NATIONAL LIBRARY OF MEDICINE Washington ■*,* m n- \ v x ' c^u^'^i^ (S * ti/mx \// t'f/j \ SYSTEM OF SURGERY: by y BENJAMIN ^ELL, MEMBER OF THE ROYAL COLLEGES OF SURGEONS OF EDINBURGH AND IRELAND, ONE OF THE SURGEONS TO THE ROYAL INFIRMARY, AND FELLOW OF THE ROYAL SOCIETY OF EDINBURGH. ILLUSTRATED WITH COPPERPLATES. volume m. , SECOND AMERICAN, FROM THE SEVENTH EDINBURGH EDITION, CORRECTED AND ENLARGED. TROY, NEW-YORK: O/,/ .^ • 0e.-?/\ 0 > ' T» J CO PRINTED BY O. PENNIMAN AND CO. TOR THEMSELVES; THftMAS AND ANDREWS, BOSTON; T. S. ARDKN, NEW-YORK; AND J. CONRAD AND CO. PHILADELPHIA. 1804. CONTENTS. CHAPTER XXIII. Page Of hernia, - - - i Sea. II. Of the Bubonocele, - ib. Sea. III. Of the Hernia Congenita, ' - 21 Sea. IV. Of the Crural or Femoral Hernia, 23 Seft. V. Of the Exomphalos, or Umbilical Rup- ' ture, - - - - 27 Sea. VI. Of Ventral Hernia, - 30 Sea. VII. Of the Hernia of the Foramen Ovale, 31 Sea. VIII. Of the Hernia Cyjiica, or Hernia of the Urinary Bladder, - -32 CHAPTER XXIV. ON THE HYDROCELE,__ 36 Sea. I. General Remarks on the Hydrocele, ib. Sea. II. Of the Anafarcous Hydrocele of the Scrotum, - - - 40 Sea. III. Of the Hydrocele of the Tunica Vagi- nalis Teftis,. - - 47 Sea. IV. Of the Hydrocele of the Hernial Sac, 97 Sea. V. Of the Anafarcous Hydrocele of the Spermatic Cord, - - 101 Sea. VI. Of the Encyjied Hydrocele of the Sper- matic Cord, - - 103 CHAPTER XXV. ON THE HEMATOCELE, « HO iv CONTENTS. Page CHAPTER XXVI. Of THE varicocele, circocele, spermato- cele, AND PNEUMATOCELE, - IJ6 CHAPTER XXVII. OF THE SARCOCELE, OR SCHIRROUS TESTICLE, I 19 CHAPTER XXVIII. OF THE DISEASES OF THE PENIS, - I 39 Sea. I. Of the Phymofis, - ib- Sea. II. Of the Paraphymofis, - 142 Sea. III. Of Amputation of the Penis, 145 CHAPTER XXIX. OF THE STONE, - J49 Sea. I. General Remarks on Urinary Calculi, ib. Sea. II. Of Sounding or Searching for the Stone, \$$ Sea. III. General Remarks on the Operation cf Lithotomy, - " l64 Sea. IV. Of the Operation of Lithotomy by the Lejfer Apparatus, - " x°° Sea. V. Of Lithotomy by the Greater Appa- ratus, - *73 Sea. VI. Of the High Operation for the Stone, 176 Sea VII. Of the Lateral Operation, 182 Sea. VIII. Of Nephrotomy, - 215 Sea. IX. Of Stones in the Urethra, - 217 CHAPTER XXX. OF INCONTINENCE OF URINE, - 225 CHAPTER XXXI. OF SUPPRESSION OF URINE, - - 229 CHAPTER XXXII. Obstructions in the urethra, - 241 CONTENTS. v Page CHAPTER XXXIII. Of the fistula in perineo, - 260 CHAPTER XXXIV. Of haemorrhoids, or piles, - 271 CHAPTER XXXV. Of condylomatous excrescences, and similar affections about the anus, 279 CHAPTER XXXVI. Of a prolapsus ani, - - 2^i CHAPTER XXXVII. Of an imperforated anus, - 284 CHAPTER XXXVIII. Of the fistula in ano, - 288 CHAPTER XXXIX. Of fractures, - 3*4 Sea. I. General Obfervations on Fradures, ib. Sea. II. Of Fradures of the Nofe, - 332 Sea. III. Of Fradures of the Bones of the Face, 333 Sea. IV. Of Fradures of the inferior Maxilla- ry Bones, - 335 Sea. V. Of Fradures of the Clavicles and Ribs, 337 Sea. VI. Of Fradures of the Sternum, 341 Sea. VII. Of Fradures of the Vertebra, Os Sa- crum, Coccyx, and OJfa Innominata, 343 Sea. VIII. Of Fradures of the Scapula, 345 Sea. IX. Of Fradures of the Humerus, 346 Sea. X. Of Fradures of the Bones of the Fore- Arm, - 349 Sea. XI. Of Fradures cf the Bones of the Wrifl, Hands, and Fingers, - 352 Sea. XII. Of Fradures of the Femur or Thigh Bone, - - 354 vi CONTENTS. Sea. XIII. Of Fradures of the Patella, 361 Sea. XIV. Of Fradures of the Bones of the Leg, - - - 366 Sea. XV. Of Fradures of the Bones of the Foot and Toes, - 370 Sea. XVI. Cf Compound Fradures, 371 CHAPTER XL. Of luxations, - 383 Sea. I. General Remarks on Luxations, ib. Sea. II. Of Luxations of the Bones of the Cra- nium, - - 395 Sea. III. Of Luxations cf the Bones of the Nofe, 396 Sea. IV. Of Luxations of the Lower yaw, ib. Sect. V. Of Luxations of the Head, - 400 Sea. VI. Of Luxations of the Spine, Os Sa- crum, and Os Coccyx, - 401 Sea. VII. Of Luxations of the Clavicles, 405 Sea. VIII. Of Luxations of the Ribs, 407 Sea. IX. Of Di/locations of the Humerus at the Joint of the Shoulder, - - 409 Sea. X. Of Luxations of the Fore-Arm at the "Joint of the Elbow, - - 422 Sea. XL Of Luxations of the Bones of the WriJl, 425 Sea. XII. Of Luxations of the Bonesrof the Metacarpus and Fingers, - - 427 Sea. XIII. Of Luxations of the Femur at the Hip Joint, - - - 428 Sea. XIV. Of Luxations of the Patella, 435 Sea. XV. Of Luxations of the Tibia and Fibu- kt at the Joint of the Knee, - 4-27 CONTENTS. vii Page Sea. XVI. Of Luxations of the Foot at the Joint of the Ankle, - - 439 Sea. XVIL Of Luxations of the Os Calcis, and other Bones of the Foot. - - 440 CHAPTER XLI. Of distorted limbs, . - 442 CHAPTER XLII. Of distortions of the spine, - 448 CHAPTER XLIII. Of necrosis, - - - 451 CHAPTER XLIV. Of imputation, - - 457 Sea. I. General Remarks on the Operation of Amputation, - - ib. Sea. IL Of the Caufes which may render Am- putation neceffary, - - 458 Sea. III. General Remarks on the Method of Amputating Limbs, - - 470 Sea. IV. Of Amputating the Thigh, 475 Sea. V. Of Amputating the Leg, ~ 492 Sea. VI. Of Amputating with a Flap, 497 Sea. VII. Of Amputating at the Hip Joint, 499 Sea. VIII. Of the Flap Operation immediately above the Knee, - - 503 Sea. IX. Of the Flap Operation below the Knee, 508 Sea. X. Of Amputating the Foot, Toes, and Fingers, - - - 509 Sea. XL Of Amputating the Arm at the Joint of the Shoulder, - - 512 Sea. XII. Of Amputating the Arm, 516 viii CONTENTS. Pago CHAPTER XLV. Of removing the ends of bones in dis- eases of the joints, - - 5T7 CHAPTER XLVI. •Of issues, - 522 CHAPTER XLVII. Of the inoculation of the smallpox, 527 CHAPTER XLVIII. Of preventing or diminishing pain in chirurgical operations, - 530 CHAPTER XLIX. Of midwifery, - • - $$$ Sea. I. General Obfervations on Midwijcry, ib. Sea. II. Of the Cafarean Operation, 53$ Sea. III. Of the Divifion of the Symphyfis Pubis 538 CHAPTER L. Of opening dead bodies, - - 542 CHAPTER LI. Of embalming, - . 545 CHAPTER LII. Of bandages, - * 547 SYSTEM OF SURGERY. CHAPTER XXIII. OF HERNIA. SECTION II. Of the Bubonocele. CONJOINED with the general fymptoms of her- nia enumerated in the laft feaion, the particu- lar appearances of the bubonocele, or inguinal hernia, arc, a loft fomewhat elaftic tumor, beginning in the groin, and defcending by degrees into the fcrotum in men, and labia pudendi in women. When a portion of gut forms the difeafe, the tumor is commonly tenfe in proportion to the degree of flriaure in the opening ci the tendon ; and when the parts inflame, handling or prcilu:".'; always gives pain. When it Contains omentum only, the tumor is both more foft, comprcffible, and more unequal, than when gut alone is down; the fcrotum becomes more ob- long than in an inteftinal hernia; and when the cuan- tity of omentum is large, k is alfo much more weigh- Vol. III. B 2 Of Hernia. Chap. XXIII. ty than a gut rupture of the fame fize : but in a great proportion of cafes, the tumor is compofed both of gut and omentum : in this cafe the diftinguihSing fymptoms of each can never be fo clearly marked. Various fymptoms indeed are enumerated by authors for diftinguifhing the contents of herniae ; but when- ever the cafe is complicated, every candid praaitioner will admit, that no certainty can be obtained of this till the tumor is laid open. As thefe parts are liable to other tumors with which the inguinal and fcrotal hernia may be confounded, praaitioners fhould be as much as poflible acquainted with the marks of diftin&ion. Thefe tumors are,, glandular or other fwellings in the groin, whether from the venereal difeafe or any other caufe; that fwelling of the teftis termed hernia humoralis ; and the different varieties of hydrocele. The venereal bubo and other glandular tumors in the groin, are diftinguifhed from hernia, not only by their wanting all the general fymptoms of hernia, but by that incomprcffible hardnefs with which glandular fwellings are at firft attended, and by the fluauation of matier which in their fuppurated ftate is obfervable. In the hernia humoralis, the hardened and enlarged ftate of the tefticle; its being exquifitely painful to the touch ; remarkably heavy in proportion to its bulk ; and the j'permatic procefs being commonly free from fwelling ; may be confidered as certain marks of diflinaion. In the hernia humoralis, too, the intef- tines are free and unobflruaed, and the other general fymptoms of hernia are wanting. In the hydrocele of the tunica vaginalis teftis, the tumor in general is more equal than in hernia : in the former, it begins in the under part of the fcrotum, and proceeds upwards ; whereas the reverfe occurs ia hernia. In hydrocele the fpermatic cord is in moft inftances diftirictly felt, whereas in hernia where the tumor defcends to the fcrotum, the fpermatic cord cannot in any part of its courfe be diftinguifhed. In Sea. II. Of Hernia. 3 hydrocele, the fluauation of a fluid is diftinguifhable ; in hernia it is not. From the anarfarcous fwelling of the fcrotum, or hydrocele of the dartos as it is termed, hernia is eafily diftinguifhed ; and indeed the means of diftinaion are fo obvious, that they need not be enumerated; but there is another variety of hydrocele, the hydrocele of the fpermatic cord, which in fome inftances it is diffi- cult to diftinguifh from hernia, and which therefore requires particular attention. Where the water is colkaed in one or more cells of the fpermatic procefs, and begins in the under part of the cord, and proceeds upwards, this alone ferves as fufficient means of diftinaion between it and her- nia, in which the fwelling mull always proceed from above downwards; but it fometimes happens, that the water begins to collea even within the opening of the abdominal mufcle, and by degrees falls down- wards. In this cafe we cannot determine from the ftate of the tumor alone, whether it is the one difeafe or the other. The general fymptoms of hernia, fuch as pain and tenfion of the abdomen, vomiting, and obftruaed interlines, muft be kept in view; for not being conneaed with hydrocele, they ferve to afcer- tain the nature of the cafe, in which their abfence might long remain doubtful. In fome cafes, however, thefe and every other means of diftinaion are want- ing ; but even in fuch circumftances a praaitioner of experience will never incur the rifk either of hurting his patient, or his own reputation, which the miftak- ing a hernia for a hydrocele, and treating it as fuch, muft always do, and which, to the difgrace of furge- ry has in fome inftances been done. In all fuch cafes of doubt, as well as in every tu- mor of the tefticle where the moft perfea certainty is not obtained, and in which an operation becomes ne- cefTary, the furgeon fhould proceed as he would do in hernia: by doing fo, every rifk will be avoided : on B 2 4 Of Hernia. Chap. XXIII. the tumor being laid open, the true nature of the dif- eafe will become evident, and the practitioner will be at liberty to apply the means beft 1'uited for the cure. Whereas in proceeding differently as in fome cafes^ has been done, and treating as a hydrocele what after- wards proves to be hernia, he not only incurs the rifk of injuring his own reputation, but of deiLroying his patient. In the treatment of the bubonocele, when the means pointed out in the laft fection as applicable to every ftate of hernia do not fuceeed, we are then under the neceffity of proceeding to the operation ; and the me- thod of doing it is this : A table of a convenient height being fixed in a proper light, the patient muft be placed upon it with his head and body almoft horizontal, whiift his but- tocks are raifed with pillows beneath them. The legs hanging over the edge of the table muft be feparated fo as to admit the operator between them ; and fhould in this fituation be firmly fecured by an affiftant on each fide, who fhould take care at the fame time to keep the thighs fo far raifed as to relax the abdomi- nal mufcles. That we may obtain as much empty fpace as poffi- ble for returning the protruded parts, the patient fhould be advifed to empty his bladder ; and the parts having been previoufly fhaved, an incifion muft now be made with a.fcalpcl through the fkin and part of the cellular fubftance, beginning an inch above the fu- perior end of the tumor, and proceeding down to the moft depending part of the fcrotum. Even where the tumor does not reach to the bottom of the fcrotum, the parts fhould be laid open in this manner. By a free external ir.ciiicn, we are enabled to finifh the op- eration with more eafe than when the firft opening is fmali: it does not give much more pain; and being continued to the bottom of the fcrotum, the matter in the upp-r part of the fore is prevented from col- leaing below, which otherwife it is ready to do. s&a. n. Of Hernia. J The operator muft now proceed to divide the reft of the cellular fubftance covering the fac ; and even this fhould be done with caution : for although in a great proportion of cafes, the fpermatic veffels lie be- hind the protruded parts, yet occafionally they are found on the anterior part of the tumor; fo that in order to avoid the rifk of wounding them, as foon as the fkin is divided, the remainder of the operation mould be conduaed with much attention, care being taken to avoid every large blood velTel that makes its appearance. This circumftance of the prolapfed parts getting down behind the fpermatic veffels, has never, fo far as I know, been mentioned by authors: it muft there- fore be a rare occurrence. As I met with it, however, in one cafe, where the fka was obvious, the poffibility of its happening I have no reafon to doubt. If we at- tend 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 well, that in no part of the human body is nature more apt to defert her ordinary courfe, than in fome circumftances relating to the teftes and their blood veffels. I have already obferved, that till near the period of delivery, the tei- ticles continue in the abdomen; and about this time, that they fall down in a gradual manner to the fcro- tum. Many inftances, however, occur, of both teftes remaining in the abdomen through life ; while fome- times one remains, and the other falls into the fcro- tum. In others, one or both fall into the groin, and never proceed farther; a circumftance which young praaitioners fhould be aware of, as inftances have oc- curred of a tefticle refting in the groin being miftak- en for a hernia, and of much pain being excited by attempts made for reducing them. Now, if we fre- quently meet with fuch varieties as this in the me. chanifm of thefe parts, why may not nature fometimes produce fuch a conformation as, on a hernial fac fall- ing into the fcrotum, may place it behind both the 6 Of Hernia. Chap. XXIII. fpermatic cord and the tefticle ? And as I have fhewn that it has happened, and as it may therefore occur again, I confider it as a farther argument for the pro- priety of dividing the parts in the cautious manner I have mentioned.* It is ufual, in making the firft incifion, to pinch up the teguments, and then to divide them with a fcal- pel; but no furgeon of fteadinefs and dexterity will ever proceed in this manner. This incifion of the fkin is done with much more neatnefs, and with equal fafe^ ty, 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 tenfe, while, with the fcalpel in his right hand, he divides the fkin from one end to the other. The fac being laid bare, an opening muft be made in it, fo as to bring its contents into view ; and the moft fafe place for this being formed, is, not about the middle of the tumor, as is commonly direaed, but as near to the under point of it as poffible : it is here done with the fame eafe as in any other part; and be- fides, the gut is feldom 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 in this fituation, is lefs than in any other part of the tu- mor. In making this perforation of the fac, confifts the greateft nicety in the operation, the utmoft caution being neceilary to avoid the parts which it contains. Good eyes and a fteady hand are in no operation more requifite than in this : with thefe, any praaitioner ac* quainted with the anatomy of the parts, will do the operation properly, and without them the beft anato- mift muft go wrong. With the fame fcalpel that divided the fkin and cel- lular fubftance, the operator muft proceed llowly, di. * Since this went to the prefs, I find that an inftance is recorded by Le Dran, in his Treat fe of Ruptures, of the fpermatic velTels having been found pn the anterior part of a bubonocele. This fituation, therefore, of thefe VeiTtis, is perhaps more frequent than is commonly imagmed. Sea. II. Of Hernia. J viding one fibre of the fac after another, till an open* ing is formed in it \ which may be always difcovered with the blunt end of a probe : if the probe paffes in eafily, we may conclude with certainty that the fac is divided ; and if it does not, the incifion muft be con- tinued in the fame gradual manner fomewhat deeper, when the fame trial with the probe muft be repeated. In profecuting this divifion of the fac, we derive much advantage from the ufe of a fmall fharp pointed direaory, open at the extremity, as is represented in Plate LXVI. fig. 3. By pufhing the end of it below fome of the fibres of the fac, they are eafily feparated from the parts beneath, and may thus be divided with fafety; and in the fame manner the reft of the fac muft be divided, till this part of the operation is com- pleted.* In almoft every hernia in the groin, and even where the tumor extends to the fcrotum, if the parts are re- cently protruded, the hernial fac is thin, and therefore eafily cut through ; but it is neceffary for the infor- mation of young praaitioners, to obferve, that when hernia is of long duration, the fac frequently becomes fo thick, as to require much more diffeaion than be- ginners commonly expea: by going on, however, with the caution I have direaed, every rifk of wound- ing any part of importance may be avoided. As foon as an opening is made through the fac, a circumftance of which we become certain, as I re- * In the 4th volume of Memoirs of the Paris Academy of Surgery, there is a.paper on Hernix, by Monfreur Louis. But although it contains many ufeful obfervations, Mr. Louis in one point I think has gone far wrong, in ridiculing that degree of caution which in dividing the hernial fac is un- queftionably requifite : the divifion of the fac, he fays, is attended with fo little"difficulty, that he does not confider it as different in that refpeet from the firft external incifion of the fkin. His words are : " Jamais le fac ne " m'a donne ni plus de peine, ni plus d'tmbarras que la peau ; on divife, " pour ainir dire, celleci du premier trait, et le fac dufecond." In the hands of a very expert operator, the fcalpel, even in this manner, may be fo managed as to do no harm ; but, in common practice, much mifchief would be done by proceeding as Mr. Louis has directed. It might tend to fliow the dexterity of an operator, but thli would always be at the hazard of the patient. S Of Hernia. Chap. XXIII. marked above, by a probe paffing eafily in, it ought then to be farther enlarged, by cutting upon the di- reaor, till it is of fuch a fize as to admit the forefin- ger of the operator. The forefinger of the left hand muft now be intro- duced, and ufed as a direaor for entering the narrow blunt pointed biftoury,, reprefented in Plate LXIV. fig. 2. with which the hernial fac muft be divided along its whole length up to the opening in the ex- ternal oblique mufcle. With the finger ufed as a di- reaor for the biftoury, this part of the operation is performed with fafety; and the biftoury here deline- ated, renders all the inftruments formerly employed 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 commonly rufhes out, and the pro- truded parts come fully in view: if a portion of gut is down, and not much entangled with omentum, by being now fet at liberty, more of it comes inftantly on the fac being opened ; thereby giving the appearance of having been colleaed in a larger quantity than the fize of the tumor gave reafon to expea. The portion of gut that we meet with in hernial fwellings is various, no part of the inteftinal canal be- ing entirely exempted from falling down. Hitherto the ileum has been commonly fuppofed to form the fubftance of a great proportion cf hcrnice, but later and more accurate obfervation renders it probable that the caecum, appendix vermiformis, and part of the colon, are perhaps as frequently contained in hernias as any other portion of gut. * The fac being laid fully open, the parts contained in it fhould be examined with the niceft attention, in order to difcoyer whether they are found or not; and if upon attentive infpeaion they appear to be found, that is, if they are not evidently in a ftate of gangrene, even although they feem to be inflamed, they fhould be immediately returned into the abdomen. SeCc. II. Of Hernia. 9 Whether inteftine or omentum, or a portion of each, have been contained in the tumor, thofe parts of them which have come laft down fhould be firft pufhed back, the difficulty and trouble of returning them being thereby much leffencd : and in making the reduaion, it both anfwers the purpofe better, ;\r>d is lefs likely to do harm, to apply the fingers to that part of the inteftine connected with the mef'entery than to the convex part cf it. While the reduaion is go- ing on the patient's thighs and loins fhould be ftill more elevated than they were during the preceding fteps of the operation; for 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 little more of the gut, the difficulty that occurred to the reduaion is thereby removed ; and if the protruded parts are not of great magnitude, they may thus be fometimes reduced, without the opening being enlarged by which they paffed from the abdo- men : but when this cannot be done with eale, it fhould never be attempted ; more danger being to be dreaded from force applied to the gut, than can ever occur from finifhing the operation by enlarging the opening in the tendon of tht external oblique mufcle. As the tendon of this mufcle runs in an oblique di- reaion from above downwards, and as the opening through which the contents of a hernia protrude, is formed by a feparation of the tendinous fibres of the mufcle from each other, the direction of this openin;; 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 paiTage, then, for the reduaion of the parts that have paffed through it, as a tranfverfe feaion of the tendon is not neceffary, the knife fhould be carried obliquely ir?w:irdr,, fo as merely to conti- nue the natural fep.vration of the tendinous fibres. io Of ILmia. Chap. XXIII. The finger was recommended as the beft direaor for the knife in opening the fac, and in dividing the tendon it proves equally ufeful. By infinuating the finger into the aperture of the tendon immediately above the protruded parts, the point of the blunt bif- toury, Plate LXIV. fig. 2. is eafily introduced upon it; and in this manner, by keeping the end of the fin- ger a little before the biftoury, the opening may be enlarged to any neceffary extent without rifk of wound- ing the contiguous parts. In general, a very fmall enlargement of the natural opening in the tendon proves fufficient: but the fize of the opening fhould be fully equal to the objea in view ; for it is better to make it fomewhat too large, than to run any rifle of hurting the gut by forcing it through a fmall aperture. If on the introduaion of the finger any adhefions of the gut to the contiguous parts are difcovered, the incifion in the tendon fhould be made larger than might otherwife be neceffary, that the finger may be fo free- ly admitted, as to deftroy fuch adhefions as it can reach ; for if not removed, the operation would very probably fail. Befides thefe internal adhefions, it fometimes hap- pens, by long confinement in the fcrotum ; preffure ; and perhaps from other caufes ; that ftrong adhefions are formed among the parts contained in the fac : and before reducing them, it is always right to attempt to feparate them. When thefe adhefions occur, as they fometimes do, between different parts of the gut, they fhould be fep- arated with much care; but conneaions of this kind between one portion of gut and another, are feldom firm, and are commonly eafily feparated : when form- ed by means of long filaments, which is fometimes the cafe, the eafieft method of removing them is to cut them, either with fciffars or a biftoury ; but when one part of the gut adheres fo firmly to another as not to be feparated but v.ith difficulty, it is much better to Sea. II. Of Hernia. 11 return the whole even in this ftate to the abdomen, than to run the rifk of hurting it by employing much force. When, again, adhefions form between the gut and the hernial fac, or between the gut and omentum, if the filaments by which they are produced cannot be otherwife removed, as there is no great hazard in wounding the omentum, and ftill lefs from hurting the fac, a fmall portion of both may be diffeaed off, and returned with the gut to the abdomen ; and in like manner, when the omentum adheres fo firmly to the fac as not to be feparated in any other manner, no dan- ger can accrue from the fac being encroached on. The rifk attending this praaice is trifling, when compared with the inconveniencies that would enfue from leaving either the omentum or gut adhering ex- ternally to the hernial fac, as is advifed by fome when thefe adhefions cannot be eafily divided. The leaft portion of gut being left down, would run much rifk of being injured by expofure at the different dreffings ; and by leaving part of the omentum to protrude through the opening from the abdomen, one advan- tage to be expeaed from the operation would be loft, namely, the prevention in future of that rifk to which a patient with a portion of protruded omentum muft be always liable, of a piece of gut flipping down, and perhaps of becoming ftrangulated. After returning the contents of the fac into the ab- domen, it has been propofed by fome, to pafs a liga- ture round the upper part of the fac juft at its neck, with a view, as we are told, of procuring a reunion of its fides, in order that it may ferve as a means of pre- venting future defcents of the bowels. But as a ligature cannot be applied in this manner without rifk of injuring, or even of deftroying the fper- matic veffels, with which the pofterior part of the fac is immediately conneaed, the praaice, from this con- fideration alone, fhould be laid afide ; but in reality it does not appear to be neceffary, as this very union of ia Of Hernia. Chap. XXIII. the fides of the fac is always produced merely by that degree of inflammation which fucceeds to the opera- tion. Hitherto I have advifed the contents of herniae to be immediately reduced, on the fuppofition that they have been only difplaced ; that they have been ad- hering to each other or to the neighbouring parts ; or perhaps that they have been more or M* in a ftate of inflammation. But when it appears that this inflam- mation has already ended in gangrene, as the return of mortified parts, whether omentum or inteftine, might be attended with hazard, more caution is re- quired. When the omentum is found in a ftate of mortifi- cation, as a portion of it may be removed without much rifk, it has been the common praaice to cut off the difeafed parts ; and in order to obviate any incon- venience from the hemorrhagy that might enfue, we are advifed to make a ligature on the found parts pre- vious to the removal of thofe that are mortified ; while, by leaving the ends of the ligature hanging out of the wound, the furgeon has it in his power to remove it whenever he may think fit. Ligatures on the omentum, however, having: fre- ouently induced bad fymptoms, fuch as naufea, vomit- ing, cough, fever, pains in the belly, and inability to fit erea ; and as we now from experience know, that no hemorrhagy of importance ever occurs from its being divided, fuch parts as have become gangrenous may therefore be freely cut off, and the remaining found parts be introduced into the abdomen, without ligatures being put upon them. Of this I am con- vinced from experience, and it is alfo the opinion of others :* but if it fhould ever happen, on cutting off part of the omentum, that a veffel of any fize is di- * A very accurate y;aper upon th:s fubjetSb may be k-n in t!'c third volume of Mc'moires de l'Academie Royale de Chirurgie of Pnris, hv Mon- de ur Pipclet, in which fcveral cafes are related of the bad efFcC?ts produc- ed by ligatures on the omentum. Mr. Pott is alfo of this opinion. VkIc Trcr-.tia- on Ruptures. Sea. IL Of Hernia. J3 vided, a ligature may with fafety be paffed upon it with the tenaculum, without including any part of the membrane; and the ends of it being left to hang out at the wound, it may afterwards be pulled away at pleafure. Another circumftance fometimes occurs, that ren- ders the removal of part of the omentum neceffary: when a hernia has been of long duration, and a por- tion of omentum has been long down, from the pref- fure made by the ufual fufpenfory bandage, the pro- truded parts are apt to become thickened, hard, and colleaed into lumps. When thefe lumps are not large, they need not be removed, and when fmall, they may be returned into the abdomen without haz- ard ; but whenever it appears, that by their bulk and hardnefs they might do mifchief if forced into the belly, they ought certainly to be cut off. When we determine to remove any part of the omentum, the eafieft and fafeft method of doing it is this. The membrane fhould be carefully expanded at the part intended to be cut, in which ftate it is ea- fily divided with thin edged fciffars, more fo indeed than with any other inftrument. When fully fpread out, any turn of the inteftine that may be enveloped in it, is at once brought to view, which, without this precaution, we would run the rifk of dividing with the fciffars. When, again, a portion of gut is found to be mor- tified, if returned in this ftate, a difcharge of feces would certainly take place into the cavity of the ab- domen, as foon as the mortified fpot fhould feparate from the found. For the prevention of this, which would foon terminate in the death of the patient, if a fmall fpot only is difeafed, we fhould endeavour, with a needle and ligature, to ccnnea the found part of the gut immediately above the mortified fpot, to the wound in the abdominal mufcles. By this the feces are difcharged by the wound, when the mortified fpot either feparates or is cut out -t and different inftances r4 Of Hernia. Chap. XXIIL have occurred, where the lofs of fubftance produced by the mortification was not extenfive, of the opening into the gut becoming gradually lefs, and at laft heal- ing entirely: but whether the event fhould prove fo fortunate or not, whenever a portion of gut is com- pletely mortified, it fhould be fecured with a ligature to the contiguous parts. And farther, when the mortification is extenfive, and includes, fo far as it goes, the whole circumfer- ence of the gut, the gangrenous parts fhould be cut out at once; and if the quantity thus taken away is not fo corffiderable as to prevent the ends of the gut from being brought into contaa, it fhould be done immediately in the manner pointed out in Chapter ILL Seaion XII. when treating of wounds of the intefti- nal canal: this at leaft affords a chance of the ends of the gut being made to reunite ; and if this unluck- ily fhould not happen, a paffage for the feces will ftill be fecured by the groin. Although in this manner many have recovered who otherwife muft have died; yet it muft be admitted, that the rifk of patients in this fituation is very con- fiderable: but although a fmall proportion only fliould recover, ftill praaitioners would be to blame were they to omit thofe means which afford the beft chance to their patients. 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 inteftinal canal by mortification in a cafe of crural hernia ; and we are told by different authors, of fimilar recoveries equally remarkable. It is to the moderns chiefly, I may remark, that we owe this important improvement in the treatment of hernia. It is even recorded of Rau, who lived in a verv late period, that on opening a hernial fac, where a gangrenous ftate of the parts was difcovered, as the cafe was fuppofed to be defperate, he laid down his knife, and proceeded no farther in the operation. Sea. LT. Of Hernia, 15 The patient, who died next day, would, in modern praaice, have had at leaft fome chance for life. When it is therefore difcovered, that mortification has taken place, all the difeafed parts fhould be cut off, and the remaining found part of the gut being retained with the fingers till properly fecured with a ligature, the opening in the external oblique mufcle may then be dilated with fafety : whereas, if it fhould be enlarged before the difeafed part of the gut is tak- en away, the gangrenous portion might flip up togeth- er with the found; but by this precaution, every rifk of this kind is avoided. The parts forming a hernia being all completely replaced, when the fac in which they were contained is found to be hard, enlarged, and much thickened, as no advantage could be derived from preferving it, fuch parts of it as can be cut away with fafety fhould be removed: all the lateral and foreparts of the fae may be fafely cut off; but being commonly firmly conneaed with the fpermatic veffels behind, this part of it ought not to be touched. In common praaice, the parts are now dreffed with foft lint, and a fufpenfory bag employed for retaining it. But it anfwers better to draw the fides of the cut previoufly together, including the fkin, cellular fub- ftance, and anterior part of the hernial fac, with a proper number of futures, by which the cure is much more quickly accomplifhed, at the fame time that the parts are rendered more firm than they otherwife would be : at one time, this praaice appeared to me to be hazardous ; and I advifed it not to be adopted, as in two inftances a portion of gut got down between the futures, and one of the patients died before it was perceived: farther experience, however, has made it obvious, that this may be always prevented, and that in various v/ays it proves ufeful: when the futures are not above half an inch from each other, and made to pafs to the bottom of the fore, fo as to include all the anterior part of the fac, this accident can never 16 Of Hernia. Chap. XXIII. happen. With a view to give a free vent to any matter- that may form in the courfe of the cut, I have, ;.:i fome inftances, left an opening at the under part of it, but this precaution I now believe to be unnecefia* ry : the futures being completed, the parts fliould be ail covered with a pledget of any emollient ointment, together with fome plies of foft lint, and the whole retained by the T bandage. The patient muft now be carried to bed; and be- ing fo placed as to have his loins fomewhat elevated above the reft of his body, he fhould in this fituation be hid to reft : opiates are here particularly ufeful'. to prevent, or at leaft to moderate, the fever which commonly fucceeds, the patient fliould be kept cool : in plethoric habits, bloodletting fhould be prefcribed, together with a rigid low diet; and, laftly, if the bel- ly is not naturally open, a frequent ufe of gentle lax- atives is particularly proper. When, however, the ftrength has been previoufly much reduced, either by long ficknefs or any other caufe, inftead of bloodletting and a low diet, a nour- ifhing regimen becomes neceffary ; for if a patient in fuch circumftances is not properly fupported, he will not fo readily recover: it is alfo proper to remark, that, in common praaice, the indifcriminate ufe of bloodletting, and an abftemious regimen, in every cafe of hernia, appears to be too rigidly adhered to ; for, although it proves always uTcful in hernia, attend- ed with inflammation, yet daily experience makes it obvious, that it proves hurtful where the fyftem has been already much reduced by evacuations, and where r.o inflammatory fymptoms take place. The fore fhould be looked at and dreffed daily, by which means any change that may take place in it will be quickly difcovered : the ligatures in the courfe of fix or feven days fhould be withdrawn, and as foon as the parts are firmly cicatrized, a well adapted trufs fhould be applied to them, and never afterwards laid afide: fome indeed afiert, that a truft after this oper- Sea. II. Of Hernia. 17 ation is unneceffary, and where the cure has been ac- complished with ligatures deeply placed, in the man- ner I have pointed out, it might in fome inftances be fo complete, particularly during youth, as to prevent all future defcents; but as the contrary has, in vari- ous inftances, happened, the patient fhould be always put on his guard againft it. In performing this operation, it was propofed a confiderable time ago by Mr. Petit, of Paris, and oth- er French praaitioners, to reduce the protruded parts, without dividing the fac : fince that period, the prac- tice has been adopted by others. Dr. Monro thinks favourably of it, and on his fuggeftion I have, in dif- ferent cafes, performed the operation in this manner. But, however unwilling I am to differ from fuch au- thority, I cannot in this inftance avoid it: the chief reafon afligned for not opening the fac, is, that we thereby prevent the air from finding accefs' to the in- Jeftines; but although this would be highly definable, if the operation could otherwife be equally well per- formed, as it does not appear to me that this can be done, I think it right to obferve, that the praaice fhould be received with caution, till, by further obfer- vation, it is afcertained, whether it proves beneficial or not. The beft mode of doing it would be for the furgeons of thofe hofpitals in which hernise moft fre- quently occur, to perform the operation a confidera- ble number of times in each method, and to judge from the refult, for we fhould not decide upon a point of fuch importance on the experience to be obtained from a few cafes. The chief objeaion to the praaice is, that unlefs the hernial fac is laid open, we cannot poffibly diftin- guifh the ftate in which the parts contained in it are; fo that parts might be returned into the abdomen in fuch a ftate of difeafe as would add greatly to the haz- ard of the patient. The interlines are not only liable to mortify, but colleaions are fometimes found in the Vol. III. C iS Of Hernia. Chap. XXIIL hernial fee, of a fetid putrid ferum, which, on being. pufhed into the abdomen, might do much harm. And befides, it has fometimes happened, on laying open a hernial fac, that the caufe of ftrangulation has been difcovered, either in the fac itfelf, or among the parts contained in it: for although, in a great proportion of cafes, a ftriaure of the paflage through which the parts have come down, is to b# confidered as the caufe of all the bad fymptoms, yet inftances of the contrary fometimes occur ; 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 dura- tion, fymptoms of ftrangulation at laft fupervened; and on laying open the fac, the appendix vermiformis was found fo tightly twilled rcund a portion of gut, as left no reafon to doubt of this alone being the caufe of the mifchief. If the parts had here been returned without dividing the fac, no advantage would have been derived from the operation; and, after death, the praaitioner would have had the mortification to find, that the patient's life might have been faved, if this very neceffary meafure had not been omitted. Inftances of the protruded parts being returned in- to the abdomen without opening the fac, are enume- rated by different French praaitioners ; and in fome which ended fatally, it was found on diffeaion, that the ftrangulation of the gut had been the effea of ftriaure formed by the parts contained within the fac, and not by the tendon of the external oblique muf- cles through which they had paffed. Difafters of a fimilar nature having occurred to Mr. Petit and others, who had adopted the praaice, it has long in France been very generally laid afide ; but in a point of fuch importance, this will not be univerfal- ly done till further experience fhall evince whether it ought to be continued or not. By fome again, we are advifed to reduce not only the protruded bowels, but even the hernial fac itfelf; vvhilll others allege, that the fac can never be reduc- Sea. II. Of Hernia. 19 ed. Mr. Louis, in the paper I have quoted, is clearly of this laft opinon, as Mr. Pott alfo is. But we have the teftimony of different authors of credit, and par- ticularly of Mr. Le Dran, to the contrary ; and I have now met with it in more than one inftance, where the appearances were fo unequivocal as to leave no doubt with me refpeaing it. In hernise of long duration, where the parts have been long and repeatedly down, fuch firm adhefions ufually form between the fac and the contiguous parts, as to reduce them apparently into one infepara- ble mafs ; fo that, in fuch circumftances, all attempts to reduce the fac would be in vain. But although this would perhaps in every inftance be the cafe in ruptures of long continuance, we are not warranted in fuppofing that it would be fo in every cafe of re- cent hernia. We know that the aahefion of one part -» of the body to another, cannot any where be inflan- taneoufly produced. Even where recent divifion has taken place, and when the divided parts are kept in clofe contaa, the fpace of fome days is commonly re- quired to produce 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 in a ftate of inflammation, a ftill longer period muft be required for this effea; and in faa, although there is fcarcely perhaps an inftance of a hernial fac of long duration being reduced, yet there are fundry indifputable faas which fhow, that in re- cent ruptures it may be returned. In one of thofe to which I allude, the gut had been down five or fix days, and formed 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 diffeaion after death, which happened in two davs from the operation, the paflage through the external oblique mufcle was found diluted, but no ex- iftence of a fac could be traced into it. This alfo c 2 so Of Hernia. Chap. XXIIL was the cafe with the other, which had been down for twelve or thirteen days. It is not, however, my own opinion, that this is a matter of much praaical importance, I mean the poffibility of reducing the her- nial fac or not; for the reafons I have enumerated againfl the return of a hernia without opening the fac, occur with equal force againfl: our returning the fac itfelf unopened. The obfervations that I have hitherto made relate chiefly to hernia in the male fubjea ; but as the fame openings in the external oblique mufcles cxift in fe- males, fo they are alfo liable to the variety of rupture we have juft been defcribing. In males, however, the bubonocele is more fre- quently met with than in women, and as in them too the cellular membrane furrounding the fpermatic vef- fels is very lax and dilatable, fo hernial fwellings of this part are commonly much larger in them than in women. But inftances fometimes occur, even in wo- men, of the bubonocele being of great bulk: I have known the protruded parts fall down to the very bot- tom of the labia pudendi. As the openings in the external oblique mufcles of females are exceedingly fimilar to thofe in the male, fo the treatment, of bubonocele is in them very fimi- lar to what is found to anfwer in men. When glyf- ters, bloodletting, and the other remedies enumerated above do not fucceed, the fame operation of laying open the hernial fac, and enlarging the opening in the tendon of the oblique mufcle, is here equally proper as in the other fex. With modeft women, hernias often take place with- out the praaitioner in attendance being made acquaint- ed with them ; whenever therefore fuch fymptoms of cholic occur in females as give reafon to fufpea the exiftence of hernia, a particular examination fhould always be made, in order if poffible to difcover the caufe of the mifchief, from the removal of which alone a cure can be obtained. Sea. III. Of Hernia. 21 In this manner, I have, in different inftances, faved the lives of patients, who other wife in all probability would have died, without the caufe of their difeafe be- ing known: with fome women this would happen from delicacy alone; but inftances alfo occur, of her- nias ending fatally, where the tumors are fo fmall as fcarcely to attract attention even from the patient. SECTION III. Of the Hernia Congenita. FROM the anatomical defcription given in the firft feaion of this chapter, of the parts chiefly con- cerned in hernia, it appears, that in the common her- nia of the fcrotum, the parts protruded from the ab- domen muft neceffarily be contained in a bag or fac perfeaiy diftina from the teftis: in that kind of rup- ture, the teftis therefore remains in its ufual fituation, furrounded by its own proper membrane the tunica vaginalis, and not in contact with any other part. But from the fame defcription it appears, that if in early infancy a portion of gut fhould flip down by the , fame paflage with the tefticle, that the parts fo pro- truded muft be in immediate contaa with the teftis, and muft thus be contained in the tunica vaginalis ; fo that in this rupture, very properly by Haller term- ed hernia congenita, the tunica vaginalis teftis forms the hernial fac. The difcovery of this variety 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 being found in the fame bag with the tefticle; a circumftance which, till this dif- covery, was confidered as a clear proof of the perito- naeum being frequently ruptured in hernia, as till of late this phenomenon could not otherwife be explain- 22 Of Hernia. Chap. XXIIL ed. But we now know, that the peritonaeum is never ruptured in hernia ; and that the parts forming a her- nial tumor being found in contaa with the tefticle, is a circumftance eafily explained from the more accu- rate knowledge we have obtained of thefe parts. The treatment of the congenital hernia fhould be nearly the fame with that of bubonocele in its more ordinary form. When the parts can be replaced without an operation, it ought always to be done, a trufs being at the fame time recommended as a pre- ventive of future defcents; and when fymptoms of of ftrangulation take place, which cannot be other- wife removed, than by the operation, it here becomes equally proper as in the common form of the difeafe. When from a hernia having taken place in early infancy, and from the parts having continued to fall into the fcrotum occafionally from that period down- wards, there is reafon to fufpedt that a rupture in which ftrangulation has taken place is of the congeni- tal kind, the furgeon, in dividing the fac, fhould pro- ceed with ftill more caution than in common hernia; for the tunica vaginalis which here forms the fac, is commonly much thinner than the ufual fac of a her-, nia. On the parts being returned, more attention is alfo neceffary in dreflingr the wound than in other ca- fes of rupture; for the tefticle being here laid bare by the vaginal coat being cut open, if not treated with much delicacy it might probably inflame, and be thereby the caufe of much additional diftrefs and dan- ger. The teftis therefore fhould be immediately en- veloped with its own proper covering, the loofe tuni- ca vaginalis ; and every dreffing fhould be fo condua- ed as to prevent with as much certainty as poffible the external air from finding accefs. In other circumftances the management cf the her- nia congenita is the fame with that of any other rup- ture. Sect. IV, * Of Hernia. 23 SECTION IV. Of the Crural or Femoral Hernia. THE feat of the crural hernia, as I have remarked above, is on the upper and anterior part of the thigh; the protruded parts paffing out at the fame opening through which the large blood veffels of the thigh are tranfmitted from the abdomen. In the defcription given in the firft feaion of this Chapter, of the external oblique mufcles of the abdo- men, I remarked, that the under edge of thefe muf- cles, by doubling backwards, affumes the appearance of a ligament, extending in an oblique direction from the fpine of the ileum near to.the fymphyfis pubis, and forming what is commonly termed the ligament of Poupart or Fallopius. Excepting at its two extremities, where this liga- ment is attached to the pubes and ileum, it is not in any other part conneaed 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 hollow in that bone, through which the large artery and veins of the thigh find a paflage, the reft of the cavity being filled up with cellular fubftance, glands, and fat; and all thefe parts again are covered with and tied down by a firm tendinous aponeurofis of the fafcia lata of the thigh. It is under the tendon or ligament juft now defcribed, that the parts compofing a crural hernia defcend. In fome inftances they pafs immediately over the femo- ral artery and vein ; in others, they are found on the outfide of thefe veffels; but more frequently they lie on the infide, between them and the os pubis. As the protrufion and ftrangulation of any of the contents of the abdomen, excites nearly the fame fymptoms, wherever this difeafe takes place 5 fo the 24 Of Hernia. Chap. XXIII. fymptoms of crural hernia are fo fimilar to thofe des- cribed in the two firft feaions of this Chapter, that it is not neceffary to mention them here. The cure of the femoral hernia is alfo conduaed upon the fame principles with that of bubonocele, de- fcribed in the fecond feaion ; fo that when fymptoms of ftrangulation take place in it, the fame remedies fhould be employed that were advifed above for bu- bonocele. Only here, in attempting to reduce the parts by the hand, the preffure fliould be made di- reaiy upwards, inftead of obliquely outwards, as was advifed in the other ; and when thefe means do no| fucceed, the operation itfelf muft be employed. In defcribing the operation for the inguinal hernia, I advifed the external incifion to be free and exten- five. It is ftill more neceffary in the crural hernia., from the parts concerned in it being more deeply feated. By timidity in making the firft incifion, the operator is frequently much incommoded in all the fubfequent parts of the operation. The external cut fhould extend at leaft from an inch above the upper end of the tumor to the fame length below the moft depending part of it. The membrana adipofa, tendinous expanfion of the fafcia lata, and hernial fac, being all divided, if the protruded parts are found in a fit ftate for reduaion, we fhould immediately attempt to replace them ; and as the fpace below the ligament through which they have paffed is confiderable, this may commonly be done without dividing it, merely by preffure properly applied with the fingers, while the patient is placed in the pofture direaed above for the operation of the bu- bonocele as being beft fuited for favouring a return of the bowels. When the contents of the tumor can be reduced without dividing the ligament, the patient is thereby faved from a good deal of hazard, as from the fitua- tion of the fpermatic veffels and epigaftric artery with £ea. IV. Of Hernia. 25 refpea to this ligament, any cut made into it is done with the rifk of thefe veffels being injured. The fpermatic veffels in paffing along towards the opening in the external oblique mufcle, run nearly upon the very edge or border of Poupart's ligament, fo that I confider it as impoffible to make a free di- vifion of the ligament without cutting them acrofs. We have been advifed indeed by fome, in order to avoid the fpermatic veffels, which they allow would be wounded, if the incifion fhould be carried direaiy upwards, to cut in an oblique direaion outwards. They admit, that in this way the epigaftric artery may probably be divided; but the rifk attending the divi- fion of that artery they do not confider as of much importance; and if the difcharge of blood which it might produce fhould happen to be confiderable, they fpeak of it as an eafy matter to take it up with a liga- ture ; for which purpofe needles of various fhapes have been invented. Even in emaciated people, however, it is difficult to reach the epigaftric artery with a ligature, and in corpulent patients it muft of- ten be impoffible; fo that the younger part of the profeffion fhould be cautious in receiving the direc- tions ufually given on this point. On reading the re- marks of the late Mr. Sharpe on it,* to fecure the epi- gaftric artery with a ligature, one would expea to be the eafieft of all operations ; but the difficulty which attends it, is fuch, as muft convince all who have tri- ed it, that Mr. Sharpe himfelf never put it in prac- tice. But even although the epigaftric artery could with certainty be avoided, if a hernia is large, the ligament is fo much ftretched as to bring the fpermatic veffels fo nearly on a line with the under edge of it, as to render it altogether impoffible to divide the one with- out the other; and whoever will examine thefe parts in this fituation, will fee that this cannot be avoided, * Critical Inquiry into the prefent ftate of Surgery. 26 Of Hernia. Chap. XXIIL whether the incifion is carried direaiy upwards, or obliquely outwards or inwards. Some' who have been fenfible of the danger attend- ing this part of the operation, have propofed merely to dilate the paflage in (lead of dividing the ligament j and Mr. Arnaud, a French author, delineates a curv- ed levator for the purpofe of fupporting the ligament till the protruded parts are reduced : but as we are to fuppofe in every cafe of ftrangulated hernia, that the paffage through which the parts have fallen down is already dilated to nearly its utmoft poflible extent, in fuch a fituation to attempt a farther dilatation, without the affiftance of the knife, would feldom, it is proba- ble anfwer any good purpofe. A confiderable time ago it occurred to me, that in this part of the operation fome affiftance might be de- rived from performing it in the following manner; and having fince had occafion to put it in praaice with fuccefs, I can now with fome confidence recom- mend it. Inftead of dividing the ligament in the or- dinary way, from below upwards, I make a flight in- cifion into it, about an inch in length, beginning above and proceeding to the under edge of it. The firft fcratch with the fcalpel fhould be flight; but by repeated touches, it fhould be made to pene- trate almoft through the whole thicknefs of the liga- ment, till at laft only a thin layer of it remains: in this fituation the protruded parts may for the moft part be returned with cafe, as the ligament where thus weakened by the incifion will yield gradually to the preffure applied for the reduaion of the inteltines. As in this manner the opening may be enlarged to any neceffary extent, and as the fpermatic veffels and epigaftric artery are thus avoided, the operation may not only be done with equal certainty, but with the fame fafety, as for any other rupture. For, by not penetrating with the fcalpel through the whole thick- nefs of the ligament under which thefe blood veffels lie, they are thereby kept free from danger during Sea. V. Of Hernia. 2 7 this part of the operation ; and the preffure afterwards ufed for the reduaion of the protruded parts, if done in a gradual manner, can never injure them material- ly, as blood veffels of the fize and ftrength of thefe eafily admit of much more extenfion than is here re- quired. In every other circumftance, the crural hernia, as I have obferved already, requires the fame method of treatment with bubonocele, for which the fecond Sec- tion of this Chapter may be confulted: only I may remark, that the dreffings are more eafily retained af- ter this operation, by a piece of leather fpread with plaf- ter moderately adhefive, than with any kind of band- age. I have already obferved, that the crural hernia is more frequent in women than in men, owing to the particular conformation of the parts in which it oc- curs. In women the fame mode of operating fhould be obferved as in men; for as in them there is the fame rifk of wounding the epigaftric artery, the fame precautions are neceffary for avoiding it, and by at- tending to the direaions given above, it may be al- ways done. SECTION V. Of the Exomphahs, or Umbilical Rupture. IN this variety of hernia, the parts protruded from the abdomen pafs out at the umbilicus ; and the contents of the hernial fac are here, as in every other rupture, exceedingly various. In fome inftances they confift of interlines only ; fometimes of omentum on- ly ; and frequently of both. In fome, part of the fto- mach, liver, and fpleen, have been found in the fac of an umbilical rupture. 28 Of Hernia. Chap. XXIII. As all thefe parts are naturally contained in the pe- ritonaeum, the hernial fac, it is evident, muft here as in other ruptures be formed by that membrane being carried alon<; with fuch parts as are protruded. Ac- cordingly, in every recent inftance of umbilical her- nia, this fac is in general evident; but when the tu- mor is large, the fac becomes fo intimately conneaed with the contiguous parts, in confequence of the weight and preffure of its contents, that many have doubted whether this fpecies of hernia has a fac or not. In fome inftances the tumor has increafed to fuch a degree, as aaually to burft the furrounding parts; not only the fac, and cellular fubftance, but even the fkin itfelf. Umbilical hernise occur moft frequently in early infancy, and in corpulent people more frequently than in others, from this obvious reafon, that by the great bulk of parts contained in the abdomen of fat people, the furrounding mufcles are kept conftantly diftend- ed, by which the opening at the umbilicus, through which the parts are protruded, is made more pervi- ous : for a fimilar reafon, women in the laft months of pregnancy are particularly liable to this rupture. If attended to in due time, a right bandage will commonly effea a cure; and, when produced by pregnancy, a temporary removal of the difeafe, is, in general, a certain confequence of delivery. While a woman continues pregnant, we can feldom remove an umbilical rupture, but by employing a bandage early we can in this fituation prevent the tumor from be- coming larger. Although different portions of the aliamentary ca- nal are occafionally met with in umbilical ruptures j yet by experience we know, that moft frequently they contain omentum only: hence umbilical hernia? are not in general fo hazardous as other ruptures. It happens, however, as I have obferved above, that in fome cafes a portion of gut alone is pufhed out, by which the ufual fymptoms of ftrangulation are apt to Sea. V. Of Hernia. 2g be induced. In this fituation, when the means ufual- ly employed for returning the gut do not fucceed, as a ftricture of the paflage through which it has fallen, is to be confidered as the fole caufe of the danger ; fo a cure, it is evident, muft depend entirely on this be- ing removed. In performing this operation, a free external incifion along the courfe of the tumor is the firft flep to be taken; and on laying the protruded , parts bare by a cautious divifion of the fac, if they are found in a ftate fit to be returned, and if this cannot be effeaed but by enlarging the paflage into the ab- domen, it may be done with fafety by introducing the finger, and enlarging the opening with a blunt point- ed biftoury. This incifion, I may remark, may be made with almoft equal fafety in any direaion ; but left the ligament formed by the umbilical veffels fhould be wounded, which, however, would not probably do much harm, yet when an operator is of a different opinion, it may always be avoided by making the cut on the left fide of the umbilicus, and carrying it a little obliquely upwards and outwards. When, again, the prolapfed parts, on being laid open, are found to be fo much difeafed as to render their reduaion improper, the direaions formerly giv- en for fimilar occurrences in other cafes of hernia, will apply with equal propriety here, and need not now be repeated. By Albucafis, Guido, Aquapendens, and others, it has been propofed, with a view to obtain a radical cure without the operation, to lift up the fkin cover- ing the tumor, with the finger and thumb, fo as to feparate it from the gut beneath ; and a cord being paffed round the parts thus raifed up, a ligature to be made fo tight as to induce mortification over the whole of them. In other inftances again, when the form of the fwelling did not admit of this, the fame precaution be- ing taken for avoiding the gut, a needle containing a double ligature was introduced through the bafis of yy Of Hernia. Chap. XXIII. the tumor, near to. its centre, and the ligatures af er- wards tied one above and the other below, of fuch tightnefs as to induce the wiflied for effea. But as the praaice thus recommended did not an- fwer the purpofe, for it did not prevent a return of the difeafe, and as the deftruaion of fkin rendered every future defcent more dangerous, fo it is now, at leaft by regular praaitioners, very univerfally ex- ploded. In Plate LXV. fig. 3. is reprefented the belt ban-' dage I have ufed for umbilical hernias. SECTION VL Of Ventral Hernia. IN ventral hernia the parts forming the tumor arc* protruded between the interftices of the abdominal1 mufcles. No part of the abdomen is altogether ex-j empted from thefe tumors, but they are moft frequent ia the parts moft contiguous to the linea alba ; and when the ftomach alone forms the tumor, the fwell- ing is fituated juft under, or immediately to one fide of the xiphoid cartilage. The treatment of this rupture correfponds with that Of exomphalos. When the parts are reducible by the hand alone, a cure may be frequently obtained by the conftant ufe of a trufs ; and, again, when fymptoms of ftrangulation occur, which cannot be removed but by an incifion through the ftriaure, this muft be done in the manner pointed out in the laft feaion, fo as to admit of the parts being replaced. The after treat- ment of the parts concerned in the operation, is the fame here as in the umbilical rupture. Sea. VIL Of Hernia. 31 SECTION VII. Of the Hernia of the Foramen Ovale. IN this rupture, the vifcera protrude through the fo-- ramen ovale of the pubis and ifchium. It is not a frequent variety of the difeafe ; but as it has been met with, it is neceffary to defcribe it. The fymptoms of this hernia being vej«y fimilar to thofe arifing from ftrangulated interlines in other parts, they need not be enumerated here : only it is proper to remark, that in this rupture the tumor is in men formed near to the upper part of the perinseum ; and in women, near to the under part of one of the labia pudendi. In both fexes it lies upon the obturator ex- ternus, between the peaineus mufcle and the firft head of the triceps femoris. The foramen ovale being partly filled up by a mem- branous 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 fora- men for the tranfmiilion of different blood veffels and nerves, it is now known, that in this rupture the vif- cera pafs out at that opening, by gliding down in the courfe of thefe veffels. The general mode of treatment pointed out in the preceding feaions for other hernias, muft be here kept in view ; and when the parts are reduced, a trufs pro- perly adapted to the parts, muft be trufted to for re- taining them. But, as it will fometimes happen in this, as in every other hernia, that the parts cannot be reduced with the hand alone, when this is found to be the cafe, it muft be done by dilating the paffage through which they protrude. The tumor, however, that takes place here, being in general fo fmall as fcarcely to be noticed but by the moft minute atten- 32 Of Hernia. Chap. XX ILL tion, unlefs a local pain, with the ufual fymptoms of a ftrangulated gut happen to lead to it, it is feldom difcovered from its fize, till it is too late to expea much affiftance from art. But whenever the operation becomes neceffary, as it muft always be when fymptoms of ftrangulation arife from a portion of protruded gut that cannot by any other means be reduced, after carefully laying the prolapfed parts bare, if they cannot be reduced but by dilating the paffage, and as death muft enfue fre- duaion cannot be accomplifhed, it ought undoubted- ly to be attempted : but as it is almoft impoffible to enlarge this opening with an inftrument, without di- viding fome of the blood veffels that pafs out at the foramen ; and as this would probably end in the death of the patient, the depth and fituation of the parts rendering the application of a ligature impraaicable; it is more advifable, by means of a flat hook, to dilate the paffage to a fufficient fize, by gentle gradual ftretching. By infinuating the end of the hook be- tween the interline and ligament, and pulling it gra- dually upwards, a degree of dilatation may be obtain- ed, fufficient for the reduaion of the gut, without in- curring that hazard which the divifion of the ligament with the knife or any fharp inftrument muft always occafion. A hook for this purpofe is delineated in Plate LXVI. fig. 2. SECTION VIII. Of the Hernia Cyflica, or Hernia of the Urinary Bladder. TfN this rupture, the urinary bladder is the organ J[ protruded ; and the fituations in which it occurs, are either the groin and fcrotum through the opening in the external oblique mufcle cf the abdomen 5 the Sed. VIII. Of Hernia. 33 forepart of the thigh under Poupart's ligament; or the perinseum through fome of the mufcular inter- flices of that part.* Inftances have like wife happen- ed, of the bladder being pufhed into the vagina, fo as to form hernial tumors of confiderable bulk. As only a part of the bladder is covered with the peritonaeum ; and as the bladder, in order to get into the opening in the external oblique mufcle, or under the ligament of Fallopius, muft infinuate itfelf be- tween that membrane and the abdominal mufcles, it is evident, that the hernia cyftica cannot be covered with a fac, as inteftinal ruptures ufually are. In the perinseum, again, that portion of the bladder moft liable to fall into it, is in no way conneaed with the peritonaeum. In fome inftances, this rupture occurs by itfelf, without any complication ; and in others it is accom- panied with interlines and omentum, both in inguinal and femoral herniae : when complicated with a bubo- nocele, the protruded portion of the bladder lies be- tween the hernial fac and fpermatic cord ; that is, the inteftinal hernia lies anterior to it. The ufual fymptoms of this hernia are, a tumor, attended with fiuauation, either in the groin, in the forepart of the thigh, or perinaeum, which gradually fubfidcs when the patient voids urine, and becomes larger when the bladder is full. When the tumor is. targe, before water can be paffed with freedom, it is commonly neceffary to employ preffure, at the fame time that, when in the groin or thigh, the parts re- quire to be as much elevated4 as poffible ; but when the tumor is fmall, and efpecially when no ftriaure has taken place, the patient generally voids urine eafi- ly, and without affiftance from external preffure. When a hernia of the bladder takes' place without any complication, it commonly proceeds from a fup- * An inftance of this is recorded in vol. iv. of M-jrrokcs de l'Acadcnu'e Rovalc de Chirurgie, by Mous. Pipelet le Jainc, p. 181. Vol. III. D 34 Of Hernia. Chap. XXIII. preffion of urine. In the method of cure, there- fore, every caufe of fuppreflion fhould, as far as pof- fible, be guarded againfl; and if the protruded por- tion of bladder can be reduced, a trufs properly fitted to the part, fhould be worn for a confiderable time. But when the parts cannot be reduced, as long as no fymptoms appear to render the operation neceffary, a fufpenfory bag, fo fitted as effeaually to fupport the tumor without compreffing it, is perhaps the only re- medy we fhould employ. When, again, a portion of bladder protrudes into the vagina, after reducing the parts, which we do by laying the patient on her back, with her loins eleva- ted, and prefling with the fingers from the vagina, de- fcents in future may, in general, be prevented by the ufe of the peffary reprefented in Plate LXVI. fig. i. And the fame means, I may remark, are employed with fuccefs, in preventing defcents of the inteftinal canal into the vagina ; a fpecies of rupture fometimes met with. It may happen, however, if inflammation occurs here, that the divifion of the parts producing the ftric- ture will be as neceffary as in any other rupture. In which event, the mode of operating pointed out in the preceding feaions fhould be kept in view. Only it muft be remembered, that as in the hernia cyftica without any complication, the protruded parts are not covered with a fac, fo ftill more caution is required in laying them bare, than is neceffary in common rup- tures. It fometimes happens, that ftones are produced in the protruded portion of the bladder. In which event, if it fhould ever be neceffary to cut into them, if the bladder can be eafily retained in its prolapfed ftate till the wound is healed, it ought always to be done, in order to prevent that internal extravafation of urine which otherwife would occur, and which certainly would do harm. The fame precaution is neceffary, Sea. VIIL Of Hernia. 35 when by accident in the operation for the hernia cyf- tica, the bladder is opened ; or when any part of it is in a ftate of mortification, and therefore unfit to be returned into the abdomen.* * The bell: accounts of all the varieties of hernia are to be met with in the works of Le Dran, Heifter, and of Mauchart, in a Treatife de Hernia Incarcerata; in the different volumes of Meraoires de l'Academie Royale de Chirurgie de Paris ; in the Medical ElTays of Edinburgh 5 in the works of the late Dr. Monro; in Haller de Hernia Congenita, in his Opufcula Pathologica; in Mr. John Hunter's very accurate account of the ftate of the teftis in the fcetus, to be met with in Dr. Hunter's Medical Commen- taries ; in Mr. Pott's and Dr. Richter's valuable works on this fubject. Thefe are the beft modern authors on this fubj-.it; and very little fatis- fa&ion is to be obtained from any of the ancient writers upon it. D 2 35 On the Hydrocele. Chap. XXtV, CHAPTER XXIV, ON THE HYDROCELE. SECTION I. General Remarks on the Hydrocele. EVERY tumor formed by a colleaion of water", may, from the import of the w7ord, be called a hydrocele, but, in chirurgical language, the term im- plies a watery fwelling in the fcrotum or fpermatic cord. This, as well as- all tumors in the fcrotum or groin, not immediately produced by the protrufion of parts from the abdomen, were, by ancient writers, termed falfe or fpurious hernias, from the refemblance which they bear to the true hernia, or rupture; but no ad- vantage is derived from this diftinaion: and. as it arofe from an erroneous opinion of the origin of her- nise, I fhould not have taken notice of it here, but with the view of making the writings of the ancients' upon this fubjea intelligible. -Indeed, the doarines of the writers of the laft and preceding centuries concerning hydrocele, are fo con- futed and perplexed, that they do not merit attention ; for, as they were ignorant of the anatomy of the parts ui which the difeafe is feated, the ideas which they formed of it, gave rife both to an erroneous patholo- gy and pernicious praaice. Not being acquainted with the ftrudure of the parts affe&ed, they proceed- ed with much' unneceffary d, cad in the treatment of the difeafes to which they were liable; for, bv fup- pofing an immediate conneaion to fubfift between the coats of the tefticle, the cavity of the abdomen, liver, Sea. L On the Hydrocele. 37 kidneys, and other vifcera, they were induced to con- fider the colleaion of water in hydrocele, as a depo- fition from thefe parts, and as tending to free them, and perhaps the fyftem at large, from difeafes of im- portance. In confequence of this, their praaice was timid and indecifive; fo that every chirurgical operation, in which thefe parts were concerned, became a matter of much importance to refolve upon, and very tedi- ous, painful, and uncertain in the execution. From the time of Celfus to the middle of the laft century, little progrefs feems to have been made in this part of chirurgical pathology. Indeed, from Cel- fus downwards, authors feem to have copied almoft exaaiy from one another, till Wifeman, Le Dran, Garangeot, and Heifter, gradually elucidated the fub- jea: but it was not clearly underftood till the dis- coveries of Monro, Haller, Hunter and Pott, made the anatomy of the parts plain and intelligible. So much attention, however, is ftill given to the confuf- ed accounts of ancient writers, that the real nature of the difeafes of the teftes, and their appendages, is, from this caufe alone, lefs underftood than it other- wife would be. There is perhaps no part indeed of furgery with which ftudents in general are fo little ac- quainted. Nothing but a flria attention to the difcoverieS of late anatomifts, can convey clear and diftina ideas concerning them; arid, whoever will make himfelf acquainted with thefe, will find, that the hydrocele and affeaions of the teftes, may be explained with as much clearnefs and fimplicity as any other clafs of difeafes. In the firft Seaion of Chapter XXIII. I gave a defcription of thefe parts, in fo far as was ne- ceffary for the confideration of hernia. Referring to. what I had then occafion to fay, commencing in page £27, and ending page 533, Vol. II. I have now only to add what may be neceffov for underftanding more completely the difeafes of the teftes, and their tunica 38 On the Hydrocele. Chap. XXIV. As from the forefaid defcription it appears, that the teftio while in the abdomen is firmly attached to the peritonaeum behind, fo, when in the fcrotum, as the vaginal coat with which it is there furrounded, is evi- dently a continuation of the peritoneum, it muft of neceffity be ftill conneaed with that membrane, in the fame manner as while it remained in the abdomen. And accordingly we find, that, although the tefticle lies loofe in this fac, or vaginal coat, in every other part; yet, along its pofterior part, it is firmly attached to it. At this part, the different veffels of the teftis ftill enter; and at this the peritonaeum, ox what is now the tunica vaginalis, is refleaed over it, and eve- ry where clofely attached to it, thereby forming the tunica albuginea, or immediate covering of the tefti- cle ; fo that the tunica jjbuginea is demonflrably a mere continuation of the-other, or vaginal coat. The inferior part of this procefs of the peritonaeum being fomewhat wider below than above, leaves the tunica vaginalis of a pyramidal form; and it is alfo fomewhat longer than the teftis, reaching from the fuperior part of the epididymis, where it begins, to a little below the inferior point of the tefticle, where it terminates. It is altogether of fuch a fize as to allow the teftis to roll eafily within it; its principal ufe ap- pearing to be, to retain a fmall quantity of a fine ex- halation, which is conftantly fecreting, either from its own furface, or from the furface of the teftis itfelf, for the purpofe of keeping the latter moift and eafy. The vaginal coat, of which I have thus .given a de- fcription, is the only loofe covering belonging either to the fpermatic cord or teftis: for although, by ma- ny, a vaginal coat of the fpermatic cord is alfo de- fcribed, together with a fuppofed feptum between it and the vaginal coat of the teftis, yet no fuch cover- ing is, on diffeaicn, found to exift. The upper part of what may be called the fpermatic procefs of the peritonaeum, is evidently clofed, as has been defcribed above, foon after' the defcent of the tefticle • and a Sea. I. On the Hydrocele. 39 firm adhefion taking place between the cord and that part of the fac with which it is enveloped, no veftige can be traced, either of a vaginal coat of the fperma- tic cord, or of any particular feptum between this coat and the tefticle : this, it is of importance to notice, as the difeafes of thefe parts cannot otherwife be under- ftood. As the difeafes we are now to confider are chiefly feated in the coverings of the teftis, I have given a more particular account of them, than is neceffary in fpeaking of the teftis itfelf; with refpea to which, I fhall only obferve, that it is evidently very vafcular, being compofed almoft entirely of different convolu- tions of veffels. Befides the vaginal coat proper to each tefticle, the two teftes have for their further proteaion, a more external covering, the fcrotum; a bag formed almoft entirely of fkin and cellular fubftance ; for that body, the dartos, which has been commonly defcribed as mufcular, is now clearly proved to be altogether cel- lular. Even the feptum fcroti, or that membrane which divides one tefticle from another, is compofed of cellular fubftance in a more condenfed ftate. By air it is eafily inflated, and it is alfo pervious to water; fo, of courfe, it partakes of all thofe watery effufions, to which the more external parts of the fcrotum are liable. This ftruaure of the fcrotum it is neceffary to be acquainted with, as, from the defcriptions which, till of late, have been given of it, young praaitioners are induced to confider it as mufcular, and to fuppofe that the feptum, with its rapha, are ligamentous ; and hence they are led to be more cautious than they need be in performing operations on this part. Having thus premifed an account of the anatomy of the parts in which the water in hydrocele is colle£t- ed, I fhall now proceed to confider the different vari- eties of the difeafe. 40 On the Hydrocele. Chap. XXIV, All the varieties of hydrocele which have been men- tioned by authors, may, I think, be comprehended under the two following, the anafarcous, and encyfted. In the former, the ferum is diffufed over all the fub- ftance of the part in which it is feated ; it is not col- leaed in any particular cavity, but occupies equally all the cells of the" part: in that which I term encyft- ed, the water is colleaed in one diftina bag, and a fluauation of a fluid is, in general, perceived in it. The fcrotum, with its contents, the tefticle and its ap- pendages, are liable to both varieties of the difeafe ; and the fpermatic cord, with its coverings, are alfo li- able to both. We fhall firft confider thofe of the fcrotum. SECTION II. Of the Anafarcous Hydrocele of the Scrotum. THE fcrotum, from its cellular ftruaure, and im* mediate conneaion with thejtrunk of the body4 is apt to partake of every diffufable fwelling with which the upper part of the body is attacked : and, accord* ingly, we find, that general anafarcous fwellings fel- dom fubfift for any length of time, without affeaing the fcrotuia. A local anafarca of the fcrotum, is fometimes indeed produced by a local caufe, to wit, by the preffure of a tumor on the lymphatics of the part; by external injuries ; and occafionr.ily by an effufion of urine from a rupture of the urethra : but fuch occurrences are rare ; a general difeafe of the conftitution being the ufual forerunner of thefe tu- mors. As foon as water has colleaed in any confiderable quantity in the fcrotum, a foft, inelaftic, colourlefs tu- mor is obferved over the whole of it; impreffions are eafily received and retained for fome time; the fkin 6ea. II. On the Hydrocele. 4* at firft preferves its natural appearance; and the ru- gae of the fcrotum, which, in a ftate of health, are ob- vious, are not for fome time much altered ; but as the fwelling advances, the rugae gradually difappear, till at laft they arc totally obliterated: the tumor, from being at firft foft, and of a confiftence fimilar to dough, by degrees turns more firm, and the fkin at lai? ac- quires an unnatural white fiiining appearance. At length it becomes large ; and although originally con- fined to the fcrotum, it at laft fpreads up the groin : the penis likewife becomes affecled, and often fo fwell- ed and diftorted, as to excite much inconvenience and diftrefs ; and although the fcrotum is compofed of parts which readily admit of dilatation, yet, in fome inftances, the tumor becomes fo enormous, as to burfl from one end to the other. Thefe appearances of the difeafe are fo charaaerif- tic, as to render it almoft impoffible to confound this fpecies of hydrocele with any other tumor of the fep- tum. I have already obferved, that inftances fometimes occur, of the fcrotal anafarca being produced by a%- cal caufe ; but, in a great proportion of cafes, it is in- duced by a general tendency to dropfy ; fo that the cure will chiefly depend upon the removal of that hab- \t of body, by which it was at firft produced. The treatment of this difeafe of the fyftem falls to the province of the phyfician, fo that I fhall not enter upon it at prefent; but the aid of furgery is freeucur- ly required, for relieving the diftrefs which tlide tu- mors always induce when they become large. In thefe circumfb.-ices, the objeft of furgery is, by drawing off the water, to di^hdfti the fize of the tumor, or even to remove it altogether, which not only gives much i.amedi.ite rolic', but is a means of the diftended prots recovering their tone more readily than they otherwife would do. Different methods have been propofed for evacuating the water ; the inrroduaion of a feton, paff- ing a trocar, incifions, and punaures. 42' On the Hydrocele. Chap. XXIV. All of thefe, excepting that by the trocar, ferve ve- ry tiRauaily to evacuate the diffufed water ; and therefore we are to adopt that which not only excites leaft pain, but which is leaft liable to produce trouble- fome confequences; and this unqueftionably is the method by punaures. The feton and long fcarifications may difcharge the water more quickly than punaures ; but in dropfical conftitutions, fuch as the anafarcous hydrocele is com- monly conneaed writh, they almoft conftantly do harm. For the firft two or three days, fcarifications give the patient much fatisfaaion : the water is almoft entirely difcharged, the tumor is of courfe greatly diminifhed, and much relief is thereby obtained. About this time, however, the fcarified parts commonly begin to fret, their edges turn hard and inflamed, and by degrees, an eryfipelatous rednels fpreads over the neighbouring parts. ->* That fretful uneafinefs at firft complained of, ter- minates at laft in what the patient terms a burning l^ld of pain, which frequently becomes fo tormenting, aTentirely to deftroy reft; and it too commonly hap- pens, that all our remedies fail in preventing the ac- ceffion of gangrene, by which the patient is in gener- al carried off. I will not fay that fcarifications always e»d in this fatal way; but I have in many inftances found that they did fo ; and, on the contrary, although punaures fometimes terminate in the fame manner, they are by no means fo ready to do fo. As fcarifications are fo apt to do harm, there is much reafon to fufpea that the trocar and feton, which both excite ftill more irritation, would prove ftill more hurt- ful. They are now, accordingly, in the anafarcous hydrocele very generally laid afide. When fcarifications* are to be employed, we make them with the fhoulder of a lancet: they fhould pen- etrate the cutis vera, but fhould not be carried to a greater depth, and they fhould not exceed an inch in S.:Q. II. On the Hydrocele. ' 43 length : punaures fhould be carried to the fame depth ; ,',::-( they, as well as fcarifications, fhould be always on the moft prominent and moft depending parts of the ru'.ner : punaures are beft made with the point of a lancet: five or ilx are commonly fufficient at once ; but as they are apt to heal before the ferum is all dif- charged, they require from time to time to be re- newed. Preferving the parts dry, by a frequent renewal of dry linen cloths, in order to imbibe the moifture, is here a very neceffary attention ; indeed, the want of it feems often to be the caufe of much of the mifchief that enfues from this operation. When either fcarifications or punaures go wrong, by beginning to inflame and turn painful, inftead of the warm emollient poultjces and fomentations ufually employed, a cold faturnine folution applied upon foft linen, not only proves more effeaual in putting a flop to the inflammation, but affords more immediate re- lief to the prefent diftrefs. Lime water, employed in the fame manner, proves alfo an ufeful application. Mortification, however, will take place in fome in- ftances, notwithftanding all that 'we can do to prevent it: in this cafe, we trull chiefly to the internal ufe of bark, wine, and other tonics, and to warm d re flings and other external applications ufually employed in gangrene: as this variety of gangrene is almoft always accompanied with much irritation, I often «,ive opium with advantage : opium proves chiefly uf-fol, by re- moving pain and general irritability ; but as we know from experiment, that it aas as an antifeptic, it may in fome cafes flop the progrefs of gangrene, by aelhig direaiy on the difeafed parts. In a great proportion of cafes, the utmoft danger is to be dreaded from the punaured parts being attack- ed with gangrene ; yet, in a few inftances, very unex- peaed cures are obtained, after all fhe teguments have- been deftroyed by it. A remarkable inlni.-ce of this occurred ;o&\z years ago, in the Royal Infirmary here ; 44 On the Hydrocele. Chap. XXIV, the whole fcrotum feparated, and left the tefticles bare. Durir.g the time that the fore remained open, all the water colleaed in other parts of the body was evacu- ated, and, by the ufe of large quantities of bark, and mild dreffings to the fore, the patient got well. In the courfe of the cure, the teftes became enveloped with a thick cellular fubftance, which ferved as a very good means of proteaion. It muft have been fome fmiilar produaion, I fuppofe, which Hildanus fpeaks of as a regenerated fcrotum.* I have already obferved, that, although the anafar- cous hydrocele depends, for the moft part, on a ge- neral tendency to dropfy, that fome inftances, howev- er, occur, of a local caufe producing a mere local drop- fy of the fcrotum. Thus it has, in fome inftances, arifen from tumors in the groin and abdomen obftrua- ing the paffage of the lympnatics. In this cafe, if the tumors producing the obftruaion can be extirpated, no other means will afford fuch effeaual relief; but, when fo deeply feated as to render any attempt for re- moving them unfafe, tlie praaice I have pointed out, of making punaures in the moft depending part of the tumor, muft-be employed, from time to time, to palliate the fymptoms. It has fometimes happened, in fuppreflion of urine, whether arifing from ftriaures in the urethra, or from flones impaacd in it, that the urethra has burft, and the urine, in this manner, getting accefs to the cellu- lar texture of the fcrotum, an anafarcous fwelling rifes immediately over the whole of it; nor does it com-; monly diminifh till the caufe by which it is produced is removed. In order to prevent the formation of finufes, which, in fuch circumbailees, 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 rcacinno the wer.nd in the urethra. In * Obfervat. Cbirurg Cent. j. Obf. 76; Seft. II. On the Hydrocele. 45 this manner, a free vent will not only be given to the urine already diffufed, but the further colleaion of it may probably be prevented. If a ftone impaaed in the urethra is found to be the caufe of the cfil Hon, it fhould be cut out; and, if the obftruaion is produced by itriaures, they muft be removed by a proper ufe. of bougies. The caufe being thus removed, if the habit of body of the patient is good, and untainted with any venereal or other general affeaicn, by dreff- ing the fore properly, with fort eafy applications, the opening in the urethra will probably heal, and a com- plete cure will, in this manner, be obtained. But when thefe ailments are cour,!ie;vted with any general affeaion, particularly with lues venerea, neither mer- cury nor any other internal medicine, will remove them. Cafes of this kind muft have occurred to every prac-- titioner. I have met with them, both in the hofpitai and in private praaice; where, notwithftanding all the internal remedies that were employed, the paffage from the urethra remained open, and continued to af- ford a vent to the urine. In fuch cafes, we depend chiefly upon a proper application of bougies. The fcrotal anafarca, of a local nature, has alfo hap- pened from the rupture of a hydrocele of the tunica Vaginalis teftis: when the hydrocele of the tunica va- ginalis arrives at a great fize, jumping from a height, or a violent blow or bruife, will readily burft it; and the water, not finding a paffage outwardly, muft ne- , ceffarily diffufe itfelf over the fcrotum. Different in- ftances of this have been met with, two of which are related by Douglas ;* and others have fallen within my own obfervation. A fwelling of a fimilar kind is alio fometimes induced by the water of the hydrocele of the tunica vaginalis being improperly drawn off in the operation of tapping. When the orifice in the fkin is allowed to recede from the opening in the va- * Treatife oa the Hydrocele, by John Douglas, p. 8. 46 On the Hydrocele. Chap. XX1V/ ginal coat before the water is all difcharged, as is apt to happen when the operation is done with a lancet, the remainder of the colleaion diifufes itfelf through the cellular fubftance of the fcrotum, an inconveni- ence that may be always prevented, by ufing a trocar for this operation, inftead of a lancet. In whatever way the fwelling is produced, the cure fliould confift in laying the tumor fufficiently open* not only for evacuating the diffufed ferum, but for ef- feaing a radical cure of the hydrocele of the tunica vaginalis. Some have imagined, that danger may en rue from performing the radical cure for the hydrocele in this ' fituation ; but I have done it in different inftances, and no harm has ever enfued from it. The patient, in fome cafes, may decline the operation, and, in oth- ers, his habit of body may render it improper; but, when this does not happen, few will doubt of its be- ing better to give a patient, in fuch circumftances, im- mediate and effeaual relief, by performing the radical cure at once, than to fubjea him, in the firft inftance* t-> a good deal of confinement, for removing the dif- fufed fwelling or" the fcrotum, and to leave him under the fame neceffity as before, of fubmitting to the radi- cal cure for the hydrocele of the tunica vaginalis. When, for either of the reafons, however, that I have mentioned, this operation is not to be perform- ed, we endeavour to aflut the difcuffion of the tumor, by fufpending the fcrotum ; confining the patient to a horizontal pofture; and by th j application of aftrin- gents to the parts affeaed. Of thefe we have a great variety; but I have found none anfwer fo well as a cold fo'ution of crude fal ammoniac, in the proportion of half an ounce of the fait to a pound of water and two ounces of vinegar; or poultices, prepared with crumb of bread, foaked in equal pans of cold water, vinegar, and brandy. I have thus confidered all the varieties of anafar- cous tumors, to which the fcrotum is liable* to: a her {Sect. II. On the Hydrocele. 47 with the mode of treatment that appears to be adapt- ed to each of them; for, with refpea to the hydro- cele of the dartos, a difeafe particularly defcribed by ancient writers, as that part of the fcrotum is now known to be entirely cellular, fo any water colleaed in it muft tend to form that very difeafe we have juft been defcribing, an anafarcous fwelling of the whole fcrotum. We now proceed to confider that fpecies of hydro- cele which, from being feated within the cavity of the fcrotum, may be termed the encyfted hydrocele of the fcrotum. Of this there are two varieties, the hydro- cele of the tunica vaginalis teftis, and that fpecies of tumor formed by water colleaed in the fac of a her- nia. SECTION III. Of the Hydrocele of the Tunica Vaginalis Tejlis. HEN treating of the anatomy of thefe parts, I had occafion to remark, that, in a ftate of health, an aqueous fecretion is always found in the tunica vaginalis ; the principal ufe of which feems to be, to lubricate, and keep the furface of the tefticle foft and eafy. In a ftate of health, this fluid is abforbed by the lymphatics of the part, its place being fupplied by a frefh fecretion ; but, in difeafe, it frequently happens, either that the fecretion of this fluid is morbidly in- creased, or the powers of the abforbing veffels of the part are diminifhed. The effea of either of thefe caufes muft be, to induce a preternatural colleaion in the cavity cf the vaginal coat; and thus the variety o: hydrocele h produced that we are now to confider. The fvmptoms induced by it are thefe : a foft col- ourlcfs tuuior is at firft perceived at the inferior point w 48 On the Hydrocele. Chap. XTIVv of the tefticle ; chiefly remarkable when the patient k erea : it excites no pain, and it does not become lefs- by preflure. The fhape of the tumor is at firft nearly globular; but it afterwards becomes pyramidal, being larger below than above : as it advances in fize, it be- comes proportionally more tenfe, and the natural ru- gee of the fcrotum lefs perceptible. For a confidera- ble time', it does not extend farther than the ufual boundaries of the fcrotum; but, on longer continu- ance, it advances to the abdominal mufcles : fo thaty although in the early periods of the difeafe, the fper- matic cord may be diftinaiy felt; in its more advanc- ed ftate, it is net eafily diftinguifhed. Before arriving at this height, the weight of the tu- mor is for the moft part confiderable, by which the fkin of the contiguous parts is dragged fo much down- wards, as to make the penis fhrink confiderably, and fometimes difappear almoft entirely. In this advanc- ed ftate of the difeafe, the tefticle, which ufually lies at the back part of the tumor, and which, for fome time after its commencement, could be diftinaiy felt, is not fo clearly difcovered. On minute examination, however, a hardnefs may always be felt along that part of the fcrotum where the teftis is fituated ; and at this point, preffure excites fome degree of uneafinefs. In a great proportion of cafes, the fluauation of a fluid is obviouily difthv.a'h'heef on preffure. It fome- times happens, however, in that tenfe ftate of the tu- mor, ufually produced by a long continuance of the difeafe, that the fluid contained in it is not evidently difcovered : nor, in this fituation, is the ordinary cha- ncier: ftic m?:rk of hydrocele more to be depended on ; I mean the tranfparency of the tumor, when ex- pofed to the light of a candle, or of the fun. In the early ftages of the difeafe, when the contents of the tumor are not difccloured, and the vr.-;inai coat has not acquired much thicknefs, the fluid contained in it, on being expofed to this trial, ufually app^rrs trans- parent ; and, in meeting with this, we neceffarily con- Sea. III. On the Hydrocele. 49 fider it as a corroborating proof of the exiftence of ferum. The abfence, however, of this, is not a proof of the contrary; for, as the tranfparency of the tu- mor 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 effea, inval- idate the certainty of the teft. During the whole continuance of the difeafe, the patient does not complain of pain in the tumor itfelf; but fome uneafinefs is commonly felt in the back, by the weight of the tumor on the fpermatic cord. This, however, is generally prevented entirely, or much al- leviated, by the ufe of a fufpenfory bandage. Thefe are the ufual appearances of a hydrocele when confined to one fide of the fcrotum. In fome inftan- ces, however, we meet with a double hydrocele, when the tumor occupies the cavities of both tunicae vagi- nales, and inftead of being confined to one fide of the fcrotum, extends equally over the whole of it. As this variety of hydrocele is fometimes confound- ed with other difeafes, it is particularly neceffary to hold fuch circumftances in view, as moft certainly tend to charaaerize and diftinguifh them. Thefe dif- eafes are, all the varieties of fcrotal herniae ; the ana- farcous hydrocele of the fcrotum ; the encyfted hy- drocele of the fpermatic cord ; the farcocele, or fchir- rous tefticle ; and the hernia humoralis, or inflamed teftis. In the hydrocele of the tunica vaginalis, the tumor begins at the bottom of the fcrotum, and proceeds flowly upwards. It is of a fmooth equal furface. In a great proportion of cafes the fpermatic cord is felt at the upper part of it, and the fluauation of a fluid is diftinguifhed through its whole extent. Preffure does not make the fwelling recede, nor is it affiled by the pofture of the patient, if it be not on its very firft approach ; whereas, in hernia, befides pain, fick- Vol. III. E 50 On the Hydrocele. Chap. XXIV. » nefs, and other affeaions of the ftomach and bowels which commonly take place, the tumor begins in the groin, and only at laft proceeds to the fcrotum. It has not the pyramidal form of a hydrocele. ^ It is fre- quently foft and compreffible, giving a fenfation fimi- lar to what we receive from preffure upon dough ; but no equal or diftina fluauation is perceived in it. In moft inftances, the tumor can be made to recede, ei- ther altogether or in part, by moderate preffure, and putting the patient in a horizontal pofture; and in hernia descending to the fcrotum, the fpermatic cord can never be clearly diftinguifhed. However improbable it may appear, this variety of hydrocele has, in fome inftances been confounded with anafarcous tumors of the fcrotum ; but the means of diftinaion are fo evident, from the hiftory which I have given of the two difeafes, that it is not here ne- ceffary to enter farther upon the fubjea. It muft, in- deed, be grofs inattention only that can ever make the anafarcous hydrocele be miftaken for any other difeafe. From the encyfted hydrocele of the fpermatic cord, it may commonly be diftinguifhed by the tefticle in the latter being plainly felt at the under part of the tumor; whereas, in this difeafe, the teftis is feldom diftinaiy perceived if it be not at the back part of the tumor. In two cafes, I have met with the tefticle on the anterior part of a hydrocele ; and, in a third, al- though fixed behind in its ufual fituation, it alfo ad- hered at one point to the middle and anterior part of the tunica vaginalis. This I fufpeaed to be the effea of inflammation, induced either by hernia humeralis or fome other difeafe ; and on inquiry, it appeared that the patient at one time had been long confined with inflammation of this tefticle, the effea of a bruife. In the encyfted hydrocele of the cord, the tumor firft appears above the tefticle, and by degrees falls downwards j while the very reverfe happens in the hy- Sea* III. On the Hydrocele. 51 • drocele of the tunica vaginalis, in which the tumor at firft always forms below, and from thenee proceeds upwards. In a few inftances, thefe two varieties of hydrocele have been known to exift at the fame time in the fame patient. In this cafe the ferum, although colleaed in two diftina cyfts, gives the appearance of one uniform tumor ; and a fluctuation is diftinaiy felt from one end of it to the other. But, in any inftance that I have feen of this combination, the tumor has been fomewhat contraaed, having rather a lefs diameter at that part where the two colleaions are feparated from each other j fo that, where this appearance takes place, we may, in general, fufpea that the ferum is collea- ed in two diftina bags. This, however, does not al- ways happen ; for occafionally I have met with this appearance where the difeafe was fixed in the.tunica vaginalis alone. The circumftances which moft clearly diftinguim hydrocele from a fchirrous tefticle are thefe: in the latter the fwelling is hard; it does not yield in any degree to preffure; the furface of the tumor is com- monly rough and unequal; it is in general attended with a good deal of pain, and is always heavy in pro- portion to its fize: whereas, in hydrocele, the fwell- ing commonly yields to preffure ; its furface is fmooth ; little or no pain takes place; and the tumor is light in proportion to its bulk. Thefe differences will always ferve as a fufficient means of diftinaion between this fpecies of hydrocele and a pure unmixed farcocele. But when a fchirrous tefticle is combined with an effufion of water into the tunica vaginalis, forming what has very properly been termed a hydro-farcocele, the means of diftinaion are not fo obvious. In the incipient ftate of thefe eftu- fions, the difference between the two difeafes is fuf- ficiently apparent; but, when far advanced, the moft attentive obferver often finds it difficult, and fometimes e 2 52 On the Hydrocele. Chap. XXIV. impoffible, to mark the diftinaion. In fuch doubtful cafes, however, by proceeding in the cautious manner to be afterwards pointed out, no detriment will occur to the patient, from any uncertainty that may take place. From the hernia humeralis, 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 affeaion of the urethra.* The fkin is more or lefs aflfeaed with an inflammato- ry rednefs; it is attended with much pain, efpecially on being handled, and the tumor is hard and firm, fo that no fluauation is felt in it, unlefs in its more ad- vanced ftate, when fuppuration fometimes, although rarely, takes place between the fcrotum and tefticle; in which cafe, the ufual fymptoms of abfcefs, particu- * larly the pointing of the tumor, and its being much difcoloured, ferve to diftinguifh it. In forming a prognofis of this difeafe, we fhould be chiefly direaed by the habit of body of the patient. In a great proportion of cafes we are to confider it as a local affeaion; and, in this ftate the moft favoura- ble expectations may be formed of it. For, whatever may have been alleged by fome, of the hazard of eve- ry operation for a radical cure, in a fimple unmixed hydrocele, if the conftitution is not very unhealthy, it may at all times be advifed with a very fair profpecl of fuccefs. In the radical cure of the hydrocele, in whatever way it is done, fome pain will be excited ; the parts will inflame, and of courfe fome degree of fever will take place. In fome inftances, thefe fymptoms have gone rather farther than was wifhed for; but, under the limitations I have mentioned, of an unmixed ftate * The operation of lithotomy is frequently attended with an inflamma- tion of one, and fometimes of both teftides; probably from the inflam- mation induced by the operation in the neighbourhood of the caput gal- linaginis, being communicated along the vas deferens to the teftis. Sea. IIL On the Hydrocele. 53 of the difeafe, in a conftitution otherwife healthy, the operation I fhall prefently defcribe, when properly performed, and the cure thereafter rightly conduaed, never fails of the moft complete fuccefs, while, in no inftance, has it ever, in the courfe of my experience, proved fatal. But, on the contrary, in conftitutions otherwife dif- eafed, in very aged people, and in infirm habits of body, we are by no means to expea fuch certain fuc- cefs : even in fuch circumftances, however, the opera- tion often fucceeds. I have, in various inftances, per- formed it under one or other of thefe difadvantages, and I never knew it fail. Others, however, have found that it has done fo ; and it may readily be fup- pofed, when praaifed upon the old, infirm, and dif- eafed, that the fymptomatic fever may run too high for the ftrength of the patient; and that the fuppura- tion produced by a high degree of inflammation, may afterwards tend to deftroy the remains of a conftitu- tion already greatly impaired. This, however, fhould not be laid to the account of the operation, but to the impropriety on the part of furgeons, in advifing it in patients already perhaps in danger with other difeafes. In fuch circumftances, no operation fhould be per- formed, and the patient fhould be defired to trufl en- tirely to a proper ufe of a fufpenfory bandage. In judging therefore of the event of a hydrocele, I would fay, that in conftitutions fuch as the operation fhould be advifed in, fcarcely any danger is to be dreaded; while, on the contrary, in the infirm, and efpecially in fuch as are otherwife unhealthy, that fome rifk will occur from any operation we can pro- pofe, and that the dagree of rifk will be nearly in pro- portion to the nature and extent of that difeafe with which the conftitution is affeaed. As long as a hydrocele keeps within moderate lim- its, patients in general, rather fubmit to the inconve- nience than undergo the pain of an operation ; at leaft this is commonly the cafe with people of rank, who 54 On the Hydrocele. Chap. XXIV. can more readily fubmit to any diftrefs which it ex- cites, than patients of a poorer clafs, whofe labour is frequently impeded by the fize of the tumor. At laft, however, by its bulk, it excites in all a ftrong defire to have it removed ; for, befides the defire naturally implanted in all mankind, to be found and entire in thefe parts, the water colleaed in a hydrocele, is, in fome inftances fo very confiderable, as to be the caufe of much inconvenience. When, from timidity, or any other caufe, the operation has been too long delayed, I have known the tumor become fo large, as in courfe of time to cover a confiderable part of each thigh, and in length to extend from the groin to the knee. Various methods have been propofed for the cure of hydrocele ; all of which, however, may be reduced to two : fuch as have in view only a temporary relief, and which is therefore termed the palliative cure; and fuch as are meant to effea a radical cure, or a final removal of the difeafe. Whatever advantages may be experienced from the ufe of internal medicines, in dropfy of the conftitu- tion, no praaitioner, I believe, has fo much confidence in remedies of this clafs, as to expea much advantage from them in encyfted dropfy of any kind. We have daily proofs of their failure in partial hydropic collec- tions, wherever they are feated ; and in none more frequently than in the hydrocele. We are told, indeed, of this difeafe being cured by different medicines, particularly by the ufe of draftic purgatives ; but, although I have often known them employed, it was never with any advantage, and, when pufhed to any extent they are fur? to do harm. As it is always proper, however, to confine the pa- tient to bed for fome time after any operation of im- portance, in order to prevent him from being after- wards difturbed, his bowels fhould be emptied by a purge immediately before any operation for the radi- cal cure of a hydrocele is performed ; but this is al- moft the only way in which purgatives can here prove Sea. III. On the Hydrocele. $$ ufeful. Internal medicines, therefore, being found in- effeaual and we know of no external applications to be depended upon, we are to feek for that relief from furgery which experience fhows it never fails to afford. When the tumor in the fcrotum has become fo large as to be inconvenient from its fize, if the patient either refufes torfubmit to the operation for a radical cure, or if his ftate of health renders that operation improper, in fuch circumftances, the palliative treat- ment, or a mere evacuation of the water by punaure, is the only means we can employ. Two methods are propofed for drawing off the wa- ter in this manner ; by the punaure of a lancet, and piercing with a trocar. By fome it is alleged, that by the punaure of a lancet the water can neither be fo completely or fo properly drawn off as with a trocar; for the orifice in the fkin being apt to recede from the opening in the tunica vaginalis, the water is thereby either ftopt altogether, or it is apt to infinifate into the furrounding parts. By others again, it is faid, that the difficulty of introducing the trocar is fuch as to render it hazardous from the contiguity of the tefti- cle ; and inftances are not wanting to fhow, that even in the hands of expert furgeons, the teftis has been much injured by a trocar reaching it in this operation. Indeed the ordinary triangular form of this inftru- ment makes it both difficult and unfafe to introduce it; but the trocar, of a flat form, an improvement which I propofed a good many years ago, enters with as much eafe as a lancet. This inftrument is repre- fented in Plate LXVII. fig, 4. and in Plate LXX1II. fig. 2. another form of the trocar is delineated, with either of which, an opening may be made in the tu- nica vaginalis with perfea fafety, and the water with this inftrument being much more freely drawn off than with a lancet, by which effufions are often pro- duced into the cellular fubftance of the fcrotum, the ufe of a lancet for this purpofe fhould therefore be laid afide. $6 On the Hydrocele. Chap. XXIV, The inftrument being fixed on, the next point of importance is the part of the tumor in which' the punaure fhould be made. Even in this fimple ope- ration, an acquaintance with the anatomy of the parts proves ufeful. The teftes, as I have endeavoured to fhow, do not hang loofe in their vaginal coats ; be- ing, on the contrary, firmly attached to them behind. Hence at this part, even in the largeft hydrocele, no fluid is met with ; fo that if, through ignorance or in- attention, the trocar fhould be inferted here, one in- ftance of which I have feen, the inftrument would pierce the btfdy of the teftis, while it would not leffen .the tumor, as it would not reach the cavity of the va- ginal coat in which the fluid is colleaed. The trocar mould be introduced in the anterior and moft depend- ing part of the tumor. The patient being feated in a chair, or on a table, with the fcrotum hanging over the edge of it, the operator, with his left hand, fhould grafp the tumor behind, in fuch a manner as to pufh the contained fluid as much as poffible into the anterior and under part of it. This being done, if a common round tro- car is ufed, a fmall opening about a quarter of an inch in length fhould be made through the fkin, with the fhoulder of a lancet, on that point where the trocar is to enter ; but with a flat trocar this precaution of pre- vioufly dividing the fkin is unneceffary. The opera- tor now takes the trocar in his right hand, and hav- ing fixed the head of it in the palm of his hand, he places the forefinger along the courfe of it, leaving as much of the point of the inftrument uncovered as may freely penetrate the tunica vaginalis ; and this being pufhed in, the flilette fhould be withdrawn immedi- ately on the end of the canula having entered the cyft. The water will now run off; and, if the tumor is not uncommonly large, it may be all drawn off at once ; but when the fwelling is large, as the hidden difcharge of the fluid, by taking away too quickly the fupport which it gave to the veffels of the teftis and vaginal Sea. III. On the Hydrocele. 57 coat, might endanger the rupture of fome of them, it is better from time to time to flop 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 applied to the orifice ; and a comprefs of foft linen being laid over the fcrotum, the whole fhould be firmly fupported, either with a well adapted fufpenfory, or a proper application of the T bandage.* The patient being in this ftate" laid in bed, all kind of uneafinefs is, in a few minutes, commonly gone, and he goes about his ordinary bufmeflpftrithout inter- ruption. In a few inftances, however, it has happen- ed, either from the external air finding accefs to the tefticle, or from the fore produced by the trocar be- coming inflamed, that the whole body of the tefticle has been feized with inflammation, by which a radical cure of the difeafe has been obtained. This, howev- er, is a rare occurrence, and hardly to be looked for. About four years ago, the public was favoured with fome obfervations on this difeafe by Mr. Keate, of London, in which fome cafes are related of hydrocele being cured by the external ufe of a flimulating ap- plication, a ftrong folution of fal ammoniac in vinegar and fpirit of wine. The following is the formula em- ployed by Mr. Keate: 5>. Sal. ammoniac, in pulv. trit. ^ i. Acet. fpirit. vin. rea. fing. ^ iv. A quantity of foft old linen, well moiftened in this, is defired to be folded round the fcrotum, to be fup- ported with a fufpenfory bag, and renewed three times a day : but, although I have given this method a fair trial in upwards of twenty cafes, in fome while the cyft remained diftended, and in others immediately after the water was drawn off, I have not been fo for- tunate as to fucceed. In fome, the application of dif- * Some very judicious remarks, on the importance of a due compref- fron in fuch cafes, may be nret with in remarks upon this fubjecSt, in the works of the late Dr. Monro. 58 On the Hydrocele. Chap. XXIV. ferent ftimulants and aftringents after the operation of tapping, has appeared to prevent the colleaion from returning fo quickly as it otherwife might have done; but even this has not been frequent, and in no in- ftance, in the courfe of my obfervation, has it produ- ced a cure. With the fame view, I have employed a variety of ftimulants and aftringents, fuch as volatile liniment, prepared with fix parts of oil, one of camphor, and one of fpirit of hartfhorn; tinaure of cantharides; the fleams of vinegar ; poultices of vinegar and crum of bread ; ancf compreffes of linen, foaked in brandy: and the praaice being neither attended with difficulty or hazard, I mean to continue it till farther experi- ence fhows, whether it fhould be retained or not. That it will often prove fuccefsful in removing a hy- drocele, by promoting the abforption of the fluid con- tained in the tunica vaginalis, is fcarcely to be ex- peaed ; but we may reafonably fuppofe, that ftimu- Iating applications, capable of exciting inflammation in the teftes, may accomplifh a cure, after the water has been drawn off with a trocar. Drawing off the water with a trocar is an operation eafily performed, and it very feldom does harm ; but when not done with caution, efpecially when the pa- tient is allowed to walk or ride foon after the water is taken away, it fometimes ends in very troublefome fymptoms. If the habit of body is bad, this will hap- pen with whatever attention it may be done. Of this every praaitioner may have met with inftances ; and two are related by Mr. Pott, one of which terminated fatally, and gangrene enfued in the other, which, in a few days, deftroyed not only a good deal of the fcro- tum, but even a confiderable portion of the tunica va^ ginalis.* Both of thefe, indeed, occurred in very unhealthy conftitutions ; but it is proper to have it known, that even this operation may, in certain hab- Cafes iii. and ixii. Trtatife on the Hydrocele. Sea. HI. On the Hydrocele. 59 its of body, be produaive of very diftrefsful confer quences. Drawing the water off in this manner, in order to give relief from the bulk and weight which it produ- ced, would probably be the firft idea that occurred to praaitioners in the treatment of hydrocele ; but be- ing found inadequate to the complete removal of the difeafe, various other methods were afterwards intro- duced. The aaual 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 difeafe. Celfus advifes the cyft of a hydrocele to be cut away, and many of his followers do the fame. Tents, both folid and hollow, were afterwards employed; as was like- wife the ufe of the feton, which we find recommended by Fabricius ab Aquapendente, and other writers, even of a more early period. Various applications, of the cauftic kind, have at different times been in vogue : injeaing wine, diluted ardent fpirits, and oth- er irritating liquids, into an opening in the vaginal coat, has been propofed, as a means of inducing a de- gree of inflammation fufficient for effeaing a radical cure ; and a fimple incifion of the cyft containing the water, has been praaifed for the fame purpofe. Thefe are the means which, at different periods, have been employed for the cure of hyorocele. Ancient praai- tioners 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 re- medies aaed in effeaing a cure. In confequence of this, they were applied at random y and none of them proving in general fuccefsful, the ignorance they la? boured under in the theory of the difeafe, made them frequently propofe varieties in the method of cure. The moderns poffefs onfi important advantage over the ancients, from knowing that the water in hydro- cele is contained in a particular cyft having no imme- 60 On the Hydrocele. Chap. XXIV. diate communication with any other part or cavity of the body, and from finding that this difeafe refembles, in many refpeas, other encyfted tumors, with the means of curing which they are well acquainted. Both in encyfted tumors and hydrocele, the con- tents of the fwelling are fecluded from the external air. Neither of them have any communication with any other part of the body ; and, although the bag containing the matter of an encyfted tumor, is in fome meafure, a new formation, yet in many inftances, it is found to be equally firm and elaftic with the tunica vaginalis teftis. • In the treatment of encyfted tumors, praaitioners are now agreed, that befides evacuating the matter, means muft be employed for deftroying the cavity which contained it, otherwife it will collea again. To accomplifh this, different methods have been propof- ed ; fome with a view to deftroy entirely the cyft which contained the matter, and others, as it is faid, to fill up the cavity, by a formation of new part$. But we know, that unlefs the coats of a cyft are much extended, hard, or greatly thickened indeed, no part of it fhould be removed. It is*alfo known, that to fill up the cavities of tumors with a formation of new parts, is a mere imaginary thing, being what neither nature or art can do to any extent; and we likewife know, that the cavity of every tumor may be more effeaually deftroyed by producing an adhefion of its fides, than by any other means. Parts of the human body, in a ftate of inflamma- tion, very readily adhere together. So eafily indeed do they do fo, that fome art is required to prevent the adhefion of contiguous inflamed parts, of which every praaitioner muft have met with examples. Hence, abfceffes and encyfted tumors are more eafily cured by exciting inflammation over their internal furfaces, after their contents are ev2fcuated, than by any other means ; and, in like manner, it is now known, that the hydrocele of the tunica vaginalis may be treated Sea. III. On the Hydrocele. 61 upon the fame principles, and with the fame general effeas. This is the moft fimple idea that can be given of the praaice that fhould be kept in view in the cure of hydrocele ; and I hope it will ferve to render it clear and intelligible. The intention, then, of every means now in ufe for the radical cure of this fpecies of hydrocele, is, to in- duce fuch a degree of inflammation on the parts in which it is feated, as may tend to obliterate entirely the cavity of the tunica vaginalis, by making it ad- here firmly to the tunica aibuginea, the furface of the tefticle. Some individuals, indeed, ftill proceed upon the fuppofition of a total deftruaion of the fac being ne- ceffary for a complete cure ; but extenfive experience now makes it evident that this is not the cafe. When the fac has become unufually thick or hard, it proves fometimes ufeful to remove thofe parts of it that are particularly difeafed; and when it has been diftended to fuch a degree as entirely to have loft its tone, re- moving a part of it may forward the cure, by allow- ing the fcrotum to contraa more readily ; but it hap- pens fo feldom from any of thefe caufes, that I have only met with a very few inftances, in which it ap- peared neceffary to remove any part of it. A cure may indeed be obtained of this variety of hydrocele, by removing the fac entirely ; for the contiguous parts from which it is cut away, readily adhere together, fo as to deftroy the cavity in which the fluid was con- tained ; but what I wifh to have underftood, is, that we are not to confider it as neceffary, as the fame end may be obtained by much more lenient meafures. I fhall now proceed to fpeak more particularly of the feveral means at prefent moft frequently employ- ed by praaitioners for effeaing a cure, and fhall treat moft minutely of thofe now in general ufe. Thefe are, excifion of the tunica vaginalis; the application of cauftic; the ufe of a feton; a fimple incifion of 62 On the Hydrocele* Chap. XXIV.- the fac; and injeaing wine and other acrid liquors into the tunica vaginalis, after drawing off the fluid which it contained. The method of cure, by removing the vaginal coat, which was well known to the ancients, had nearly fallen into difufe, when it was revived by the late Mr. Douglas of London ; and by a few praaitioners it is ftill continued. The method of doing it is, firft to diffea out an oval piece of the fcrotum, which Mr. Douglas confiders as always neceffary ; and having then laid the vaginal coat open, to cut it away by dif- ferent fnips with fciffars. But, whoever may contin- ue to think favourably of the excifion of the fac, will find, that it may be more eafily done with a fcalpel than with fciffars ; and it can feldom or never be ne- ceffary to remove any portion of the fcrotum. As much danger might enfue from the incifion be- ing carried too near to the tefticle, all the pofterior part of the fac, or that part of it by which the tefticle is Conneaed to the fcrotum, fliould be allowed to re- main. On the fac being removed, the parts muft be dreffed, and treated in every other refpea in the fame manner as in the operation with the fimple incifion to be hereafter defcribed. The cure by cauftic has commonly been conduaed as follows : the fcrotum being fhaved, a piece of com- mon pafte cauftic, properly fecured with adhefive plaf- ter, is applied, of about a finger's breadth, the whole length of the tumor ; and if, on removing the cauftic, it has not penetrated the tunica vaginalis, an opening is made in it with a fcalpel, fo as to evacuate the con- tents, lay bare the tefticle, and admit of proper dreff- ings. But Mr. Elfe, one of the lateft writers in favour of the method-of cure by cauftic, fays, that there is no neceffity for fuch an extenfive application of cauftic as many have recommended ; that an efchar, of the fize of a fhilling, is fufficient; that this may be always fully obtained by the application of cauftic pafte, of Sea. III. On the Hydrocele* 63 the fize of a fixpence, which he direas to be laid up- on the anterior and under point of the fcrotum, and to be properly fecured by adhefive plafter, in order to prevent it from fpreading.* The cauftic commonly produces all its effeas in the fpace of five or fix hours, and may then be re- moved. At this time, digeftives, or an emollient poul- tice, muft be applied over the fcrotum ; and the whole properly fufpended with a bandage. Inflammation, Mr. Elfe obferves, is foon induced over the whole tunica vaginalis ; and the febrile fymp- toms that fucceed, he advifes to be kept moderate by bloodletting, injeaions, emollient poultices, and a low regimen. In a few days, the efchar of the fcrotum feparates, and comes away; and, in a gradual man- ner, in the courfe of four, five, or fix weeks, the whole tunica vaginalis comes off, when the wound, for the moft part, foon heals, and a complete cure is obtained* In the cure of the hydrocele by the feton, the fol- lowing is the method of applying it, as advifed by the late Mr. Pott, who wrote a full and ingenious treatife on the fubjea : he ufed a trocar; a filver canula, five inches in length, and of fuch a diameter as to pafs ea- fily through the canula of the trocar ; and a probe, fix inches and a half long, having, at one end, a fine fleel trocar point, and at the other, an eye, which car- ries a cord of coarfe white fewing filk, of fuch thick- nefs as to 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 withdrawn, and the water difcharged, the feton canu- la is paffed through that of the trocar, till it reaches the upper part of the tunica vaginalis, and is felt in the fuperior part of the fcrotum. This being done, the probe, armed with its feton, is to be conveyed through the latter canula, the vaginal coat and tegu- ■ * Vide An Eflay on the cure of the hydrocele of the tunica vaginalis tefti6, by Mr. Elfe, ad edit. p. 33. 64 On the Hydrocele. Chap. XXIV* ments to be pierced with the point of it, and the feton to be drawn through the canula, till a fufficient quan- tity is brought out at the upper orifice, when both canulas are to be withdrawn, and the operation is fin- ifhed* About the end of the third day, the parts begin to inflame ; when fomentations, poultices, a fufpenfory bandage, a temperate regimen, and a lax belly, are ordered, to keep the fymptoms moderate. As foon as the parts become eafy, by the inflammation leffen- ing, 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 dreffing ; the dreffings, confifting of nothing more than a fuperficial pledget on each orifice, and a difcutient cerate, fuch as the ce- ratum faturninum, to cover the fcrotum. In the treatment of the hydrocele with a feton, I fhould wifh to follow Mr. Pott's method, in every cir- cumftance but the mode of introducing it, which is rendered unneceffarily complex, by the number of in- ftruments propofed for it. In Chapter I. I have de- fcribed the manner of opening abfceffes with a feton, and the direaions then given prove equally applica- ble here. Let an opening be made with a fcalpel, a large lan- cet, or fharp pointed biftoury, in the fuperior part of the tumor, large enough to admit, with eafe, a cord, confifting of about thirty threads of common white fewing filk. A direaor, with an eye at one end, Plate CXIII. fig. 3. in which the cord is inferted, is to be introduced at this opening ; and its farther ex- tremity being carried down to the moft depending part of the tumor, an opening is there to be made, half an inch in length, by cutting on the direaor with the bif- toury. The direaor being now drawn down till a fufficient quantity of filk is left hanging out below, the operation is in this manner finifhed. In every other refpea, the management of the feton fliould be the fame with the method defcribed above from Mr. Pott; Sea. III. On the Hydrocele. 6$ or, inftead of introducing the cord with a direaor, it may be done with a filver canula and perforator, re- prefented in Plate CXIII. fig. i. 2. and 4. By making the firft opening in the upper part of the tumor, the inftrument conduaing the feton is more eafily introduced along the courfe of it, than when the firft opening is made below; for, in this cafe, the tu-> mor remains diftended to the laft : whereas, when op- ened below, the contents rulh out immediately; and the vaginal coat collapfes fo much about the tefticle, that I have known' it difficult to get the inftrument infinuated between them, by which the teftis has, in different inftances, been injured ; and, by making the under opening half an inch long, any matter which forms in the courfe of the cure is eafily and readily difcharged : whereas, in Mr. Pott's method of opera- ting, where the opening is not larger than the fize of the trocar, as this is completely filled by the cord, the matter is thereby allowed to colka; an incifion be- comes neceffary, to difcharge it; and thus the patient is expofed to pain and difappointment, as I have feen in various inftances, where the precaution I have men- tioned has been omitted, of making the opening at the moft depending part of the tumor fufficiently large for difcharging any matter that may form. Before entering farther into the confideration of the method of cure by the feton, I fhall proceed to defcribe the operation for a radical cure, by incifion. The patient being laid upon a table of convenient height, and properly fecured by affiftants, with the fcrotum lying nearly on the edge of the table, the op- erator, with one hand, fhould grafp the tumor behind, fo as to hold it firm, and make it fomewhat tenfe on the anterior part of it: with a round edged fcalpel in the other, he fhould now divide the external teguments by one continued incifion from the upper end of the tumor, all along its anterior furface, down to the moft depending point of it. Vol. III. F 66 On the Hydrocele. Chap. XXIV, If the incifion has been properly made, the divided fcrotum will retraa, and the tunica vaginalis will be laid bare, for the breadth of about half an inch over its whole length. An opening is now to be made in the vaginal coat, juft at the upper end of the tumor, where the firft incifion commenced, and it may be done either with a lancet, or fharp pointed biftoury, or a fcalpel. This opening fhould be of fuch a fize, as freely to receive the finger of the operator ; which, being inferted, a probe pointed biftoury is to be con- duaed upon it, and the fac divided to the very bot- tom, direaiy in the courfe of the firft incifion. By the previous divifion, of the fkin, with the fcalpel in- ftead of the biftoury, the operation is done with more accuracy, and lefs pain ; for the fcalpel, from its con- vexity, admits of a finer edge than an inftrument of any other form is capable of receiving, and hence it cuts with more eafe. By making the incifion of the teguments and tuni- ca vaginalis together, as in fome inftances I have feen done, the operation may be fomewhat fhortened; but the time gained by it is not more than a fecond or two, while the incifion is apt to be ragged and une- qual : for, when done in this manner, particularly if the tunica vaginalis is firft opened in the moft depend- ing p artof i:, as fome have advifed, the parts cannot be kept fufficiently tenfe for completing the incifion. I have defined, that the firft opening in the vaginal coat may be fo large, as eafily to receive the finger of the operator, which ought to be pufhed in behind the biftoury, without withdrawing the inftrument, as is commonly done. In this manner, we fhorten the op- eration, and, by giving a free vent to the fluid contain- ed in the fac, we prevent it from fpreading and form- ing vefications in the cellular fubftance of the vaginal coat, and contiguous part, as it is apt to do when the opening in the fac is too fmall. .By making the firft opening in the upper end of the fac, much trouble and inconvenience is prevented, which always occur from Sea. III. On the Hydrocele. 67 making it below. For, as I have before remarked, when the tumor is firft opened below, the water is in- ftantly difcharged ; and, as this is followed by an im- mediate collapfe of the tunica vaginalis, the direaion in which it fhould be cut is not afterwards eafily dif- covered ; whereas, by making the firft opening above, as the water is thereby gradually emptied on the open- ing being carried downwards, the vaginal coat contin- ues diftended at the bottom, till the whole is finiffied. With a view to fave fome pain to the patient, the late Mr. Hunter advifed the incifion, both of the fcro- tum and tunica vaginalis, to be only two-thirds of the length of the tumor; and others have thought even that one half of this is fufficient. But the difference of pain between incifions of thefe different lengths is inconfiderable, and not to be regarded when compar- ed with the effeas that refult from them. When the incifion is carried the full length of the tumor, the operation fucceeds in every inftance, if the fubfequent part of the treatment meets with due attention ; where- as 1 have known various inftances of thefe partial openings being followed with a return of the difeafe. It is particularly proper to carry the incifion of the tunica vaginalis, down to the moft depending point of the tumor; otherwife the contents of the fac will not be completely difcharged, while room will be given for colleaions of matter during the cure. It is alfo proper to remark, that, in making this incifion of the fac, it ought to terminate at fome diftance from the teftis ; for I have, in different inftances, obferved, where the vaginal coat has been cut near to the tefti- cle, that the inflammation was particularly fevere. The incifion being completed, the tefticle covered with its tunica albugina, is brought fully in view. In fome inftances, the teftis protrudes from the furround- ing parts; in which cafe, it fhould be immediately re- placed, and covered as quickly as poffible from the air; and if no part of the tunica vaginalis is to be re- F 2 68 On the Hydrocele. Chap. XXIV. moved, the dreffing may be finifhcd dircaiy on the fac being opened. Unlefs the fac is difeafed, or fo much diftended as entirely to have loft its tone, no part of it, as I have obferved above, fhould be removed: but.when har- dened to the firmnefs of cartilage, as I have more than once feen, as, in this ftate, it is apt to excite pain when applied to the tender furface of the teftis, it ought undoubtedly to be removed ; and as, in this ftate, it commonly feparates with eafe from the fur- rounding cellular fubftance, it is eafily and quickly cut away with a fcalpel or biftoury. The removal of any portion of the fac from the mere enlargement of the tumor, can feldom be neceffary ; not once in fifty inftances. Hitherto I have been fuppofing that the difeafe is confined to one fide of the fcrotum ; but, in fome in- ftances, as I have remarked above, we meet with a hydrocele in both fides at once. In this cafe, the common praaice is, to do the operation twice in all its parts, both in the fcrotum and tunica vaginalis, by laying each colleaion open, from top to bottom, by a double incifion. Some advife both operations to be done at the fame time; but, in general, praaitioners are afraid of too much inflammation being induced by this ; fo that one fide is commonly allowed to heal before the other is opened. In this manner, the pa- tient is expofed to delay, uncertainty, and to the con- finement arifing from twro operations. This, however, is not neceffary, as the operation may be done on both fides at once, with little more pain, and, fo far as I have feen, with no more hazard, than in the ufual method of doing them feparately. The method in which I have done it is this : After finiihing the operation on one fide, an open- ing is made into-the vaginal coat of the opnofite tefti- cle, at the upper end of it, through the iVptum fcro- ti; and the incifion being- carried down to the bottom of the tumor, the cyft is thus equally well laid open, Sea. III. On the Hydrocele. 69 the ferum is as completely difcharged, and the difeafe is not more liable to return, than by doing the opera- tion in the ufual manner, and at different times. Whether the hydrocele is double, or confined to one fide, as foon as the incifion is finifhed, if the tef- tis is found, the wound fhould be quickly dreffed ; and, I think it right to obferve, that, on the manner in which this is done, much of the fuccefs of the ope- ration at all times depends, more indeed than is com- monly imagined. If the vaginal coat is merely wrapped about the tef- ticle, without the interpofition of dreffings, or, if the divided fides of it are immediately united with futures, as fome have advifed, partial adhefions are apt to take place, before a degree of inflammation is produced over the whole, fufficient for rendering the cure com- plete. In this manner, cavities are left, which either fill with pus during the cure, and require to be laid open, or they afterwards give rife to colleaions of fe- rum, and thus occafion a return of the difeafe, differ- ent inftances of which have fallen within my obferva- tion. And, again, the praaice of fluffing the cavity of the fore with dreffings, is alfo a frequent caufe of mifchief. By rubbing, or preffing upon the furface of the teftis, fuch a degree of inflammation is fome- times induced, as excites much pain, inflammation, and fever. But this is almoft always the fault of the operator; for, in a great proportion of cafes, if the dreffings are properly managed, no violent fymptoms ever occur. After having tried various ways of dreffing the parts, the method I have now long purfued, and which in no inftance I have found to fail, is this : the tefti- cle being properly placed in the newly divided fac, two pieces of foft old linen, exaaiy the length of the cut, previoufly dipped in a linament of wax and oil, are, by the help of a probe, inferted to the bottom of the fac, one on each fide of the tefticle, between it and the vaginal coat, care being taken to leave a fuf- 7o On the Hydrocele. Chap. XXIV. ficient quantity of each pledget hanging out of the wound, to admit of its being eafily withdrawn at the firft dreffing; otherwife, if the fwelling, which after- wards takes place, fhall be confiderable, they may, for fome days, be entirely covered, and even at laft re- moved with difficulty, as I have feen in different in*. fiances where this piece of attention has been omitted. If the tefticle has pufhed forward, and is with diffi- culty retained in its fituation, as it will be apt to flip out between the lips of the wound between one dreff- ing and another, no means fhould be omitted that can with fafety be employed for preventing it, as it cannot afterwards be fo eafily replaced ; and, from want of attention to this, I have known the tefticle entirely extruded from the fcrotum, and in one inftance, from fufficient pains not being taken to replace it, the cure was completed with the teftis in this fituation ; when, inftead of being covered with the vaginal coat and fcrotum, it was covered with fcarf-ikin only. The belt method of preventing fuch a misfortune, is, to draw the edges of the divided tunica vaginalis and fcrotum nearly together, after the teftis has been properly placed, and the pledgets of oiled linen in- ferted ; and, in this fituation, to fecure them, either with two or three futures, at proper diftances from each other, or with flips of plafter, fufficiently adhe- five for retaining them. This being done, the whole fcrotum is covered with a large pledget of faturnine cerate, or common wax ointment, by which the parts are kept much more foft and eafy, than when dreffed, in the ufual way, with dry lint, at the fame time that the dreffings are much more eafily removed. A cufhion of foft tow, with a proper comprefs, is placed over the pledget of ointment, and the whole are retained by the T band- age, or common fufpenfory bag. The patient is now carried to bed : a quieting draught fhould be given ; and he fhould be enjoined to remain as much as pof, Sea. III. On the Hydrocele. 7* fible in the fame pofture; for much motion at this period certainly does harm. The intention of this operation being to induce a moderate degree of inflammation in the tunica vagina- lis and furface of the tefticle, if the pain, inflamma- tion, and fwelling, which, in fome degree, always fuc- ceed, do not run to a great height, nothing is to be done for the firft two or three days after the opera- tion ; but, when thefe fymptoms become violent, and efpecially when much fever is induced, means muft be employed to leffen or remove them. The remedies we chiefly depend on, are bloodlet- ting, gentle laxatives, a low cooling diet, and warm emollient poultices and fomentations to the part, in order to forward a plentiful fuppuration, which com- monly tends to moderate every bad fymptom more effeaually than any other remedy. By thefe means, the inflammation is in general eafily kept within pro- per bounds; but where the mode of dreffing I have pointed out is adopted, they are not often required. In a great number of cafes, in which I have done the operation in this manner, I have only once found it neceffary to advife bloodletting, and very rarely fo- mentations or poultices. In moft cafes, the inflammation of the tefticle does not rife higher than in the fimple hernia humoralis from gonorrhoea ; and it gradually fubfides as the fup- puration advances. The abatement of the inflamma- tion is alfo affifted by continuing a cool diet, the oc- cafional ufe of opiates, and keeping the belly open. Often in two days, and always by the end of the third, I remove all the dreffings, except the pledgets inferted between the teftis and tunica vaginalis. This is one important advantage we derive from covering large fores with pledgets of ointment. The dreffings are eafily removed at any period; fo that, without waiting for a plentiful fuppuration, as is commonly done, the patient may, at any time, be relieved from that diftrefsful uneafinefs, of which all thofe complain 7 2 On the Hydrocele. Chap. XXIV. in whom the firft dreffings are feveral days in being taken away. They are always rendered ftiff and un- comfortable, by the blood difcharged upon them after the operation; and the matter at firft fecreted being thin and acrid, I have, in various inftances feen, when the dreffings have not been removed for fix or feven days, and in fome cafes even in lefs, that the whole contiguous parts have been excoriated by the acrimo- ny of the matter alone, and by which more uneafinefs has been induced during the courfe of the cure, than by any other circumftance conneaed with the opera- tion : nay, in fome, the inflammation induced in this manner has an obvious influence on that of the tefti- cle, and tends to render it much more fevere than it otherwife would be. On fome occafions, at the firft dreffing, and always at the fecond or third, the pledgets inferted between the tunica vaginalis and tefticle come away ; and when- ever this happens, they fhould be renewed. It is alfo proper to renew them daily, for the firft fourteen or fifteen days after the operation ; not, however, of the fame depth as the firft, as, during the latter part of the cure, it proves fufficient, if. they are merely infert- ed fo far as to prevent the divided edges of the tunica vaginalis from adhering to the tefticle before the ad- hefive procefs has taken place in the parts more deep- ly feated. To,this point, I muft obferve, the moft particular attention is neceffary; for, when this mode of operating fails, that is, when the difeafe returns, it is, almoft in every inftance, from this precaution be- ing overlooked. In my own praaice, the difeafe has not returned 1n a fingle inftance : but I have met with different cafes in which it has done fo, and in all of them from the caufe I have mentioned, to wit, the divided edges of the tunica vaginalis being allowed to adhere to the tefticle, before adhefion had taken place between the parts more deeply feated. In almoft every circumftance, the treatment of hy- drocele by this operation is the fame with what an- Sea. III. On the Hydrocele. 73 fwers beft in a common abfcefs. After opening an abfcefs, if the lips of. the newly divided parts are al- lowed too early to adhere, either to each other, or to the parts beneath, the operation will moft probably fall to be renewed, as matter will thus be allowed to collea, by which the patient will be nearly in the fame fituation as before ; while all manner of rifk of this is prevented, by the cut being kept open till the fides of the abfcefs adhere to each other. In like manner, we never fail in the cure of hydrocele, if the external cut is kept open, not till the cavity of the tunica vaginalis fills up with granulations, as fome have imagined to be neceffary in this mode of operating, but merely till fuch a degree of inflammation is induced upon the tefticle and vaginal coat, as terminates in their adhe- fion to each other. This idea of the whole cavity of parts in this fitua- tion being to fill with new granulations, has been held out by fome as an objeaion to this operation ; and as many believe that it aaually happens, I have judged it proper to fpeak of it more particularly than thofe will confider as neceffary, who have been accuftomed to operate in this manner. No fuch procefs takes place : inftead of it, the tefticle and vaginal coat, foon after the operation, become inflamed ; till the fixth or feventh day, the inflammation continues gradually to increafe, when the whole tumor, as I have obferv- ed above, has acquired the ufual fize and appearance of a common hernia humoralis from gonorrhoea. About this period, the tunica vaginalis is found to adhere to the teftis, over all the pofterior and lateral parts of the tumor, and on the flips of oiled linen be- ing gradually leffened, and at laft withdrawn, by the fourteenth or fifteenth day, or foon thereafter, the ad- hefion becomes complete ; the tumor of the teftis gradually fubfides, and the fore produced by the cut, and now reduced to a line, heals ift a fhorter or long- er time, according to the habit of body, age, and oth- er circumftances of the patient. In fome, the cure m 74 On the Hydrocele. Chap. XXIV. complete in three weeks; I have known it in lefs ; while, in others, it runs on to the fourth, fifth, and in a few cafes, to the fixth week. Having thus given an account of the different ope- rations ufually employed for the radical cure of the hydrocele, I fhall now make a few obfervations on the comparative advantages of the three laft, to wit, thofe by cauftic, the feton, and the fimple incifion; one or other of thefe being now commonly praaifed for the removal of this difeafe. From the teftimony of many refpeaable authors of the efficacy of each of thefe, there is no reafon to doubt that any of them would, in moft inftances, prove effeaual: that the cauftic, when properly man- aged, will for the moft part fucceed, we have every reafon to believe; and the fame may be fafely affert- ed both of the feton, and the fimple incifion; but every praaitioner being apt to be prejudiced in favour of a particular method, he generally continues to prac- tife that mode, and no other; and finding that it com- monly fucceeds, he by degrees comes to perfuade himfelf, that other methods of cure, with which he has not had fuch opportunities of becoming acquaint- ed, are liable to objeaions, which thofe who have praaifed them do not find to be the cafe. I happened to attend the hofpitals in London, about the time that Mr. Pott's publication on the feton, and Mr. Elfe's treatife on the cure of the hydrocele by cauftic, were publifhed; when, of courfe, the various means of curing the difeafe were frequently the fub- jea of medical converfation. I was thereby induced to "pay much attention to the fubjea ; and having the advantage of feeing the praaice of different hofpitals, and not being particularly biaffed in favour of any particular method, I was thus furnifhed with the beft opportunity that could be wiflied for of forming an opinion: and the refult of all the obfervation 1 was either at that time able to make, or fince that period, hoth in the hofpital here, and in private praaice, is, Sea. III. On the Hydrocele. 75 that although all the three modes of operating, by cauftic, the feton, and fimple incifion, are perhaps equally capable of producing a radical cure ; yet that of the three, the latter, to wit, the mode by the fimple incifion, is liable to feweft objeaions, and effeas a cure both with leaft trouble to the operator, and leaft rifk to the patient: and, of the other two, the treat- ment by cauftic appears to me to be the beft. I have feen all the three produce troublefome fymp- toms, fuch as pain, and tenfion of the abdomen, in- flammation, and fever; but, from much obfervation, I can, without hefitation fay, that the feton is more frequently produaive of thefe than either of the oth- ers ; nor need we wonder at this being the cafe ; for the cord which is here introduced, lying in clofe con- taa with the body of the teftis, muft neceffarily occa- fion a confiderable and continued irritation, as long as it remains applied to it. The feton is likewife attended with other inconve- niencies, to which neither of the others, when proper- ly managed, are liable. When the inflammation, which fucceeds to the introduaion of the cord, runs high, as it frequently does, it commonly terminates in fuch a plentiful fuppuration, that the matter produced by it cannot be readily difcharged at the opening made for the feton. In confequence of this, it finds accefs to the neighbouring parts; and different abfceffes are accordingly formed, which muft all be difcharged by as many openings. This may, in part, be obviated, by making the inferior opening of the fize I have di- reaed ; but, in fome inftances, I have found even that this has not proved fufficient, owing to the opening being reduced in fize by the fwelling and inflamma-f tion of the tumor. Another objeaion to this operation, which I think of importance, is this: it does not admit of free ex- amination, either of the ftate of the tefticle, or of the fluid contained in the fac. I know that in a fimple uncomplicated hydrocele, the ftate of the tefticle re^ y6 On the Hydrocele. Chap. XXIV. quires no examination ; nor would we think of re- moving it, either on account of a mere enlargement, or diminution of its fize, provided it is not otherwife difeafed. But we know well, that cafes fometimes occur, which elude the utmoft fkfll and penetration of the furgeon ; no diagnoftic fymptoms, with which we are yet acquainted, being fuflicient to direa us with abfolute certainty. The moft experienced praaitioner will admit, that at times, he has been miftaken in his opinion refpea- ing the nature of fuch tumors ; a real farcocele, or fchirrous tefticle, attended with fome effufion of a flu- id, being in fome inftances, miftaken for a pure un- mixed hydrocele ; and vice verfa, a fimple uncompli- cated cafe of hydrocele has been miftaken for, and treated as a fchirrous tefticle. Such occurrences eve- ry praaitioner muft have met with ; and among oth- ers, who confefs their having been deceived in this manner, a very candid acknowledgment is made of it by Mr. Pott ;* and Mr. Elfe takes notice of a fimilar occurrence in which he was concerned. I have been concerned in different cafes, where the moft experienced furgeons were at a lofs to determine the real nature of the difeafe; that is, whether the fwelling in the fcrotum was a fimple hydrocele of the vaginal coat, or an effufion of a fluid into that bag produced by a fchirrous tefticle. In all fuch cafes of doubt, the furgeon fhould proceed as if the tumor was a real farcocele. If, on laying open the fwelling, the tefticle is found difeafed, that is, if it is in fuch a ftate as to require extirpation, it fliould be removed immediately ; while, on the contrary, if it appears to be found, he will treat it as a cafe of fimple hydrocele. * Treatife on the Hydrocele, p. 288. In this cafe, which, from every circumftance, had been confidered as a farcocele, the teftis, after being re- moved, was found to be perfectly found, the difeafe being a real hydro- cele of the tunica vaginalis. The mere poflibility of fuch an occurrence with fuch an attentive ob- ferver as Mr. Pott, ought to fervc as a moft convincing argument with practitioners of the necefiky of proceeding with tire utmoft caution in all fuch cafes, where there is the leaft caufe for doubt. Sea. UL . On the Hydrocele. 7J In feveral inftances of this kind, where, by different praaitioners, a mere colleaion of water was expeaed without any other affeaion, the tefticle has been found to be fo much difeafed, as to render immediate extir- pation proper. Now, if in fuch circumftances a cure had been attempted by the feton, the tefticle would have been allowed to remain expofed to the irritation produced by the cord, which probably would have in- duced very troublefome and even alarming fymptoms ; for we know that every fymptom of a fchirrous tumor, is uniformly rendered worfe by irritation. It has indeed been alleged, that the real ftate of the teftis may be always known, by drawing the water off from the tunica vaginalis with a trocar; and this has accordingly been recommended as a previous flep to the introduaion of the feton, with a view to afcertain the ftate of the tefticle. But it often happens, even after all the water is drawn off, that the thicknefs pro- duced by the vaginal coat and fcrotum collapfing in large folds about the teftis, precludes effeaually every accurate examination of this land. Of this, where the tumor has been large, every praaitioner muft have met with inftances ; and we need not be furprifed at its being fo, when it is known that inftances occur, in which it requires a good deal of experience to deter- mine, whether a tefticle is fo much difeafed as to re- quire extirpation, even when completely laid bare in the common operation for the hydrocele. Of this I have known feveral cafes in which a difference of opin- ion occurred, even among furgeons of obfervation; and among thefe, the moft remarkable happened in an operation performed by a late very eminent furgeon. The cafe was fuppofed to be a fchirrous tefticle con-• neaed with the effufion of a confiderable quantity of a fluid into the tunica vaginalis. On laying open the tumor, the tefticle was found enlarged and hard; but being neither painful nor unequal on the furface, the operator thought it improper to remove it: the fur- geons prefent were of a different opinion; but the 78 On the Hydrocele. Chap. XXIV. event of the cafe, which was favourable, tended to evince the fuperior judgment of the operator, although, previous to the operation, he had entertained a very different opinion. I have alfo obferved above, that when the feton is ufed, the contents of the cyft cannot be properly af- certained. It fometimes happens, as will be more par- ticularly noticed in the next feaion, that a portion of gut is contained in the upper part of a hydrocele. Of this I have met with feveral cafes, in fome of which no fufpicion was entertained of it, till the fac was laid open, although in two of them the water had previ- ously been drawn off with a trocar. In other inftances, the water of a hydrocele is con- tamed in hydatids ;* a circumftance not to be difcov- ered previous to the opening of the tumor : and as it will be readily admitted that the method of cure by feton is ill fuited for difcharging hydatids, this of itfelf is a material objeaion to the praaice ; fo that, al- though the feton, in every other refpea were equally eligible with the fimple incifion, which, for the rea- fons formerly given, I think it is not, yet the three laft objeaions that I have adduced againfl it, feem to be fufficient reafons for fetting it afide. With refpea to the mode of treatment with cauftic, I have only to obferve, in addition to what has already been faid of it, that where patients are naturally timid, and do not incline to fubmit to the operation by the knife, this may be put in praaice. But the method of cure by cauftic is liable to one important objeaion, which never attends the cure by incifion, to wit, that of being produftive of finufes, and colleaions of matter, in the fcrotum and cellular fubftance connefting that bag to the tunica vaginalis. Two inftances of this I have feen, in which it was ne- ceffary to difcharge colleaions of matter by different * Thofe who doubt of the exiftence of hydatid* in cafes of hydrocele, as fome have done, will find dilUrtnt inftancv. of them recorded'i.i Mor- gagni de CauGt et Scdibut Morborurn. • Sea. III. On the Hydrocele. fo. openings ; and a remarkable cafe of it is related by Douglas, in which an extenfive incifion became ne- ceffary for removing the colleaed matter.* For this reafon, therefore, and as the method of cure by inci- fion brings the ftate of the tefticle immediately and more completely into view, and efpecially as, from all the experience I have had of the two different modes of operating, that by incifion feems to produce the leaft troublefome fymptoms, I am decidedly of opin- ion that it fhould be preferred. In points of fuch importance, no perfon fhould form any opinion haftily. Nothing but various opportuni- ties of patting the different operations in praaice, can enable any one to judge of the merits of each. Even in the writings of the late celebrated Mr. Sharpe, we find a remarkable inftance of this. In his treatife on the operations of furgery, he fpeaks of the radical cure of hydrocele, whether by cauftic or incifion, or in whatever way it is done, as a very dangerous opera- tion, and feems to think that it will be entirely laid afide.f At that time it is evident that Mr. Sharpe* s experi- ence in this difeafe was not fufficient to warrant a de- cifive opinion. It proved to be contrary to the direa experience of fome of our beft furgeons ; and Mr. Sharpe himfelf feems afterwards to have been convinc- ed that his firft ideas of it had been ill founded.} Still, however, his firft opinion had much influence with a great proportion of furgeons ; fo that, till of late years, the radical cure of hydrocele was feldom attempted but in large hofpitals: and when at laft it was found that the danger attending it was lefs than had been re- prefented, ftill, the terror induced by Mr. Sharpe's ac- count of the mode of operating by incifion, was fuch, that almoft all who wrote upon it, were afraid of ad- vifing it to be fo generally performed as it ought to be. • p. 105. f Tenth Edition, Chap. IX. \ Vide Critical Inquiry, firft edition, p. 8<5. So On the. Hydrocele. Chap. XXIV. When the earlier editions of this work were p'ub- lifhed, although I gave the lame opinion of this ope- ration that I have now done, and of the preference to which it appeared to be entitled, and although my ex- perience of its utility and fafety had at that time been confiderable, yet, finding it fpoken of with much cau- tion by many, and among others by Mr. Pott, I did not venture to recommend it fo warmly for general ufe, as I am now by much additional experience ena- bled to do. Although I had performed the operation in a great number of cafes, without lofing a patient, yet, as in fome the inflammation came to a confidera- ble height, I was afraid that in others the dreadful ac- counts that were given of it by authors might occa- fionly be realized. This induced me not only to fpeak of it with caution, but to endeavour, if poffible, to dif- cover the caufe of the violence of this fyinptom ; for it obvioufly appeared, not merely from my own ob- fervation, but from all the accounts which had been given of this operation, that the danger attending it was always in proportion to the degree of inflamma- tion ; and therefore, if this could be rendered mode- rate, that little or perhaps no hazard would enfue from it. I did not find that the length of the incifion had much influence ; for, whether it was to the full extent of the tumor, or only to one-third of that length, the inflammation appeared to be the fame. Some advan- tage indeed was derived from attending to the direc- tion' of the incifion; for, v/herever it was carried too near the tefticle, as is fometimes done at the bottom of the fac, the pain and inflammation were always fe- vere; but the moft frequent caufe of the violence of thefe fymptoms appeared at laft to be the mode of dreffing the parts after the operation. It had com- monly been the praaice to cram a confiderable quan- tity of dreffings into the cavity of the tunica vaginalis-; and, with a view to make the furface of the parts flough quickly off, a procefs which at that time was Sea. III. On the Hydrocele. 8t judged neceffary for the cure, red precipitate and oth- er irritating fubftances were made ufe of by many. The impropriety of thefe being obvious, dry lint was, by Mr. Pott and others, propofed to be ufed inftead of them. This was an important improvement, and it tended more than any other circumftance to leffen - the dread that had been conceived of this operation by the writings of Mr. Sharpe. Still, however, the inflammation run in many inftances too high; the parts fwelled to a great fize, and the patient, for the firft two or three weeks of his confinement, was often kept in much diftrefs and anxiety. Having frequently found that the dry lint inferted into the tunica vaginalis, adhered, at the firft dreffing of the parts, fo firmly to the furface of the teftis, that it could not be withdrawn, I at laft began to conclude that this might render the inflammation more fevere than it otherwife would be ; and it foon appeared that my conjeaure was well founded. For feveral years paft I have covered the pledgets applied to the furface of the teftis, as has been advifed above, either with fine oil, or with a thin linament of oil and wax, which anfwers better. This gives much lefs pain, in the firft inftance, than dry lint, and the pledgets never ad- here to the contiguous parts; fo that they can be as eafily removed at the firft dreffing of the fore, as at any future period of the cure. The effea of this, and of proceeding in the other parts of the treatment, in the manner I have mention- ed, has been, that during all this period the inflamma- tion has never gone farther than I could have wifhed it to do; never fo far as to excite the leaft caufe of anxiety. The tefticle fwells and inflames, but in no greater degree than is neceffary for preventing a re- turn of the difeafe. Of this the cleareft proof that can be given, is, that of upwards of one hurdred and fif- ty patients on whom I have operated in this manner, I have only once found it neceffary to advife blood- Vol. III. G 82 On the Hydrocele. - Chap. XXIV. letting; and very rarely, as I have formerly obferved, fomentations or poultices. I may further mention one important advantage of this operation, in addition to what I have faid of it, that it may be confidered as abfolute fecurity againft a return of the difeafe. I have known indeed two in- ftances, and I have heard of other two in which the difeafe returned after this operation was performed. But thefe are all the inftances I can hear of its failure in the courfe of thefe laft twenty-five years; and in all of them the caufe was evidently traced to want of that perfevering attention during the cure, fo neceffary for the fuccefs of every operation, and particularly for that of the hydrocele. That this operation is not hazardous, and that it may with confidence be relied on againft future re- turns of the difeafe, I am warranted in afferting, not only from the univerfal fuccefs attending it in this country with others, but from the fuccefs arifing from it in my own praaice. Almoft every operation that had been propofed for the cure of hydrocele, had, by one or other of our furgeons, got a fair trial; to wit, that by excifion or cutting away the greateft part of the tunica vaginalis; by injeaing wines and other liquids into the cavity of the fac; by irritation, excited with tents of various kinds, both folid and hollow; and more lately by the feton. But, however keenly one and all of thefe me- thods had for a time been fupported by thofe who firft introduced them, they were at laft entirely laid afide; fo that, for thefe laft five years and more, fcarcely any has been attempted through the greateft part, or per- haps the whole of Scotland, but that by incifion : and although, as I have obferved above, I have been able to trace a return of the difeafe in four inftances, all of them from caufes which ought not to have occurred, not one, fo far as I know, has died of the operation. I have now performed this operation in a very large number of cafes, and in every variety of age, from Sea. III. On the Hydrocele. 83 the third to the feventy-fifth year: not one of the number has either died or been in danger; nor has the difeafe returned in any of them. In various in- ftances, at firft, the inflammation, as I have obferved above, arrived at a confiderable height; but not in a fingle inftance, fince the operation has been done in the manner I have mentioned. I have therefore no reafon to doubt of the objec- tions which have been made to this operation, being foon done away, and I alfo believe, that the more it is put in praaice, the lefs dread will be entertained of it. For my own part, I now confider it as a matter of nearly the fame fimplicity as the treatment of a com- mon abfcefs in any part of the body. The cure is conduaed upon the fame principles. It is accom- pliffied in the fame time; commonly in lefs than the cure of abfceffes of equal magnitude ; and, from the event, I am warranted to fay, that it is not attended with more hazard. Others, from not being fo fortunate, and with whom a high degree of inflammation was often induc- ed, not conceiving that this inconvenience could be leffened, either by any alteration to be made in the mode of performing the operation, or in the manage- ment of the dreffings, were naturally induced to make trial of other means of obtaining a radical cure of the difeafe. The late Mr. James Rae of this place, who was per- haps one of the beft informed praaitioners, as I be- lieve him to have been one of the beft operators of the age, was I believe, the firft who revived the ufe of the feton in this kingdom for the cure of the hydro- cele. He, as well as Mr. Pott, who afterwards wrote upon it, having from the* caufes I have mentioned, conceived a dread of the mode of operating by the fimple incifion ; and Mr. Rae having previoufly made many unfuccefsful trials of the method of cure by in- jeaing wine and other liquids into the tunica vagina- g 2 84 On the Hydrocele. Chap. XXIV. lis teftis, they both keenly adopted the praaice with the feton. Being ftrongly recommended by two fur- geons of fuch reputation, it was at firft adopted by others; but the inflammation induced by it was found in fome inftances, to be fo great and alarming, and the diftrefs arifing from matter colleaing within the tunica vaginalis, and from the openings neceffary for the difcharge of it, was fo confiderable, that the prac- tice never got into general ufe ; and it now appears to be laid afide even by thofe who at one period had formed the moft favourable opinion of it. I have not heard of its being performed in a fingle inftance in this place, for thefe laft twenty years : it feems to be falling into difufe in England ; and althougrrin fome parts of the Continent it was at firft adopted, on the recommendation of Mr. Pott, I do not now learn that it is ever attempted. About the fame period that Mr. Pott wrote upon the ufe of the feton, the late Mr. Elfe began to revive, with fome improvements, the method of curing the hydrocele with cauftic ; and if any fufficient reafon had occurred for laying afide the operation by the fim- ple incifion, I would have been of opinion that the method of cure recommended by Mr. Elfe, fhould have been preferred to every other with which we are yet acquainted. It gives much lefs pain than the fe- ton, and it cures the difeafe with equal certainty. The method of cure by excifion, that is, by cutting away the tunica vaginalis, cannot be compared to that by the fimple incifion; for it does not accomplifh a cure more quickly, nor with more certainty, while it obvioufly renders the operation much more tedious and more painful, the chief reafons, no doubt, for this mode of operating being now very generally exploded. The laft variety of operation that has been recom- mended for the cure of hydrocele, is alfo the revival of an old one, to wit, the injeaing of wine and other liquids into the tunica vaginalis teftis. Sea. III. On the Hydrocele. S$ The merit of firft propofing the cure of this difeafe bv injeaions, has commonly been given to a Mr. Munro, a furgeon of this country ; but we now have evidence of the praaice having been propofed and adopted upwards of fifty years fooner. Tents, armed with irritating ointments having long been employed, we need not wonder at injeaions being confidered as a better method of conduaing the fame remedies to the parts upon which they were to aa. Whether in- jeaions were earlier ufed for this purpofe or not, we do not certainly know ; but in 1677, there is a third edition of what is intituled Les Oeuvres Chirurgicales, of a Monfieur Lambert at Marfeilles, in which a par- ticular account is given of the method of curing hy- drocele by injeaions. The liquid Mr. Lambert pre- ferred, was a flrong folution of corrofive fublimate, in lime water; and he enumerates many cafes in which it proved fuccefsful. But whether from the pain which it excited being fevere, or for other reafons with which we are not acquainted, this mode of ope- rating appears to have been for a long time laid afide, till it was afterwards praaifed by Mr. Munro. He at firft made ufe of fpirit of wine; but although it cur- ed the difeafe, the pain which it excited was fo fevere, that he immediately laid it afide, and employed wine inftead of it. The praaice being favourably received by fome of the firft furgeons of this place, particularly by the late Dr. Monro, Mr. Douglas, Mr. Lauder, and the late Mr. Rae, it was for fome time frequently praaifed, efpecially by Mr. Douglas and Mr. Rae. The liquids they employed were diluted fpirit of wine, lime water, a folution of alum, and red wine, both by itfelf, and diluted. But however favourably they were at firft induced to judge of the praaice, and although very anxious for its fuccefs, it was in the courfe of a few years, laid afide by all of them, and evidently upon good.grounds. rljhe injeaion either excited fevere pah*, on being firft 86 On the Hydrocele. Chap. XXIV. thrown in, and was fucceeded by violent- inflamma- tion, and this, in fome, by diftrefsful colleaions of matter ; or the cure did not prove permanent. ^ In a few cafes, the difeafe returned almoft immediately, that is, in the courfe of two or three weeks; but this was not frequent. For the moft part, the cure ap- peared to be complete, and continued to be fo, till at fome diftant period, to the great difappointment both of the patient and furgeon, a recurrence of the fwell- ing was obferved. In fome, this happened in five or fix months ; in others, not till three or four years had elapfed. About the fame period, fome unfuccefsful trials be- ing made with injections in London, both by the late Mr. Sharpe and others, the praaice was altogether laid afide there, as it had been here, till of late that fome attempts have been made to revive it. But although for a period of more than forty years, this operation was Scarcely heard of in Britain, it was frequently praaifed in France, and other parts of the Continent, where many trials and experiments were made for curing the hydrocele by injections. Trials were made with fpirit of wine, both by itfelf, and di- luted with water ; with a folution of common cauftic in water, in the proportion of two grains to the ounce ; with blue vitriol in water, in the fame proportions ; with lime water, both by itfelf, and with mercurius fublimatus corrofivus diffolved in it in various propor- tions, from a quarter of a grain to two grains, to the ounce; with flrong folutions of alum, of faccharum faturni, infufions of red rofe leaves, infufions of oak bark, and with red wine, both by itfelf, and reduced with water to various degrees of ftrength, according to the fancy of the operator. Many give the preference to an infufion of red rofe leaves : others make ufe of the corrofive fublimate ; but it requires, even when much diluted, to be ufed with great caution. In general, the preference is giv- en to wine : when claret or burgundy are employed, Sea. III. On the Hydrocele. 87 they are commonly mixed with a ilxth or feventh part of water; and when port is ufed, a third or fourth part of water is added. Where no pain is excited by the injeaion thus diluted, the liquid fhould be dif- charged, and pure wine thrown in; for where no pain takes place, a cure is not to be looked for. The operation is done in different ways ; fome pre- ferring a lancet for making the opening into the tu- mor, and others injeaing the liquid with a common fyringe ; but in my opinion, the beft method of per- forming it is the following. The furgeon fhould be provided with a flat trocar, of the form and fize reprefented in Plate LVIII. fig. 3. together with a bag of refina elaftica, fitted with a pipe, reprefented in the fame plate, fig. 1. The pipe fhould be fomewhat longer than the canula of the tro- car, fo as to pafs about an eighth part of an inch be- yond it. If longer than this, it might injure the tef- tis ; and when fhorter, the liquid does not pafs fo ea- fily. The quantity of liquid to be injeaed fhould be gently warmed, and put into the bag before the ope- ration is begun. The patient being laid in a horizontal pofture, either upon his bed or on a table, and fecur- ed in the ufual way by affiftants, the water fhould be drawn entirely off from the tumor, by paffing the tro- car into the anterior and moft depending part of it. The operator, fecuring the canula of the trocar with his left 'hand, is now with his right, to pafs the tube of the injeaion bag entirely through it, and with gen- tle preffure, to force as much of the liquid which i\ contains into the cavity of the tunica vaginalis, as may be neceffary for eafily reaching every part of it, as well as the whole furface of the teftis. The bag fhould now be removed, taking care to leave the tube within the canula of the trocar, fo that by turning the flop cock, the liquid may be retained in the cavity of the tumor. The furgeon fhould ftill keep the canula of the trocar fixed, otherwife it might recede, by which the liquid would infinuate into the cellular fubftance. 88 On the Hydrocele. Chap. XXIV. of the fcrotum, and in this manner do harm. He fhould alfo, with very gentle preffure, make the liquid pafs to every part of the cavity during the time it is retained in it ; and at the end of four minutes, it fhould be entirely difcharged through the canula of the trocar, after withdrawing the tube of the elaftic bas- Some have faid that the injeaion fliould be retain- ed about three minutes : others think that it cannot be depended on in lefs than fix or feven. But thofe who have operated moft frequently in this manner, are of opinion, that the fpace of four minutes is better than either. It fometimes happens that intenfe pain is given almoft inftantaneoufly on the injeaion being introduced. In this cafe, it fhould be difcharged as foon as it has been made to pafs to the different parts of the tunica vaginalis. Some again are of opinion, that after the quantity of liquid firft injeaed is difcharged, a fimilar quantity fhould be immediately thrown in, and retained for the fame length of time, and that the operation will be very apt to fail if this is omitted. This however, is feldom done, although I believe it would be a real improvement on the operation. The quantity of liquid to be injeaed, fhould always depend on the fize of the tumor. Some have thought that it fhould be equal to the quantity drawn off by the operation ; but this does not appear to be neceffa- ry, while the injeaing of fuch a quantity is apt to do harm. After having collapfed completely, the parts do not again yield eafily to hidden diflention ; fo that violent pain has been induced by it. Where the tu- mor is fmall, that is, where only five or fix ounces of ferum are colleaed, the quantity of injeaion need not exceed three or four ounces; while it fhould not be lefs than feven or eight ounces, where a pound of fe- rum has been drawn off; and in this proportion, ac- cording to the fize of the tumor. SeCt. III. On the Hydrocele. 89 * Lefs than any of thefe quantities might anfwer j but it would require more handling to bring it into contaa v/ith all the parts which it ought to touch ; and as a larger quantity is eafily introduced, it fhould always be advifed. On the injeaion being difcharged, and not a drop fhould be left, the fcrotum fhould be covered with a pledget of common cerate, a comprefs being applied over it, and retained with a fufpenfory bag. The pa- tient fhould be defired to remain in bed for feveral days, and to give aid to the fufpenfory bandage, by inferting a fmall pillow beneath it. It often happens, that the pain is inconfiderable from the firft ; fcarcely any inflammation or tumor being perceived on the teftis ; and the patient, confidering himfelf as well, walks abroad, in ten, twelve, fourteen, or fifteen days. But, with others, a very fevere degree of pain takes place on the firft introduction of the in- jeaion, not merely in the teftis, but in the back, and over the whole loins. In moft inftances, this foon be- comes moderate, and the treatment goes eafily on ; but, in others, it is fucceeded by great inflammation in the teftis and fcrotum; and, in a few, this termi- nates in colleaions of matter within the cavity of the tunica vaginalis. Thefe violent fymptoms the praaitioner endeavours to obviate by bloodletting, a low diet, the ufe of lax- atives, and all the remedies ufually employed in her- nia humoralis ; fuch as all the faturnine applications ; and warm emollient fomentations and poultices, when fuppuration is likely to take place. When matter forms in the tunica vaginalis, the treatment confifts in laying the colleaion open from one end to the other, and conduaing the cure, as has already been advifed in the operation by the fimple in- cifion. The formation of matter, I believe, is not fre- quent ; but I know that it occafionally happens ; and fo much are the praaitioners on the Continent afraid of it j of the height to which the inflammation might 90 On the Hydrocele. Chap. XXIV. otherwife advance ; and of the dreadful diftrefs that S. in fuch circumftances enfue, from fuppuration taking place, that they feldom perform the operation without premifing purging and bloodletting, and often repeat the bloodletting once and again during the cure, pre- cautions never judged neceffary in the method of cur- ing the hydrocele by the fimple incifion. The proportion of thofe that are radically cured by this method of operating, it is difficult to afcertain; for, although in fome the difeafe returns in the courfe of two or three weeks; in others, it is not perceived for feveral months ; and, in fome, as I have obferved above, not till two or three years have elapfed. Hence, in hofpital praaice, where patients are feldom heard of after being difmiffed, the point in queftion cannot be determined ; and it is chiefly in foreign hofpitals that hitherto this operation has been performed. From the beft information that I have been able to procure, it appears, that although, in many, a complete cure is obtained, yet that the difeafe returns early, that is, in the fpace of a few weeks, in a ninth or tenth part of all on whom the operation is performed; and in five of eight or nine, at fome uncertain period in future. Under this conviaion, I have judged it proper to ftate all that has come to my knowledge of what re- lates to this operation; and I am the more induced to it, from finding that others^ either from an unneceffa- ry dread of the operation by the fimple incifion, and which I confider as the beft and moft rational that is yet known, or from a mifreprefentation in the accounts they may have received of the method of cure by in- jeaionj are again endeavouring to introduce it in Britain. From the hiftory that I have given of the method of curing the hydrocele by injeaions, the conclufion that I have formed of it would readily be drawn by any one; but, in addition to this, many powerful ar» guments may be adduced againft it. Sea. III. On the Hydrocele. 91 1 ft, We do not, from experience, find, that other tumors, produced by fluids contained in cyfts, are readily cured by injeaions. Few, I believe, would now think of attempting the cure of abfceffes or en- cyfted tumors by injeaions. In tumors induced by fluids colleaed in the burfse mucofae, where, from the contiguity of joints, extenfive incifions might have done harm, I have in various inftances, made trial of injeaions ; but feldom with any advantage. In fome, they excite pain and inflammation; and where this does not happen, although they may leffen the dif- charge, this proves only temporary; fo that a cure is afterwards to be obtained by the introduaion of a cord, or the enlargement of the opening to as great an ex- tent as with fafety can be ventured upon. Mr. Earle, indeed, has faid, and he gives it as a rea- fon for the praaice he has adopted in hydrocele, that he has frequently fucceeded in procuring adhefion and confolidation of parts in finufes, and other large cavi- ties, by injeaions of various kinds : but, as this has neither happened in the courfe of my own experience, nor with any other praaitioner with whom I am ac- quainted, I muft leave the praaice in the hands of thofe with whom it has anfwered better. At one period, a praaitioner in this country got in- to notice, by announcing frequent cures of the fiftula in ano as well a6 other finufes, by injeaions. Some timid patients, both here and from England, put them- felves under his care. His reputation, however, was not of long duration ; for I do not find that he prov- ed fuccefsful in one of twenty cafes, although the pa- O tients commonly remained long under his care. The injeaions were thrown in frequeetly, and with much attention ; and liquids of various kinds were employ- ed ; fome that feemed to aa folely by their aftringen- cy, and others by exciting inflammation. 2d, When the tunica vaginalis has been much dif- tended, as it will not collapfe equally round the tefti- cle on the fluid being drawn off, cavities will thus be 92 / On the Hydrocele. Chap. XXIV! formed, by which feparate colleaions will be apt to take place, either of a ferous fluid, or of purulent mat- ter, if inflammation has been excited. This was my opinion of the probable effea of injeaions, long be- fore the laft edition of this volume was publifhed ; and fince that period, different cafes have occurred, which render it certain that the fufpicion was well founded. 3d, When inflammation, excited by an injeaion, goes too far, and with whatever care the operation is done, it fometimes happens, the diftrefs produced by it is fevere. Befides the pain arifing from the inflam- matory flage of the difeafe, if fuppuration takes place, the patient muft fubmit to that painful diftention which the hidden formation of matter in this confined ftate always excites ; to the febrile fymptoms with which it is attended ; and to an incifion equally extenfive for difcharging the matter, as if the mode of cure by in- cifion had been adopted at firft. 4th, The ftate of the teftis cannot, in this mode of operating, be examined with the fame accuracy, as when the operation is done by incifion. Hence it may be in fuch a ftate of difeafe as to be injured by the injeaion, without our being previoufly able to dis- cover it. Some indeed have faid, that, on the water being drawn off, we may always know with certainty wheth- er the tefticle is found or not. This when it is much enlarged, is certainly the cafe; but where the tunica vaginalis is thickened, as it generally is when it has 0 been long much diftended, the teftis, if not confidera- bly enlarged, as well as the epididymis, may be mate- rially difeafed, without our being able to difcover it. Of this I have feen various inftances ; in fome of which, as I have obferved above, praaitioners of much experience were deceived. 5th, The views of modern furgeons in the cure of the hydrocele, are, as I have already had occafion to remark, to excite fuch a degree of inflammation over Sea. III. On the Hydrocele. ' 93 the furface of the tefticle, as well as of the tunica va- ginalis, as may produce a firm adhefion between them. Now, inftances often occur, in which the tunica va- ginalis is fo thick, callous, and infenfible, that a much more irritating injeaion would be required to make it inflame than the tefticle itfelf can bear. Nay, cafes are fometimes met with, in which differ- ent portions of the tunica vaginalis are as firm and hard as cartilage; a ftate highly improper for any at- tempt to cure the difeafe by injeaions, or in any other way than by removing the hardened parts; and yet this fometimes happens, as I have more than once feen, where previoufly it could not be difcovered, and in which the tunica vaginalis teftis appeared to be in its ufual ftate, till the contrary was found to be the cafe, on laying the parts open by fimple incifion. 6th, The chief, and perhaps only advantage which the mode of operating by injeaion feems to poffefs, over that by incifion, is, that it is lefs painful in the execution; but although this may be a reafon for ad- vifing it with timid patients, who will not fubmit to the other, it is not fufficient to warrant praaitioners in giving it the preference. The prevention of pain is at all times a moft defirable object; but it is far from being the only one in chirurgical operations. Our chief view, is the fafety of our patient in the firft inftance, together with his complete fecurity againft a return of the difeafe. In fo far as one mode of oper- ating is lefs painful than another, and attended with- equal certainty in fecuring againft a relapfe, it ought certainly to be preferred ; but this is, as I have already had occafion to remark, far from being the cafe with the mode of curing the hydrocele by injeaions ; fo that patients treated in this manner, are, for a confid- erable time, liable to all the diftrefs and anxiety, which uncertainty in points of importance in every inftance gives, while the chief difference between it and the method of operating by incifion, which I have fhewn to be attended with complete fafety as well as fecurity, I 94 On the Hydrocele. Chap. XXIV. confifts in the degree of pain which it excites being lefs. This of itfelf would have little influence even with the moft timid, were they to know, that, in the mode of operating by incifion, the cutting part of it is done in lefs than a minute; when the dreffings are properly conduaed, that the tefticle does not inflame more than is neceffary for a cure ; and that the fubfe- quent pain is for the moft part inconfiderable ; not to be compared with what is experienced from matter colleaing within the cavity of the tunica vaginalis, as fometimes happens in the mode of operating by injec- tion, as well as in that by the feton. 7th, As an argument in favour of this operation, it is faid, that when it fails, we ftill have it in our pow- er to perform it over again, or to advife the radical cure by incifion. This, however, leads to much vex- ation, diftrefs, and difappointment in the firft inftance, while I think it probable, that one effea of injeaions, when they do not fucceed, muft be to render any oth- er operation that may be afterwards performed more uncertain than it otherwife would be, or to require a higher degree of inflammation to be induced. Some have imagined, that injeaions in the cure of hydrocele prove ufeful, only in fo far as they excite inflamma- tion, and confequent adhefion of the tunica vaginalis to the furface of the teftis; whilft others are of opin- ion, that they aa folely by their aftringency. By flrengthening or corrugating the fecreting and abfor- bent veffels of the parts, they may be fuppofed to aa both by preventing a too plentiful fecretion of the flu- id naturally contained in the tunica vaginalis, and by promoting a more equal abforption ; and we accord- ingly find, that fuch fluids only are now ufed for thefe injecligns, as are in a confiderable degree aftringent, fuch as infufions of red rofe leaves, folutions of alum, and red wine. My own opinion is, that a permanent cure is never to be depended on, where inflammation is not induc- ed fufficient to produce a firm adhefion between the Sea. III. On the Hydrocele. 95 tunica vaginalis and teftis ; but there is reafon to think, that this feldom takes place from injeaions; and I conclude that it is fo, not only from the trifling degree of pain which, in moft inftances, the injeaions now ufed commonly give, and from the fwelling of the parts, which ufually takes place, being inconfiderable, but from the difeafe often returning, after it had been fuppofed to be cured, and which could not happen, if thefe parts had been made to unite by inflammation. Now, if this is the faa, and I firmly believe it to be fo, that injeaions, in a great proportion of cafes, aa chiefly by their aftringency, and not by deftroying the cavity of the tunica vaginalis, they may readily be fup- pofed to render, not only the tunica vaginalis, but ev- en the furface of the teftis more callous than it was be- fore, by which a greater degree of inflammation will be required, than might otherwife be fufficient, when any other operation becomes neceffary for a perma- nent cure. In anfwer, however, to all thefe objeaions, it may be faid, that the praaice has already gained ground in feveral parts of the Continent, and that Mr. Earle, a furgeon of our own country, has brought forth two publications on the fubjea, in both of which it is re- commended in the warmeft manner, and a number of cafes recited, in which it appears to have proved fuc- cefsful. To this I fhall only obferve, what I have already hatl occafion to do, refpeaing the praaice of foreign- ers in the hydrocele ; that having been later than the Britifh furgeons, in acquiring a knowledge of the true nature of the difeafe, they have hitherto remained be- hind them in every thing that relates to it. Their praaice has therefore been timid, changeable, and in- decifive. This, however, I only mean as a general ob- fervation ; for fome foreigners there are, whofe knowl- edge in this, as in all other difeafes, would do them much honour : but all who have read what in gener- 96 On the Hydrocele. Chap. XXIV. al has been written upon this fubjea by foreign fur- geons, or who have had opportunities of feeing their praaice, muft admit, that in the treatment of hydro- cele they ought not to be followed. And again, with refpea to the obfervation of Mr. Earle, I need only obferve, that this writer obvioufly labours under a deep rooted prejudice againft every mode of operating, except that by the feton, of which he once feems to have entertained a very high opinion, and the mode of cure by injeaion, which he has now very keenly adopted. In one part, indeed, of his trea- tife, he makes the following candid declaration: " I " muft confers, that I took an early and deep rooted " diflike to the cure of hydrocele by incifion."* La- bouring under this kind of terror at other operations, and difappointed, as it would feem, in his expeaation of the operation by the feton, he was thus ready to adopt the praaice of curing the difeafe with injeaions, in the eafy manner reprefented by the French, and which he has accordingly with great zeal done. If longer experience, and farther improvement, fhall evince the mode of curing the hydrocele by injeaions to be equally fafe and certain with that by the fimple incifion, and fhall obviate the objeaions that I have ftated againft it, none will be more ready to adopt it than I fhall be. In the mean while, and in the pre- fent ftate of our knowledge, few praaitioners will ad- vife it, if it be not with thofe patients whofe timidity precludes the more certain and equally fafe method of cure, the operation by incifion. * Vide A Treatife on the Hydrocele, &c. by James Earle, Ef