by the flow of urine which brings them into it; but when they happen to fix in it, they are commonly turned out with much eafe, merely by the end of a blunt probe being infinu- ated behind them, and then pulled forwartl: Or, when this does not fucceed, it may always be effeCted with fafety, by cutting open the extremity of the.ure- thra fo far as to admit of the introdudion of a pair of fmaU forceps by which the ftones may be extraded. C c c CHAP. 386 Incontinence of Urine. Chap. XII. CHAP. XII. of INCONTINENCE of URINE. Incontinence of urine may be produced by various caufes; but as it is frequently conneded with calculous complaints, and is in fome inftances the confequence of the operation of lithoto- my, we are hence induced to take the fubjed under confideration in this place. The ordinary caufes of this malady may be re- duced to the following heads. i. Irritation about the neck of the bladder, pro- duced by the fridion of ftones contained in it. Thus we know, that inability to retain urine, is a very fre- quent fymptom of ftone in the bladder ; and we can- not fuppofe this to proceed from any other caufe than the conftant stimulus communicated by the ftone to the coats ofthe bladder. For, if it always originated, as has been fuppofed, from a total lofs of power in the fphinder vific£e, the difeafe would feldom or nev- er admit of a cure. But we know well, that an in- continence of urine, depending upon a ftone in the bladder, is very commonly removed entirely by the operation of lithotomy : And we likewife know, that it is very frequently much relieved, even when the ftone remains in the bladder, by the ufe of thofe rem- edies which moft effedually remove irritability; par- ticularly by a plentiful ufe of mucilaginous drinks, and by a free uSe of opiates. Indeed, by a continued ufe of thefe remedies, this variety of the difeafe is com- monly more effectually removed than by any other means, Chap. XII. Incontinence of Urine. 387 means, extradion ofthe ftone excepted; which, when thefe fail, is to be kept in view as the only refource upon which we are to depend. 2. A conftant Stillicidium, or incontinence of urine, is a frequent confequence of paralytic affedions ; and it would appear, that the fphinder of the bladder now and then lofes its contradile power, while the natural tone of its body, or of the mufcle termed Detrufor Urinae, remains entire. In this variety of the dilorder, the obstinacy of the paralytic affedion with which the conftitution in general may be attack- ed, commonly renders fruitlefs every attempt to re- move it. But the moft obvious remedies to be em- ployed for it, are, tonics, particularly Peruvian bark, chalybeates, and efpecially the cold bath general and local. In every affedion of this kind, the local ap- plication of cold to the perinaeum has more influence than any other remedy. Cloths wet with vinegar and cold water, or with a ftrong folution of faccharum fa- turni in vinegar, are Sometimes of ufe; but the moft effedual method of applying cold, is by dafhing water diredly from the fountain upon the perinaeum and fundament. 3. An incontinence of urine is not an unfrequent confequence of laceration produced in the operation of lithotomy in mak fubjeds ; and in the fame ope- ration, and by violence done to the parts in delivery, in females. It ought to be remembered, however, when in the lateral operation of lithotomy much laceration is produced, that in general it proceeds from the mufcles and other parts not having been freely enough divided by the knife : And accordingly, except in cafes of exceeding large ftones, this incon- venience of an incontinence of urine feldom fucceeds to this operation, when it is properly performed. 'As the difeafe in this cafe depends upon nearly the fame caufe as the one laft mentioned, namely, on a lofs of power in the retaining parts, the fame remedies be- come 388 Incontinence of Urine. Chap. XII. come neceffary; and by a due perfeverance in the ufe of thefe, particularly of cold bathing, many are at laft very effedually relieved from this fpecies of the diforder. But it does frequently happen, in every variety ofthe difeafe, that no relief is obtained from any remedy whatever ; in which cafe it becomes an objed of im- portance to prevent the urine from incommoding the patient, which it does in a very diftreffing manner, if fome effedual means are not employed to guard againft it. When the diforder proceeds from either of the two laft mentioned caufes, namely, from a paralyfis of the fphinder ofthe bladder, or from laceration, compreflion of the urethra anfwers very effedually for preventing any inconvenience produced by it, as the preffure can be fo modified as to be applied and removed at pleafure. Nuck invented the firft inftru- ment for this purpofe that we find any defcription of. The Jugum, or Yoke, as it is termed, in Plate XIX, fig. i. is an improvement upon this; and, when prop- erly fitted, it anfwers the purpofe exceedingly well. When lined with quilted filk or velvet, it fits eafily on the penis, and by means of the fcrew the preffure can be made of any degree of tightnefs. For wromen an- , other invention becomes neceffary, as the preffure here muft be applied through the vagina. Peffaries of fponge have been invented for this -purpofe ; but, when the parts are not fo irritable as to prevent the application of them, nothing anfwers fo well as the ordinary peffaries of ivory, or of any folid timber, fuch as lignum vitas. In Plate XX, are reprefented peffaries of different fizes. In the introdudion of thefe instruments, care fhould be taken to have them very finely polifhed, and they fhould likewife be well covered with oil. After being fairly paffed into the vagina, the peffary fhould be placed diredly acrofs, fo as to prefs with as much effed as poffible againft the urethra. This Plate XIX. \ ) 54304203242�9156553�733752 Plate XX fX. Chap. XII. Incontinence of Urine. 3^2 This method of obviating the inconveniences pro- duced by an incontinence of urine, by preffure, is not, however, applicable when the diforder proceeds from irritation about the neck of the bladder ; for the con- tinual defire to pafs water, with which patients in fuch circumftances are conftantly tormented, renders every attempt to SuppreSs a complete evacuation of it total- ly inadmiffible. It is therefore a matter of import- ance, for praditioners to attend to the different caufes by which the diforder is produced ; for here it is ev- ident, that a remedy well calculated for one variety of the difeafe^ may prove very prejudicial in the others. In aU fuch inftances where preffure upon the ure- thra is found to be improper, much relief may be ob- tained by having a machine properly fitted to ferve as a refervoir for the urine. The inftrument formerly referred to, reprefented in Plate XIX, has been ufed by different people, and with much advantage. It ought to be made fo as to apply as clofely as poffible to one of the thighs; and, when properly fixed to a circular bandage round the body, it commonly re- mains fufficientiy firm, and at the fame time admits of a change of pofture in any ordinary exertion ofthe body. Inftruments of this kind, however, prove ire- ful only in men. In women, all that can be done, is, to apply fponge and foft linen in fuch quantities as will effedually abforb the urine as it paffes off. By one or other of the methods here pointed out, moft ofthe inconveniences induced by this diforder may be much obviated ; and in courfe of time it fre- quently happens, that when the original caufes which produced it are removed, the difeafe itfelf is at laft completely cured. CHAP.--* 390 Suppreffion of Urine. Chap. XIII, CHAP. XIII. of a SUPPRESSION of URINE. THE diforder treated of in the laft chapter, namely, an Incontinence of Urine, is always attended with fome inconvenience ; but the difeafe now under confideration, proves, in every inftance, very alarming, and on many occafions is produdive of more real mifery than almoft any other to which the human body is liable*. Various cauSes tend to the produdion of this dif- order ; and in the treatment of it, a nice difcrimina- tion of them is neceffary. i. In the preceding chapter we have feen, that an incontinence of urine is often produced by the sphinc- ter of the bladder becoming paralytic, while the de- trufor urina? ftill retains its power of contradion. In a fimilar manner, a fyppreffion of urine frequently oc- turs in paralytic diforders, and feems to originate from lofs of Dower in the body of the bladder, while the fphinder ftill preferves its ufual power of retention. Although this fpecies of the difeafe is often con- neded with a paralytic affedion of all the under part of the body, yet it is frequently induced by the perni- cious cuftom of people remaining too long, efpecially when drinking freely of diuretic liquors, without void- ing * It is that fpecies of the difeafe we here mean to confider in which the urine is collected in the bladder, but which by fome impediment or other is prevented from being evacuated. When this difcharge is fuppreffed by any affection of the kidneys, a variety of the difeafe is produced, which it is not in the power of any chirurgical opera- tion to relieve ; fo that the confideration of it does not belong to our department. Chap. XIII. Suppreflion of Urine. 391 ing urine; by which means the bladder is fometimes fo over diftended, as to lofe entirely aU power of con- tradion. In this variety of the difeafe the catheter is commonly found to be a very certain remedy ; and as in cafes of this kind it is generally eafily introduced, it ought always to be employed as foon as the fup- preffion is evidently formed ; and as a complete cure of the diforder will be more readily obtained by a- voiding the caufe which produced it, namely, an over diftention of the bladder, than by any other means, this circumftance ought to be very particularly at- tended to. When, therefore, the leaft inclination to void urine is felt while the inability to difcharge it continues, the catheter fhould be immediately em- ployed. For although the* introdudion of the cathe- ter is always difagreeable, and fhould never be at- tempted but when neceffity points it out, yet in fuch circumftances as we are now confldering, much delay or caution on this point might frequently prove very detrimental. The method of introducing the cathe- ter, both in male and female fubjeds, is the fame with the operation of founding for the Stone, which we have already deScribed. 2. A Suppreflion oS urine frequently occurs in the laft months of pregnancy, from the uterus, during that period, prefling much upon the neck of the bladder. So-effectually indeed does this preffure of the womb obftrud the paffage of the urine, as on many occafions to prevent the evacuation of a single * drop, unlefs the catheter is ufed : And as the inftru- ment is in females commonly introduced with much eafe, it ought always to be employed when any diffi- culty in voiding urine is perceived. By delaying the ufe of the catheter too long, much diftrefs is fre- quently incurred. In different inftances, the bladder has from this caufe been diftended to fuch a degree as to lofe entirely its power of contradion ; and in a 392 Suppreffion of Urine. Chap. XIIL few cafes, even a complete rupture of its coats has #- been produced. J As Soon, therefore, as any neceffity occurs for the 1 ufe of the catheter, by the bladder being much dif- | tended, it ought to be regularly employed. \> Tumors in the vagina and neighbouring parts, j when they happen to arrive at any confiderable mag- nitude, have frequently the effed of compreffing the} ^ urethra fo much as to induce a total foppreflion of hj urine ; and it is not an unfrequent confequence of a prolapfus uteri. r ^ The method of treatment beft calculated for a J complete removal of a prolapfus uteri, as likewife the means of cure commonly employed in cafes of tu- mors in the vagina, will be the fubjeds oS differeni: chapters; only it muft be remembered, that till thefe views are accomplifhed, the urine fhould in the mean time be regularly drawn off by means of the catheter, whenever it is found to be collected in any confider- . able quantity. The very irritable ftate ofthe parts about the neck , of the bladder, which often prevails in cafes of fop- preflion of urine, renders it neceffary in fome inftances to employ the catheter often. Inftead of this, fome praditioners have advifed the common catheter to be allowed to remain in the bladder a confiderable time at once, fo as to admit of the urine being evacuated as quickly as it is fecreted : But this is a pradice which ought by no means to be admitted ; for the ir- ritation produced from a long continuance of this in- ftrument in the bladder, commonly does more harm than is ever experienced from a frequent introdudion of it. When it is wifhed, however, to allow a cathe- ter to remain in the bladder, either for this purpofe, or in cafes of wounds in the urethra, the hard filver tubes in common ufe ought not to be employed ; a flexible inftrument of this kind, prepared with the* Refina Elaftica, Chap. XIII. Suppreflion of Urine. 393 Elaftica, is found to anfwer this intention better than any other. « 3*- A ftoppage to the flow of urine is not an un- frequent confequence of fcirrhofities of the proftate gland, and of obftrudions formed in the urethra in cafes of virulent gonorrhoea. The treatment beft fuited to thefe affedions will alfo be the fubjed of a different chapter. That fpecies of foppreflion of urine induced by ftones impaded in the urethra, has been already treat- ed of, and the remedy pointed out. 4. But the moft alarming variety of the difeafe is that which proceeds from inflammation about the neck of the bladder, inducing pain and fuch a degree of fwelling in the parts as renders the introdudion of the catheter inadmiffible. Suppreflion of urine from an inflammatory affec- tion of the neck of the bladder, is not unfrequently found to originate from inflammation in cafes of gon- orrhoea proceeding backwards along the courfe of the urethra : An improper ufe, too, of astringent injec- tions has frequently induced this fpecies ofthe difeafe ; and as the bladder is equally liable with other parts of the body to the influence of thofe caufes which induce inflammation, whatever has any effed of this kind in other parts will be produdive of the fame confequen- ces here. The method of treatment is nearly the fame, by whatever caufe the inflammation may have original- ly been induced. Blood fhould be difcharged in a confiderable quantity from fome ofthe larger veffels, and leeches ought to be applied upon the perineum as near as poffible to the feat of the difeafe. Opiates fhould be prefcribed in large dofes ; injedions of warm water or milk fhould be repeatedly thrown up by the redum ; and the whole body fhould be immerfed in the warm bath. By thefe means, when the caufe in- ducing the diforder is not of an ohftinate nature, the 0 . D d d inflammation 394 Suppreflion of Urine. Chap. XIII. inflammation producing the foppreflion of urine will: fometimes be removed before any troubk'fome fymp- toms supervene.. But when they do not prove^ffeftjjiU-- when the bladder becomes painfully diftended } and when every attempt to introduce the catheter has fail- ed, fome other means ought to be immediately em- ployed for relief. With this view, nothing in fuch cir- cumftances is to be depended on, but puncturing the bladder in order to difcharge the urine coUeded in it. Various methods have been propofed for effeding this operation.—By fome it has been advifed to pundure the bladder a little above the pubes 3 oth- ers have propofed to cut the membranous part of the urethra, proftate gland, and neck of the bladder: And an opening from the perinasum directly into the body of the bladder, has been likewife recommend- ed*. It is not neceffary, however, in order to reach the body of the bladder, to lay the urethra open, and to divide the proftate gland : This method, there- fore, of removing a foppreflion of urine, is now very defervedly laid afide. Punduring the bladder above the pubes, has been recommended by many reSpedable authors, particu- larly by the late Mr. Samuel Sharp ; and as it is ftill pradiSed by many in preference to every other method, we fhall here defcribe the method of doing it. There is no difficulty in perforating the bladder in this place ; for if an opening be made any where with- in two or three inches of the upper part of the pubes, if it be carried deep enough, it muft of necessity, in this diftended ftate ofthe bladder, be fore to reach it: But the beft fituation for entering the perforating in- strument, is about an inch or an inch and a half above the fymphifes of the pubes. We are direded by writers upon this fubjed, firft to make an incifion of about two inches in length through the common teguments and mufcles, and then * Vid. the works of Saviard, Tolet, and Cojet. Chap. XIII. Suppreflion of Urine. 395 then to perforate the bladder with a trocar. But there is no neceffity whatever for this extenfive divifion of the teguments and mufcles ; for the operation may be done with equal fafety, and with much lefs pain to the patient, by merely pufhing a trocar at once through the fkin, mufcles, and bladder. As foon as the tro- car has fairly entered the bladder, the ftUette fhould be withdrawn, and the canula fecured in its fituation by pieces of ribbon or tape conneded with it and made fast round the body of the patient; and a piece ', of cork ought to be fitted to the canula, that the urine may pafs off at proper intervals only, by which means alone the patient can be kept dry and comfortable. In corpulent people, a trocar with a canula two inches long, is found to be neceffary ; but in others the inftrument need not be longer than an inch and a half. This circumftance, it may be remarked, is of fome importance, and ought to be attended to ; for when a long canula is ufed, and more efpecially when the pundure is made very contiguous to the pubes, there is always fome rifk, upon the evacuation of the urine, of pain and diftrefs being produced by the preffure ofthe canula upon the back part of the blad- der. Of this we have an inftance on record, in which the extremity ofthe inftrument was found, af- ter death, to have penetrated not only the back part ofthe bladder, but even the redum*. The canula, it muft be remembered, is to be retain- ed in its fituation till the caufe which produced the ob- ftrudion is fo far removed that the patient can void his urine in the ufual manner ; but it has been veiy properly remarked f, that a canula cannot be kept a- bove ten or fourteen days in the bladder, without con- trading Such a calculous crust, as renders its extradion exceedingly difficult, and, in fome inftances, even im- practicable. The canula, therefore, fhould be taken * Vid Sharre's Operations of Surejcry, chap. xv. f Vkj. Critical Injury, &c by Mr. Sharpe, ch. iv. 396 Suppreflion of Urine. Chap. XIII. out and cleaned every two or three days ; but, pre-. tf vious to withdrawing it, a firm probe of a fufficient length ought to be paffed through it into the bladder, upon which it may be again returned with eafe and fafety as foon as it is properly cleared ofthe incrustation. To this mode of operating, however, fome objec- tions occur. From the fituation of the canula above the pubes, the bladder is fufpended by it for a confid- erable length of time, and is thereby liable to fuffer. Befides, if the bladder flips off from the extremity of the canula, the operation muft either be repeated, as we are told by Daran, was once done, or the patient muft be left in nearly the fame ftate in which he was previous to the punCture being made. If, on the other hand, we confider the advantages tH attending the mode oS punduring the bladder from ^ the perinasum, namely, that it is done with great eafe; that the urine contained in the bladder is more readi- ly evacuated than by punduring above the pubes; and that it is likewiSe kSs liable to eScape into the neighbouring parts ; we will have no hesitation in giving it the preSerence, in perhaps every inftance of Suppreflion of urine. With a view to pundure the bladder from the' pe- rineum, the patient ought to be laid upon his back ; and his thighs being properly feparated and fecured by affiftants, an incifion fhould be made of about an inch and a half in length, beginning at thetrommence- ment of the membranous part of the urethra, and continuing it towards the anus, in a line parallel to, but at leaft half an inch distant from, the rapha pe- rinari. In this manner the fkin and cellular fubftance ought to be freely divided ; which puts it in the pow- er of the operator not only to introduce the trocar with more eafe, but to avoid the urethra with much more certainty than he otherwife could do. This being done, as the bladder is always much diftended when this operation is neceflary, it will be yery / . Plate X\I. '^f \ ,. Chap. XIII. Suppreflion of Urine. 397 very eafily diftinguifhed by preflure at the bottom of the wound: But, whether it fhould be felt by the finger or not, there need be no hesitation in pufhing in the trocar a little above and to the left of the prof- tate gland, which, if the parts lhave been freely divid- ed, may be always difcovered; and if the point ofthe instrument be direded a very Uttle upwards, there can be no danger of wounding either the ureters or vafa deferentia, which fome have been afraid of in this op- eration ; and at the fame time there muft be an abfo- lute certainty, if the trocar is carried deep enough, of its reaching the bladder. It has been alleged, and with fome reafon, that in this part of the operation the furgeon muft be at fome lofs to know when the instrument has reached the bladder; and feveral inventions have been propofed to obviate this inconvenience. In Plate XXI, fig. 4. is reprefented a very fimpk contrivance for this pur- pofe : It consists of a trocar, with a canula ofthe ufu- al form, and a deep groove in the ftilette, fo that u- rine begins to flow along the groove, immediately, on the instrument having entered the bladder. As foon, therefore, as by this circumftance it is known that the trocar is properly introduced, the ftilette fhould be withdrawn ; and the canula fhould be fecured in its fituation by two pieces of tape, conneded with two rings upon its brim, being firmly tied to a circular ■*- bandage found the patient's body: And if one of thefe tapes be tied behind immediately above the facrum, and the other diredly above the pubes, the canula will not be eafily difplaced. • It is equally neceffary here as when the operation is done above the pubes, to change the canula, or at leaft to clean it every now and then ; and in this fitu- ation too, fo long as the canula is found to be necef- fary, the urine may be retained and drawn off at pkaf- ■;ire, by a plug of coik properly adar<:ed to the canula. 3$t Suppreflion of Urine. Chap. XIIL In treating of this operation we have not mentioned a method that has been propofed of perforating the bladder by means of a curved trocar entered from the redum. Indeed it fcarcely deferves to be noticed, as no advantages can probably occur from it that may not with more certainty be obtained from perforating in the perinseum; and it is attended with this very ma- terial inconvenience, that by paffing the inftrument in at the back part of the bladder, much rifk muft be incurred of wounding either the ureters, vafa deferens tia, or veficulae feminaks; while at the fame time a paffage will be formed by which the fasces may find accefs to the cavity of the bladder, and by which much mifery may be induced: Without further con- fideration, therefore, we can with freedom venture to fay, that this irfethod of operating ought never to be employed. In the operation of lithotomy in females, we affign- ed reafons, which appear to be fufficientiy conclusive againft the method of cutting into the bladder from the vagina; but thefe reafons do not apply with equal force againft the propriety of punduring in this part. On the contrary, whenever there is any neceffity for performing this operation in women, it cannot poffibly be done in any other way either with fo much eafe or certainty, as from the vagina. When the bladder is much diftended wlh urine, it is readily difcovered by the finger from the vagina; and from this circumftance it may with great fafety be perforated with a trocar. The fore finger of the left hand being introduced into the vagina, the point of the inftrument ought to be eonduded upon it, and fhould at once be pufhed through the vagina into that part ofthe bladder which is firft difcovered by the finger ; for here the ureters run no rifk of being wounded, which farther back they certainly would do. After the trocar is fairly intro- duced into' the bladder, and when the urine is all c- vacuated, the canda ought to be left in its place, and fhould Chap. XIIL Suppreflion of Urine. 399 fhould be continued there as long as the caufe fujpfifts which produced the foppreflion. That the canula may be firmly fecured, it ought to be of a fufficient length for paffing out at the vagina, and to admit of its being tied to the T bandage by means of tapes properly conneded with it. CHAP. 400 Obflrucltons in Chap. XIV. CHAP. XIV. OBSTRUCTIONS in the URETHRA. IN the preceding fedion, when treat- ing of the caufes of foppreflion of urine, obftrudions produced by claps, of which caruncles are fuppofed to be the moft common, were mentioned as the moft frequent and moft remarkable. But although we have particularly mentioned the ' term Caruncle, by which is meant, a flefhy excrefcence arifing from the membrane of the urethra, we are by no means convinced that it is a frequent occurrence. That foch excrefcences are fometimes met with, par- ticularly towards the extremity ofthe yard, there is no reafon to doubt; but as I have had many opportuni- ties of diffeding thefe parts, in patients who had long laboured under fymptoms fuppofed to proceed from caruncles in the back part of the urethra, and as caruncles were not in any of thefe found to be the caufe of the diforder, I ar& therefore clearly of opinion that their existence in the more remote parts of the ure- ^ thra is a very uncommon occurrence. I have often ^ obferved produdions of this kind, within half or a quarter of an inch ofthe extremity ofthe urethra, ef- pecially in cafes where the glans and prepuce have been covered with watery excrefcences of a fimilar na- ture : But from having never, even in cafes of this kind, found thern fpread farther up the canal, although it is not a proof that they never occur in other parts of it, yet this, together with fome obfervations of a fimilar nature by Dionis, Saviard, Mr. Petit, and others, Chap. XIV. the Urethra. 401 others, is fufficient authority for the opinion we have advanced, that caruncles in the more remote parts of the urethra is a circumftance rarely met with. Daran indeed /peaks much of this fpecies of obstruction ; and he no doubt had more pradice in diforders of tin's nature than perhaps ever fell to the fhare of any other individual: But if he is properly attended to, it wiU be found, that his ideas on this fubjed are by no means accurate ; for he evidently confounds other caufes of obftrudion, particularly callous ftridures and cicatrices of old ulcers, with, and mistakes them for, caruncles. Praditioners in former times, as well as many in more late periods, have doubted fo little of the fre- quent occurrence of caruncles, that almoft every in- ftance of obftruded urethra Succeeding to a clap has been attributed to this cauSe. What we have here advanced, however, will have Some influence in fet- ting this matter in a different point of view; and we fhall now proceed to enumerate the different caufes by which obftrudions in the urethra may be produced. 1. Although we have Said that caruncles are rare- ly if ever met with in the foperiour part of the ure- thra, yet as they fometimes occur towards the ex- tremity of this canal, we cannot avoid mentioning this as one caufe of thefe obftrudions. We muft a- gain obferve however, that in every inftance we have met with of caruncles, or carnofitks as they, are Sometimes termed, they have always been of the fame nature with thofe warty excrefcences So frequently ob- ferved upon the prepuce and glans as a confequence of gonorrhoea : Moft frequently, too, they have been conneded with external affedions of this kind. 2. Ulcers in different parts of the urethra have on fome occafions been known to produce very complete obftrudions. On opening the bodies ot patients who have at the time of death laboured under gonorrhcea,it has frequents Eee ly 402 ObflruRions in Chap. XIV. ly been found that no ulceration could be difcovered; and this gave rife to the idea that ulcers in fuch cafes never take place. We now know indeed that very great quantities of matter, even of a purulent kind, may be furnifhed by parts merely inflamed, and that are not in any degree ulcerated : But we alfo know, that parts remaining for any confiderable length of time in fuch a high degree of inflammation as to furnifh a great fupply of pus, are very apt to become ulcerated; and if this happens in other parts of the body, we may conclude that the fame caufe will be productive of the fame effeds in the urethra. Accordingly, there is no reafon to doubt ofthe existence of ulcers merely as the confequence of an inflamed ftate of the urethra ; but it is likewife certain, that ulcers are fometimes met with in the urethra from the fame Caufe by which fores ot chancres are produced in the glans, namely, from the mechanical effeds of the venereal poifon, independent Of the intervention of any degree of inflammation. The excretory duds of the different glands in the urethra, particularly ofthe proftate gland, as alSo the duds ofthe veficuke feminaks, and the other parts a- bout the verumontanum, have commonly been coh- fidered as being particularly obnoxious to the effeds ofthe venereal virus; and ulcerations are according- ly faid to be more frequently met with in thefe parts than in any other. Whatever may have occurred to others for the foundation of this opinion, I will not pretend to fay; but, from all I have beCn able to learn of this fubjed from my own experience, I would fay, that ulcers occur much more frequently towards the extremity of the urethra than in other parts of it, and that they are very rarely found far- ther back than an inch or two from the point of the yard. 3. Diffedion has fhown that a mere contracted ftate of the urethra is to be confidered as a frequent caufe Chap. XIV. the Urethra. 4°3 caufe pf obftrudion. In fome inftances the flridure has been confined to one point, and in others the paf- iage has been found contraded in different parts. A real contraded ftate of the urethra is probably more frequently produced by the cicatrices of old ulcers, than by any other caufe; but as parts which have continued long in a ftate of inflammation, are very apt to become thickened, and even harder than they are ever found to be in a state of health, a gonorrhoea, attended with much inflammation, may frequently, it is probable, be produdive of this effect. Astringent injedions are SuppoSed by thoSe who confider them to be pernicious, as apt to produce a contraded ftate of the urethra more frequently than any other caufe. Injedions of this kind, when im- properly applied to parts already in a ftate of high in- flammation, will no doubt often do much mifchief; and, by increafing the inflammatory ftate of the ure- thra, may in this manner tend to produce ftridures : But this is evidently not the fault ofthe remedy, but ofthe improper ufe of it. Similar objedions might with equal reafon be adduced againft the ufe of every medicine with which we are acquainted; for no rern- edy ever proves more effedual, or more safe in its operation, than astringent injedions in cafes of gonor- rhoea. When properly applied, indeed, many•caies occur of obstinate elaps being fafely cured by injec- tions which cannot be removed by any other means. 4 Tumors in the cellular fubftance surrounding the urethra, or in any of the glands conneded with it, very frequently produce moft complete obftrudions in the courfe of this canal. And inflammation, whether originally induced by a gonorrhoea or by any other caufe, if it terminates in fuppuration, is often at- tended with this effed. In fuch cafes, indeed, as foon as the matter coUeded in the abfcefs is difcharged, the obftrudion produced by it is in general removed: In fome inftances, however, it happens otherwife ; for, m 404 ObflruSiions k Chap. XIV. different cafes of this namre, I have found, that the compreflion produced by the tumor has induced fuch a firm adhefion between the fides of the urethra as to obliterate the canal entirely. This, however, can on- ly occur from a long continuance of the preffure pro- duced by the tumor; and which, again, can never be continued for any confiderable length of time in fuch a degree as completely to obftrud the paffage, unlefs the urine has forced fome other opening for itfelf: And accordingly, in all fuch cafes, one or more open- ings, communicating with the urethra, are found be- tween the feat of the difeafe and the proftate gland. 5. Of all the caufes produdive of obstruction to the paffage of the urine, which I have ever been able to difcover, none are fo frequent as a particular kind of fulnefs or enlargement of the corpus fpongiofum u- rethra;. On diffeding the penis of fuch as have labour- ed long under obstructions of this kind, an enlargement or thickening of the fubftance of the urefhra as now defcribed, has been very often met with; and this en- largement has, in many inftances, proceeded fo far as totally to obftrud the paffage of the urine. In fome of thefe this affedion of the urethra was confined to a particular fpot. In others it extended a eonfiderable length ; while in fome it was found to have attacked different parts ofthe canal, leaving in- termediate fpaces of it perfedly found. We have thus enumerated the caufes which appear moft frequently to be produdive of obftrudions in the urethra. We fhaU now proceed to the method of treatment beft calculated for their removal. When obftrudion of the urethra arifes from caufes enumerated under the fourth head, our pradice muft be direded by the nature of the tumor by which the diforder is produced. Accordingly, when tumors of an indolent or fcirrhous nature are found to induce fuch obftrudions, extirpation of the difeafed parts, v/hen this is found to be pradicabk, is the only- means Chap. XIV. the Urethra. 405 means of relief which will probably prove ufeful: But although tumors of this kind which appear externally, and which do not penetrate deep, may be extirpated with fafety ; yet when the proftate gland, or any of the parts about the neck of the bladder, are found to be the feat ofthe difeafe, the removal of them cannot poffibly be attempted. In fuch defperate cafes, cicuta has been often ufed; but feldom, I believe, with much advantage. In an ulcerated ftate of the parts, a plen- tiful ufe of uva urfi has been known to give relief; but nothing with which we are acquainted, affords fuch a probable chance of relief, as long continued, though very gentle, courfes of mercury. In the mean time, a plentiful ufe of mucilaginous drinks is found to prove ferviceable, and the violence of the pain muft be obviated by adequate dofes of opiates. When, again, fuch tumors are evidently of an in- flammatory nature, if they are not foon removed by difcuflion, the moft effedual means fhould be employ- ed for promoting their fuppuration. Thefe we have already in a former publication pointed out*. As foon as by thefe, or fimilar means, the formation of matter is accomplifhed, the abfcefs in which it is coUeded fhould be immediately open- ed. In fome other parts of the body, whenever an inflammatory tumor is probably to terminate in sup- puration, it is confidered as good pradice to delay eivine vent to the matter till pus is thoroughly form- ed ; but in this fituation, as much diftrefs would for certain be produced by any confiderable delay, the ab- fcefs ought undoubtedly to be opened as foon as there is the leaft reafon to fuppofe that the preffure upon the urethra would be diminifhed by doing fo; and this muft always be the cafe whenever any collection of matter is evidently difcovered. In every abfcefs therefore, of this kind, the cure of the foppreflion of K urine # Vid. Treatife on Inflammation and if confequences. 406 Obftruclions in Chap. XIV. urine produced by it wUl be accomplifhed with more certainty by difcharging the matter contained in it than by any oth,e? means. If, on laying the coUecr tion open, however, it fhall be found that the Stoppage in the urethra, is not removed, ^eeourfe muft be had immediately either to a bougie or a catheter: By in- troducing a bougk of a proper fize and confiftence, and paffing it easily along the urethra, any obstruc- tion produced by the preffure of the abfcefs may in general be effedually removed; and by continuing to infert either a bougie or a flexible catheter, and allow- ing it to remain for feveral hours daily, every effed which fuch obftrudions might otherwife produce, wiU be very certainly obvkted. In fome inftances, again, when abfceffes of this kind are allowed to prefs too long upon the urethra before they are opened, the urine bursts into the cel- lular membrane of the perinaaum and other contigu- ous parts, and from thence forms one or more exter- nal openings ; and in this manner induces a diforder which always proves very diftreffing to the patient, and extremely perplexing to praditioners. This, however, will be afterwards more particularly confid- ered, when we come to fpeak of the fistula inperinseo. In the other cafes of obftrudions in the urethra, pro- ceeding from caruncles when they happen to occur ; from ulcers, and the cicatrices produced by them; from flridure and contradion of the urethra ; and from an enlarged and thickened ftate of the corpus fpongiofom urethras ; when thefe arife from a venereal caufe, the diforder of the general conftitution muft be particularly attended to ; and we know that it can be effedually removed by a proper ufe of mercury only." At the fame time, we muft attend to the local affec- tion of the urethra; and here a little confideration wilt render it evident, that the feveral caufes of the difor- der muft operate in the fame manner with tumors mentioned above, namely, by inducing a diminifhed or Chap. XIV. the Urethra. 407 or contraded ftate of the urethra : And this accord- ! ingly accounts for the univerfal utility of the bougie 1 in Obftrudions of this paffage; a rettiedy which, in every affedion of this nature, proves chiefly fervicea- i; ble'by its mechanical adion on'the obftrUded part. I- It has been alleged indeed by many, particularly by Mr. Daran and Mr. Sharpe, that, ^in removing ca- runcles and other caufes ofobftrudioh, bougies prove more ufeful by what they term their 'Suppurative (? quality, than by any Other property: • By-which they > mean to fay, that bougies may be eompofed of fuch materials as will induce a fuppuration upon the ca- runcles to which they are applied ; and that this fup- ;■ puration, if continued for a fuffident length of time, wiU ultimately destroy all fuch difeafed parts*. This idea, although founded on inaccuracy, con- • tinues ftill to prevail: But a very little attention muft fet the matter in a more diftind point of view ; and will make it appear, that the effed in general expe- rienced from bougies, is obtained more from the me- chanical preffure produced by them, than from any other property. Among other reafons which might f be mentioned as a refutation ofthe opinion refpeding 1 the advantages to be obtained from the suppurative effeds of bougies, the following feem to be fufficient . for our purpofe. 1. Thofe who allege that bougies prove common- ly ufeful by inducing fuppuration, have always affirm- ed * For Mr. Daran's account of this matter, fee his Treatife on Difeafes ofthe Urethra: And Mr. Sharpe's account of it may be feen in his Critical Inquiry, chap. vi. Although Mr. Sharpe is cleariv of opinion, that the principal advantage derived from bou- gies proceeds from their influence in inducing fuppuration; yet, \\ henever he attempts to inveftigate the matter with accuracy, he is obliged to acknowledge, that the preflure produced by them has no inconfiderable effect: For he fays, " That though I have a great opinion ofthe good effetts pioduced by the fuppuration, yet I be- lieve alfo, that bougies operate by diftending the urethra ; and I vill gofo far as to give it as my judgmertt, that even the cures done bv Mr. Daran are wrought partly by diftention, and partly by fup- piiraiion ; though he himfelf afcribes them to fuppuration only. Vide p. 171, fourth edition, loc. cit. 40S Obflruclions in Chap XIV, j ed that fuch cafes of foppreflion of urine as are re- j lieved by this remedy, originate moft frequendy from caruncles in the urethra; and that the fuppuration produced by the bougies, tends to deftroy, or as it were to diffolve, them. Although excrefcences of this ^ nature may fometimes prove the caufe of obstruc- tions in the urethra ; yet, as we have already endeav- oured to fhow, they are by no means a frequent one. From all the experience, indeed, which I have had in affedions of this kind, I would fay, that there does not one tenth of the whole depend upon the exiftence of this caufe. It muft therefore follow, if this idea refpeding the caufe of the diforder be Ul founded, that the foppofed modus operandi ofthe remedies em- ployed in it muft likewife be erroneous; for every praditioner who has attended much to this branch of bufinefs, muft acknowledge, that bougies in every complaint of this nature, prove much more frequently ufeful than the caufe upon which they have been fup- pofed chiefly to operate is found to exist. Indeed the general utUity of bougies in cafes of obftruded urethra, muft be acknowledged by all who have ufed them, while fcarcely any advantage is derived from the ufe of any other remedy. 2. But although we fhould allow that caruncles are frequently formed in the urethra, we cannot ad- mit that a fuppuration induced upon them would have much influence in removing them. We know, that, in other parts of the body, warts or other hard excrefcences cannot be carried off merely by a fuppuration being formed upon them ; and we cannot fuppofe that there is much difference in this refped between the fame diforder in the ure- thra, and in other parts of the body. 3. It has been faid, that thefe bougies, at the fame time that they ad by inducing fuppuration, have like- wife fome influence as an application of a cauftic na- ture j and that many of Mr. Daran's bougies, the composition Chap. XIV. the Urethra. 40$ composition of which was kept fecret, were evidently poffeffed of this property.—Mr. Daran, in order to render the operation of his remedy as myflerious as poffible, did indeed allege, that his bougies were endowed with many virtues : But no candid pradi- tioner wiU fay, that any application of this kind, pof- feffed of a degree of causticity fufficient to deftroy warts, can with propriety be introduced into the ure- thra ; for, if made of fuch a ftrength as to corrode thefe excrefcences, they would furely be in great dan- ger of injuring the whok courfe of the urethra to which they are applied.—Indeed, the mildest materi- als we can employ, frequently produce inconveniences by their ftimulating power. For upon withdrawing any bougie that has remained long in the urethra, it is almoft always found covered with matter or pus. It is this circumftance, we imagine, that firft suggest- ed the idea of bougies ading by inducing fuppura- tion ; which, however, is to be confidered only as a neceflary effed of a stimulus applied to a delicate fen- fible membrane, and in no refped effential to the cure ofthe diforder for which the bougie was ufed. 4. But without having recourfe to the suppurative or efcharotic effeds of bougies, the advantages fre- quently derived from them, in obftrudions of the ure- thra, may, as We have already endeavoured to fhow, be_eafily and fimply accounted for upon the principle of mechanical preflure alone. We have thus thought it proper to confider the adion of bougies with minutenefs ; for till once the idea is thoroughly exploded of medicated bougies, as they are termed, being neceffary, much mifchief may be done, by forming them of irritating or even of ef- charotic materials, as is fometimes the cafe, inftead of rendering their compofition perfedly mild and inof- fensive, as in every inftance it ought to be. The opinion we have endeavoured to eftablifh be- ing admitted, namely, that bougies ought to operate & F f f fokly 4io Obflruclions in Chap. XIV. fokly by mechanical preffure, it muft neceffarily fol- low, that, in the formation of bougies, much will de- pend on their being made of a proper confiftence, neither too hard nor too Soft. When too Soft and compreffible, they cannot ad wkh advantage againft the obftruding cauSe, and againft which preffure is intended to be applied ; and when too hard, they are apt to crack, and are neither introduced into nor re- tained in the urethra with So much eaSe as when made of a proper confiftence: Bougies ought likewife to have a Smooth polifhed furface, to facilitate their introduc- tion ; and laftly, they ought, as we have already re- marked, to be eompofed of very mild materials, fo that when introduced they may give as little irritation as poffible. Bougies may be made of a great variety of mate- rials ; but, fo far as my experience enables me to judge, no compofition anfwers the feveral purpofes we have mentioned fo well as a plafter of which fim- pk diachylon forms the bafis.—The following form I have had much experience of. R. Emplaft. Diachyl. fimpl. jiv. Cerae puriff. - jiB. Ol. Oliv. opr. - - 3iij. The bees wax and oil give a degree of foftnefs to the diachylon which prevents it from cracking, which it is otherwife apt to do upon being long kept; be- fides, a better polifh can be given to bougies prepar- ed from a plafter eompofed partly of wax, than can be given to thofe made of any other materials. Bur- gundy pitch, rofin, and even fome of the turpentines, have been advifed as proper additions to thefe materi- als : But all of them tend to render the compofition too irritating ; and as wax communicates a fufficient degree of tenacity to it, thefe ought never to be em- ployed. The diachylon fhould be flowly melted, and the wax being alfo melted in the oil in a different veffel, let Chap. XIV. the Urethra. 411 let the two be mixed properly together; and while the liquid continues ftill tolerably warm, let pieces of fine firm old linen be dipt in it, care being taken, by means of a fpatula, to cover the whole linen as equal- ly as poffible.—If the liquid is of a proper heat, no more of the plafter will adhere to the linen than is juft neceffary; but as air bubbles are apt to occafion inequalities on the furface of the cloth, the fpatula made ufe of ought to be fomewhat warmer than the plafter, and by means of it the whole fhould be ren- dered perfedly fmooth. Some indeed have defired the plafter to be fpread entirely by the fpatula, rath- er than to dip it: This, however, is attended with much more trouble, and does not cover the cloth with that equality which the formation of bougies re- quires. . As foon as the dipt cloth is fufficientiy cold, it may be formed into bougies; and the manner of do- ing it is this : The number intended to be formed ought aU to be cut; and the eafieft and moft exad method of doing this is by means of a fharp pointed knife direded by a ruler. The pieces ought to be from nine to ten and eleven inches in length ; and as they fhould always be fmaller at the point which enters the urethra than at the other, this circumftance fhould be attended to in the cutting of it into flips, The thicknefs of the linen, and of the plafter with which it is fpread, muft in fome meafure determine the breadth of thefe flips for the different bougies: But when the linen is of a proper degree of finenefs, and is rightly fpread, a bougie of a middle fize, may be formed of a flip of about five eighths of an inch broad at its largeft end ; and the point of it may be made of a proper fize, and may be thus adapted to a- ny particular cafe, by making the piece of Unen taper more or lefs from about two or three inches from its fmaller extremity. Thefe flips of fpread linen are now to be rolled up as neatly as poffible by the fin- gers i 4i % ObftrueJions in Chap. XlV. gers; and in order to give them a fmooth polifhed Sur- face,ihey fliould be Smartly roUed between a piece of fmooth hard timber and a plate of fine polifhed mar- ble. This being continued till the whole are render- ed perfedly fmooth and firm, and their points being rounded properly in order to facilitate their introduc- tion, they are in this ftate to be preServed for ufe. The diredions we have now given wiU convey an idea of the method of preparing bougies j but no furgeon can ever become fo expert in forming them, as thofe artists who are daily accuftomed to prepare them in very confiderable quantities. We come now to the application of the bougie.— When that kind of obftrudion occurs which points out the bougie as the moft proper remedy, the Sol- lowing is the method of ufing it: A bougie, adapted to the fize of the paffage through which it is to go, is to be well covered with fine oil, in order to facilitate its introdudion ; and the penis being firmly grafped and extended with one hand, the point of the inftru- ment is to be inferted into the urethra with the oth- er ; and being pufhed forward with caution, it is in, this manner to be carried on till it meets with the caufe of obftrudion; when, if a moderate force makes it pafs, our objed is fo far accomplifhed ; but if, af- ter different attempts, it cannot be eafily carried through, it fhould be immediately withdrawn; and at next trial, which in order to avoid any rifk of in- flammation, fhould not be made till the following day at fooneft, a bougie with a fmaller point fhould be employed. A great deal of nicety is requifite in this part of the operation; for, by proceeding gradually and with due caution, every rifk may be avoided of injuring the urethra, at the fame time that the objed in view may be often accomplifhed with more certainty than if much force was made ufe of. As foon as we rej.ch the caufe of obftrudion, if a bougie of the fmalkft Chap. XIV. the Urethra. 413 fmaUeft fize is employed, inftead of pufhing it on with force, as to a certain degree may be done with a catheter, it anfwers the purpofe much more cer- tainly to twirl it between the finger and thumb, fo as to make it prefs very moderately upon the part which it ought to pafs. But, on the other hand, al- though mifchief has often accrued from too much violence being ufed in inferting bougies, and although every praditioner ought therefore to be warned of the danger occurring from it; yet, when much re- fiftance is met with, there is a neceffity for pufhing them on with fome degree of firmnefs. If this, however, is done with due caution and in a proper diredion, which experience alone can teach, it may frequently be accomplifhed without any rifk, and with much advantage to the patient. In many cafes, indeed, unlefs a tolerable degree of force be ufed, the bougies will not pafs through the obftrudion, and no benefit will therefore be derived from them; for un- lefs a bougie be made to pafs the point of obftrudion, it cannot operate to any advantage. This, I muft obferve, is a point of much impor- tance, and ought to be kept in view. For although no unneceffary force fhould be ever employed, yet in cafes of this kind we commonly meet with too much timidity: For, in ordinary pradice, if the bougie meets with any unufual refiftance, and if it cannot, on the firft or fecond attempt, be introduced, the cafe is commonly confidered as defperate, and no further trials are made. I can from much experience, how- ever, fay, that fcarcely any cafe ever occurs in which the bouo-ie, by a frequent repetition of cautious tri- als, may not be introduced. Even where 1 have been convinced that the paffage of the urethra has at a particular point been entirely obliterated by the fides of it adhering to one another, and where the u- rine has been voided by openings in the perinaeum, 414 Obftruftiom in Chap. XIV. the bougie, with a due degree of force properly ap- plied, has at laft effeded a cure. In fome inftances, bougies with very fmall points will enter, when others of a larger fize will not pen- etrate ; but, in general, when the obstruction is found to be unufually firm, thofe of a middling fize are preferable to Such as have very Small points: For bougies of this form are very apt to bend if they do not pafs forward at once j and as foon as the point yields in any degree, the bougie fhould be withdrawn, as it cannot afterwards be pufhed forward; for if more force is now employed, inftead of being carried far- ther into the urethra, it becomes twifted, and is fore to produce a good deal of pain in the extradion.* By different cautious trials, the bougie will at laft be made to pafs the different points of obftrudion, for in fome inftances they are met with in more points than one ; and as inftances have occurred of bougies flipping into the urethra altogether, and even into the bladder itfelf this accident ought to be care- fully guarded againft by a piece of narrow tape or foft thread, conneded with the extremity of the bou- gie, and either tied round the penis behind the glans, or to a circular belt paffed round the body. Certain regulations have been mentioned by au- thors for the length of time a bougie ought to be kept in the urethra : But with fome patients they oc- casion a good deal of pain, while with others they produce little or no uneafinefs; and as it is the de- gree of pain induced by them which ought to regu- late the rime they remain in the urethra, nothing de- cisive, • With a view to give more firmnefs to bougies, Mr. Deafe, an ingenious furgenji of Dublin, recommends their being formed up- on cntgut.—V'd. Obfervationson the different Methods of treating the Venereal Difeafe, by William Deafe, Dublin, We may likewife mention, that, for purpofes of this kind, catgut alone anfwers exceedingly well.—When cut into the length of bou. gies, and on beinc* properly polifhed by rubbing on a plate of marble, they become fufficientiy firui tor forcing almoft any obfrruction. that can occur. Chap. XIV. the Urethra. 41S cifive, it is evident, can be faid upon this fubjed. When their introduction is attended with much pain, they ought neither to be allowed to remain long at once, nor fhould they be ufed above once in the two or three days: But when they can not only be intro- duced but be retained in the urethra without produc- ing much uneafinefs, they ought to be kept almoft conftantly employed; for as it is by preffure almoft fokly that they produce any advantage, and as this preffure muft be continued for a certain length of time according to the nature of the obftrudion, the more conftantly the bougie can be ufed, the more quickly a cure will probably be accomplifhed. And with the fame view the fize of the bougie fliould be gradually increafed, till one of fuch a thicknefs can be eafily introduced as the urethra could probably receive, were we certain that no obftrudion existed. When much uneafinefs is incurred by the ufe of bougies, the patient fhould never employ them but when he can confine himfelf either to bed, or at leaft to his apartment; but with many the diftrefs produced by them is fo trifling, that they can walk eafily with bougies of the largeft fize inferted along the whole courfe ofthe urethra. Nothing certain can be faid with refped to the length of time that bougies fhould be ufed, as this muft be always regulated by their effeds; which, a- gain, will in a great meafure depend on the nature of the obftrudion. This, however, we can with free- dom propofe, that the bougies ought to be continu- ed, not only while any difficulty in paffing water re- mains, but for a confiderable time thereafter. In the ufe of bougies, care fhould be taken never to pufh them altogether into the bladder : For, even when prepared of the very beft materials, a portion of the compofition may crack and fall off"; and if this fhould happen to be too large to pafs off with the urine, i: may be a means of creating much dif- trefs. 416 Obftruftions in Chap XIV, trefe, by ferving as a nucleus for a {tone. When it is neceflary to pafs any inftrument of this kind fo far as the bladder, a catheter ought undoubtedly to be employed ; for the rifk attending the introduction of a bougie to fuch a length muft be always confidera- ble. Several kinds of flexible catheters have been in- vented for the purpofe of remaining in the urethra with eafe, and for anfwering both the intention of a catheter and of a bougie. Various methods have been propofed for preparing thefe inftruments; but the moft convenient form of any I have met with confifts in a tube formed of flexibk filver wire, wrapped spirally round a fteel probe of a proper length and thicknefs; and this being neatly covered with a piece of fine linen fpread with a bougie plafter, and the probe upon which it was formed being withdrawn, the in- ftrument is thus completed; only it muft be after- wards furnifhed with a filver wire or ckanfer, in a fimilar manner with other catheters.—Thefe inftru- ments, however, do not prove fo ferviceable as was once expeded; but when it is ever neceffary to al- low a catheter to remain long in the urethra, one of this flexible form anfwers the purpofe exceedingly well. It muft be remembered, however, that as thefe catheters are covered with plafter, they ought not to be allowed to remain long in the bladder, for the fame reafon that we have defired bougies not to be inferted into it. W^hen it is neceffary to leave a flexible catheter in the bladder, thofe eompofed of the refina elaftica fliould be employed, as the adhe- five property of this fubftance prevents it from crack- ing and falling off, as every kind of plafter is apt to do. When fpcaking of the formation of bougies, we have faid, that as it is chiefly by mechanical preffure they prove ufeful; fo a proper confiftence is the , principal circumftance to be kept in view in their compofition. Chap. XIV. the Urethra. 417 compofition. This, we muft ftill fay, ought to be the leading objed in the-employment of bougies: But when any tolerable certainty occurs of a chan- cre or internal ulceration exifting in the urethra, as nothing would probably prove fo ufeful in cicatrising the ulcer as a local application of mercury, a confide erabk quantity of quickfilver extinguifhed in honey may with advantage be added to the compofition we formerly mentioned.—If two ounces of mercury, t properly extinguifhed in this manner, be added to every fix ounces of plafter in a melted ftate, a pretty ftrong mercurial preparation will thus be obtained ; and as mercury in this ftate produces little or no ir- ritation, it may be employed with perfed fafety.— Red precipitate in fine powder has been Sometimes advifecLto be Sprinkled upon bougies, not only to be applied in this manner to ulcers in the urethra, but with a view to corrode other cauSes of obftrudion : This, however, is a pradice which we hope is now generally laid aside, as in many inftances the pre- cipitate would furely prove too violent a stimulus for the internal furface ofthe urethra. Whatever may, in diforders of this kind, be the immediate caufe of obftrudion to the free paffage of the urine, a venereal taint will for the moft part be found to be the original caufe.of the whok: We have therefore defired, that at the fame time the ufe of bougies is perfifted in, the patient ought to be put upon a very complete courSe oS mercury, in order to destroy every poffibiUty of his fuffering again from the fame caufe; for we need fcarcely obferve, that as long as any venereal infedion continues to prevail, little or no permanent advantage can be expeded, either from the ufe of bougies or any other remedy. We have thus entered folly into the confideration ofthe ufe of bougies. Indeed, too much attention cannot be given to a pradice from which foch mate- rial advantages may be derived: For by a proper Ggg ufe 418 ObflruRims in Chap. XIV. ufe of this remedy, almoft every cafe of obftruded urethra proceeding from any of the caufes we have enumerated, may be either altogether cured, or at leaft greatly relieved; and was it not for the advan- tages derived from bougies, almoft every inftance of fuch obftrudions would terminate in the moft com- plete degree of mifery. Before concluding the Subject now under confid- , eration, we muft not omit to mention the effeds of bougies in fome cafes of troublefome gleets.—When- ever a difcharge of this kind is kept up by an exco- riation or flight ulceration of the urethra, as is fome- times the cafe, no remedy whatever proves more ef- fedual than bougies of the mercurial kind, fuch as we have recommended; and even in the ordinary kind of gleet proceeding merely from a relaxed State ofthe excretory duds opening'into the urethra, noth- ing will more certainly effed a cure than the com- preffion induced by the common bougies.—Whether they operate by affording a proper fupport to the re- laxed membrane ofthe urethra, or by inducing fome degree of inflammation upon the affeded parts/ I know not; but in many inftances of thofe obstinate gleets which have refilled the moft powerful injec- tions, bougies have been found to prove effedual. We have hitherto confidered obftrudions of the urethra in male fubjeds: But the fame affections oc- cur in women ; and when they do fo, they demand an equal fhare of attention. As bougies afford the eafieft means of removing foch obstructions, this method of cure fhould always be firft attempted: But in women it fometimes happens, that tumours of foch a fize form in the urethra as cannot poffibly be cured by this remedy ; and as the urethra in females is not only very fhort, but much wider than in men, fweU- ings of this kind may often be removed either by lig- ature or with the fcalpel.—Nay, we know from ex- perience, that a tumor adhering, even to the bladder itfelf, Chap. XIV. the Urethra* 41 £ itfelfj may, in women, be taken off, not only with eafe, but with fafety. In fuch cafes, there is a ne- ceffity for laying the urethra open j which, at either of tie fides, may be done with great Safety, and with- out any rifk of wounding the vagina: And if an in- cifion be made here with freedom, any tumor fituat- ed near to the neck of the bladder, may be fo far puUed down as to admit of the application of a liga- ture $ and whenever it can be laid hold of, this may be done without any danger. A remarkable cafe is related of this kind by Mr. Warner, where a tumor ofthe fize of a turkey's egg, produced from the internal membrane of the blad- der, was extirpated by ligature, and with moft com- plete SucceSs*. When Such tumors are not So large as totaUy to obftrud the paffage of the urine, or to be produdive of much diftreSs, a prudent pradition- er would no doubt rather wifh to avoid touching them : But when the reverfe of this is the cafe, and when the urine is voided with much difficulty, necef- fity in fuch circumftances points out the propriety of the operation we have recommended ; but it muft be comfortable Sor a patient, in a fituation which would otherwife be defperate indeed, to know that a reme- dy can be employed from which a cure may be ex- ^ItVas been advifed even by praditioners of repu- tation, when obftrudions of the urethra proceed from caruncles or carnofities, as they are termed, to def- troy them by the ufe of lunar cauftic; and instru- ments have been invented for applying the caustic with as much fafety as poflible to the difeafed parts : But the rifk of injuring the contiguous parts by ap- plications of this nature, even when guarded in the molt cautious manner, is evidently fo great, as muft forever prevent the pradice from being generally received. CHAR • vjd. Cafes and Remarks in Surgery, by lofeph 42$ Ofthe Fiftuta. Chap. XV. CHAP. XV. or the FISTULA in PERINffiO. By the term Fiftula in Perinjeo is meant, a finuous ulcer of this part, communicating moft frequently with the urethra only, but in fome inftances diredly with the body of the bladder. The term however, is not ftridly confined to ulcers of this kind in the perinaeum; it is alfo applied to fores of a fimilar nature opening into the fcrotum, or terminating in any part ofthe penis. The word Fiftula ought with propriety to be re- ftrided to that fpecies of finus in which the edges of the fore have become hard and callous; but custom now applies it indifcriminately to every ulcer that is not fuperficial, but which lies deep, and difcharges its contents by one or more narrow openings in the external teguments. In confequence ofthe latitude given to the mean- ing ofthe term Fiftula, a great variety of appearan- ces are exhibited under this general denomination of Fiftula in Perinseo. In fome inftances a fingle open- ing is met with in one part or other ofthe perinaeum or penis, difcharging matter mixed with urine; and this without any hardnefs or inflammation of the con- tiguous parts.. But in others, inftead of this fimpk form of the difeafe, along with one or more external openings communicating with the urethra, at which all, or at leaft the greateft part, of the urine is paffed, the parts contiguous to tnefe opening- are very much difeafed. Chap. XV. in Perinao. 421 difeafed. In fome inftances they are found merely in a hard caUous State/without much enlargement; but in others 'they are not only exceedingly hard, but much Swelled, inflamed, and very painful. In a few cafes, this hardnefs and enlargement is confined' to a fmall Space; but moft frequently, when the diforder has been of long continuance, it extends nearly from the anus to the fcrotum, reducing the whole perinse- um to a ftate of callofity. In many, too, the mala- dy does not ftop here; but the Scrotum, and even the fore part ofthe penis, are liable to be affeded by it j and when the urine unfortunately efcapes into the cellular fubftance of thefe parts, particularly when it lodges in any part of the fcrotum, it is apt to termi- nate in a great deal of mifchief. As a confiderable part ofthe urine, and fometimes the whole of it, is evacuated by fores of this nature, they are, on every occafion, productive of much dif- treSs; and merit therefore the greateft attention from praditioners. In treating of this diforder, the caufes which give rife to it are to be firft confidered. They are in gen- eral as follow. 1. Wounds and other injuries of the urethra and bladder, from external violence, in whatever manner they may be produced. In the old method of performing lithotomy by the apparatus major, the parts were fo much bruifed and lacerated, that the wound feldom healed kindly, and frequently terminated in fistulous fores ofthe perine- um ; but when the operation is well performed ac- cording to the prefent improved method, this is fel- dom the cafe. From fome caufe or other, however, ir happens in a few inftances, that the urine does not flow freely, by the yard; and as it finds a ready paf- fage by the wound, it continues to come off in this manner, till the edges of the fore becoming callous, the diforder in question is produced, In fome cafes of . 42$ Of the Fiftula Chap XV. of this nature, a dired communication is kept up be- tween the neck of the bladder and the fbrej but in Others, the urine paffes firft into the urethra, and from thence is difcharged by the wound in the peri- neum. This difeafe is fometimes the confequence of incifions made into the urethra, for the purpofe of extrading ftones lodged in it, when the wounds do not heair but ^continue open and give vent to the urine which they fometimes do for a considerable length of time. 2. Inflammation in any part of the urethra, by whatever caufe it may be induced, if it terminates in an abfcefs, is very apt to corrode the membrane of this canal, and to produce a Sinuous opening, at which the urine is discharged along with pus. This foecies of the diforder, we may remark, is not an un- fcequent confequence of virulent gonorrhoea: For when the inflammation fpreads along the perinaeum towards the anus, if it be not quickly removed by bloodktting and fuch other means as are employed, it wiU be very apt to terminate in fuppuration. Abfceffes which form originally in the foft parts about the anus, are alfo known to give rife to it by communicating inflammation and flridure, termi- nating in fuppuration, to the ceUular fubftance con- neded with the urethra. 3. The feveral caufes enumerated in the laft Chap- ter, inducing obftrudion ofthe urethra, by impeding the free difcharge of the urine, frequently give rife to the difeafe now under confideration: And according- ly we find that fistulous fores in the perinseum are very commonly conneded with an obftruded ff ate of the urethra. As the diforder may be thus induced by a variety of caufes, it is neceflary to have thefe in view when we endeavour to accomplifh a cure. In order, how- ever, to render this very perplexing branch of pradice ai Chap. XV. mPcrbueo* 4*1 as obvious and Simple as poffible, it is neceflary to 're- mark, that the different caufes we have enumerated tend to the prodadion of the difeafe by two general effeds only : I. By the formation of a paffage directly into thtt urethra or bladder, either by external violence or by the deftrudion of part ofthe urethra as a confequent* i>f ulcers feated in it, or of matter coUeded in abfeefl- cs tending to abrade its fubftance ; this, we fuppofe, may occur, independently of any obftruction to the {railage ofthe urine. 2. By the fole influence of obftrudions in the ure- thra : Thefe, by putting a ftop to the free evacuation of the urine, at firft induce a fuUnefs and tenfion of the urethra, which, if it be not fuddenly removed by fuch means as are employed, it very commonly terminates in a complete rupture of this canal. In the treatment, therefore, of this diforder, we are to be direded by one or other of thefe general ef- feds ; and it is to be remarked, that in no difeafe is it of more importance to diftinguifh accurately bei tween the caufes tending to induce it When the opening into the 'urethra has been produced by a previous obftrudion, no external application, nor any remedy direded to the fyftem in general, wiU have any effed; while a proper and long continued ufe of the bougies, by removing the obftrudion, will very commonly accomplifh a cure: And on the oth- er hand, when the diforder has not originated from any obftrudion, but has been induced by a fimple opening in the urethra, bougies ate not only very unneceffary, but frequently do a great deal of mif- chief.—This, we muft obferve, is a diftindion which is not fo much attended to in pra&sce as it ought to be. Affedions of this kind are commonly treated with bougies only, whatever may have been the caufe which at firft induced them: But we fhaU foon make it appear that this muft frequently" prove prejudicial. 424 Ofthe ftftula Chap. XV. In the cure of thefe diforders, too, it is a matter of the firft importance to diftinguifh between fuch af- fedions as are merely local, and thofe that are evi- dently conneded with fome general diforder of the fyftem. For however well our means of cure might be direded towards the topical management of the fores, if the patient at the fame time laboured under lues venerea, fcrophula, or fcurvy, no permanent cure could be expeded, unlefs proper remedies were employed for the removal of thefe affedions. We fhall now proceed upon the fuppofition, that the fores are merely local, or that any general affec- tion with which they may have been conneded, is as much as poffible removed; and we fhall likewife fuppofe that the diforder has been originally induced fc»y fome obftrudion in the urethra.—In fuch circum- stances, if the diforder has nc* been of long continu- ance, and if the parts, through which the opening runs that communicates with the urethra, are not much difeafed, the bougie is almoft the only remedy that is neceffary : By a proper and long continued ufe of bougies in, the manner we have defcribed in the laft chapter, the obftrudion will in all probability be removed; at kaft, I have as yet met with very few inftances of the contrary : And as foon as this is ef- feded, which will be known by the instrument paffing in without any impediment, and by the urine flowing in a full stream when the orifice at the fore is com- preffed, if this preternatural opening does not now in the courfe of a fhort time heal of itfelf, it will be found to be prevented by its edges having become hard, and by their being covered as it were with a morbid produdion of the furrounding cuticle. Till this obstacle to the progrefs of the cure is re- moved, no advantage, it is evident, can be derived from any means to be employed. We are therefore to attempt the deftrudion of thefe callous edges of the fore, as foon as it is found that the bougies, after removing Chap. XV: in Perinao. 4-5 removing the obftrudion in the urethra, have not proved altogether effedualj and the method of doing it is this : The patient muft be laid down upon a table, in nearly the fame pofture as is ufed in the op- eration ofthe ftone; and a ftaff being introduced into the urethra, fo as to pafs the opening a* which the urine is difcharged, it is in this fituation to be held firm by an affiftant; while the furgeon, introducing a fmall probe at the external opening of the fore, and cutting upon it in the diredion of the finus, is thus to lay it open through its whole length, till it termi- nates either in the urethra, or, if neceffary,.in the blad- der itfelf. When more openings than one are difcovered, they muft all be laid open in the fame manner. In fome inftances, there are two or three finufes in the cellular membrane, leading from one opening in the urethra; but in others, there are as many openings in the urethra as there are finufes or fores outwardly. This, however, is not a frequent occurence : But it is a matter of little importance, as the fame method of treatment anfwers equally well in both cafes ; for whether the different finufes originate from one com- mon opening in the urethra, or not, they ought all to be laid completely open from one extremity to the other. In general, this fimple divifion of the finufes would prove fufficient; but when any of the parts through which they run have become uncommonly hard, a fmall portion ot* fuch difeafed parts as lie moft contiguous to the fores may be removed by the fcalpel. This, it may be obferved, however, is not often neceffary, as the inflammation and confequent fuppuration, induced by the divifion ofthe parts af- feded, very commonly removes any flight degree of callosity; but when the hardened parts are extenfive, and appear too confiderable to be removed in the courfe of the fubfequent fuppuration, fuch a propor- H h h tion 426 Ofthe Fiftula Chap. XV. tion of them fhould be taken off by the fcalpel as will not probably be removed in this manner. This, however, is a circumftance upon which nothing deci- sive can be faid; for the neceffity of removing a por- tion of fu.Gh.difeafed parts or not, and the quantity to be removed, mult, in all fuch cafes, be left to the judgment of the operator. After all the finufes have thus been freely divided, the ftaff fliould be withdrawn, and the divided parts ought to be gently feparated by the introdudion of foft lint fpread with any emollient ointment, in order to prevent their immediate reunion. But although it is neceffary for this purpofe to infert fome foft eafy application between the lips of the wound, yet this ought to be done with much caution ; for fluffing or cramming the fores, as is fometimes done, always does mifchief, and in fome inftances even renders all the other fteps ofthe operation ineffedual. The fores are now to be covered with a pkdgit of emollient oint- ment ; and proper compreffes being applied over it, the T bandage fhould be employed to Sustain the whole. About twenty four hours after the operation, an emollient poultice fhould be applied over the dreff- ings ; and as foon as a free fuppu*ation is formed, the whole fhould be removed, and light easy dreffings fhould be continued till the different fores are healed by a proper adhefion of the parts at the bottom of each. A very material part of the cure is found to con- sist in the dreffings being duly attended to. Indeed, regular and proper dreffing is of fo much importance, that without it all the previous fteps of the operation will avail nothing in effeding a cure : And it is to this circumftance chiefly, we are to attribute the fu- perior fuccefs, which occurs in cafes of this kind, in private pradice, over what is commonly obferved in hofpitals,. where fuch care and attention can feldom be * Chap. XV. in Per'mao. 427 be obtained. Even in private there is much differ- ence met with in the cure of fores of this nature : I have known inftances of fistulous openings in the pe- rineum of a veiy bad appearance, completely cured by one praditioner, when feveral others had failed entirely, owing in a great meafure to the difference of attention with which they were treated. I have not yet mentioned the ufe of the bougie, nor of the catheter, as a neceffary part of the treat- ment fubfequent to the operation : And in this I fhall poffibly appear to be fingular; for, in all cafes of this kind, we are commonly direded to keep a bou- gie conftantly inferted from the time of the operation, excepting at the time of voiding urine, when a cathe- ter is advifed to be employed; and in order to avoid the trouble of withdrawing the one and inferting the other, fome praditioners have advifed a flexible ca- theter to be kept in the urethra from the firft. The advantages SuppoSed to accrue Srom the uSe ofthe bougie, is the prevention of any undue contrac- tion ofthe urethra; and by the catheter it is intended to prevent the urine from paffing out at the fore dur- ing the cure.—Thefe motives, for the ufe of both the one and the other, are plausible; and they have ac- cordingly been very generally adopted.—I am free to confefs, too, that, following the example of others, I have often, in cafes of this kind, employed both The catheter and bougie; but I cannot fay that I ever did fo with any advantage, and in many inftances I think I have feen them do much harm. For, in every cafe in which they are ufed, they keep the urethra too much diftended for admitting of an eafy cure ofthe fores; and if the catheter be not inferted fo far as to pafs fully into the bladder, part ofthe urine,' in coming off, almoft conftantly paffes between it and the ure- thra fo as to get accefs to the wound, and in this manner has the fame influence upon the fore as if no catheter was ufed : And again, if a catheter is paffed entirely 428 Of the Fiftula Chap XV. entirely into the bladder, and is preferved in this fit- uation for any confiderable time, it almoft conftantly does harm, by inducing pain, inflammation, and fwelling about the neck of the bladder. But whoever will attempt a contrary pradice, and will endeavour to cure affedions of this nature with- out any aid from thefe instruments, will foon find that they are not neceffary ; and that the wound in the urethra from the operation we have defcribed, is in general much more eafily cured, without the aflift- ance either of bougies or of the catheter, than when they are employed ; for, inftead of forwarding the cicatrization of the fores, they uniformly tend to retard it, by frequently tearing open fuch adhefions, as na- ture, if left to herfelf, would have made altogether complete. This, we muft again remark, is a point of much im- portance, and merits the utmoft attention of pradi- tioners. The ufe of the bougie, in aU fuch cafes, is at prefent fo univerfal, that the cure of a fiftula in peri- naeo by an operation, is almoft never attempted but where bougies are at the fame time employed; but, from much experience in this branch, I am now per- fedly fatisfied, that many more cures would be ac- complifhed if the bougie and catheter were both laid afide. In real obftrudions of the urethra, bougies, as we have faid, are almoft the only remedy to be depended on ; but, fo far as I have feen, they are of no farther ufe after thefe obftrudions ase removed; when, there- fore, a fistulous opening remains after the removal of the obftrudions, the operation we have defcribed ought alone to be depended on; and in this part of the cure bougies ought never to be employed. But it is fajd by thofe who patronife the ufe of the bougie and ofthe catheter, that if the urine be allowed to pafs out by the fore, the cure will be thereby, if not altogether interrupted, at kaft much retarded. To Chap. XV. in Perinao. 429 To this it may be anfwered, That after the operation of lithotomy, we do not find the cure retarded, al- though the urine comes at all times into immediate contad with, and during the firft days after the ope- ration paffes conftantly off by, the wound. In what manner this is effeded, I fhall not at prefent deter- mine ; but that the fad is fo, no praditioner will de- ny : And from all the experience I have had in thefe matters, openings in any other part of the urethra re- quire as little afliftance from the catheter, as they do in that part of it which is divided by the operation of lithotomy ; and every lithotomift, I believe, would fpurn at the idea of keeping a catheter constantly in the bladder after this operation, in order to prevent the urine from paffing off by the wound. After the operation of lithotomy, it happens, in- deed, in a few cafes, that a contradion of the urethra is produced by the cicatrix of the fore, and in fuch in- ftances, after the parts are firmly united, bougies are fometimes of ufe, by effeding a diftention of the ftridure : And in a few cafes, too, where the fore is prevented from healing, by the urine continuing to pafs off by the wound in confequence of the forma- tion of ftridures or adhefions in the urethra, the bou- gie is employed with advantage even during the progrefs ofthe cure. But thefe are rare occurrences, and°no praditioner of experience ever thinks it right to have recourfe to bougies, till the prefence of fome obftrudion renders them altogether neceffary ; and in the fame manner they ought never to be employed in the operation we have been defcribing, till the propriety of ufing them is pointed out by the forma- tion of fome degree of obftrudion. When the parts composing the perinasum have be- come hard and otherwife difeafed, before any operation fiich as we have defcribed is put in pradice, we are com- monly direded to a long and continued ufe of poul- tire*; of mercurial fridions; and the ufe of refolvent gum 430 Ofthe Fiftula Chap. XV. gum plafters. So far, however, as I have ever Seen, little or no advantage is derived from thefe remedies; for any fuppuration expeded from their ufe, is, in general, very partial, and has feldom much effed in removing, or even in relieving, the diforder for which it is induced. And, again, when the hardened parts are extenfive, and when no relief is obtained from the difcutient remedies we have mentioned, we are in general di- reded to cut them entirely away with a fcalpel. There is not, however, the leaft neceffity for fuch a meafure, for although it may be proper to remove the edges of the fores when they have become caUous, there is never any good caufe for extirpating every part that is become hard. This would frequently he a very cruel operation; and as it could feldom be produdive of any advantage, it ought rarely, if ever, to be put in pradice. When, again, a preternatural opening is found in the urethra, either by external violence or by the abrasion of its fobftance by abfceffes feated in it, a dif- ferent kind of pradice becomes neceffary.—When an abfcefs in the perinaeum, or in any part of the urethra, has been the caufe of the diforder, much attention fhould be given to a free difcharge of the matter; ev- ery p^rt ofthe cellular fubftance in which it is found to lodge, ought to be laid open ; and any inflamma- tory tumor that has not suppurated freely fhould be treated with warm fomentations and poultices.—In this manner many foch affedions, which if negkded would terminate in much diftrefs, may be brought to heal; but when even by thefe means the fores do not unite, but continue vo difcharge matter, and efpecially when they become fistulous, the method of treatment we have formerly pointed out muft be likewife em- ployed here. Diforders of this kind induced by wounds ofthe urethra, require a fimilar method of cure.—By the removal Chap. XV. in Perinao. 431 removal of extraneous matter, and by the ufe of poul- tices to abate inflammation, a cure will frequently be effeded without any other affiftance ; but, when the ftate of the fores requires it, they ought to be laid open, and treated in every refped in the manner we have already direded. The moft diftreffing variety of this diforder is that in which the urine paffes off diredly from the body of the bladder without communicating with the ure- thra. This fpecies*of the difeafe, we may remark, h readily diftinguifhed from the other by the urine drilling off infenfibry and at all times ; whereas, when the external opening does not communicate diredly with the bladder, and when the urine paffes firft through part of the urethra, the patient has common- ly the power of retention in full perfedion; a circum- ftance which renders his fituation much more com- fortable than when the urine is conftantly paffing off. —But although this variety of. the diforder is eafily diftinguifhed from the other, it cannot be fo readily cured; for in fuch cafes, the finufes from whence the urine is difcharged communicate diredly with the bladder, and nothing has any effed in removing them but laying them open to the very bottom. When, therefore, a patient labouring under this diforder finds his fituation to be fo diftreffing as to render the pain and rifk of fuch an operation an eligi- ble alternative, it ought undoubtedly to be employed as the only means from which any probable chance of relief is to be expeded. As the intention and principle of this operation are the fame as of that in which the urethra only is con- cerned, all that need be faid with refped to the mode of performing it, is, that a ftaff fhould be introduced into the bladder ; the different finufes fhould be laid freely open to the bottom; any callofsties of their ed^es fliould be removed to fuch a depth as can be done with fafety; and the wounds thus produced ought 432 Of the Fiftula, He. Chap. XV. ought to be treated with light eafy dreffings, fuch as we have already advifed. In this manner, a great proportion of aU who are afflided with fuch diforders may be effectually cured, provided the means we have recommended are em- ployed in due time, and are properly perfifted in: But in long continued fistulous fores of thefe parts, where the furroundbg cellular membrane has become much hardened, and otherwife difeafed ; and efpecially, when the fyftem is tainted either with fcurvy, fcroph- ula, or lues venerea; it muft be acknowledged that no means with which we are acquainted will prove at all times fuccefsful. l«m.~»»« * L11 than 450 Explanation ofthe Plates. than ought to be cut. It is the proftate gland and a fmall portion of the neck of the bladder only which fhould be divided by this knife; but as it is always neceffary to infert the point of it far into the bladder before this can be done, the fides and even fundus of it are in this manner very apt to fuffer. The only advantage which this inftrument is fup- pofed to poffefs over the cutting gorget or diredor is, that being inferted fhut, and withdrawn open, only one cut is made in the parts through which it is made to pafs; whereas, it is alleged, that, in the ufual meth- od of employing the gorget or diredor, one incifion is formed by the introdudion of the instrument, and another when it is withdrawn. But, by attending to the diredions we have given in the chapter on Lithot- omy, this inconvenience commonly attributed to the gorget, and confequently to the diredor, may be al- ways avoided; and as thefe inftruments form a more free cut than the lithotome cachee, and as they do not fo readily injure any part of the bladder which ought not 'to be cut, they fhould therefore be preferred. Fig. 3. Forceps with a fcrew H paffing through their handles.—When a ftone is properly fixed in the forceps, various inventions have been propofed for preferving them in the Same ftate; but the one we have here represented is the beft and the moft Simple of any that has been mentioned. Plate XIX. [Oppofite to page 388.] Fig. 1. A jugum which anfwers the purpofe of compreffing the penis very completely, and it fits up- on the parts without producing any pain or uneafi- nefs. It confifts of a piece of elastic fteel lined with velvet or foft flannel. By means of the fcrew A, it can be made wide or strait at pleaSure; and the cufh- ion B being placed upon the urethra, any neceffary * degree of preffure may be produced upon it, by turn- N ing Explanation ofthe Plate*. 451 ing the fcrew with which the cufhion is conneded. By means of this cufhion and fcrew, the preffure is chiefly confined to the urethra; fo that the circulation is fcarcely interrupted through the reft ofthe penis. Fig. 2. A receptacle for the urine mentioned In page 389. It may be made either of tin or filver, or any other metal. It is fomewhat convex on one fide, with a concavity on the oppofite fide, by which it applies eafily to the infide of the patient's thigh. CD, Two tubes for fixing two pieces of tape, by which, when the penis is put into the neck of the in- ftrument, it may be tied to a circular bandage round the body ; and the tube /''Serves to fix a piece of tape for tying the inftrument round the thigh of the pa- tient. This inftrument, when properly fitted, fits very eafily, and has frequently proved very ufeful to pa- tients who could not retain their urine, and with whom the jugum, for the reafons we have formerly enumerated, could not be employed. A receptacle of this kind, of a fize fufficient to con- tain three or four gills, may be fo adapted to the thigh as to admit of every neceffary exercife. F.ig. 3. A bandage, originally invented by Mr. Gooch, for retaining the redum in cafes of prolapfus ani. F, a plate of elastic fteel covered with foft leath- er, which ought to be exadly fitted to the parts on which it refts ; and the cufhion T fhould be fluffed in foch a manner as to produce an equal and eafy preffure on being applied to the end ofthe gut after it is replaced. G, a ftrap to be fixed with a buckle on the fore part ofthe body above the pubes; and H H, two Straps conneded with the upper part of the in- ftrument, which, by paffing over the fhoulders, and being fixed by fmall knobs on each fide ofthe buckle, ferve to retain it exadly in its place. Plati 452 Explanation of the Plates. Plate XX. [Oppofite to page 389.] Fig. 1. An inftrument mentioned in page 322, originally invented by Dr. Butter, for injeding liquids into the bladder. A A, the handles of two thin plates of timber, which ferve to comprefs a bladder placed between them, in which the liquor to be in- ]eded is' contained. B, a stopcock of a pipe with which the bladder muft be conneded; and to the ex- tremity of this fhort pipe a longer tube C is adapted. to be inferted into the urethra when the liquid is to be injeded. Fig. 4, is a funnel for conveying the liquid into the bladder, by inferting the fmall extremity of it into the fhort pipe near to B, on the tube C being removed. Fig. 2, and 3. Two peffaries for the purpofe of Supporting the prolapfed parts in cafes of a prolapfus uteri, and for compreffing the urethra in cafes of an incontinence of urine. Before being introduced, they fhould be well covered with any emollient ointment, or with fweet oil; and they fliould be made to lie diredly acrofs the diameter of the vagina, fo as to fupport the prolapfed parts as much as poflible. Thefe instruments may be made of any timber capable of receiving a fine polifh: Butmuch attention, we may remark, is neceffa- ry to this circumftance; for unlefs they be made per- fedly fmooth, they cannot poffibly be ufed. Thefe peffaries, when a patient can admit of them, tend to fupport the relaxed parts better than any other; but even with the utmost attention to their being thor- oughly polifhed, they frequently produce fo much ir- ritation as to become altogether inadmiffible. When peffaries of this kind cannot be employ- ed, other inventions have been propofed. Peffaries eompofed of the refina claftica, are in general found to fit eafily; and they commonly anfwer, for fome time, the purpofe of fupporting the relaxed parts ; but as they become foft and glutinous by long im- mersion Explanation ofthe Plates. 455 merfion in the natural mucus of the vagina, they foon lofe that elasticity which a continued fupport of thefe parts requires. A piece of foft fponge being immerfed in common glue, or in melted bees wax, and being kept in a compreffed ftate till cold, and being then cut into a proper form, and inferted into the vagina, commonly expands fo much on the wax or glue melting, as to afford in moft cafes a very ef- fedual and easy fupport to the relaxed parts: And in order to render the application ofthe fponge ftill more eafy, it fhould be previoufly covered with a Small bag of Soft waxed linen, which prevents the fponge when it expands from fretting the fides of the .vagina, which it is otherwife ready to do. Peffaries of every kind, before being introduced, ought to have a piece of firm packthread or catgut tied to them, which by hanging out from the vagina, admits of their being more eafily removed than they otherwife can be. A great variety of inftruments have been propofed ■ by different authors for the purpofe of preventing a prolapfus uteri; but thefe in general have been of a very complicated nature, and have never anfwered the purpofe fo eafily as one or other of thofe we have now mentioned. Plate XXI. [Oppofite to page 397.] Fi°\ 1. A trocar of a flat form, which may be in- troduced into the abdomen or fcrotum with much eafe, and with no rifk to the contained parts. This instrument consists of a ftilette or perforator, fig. 3, exadly adapted to the Silver canula, fig. 2. The can- ula is left open on one fide, which admits of the per- forator being broader through its whole length, as is reprefented in fig. 1. By this means an opening is - made by the perforator, of a fufficient fize for ad- mitting the canula with much eafe; and as the fides ofthe canula do not fal) clofe together on the perfo- rator . 454 Explanation ofthe Plates. rator being withdrawn, this inftrument is not liable to an objedion which has been adducecl againft the tro- car of Mr. Andre, reprefented in Plate X, Vol. I. viz. there being fome rifk ofthe Steel plates of which the camila of that inftrument is eompofed doing fome injury to the contents of the abdomen, on their fall- ing together, which they do with fome force on the perforator being withdrawn. The instrument of which I now give a reprefentation, is the invention of Mr. Wallace furgeon in GfaSgow. Fig. 4. A trocar of a common triangular form, for the purpofe of punduring the bladder where this operation is neceffary in cafes of foppreflion of urine. The round or triangular form of this inftrument ren- ders it more proper for this operation than the tro- cars with lancet points, as the fine points of thefe are not fo well adapted for the different fteps of the op- eration. And the groove in the perforator, by com- mencing at the point, and being continued through me whole of it, ferves to point out with much cer- tainty its entrance into the bladder; for the urine is obferved to flow along this groove immediately on the point of ft having entered the bladder. Fig. 5. A flat filver canula, with a fmall degree of curvature for leaving in the opening after the opera- tion for the empyema. END of VOLUME I. »*»»e>»CCG^Q|frg4"