\5^. 
 
^ 
 
 PERKINS LIBRARY 
 
 Uuke University 
 
 Kare Dooks 
 
 / ) * (/ J^*^A^U^-r 
 
 > / 
 
^ SYSTEM A^/^-^^a 
 
 SURGERY: 
 
 OF 
 
 BY 
 
 BENJAMIN BELL, 
 
 MEMBER OF THE ROYAL COLLEGES OF SURGEONS OF EDINB0RGH AND 
 
 IRELAND, ONE OF THE SURGEONS TO THE ROYAL INFIRMARY, 
 
 AND FELLOW OF THE ROYAL SOCIETY OF EDINBURGH. 
 
 ILLUSTRATED n'lTH COPPERPLATES. 
 
 VOLUME IIL 
 
 ;F.C0ND AMERICAN, FROM THE SEVENTH EDINBURGH EDITION, 
 
 CORRECTED AND ENLARGED. 
 
 
 TROY, NEW-YORK; 
 
 PRINTED BY O. PENNIMAN AND CO. 
 
 FOR themselves; THOMAS AND ANDREWS, BOSTON; T. S. ARDEN, 
 NEW-YORK; AND J. CONRAD AND CO. PHILADELPUIA. 
 
 1804. 
 

 
 7"i 
 
 c 
 
 •-. .'v 
 
 <'^ 
 
 <£5^ 
 

 CONTENTS. 
 
 CHAPTER XXm. 
 
 Page 
 Of HERNIiE, - - - I 
 
 Se£t. 11. Of the Bubonocele^ - ib. 
 Sed. III. Of the Hernia Congenita, - 2 1 
 Se£l. IV. Of the Crural or Femoral Hernia, 23 
 Sedl. V. Of the Exomphalos, or Vmhilical Rup- 
 ture, - - > . 27 
 Se<a. VI. Of Ventral Hernia, - 30 
 Sed. VII. Of the Hernia of the Foramen Ovale, 31 
 Sea. VIII. (y //j^ Hernia Cyjiica, or Hernia of 
 the Urinary Bladder, - - 3* 
 CHAPTER XXIV. 
 On the hydrocele, - - 36 
 Sed. I. General Remarks on the Hydrocele, ib. 
 Seft. II. 0/" the Anafarcous Hydrocele of the 
 
 Scrotum, - - - 40 
 Sedl. HI. Of the Hydrocele of the Tunica Vagi- 
 nalis Tejiis, - - 47 
 Se£l. IV. Of the Hydrocele of the Hernial Sac, 97 
 Sed. V. Of the Anafarcous Hydrocele of the 
 
 Spermatic Cord, - - loi 
 Se6l. VI. Of the Encyfied Hydrocele of the Sper- ' 
 
 7?iatic Cord, - - 103 
 
 CHAPTER XXV. 
 
 On the HiEMATOCELE, - 1 10 
 
Page 
 
 Iv CONTENTS. 
 
 CHAPTER XXVL 
 Of the varicocele, circocele, spermato- 
 cele, AND PNEUMATOCELE, - Il6 
 
 CHAPTER XXVII. 
 
 Of the sarcocele, or schirrous testicle, 119 
 
 CHAPTER XXVIII. 
 
 Of the diseases of the penis, - 139 
 
 Sea. I. Of the Phymofis, - ib. 
 
 Se6t. II. Of the Paraphymofis, - 142 
 
 Sedt. III. Of Amputation of the Petiis, 145 
 CHAPTER XXIX. 
 
 Of the stone, - - 149 
 
 Seel. I. General Remarks on Urinary Calculi, ib. 
 
 Seel. II. Of bounding or Searching for the Stone, 155 
 Sedl. III. General Remarks on the Operation of 
 
 Lithotomy, - - 164 
 Se6t. IV. Of the Operation of Lithotomy by the 
 
 Leffer Apparatus, - - 168 
 Se£l. V. Of Lithotomy by the Greater Appa- 
 ratus, - - ' '^I'h 
 Se6l. VI. Of the High Operation for the Stone, 176 
 Sed 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 
 
 CHAPTER XXXIII. ^'^ 
 
 Of the fistula in perin^o, - 260 
 
 CHAPTER XXXIV. 
 
 Of hemorrhoids, or piles, - 271 
 
 . CHAPTER XXXV. 
 
 Of condylomatous excrescences, and 
 
 similar affections about the anus, 279 
 CHAPTER XXXVI. 
 Of a prolapsus ani, - - 281 
 
 CHAPTER XXXVII. 
 Of an imperforated anus, - 284 
 
 CHAPTER XXXVIII. 
 Of the fistula in ano, - 288 
 
 CHAPTER XXXIX. 
 Of fractures, . _ . ^14 
 
 Sect. I. General Obfervaiions on Fradures, ib. 
 
 Sea. II. Of Fradures of the Nofe, - 332 
 
 Seft. III. Of Fra6lurcs of the Bones of the Faec, 2i33 
 Se6l. IV. Of Fractures of the inferior Maxilla- 
 ry Bones, - - . -^-jp 
 Seft. V. Of Fractures of the Clavicles and Ribs y 337 
 Scd. VI. OfFradures of the Sternum, 341 
 Sea. VII. Of Fradures of iheVeriebra, Os Sa- 
 crum, Coccyx, and Ojfa hmominata, 343 
 Sea. VIII. OfFradurcs of the Scapula, 345 
 Sea. IX. OfFradurcs of the Humerus, 346 
 Sea. X. Of Fradures of the Bones cf the Fore- 
 
 Ar?u, - _ _ 
 
 Sea. XL Of Fradures of the Bones of the 
 
 Wrijl, Hands, and Fifjgers, - 3^2 
 
 Sea. XII. Of Fradures cf the Femur or Thigh 
 Bone, . , 3^4 
 
 349 
 
vi CONTENTS. 
 
 Page 
 
 Sea. XIII. Of Fradurcs of the Patella, 361 
 
 Sea. XIV. Of Fradurcs of the Bones of the 
 
 Leg, - - - 366 
 
 Sea. XV. OfFracIures of the Bones of the Foot 
 
 and Toes, - - ' - 370 
 
 Sea. XVI. Of Compound Fractures, 371 
 
 CHAPTER XL. 
 
 Of LUXATIONS, _. - - 383 
 
 Sea. I. General Remarks on Luxations, ib. 
 
 Sea. II. Of LuKat'ions of the Bones of the Cra- 
 nium, - - - 395 
 Sea. Ill, Of Luxations cf the Bones of the Nofe, 396 
 Sea. IV, Of Luxations of the Loiver "Jaw, ib. 
 Sea. 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 cf the Clavicles, 405 
 Sea. VIII. Of Luxations cf the Ribs, 407 
 Sea. IX. Of Di/locations of the Hu?}ierus at the 
 
 foint of the Shoidder, - - 409 
 
 Sea. X. Of Luxations of the Fore- Arm at the 
 
 Joint cf the Elbow, - - - 422 
 
 Sea. XI. Of Luxations of the Bones of the Wrijl, 425 
 Sea. XII. Of Luxations of the Bones cf the 
 
 Metacarpus and Fingers, - - 427 
 
 Sea. XIII. Of Luxations cf the Femur at the 
 
 Hip Joint, - - - 428 
 
 Se^. XIV. Of Luxations of the Patella, 435 
 
 Sea. XV. Of Luxaiiofis of the Tibia a7id Fibu- 
 la at the Joint cf the Knee, - 437 
 
CONTENTS. vu 
 
 Page 
 
 Se6l. XVI. Of Luxations of the Foot at the 
 
 Joint of the Ankle, - - 439 
 
 Sea. XVII. Of Luxations of the Os Gala's, and 
 other Bones of the Foot. - - 440 
 
 CHAPTER XLI. 
 Of distorted limbs, . - 442 
 
 CHi^TER XLII. 
 Of distortions of the spine, - 448 
 
 CHAPTER XLIIl. 
 Of necrosis, - - - 451 
 
 CH/VPTER XLIV. 
 Of amputation, - - 457 
 
 Se£l. I. General Remarks on the Operation of 
 
 A?nputation, - - ib. 
 
 Se£t. lis Of the Caufes which may render Am- 
 putation neceffary, - - 458 
 Sect. III. General Remarks on the Method of 
 
 Amputating Limbs, - - 470 
 
 Se£t. IV. Of Amputating the Thigh, 475 
 
 Se6l. V. Of Amputating the Leg, - 492 
 
 Se£l. VI. Of Amputating with a Flap, 497 
 
 Se£t. VII. Of Amputating at the Hip Joint, 499 
 Se£l. VIII. Of the Flap Operation immediately 
 
 above the Knee, - - 503 
 
 Se<51:. IX. Of the Flap Operation below the Knee, 508 
 Sedl. X. Of Amputating the Foot, Tecs, and 
 
 Fingers, ... 509 
 
 Sed. XI. Of Amputating the Arm at the Joint 
 
 cf the Shoulder, - - 512 
 
 Se(a. XII. Of Amputating the Arm, 516 
 
Ylii CONTENTS. 
 
 fage 
 
 CHAPTER XLV. 
 
 Of removing the ends of bones in dis- 
 eases of THE JOINTS, - - 517 
 
 CHAPTER XLVI. 
 
 Of issues, - - - 522 
 
 CHAPTER XLVII. 
 
 Of the INOCULATION OF THE SMALLPOX, 527 
 
 CHAPTER XLVIII. 
 
 Of PREVENTING OR DIMINISHING PAIN IN 
 
 GHIRURGICAL OPERATIONS, - 530 
 
 CHAPTER XLIX. 
 
 Of MIDWIFERY, - - 533 
 
 Sect. I. General Obfervations on Midwijery, ib. 
 Seft. II. Of the Cafarean Operation, 535 
 
 Seft. III. Of the Divifwn of the Symphyfis Pubis 538 
 CHAPTER L. 
 
 Of OPENING DEAD BODIES, - - 542 
 
 CHAPTER LI. 
 
 Of EMBALMING, - - 545 
 
 CHAPTER LII. 
 
 Of BANDAGES, - - - 547 
 
A 
 
 SYSTEM 
 
 OF 
 
 SURGERY. 
 
 CHAPTER XXIII. 
 
 OF HERNIiE, 
 
 SECTION II. 
 
 Of the Bubonocele. 
 
 CONJOINED with the general fymptoms of her- 
 nia enumerated in the laft feftion, the particu- 
 lar appearances of the bubonocele, or inguinal hernia, 
 are, a foft Ibmcwhat elallic 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 
 m proportion to the degree of ftrifture in the opening 
 of the tendon ; and when the parts inflame, handling 
 or preflTure always gives pain. 
 
 When it contains omentum only, the tumor is both 
 more foft, comprefliblc, and more unequal, than when 
 gut alone is down ; the fcrotum becomes more ob* 
 long than in an inteflinal hernia ; and when the quan- 
 tity of omentum is large, it is alfo much more weigh- 
 
 Vol. III. B 
 
1 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 diftinguifhing 
 fymptoms of each can never be fo clearly marked. 
 Various fymptoms indeed are enumerated by authors 
 for diftinguifhing the contents of hernioe ; but when- 
 ever the cafe is complicated, every candid pradlitioner 
 will admit, that no certainty can be obtained of this 
 till the tumor is laid open. 
 
 As thefe parts are hable to other tumors with which 
 the inguinal and fcrotal hernia may be confounded, 
 pradtitioners fhould be as much as poflible acquainted 
 with the marks of diftindion. 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 humorahs ; 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 incompreffible hardnefs with which glandular 
 fwellings are at firft attended, and by the fluctuation 
 of matter 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 fpermatic procefs being commonly free 
 from fwelling ; may be confidered as certain m.arks of 
 diftinclion. In the hernia humorahs, too, the intef- 
 tines are free and unobftrucled, 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 in 
 hernia. In hydrocele the fpermatic cord is in mofl: 
 inftances diftindly felt, whereas in hernia where the 
 tum.or defcends to the fcrotum, the fpermatic cord 
 cannot in any part of its courfe be diftinguifhed. In 
 
Sea. 11. Of Hernia. 3 
 
 hydrocele, the flii£luatioii of a fluid is diftlnguifiiable ; 
 in hernia it is not. 
 
 From the anarfarcous fvvelling of the fcrotum, or 
 hydrocele of the dartos as it is termed, hernia is eafily 
 diftinguillied ; and indeed the means of diflindion are 
 fo obvious, that they need not be enumerated ; but 
 there is another variety of hydrocele, the hydrocele of 
 the fpermatic cord, which in iome inllances it is diffi-' 
 cult to diflinguifh from hernia, and which therefore 
 requires particular attention. 
 
 Where the water is collected 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 diftindipn between it and her- 
 nia, in which the fwelling muft always proceed from 
 above downwards ; but it fometimes happens, that 
 the water begins to colled: 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, \T)miting, and 
 obftruded inteftines, muil be kept in view ; for not 
 being conneded with hydrocele, they ferye to afcer- 
 tain the nature of the cafe, in which their abfence 
 might long remain doubtful. In fome cafes, however, 
 thefe and everv other means of diftindlion are want- 
 ing ; but even in fuch circumftances a praditioner of 
 experience will never incur the riik 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 perfect certainty is 
 not obtained, and in which an operation becomes ne- 
 ceflfary, the furgeon (liould 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- 
 eafc will become evident, and the practitioner will be 
 at liberty to apply the means bell i'uited for the cure. 
 Whereas in proceeding differently as in fome cafes 
 has been done, and treating as a hydrocele what after- 
 ■\vards proves to be hernia, he not only incurs the ri(k 
 of injuring his own reputation, but of dellroying his 
 patient. 
 
 In the treatment of the bubonocele, when the means 
 pointed out in the lafl fection as applicable to every 
 itate of hernia do not fucceed, we are then under the 
 r.ecefnty 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 mufl be placed upon it with 
 his head and body almofl horizontal, whilft 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 (hould 
 in this fituation be firmly fecured by an afiiftant on 
 each fide, who fliould 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 poili- 
 ble for returning the protruded parts, the patient 
 fhould be advifed to empty his bladder ; and the parts 
 having been previouily fhaved, an incifion muft now 
 be made with a fcalpel through the fkin and part of 
 the cellular fubftance, beginning an inch above the fu- 
 perior end of the tumor, and proceeding dowH to the 
 moil 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 incifion, we are enabled to finifii the op- 
 eration w^ith more eafe than when the firfl opening is 
 fmall : it does not give much more pain ; and being 
 continued to the bottom of the fcrotum, the matter 
 in the upper part of the fore is prevented from col-- 
 lecling below, which otherv/ife it is ready to do. 
 
Seel. II. Of Hernia. 5 
 
 The operator mufl; now proceed to divide the reft 
 of the cellular fubflance covering the fac ; and even 
 this fliould be done with caution : for although in a 
 great proportion of cafes, the fpcrmatic 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 rilk of wounding them, as foon as 
 the ^\m. is divided, the remainder of the operation 
 fliould be conduced with much attention, care being 
 taken to avoid every large blood veflel that makes its 
 appearance. 
 
 This circumftance of the prolapfed parts getting 
 down behind the fpermatic veifels, has never, fo far as 
 I know, been mentioned by authors : it mufl there- 
 fore be a rare occurrence. As I met with it, however, 
 in one cafe, where the fai^l was obvious, the pofTibility 
 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 tef- 
 ticles continue in the abdomen ; and about this time, 
 that they fall down in a gradual manner to the fci'o- 
 tum. Many inftances, however, occur, of both tefles 
 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 
 pradlitioners fliould be aware of, as inilances have oc- 
 curred of a teflicle refling in the groin being miflak- 
 en for a hernia, and of much pain being excited by 
 attempts made for reducing them. Now, if we fre-f 
 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 teflicle ? 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 proi- 
 priety of dividing the parts in the cautious manner I 
 have nientioned.* 
 
 It is ufual, in making the firft incifion, to pinch up 
 the teguments, and then to divide them with a fcal- 
 pel ; but' no fui-geon 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 rnufl: be made 
 in it, fo as to bring its contents into view ; and the 
 mofl fafe place for this being formed, is, not about 
 the middle of the tumor, as is commonly direded, 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 lituation, is lefs than in any other part of the tu- 
 mor. In making this perforation of the fac, confifts 
 the greatefl nicety in the operation, the utmoft caution 
 being necelfary 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 practitioner ac- 
 quainted with the anatomy of the parts, will do the 
 operation properly, and without them the befl anato- 
 mift mud go wrong. 
 
 With the fame fcalpel that divided the Ikin and cel- 
 lular fubilance, the operator muft proceed {lowly, di- 
 
 * since this went to the prefs, I find that an inftance is recorded by Le 
 Pran, in his TreaOfe of Ruptures, of the fpermatic vefTcls having been found 
 on tlie anterior part of a bubonocele. This fituation, therefore, of thei't 
 vclTcls, is perhaps more frequent than is conimonly imagintd. 
 
Sea. ir. Of Hernia. y 
 
 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 palTes in 
 eafily, we may conclude with certainty that the fac is 
 divided ; and if it does not, the incifion mud 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 (harp pointed 
 directory, open at the extremity, as is reprefented in 
 Plate LXVI. fig. 3. By pufliing 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 neceflary for the infor- 
 mation of young praftitioners, to obferve, that when 
 hernia is of long duration, the fac frequently becomes 
 fo thick, as to require much more difledion than be- 
 ginners commonly expe6t : by going on, however, 
 with the caution I have direded, every ri{k 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 Surgcrv, there 
 is a paper on Hernia;, by Monfieur Louis. But although it contains many 
 ufcful obfervations, Mr. Louis in one point I think has gone fi.r wrong, in 
 ridiculing that degree of cantion 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 coniidcr it as different in that refpeA from 
 the firfl external incilion of the fkin. His words arc : " Jamais Ic fac ne 
 " m'a donne ni plus de peine, ni plus d'cmbarras que la peau ; on divife, 
 " pour ainfi dire, celled dn premier tr.il/, et le fac du fecondr In tlic hands 
 of a very expert operator, the fcalpcl, even in this manner, mav be fo 
 managed as to do no harm ; but, in common pradlice, much mifcliief would 
 be done by proceeding as Mr. Louis has dirc<n:ed. It mii^ht tend to lliovv 
 the dexterity of an operator, but this vvoiiJd always be at the hazard of 
 the patient. 
 
8 Of Hernia. Chap. XXIII. 
 
 marked above, by a probe pafiing eafily in, it ought 
 then to be farther enlarged, by cutting upon the di- 
 jeclor, till it is of fuch a fize as to admit the forefin- 
 ger of the operator. 
 
 The forefinger of the left hand mufl: now be intro- 
 duced, and ufed as a director for entering the narrow 
 blunt pointed biftoury, reprefented in Plate LXIV. 
 fig. 2. with which the hernial fac mud be divided 
 along its whole length up to the opening in the ex- 
 ternal oblique mufcle. With the finger ufed as a di- 
 reQor 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 unneceiTary. 
 
 On laying the fac open at the bottom, a quantity 
 of coloured fluid commonly ruflies 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 nov/ fet at liberty, more of it comes inftantly on 
 the fac being opened ; thereby giving the appearance 
 of having been colleflicd in a larger quantity than the 
 fize of the tumor gave reafon to expect. 
 
 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 dov/n. Hitherto 
 the ileum has been commonly fuppofed to form the 
 fubftance of a great proportion of hernise, but later 
 and more accurate obfervation renders it probable that 
 the c^curn, 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 ftiould be examined with the niccft attention, in 
 order to difcover whether they are found or not ; and 
 if upon attentive infpedion they appear to be found, 
 that is, if they are not evidently in a ft ate of gangrene, 
 even although they feem to be inflamed, they Ihoulcl 
 be immediately returned into the abdomen. 
 
Sea. II. Of Hernia. 9 
 
 Whether Intefline or omentum, or a portion of 
 each, have been contained in the tumor, thofe parts 
 of them which have come laft; down fliould be firft 
 puflicd back, the difficulty and trouble of returning 
 them being thereby much leffened : and in making 
 the redudion, it both anfwers the purpofe better, and 
 is lefs hkely to do harm, to apply the lingers to that 
 part of the intefline connected with the mel'entery than 
 to the convex part of it. While the red ud ion is go- 
 ing on the patient's thighs and loins fhould be (till 
 more elevated than they were di'»^««ig the preceding 
 fteps of the operation ; for this pofture of thefe parts 
 tends much to facilitate the return of the protruded 
 inteltines 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 reduction 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 pafled from the abdo- 
 men : but when this cannot be done with eafe, it 
 ihould never be attempted ; more danger being to bo 
 dreaded from force applied to the gut, than can ever 
 occur from finiiliing the operation by enlarging the 
 opening in the tendon of the external oblique mufcle. 
 
 As the tendon of this mufcle runs in an oblique di- 
 redlion from above downwards, and as the opening 
 through which the contents of a hernia protrude, is 
 formed by a feparation of the tendinous hbres of the 
 nmfcle from each other, the direction of this opcnin>>- 
 IS of courfe the fame with that of the tendon ; that is, 
 it runs fomewhat obliquely Irom the fpine of the ileum 
 to the OS pubis. 
 
 In enlarging this palfagc, then, for the redu6lion of 
 the parts that have pafTed through it, as a tranfverfe 
 fe£tion of the tendon is not neceifary, the knife fhould 
 be carried obliquely upwards, fo as merely to conti- 
 nue the natural feparatipn of the tendinous fibres. 
 
10 Of Henna. Chap. XXIII. 
 
 The finger was recommended as the beft director 
 for the knife in opening the fac, and in dividing the 
 tendon it proves equally ufeful. By infmuating 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 neceifary extent without rifls. of wound- 
 ing the contiguous parts. 
 
 In general, a ve^-y fmall enlargement of the natural 
 opening in the tendon proves fufficient : but the fize 
 cf the opening ftiould be fully equal to the objeft in 
 view ; for it is better to make it fomev/hat too large, 
 than to run any riili of hurting the gut by forcing it 
 through a fmail aperture. 
 
 If on the introduction of the finger any adhefions 
 of the gut to the contiguous parts are difcovered, the 
 incifion in the tendon fhould be made lar;][er than might 
 otherwife be neceifary, that the finger may be fo free- 
 ly admitted, as to dellroy fuch adhefions as it can 
 reach ; for if not removed, the operation would very 
 probably fail. 
 
 Befides thefc internal adhefions, it fometimes hap- 
 pens, by long confinement in the fcrotum ; preifure ; 
 and perhaps from other caufes ; that flirong adhefions 
 are formed among the parts contained in the fac : and 
 before reducing them, it is ahvays 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 connedions 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 eafiefl method of removing them is to cut 
 them, either with fciffars or a biiloury ; but when one 
 part of the gut adheres fo firmly to another, as not to 
 be feparated but with difficulty, it is much better to 
 
Sea. II. Of Hcrn'KX. 1 1 
 
 return the whole even in this (late to the abdomen, 
 than to run the rill;, 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 flill Itfs trom hurling 
 the fac, a fmall portioh of both may be diffeded oR, 
 ;and returned with the gut to the abdomen ; and in like 
 manner, when the omentum adheres fo firmly to the 
 iac as not to be feparated in any mother manner, no dan- 
 ger can accrue from the fac being encroached on. 
 
 The rilk attending this pradlice is trifling, when 
 .compared with the inconveniencies that would enfuc 
 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 lead 
 portion of gut being left down, would run much rifk 
 of being injured by expofure at the different dreflings ; 
 and by leaving part of the omentum to protrude 
 through the opening from the abdomen, one advan- 
 tage to be expected from the operation would be loft, 
 namely, the prevention in future of that rifle to v/hich 
 a patient with a portion of protruded omentum mufl 
 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 jufl 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 hgature cannot be applied in this manner 
 without rifl-i of injuring, or even of deflroying the fper- 
 matic vefTels, with which the poflerior part of the fac 
 is immediately connected, the practice, from this con- 
 fideration alone, fhould be laid afide ; but in reality it 
 docs not appear to be neceflfary, as this very union of 
 
11 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 hernias to 
 be immediately reduced, on the fuppofition that they 
 have been only diiplaced ; that they have been ad- 
 hering to each other or to the neighbouring parts ; or 
 perhaps that they have been more or lefs in a ftate of 
 inflammation. But when it appears that this inflam- 
 mation has already ended in gangrene, as the return 
 of mortified parts, whether omentum or intefl:ine, 
 might be attended v/ith 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 rifl;, it has been the common pradice to cut off 
 the difcafed 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 j 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- 
 quently induced bad fymptoms, fuch as naufea, vomit- 
 ing, cough, fevef, pains in the belly, and inability to 
 fit erect ; and as we now from experience know, that 
 no hemorrhagy of importance ever occurs from its 
 being divided, fuch parts as have become gangrenous 
 mav therefore be freely cut ofl', and the remaining 
 found parts be introduced into the abdomen, without 
 ligatures being put upon them. Of this I am con- 
 vinced from expei'ience, and it is alfo the opinion of 
 others :* but if it fliould ever happen, on cutting oiT 
 part of the omentum, that a vefl^el of any fize is dir 
 
 * A very accurate paper upon this fiibje<5l may be feen in the third 
 volume of Mcmoircs de i'Academie Royalc de CJhirurgie of Paris, by Mon-: 
 f)tiu- Piyiekt, in which frveral >.-.i'es arc relati^d of the bad cffcdls product 
 cd by Jigitiirts on the omentum. 
 
 Mr. Poit is alfo of this opinion. Vide Trcatife on Ruptures. 
 
Sea. II. Of Hernia, 13 
 
 vided, a ligature may with fafety be pafled 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 circumflance fometimes occurs, that ren- 
 ders the removal of part of the omentum neceflary : 
 when a henia 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 
 collected :nto lumps. When thefe lumps are not 
 large, ther need not be removed, and when fmall, 
 they may be returned into the abdomen without haz- 
 ard ; but ivhenever 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 ve determine to remove any part of the 
 omentum, the eafieft and fafeft method of doing it is 
 this. The membrane fliould be carefully expanded 
 at the part intended to be cut, in which fhate it is ea- 
 fily divided with thin edged fciflars, more fo indeed 
 than with any other inftrument. When fully fpread 
 out, any turn of the intelline that may be enveloped 
 in it, is at once brought to view, which, without this 
 precaution, v/e would run the rilk of dividing with 
 the fciffars. 
 
 "When, sgain, a portion of gut is found to be mor- 
 tified, if returned in this (late, a difcharge of feces 
 would certainly take place into the cavity of the ab- 
 domen, as foon as the mortified fpot lliould feparate 
 from the found. For the prevention of this, which 
 would foor. terminate in the death of the patient, if a 
 finall fpot only is difeafed, we fhould endeavour, with 
 a needle and ligature, to conned the found part of 
 the gut immediately above the mortified fpot, to the 
 wound in the abdominal mufcles. By this the feces 
 are difchai'ged by the wound, when the mortified fpot 
 either feparates or is cut out 5 and different inftances 
 
14 Of Hernia. Chap. XXIir. 
 
 have occurred, where the lofs of fubftance produced 
 by the mortification was not extenfive, of the openinp- 
 into the gut becoming gradually lefs, and at lait heal- 
 ing entirely : but whether the event {hould 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 confiderable as to prevent the ends of the gut 
 from being brought into contac):, it fhould be done 
 immediately in the manner pointed out in Chapter III, 
 Sedion XII. when treatiDjT of wounds of :he intefli- 
 
 o 
 
 nal canal : this at leafl affords a chance o:' the ends 
 of the gut being made to reunite ; and if this unluck- 
 ily fhould not happen, a paffage for the feces will flill 
 be fecured by the groin. 
 
 Although in this manner many have recovered who 
 otherwife mufl have died ; 3^et it mufl be admitted, 
 that the rifk of patients in this fituation is very con- 
 fiderable : but although a fmall proportion only 
 fliould recover, ftill praftitioners would be to blame 
 were they to omit thofe means which afFcrd 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 leafl one foot of the inteftinal canal 
 by mortification in a cafe of crural hernii ; 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, whc lived in a 
 very late period, that on opening a hernial fac, where 
 a gangrenous flate 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. II. Of Hcm'ia. 15 
 
 The patient, who died next day, would, in modern 
 praftice, have had at leaft feme chance for life. 
 
 When it is therefore difcovered, that mortification 
 has taken place, all the dileafed parts fliould be cut 
 off, and the remaining found part of the gut being 
 retained with the fingers till properly fccured with a 
 ligature, the opening in the external oblique mufclc 
 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 rilk 
 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 prcferving it, 
 fuch pai-ts of it as can be cut away with fafety fhould 
 be removed : all the lateral and foreparts of the fac 
 may be fafely cut off; but being commonly firmly 
 connefted with the fpermatic veffels behind, this part- 
 of it ought not to be touched. 
 
 In common practice, 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 llun, cellular fub- 
 ftance, and anterior part of the hernial fac, with a 
 proper number of futures, by which the cure is much 
 more quickly accomplilhed, at the fame time that the 
 parts are rendered more firm than they otherwife 
 would be : at one time, this pra£lice appeared to me 
 to be hazardous ; and I advifed it not to be adopted, 
 as in tVv'o 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 
 
1 6 Of Hernia, Chap. XXIIL 
 
 happen. With a view to give a free vent to any matter 
 that may form in the courfe of the cut, I have, in 
 fome inftances, left an opening at the under part of 
 it, but this precaution I now beheve to be unnecefTa- 
 ry : the futures being completed, the parts fliould be 
 all 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 muil 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 laid to reft : opiates are here particularly ufeful : 
 to prevent, or at leaft to moderate, the fever which 
 commonly facceeds, the patient ftiould be kept cool : 
 in plethoric habits, bloodletting fliould be prefcribed, 
 together with a rigid low diet ; and, lailly, 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- 
 ifliing regimen becomes neceifary ; 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 praftice, the indifcriminate ufe of 
 bl(K:)dletting, and an abftemious regimen, in eveiy 
 cafe of hei-nia, appears to be too rigidly adhered to j 
 for, althoufijh it proves alv/ays ufeful 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 
 no inflammatory fymptoms take place. 
 
 The fore ftiould be looked at and drcfted daily, by 
 tvhich means any change that may take place in it 
 will be quickly dll'covered : 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 aiTert, that a trufs after this oper- 
 
Sea. 11. Of Hernia. 17 
 
 ation is unnecefTary, and where the cure has been ac- 
 compllfhed 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 pra6litioners, 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' affigned for not opening the fac, is, that we 
 thereby prevent the air from finding accefs to the in- 
 teftines ; but although this would be highly defirablcj 
 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 pra£lice 
 fhould be received with caution, till, by further obfer- 
 vation, it is afcertaincd, whether it proves beneficial 
 or not. The bcft mode of doing it would be for the 
 furgeons of thofe hofpitals in which hernioe 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 objection to the pradice is, that unlefs 
 the hernial fac is laid open, we cannot poflibly diftin- 
 guifli 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 inteftines are not only liable 
 to mortifv, but colleflions are fometiraes found in the 
 
 Vol. III. C 
 
i8 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 fometimcs 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 flriclure of the paflage through which the 
 parts have come down, is to be 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 fcrctal hernia of long dura- 
 tion, fymptoms of ftrangulation at laft fupervened ; 
 and on laying open the fac, the appendix vermiformis 
 was found fo tightly twifted round 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 practitioner would have had the mortification to 
 find, that the patient's Hfe 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 practitioners ; and in fome 
 which ended fatally, it was found on diiTection, that 
 the ftrangulation of the gut had been the effeft of 
 ftriClure formed by the parts contained within the fac, 
 and not by the tendon of the external oblique muf- 
 cles through which they had palTed. 
 
 Difafters of a fimilar nature having occurred to Mr» 
 Petit and others, who had adopted the pradice, it has 
 long in France been very generally laid afide ; but in 
 a point of fuch importanccj^this will not be univerfal- 
 iy done till further experience fliall 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 itielf ; 
 whiift others allege, that the fac can never be reduc- 
 
Seia. It. 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 refpedling it. 
 
 In hernial 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- 
 blc 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 fuppofmg that it would be fo in every cafe of re- 
 cent hernia. We know that the adhefion of one part 
 of the body to another, cannot any where be inftan- 
 taneoufly produced. Even where recent divifion has 
 taken place, and when the divided parts are kept in 
 clofe contaft, the fpace of feme 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 flate of inflammation, a ftill 
 longer period mufl be required for this effeft ; and in 
 fad, although there is fcarcely perhaps an inftance of 
 a hernial fac of long duration being reduced, yet there 
 are fundry indifputable fads 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 difledion after death, which happened in 
 two days from the operation, the pafTage through the 
 External oblique mufcle was found dilated, but no ex- 
 iltence of a fac could be traced into it. This alfo 
 c 2 
 
20 Of Hernia, Chap. XXIIL- 
 
 was the cafe with the other, which had been down 
 for tweh'e or thirteen days. It is not, however, my 
 own opinion, that this is a matter of much practical 
 importance, I mean the poillbility 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 fubjed ; but as the fame 
 openings in the external oblique mufcles exift in fe- 
 males, fo they are alfo liable to the variety of rupture 
 we have iull been defcribine. 
 
 In males, however, the bubonocele is more fre- 
 quentdy 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 ai*e exceedingly fimilar to thofe in the male, 
 fo the treatment, of bubonocele is in them very fimi- 
 lar to v.'hat 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 modefl women, hernias often take place with-- 
 out the praditioner in attendance being made acquaint- 
 ed v/ith them ; whenever tlierefore fuch fymptoms of 
 cholic occur in females as give reafon to fufpect the 
 exiftence of hernia, a particular examination fhould 
 always be made, in order if pofTible to difcover the 
 caufe of the mifchief, from the removal of which alone 
 a cure can be obtained. 
 
Seel. III. Of Hernia, 2 1 
 
 In this manner, I have, in different inftances, faved 
 the lives of patients, who otherwife 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 attradt attention even from the patient. 
 
 SECTION III. 
 Of the Hernia Congenita. 
 
 FROM the anatomical defcription given in the firft 
 fedion 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 necefi'arily be contained in a bag or fac 
 perfedlly diflin£t 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 contad 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 paflTage with the teilicle, that the parts ip pro- 
 truded muft be in immediate contaft 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 otkerwife be explain^ 
 
22 Of Herma. Chap. XXIII. 
 
 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 contact with the teflicle, is 
 a circumflance 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 jiefcents ; and when fymptoms of 
 of ftrangulalion 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 llrangulation 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 j 
 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 necelTary in dreffing the wound than in other ca- 
 fes of rupture ; for the teflicle 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 diflrefs and dan- 
 ger. The teflis therefore fhould be immediately en- 
 veloped with its own proper covering, the loofe tuni- 
 ca vaginalis ; aind every drefTmg fhould be fo conduct- 
 ed as to prevent with as much certainty as pofTible the 
 external air from finding accefs. 
 
 In other circumflances the management of the her- 
 nia congenita is the lame with that of any oth^^r rup- 
 ture. 
 
Sea. IV. Of Hernia. 23 
 
 SFXTION 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 pafling out at the fame 
 opening through which the large blood veffels of the 
 thigh are transmitted from the abdomen. 
 
 In the defcription given in the firft fedion of this 
 Chapter, of the external obhque 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 diredion 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 connedted with bone. By the particu- 
 lar fliape of the ileum at this part, a kind of arch is 
 formed, by the ligament pafling over a hollow in that 
 bone, through which the large artery and veins of the 
 thigh find a palTage, the rell of the cavity being filled 
 up with cellular fubftance, glands, and fiit ; 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 compofnig a crural hernia defccnd. In 
 fome inftances they pafs immediately over the femo- 
 ral artery and vein ; in others, they are found on the 
 outfide of thefe veflels ; 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 j fo the 
 
24 Of Hernia, Chap. XXIII. 
 
 fymptoms of crural hernia are fo fimilar to thofe def- 
 cribed in the two firfl fedions of this Chapter, that 
 it is not necelTary to mention them here. 
 
 The cure of the femoral hernia is alfo conducted 
 upon the fame principles with that of bubonocele, de- 
 fcribed in the fecond feftion ; fo that when fymptoms 
 of llrangulation take place in it, the farne remedies 
 fhould be employed that were advifed above for bu- 
 bonocele. Only here, in attempting to reduce the 
 parts by the hand, the preiTure fhould be made di- 
 reftly upwards, inftead of obliquely outwards, as was 
 advifed in the other ; and when thefe means do not 
 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 neceflary in the crural hernia, 
 from the parts concerned in it being more deeply 
 feated. By timidity in making the firil incifion, the 
 operator is frequently much incommoded in all the 
 fubfequent parts of the operation. The external cut 
 Ihould extend at leafl from an inch above the upper 
 end of the tumor to the fame length below the mofl 
 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 flate for redudion, 
 we fhould immediately attempt to replace them ; and 
 as the fpace below the ligament through which they 
 have paflfed is confiderable, this may commonly be 
 done without dividing it, merely by prefTure properly 
 applied with the fingers, while the patient is placed in 
 the pofture directed above for the operation of the bu- 
 bonocele as being befl 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 ^nd epigaflric artery with 
 
(Sea. IV. Of l-lcrnicz. 25 
 
 refpect to this ligament, any cut made into it is done 
 Tifith the rifk of thefe veffels being injured. 
 
 The fpermatic veffels in pafling 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- 
 yifion of the ligament without cutting tlieui acrofs. 
 
 We have been advifed indeed by fome, in order to 
 avoid the fpermatic veffels, which they allow would 
 be wounded, if the incifion fliould be carried directly 
 upwards, to cut in an oblique dircftion outwards. 
 They admit, that in this way the epigaftric artery may 
 probably be divided ; but the rilk 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 Ihould 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 fliapes 
 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 
 profellion fliould 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 Hgature, one would expect to be 
 the eafieft of all operations ; but the dirficulty 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 veflels 
 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 prcfent ftate of Surgery. 
 
a6 Of Hernia. Chap. XXIII. 
 
 ■whether the incifion is carried direiStly 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 pafllige inflead of dividing the ligament ; 
 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 evei-y cafe of flrangulated hernia, that the 
 palfage through which the parts have fallen down is 
 already dilated to nearly its utmoft polTible extent, in 
 fiich a fituation to attempt a farther dilatation, without 
 the afliitance of the knife, would feldom, it is proba- 
 ble anfwer any good purpofe. 
 
 A confiv^erable time ago it occurred to me, that in 
 this part of the operation fome alfiftance might be de- 
 rived from performing it in the follovdng manner ; 
 and having fince had occaiion to put it in praftice 
 with fuccefs, I can now V\1th fome confidence recom- 
 mend it. Inftead of dividing the ligament in the or- 
 dinaiT 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 firfl fcratch with the fcalpel fhould be flight ; 
 but by repeated touches, it fliould be made to pene- 
 trate almoffc through the whole thicknefs of the liga- 
 ment, till at lafr only a thin layer of it remains : in 
 this fituation the protruded parts may for the molt 
 part be returned with eafe, as the ligament where thus 
 weakened by the incifion will yield gradually to the 
 prcffure applied for the reduction of the iiiteifines. 
 
 As in this manner the opening may be enlarged to 
 any necefiary 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 lig:\mcnt under which thcfe blood veiftls 
 lie, they are thereby kept free from danger during 
 
Soft. V. Of Hernia. 27 
 
 tliis part of the operation ; and the preffure afterwnrJs 
 ufcd for the redudion 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 
 e'afily admit of much more extenfion than is here re- 
 quired. 
 
 In every other circumflance, the crural hernia, as I 
 have obferv^ed already, requires the fame method of 
 treatment with bubonocele, for Vv'hich the fecond Sec- 
 tion of this Chapter may be confulted : only I may 
 remark, that the dreflings 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 fliould 
 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 diredions given above, it may be al- 
 ways done. 
 
 SECTION V. 
 
 Of the Exomphalos, or U/nbilical Rupture. 
 
 IN this variety of hernia, the parts protruded from 
 the abdomen pal's out at the umbilicus ; and the 
 contents of the hernial fac are here, as in every other 
 rupture, exceedingly various. In fome inftances they 
 confifl of inteflines 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. 
 
88 Of Hernia, Chap. XXIIL 
 
 As all thefe parts are naturally contained in the pe- 
 Htonceum, the hernial fac, it is evident, mud here as in 
 other ruptures be formed by that membrane being 
 carried along 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 connedted 
 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 actually to burJl the furrounding 
 parts ; not only the fac, and cellular fubitance, but 
 even the fkin itfeif. 
 
 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 lafl months 
 of pregnancy are particularly liable to this rupture. 
 
 If attended to in due time, a right bandage will 
 commonly efTccb 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 czl- 
 nal are occafionally met with in umbilical ruptures ; 
 yet by experience we know, that mod: frequently they 
 contain omentum only : hence umbilical herniee 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 puflied out, by 
 which the ufuai fymptoms of ftrangulaticn are apt to 
 
Sea. V. Of Hernia, 29 
 
 be induced. In this fituation, when the means ufual-' 
 ly employed for returning the gut do not fucceed, as 
 a ftrifture of the pafTage through which it has fallen, 
 is to be confidered as the fole caufe of the danger ; fo 
 a cure, it is evident, mud depend entirely on this be- 
 ing removed. In performing this operation, a free 
 external incifion along the courfe of the tumor is the 
 firft ftep 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 effeded but by enlarging the paflage into the ab- 
 domen, it may be done with fafety by introducing the 
 fmger, and enlarging the opening with a blunt point- 
 ed biftouiy. This incifion, I may remark, may be 
 made with almoft equal fafety in any direftion ; but 
 left the ligament formed by the umbilical veifels 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 carr}^iiig 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 reduftion improper, the diredtions 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 
 pafled 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 
 
30 Of Hernia. Chap. XXIH/ 
 
 the tumor, near to its centre, and the ligatures afrer- 
 wards tied one above and the other below, of fuch 
 tightnefs as to induce the wifiied for effect. 
 
 But as the pratlice thus recommended did not an- 
 fwcr the purpofe, for it did not prevent a return of 
 the difeafe, and as the deilrudlion of fkin rendered 
 every future defcent more dangerous, fo it is now, at 
 leaf): by regular praditioners, very univerfally ex- 
 ploded. 
 
 In Plate LXV. fig. 3. is reprefented the befl ban- 
 dage I have ufed for umbilical heniiss. 
 
 SECTION VJ. 
 
 Of Ventral Hernia. 
 
 IN ventral hernia the parts forming the tumor arc' 
 protruded between the interflices of the abdominal 
 mufcles. No part of the abdomen is altogether ex- 
 empted from thefe tumors, but they are moll frequent 
 in the parts mofl contiguous to the linea alba ; and 
 when the flomach 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 
 conflant ufe of a trufs ; and, again, when fymptoms 
 of (trangulation occur, which cannot be removed but 
 by an incifion through the ftricture, this muft be done 
 in the m?.nner pointed out in the laft feftion, 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. VII. Of Hernia. 3t 
 
 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 difcafe ; but as it has been 
 met with, it is neceflary to defcribe it. 
 
 The fymptoms of this hernia being very fimilar to 
 thofe arifing from ftrangulated inteftines 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 perina;um ; 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 peclineus mufcle and the firfl head 
 of the triceps femoris. 
 
 The foramen ovale being partly filled up by a mem- 
 branous or ligamentous fubltance, 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 vell'els 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 vefl'els. 
 
 The general mode of treatment pointed out in the 
 preceding fedlions for other hernia!, 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 pafTage 
 through which they protrude. The tumor, however, 
 that takes place here, being in general fo fmall as 
 fcarcely to be noticed but by the mod minute atten- 
 
32 Of Herma. ^ Chap. tXIlL 
 
 tlon, unlefs a local pain, \\i\h the ufual fymptoms of 
 a ftrangulatcd gut happen to lead to it, it is feldoui 
 difcovered from its fize, till it is too late to expedt 
 much affiilance from art. 
 
 But whenever the operation becomes neceffary, as 
 it mufl always be when fymptoms of flrangulation 
 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 ihe pafiage, and as death mufl enfue ire- 
 duction canhot be accompliflied, it ought undoubted- 
 ly to be attempted : but as it is almofl impoflible to 
 enlarge this opening with an inflrument, 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 impracticable ; 
 it is more advil'able, by means of a flat hook, to dilate 
 the paflage to a fufficient fize, by gentle gradual 
 ftretchingv By infmuating the end of the hook be- 
 tween the inteftine and ligament, and pulling it gra- 
 dually upwards, a degree of dilatation may be obtain- 
 ed, fufficient for the reduftion of the gut, without in- 
 curring that hazardAvhich the divifion of the ligament 
 with the knife or any fharp inftrument mud always 
 occafion. A hook for this purpofe is delineated in- 
 Plate LXVr. fig. 2. 
 
 SECTION VIII. 
 
 Of the Hernia C-^fica^ or Hernia of the Urinary 
 
 Bladder. 
 
 N this rupture, the urinary bladder is the organ 
 protruded ; and the fituations in which it occurs, 
 are either the groin and fcrotum through the opening 
 in the external oblique mufcle of the abdomen j the 
 
.Sea. VIII. Of Hcrni<z, 33 
 
 forepart of the thigh under Poupart's ligament ; or 
 the perinaeum through fome of the mufcular mter- 
 ftices of that part.* Inftances have likewife happen- 
 ed, of the bladder being pufhcd into the vagina, lb as 
 to form hernial tumors of confidcrablc 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 infmuate itfelf be- 
 tween that membrane and the abdominal mufcles, it 
 is evident, that the hernia cvRica cannot be covered 
 with a fac, as inteitinal ruptures ufually are. In the 
 perina:um, again, that portion of the bladder mofl: 
 liable to fall into it, is in no way conncfted with the 
 peritonaeum. • 
 
 In fome inftances; this rupture occurs by itfelf, 
 without any complication ; and in others it is accom- 
 panied with inteliines and omentum, both in inguinal 
 and femoral hernijE : when comphcated with a bubo- 
 nocele, the protruded portion of the bladder lies be- 
 tween the hernial fac and fpermatic cord j that is, the 
 inteftinal hernia lies anterior to it. 
 
 The ufual fymptoms of this hernia are, a tumor, 
 attended with fluctuation, either in the groin, in the 
 forepart of the thigh, or perinasum, which gradually 
 fubfides when the patient voids urine, and becomes 
 larger when the bladder is full. When the tumor is 
 large, before v/ater can be paiTed 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 elevated as poffible ; but when 
 the tumor is fmall, and efpecially when no ftrifturs 
 has taken place, the patient generally voids urine eafi- 
 ly, and without afliflance from external prefiure. 
 
 When a hernia of thd bladder takes place without 
 any complication, it commonly proceeds from a fup- 
 
 • An inftance of this is recorded in vol. iv. of Mcmoircs de I'Acadeinie 
 Rovale dc Cliirurglc, by Mons. Pipt'lct Ic Jcunc, p. iSi. *■ 
 
 VoL.JII. D 
 
34 Of I-Icrnicc. Chap. XXIII. 
 
 preflion of urine. In the method of cure, there- 
 fore, every caufe of fuppreffion Ihould, as far as pof- 
 fible, be guarded againlt ; 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 neceflary, a 
 fufpenfory bag, fo fitted as effect ually to fupport the 
 tumor without comprefling 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 preffing with the fingers from the vagina, de- 
 fcentS in future may, in general, be prevented by the 
 ufe of the pefTary 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 j a fpecies of rupture fometimes 
 met with. 
 
 It may happen, however, if inflammation occurs 
 here, that the divifion of the parts producing the flric- 
 ture will be as neceffar)- as in any other rupture. In 
 which event, the mode of operating pointed out in the 
 preceding feftions fhould be kept in view. Only it 
 muft be remembered, that as in the hernia cyflica 
 vvithou-t any complication, the protruded parts are not 
 covered with a fac, fo ftill more caution is required in 
 laying them bare, than is neceflary in common rup- 
 tures. 
 
 It fometimes happens, that ftones are produced in 
 the protruded portion of the bladder. In which event, 
 if it ihould ever be necelfary to cut into them, if the 
 bladder can be eafily retained In its prolapfed flate till 
 the wound is healed, it ought always to be done, in 
 order to prevent that internal extravafatlon of urine 
 which otherwife would occur, and which certainly 
 WQukl do harm. The fame precaution is neceifary. 
 
Sed. VIII. 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 bcfl accounts of all the varieties of hernia are to be met with in 
 the works of Le Dran, Heiftcr, and of Maiichart, in a Treatife de Hernia 
 Incarcerata ; in the diflerent volumes of Memoirts dc I'Acadcmie Rovalc 
 de Chirurgie dc Paris ; in the Medical HiTays of Edinburgh ; in the works 
 of the late Dr. Monro; in Hdller de Hernia Congenita, in his Opufcula 
 Patholoj^ica ; in Mr. John Hunter's very accurate account cif the flate of 
 the teftis in the foetus, to be met with in Dr. Hunter's Medical Commen- 
 taries ; in Mr. Pott's and Dr. Richter's valuable works on this fubjecl. 
 Thefe are the befl modern authors on this fubjeiit; and very little fatis* 
 faction is to be obtained from any of the ancient writers upou iu 
 
 D 2 
 
,36 On the Hydrocele. Chap. XXIV. 
 
 CHAPTER XXIV. 
 
 ON THE HYDROCELE. 
 
 SECTION I. 
 
 General Remarks on the Hydrocele. 
 
 EVERY tumor formed by a colle6lion of water, 
 may, from the import of the word, be called a 
 hydrocele, but, in chirurgical language, the term im- 
 plies a v/atery 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 hernise, from the refemblance which 
 they bear to the true hernia, or rupture ; but no ad- 
 vantage is derived from this diftindion : and, as it 
 arofe from an erroneous opinion of the origin of her- 
 niae, I fhould not have taken notice of it here, but 
 with the view of making the writings of the ancients 
 upon this fubject intelligible. 
 
 Indeed, the doclrines of the writers of the lall and 
 preceding centuries concerning hydrocele, are fo con- 
 fufed and perplexed, that they do not merit attention j 
 for, as they were ignorant of the anatomy of the parts 
 in which the difeafe is feated, the ideas which they 
 formed of it, gave rife both to an erroneous patholo- 
 gy and pernicious practice. Not being acquainted 
 with the ilru6ture of the parts aflected, they proceed- 
 ed with much unneceffary dread in the treatment of 
 the difeafes to which they were liable ; for, by fup- 
 pofing an immediate connection to fubfift between the 
 -coats of the teHide, the cavity of the abdomen, liver. 
 
Sed:. L On the Hydrocele, 37 
 
 kidneys, and other vifcera, they were induced to con- 
 fider the colleftion 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 prav}:ice was timid and 
 indecifive ; fo that eveiy 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 Ceh'us to the middle of the lad 
 century, little progrefs fcems to have been made in 
 this part of chirurgical pathology. Indeed, from Cel- 
 fus downwards, authors feem to have copied almoll 
 exaftly from one another, till Wifeman, Le Dran, 
 Garangeot, and Heifter, gradually elucidated the fub- 
 jeft : but it was not clearly underdood till the dif- 
 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 underflood than it other- 
 wife would be. There is perhaps no part indeed of 
 furgery with which Undents in general are fo little ac- 
 quainted. 
 
 Nothing but a ftrid attention to the difcoveries of 
 late anatomifts, can convey clear and diftind ideas 
 concerning them ; and, whoever will make hlmfelf 
 acquainted with thefe, will iind, that the hydrocele 
 and affedions of the teftes, may be explained with as 
 much clearnefs and funplicity as any other clafs of 
 difeafes. In the lirft Section of Chapter XXIII. I 
 gave a defcription of thef(? parts, in fo far as was ne- 
 ceflary for the confideration of hernia. Referring to 
 what I had then occafion to fay, commencing in page 
 527, and ending page 533, Vol. II. I have now only to 
 add what may be necellary for underftanding more 
 completely the difeafes of the teftes, and their tunics, 
 
38 On the Hydrocele. Chap. XXIV. 
 
 As from the forefaid defcription It appears, that the 
 teflis 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 peritoncEum, it mud of 
 neceffity be ftill connected with that membrane, in the 
 fame manner as while it remained in the abdomen. 
 And accordingly we find, that, although the tefliclc 
 lies loofe in this fac, or vaginal coat, in every other 
 part ; yet, along its poflerior part, it is firmly attached 
 to it. At this part, the different veffels of the teftis 
 ftill enter ; and at this the peritonaeum, or what is 
 now the tunica vaginalis, is reflefted over it, and eve- 
 ry where clofely attached to it, thereby forniing the 
 tunica albuginea, or immediate covering of the tefti- 
 cle ; fo that the tunica albuginea is demonflrably a 
 mere continuation of the other, or vaginal coat. 
 
 The inferior part of this procefs of the peritoneum 
 being fomewhat wider below than above, leaves the 
 tunica vaginalis of a pyramidal form ; and it is alfo 
 fomewhat longer than the teflis, reaching from the 
 fuperior part of the epididymis, where it begins, to a 
 little below the inferior point of the teflicle, where it 
 terminates. It is altogether of fuch a fize as to allow 
 the teflis to roll eafily within it ; its principal ufe ap- 
 pearing to be, to retain a fmall quantity of a fine ex- 
 halation, which is conflantly fecreting, either from its 
 own furface, or from the furface of the tefl:is itfelf, for 
 the purpofe of keeping the latter moifl 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 teflis, yet no fuch cover- 
 ing is, on diffeclion, 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 teflicle y and a 
 
Se£t. I. 0)1 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 teflis, I have given a 
 more particular account of them, than is neceflary in 
 fpeaking of the teftis itfelf ; with refpect to which, I 
 {hall only obferve, that it is evidently very vafcular, 
 being compofed almoft entirely of diiferent convolu* 
 tions of veflels. 
 
 Befides the vaginal coat proper to each tefl:icle, the 
 two teftes have for their further proteftion, a more 
 external covering, the fcrotum ; a bag formed almoft 
 entirely of fkin and cellular fubflance ; for that body, 
 the dartos, which has been commonly dcfcribed 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 fubltance 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 eft'ufions, 
 to which the more external parts of the fcrotum are 
 liable. 
 
 This ftrudure of the fcrotum it i^ necefl!ary to be 
 acquainted with, as, from the defcriptions which, till 
 of late, have been given of it, young practitioners 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 collect- 
 ed, I fhall now proceed to confider the difl;'erent vari,, 
 eties of the difeafe. 
 
40 On the Hydrocele. Chap. XXIV. 
 
 All the varieties of hydrocele which have been men- 
 tioned by authors, mav, I think, be comprehended 
 \inder the two loUowing, the anafarcouSy 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- 
 lected in any particular cavity, but occupies equally 
 all the cells of the part : in that which I term encyft- 
 ed, tiie warer is collected in one diftinct bag, and a 
 fluclLHition of a fluid is, in general, perceived in it. 
 The fcrotum, with its contents, the teflicle 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 Ihall fnlt confider thofe of the 
 fcrotam. 
 
 SECTION II. 
 
 Of the Anafarcous Hydrocele of the Scrotum, 
 
 T'HE fcrotum, from its cellular ftrudlure, and im- 
 mediate connedticn v/ith the trunk of the body, 
 is apt to partake of every difF''^:ibls fvvelling v/ith 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 aftecling 
 the fcrotum. A local anafarca of the fcrotum, is 
 fometimes indeed produced by a local caufe, to wit, 
 by the prcfiare of a tumor on the lymphatics of the 
 part ; by external injuries ; and occafionally 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 collected In any confiderable 
 quantity in the fcrotum, a foft, ineladic, colourlefs tu- 
 mor is obferved over the whole of it ; imprefiions are 
 eafily received and retained for fome time ; the fkin 
 
Sea. n. Gn the Hydroceb. . 41 
 
 at firfl preferves Its natural appearance ; and the ru- 
 t^as of die Icrotiim, which, in a ftate of health, are ob- 
 vious, are not for fome time much altered ; but as the 
 fweliing advances, the rugj^ gradually disappear, till 
 at hill they are totally obliterated : the tumor, from 
 being at firfl foft, and of a confiflence fimilar to dough, 
 by degrees turns more firm, and the fkin at lafl ac- 
 quires an unnatural white fl:uning appearance. At 
 length it becomes large ; and although originally con- 
 fined to the fcrorum, it at lafi: fpreads up the groin : 
 the penis likewifc becomes afltxted, and often fo fwell- 
 ed and diftorted, as to excite much inconvenience and 
 diftrefs ; and although the fcrotum is compofed of 
 parts which readily adijiit of dilatation, yet, in fome 
 inlfanccs, the tumor becomes fo enormous, as to burfl 
 from one end to the other. 
 
 Thefe appearances of the difeafe are fo charafterif- 
 tic, as to render it almoft impolTible to confound this 
 fpecies of hydrocele with any other tumor of the fcro- 
 tum. 
 
 I have already obfcrvcd, that inflances fomctimes 
 occur, of the fcrotal anafarca being produced by a lo- 
 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- 
 it of body, by which it was at firft produced. 
 
 The treatment of this difeafe of the fyfbem falls to 
 the province of the phyfician, fo that I fliall not enter 
 upon it at prefent ; but the aid of furgery is frequent- 
 ly required, for relieving the diftrefs which thefe tu- 
 mors always induce when they become large. In thefe 
 circumftances, the objeft of furgery is, by drawing off 
 the water, to diminiil-i the fize of the tumor, or even 
 to remove it altogether, which not only gives much 
 immediate relief, but is a means of the diftended parts 
 recovering their tone more readily than they otherv^'ife 
 would do. Diiferent methods have been prcpofed for 
 evacuating the water ; the introdudion of a feton, pafT- 
 ing a trocar, incifions, and punclures. 
 
42 On the Hydrocele, Chap. XXIV. 
 
 All of thefe, excepting that by the trocar, ferve ve- 
 ry effectually to evacuate the diffufed water ; and 
 therefore we are to adopt that which not only excites 
 leaft pain, but which is leafl: liable to produce trouble- 
 fome confequences ; and this unqueflionably is the 
 method by punctures. 
 
 The fetou and long fcarifications may difcharge the 
 water more quickly than punctures ; but in dropfical 
 conftitutions, fuch as the anafarcous hydrocele is com- 
 monly connected with, they almoft conftantly do harm. 
 For the firfl two or three days, fcarifications give> the 
 patient much fatisfadtion : the v/ater is almoft entirely 
 discharged, the tumor is of courfe greatly diminiflied, 
 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 rednefs fpreads over the neighbouring 
 parts. 
 
 That fretful uneafmefs at firft complained of, ter- 
 minates at laft in what the patient terms a burning 
 kind of pain, which frequently becomes fo tormenting, 
 as entirely to deilroy reft ; and it too commonly hap- 
 pens, that all our remedies fail in preventing the ac- 
 ceflion of gangrene, by which the patient is in gener- 
 al carried off. 
 
 I will not fay that fcarifications always end in this 
 fatal way ; but I have in many inftances found that 
 they did fo ; and, on the contraiy, although punctures 
 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 fufpect 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 flioulder of a lancet : they ftiould pen- 
 etrate the cutis vera, but ftiould not be carried to a 
 greater depth, ar.d they fnould not exceed an inch in 
 
8e£l. 11. On the Hydruek. 43 
 
 < 
 
 length : pun6liires flioiild be carried to the fame depth ; 
 and they, as well as fcarifications, fliould be always on 
 the molt prominent and moft depending parts of the 
 tumor : punftures are bell made with the point of a 
 lancet : live or fix 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 necefl'ary attention ; indeed, the want of 
 it feems often to be the caufe of much of the niifchief 
 that enfucs from this operation. 
 
 When cither fcarifications or punftures go wrong, 
 by beginning to inflame and turn painful, inftead of 
 the warm emollient poultices and fomentations ufually 
 employed, a cold faturnine folution applied upon foft 
 linen, not only proves more effeclual 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- 
 flances, notvvithftanding all that we can do to prevent 
 it : in this cafe, we truft chiefly to the internal ufe of 
 bark, wine, and other tonics, and to warm drelTings 
 and other external applications ufually employed in 
 gangrene : as this variety of gangrene is almofh always 
 accompanied with much irritation, I often give opium 
 with advantage : opium proves chiefly ufeful, by re- 
 moving pain and general irritability ; but as we know 
 from experiment, that it afts as an antifeptic, it may 
 in fome cafes ftop the progrefs of gangrene, by afting 
 directly on the difeaied parts. 
 
 In a great proportion of cafes, the utmofl: danger is 
 to be dreaded from the punctured parts being attack- 
 ed with gangrene ; yet, in a few inflances, very unex- 
 pected cures are obtained, after all the teguments have 
 been deflroyed by it. A remarkable inflance of this 
 occurred fome years ago, in the Royal Infirmary here ; 
 
44 On ihe Hydrocele. Chap. XXIV. 
 
 the whole fcrotum feparatcd, and left the tefticles bare. 
 During the time that the fore remained open, all the 
 water collected 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 teiles became enveloped 
 with a thick cellular fubdance, which ferved as a very 
 good means of protedlion. It mud have been fome 
 fimilar produdlion, 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 inflances, 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 obftruci:- 
 ing the pafTage of the lymphatics. In this cafe, if the 
 tumors producing the obftruftion can be extirpated, 
 no other means will afford fuch effectual relief; but, 
 when fo deeply feated as to render any attempt for re- 
 moving them unfafe, the practice I have pointed out, 
 of making punftures in the moil depending part of 
 the tumor, rnull be employed, from time to time, to 
 palliate the fymptoms. 
 
 It has fomctimes happened, in fuppreffion of urine, 
 whether arifing from ftri6tures in the urethra, or from 
 ftones impacted 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 diminiih till the caufe by which it is produced 
 is removed. 
 
 In order to prevent the formation of finufes, which, 
 in fuch circumilances, v/iil otherwife be apt to occur, 
 an incifion Ihould be made into the moft depending 
 part of the fcrotum, and carried to fuch a depth as is 
 fufiicieiit for reaching the wound in the urethra. In 
 
 • Olfcrvat. Chirurg. Cent. 5, Obf. 76* 
 
Sed. It Oh the Hydrocele, 45 
 
 this manner, a free vent will not only be given to the 
 •urine ah-eady diflufed, but the further colleclion of it 
 may probably be prevented. If a (tone impacted in 
 the urethra is found to be the caufe of the eft'ufion, it 
 fhould be cut out ; and, if the obflruclion is produced 
 by llridlures, 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 aft'eftion, by dreff- 
 ing the fore properly, with foft 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 complicated with any general 
 affeftion, particularly with lues venerea, neither mer- 
 cury nor any other internal medicine, will remove 
 them. 
 
 Cafes of this kind mufl have occurred to every prac- 
 titioner. I have met with them, both in the hofpital 
 and in private pradice ; where, notwithftanding all 
 the internal remedies that v/ere employed, the paflage 
 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 hyi'ocele 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 palTage outwardly, muft ne- 
 ceffarily dift'ufe itfelf over the fcrotum. Different in- 
 ftances of this have been met with, tv/o of which are 
 related by Douglas ;* and others have fliUen within 
 my own obfervation. A fwelling of a fimilar kind is 
 alfo fometimes induced by the w-ater of the hydrocele 
 of the tunica vaginalis being improperly drawn oli in 
 the operation of tapping. When the orifice in the 
 fkni is allowed to recede from the opening in the va> 
 
 " Trcitifi: «a the Hydrocele, by John Douglas, p. 8. 
 
46 On the Hydrocele. Chap. XXIV. 
 
 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 collection difiufes itfelf through 
 the cellular fubftance of the fcrotum, an inconveni- 
 ence that may be always prevented, by ufmg 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 diftufed ferum, but for ef- 
 fecting a radical cure oi the hydrocele of the tunica 
 vaginalis. 
 
 Some have imagined, that danger may enfue 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 eifedual relief, by performing the radical 
 cure at once, than to fubjecl him, in the firil inftance, 
 to a good deal of confinement, for removing the dif- 
 fufed fwelling of 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 aflifl the difcuffion of the tumor, 
 by fufpending the fcrotum ; confining the patient to a 
 horizontal pofture ; and by the apphcation of aftrin- 
 gents to the parts affected. Of thefe we have a great 
 variety ; but 1 have found none anfwer fo well as a 
 cold folution 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, foakcd in equal parts of cold water, ^ 
 vinegar, and brandy. 
 
 I have thus confidered all the varieties of anafar- 
 cous tumors, to which the fcrotum u liable, together 
 
Se6t. IL On the Hydrocele. 47 
 
 with the mode of treatment that appears to be adapt- 
 ed to each of them ; for, with refpeft 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 collected 
 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 encyftcd 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 coUeded in the fac of a her- 
 nia. 
 
 SECTION III. 
 
 Of the Hydrocele of the Tunica Vaginalis Tejlis* 
 
 WHEN treating of the anatomy of thefe parts, 
 I had occafion to remark, that, in a (late of 
 health, an aqueous fecretion is always found in the 
 tunica vaginalis ; the principal ufe of which feems to 
 be, to lubricate, and keep thq furface of the tefticle 
 foft and eafy. 
 
 In a flate of health, this fluid is abforbed by the 
 lymphatics of the part, its place being fupplied by a 
 frefli fecretion ; but, m difeafe, it frequently happens, 
 either that the fecretion of this fluid is morbidly in- 
 creafed, or the powers of the abforbing veflels of the 
 part arc diminiflied. The efictt of either of thefe 
 caufes muft be, to induce a preternatural colleftion in 
 the cavity of the vaginal coat ; and thus the variety 
 of hydrocele is produced that we are now to confider. 
 
 The fyniptoms induced by it are thefe : a foft col- 
 ourlefs tumor is at firft perceived at the inferior point 
 
48 On the Hydrccclc. Chap. XXIV/ 
 
 t)f the tefticle ; chiefly remarkable when the patient is 
 erecl : it excites no pain, and it does not become leis 
 by prcfTure. The fliape 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- 
 gae 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 that, 
 although in the early periods of the difeafe, the fper- 
 matic cord may be dillinctly felt ; in its more advanc- 
 ed ftate, it is not eafily diftinguilhed. 
 
 Before arriving at this height, the weight of the tu- 
 mor is for the mofh part conaiderable, by which the 
 fkin of the contiguous parts is dragged fo much down- 
 wards, as to make the penis flirink 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 diftindly felt, 
 is not fo clearly difcovered. On minute examination, 
 however, a hardnefs may always be felt along that part 
 of the fcrotum where the teflis is fituated ; and at 
 this point, preifure excites fome degree of uneafmefs. 
 
 In a great proportion of cafes, the fluctuation of a 
 fluid is obviouily diftinguifhed on prefl^ure. It fome- 
 times happens, hovv^ever, 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 fttuation, is the ordinary cha- 
 racleriftic mark of hydrocele more to be depended 
 on ; I mean the tranfparcncy of the tumor, when ex- 
 pofed to the light of a candle, or of the fun. In the 
 fc^.-.ly ftages of the difeafe, when the contents of the 
 tumor are not difcoloured, and the vaginal coat has 
 not acquired much thicknefs, the fluid contained in it, 
 on being expofcd to this trial, ufually appears tranf- 
 parent j and,, in meeting with this, we ncccif:irily con- 
 
SeS:. III. On the Hydrocele, 49 
 
 fider it as a corroborating proof of the exiflence 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, mufl, in proportion to this effect, inval- 
 idate the certainty of the tefl. 
 
 During the whole continuance of the difea^e, the 
 patient does not complain of pain in the tumor itfelf ; 
 but fome uncafmefs is commonly felt in the back, by 
 the weight of the tumor on the fpermatic cord. This, 
 however, is generally prevented cntirelv, 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 inflan- 
 ces, however, we meet with a double hydrocele, when 
 the tumor occupies the cavities of both tunicce 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 mod certainly 
 tend to charadlerize and diftin^uifli them. Thefe dif- 
 
 o 
 
 ea^cs are, all the varieties of fcrotal hernies ; the ana- 
 farcous hydrocele of the fcrotum ; the encyfi;ed hy- 
 drocele of the fpermatic cord ; the farcocele, or fchir- 
 rous teilicle ; and the hernia humoralis, or inflamed 
 teflis. 
 
 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 fluctuation of a fluid 
 is diltingiiifiied through its whole extent. Prefigure 
 does not make the fwelling recede, nor is it afiecled 
 by the pofture of the patient, if* it be not on its very 
 firfl: approach : whereas, in hernia, befides pain, fick- 
 
 VoL. III. E 
 
50 On ihe tlydroccJe. Chap. XXIV.- 
 
 nefs, and other affeclions of the flomach and bowels 
 which commonly take place, the tumor begins in the 
 groin, and only at lafl proceeds to the fcrotum. It 
 has not the pyramidal form of a hydrocele. It is fre- 
 quently foft and compreflible, giving a fenfation fimi- 
 lar to what we receive from prelfure upon dough ; but 
 no equal or diftinft Hu6luation is perceived in it. In' 
 mofl inflances, the tumor can be made to recede, ei- 
 ther altogether or in part, by moderate preflbre, and 
 putting the patient in a horizontal pollure ; and irk 
 hernia dcfcending to the fcrotum, the fpermatic cord 
 can never be clearly diftinguiflied. 
 
 However improbable it may appear, this variety of 
 hydrocele has, in fome inflances been confounded with 
 anafarcous tumors of the fcrotum ; but the means of 
 diilindion are fo evident, from the hiftory which I 
 have given of the two difeafes, that it is not here ne- 
 ceflary to enter farther upon the fubjeft. It muft, in- 
 deed, be grofs inattention only that can ever make 
 the anafarcous hydrocele be miftaken for any other 
 difeafe. 
 
 From the encylled hydrocele of the fpermatic cordy 
 it may commonly be diftinguiflied by the teflicle in 
 the latter being plainly felt at the under part of the 
 tumor; whereas, in this difeafe, the teflis is feldonx- 
 dlfLlndlly 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. I'his I fufpeded to be the effed: 
 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 tliis tefl;icle, the effeft of a bruife. 
 
 In the encyfi:ed hydrocele of the cord, the tumor 
 firfl appears above the teflicle, and by degrees fall? 
 downwards j while the very reverfe happens in the hy- 
 
Seft. ni. On the Hydrocele, 51 
 
 drocele of the tunica vaginalis, in which the tumor at 
 firft always forms below, and from thence proceeds 
 upwards. 
 
 . In a few inftances, thefe two varieties of hydrocele 
 have been known to exifl: at the fame time in the lame 
 patient. In this cafe the ferum, although colleftcd in 
 two diflinft cyfts, gives the appearance of one uniform 
 tumor ; and a fluctuation is diftindlly felt from one 
 end of it to the other. But, in any inflance that I 
 have feen of this combination, the tumor has been 
 fomewhat contraded, having rather a lefs diameter at 
 that part where the two colledions are feparated from 
 each other ; fo that, where this appearance takes place, 
 we may, in general, fufpect that the ferum is collect- 
 ed in two diltintt bags. This, however, does not al- 
 ways happen ; for occafionally I have met with this 
 appearance where the difeafe was fixed in the tunica 
 vaghialis alone. 
 
 The circumflances which mofl clearly diflinguifli 
 hydrocele from a fchirrous tefticle are thefe : in the 
 latter the fwelling is hard ; it does not yield in any 
 degree to prefllire ; 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 prelTure ; its furface is fmooth ; 
 little or no pain takes place j and the tunior is light 
 in proportion to its bulk. 
 
 Thefe ditferences will always ferve as a fufficient 
 means of diflindlion between this fpecies of hydrocele 
 and a pure unmixed farcoccle. But when a fchirrous 
 tefticle is combined with an eflufion of water into the 
 tunica vaginalis, forming what has very properly been 
 termed a hydro-farcoccle, the means of diflinction are 
 not fo obvious. In the incipient ftate of thefe efFu- 
 fions, the difference between the two difeafes is fuf- 
 ficiently apparent j but, when far advanced, the mod 
 attentive obferver often finds it difficult, and fometimes 
 
 £ 2 
 
52 0?i the Hydrccek, Chap. XXIV. 
 
 impofiible, to mark the diftindlon. In fuch doubtful 
 cafes, however, by proceeding in the cautious manner 
 to be afterwards pointed out, no detriment will occur 
 to the pati;::nt, from any uncertainty that may take 
 place. 
 
 From the hernia Iiumeralis, 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 affection of the urethra.* 
 The (kin is more or lefs afte<Sted with an inflammato- 
 ry rednefs ; it is attended with much pain, efpecially 
 on being handled, and the tumor is hard and hrm, fo 
 that no fluctuation 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 diftinguifli it. 
 
 In forming a prognofis of this difeafe, v/e fliould be 
 chiefly directed by the habit of body of the patient. 
 In a great proportion of cafes we are to confider it as 
 a local affedion j and, in this fl:ate the mofl fiivoura- 
 ble expedations 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 confl.itution is not very unhealthy, it 
 may at all times be advifed with a very fair profpe(5t 
 of fuccefs. 
 
 In the radical cure of the hydrocele, in whatever 
 way it is done, fome pain wdll be excited ; the parts 
 will inflame, and of* courfe fome degree of fever will 
 take place. In fome inltances, thefe fymptoms have 
 gone rather fartlier than was v/ifhed for ; but, under 
 the limitations I have mentioned, of an unmixed flate 
 
 * The operation of lithotomy is frccu.ently attended ■'.\-5t}i an inflamma- 
 tion cf one, and fometimes of both teflicles ; probabiv from the inflam- 
 miuion induced by the operation in the neighbourhood of the caput gal- 
 linaginis, bcin? cDmmunicated along the vas deferens to the tcllis. 
 
Sed. IIL On the Hydrocele. 53 
 
 of the difeafe, in a conflltution otherwife healthy, the 
 operation I lliall prefently defcrihe, when properly 
 performed, and the cure thereafter rightly conduded, 
 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 expeft fuch certain fuc- 
 cefs : even in fuch circumftances, however, the opera- 
 tion often fucceeds. I have, in various inflances, 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 pradifed upon the old, infirm, and dif- 
 eafed, that the fymptomalic fever may run too high 
 for the flrength 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 operntion, but to the 
 impropriety on the part of furgeons, in advifing it in 
 patients already perhaps in danger v/ith other difeafes. 
 In fuch circumflances, no operation fliould be per- 
 formed, and the patient fliould be defired to truft en- 
 tirely to a proper ufe of a fufpenfory bandage. 
 
 In judging therefore of the event of a hydrocele, I 
 would fay, that in conflitutions 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 degree of rifk will be nearly in pro- 
 portion to the nature and extent of that diftafe with 
 which the conflitution is aifeded. 
 
 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, Vv'ho 
 
54 On the Hydrocck. Chap. XXIV. 
 
 can more readily fubmlt 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 colle£ted in a hydrocele, is, in 
 fomc inflances 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 effect a radical cure, or a final 
 removal of the difeafe. 
 
 Whatever advantages may be experienced from the 
 life of internal medicines, in dropfy of the conftitu- 
 tion, no practitioner, I beheve, has fo much confidence 
 in remedies of this clafs, as to expect 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 
 ftequently than in the hydrocele. 
 
 We are told, indeed, of this difeafe being cured by 
 different medicines, particularly by the ufe of draflic 
 purgatives ; but, although I have often known them 
 employed, it was never with any advantage, and, 
 when pufhed to any extent they are fure 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- 
 mofl the only way in which purgatives can here prove 
 
Sea. III. On the Hydrocele, SS 
 
 ufeful. Internal medicines, therefore, being found in- 
 effeflual 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 fron\ its fize, if the patient 
 either refufes to fubmit to the operation for a radical 
 cure, or if his ftate of health renders that operation 
 improper, in fuch circumflances, the palliative treat- 
 ment, or a mere evacuation of the water by pundure, 
 is the only means we can employ. 
 
 Two methods are propofed for drawing off the wa- 
 ter in this manner ; by the pundlure of a lancet, and 
 piercing with a trocar. By fome it is alleged, that by 
 the pun6lure 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 infinuate 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 inflances 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 LXXIII. 
 fig. 2. another form of the trocar is delineated, with 
 either of which, an opening may be made in the tu- 
 nica vaginalis -with perfed fafety, and the water with 
 this inffrument being much more freely drawn off 
 than with a lancet, by which effufions are often pro- 
 duced into the cellular fubflance of the fcrotum, the 
 ufe of a lancet for this purpofe ffiould therefore be laid 
 afide. 
 
56 On the Hydrocele. Chap. XXIV. 
 
 The mfi:rument being fixed on, the next point of 
 importance is the part of the tumor in which the 
 puncture 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 
 fnow, 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 body of the teftis, while it would not lefTen 
 the tumor, as it would not reach the cavity of the va- 
 ginal coat in which the fluid is collefted. The trocar 
 fliould be introduced in the anterior and mofl: 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, fliould grafp the tumor 
 behind, in fuch a manner as to pufli the contained 
 fluid as much as pofllble 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 fliould be made through the fl;in, with the 
 flioulder of a lancet, on that point where the trocar is 
 to enter ; but with a flat trocar this precaution of pre- 
 vioufly dividing the fldn is unneceflary. The opera- 
 tor now takes the trocar in his right hand, and hay- 
 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 infl:rument uncovered as may 
 freely penetrate the tunica vaginalis ; and this being 
 puflied in, the ftilette fliould be withdrawn immedi- 
 ately on the end of the canula having entered the cyfl:. 
 The water will now run ofl" ; and, if the tumor is not 
 uncommonly large, it may be all drawn off^ at once ; 
 but when the fwelling is large, as the fudden difcharge 
 of the fluid, by taking away too quickly the fupport 
 which it gave to the veflels of the teftis and vaginal 
 
Seel. IIL Cn the Hydrocele.. ^j 
 
 coat, might endanger the rupture of fome of them, it 
 is belter iVom time io time to (lop the flow of it for a 
 few feconds ; and when the whole is thus evacuated, 
 and the canula withdrawn, a piece of adhefive plafier 
 ihould be immediately applied to the orifice ; and a 
 comprefs of foft linen being laid over the fcrotum, the 
 whole rtiould hz firmly fupported, either with a well 
 adapted fufpenfory, or a proper application oi the T 
 bandage.* 
 
 Tile patient being in this flate laid in bed, all kind 
 of uneafinefs is, in a few minutes, commonly gone, 
 and he goes about his ordinary bufmefs without inter- 
 ruption. In a few infiances, 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 dii'eafe by Mr. Keate, of 
 London, in which fome cafes are related of hydrocele 
 being cured by the external ufe of a ftimulating ap- 
 plication, a ftrong folution of fal ammoniac in vinegar 
 and fpirit of wine. The following is the formula em- 
 ployed by Mr. Keate : 
 
 §,. Sal. ammoniac, in pulv. trit. ^ i. 
 Acet. fpirit. vin. red. fing. ^ iv. 
 
 A quantity of foft old hnen, 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- 
 fion in fuch cafes, may be met with in remarks upon this fubje<St, ia the 
 works of the late Dr. Monro. 
 
58 On the Hydrocele, Chap. XXIV. 
 
 ferent flimulants and aflringents after the operation of 
 tapping, has appeared to prevent the coUedlion from 
 returning fo quickly as it otherwife might have done ; 
 but even this has not been frequent, and in no in- 
 Itance, in the courfe of my obfervation, has it produ- 
 ced a cure. 
 
 With the fame view, 1 have employed a variety of 
 flimulants and aftringents, fuch as volatile liniment, 
 prepared with fix parts of oil, one of camphor, and 
 one of fpirit of hartihorn ; tinfture of cantharides ; 
 the fleams of vinegar : poultices of vinegar and crum 
 of bread ; and compreiles of linen, foaked in brandy : 
 and the practice being neither attended with difficulty 
 or hazard, I mean to continue it till farther experi- 
 ence fliows, 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- 
 pedted ; but we may rcafonably fuppofe, that flimu- 
 lating applications, capable of exciting inflammation 
 in the tefles, may accomplifli a cure, after the water 
 has been drawn off with a trocar. 
 
 Drawing ofi' 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 practitioner may have met with inflances ; and 
 two are related by Mr. Pott, one of which, terminated 
 fatally, and gangrene enfued in the other, which, in a 
 few days, deflroyed not only a good deal of the fcro- 
 tum, but even a confiderable portion of the tunica va- 
 ginahs.* Both of thefe, indeed, occurred in very 
 unhealthy conflitutions ; but it is proper to have it 
 known, that even this operation may, in certain hab- 
 
 • Cafes ixj. and xxii. Trcatife on the Hydrocele. 
 
Sccl. III. On the Hydrocele. 59 
 
 its of body, be produdive of very diftrefsful confc- 
 quences. 
 
 Drawing the water off in this manner, in order to 
 give rehef from the bulk and weight which it produ- 
 ced, would probably be the firfl idea that occurred to 
 praclitioners 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 actual 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 : injecling 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 effeiSting a radical 
 cure ; and a funple incifion of the cyft containing the 
 water, has been praclifed for the fame purpofe. Thefe 
 are the means which, at different periods, have been 
 employed for the cure of hydrocele. Ancient pra6ti- 
 tioners feem to have been acquainted vv^ith 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 afted in eifecling a cure. In confcquence of 
 this, they were applied at random ; and none of them 
 proving in general fuccefsful, the ignorance they la- 
 boured under in the theory of the difeafe, made theni 
 frequently propofe varieties in the method of cure. 
 
 The moderns pofiefs one important advantage over 
 the ancients, from knowing that the water in hydro- 
 cele is contained in a particular cyft having no imme- 
 
6o 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 refpeds, other encylled tumors, with the 
 means of curing which they are well acquainted. 
 
 Both in encyfled 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 encylled 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 teflis. 
 
 In the treatment of encyfled tumors, pra£litioners 
 are now agreed, that befides evacuating the matter, 
 means mud be employed for deftroying the cavity 
 which contained it, otherwife it will colled again. To 
 accom.phili this, different methods have been propof- 
 ed ; fome with a viev/ 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 parts. 
 
 But we know, that unlefs the coats of a cyfl are 
 much extended, hard, or greatly thickened indeed, no 
 part of it fhould be removed. It is alfo knovra, 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 
 likev/ife know, that the cavity of every tumor may be 
 more eileciually deftroyed by producing an adhefioii 
 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, tha.t fome art is required to prevent the 
 adhefion of contiguous inflamed parts, of which every 
 practitioner muit have met with examples. Hence, 
 abfceffes and encyfled tumors are more eafily cured 
 by exciting inflammation over their internal furfaces, 
 after their contents are evacuated, than by any other 
 means ; and, in like manner, it is now known, that 
 the hydrocele of the tunica vaginalis may be treated 
 
Se6l. III. On the Hydrcccle. 6t 
 
 upon the fame principles, and with the fame general 
 efFefts. 
 
 This is the mod fimple idea that can be given of 
 the practice 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 albuginea, the furface of the 
 teflicle. 
 
 Some individuals, indeed, flill proceed upon the 
 fuppofition of a total deflrudtion of the fac being ne- 
 celVary 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 difcafed ; and when it has been diftended 
 to fuch a degree as entirely to have loft its tone, re- 
 moving a part of it may forv/ard the cure, by allow- 
 ing the fcrotum to contraft 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 neceflary 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 wifli to have underftocd, is, that 
 we are not to confidcr it as neceflary, as the fame end 
 may be obtained by much more lenient meafures. 
 
 I fnall now proceed to fpeak more particularly of 
 the fevcral means at prefent moft frequently employ- 
 ed by praftitioners for eifedting a cure, and fhall treat 
 moft minutely of thofc now in general ufe. Thefe 
 arc, excifion of the tunica vaginalis; the application 
 of cauftic J the ufe of a fcton j a ftmple incifion of 
 
63 Onihe Hydrocele. Chap. XXIV/ 
 
 the fac ; and injeding wine and other acrid liquors 
 into the tunica vaginalis, after drawing off the Huid 
 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 practitioners it is 
 Hill continued. The method of doing it is, firfl: to 
 diffeck out an oval piece of the fcrotum, which Mr. 
 Douglas confidcrs 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- 
 celTary 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 teflicle 
 is connected to the fcrotum, fliould be allowed to re- 
 main. On the fac being removed, the parts mufl be 
 dreffed, and treated in every other refpecl in the fame 
 manner as in the operation with the fimple incifion to 
 be hereafter defcribed. 
 
 The cure by caufiic has commonly been conducted 
 as follows : the fcrotum being fiiaved, a piece of com- 
 mon pafte cauitic, properly fecured with adhefive plaf- 
 ter, is applied, of about a ringer's breadth, the whole 
 length of the tumor ; and if, on removing the cauflic, 
 it has not penetrated the tunica vaginalis, an opening 
 is made in it wdth a fcalpel, fo as to evacuate the con- 
 tents, lay bare the tefticle, and admit of proper drefl- 
 ings. 
 
 But Mr. Elfe, one of the latefi: writers in favour of 
 the method of cure by cauftic, fays, that there is no 
 neceflity for fuch an extcnfive application of cauflic 
 as many have recommended ; that an elchar, of the 
 fize of a fliilling, is fufficient ; that this may be always 
 fully obtained by the application of cauftic pafte, of 
 
Sea. III. 0?i the Hydrocele, 6^ 
 
 the fize of a fixpence, which he dire£ls to be laid up- 
 on the anterior and under point of the fcrotuin, and 
 to be properly fecured by adhefive plafter, in order to 
 prevent it from fpreading.* 
 
 The cauflic commonly produces all its effects in 
 the fpace of five or fix hours, and may then be re- 
 moved. At this time, digeftives, or an emollient poul- 
 tice, muff be applied over the fcrotum j 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 fuccecd, he advifes to be kept moderate by 
 bloodletting, injections, 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 vaginahs comes off, when the wound, for the 
 mofl 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 ad\ifed by the 
 late Mr. Pott, who wrote a full and ingenious treatife 
 on the fubjeft : he ufed a trocar ; a filvcr canula, five 
 inches in length, and of fuch a diameter as to pafs ea- 
 fdy through the canula of the trocar ; and a probe, 
 fix inches and a half long, having, at one end, a fine 
 ftcel 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 EfTay on the cure of the hydrocele of the tunica vaginalis 
 teflie, by Mr. Elfc, ad edit. p. 33. 
 
64 On the Hydrocele. Chap. XXIV, 
 
 inents 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 ta 
 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 inllammation leflen- 
 ing, which is generally about the tenth or twelfth day, 
 the feton is begun to be diminifned, when fix or eight 
 threads are v/ithdrawn at every drcfcng ; the drefTmgs, 
 conliiling of nothing more than a fuperficial pledget 
 en each orifice, and a difcutient cerat.*., fuch as the ce- 
 ratum faturninum, to cover the fcrotum. 
 
 In the treatment of the hydrocele with a feton, I 
 fhould wilh to follow Mr. Pott's method, in every cir- 
 cumflance but the mode of introducing it, which is 
 rendered unneceiTarily complex, by the number of in- 
 ftruments propofed for it. Ir> Chapter I. I have de* 
 fcribed the manner of opening abfccifes with a feton, 
 and the direciions then given prove equally applica- 
 ble here. 
 
 Let an opening be made with a fcalpel, a large lan- 
 cet, or fnarp pointed bifloury, in the fuperior part of 
 the tumor, large enough to admit, with eafe, a cord, 
 confiding of about thirty threads of common white 
 fcwing filk. A direflor, 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 m.qft depending part 
 of the tumor, an opening is there to be made, half art 
 inch in length, by cutting on the director with the bif- 
 toury. The diredor 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 
 refpeft, the management of the feton fliouid be the 
 fame with the method defcribed above from Mr. Pott ; 
 
 1 
 
Se£t. III. Un the Hydrocele. 6$ 
 
 or, inftead of introducing the cord with a dire£lor, it 
 may be done with a filver canula and perforator, re- 
 prefented in Plate CXIII. fig. i. 2. and 4. 
 
 By making the firfl: opening in the upper part of 
 the tumor, the inflrument conducing the feton is more 
 eafily introduced along the courie of it, than when the 
 firfl opening is made below ; for, in this cafe, the tu- 
 mor remains diflended to the laft : whereas, when op- 
 ened below, the contents rufli out immediately ; and 
 the vaginal coat collapfes fo much about the teflicle, 
 that I have known it diflicult to get the inftrument 
 iufinuated between them, by which the tefl:is has, in 
 dilferent 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 colleft ; an incifion be- 
 comes neceflaiy, to difcharge it ; and thus the patient 
 is expofed to pain and difappointment, as I have feen. 
 in various inflances, 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 confideratlon 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 afliflants, with the 
 fcrotum lying nearly on the edge of the table, the op- 
 erator, with one hand, fliould 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 mclfion has been properly made, the divided 
 fcrotum will retract, 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 firll incifion commenced, and it may be 
 done either with a lancet, or fharp pointed bifloury, 
 or a fcalpel. This opening (hould be of fuch a fize, 
 as freely to receive the finger of the operator ; which, 
 being inferted, a probe pointed billoury is to be con- 
 duced upon it, and the fac divided to the very bot- 
 tom, directly in the courfe of the firft incifion. By 
 the previous divifion, of the fkin, with the fcalpel in- 
 flead of the bifloury, the operation is done with more 
 accuracy, and lefs pain ; for the fcalpel, from its con- 
 vexity, admits of a finer edge than an inflrument 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 fliortened ; 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 mofl depend- 
 ing p Eitof it, as fome have advifed, the parts cannot 
 be kept fufficiently tenfe for completing the incifion. 
 
 I have defired, that the firfl 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 inflrument, 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 fubflance 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 firfl 
 opening in the upper end of the fac, much trouble and 
 inconvenience is prevented, which always occur from 
 
Sed. III. On the Hydrocele. 6j 
 
 making It below. For, as I have before remarked, 
 when the tumor is firfl opened below, the water is in- 
 ftantly difcharged ; and, as this is followed by an im- 
 mediate collapfe of the tunica vaginalis, the direftion 
 in which it Ihould 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 diflended at the bottom, till the whole is finilhed. 
 
 With a view to fave fome pain to the patient, the 
 late Mr. fTunter 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 ditlerent lengths is 
 inconfiderable, and not to be regarded when compar- 
 ed with the effects that refult from them. When the 
 incifion is carried the full length of the tumor, the 
 operation fucceeds in every inflance, 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 collections 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 diflance 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 tefticlc 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 fnould be immediately re- 
 placed, and covered as quickly as poffiblc from the 
 air ; and if no part of the tunica vaginalis is to be re- 
 
68 On the Hydrocele. Chap. XXIV. 
 
 moved, the drefllng may be finiflitd directly 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, fliould be removed : but when har- 
 dened to the firmnefs of cartilage, as I Iiave more than 
 once feen, as, in this ftate, it is apt to excite pain 
 when applied to the tender furface of the teflis, 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 neceifary ; not once in fifty 
 inftances. 
 
 Hitherto I have been fuppofmg 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 practice is, to do the operation twice in all 
 its parts, both in the fcrotum and tunica vaginaHs, by 
 laying each collection open, from top to bottom, by 
 a double incifion. Some advife both operations to be 
 done at the fame time ; but, in general, practitioners 
 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 m.anner, the pa- 
 tient is expofed to delay, uncertainty, and to the con- 
 finement arifing from two operations. 
 
 This, however, is not neceffary, as the operation 
 may be done on both fides at once, v/ith 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 finifliing the operation on one fide, an open- 
 ing is made into the vaginal coat of the oppofite tefti- 
 cle, at the upper end of it, through the feptum fcro- 
 ti ; and the incifion being carried down to the bottom 
 of the tumor, the cyft is thus equally well laid open. 
 
Sed. III. On the Hydrocele. 6g 
 
 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 (hould be quickly drelVed ; 
 and, I think it right to obferve, tliat, on the manner 
 in which this is done, much of the fuccefs ot 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 dreflings, or, if the 
 divided fides of it are immediately united with futures, 
 as fome have advlfed, partial adhefions are apt to take 
 place, before a degree of inflammation is produced 
 over the whole, fufiicient for rendering the cure com-r 
 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 colledions 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 pracHiice of fluffing the cavity 
 of the fore with dreflings, is alfo a frequent caufe of 
 mifchief. By rubbing, or prefTmg upon the furface 
 of the teflis, fuch a degree of inflammation is fome- 
 times induced, as excites much pain, inflammation, 
 and fever. But this is almofl always the fault of the 
 operator ; for, in a great proportion of cafes, if the 
 dreflings are properly managed, no violent fymptoms 
 ever occur. 
 
 After having tried various ways of drefTmg the 
 parts, the method I have now long purfued, and which 
 in no inflance I have found to fail, is this : the tefli- 
 cle being properly placed in the newly divided fac, 
 two pieces of foft old linen, exactly 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-. 
 
70 On the Hydrocele. Chap. XXIV. 
 
 ficlent quantity of each pledget hanging out of the 
 wound, to admit of its being eafily withdrawn at the 
 firft dreiling ; otherwife, if the fwelHng, which after- 
 wards takes place, fliall be confiderable, they may, for 
 fome days, be entirely covered, and even at lall re- 
 moved with difficulty, as I have feen in different in- 
 ftances 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 teflicle entirely 
 extruded from the fcrotum, and in one inftance, from 
 fufficient pains not being taken to replace it, the cure 
 was completed with the teflis in this fituation ; when, 
 Inflead of being covered with the vaginal coat and 
 fcrotum, it was covered with fcarf-lkin only. 
 
 The beft method of preventing fuch a misfortune, 
 is, to draw the edges of the divided tunica vaginalis 
 and fcrotum nearly together, after the teflis 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 diflances 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. 71 
 
 fible ill the fame poflure ; 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 teflicle, 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 fir ft two or three days after the opera- 
 tion ; but, when thefe fymptoms become violent, and 
 efpecially when much fever is induced, means mult 
 be employed to leflen 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 
 effeftually than any other remedy. By thefe means, 
 the inflammation is in general eafily kept within pro- 
 per bounds ; but where the mode of drefling 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 
 neceflary to advife bloodletting, and very rarely fo-r 
 mentations or poultices. 
 
 In moft cafes, the inflammation of the teflicle does 
 not rife higher than in the fimple hernia humoralis 
 from gonorrhoea j and it gradually fubfides as the fup- 
 puration advances. The abatement of the inflamma- 
 tion is alfo afllfted 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 drefllngs, 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 drefllngs 
 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 uneafmefs, of which all thofe complaia 
 
72 On the Hydrocele, Chap. XXIV. 
 
 in whom the firfl dre/Tings are fevenil days in being 
 taken away. They are always rendered ftiiF and un- 
 comfortable, by the blood dilcharged upon them after 
 the operation ; and the matter at iirft iecreted being 
 thin and acrid, I have, in various inflances feen, when 
 the dreflings 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 circumflance connected 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 firfl; drefling, and always 
 at the fecond or third, the pledgets inferted between 
 the tunica vaginalis and tefl:icle come away ; and when- 
 ever this happens, they ihould be renewed. It is alfo 
 proper to renew them daily, for the firfl: fourteen or 
 fifteen days after the operation ; not, however, of the 
 fame depth as the firfl:, as, during the latter part of 
 the cure, it proves fuflicient, if they are merely infert- 
 ed fo far as to prevent the divided edges of the tunica 
 vaginalis from adhering to the tefl:icle before the ad- 
 hefive procefs has taken place in the parts more deep- 
 ly feated. To this point, I mufl: obferve, the mofl: 
 particular attention is neceffary ; for, when this mode 
 of operating fails, that is, when the difeafe returns, it 
 is, almofl: in every infl:ance, from this precaution be- 
 ing overlooked. In my own practice, the difeafe has 
 not returned in a fingle initance : 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 tefl:icle, before adhefion had taken place 
 between the parts more deeply feated. 
 
 In almofl: every circumfl:ance, the treatment of hy- 
 drocele by this operation is the fame with what an- 
 
Bed:. III. On ihe 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 mod probably 
 fall to be renewed, as matter will thus be allowed to 
 colled, by which the patient will be nearly in the lame 
 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 hvdrocele, 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 necelfary in this mode of operating, but merely till 
 fuch a degree of inflammation is induced upon the 
 tefcicle 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 objedlion to this operation ; and as 
 many believe that it attually happens, I have judged 
 it proper to fpeak of it more particularly than thofe 
 will confider as necelfary, who have been accuflomed 
 to operate in this manner. No fuch procefs takes 
 place : inftead of it, the teflicle and vaginal coat, foon 
 after the operation, become inflamed ; till the fixth 
 or fevcnth day, the inflammation continues gradually 
 to increafe, when the whole tumor, as 1 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 tedis, over all the poflerior and lateral 
 parts of the tumor, and on the flips of oiled linen be- 
 ing gradually leflened, and at laft withdrawn, by the 
 fourteenth or fifteenth day, or foon thereafter, the ad- 
 hefion becomes complete ; the tumor of the teflis 
 gradually fubfides, and the fore produced by the cut, 
 and now reduced to a line, heals in a fliorter or long- 
 er time, according to the habit of body, age, and oth- 
 er circumftances of the patient. In fome, the cure is 
 
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 lafl, to wit, thofe 
 by cauflic, the feton, and the fimple incifion ; one or 
 other of thefe being now commonly pradifed for the 
 removal of this difeafe. 
 
 - From the teftimony of many refpedable authors 
 of the efficacy of each of thefe, there is no reafon to 
 doubt that any of them would, in mofl inflances, 
 prove effectual : that the cauflic, Vvhen properly man- 
 aged, will for the mofl part fucceed, we have every 
 reafon to believe ; and the fame may be fafely affert- 
 ed both of the feton, and the fmiple incifion ; but 
 every practitioner 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 objections, which thofe who have 
 pra£tifed 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 
 cauflic, were publifhed ; when, of courfe, the various 
 means of curing the difeafe were frequently the fub- 
 je£t of medical converfation. I was thereby induced 
 to pay much attention to the fubje6t ; and having the 
 advantage of feeing the pradtice of different hofpitals, 
 and not being particularly biaffed in favour of any 
 particular method, I was thus furnifhed with the befl 
 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 fmce that period, 
 both in the hofpital here, and in private pradice, is, 
 
Sed. III. On the Hydrocele. y^ 
 
 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 objections, and effects a 
 cure both with lead trouble to the operator, and leafl 
 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 productive 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- 
 tacl: 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- 
 Iv managed, are liable. When the inflammation, 
 which fucceeds to the introduction of the cord, runs 
 high, as it frequently does, it ccvmmonly 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 abfcefles 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- 
 rected ; but, in fome inftances, I have found even that 
 this has not proved fufficient, owing to the opening 
 I being reduced in fize by the fwelling and inflamma- 
 tion of the tumor. 
 
 Another objection to this operation, which I think 
 , of importance, is this : it does not admit of free ex- 
 I amination, either of j^Ke ftate of the tefticle, or of the 
 fluid contained in ttie fac. I know that in a fimple 
 uncomplicated hydrocele, the ftate of the tefticle re- 
 
jG 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 (kill and penetration of 
 the furgeon ; no diagnodic f)-mptoms, .with which we 
 are yet acquainted, being fufficient to dire£l us with 
 ab folate certainty. 
 
 The mod experienced practitioner will admit, that 
 at times, he has been miilaken in his opinion refpe£t- 
 ing the nature of fuch tumors ; a real farcocele, or 
 fchirrous tefticle, attended Vvith fome effufion of a flu- 
 id, being in fome inftances, miflaken for a pure un- 
 mixed hydrocele ; and vice verfa, a fimple uncompli- 
 cated cafe of hydrocele has been miRaken for, and 
 treated as a fchirrous tefticle. Such occurrences eve- 
 ry praftitioner 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 INIr. 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 
 fweUing in the fcrotum was a hmple 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 ftiould be removed 
 immediately ; while, on the contrary, if it appears to 
 be found, he will treat it as a cafe of fnnple hydrocele. 
 
 ♦ Treatife on the Hydrocele, p. 2S8. In this cafe, wliicli, from evcrj 
 tircumrtar.ce, had been confidercd as a farcocele, the teflis, after being re- 
 moved, was found to be perfeclly found, the difeafe being a real hydro- 
 cele of the tunica vaginalis. , 
 
 The mere poffibility of fuch an occurrcn<?'e with fuch an attentive ob- 
 ferver as Mr. Pott, ought to ferve as a moft convincing argument with 
 praiflitioners of the neceflitv of proceeding with the utmoft caution iu JiU 
 fuch cafes, where there is the It aft caufe for doubt. 
 
Sea. IIL On the Hydrocele. 77 
 
 In feveral Inftances of this kind, where, by different 
 pradtitioners, a mere colledion ot water was expected 
 without any other alfedion, the tefticle has been found 
 to be fo much difeafed, as to render immediate extir- 
 pation proper. Now, if in fuch circumflances 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 troublcfome and even alarming fyuiptoms j 
 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 ^.s a previous ftep to 
 the introdudion of the feton, with a view to afcertaiii 
 the flate 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 collapfmg in 
 large folds about the teftis, precludes effedually every 
 accurate examination of this kind. Of this, where the 
 tumor has been large, every praditioner muft have 
 met with inflances ; and we need not be furprifed at 
 its being fo, when it is known that inflances 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 dilFerence of opin- 
 ion occurred, even among furgeons of obfervation ; 
 and among thefe, the mofi remarkable happened in an 
 operation performed by a late very eminent furgeon. 
 The cafe was fuppofed to be a fchirrous tefticle con- 
 nected with the elfufion 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 thougli": it improper to remove it : the fur- 
 geons prefent v/erc of a diirerent opinion j but the 
 
7? On the Hydrocele. Chap. XXIV. 
 
 event of the cafe, which was favourable, tended to 
 evince the fuperior judgment of the operator, akhough, 
 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 cyll cannot be properly af- 
 certained. It fometimes happens, as will be more par- 
 ticularly noticed in the next feclion, 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 vv-ater had previ- 
 oufly been drawn off with a trocar. 
 
 In other inftances, the water of a hvdrocele is con- 
 tained 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 obje6lion to the practice ; fo that, al- 
 though the feton, in every other refpeft were equally 
 eligible with the fnnple incifion, which, for the rea- 
 fons formerly given, I think it is not, yet the three lafl 
 objeclions that I have adduced againfl it, feem to be 
 fufficient reafons for fetting it afide. 
 
 With refpect 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 pradice. 
 
 But the method of cure by caufhic is hable to one 
 important objeclion, which never attends the cure by 
 incifion, to wit, that of being produftive of fmufes, 
 and collections of matter, in the fcrotum and cellular 
 fubflance connecting that bag to the tunica vaginalis. 
 Two inftances of this I have feen, in which it was ne- 
 ceffary to difcharge collections of matter by different 
 
 * Thofe who doubt of the cxiftcnce of hydatids iti c.ifcs of hydrocele, 
 as fome have done, will find difTcrcirc inflauccs of thcni recorded ui Mor- 
 gagni de Caufis ct Sedibus Morboruin. 
 
Sect. in. On the Hydrocele, 79 
 
 openings ; and a remarkable cafe of It is related by 
 Douglas, in which an extenfive incifion became ne- 
 ceffary for removing the colledcd 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 
 lead troublefome fymptoms, I am decidedly of opin- 
 ion that it fhould be preferred. 
 
 In points of fuch importance, no perfon fliould form 
 any opinion haftily. Nothing but various opportuni- 
 ties of putting the different operations in practice, 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 inflance 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. Sharpens experi- 
 ence in this difeafe was not fufficient to warrant a de- 
 cifive opinion. It proved to be contrary to the direct 
 experience of fome of our belt furgeons ; and Mr, 
 Sharpe himfelf feems afterwards to have been convinc- 
 ed that his firft ideas of it had been ill founded. J Still, 
 however, his firft opinion had much influence with a 
 great proportion of furgeons ; fo that, till of late vears, 
 the radical cure of hydrocele was Teldom attempted 
 but in large hofpitals : and when at laff: it was found 
 that the danger attending it was lefs than had been re- 
 prefented, (till, the terror induced by Mr. Sharpe's ac- 
 count of the mode of operating by incifion, was fuch, 
 that almoll all who wrote upon it, were afraid of ad- 
 vifing it to be fo generally performed as it ought to be. 
 
 • p. 105. 
 
 t Tenth Edition, Chap. IX. 
 
 \ Vide Critical Imiuiry, firft edition, p. 86. 
 
8o On the Hydrcccle. Chap. XXIV. 
 
 "When the earlier editions of this work were pub- 
 lifhed^ although I gave the fame 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 lofmg 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 pofiible, to dif- 
 cover the caufe of the violence of this fymptom ; 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, wherever it was carried too 
 near the teft;icle, as is fometimes done at the bottom 
 of the fac, the pain and inflammation were always fe- 
 vere ; but the mofl: frequent caufe of the violence of 
 thel'e fymptoms appeared at lafl: to be the mode of 
 drelTmg the parts after the operation. It had com- 
 monly been the pradice to cram a confiderable quan- 
 tity of drefllngs into the cavity of the tunica vaginalis ; 
 and, with a view to make ihe furface of the parts 
 flough quickly ofi:', a procefs which at that time was 
 
Se6l. III. On the Hydrccele. 8 1 
 
 judged neceflary for the cure, red precipitate and oth- 
 er irritating fubftances were made ufe of by many. 
 The impropriety of thefe being obvious, dry Hnt 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 lefi'en 
 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 fv;elled to a great fize, and the patient, for the 
 lirfl two or three weeks of his confinement, was often 
 kept in much diitrefs and anxiety. 
 
 Having frequently found that the dry lint infcrted 
 into the tunica vaginalis, adhered, at the firft drefling 
 of the parts, fo firmly to the furface of the teftis, that 
 it could not be withdrawn, I at lad began to conclude 
 that this might render the inflammation more fevere 
 than it otherwife would be ; and it foon appeared that 
 my conjctSlure was well lounded. For feveral years 
 pafl I have covered the pledgets applied to the furface 
 of the teftis, as has been advhed above, either with 
 fine oil, or with a thin linament of oil and wax, which 
 anfwers better. This gives much lufs 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 drefling of the fore, as at 
 any future period of the cure. 
 
 The effedi: 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 wiflied 
 it to do ; never fo far as to excite the leaft caufe of 
 anxiety. The tefticle fwclls and inflames, but in no 
 greater degree than is neccflliry for preventing a re- 
 turn of the difeafe. Of this the cleareft proof that can 
 be given, is, that of upwards of one hundred and fif- 
 ty patients on whom I have operated in this manner, 
 I have only once found it neceflary 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 feciirity 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 inflances I can hear of its failure 
 in the courfe of thefe lad twenty- five years ; and in all 
 of them the caufe was evidently traced to want of that 
 perfevering attention during the cure, fo necelfary 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 praftice. 
 
 Almofl 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 cxcifion or 
 cutting away the greatefl part of the tunica vaginalis ; 
 by injeding 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 firfl 
 introduced them, they were at lafl entirely laid afide ; 
 fo that, for thefe lafl five years and more, fcarcely any 
 has been attempted through the greateil 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 nov/ 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- 
 flances, at firft, the inflammation, as I have obferved 
 above, arrived at a confiderable height ; but not in a 
 fmgle inflance, fmce 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 practice, the Icfs 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 
 conduced upon the fame principles. It is accom- 
 piiflied in the fame time ; commonly in lefs than the 
 cure of abfcelfes 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 
 lelfencd, either by any alteration to be made in the 
 mode of performing the operation, or in the manage- 
 ment of the dreflings, 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 bed informed pratlitioners, as I be- 
 lieve him to have been one of the beft operators of 
 the age, was I believe, the firfl: 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- 
 jeding wine and other hquids into the tunica vagina- 
 G 2 
 
H On the Hydrccele. Chap. XXIV. 
 
 lis teftis, they both keenly adopted the pradice 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 inflances, to be fo great and alarming, and 
 the dil'trefs arifmg from matter collecting within the 
 tunica vaginaHs, and from the openings necefl'ary for 
 the difcharge of it, w^as fo confidcrable, 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 mofl: favourable opinion of it. I have not 
 heard of its being performed in a fmgle inflance in 
 this place, for thefe laft twenty years : it feems to be 
 falling^ into difufe in Ensjland ; and althou2;h in 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 cauflic ; 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, fliould 
 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 accomplilh 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 injecting of wine and other 
 , liquids into the tunica vaginalis teftis. 
 
Sed. III. Oji the Hydrocek. 85 
 
 The merit of firft propofing the cure of this difeafe 
 by injeclions, has commonly been given to a Mr. 
 Munro, a furgeon of this country ; but we now have 
 evidence of the pradice having been propofed and 
 adopted upwards of fifty years fooner. Tents, armed 
 with irritating ointments having long been employed, 
 we need not wonder at injec1:ion& being confidered as 
 a better method of conducting the fame remedies to 
 the parts upon w hich they were to ad. Whether in- 
 jections 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 Oeuvrcs Chirurgicales, 
 of a Monfieur Lambert at Marfeilles, in which a par- 
 ticular account is given of the method of curing hy- 
 drocele by injections. The liquid Mr. Lambert pre- 
 ferred, was a flrong folation 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 arc not acquainted, this mode of ope- 
 rating appears to have been for a long time laid afide, 
 till it was afterwards praCtifed 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 practice 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 f^r fome time frequently praCtifed, 
 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 practice, 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. 
 The injedlion either excited fevere pain, on being firft 
 
86 On the Hydrocele. Chap. XXIV. 
 
 thrown in, and was fucceeded by violent inflamma- 
 tion, and this, in fome, by diftrefsful colledions of 
 matter ; or the cure did not prove permanent. In a 
 few cafes, the difeafe returned ahnoH immediately, 
 that is, in the courfe of two or three weeks ; but this 
 was not frequent. For the mofl part, the cure ap- 
 peared to be complete, and continued to be fo, till at. 
 fome diftant period, to the great difappointmcnt both 
 of the patient and furgeon, a recurrence of the fwelU 
 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 practice 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 fcarcely heard of in Britain, it was 
 frequently pradifed in France, and other parts of the 
 Continent, where many trials and experiments were 
 made for curing the hydrocele by injetlions. 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 
 fubhmatus corrofivus dilfolved in it in various propor- 
 tions, from a quarter of a grain to two grains, to the 
 ounce ; with ftrong 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. 
 
Bed:. III. On the Hydrccele. 87 
 
 they are commonly mixed with a fixth 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 injection 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 injedling the liquid with a common 
 fyringe ; but in my opinion, the bed method of per^- 
 forming it is the following. 
 
 The furgeon fliould be provided with a flat trocar, 
 of the form and fize reprefented in Plate LVIII. fig. 
 3. together with a bag of refma elaflica, fitted with a 
 pipe, reprefented in the fame plate, fig. i. The pipe 
 Ihould 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 injected fhould be 
 gently warmed, and put into the bag before the ope- 
 ration is begun. The patient being laid in a horizontal 
 poflure, either upon his bed or on a table, and fecur- 
 ed in the ufual way by afiiflants, the water fhould be 
 drawn entirely olf from the tumor, by pafling the tro- 
 car into the anterior and mofl 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 inje£lion bag entirely through it, and with gen- 
 tle prefl'ure, to force as much of the liquid which it 
 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 fliould fHU keep the canula of 
 the trocar fixed, otherwife it might recede, by which 
 the liquid would infmuate into the cellular fubftance 
 
88 On the Hydrocele. Chap. XXIV. 
 
 cf the fcrotum, and in this manner do harm. He 
 ihould aifo, with very gentle prefl'ure, 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 
 fliould be entirely difcharged through the canula of 
 the trocar, after withdrawhig the tube of the elaflic 
 bag. 
 
 Some have faid that the injedion fhould 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 mofl 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 almofl inilantaneoufly on the injedion being 
 introduced. In this cafe, it fliould be difcharged as 
 foon as it has been made to pafs to the different parts 
 of the tunica vaoinalis. 
 
 o 
 
 ' Some again are of opinion, that after the quantity 
 of liquid firft injected 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 inje6ied, fl:ould always 
 depend on the fize of the tumor. Some have thought 
 that it fliould be equal to the quantity drawn off by 
 the operation ; but this does not appear to be neceffa- 
 ry, while the injeding of fuch a quantity is apt to do 
 •harm. After having collapfed completely, the parts 
 do not again yield eafily to fudden diftention ; 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 collefted, the quantity of injection 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. 
 
 i 
 
Se£t. III. On the Hydrocele, 89 
 
 Lefs than any of thefe quantities might anfwer ; 
 but it would require more handling to bring it into 
 contad with all the parts which it ought to touch ; 
 and as a larger quantity is eafily introduced, it fhould 
 always be advifed. 
 
 On the injection being difcharged, and not a drop 
 fliould 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 firfl ; fcarcely any inflammation or tumor being 
 perceived on the teilis ; 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 firfl introduftion of the in- 
 jection, not merely in the teflis, but in the back, and 
 over the whole loins. In mofl inflances, this foon be- 
 comes moderate, and the treatment goes eafily on ; 
 but, in others, it is fucceeded by great inflammation 
 in the teilis and fcrotum ; and, in a few, this termi- 
 nates in colleclions of matter within the cavity of the 
 tunica vaginalis. 
 
 Thefe violent fymptoms the praftitioner 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 faturninc applications ; 
 and warm emollient fomentations and poultices, when, 
 fuppuration is likely to take place. 
 
 When matter forms in the tunica vaginahs, the 
 treatment confills in laying the cclleclion open from 
 one end to the other, and ccnduding the cure, as has 
 already been advifed in the operation by the fmiple in- 
 cifion. The formation of matter, I believe, is not fre- 
 quent ; but I know that it occafionally happens ; and 
 io much are the pra£litioners on the Continent afraid 
 of it J of the height to which the inflammation might 
 
90 On the Hydrocele. Chap. XXIV. 
 
 othervvlfe advance ; and of the dreadful diftrefs that 
 in fuch circumflances enfuc, from fuppuration taking 
 place, that they feldom perform the operation without 
 premifmg purging and bloodletting, and often repeat 
 the bloodletting once and again during the cure, pre- 
 cautions never judged neceifary 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 j and, in fome, as I have obferved 
 above, not till two or three years have elapfed. Hence, 
 in hofpltal practice, where patients are feldom heard 
 of after being difmilfed, the point in queftion cannot 
 be determined ; and it is chiefly in foreign hofpitals 
 that hitherto this operation has been performed. From 
 the befl 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 conviclion, 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 befl 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- 
 je£tion, are again endeavouring to introduce it in 
 Britain. 
 
 From the hiftory that I have given of the method 
 of curing the hydrocele by injeftions, 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 againfl it. 
 
Sea. III. On the Hydrocele. 9! 
 
 I ft, We do not, from experience, find, that other 
 tumors, produced by fluids contained in cyfts, are 
 readily cured by inje£lions. Few, I believe, would 
 now think of attempting the cure of abfcefles or en- 
 cyfled tumors by injections. In tumors induced by 
 fluids collected in the burfas mucofas, where, from the 
 contiguity of joints, extenfive incifions might have 
 done harm, I have in various infl:ances, made trial of 
 injedions ; but feldom with any advantage. In fome, 
 they excite pain and inflammation ; and where this 
 does not happen, although they may leflen the dif- 
 charge, this proves only temporary ; fo that a cure is 
 afterwards to be obtained by the introduction 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 pradice 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 injedlions of various kinds : but, as this has 
 neither happened in the courfe of my own experience, 
 nor with any other practitioner with whom I am ac- 
 quainted, I mufl leave the practice in the hands of thofe 
 with whom it has anfwcred better. 
 
 At one period, a practitioner in this country got in- 
 to notice, by announcing frequent cures of the filtula 
 in ano as well as other finufes, by injections. 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- 
 tients commonly remained long under his care. The 
 injections were thrown in frequeetly, and with much 
 attention ; and liquids of various kinds were employ- 
 ed ; fome that feemed to aCt folely by their afl:ringen- 
 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- 
 ele ou the fluid being drawn off", cavities will thus be 
 
92 On the Hydrocele. Chap. XXIV. 
 
 formed, by which feparate colledtions 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 effect of injeclions, long be- 
 fore the lafl edition of this volume was publiflied ; 
 and fmce that period, different cafes have occurred, 
 which render it certain that the fufpicion was well 
 founded. 
 
 3d, When inflammation, excited by an injcdion, 
 goes too far, and with whatever care the operation is 
 done, it fometimes happens, the diftrefs produced by 
 it is fevere. Befides the pain arifmg from the inflam- 
 matory fl:age of the difeafe, if fuppuration takes place, 
 the patient mud fubmit to that painful dillention which 
 the fudden 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 firfl: . 
 
 4th, The fl:ate 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 injedion, 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 
 been long much diftended, the teftis, if not confidera- 
 bly enlarged, as well as the epididymis, maybe mate- 
 rially difeafed, Vvithout our being able to difcover it. 
 Of this I have feen various inftances ; in fome of 
 which, as I have obferved above, practitioners 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 
 
Se£l. IIL On the Hydrocele. 93 
 
 the furface of the telllcle, as well as of the tuiiica 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 infeniible, that a much 
 more irritating injeclion 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 (late highly improper for any at- 
 tempt to cure the difeafe by injedions, 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 teflis appeared to be in its 
 ufual (late, 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 injeftion 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, v/ho will not fubmit to 
 the other, it is not fuflicient to warrant praditioners 
 in giving it the preference. The prevention of pain 
 is at all times a mod dcfirable objedl ; but it is far 
 from being the only one in chirurgical operations. 
 Our chief view, is the fafety of our patient in the fir ft 
 inllance, together with his complete fecurity againil a 
 return of the difeafe. In fo far as OPxe mode of oper- 
 ating is lefs painful than another, and attended with 
 equal certainty in fecuiing againfl a relapfc, 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 injedions ; fo 
 that patients .treated in this manner, are, for a confid- 
 erable time, liabl^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 fliewn 
 to be attended with complete fafety as well as fecurity. 
 
94 On the Hydrocele, Chap. XXIV. 
 
 confifts In the degree of pain which it excites being 
 lefs. This of itfelf would have httle influence even 
 with the mod 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 dreflings are 
 properly conducted, that the tefticle does not inflame 
 more than is necefl^ary for a cure ; and that the fubfe- 
 quent pain is for the mod part inconfiderable ; not to 
 be compared with what is experienced from matter 
 colledting 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 difoppointment in the firfl: inflance, 
 while I think it probable, that one eft'ecl of injeftions* 
 when they do not fucceed, mud 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 injections 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 tefl:is ; whilft others are of opin- 
 ion, that they aft folely by their aftringency. By 
 ftrengthening or corrugating the fecreting and abfor- 
 bent veflTels of the parts, they may be fuppofed to a61: 
 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 
 injections, as are in a confiderable degree aftringent, 
 fuch as infufions of red rofe leaves,Tolutions 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 fufFicicnt to produce a firm adhefion between the 
 
 I 
 
Se£l. III. 0?i the Hydrocele. 95 
 
 tunica vaginalis and teftis ; but there is rcafon to think, 
 that this feldom takes place from injections ; and I 
 conclude that it is fo, not only from the trifling degree 
 of pain which, in moft inftances, the injeftions now 
 ufed commonly give, and from the fwelling of the 
 parts, which ufually takes place, being inconfiderable, 
 but from the difcafe 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 fa6l, and I firmly believe it to be 
 fo, that injeclions, in a great proportion of cafes, act 
 chiefly by their aftringency, and not by deftroying the 
 cavity of the tunica vaginalis, thcv 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 otheiAvife be fufficient, when 
 any other operation becomes necefl'ary for a perma- 
 nent cure. 
 
 In anfwer, however, to all thefe objections, it may 
 be faid, that the practice 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 fubjed, 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 fliall only obferve, what I have already 
 had occafion to do, refpedling the pradice of foreign- 
 ers in the hydrocele ; that having been later than the 
 Britifli furgeons, in acquiring a knowledge of the true 
 nature of the difcafe, they have hitherto remained be- 
 hind them in every thing that relates to it. Their 
 pradice has therefore been timid, changeable, and in- 
 decifive. This, however, I only mean as a general cb- 
 fervation ;. for fome foreigners there are, whofe know^ 
 edge in this, as in all other difeafes, would do them 
 much honour : but all who have read what in goner- 
 
96 On the Hydrocele. Chap. XXIV. 
 
 al has been written upon this fubjcct by foreign fur- 
 geons, or who have had opportunities of feeing their 
 pradice, mufl admit, that in the treatment of hydro- 
 cele they ought not to be followed. 
 
 And again, with refpecl to the obfervation of Mr. 
 Earle, I need only obferve, that this writer obvioufiy 
 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 injedlion, which he has now 
 very keenly adopted. In one part, indeed, of his trea- 
 tife, he makes the following candid declaration : " I 
 *' mufl confefs, that 1 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 diiappointed, as it would feem, in his cxpeftation 
 of the operation by the feton, he was thus ready to 
 adopt the practice of curing the difeafe v»'ith injedions, 
 in the eafy manner rcprefented by the French, and 
 which he has accordingly Vv'ith great zeal done. 
 
 If longer experience, and farther improvement, fhall 
 evince the mode of curing the hydrocele by injections 
 to be equally fafe and certain with that by the fimple 
 inciiion, and fhall obviate the objeclions 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 flate of our knowledge, few practitioners 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 Treatlfe on the Hydrocele, Sec. by James EarIe,Efq. p. 30. 
 
Se£l. IV. On the Hydrocele, 97 
 
 SECTION IV. 
 
 Of the Hydrocele of a Hernial Sac. 
 
 WHEN the parts have been long protruded in 
 hernia, a lerous fluid colleds in the bottom 
 of the fac. In the fcrotal hernia, if this extravafated 
 ferum is not foon removed by abforption, the tumor, 
 we may eafily imagine, may augment to fuch a fize as 
 to aftbrd many of the ufual marks of a hydrocele. 
 Accordingly, befides diiferent inftances that I have 
 now met of it in my own pradice, a number of ca- 
 fes, I find, are enumerated by authors, which fuffi- 
 ciently warrant the infertion of this as a real, and per- 
 haps not an unfrequent, variety of the difeafe. 
 
 It was well known to the ancients, that a confider- 
 able quantity of a fluid is frequently contained in the 
 fac of a hernia, along with the parts protruded from 
 the abdomen ; but Saviard feems to have been the 
 firfl: who fpeaks of it with precifion. Le Dran re- 
 lates difl:erent cafes of it : Heifl:er fpeaks of it under 
 the title of hydro-entrocele ; and the late Dr. Monro 
 defcribes it with his ufual accuracy, and mentions a 
 cafe of it where fix pounds of water were evacuated 
 from the tumor, by an opening made with a trocar.* 
 A cafe of it is alfo related by Douglas,! and two cafes 
 of a fimilar nature are mentioned by Mr. Pott.| 
 
 The ferum is here confined in a cyft, formed by a 
 procefs of the peritonaeum ; and, as it occupies near- 
 ly the fame fituation in the fcrotum with the hydro- 
 cele of the tunica vaginalis, fo we cannot always, by 
 the feeling alone, mark the difl'erence between them. 
 For, although the tcfl.icle, in this variety of hydrocele, 
 
 • Monro's Works, p. 579. f P. 18a. 
 
 \ Treatife on tlic Hydrocele, p. 21. 
 
 Vol. hi. H 
 
9^ 0?i the Hydrocele. Chap. XXIV* 
 
 is commonly diftinguiihed more evidently at the low- 
 er and pofterior part of the fwelling, than in the hy- 
 drocele of the vaginal coat, yet, the dill'erence in this 
 particular between the two difeafes, is not always fo 
 evident as to afford fufficient means of diilinflion. 
 
 When a portion of gut, and other paits forming a 
 hernia are down, the fulnefs they produce along the 
 fpermatic cord, ferves, in fome meafure, to diitinguilh 
 the difeafe from a funple hydrocele. And when, 
 along with this and other fymptoms of hernia, we evi- 
 dently diicover, in the tumor of the fcrotum, a fluc- 
 tuation of a fluid, if this fluid can, by preflure, be made 
 to difappear, either entirely or in part, the nature of 
 the cafe becomes thereby obvious. 
 
 This variety of hydrocele may take place as readily 
 in the hernia congenita, as in any other rupture ; and, 
 in that event, the water mull be contained in the fame 
 fac with the telHcle and protruded inteflines. 
 
 As all the fluid indeed naturally fecreted for keep- 
 ing the furface of the abdominal vifcera moifh, muft, 
 in a congenital hernia, fall into the fac, we would be 
 induced to fuppofe, that almofl; every hernia of this 
 kind Ihould be complicated with a hydrocele of the 
 fac. The two cafes of this, related by Mr. Pott, ap- 
 pear to have been conneded with hernia congenita ; 
 and I have met with it in different inftances. But 
 whether this commonly happens or not, further ob- 
 fervation muft difcover. 
 
 With whatever hernia this kind of hydrocele is con- 
 ne£led, if the water can, by preffure, be made to pal's 
 into the abdomen, this will always prove certainly 
 charaderiftic of the difeafe ; for, in no other fpecies 
 of encyfted hydrocele, can the water be made to dif- 
 appear by prellure. It may happen, hov/ever, in this 
 kind of hydrocele, that this diftinguiflnng fymptom of 
 the difeafe does not exift ; for if, by tlie preffure of a 
 trufs, or any other caufe, an adhefion is produced in 
 the groin, between the fides of the hernial fac, if the 
 under part of the fac continues open, with water col- 
 
Sc£t. IV. On the Hydrocele, 99 
 
 leiSled in it, the tumor produced by it will afford all 
 the ufual appearances of hydrocele, while no part of 
 its contents can be made to pafs into the abdomen by 
 preifure. A cafe of this kind we find related by Le 
 Dran, where the neck of the hernial fac was fhut 
 completely, and a hydrocele formed in the under part 
 of it. 
 
 In this fituation, the chief means of diftindion are 
 to be obtained from an acquaintance with the previ- 
 ous hiftory of the cafe. When, in an ambiguous cafe, 
 it is found, that, before the water began to colled in 
 the fcrotum, the patient had been liable to a hernia of 
 the fame fide, this circumflance alone will tend much 
 to determine the nature of the difeafe. But even al- 
 though a miftake fliould occur, and although a hy- 
 drocele of a hernial fac (liould, in fuch circumflances, 
 be miftaken for a fnnple hydrocele of the tunica vagi- 
 nalis, nothing bad could enfue from it ; for the treat- 
 ment adapted to one variety of the difeafe, would ap- 
 ply with nearly equal propriety to the other ; for here 
 we conclude, that the parts which at firft formed the 
 hernia are reduced, and that the fides of the fac, in 
 the upper part of it, adhere firmly together. 
 
 But, when the protruded parts (till remain down, 
 unlefs the operation for the bubonocele is at the fame 
 time to be performed, no other fliOuld be attempted, 
 but that of difcharging the water with a fmall trocar, 
 when the fize of the tumor renders it proper. For, 
 unlefs the operation for the hernia fliould be done at 
 the fame time, much harm might enfue from expof- 
 ing the bowels fo much to the air, as would neceffa- 
 rily be the cafe, by laying the tumor open for a radi- 
 cal cure of the hydrocele. 
 
 Whenever it is refolved, in this variety of hydro- 
 cele, to operate for a radical cure, the fimple incifion 
 ought unqueflionably to be advifed ; as, from the rifk 
 of injuring the bowels protruded from the abdomen, 
 neither the feton, cauftic, nor injections, are here ad- 
 H 2 
 
100 On the Hydrocele. Chap. XXIV. 
 
 miffible. Indeed, this of itfelf affords a powerful ar- 
 gument in favour of the method of operating in every 
 inftance by the fmiple incifion, which brings all the 
 parts concerned in the difeafe into view. The very 
 poiTibihty of a patient being killed, by a feton pafTmg 
 through a portion of intefline contained in a hydro- 
 cele, is a weighty objedlion againft the feton being 
 ever employed ; and every praditioner mufl: acknow- 
 ledge, that when the fpermatic procefs along the groin 
 is much diftended, and the vaginal coat of the teftis 
 much thickened, that fuch uncertainty often occurs, 
 as to render it impoiTible for the mod {ls.ilful furgeons 
 to determine with precifion, what the contents of fuch 
 fwellings really are. In the inftances to which I al- 
 lude, of a hydrocele connefted with a congenital her- 
 nia, and which I met with fome years ago, there had 
 not been previoufly any caufe to fufpect the real na- 
 ture of the cafe. They were, by fkilful praftitioners, 
 judged to be collections of water in the tunica vagina- 
 lis, without any complication whatever ; and, on the 
 tumor being laid open, together with water in contact 
 with teflicle, a piece of intefline was found protruded 
 into the upper part of the fcrotum. In one of the 
 cafes too, a fmall portion of omentum accompanied 
 the gut. 
 
 In this laft, it had been propofed, at a confultation 
 of furgeons, to employ the feton. For fome reafon 
 or other, this was fortunately rejefted ; for, on laying 
 the tumor open by incifion, it evidently appeared, that 
 if a cord had been introduced, it mufl in all probabi- 
 lity have paifed through the protruded gut. 
 
Se£l. V. On the Hydrocele. lol 
 
 SECTION V. 
 
 Of the Anafarcous Hydrocele of the Spermatic Cord. 
 
 IN the anatomical defcription given in the firft fec- 
 tion of this chapter, it was obferved, that foon af- 
 ter the defcent of the teftis, the paflage along the fper- 
 matic procefs of the peritonaeum , is completely oblit- 
 erated, by the fides of the paflage adhering together. 
 
 By external prefl"ure, and in fome inftances, per- 
 haps from other caufes, this adhefion of the fides of 
 the peritoneal procefs, is in general very firm in that 
 part of it which pafles along the groin ; but the fupe- 
 rior and more internal part of the procefs, is not only 
 more loofe in itfelf, but is connected with, and envel- 
 oped in a very loofe cellular fubftance. 
 
 From this cellular ftrudure of thefe parts we might 
 a priori, fuppofe them to be liable to the fame kind of 
 anafarcous or cedematous fwellings, with which other 
 parts of the body, of a fimilar flrutlure, are frequent- 
 ly attacked ; and accordingly we find that this is the 
 cafe. This anafarcous fwelling fometimcs accompa- 
 nies afcites ; and it now and then appears locally,, 
 without being combined with either of thefe. 
 
 The caufes of this variety of hydrocele in general, 
 are, obftruclions produced in the lymphatics, leading 
 from the part, by fchirrous affedions of the liver, 
 fpleen, and other abdominal vifcera. I have likewife 
 known it induced by the prelfure of a trufs applied 
 for the cure of a hernia.* 
 
 When the fwelling is conne£led with anafarca in 
 other parts, it is thereby fo diftinclly marked, as to 
 render a particular defcription of it unnecefl'ary. 
 When it takes place as a local difeafe, its appearances 
 are thefe : a colourlefs tumor in the courfe of the fper* 
 
 * An inftancc of this is alfo mentioned l>y Doughs. Treatife on the 
 Hydrocele. 
 
I02 On the Hydrocele. Chap. XXIV. 
 
 matic cord ; foft and inelaftic to the feel, and not at- 
 tended with fluctuation. In an ered pofture, it is of 
 an oblong figure, but when the body is in a recum- 
 bent poflure, it becomes flat. It does not commonly 
 occupy more than the ufual ftretch of the cord along 
 the groin, but occaiionally it extends down the length 
 of the tedicle, and even flretches the fcroium to an 
 enormous fize.* 
 
 By preffure, the fwelHng can be always made to re- 
 cede, never entirely, but often in great part, into the 
 cavity of the abdomen. It initantly, however, returns 
 to occupy its former fituation on the preifure being 
 withdrawn. 
 
 When the tumor is connected with general anafar- 
 ca, unlefs the caufe which gave rife to the difeafe of 
 the conflitution is removed, it would be a vain attempt 
 to endeavour to cure this particular fymptom. And 
 it commonly happens, that thefe fwel lings in the groin, 
 arifmg from anaiarca, difappear when the difeafe of 
 the fylf em is carried off. 
 
 But when the fwelling occurs as an original difeafe, 
 produced, perhaps, by fome local caufe ; a local re- 
 medy is then the bed means we can employ. In this 
 cafe, as we have not the general bad habit of body to 
 encounter, which commonly occurs in fcrotal anafar- 
 ca, we need not be fo much afraid of making a free 
 incifion into the tumor ; and accordingly, all that is 
 neceffary to be done is this : as foon as the tumor has 
 acquired fuch a fize as to become inconvenient, an 
 incifion Ihould be made with a fcalpel from one end 
 of it to the other, taking care to go fo deep, as effec- 
 tually to difcharge all the fluid contained in the cells 
 of the part ; and as the ferum is fometimes found to 
 Jiave acquired a vifcid confifl:ence, this circumftance 
 renders a deep incifion more neceffary than it other- 
 wife would be. In making this incifion, we have 
 
 * A remarkable inftance of this is related by Mr. Pott, who, from a 
 fwelling of this kind, difcharged eleven Englifli pints at once. Treatife 
 en Hydrocele, cafe x. 
 
Se<a. VI. On the Hydrocele. 1 03 
 
 chiefly to avoid what may be properly termed the con- 
 flituent parts of the fpermatic cord, the fpermatic ar- 
 tery and vein and vas deferens, and which, in every 
 inftance, may always with certainty be done. 
 
 The contents of the fwelling being removed, a 
 pledget of foft old linen, fpread with common wax 
 ointment, fliould be inferted between the lips of the 
 fore, which mull: afterwards be treated as a fimple 
 wound from any other caufe ; by poultices and fo- 
 mentations, if much pain and a fcanty fuppuration 
 take place ; and by due attention to drefling, fo as to 
 induce the formation of firm granulations from the 
 bottom. 
 
 In fome inftances, a cure has been attempted by 
 making deep punclures in different parts of the tu- 
 mor ; but while they do not with fuch certainty re- 
 move the difeafe, they are equally painful with an in- 
 cifion carried the full length of the tumor. 
 
 SECTION VI. 
 
 Of the Encyjlcd Hydrocele of the Spermatic Cord. 
 
 THE furrounding fubftance of the fpermatic cord 
 being entirely cellular, the formation of encyfl- 
 ed tumors, v/e may conclude, ought occafionally to 
 take place here, as well as in other parts of the body ; 
 and accordingly we find, in fome inftances, that wa- 
 ter, inflcad of diffufing itfelf over the whole fperma- 
 tic procefs, is colleded in one or more diftind; cells 
 or cyfts. 
 
 This kind of hydrocele being on its firfl appearance 
 fmall, gives little or no trouble, and is therefore 
 feldoni much noticed, till it has acquired a larger 
 fize. In fome, it begins in the fuperipr part of the 
 procefs ; but, in general, it is firfl perceived towords 
 the lower part of it, a little above the epididymis. By 
 
I04 On the Hydrocele, Chap. XXIV. 
 
 degrees, however, it ftretches upwards, and, in fome 
 inllances, fo far down as to reach from the abdomi- 
 nal mufclcs to the very bottom of the fcrotum ; in 
 which cafe, a perfon who had not formerly feen the 
 difeafe, might be apt to miftake it for a hydrocele of 
 the tunica vaginalis. But we have a very certain mark 
 of diftinftion between the two difeafes. 
 
 In the commencement of this variety of hydrocele, 
 the tumor is always above the teflicle, which is dif- 
 tinftly felt below ; and in the more advanced ftages 
 of the difeafe, the teftis is found at the back part of 
 it. Whereas, in the advanced ftate of a hydrocele of 
 the tunica vaginalis, although fome degree of hard- 
 nefs takes place where the tunica vaginalis adheres to 
 the tefticle, yet v/hen the tumor is large, the teftis can 
 never be diltindly felt. In the encyfted hydrocele of 
 the cord, the figure and fize of the penis is not com- 
 monly fo much altered, as when the water is collect- 
 ed in the tunica vaginalis, in which the penis frequent- 
 ly difappears almoft entirely. 
 
 In other circumftances, the encyfted dropfy of the 
 fpermatic cord, is very fimilar to the hydrocele of the 
 tunica vaginalis teftis. A fiudluation of a fluid is fen- 
 fibly difcovered on prelTure. The tumor is common- 
 ly of a pyramidal form, which is alfo the cafe with 
 the other, with its bafe or largeft extremity down- 
 ward.* And no preiTure has any influence in mak- 
 ing it difappear, either altogether or in part. 
 
 This is the appearance of the tumor when the wa- 
 ter is contained in one cyft. When feparated into 
 two diftincl cells, as fometimes happens, the line of 
 divifion is commonly evident by the tumor being at 
 that part fomewhat puckered, or diminiftied in its di-» 
 ameter. A fimilar appearance alfo takes place, when 
 
 * A hydrocele of the tunica vaginalis teftis, is fo frequently Indeed of 
 a pyramida,l form, with its bafe downwards, that this lliape may be con- 
 lidered as one of the charaAeriftic appearances of the difeafe ; every 
 ether tumor to which the teftis and its coats are liable, being either morf 
 round, or of a more irregular fliape. 
 
Sc£l:. VI. On the Hydrocele, 105 
 
 this variety of hydrocele is combined with a real hy- 
 drocele of the tunica vaginalis teftis, which, in fome 
 inflances, happens ; and in this cafe, a line of fepara- 
 tion may be obferved, where the upper extremity of 
 the tunica vaginalis terminates. 
 
 The means of diftindion between this fpecies of hy- 
 drocele, and that of the vaginal coat of the teftis, have 
 already been mentioned. The only other tumors with 
 which it is in danger of being confounded, are, the 
 anafarcous hydrocele of the fpermatic cord, and a re- 
 al hernia, either of the omentum, or of a portion of 
 gut. From the former, however, as alfo from an 
 omental hernia, it may in general be diftinguiflied. In 
 neither of thefe, is the fluftuation of a fluid to be per- 
 ceived, and to the touch they are both foft and ine- 
 laftic ; whereas, in this variety of hydrocele, the tu- 
 mor has a fpringy kind of feeling, and a fluftuation 
 is fcnfibly found in it. And in both the others, the 
 fwelling in fome degree recedes upon prefTure, which 
 it never does in this variety of encyfted hydrocele. 
 
 From a hernia of any portion of gut, it is chiefly 
 diftinguiflied by the tumor beginning, not at the ring 
 of the external oblique mufcle, as is the cafe in her- 
 nia, but farther down the cord. In the latter, the 
 fwelling commonly becomes lefs on the patient being 
 placed in a horizontal poflure ; and it is always con- 
 fiderably afl'eded both by coughing and faeezing ; but 
 no pofture, no preflure, nor any accidental circum- 
 flance, alters the fize of this variety of hydrocele. 
 The abfence of the fymptoms of hernia, too, is here 
 material in the ^diftinction. For there is neither pain 
 in the tumor, nor in the abdomen ; nor ficknefs, vom- 
 iting, nor any interruption to the paflTage by ftool, as 
 very commonly happens in hernia. 
 
 Although all the ancient writers were ignorant of 
 the anatomy of the parts concerned in this difeafe, it 
 is evident they were well aware of its exiftence. We 
 find it particularly defcribed by ^gineta, Albucafis, 
 and afterwards by Fallopius, Wifeman, and others. 
 
io5 On the Hydrocele. Chap. XXIV. 
 
 Amaud, in his Treatife on Herniae, alfo takes notice 
 of it, though not with much accuracy ; and we find 
 it more lately defcribed with exactnefs by the late Dr. 
 Monro, by Douglas, and by Mr. Pott. 
 
 This variety of hydrocele, as alfo the anafarcous 
 fwelling of the cord, and the cedematous tumor of the 
 fcrotum, are all frequent in infancy. Thefe tumors, 
 however, in childhood, fcldom prove permanent. For 
 the mod part, they readily yield to gentle friction with 
 volatile liniment, or any other flimulating or aftringent 
 application ; fuch as fpirit of wine, a ftrong folution 
 of alum in water, or of crude fal ammoniac in vine- 
 gar. The late Dr. Monro advifes the application of 
 cloths warmed with the fumes of burning benzoin. 
 
 Even the hydrocele of the tunica vaginalis fometimes 
 occurs in early life. I have met with different inftan- 
 ces of it in children under three years of age ; but it 
 is not fo readily aded upon by the external applica- 
 tion of ftimulants, as the anafarcous hydrocele. 
 
 Whether in children or adults, when this variety of 
 tumor becomes large, we employ either the means for 
 a palliative, or a radical cure, as have been already 
 advifed in the hydrocele of the tunica vaginalis teflis. 
 
 When it is our intention merely to difcharge the 
 water by a punfture, it fhould be done with a trocar, 
 in the fame manner as was directed in Section III. for 
 a hydrocele of the tunica vaginalis ; taking care to in- 
 troduce the inflrument at the mod depending part of 
 the tumor. And again, when we mean to accomplifli 
 a radical cure, the fame means are to be employed, 
 that have been already advifed for the radical cure of 
 that variety of the difeafe in the tunica vaginalis teflis. 
 The fame objedtions indeed do not here occur to the 
 ufe of the feton, as in the hydrocele of the tunica va^ 
 ginalis, from the prefence of the teflis. And if we 
 could, in every fpecies of hydrocele, afcertain the ex- 
 afl: contents of the tumor, the feton might, no doubt, 
 be here employed with fafety and advantage. But, as 
 i.t is obvious, from what I have already had occafiou 
 
Se^t. VI. On the Hydrccele, toy 
 
 to remark, that no certainty of this can at all times be 
 obtained ; and, as the hydrocele of a hernial fac, in 
 which a portion of gut is contained, may be as readi- 
 ly confounded with this as with any other fpecies of 
 the difeafe, I would therefore, even in the hydrocele 
 of the cord, lay this method of cure entirely afide. 
 
 An objedion occurs, in this variety of the diieafe, 
 to the method of cure by cauitic, which is not appli- 
 cable in the hydrocele of the tunica vai^nnalis teltis. 
 The ferum, hi fome inflances, is collected in two or 
 more cyfts ; different cafes of which I have met with ; 
 and nniilar inflances of it are related by Garengeot, 
 Doui^las, and others. Now, in this fituation, if cauf- 
 tic fhould be applied in the method recommended by 
 Mr. Elfe, upon a fmall fpot only, all the water would 
 not be difcharged ; and, in order to obtain a complete 
 removal of the difeafe, it would be necefl'ary to repeat 
 the application of the cauftic to every cyft in v^'hich fe- 
 rum might be colletled. 
 
 This, I think, is an additional reafon for our giving 
 a general preference to the method of cure by inci- 
 fion ; which, by laying the tumor open from one end 
 to the other, divides at once all the different cyfts of 
 wliich it may be compofed, and faves the patient from 
 that diftrefs and difappointment which mufl always be 
 experienced, on a complete cure not being obtained, 
 when good reafons had been previoufly given for ex- 
 peding it. I would therefore advife the treatment by 
 incifion to be preferred in this fpecies of hydrocele, 
 as I have done already in the hydrocele of the tunica 
 vaginalis ; and the mode of performing the operation, 
 and the after treatment of the patient, are nearly the 
 fame in each. 
 
 I have thus enumerated every hydrocele that can 
 be properly confidered as forming a diftinft variety 
 of the difeafe. In doing fo, as I have defcribed no tu- 
 mor but fuch as every pradlitioner of experience mufl 
 have met with, and of which the fymptoms are clear- 
 
lo8 On the Hydrocele. Chap. XXIV. 
 
 ly and diftin6lly marked, fo it will not, I hope, be con- 
 fidered as an unneceflary degree of minutenefs, that I 
 have particularly taken notice of them all. 
 
 I can by no means agree with fome authors, partic- 
 ularly with Mr. Sharpe* and Mr. Elfe, who think that 
 it might be better to confine the defcription of hydro- 
 cele to two varieties. We need not indeed wonder at 
 Mr. Sharpe fpeaking in this manner ; for, even at the 
 late period in which he wrote, although the exiftence 
 of all the varieties of the difeafe that I have mention- 
 ed had been defcribed by different authors, yet they 
 "were not underllood with much accuracy ; and it is 
 evident from Mr. Sharpens writings on the fubjeft, 
 that his ideas of them were in many refpecls more 
 confuted than might have been expetied in one of his 
 ufaal accuracy and penetration. But, whatever was 
 the cafe with Mr. Sharpe, it is truly furprifmg, 
 that thofe who are unqueflionably well informed in 
 every circumftance relating to this difeafe, and who 
 muft be convinced, from frequent diffe6lions, of the 
 exiftence of all the varieties that I have been mention- 
 ing, ihould obje£l to their being retained. Where no 
 evident or marked diftin£lion occurs between one tu- 
 mor and another, an attempt to eftablifh a difference 
 would be ufelefs, and therefore improper ; but where 
 appearances point out an obvious variety, it would 
 furely be confidered as much want of accuracy in an 
 author to omit the detail of them. 
 
 In the defcription that I have given of the five dif- 
 ferent fpecies of hydrocele, to wit, the anafarcous 
 fwelling of the fcrotum, the hydrocele of the tunica 
 vaginalis teftis, the hydrocele of the hernial fac, the 
 anafarcous and the encyfted hydrocele of the fperma- 
 tic cord, it was neceffary to enumerate the fymptoms 
 of each, as they occur feparately and uncombined. It 
 fometimes happens, however, that one, two, or more 
 of the different varieties occur at the fame time in the 
 
 * Trcatife on the OperatioBS of Surjcrj-, 
 
Sed. VL On the Hydrocele. 1 09 
 
 fame patient. I have met with inftances of three, and 
 not unfrequently with two varieties in the fame perfon. 
 The late Dr. Monro mentions an inftance of four fpe- 
 cies of hydrocele being all combined in one cafe.* 
 
 In fuch cafes, fome difficulty and confufion is, no 
 doubt, to be expeded ; but praftitioners, in forming 
 a judgment of their nature, mufl be entirely direfted 
 by due attention to the various fymptoms which take 
 place in each variety of the difeafe, when met with 
 feparately, and unconnefted with others. 
 
 We now proceed to the confideration of the other 
 varieties of falfe hernia ; and firll of the hsematocele. 
 
 • vide Monro's Works, 4to. p. 576. 
 
iia On the Hamaiocele. Chap. XXV, 
 
 CHAPTER XXV. 
 
 ON THE HEMATOCELE. 
 
 THE hsematocele is a tumor in the fcrotum or fper- 
 matic cord, produced by extravafated blood. 
 
 The ufual feat of this difeafe is in the tunica vagi- 
 nalis of the teftis ; but, in fome inllances, it is feated 
 in the fpermatic procefs, and occafionally it is met with 
 in the dartos. 
 
 The hsematocele always arifes from the rupture or 
 divifion of one or more blood vcfiels, and it is mofl 
 frequently the eife£t of external violence. Blows up- 
 on the fcrotum, and bruifes received in riding, fome- 
 times burft the veins, not only in the cellular fubflance 
 of the fcrotum, but in the vaginal coat of the tefticle. 
 Accidents of a fimilar nature have produced fimilar 
 affections in the courfe of the fpermatic cord ; and, as 
 the parts in this fituation are foft and cellular, the rup- 
 ture either of an artery, or a vein of any confiderable 
 fize, is, for the mofl part, attended with a plentiful ex- 
 travafation of their contents. 
 
 In the tunica vaginalis teftis, a hasmatocele is fome- 
 times induced by the point of a trocar, or of a lancet, 
 in tapping for a hydrocele, wounding fome of the 
 blood veffels of the fac, which, in fuch cafes, are com- 
 monly enlarged. 
 
 We become certain of what has happened, by the 
 ferum, as it runs off, being fuddenly tinged with blood ; 
 but, in fome inffances, this does not appear till the col- 
 lection is all difcharged, when the firft intimation we 
 receive of it is by the fudden appearance of a tumor 
 in the fite of the hydrocele. I have now met with va- 
 rious inflances of this, in all of which the tumor pro- 
 duced by the extravafated blood arrived at a very con- 
 fiderable height in the courfe of a few hours. 
 
Chap. XXV. On the Hamaiocele* 1 1 1 
 
 In fome, the difeafe is produced in a different man- 
 ner. Where the quantity of ferum has been large, 
 the fudden difcharge of it, by taking aw ay the fupport 
 which the velfels have been accuftonied to receive from 
 it, is not unfrequently the cauie of the rupture of foine 
 of them ; and, from repeated obfervation, I think it 
 may be confidered as certain, that whenever a large 
 tumor is produced fuddenly, that is, in the courfe of 
 an hour or two, either in the fcrotum, or fpermatic 
 cord, after the contents of a hydrocele have been dif- 
 charged by tapping, that it arifes entirely from extra- 
 vafated blood ; for collections of water are never known 
 fo quickly to become large. 
 
 In the fpermatic procefs, injuries of the fame kind 
 will be attended with a hmilar effetb upon the fmall 
 veins of the fac containing the water ; and more con- 
 fiderable violence has, in fome inftances produced a 
 rupture of the fpermatic artery and vein. 
 
 But in whatever way the tumor has been produced, 
 the appearances are nearly fimilar to thofe of watery 
 colledions in the fame parts ; fo that it is not neceffa- 
 ry to repeat them here ; only it may be remarked, 
 that, when blood is extravafated in the cellular fub- 
 ftance of the fcrotum, it is eafily diflinguifiied from a 
 collection of water by the colour, as it affumes all the 
 ufual appearances of an echymofis. When the col- 
 lection is feated in the tunica vaginalis, the means of 
 diltindion are not fo obvious ; but I may remark, that 
 a tumor produced by blood is heavier than one of the 
 fame fize produced by water ; and pradlitioners, much 
 accuftomed to handle thefe fwelhngs, can in fome in- 
 ftances judge of their contents from their confidence, 
 by the difference which this gives to manual exami- 
 nation. 
 
 The treatment of this kind of tumor, is nearly the 
 fame with that which I have advifcd in Seel. IV. Chap. 
 XXIV. In the commencement of the anafarcous or 
 diilufed hasmatocele, when produced by external vio- 
 lence, whether in the fcrotum or fpermatic procefs. 
 
112 On the Hamatoccle. Chap. XXV. 
 
 the application of ardent fpirits, a folution of alum, 
 volatile liniment, or a ftrong folution of fal ammoniac 
 in vinegar, will, in fome instances, remove it. But, 
 when this does not fucceed, and efpecially if the tu- 
 mor acquires a greater bulk, it mufl, in that cafe, be 
 laid open, and, in every refpeft, treated in the fame 
 manner as has been already directed for the hydrocele ; 
 only I may remark, that, if a ruptured blood veflel is 
 difcovered, the only effectual means of preventing a 
 return of the tumor, is to fecure it with a ligature. 
 
 In like manner, all colledions of blood, whether in 
 the vaginal coat of the teftis, or in the cyft of a form- 
 er hydrocele of the fpermatic cord, are to be laid op- 
 en by an incifion, extending the whole length of the 
 tumor, and, in other refpefts, treated exaftly as I have 
 advifed in the fourth feftion of the preceding chapter, 
 for a hydrocele. And I need fcarcely oblerve, that, 
 if any ruptured veffel comes in view in the courfe of 
 the operation, it ought to be immediately fecured with 
 a ligature : otherwife a conftant difcharge of blood 
 may be looked for during the cure ; the patient will 
 be thereby much incommoded and weakened, and the 
 cure unneceflarily protrafted. 
 
 It fometimes happens, however, whether the difeafe 
 is feated in the fpermatic procefs, or tunica vaginalis 
 teftis, that the veffels from whence the blood is dif- 
 charged cannot be difcovered ; a very confiderable 
 oozing, continuing from day to day, notwithftanding 
 the ufe of bark, vitriolic acid, and every other means 
 that are commonly employed. As patients in this fit- 
 uation foon become weak and emaciated, one great 
 object of the practitioner is to fupport them with nour- 
 ifhing food. A moderate allowance of animal food 
 proves always ufeful ; nor is it found that a liberal ufe 
 of wine does harm. In fome inftances, I have even 
 thought that it tended to leifen the difcharge. 
 
 I have uniformly, however, found, that local rem- 
 edies prove chiefly ufeful, particularly the application 
 of ardent fpirits, ether, or tindure of myrrh, to the 
 
Chap. XXV. On the Ha?natocele, 113 
 
 furface of the fore : pledgets of foft liiit, foaked in 
 one or other of thefe, and renewed from time to time, 
 not only ferve to check the difcharge of blood, but 
 tend, for the moll part, to promote the formation of 
 good matter. 
 
 In fome inftances, however, all our endeavours fail, 
 and the patient contiiming to lofe ground daily, we 
 are warranted in advifing any meafure that may pro- 
 bably tend to fave him. In fuch circumflances, the 
 extirpation of the teflicle has been advifcd. At one 
 time, I was induced to think favourably of this mea- 
 fure ; but further experience has not fhown, that 
 much dependence is to be placed on it. At leafl:, in 
 two cafes, in which it was put in practice, no advan- 
 tage was derived from it ; while, in both, it was the 
 caufe of much additional diftrefs. I do not therefore 
 mean ever to advifc it again. 
 
 Another variety of tumor produced by blood is 
 mentioned by Mr. Pott, in which the blood is con- 
 tained within the tunica albuginea of the teftis. It 
 proceeds, he thinks, from a relaxation or diflblution 
 of part of the vafcular ftru£lure of the tefticle ; and, 
 when the quantity of blood coUeded is confiderable, 
 it produces, Mr. Pott remarks, a fludtuation fome- 
 what like to that of a hydrocele of the tunica vagi- 
 nalis. 
 
 When this is miftaken for a hydrocele, as it has 
 fometimes been, and an opening with a trocar is made 
 in it, a difcharge is produced, of a dark duflvy colour- 
 ed blood, nearly of the confidence of thin chocolate ; 
 but the diminution of the tumor, by this evacuation, 
 is feldom confiderable. 
 
 The perforation, therefore, made in it with the tro- 
 car does no good ; and as the teflicle is commonly fo 
 far fpoiled by the difeafe as to be rendered entirely 
 ufelefs, caflration is advifed as the befl remedy.* 
 
 • Pott's Trcatife on the Hydrocele. 
 
 Vol. hi. I 
 
114 Onihe Hcemaiccek* Chap. XXV* 
 
 I have different times met with a difeafe very fimi-' 
 lar to this defcribed by Mr. Pott : but as the blood 
 in fuch inftances did not appear to be extravafated^ 
 but to be ftill contained in the veiTels of the teftis, in 
 an enlarged varicofe ftate, I am not inclined, there- 
 fore, to refer this kind of tumor to any jpecies of ha^- 
 matocele, but rather to confider it as a variety of va- 
 rix. I have even feen this variety of tumor miftaken 
 for a hydrocele, and treated as fuch, by a trocar be- 
 ing plunged into it, when the effects were exaftly 
 what are defcribed by Mr. Pott. But, if the blood 
 had been extravafated, a more copious difcharge 
 would have taken place from the perforation, than 
 was obtained by it in any of the cafes to which I al- 
 lude. Even where the tumor has been of a confide- 
 rable fize, I never found it pofTible to evacuate in this 
 manner more than a fpoonful or two of blood, and 
 although, in fuch cafes, the blood appears evidently 
 more vifcid than in a flate of health, this is not in fuch 
 a degree as ought to prevent it from being freely dif- 
 charged by the canula of a trocar, were it lodged in 
 a flate of extravafation. 
 
 In all the cafes that I have feen of this tumor, when 
 it was not opened, but merely fupported by a fufpen- 
 fory bag, it has remained indolent and ftationary for 
 many years. But whenever it has been touched with 
 an inflrument in order to difcharge its contents, it has 
 from that moment gone wrong. The patient who 
 had fuffered little previous pain, foon became greatly 
 diftrefsed ; the fwelling then began to increafe ; fepa- 
 rate encyfted collections formed in it ; thefe at lafl 
 burfl and left an ugly fore of an unequal furface, and a 
 putrefcent bloody difcharge, on which no application 
 had any effect ; {o that caftration at lafl became necefla- 
 ry. Even this dCes not always afford relief ; for, infome 
 inflances, fuch a fpongy relaxed flate of the veffels 
 takes place along the vv'hole courfe of the cord, that, 
 though they are fecured with ligatures to-day, blood 
 burlts out at different parts to-morrow. Of this I 
 
chap. XXV. On fhe Hamatocek» 115 
 
 was once concerned in a very diftrefsful inftance. Af- 
 ter the ufual operation of caftration, frelh hsemorrha- 
 gies occurred at every dreffing ; the veflcls were at 
 different times fecured with ligatures, but to no pur- 
 pofe ; the blood burft out again and again ; and the 
 patient, after flfte^^g much diitrcfs from this caufc 
 alone, at laft died. 
 
 The chief differences which, before laying the parts 
 open, can be obferved between this variety of tumor 
 and a hydrocele of the tunica vaginalis, is, that in 
 this, the fluduation is never fo evident as in the oth- 
 er ; the tumor is heavy in proportion to its fize ; the 
 form not fo pyramidal as that of a hydrocele ; and if 
 properly fupported with a bandage, it does not receive 
 any additional increafe. Whenever thefe circumftan- 
 ces, therefore, occur in the fame cafe, they give much 
 reafon to fufpect, that the difeafe is of this kind j and 
 therefore, that no operation fliould be advifed. The 
 patient (hould be deHred to trufl entirely to a \Me\\ 
 adapted fufpenfory bag ; to avoid fevere fatigue ; and 
 to prevent a coftlve flate of the bowels, which in all 
 difeafes of thefe parts, very conflantly does harm. 
 
 M 
 
n6 Of the Varicocele, "^c. Chap. XX VL 
 
 CHATTER XXVI. 
 
 OF THE VARICOCELE, CIRCOCEI^JE, »ERMATOCELE, 
 AND PNEUMATOCELE. 
 
 BY the term varicocele, is meant a varicofe diflen- 
 tion of the veins of the fcrotum, which in this 
 flate form a tumor of hard knotty inequalities, feldom 
 attended with pain, and commonly productive of no 
 inconvenience, if it be not from its bulk. 
 
 The circocele is a tumor of the fpermatic 'cord, ex- 
 tending from the fuperior part of the fcrotum to the 
 abdominal mufcles, and is produced by a varicofe dif- 
 tention of the fpermatic vein. 
 
 Thefe tumors are occafionally produced by preflure 
 on the courfe of the veins ; but we are feldom able 
 to dillinguifh the caufe of it, in which cafe, we con- 
 clude, that they arife from debility or relaxation in the 
 veflels in which they occur. 
 
 When tumors in the courfe of the veins are per- 
 ceived to give rife to thefe tumors, or when the pref- 
 fure of a hernial trufs upon the fpermatic cord appears 
 to have produced them, the removal of this evident 
 caufe of the difeafe, fhould be the firfl attempt towards 
 a cure. 
 
 When produced b]'' the prefTure of a trufs, or of 
 any other fimilar caufe, an alteration in the bandage 
 will fometimes remove them. When the prefTure of 
 fchirrous tumors give rife to them., thefe muft be ex- 
 tirpated when it can be done w-ith fafety ; and when 
 produced by tumors tending to fuppurate, warm emol- 
 lient applications will be the moft ufeful remedy. 
 
 But v/hen a general relaxed ft ate of the veins ap- 
 pears to be the caufe of their diftention, fuch reme- 
 dies fhould be employed as will moft elfedually re- 
 
Chap. XXVI. Of the Varicocele^ ^c, 117 
 
 cover that tone of which- they have been deprived by 
 the long continuance of the difeafe. With this view, 
 nothing commonly anfwers fo well as the ufe of a 
 proper fufpenfory banth/^, and the application of a 
 folution of alum, a foluiion of crude fal ammoniac in 
 vinegar, and other aflringents, to the parts affefted. 
 
 By due attention to this kind of management, the 
 increafe of ahnofl every tumor depending upon this 
 caufe, may be prevented ; and fo much relief will be 
 thereby obtained, as to render the harfh remedies of 
 the knife, the cautery, and ligature, recommended by 
 ancient writers for the removal of thefe tumors, alto- 
 gether unneceflary. 
 
 By the fpermatocele, is meant, a morbid diftention 
 of the epididymis and vas deferens, produced, as is 
 fuppofed, by a ftagnation of femen. This may arife 
 from tumors, ftridure, or inflammation about the 
 caput gallinaginis, or in the courfe of the vas defer- 
 ens ; but there is reafon to think, that it is mod fre- 
 quently induced by inflammation. 
 
 When produced by Inflammation, general and top- 
 ical bloodletting, gentle laxatives, a low cooling diet, 
 and refl of body, will commonly prove the mofl: ufe- 
 ful remedies, and of thefe none are more to be truft- 
 ed than topical bloodletting with leeches which fliould 
 be repeated from time to time, according to the ur- 
 gency of fymptoms. And again, when tumors 
 are difcovered to prefs upon the vas deferens, they 
 (liould cither be, brought to fuppurate, or removed 
 with the fcalpel, when it can be done with fafcty. 
 At other times thefe tumors are conneded with lues 
 venerea ; in which cafe, a well directed courfe of 
 mercury will be moft likely to anfwer. 
 
 By fome we are told, that all the other means hav- 
 ing failed, caftration has at lafl: been found requifite. 
 
 This, however, I can fcarcely fuppofe to be necef- 
 fary in any cafe ; at lead I never met with an inftance 
 of its being fo. 
 
118 Of the Varicocele, ^c. Chap. XXVI. 
 
 The term pneumatocele, is applied to fignify a dif- 
 tention of the fcrotum by a colledion of air. 
 
 This has been defcribed by mod of the ancient 
 writers as a frequent occurrence ; but there is much 
 reafon to think, that a great proportion of all the tu- 
 mors which they defcribe as containing air, were eith- 
 er formed by colleftions of water, or by the protru- 
 lion of fome of the bowels. That fpecies of hernia 
 to which young children are liable, is to this day, by 
 our common people, termed a wind rupture, as is the 
 cafe with all thofe collections of water m the fcrotum, 
 "with which new born infants are aiTected. But we 
 know well, that none of thefe tumors are formed by 
 air ; and that their contents are of a very different 
 pature. 
 
 In wounds of the lungs, air Is fometimes thrown 
 into the furrounding cellular fubftance, and in that 
 way pafles into the fcrotum, as it does in particular 
 inftances over the whole body ; and in high degrees 
 of putrid difeafes, fo much air may be feparated from 
 the blood, as to diftend the cellular fubftance of the 
 fcrotum, as well as of other parts. But a real pneu- 
 matocele has never probably exifted as a mere local 
 affection of the fcrotum ; at leaft I have never feen it. 
 
 In the cafe of air fpreading to the cellular fubftance 
 of thefe parts, as a confequence of a wound of the 
 lungs, the fame remedy proves eifeclual that we em- 
 ploy for anafarcous fweUings formed by water, to wit, 
 fmall punctures with the point of a lancet, which are 
 found to be fufficient for difcharging great quantities 
 of air. But whenever the difeafe is induced by fuch 
 a degree of putrefcency in the fyftem, as excites a fe- 
 paration of air from the blood, there can be little rear 
 Jon to look for advantage from any means that qaii 
 be employed. 
 
Chap. XX VII. Of the Sarcocek. 1 1 9 
 
 CHAPTER XXVII, 
 
 OF THE SARCOCELB, OR SCHIRROUS TESTICLE, 
 
 THE term farcocele, Implies a firm flefliy enlarge- 
 ment of the tefticle : a fimple inflammatory 
 fwelHng of the teflis affords a tumor of fome degree 
 of firmnefs ; but the true farcocele, or fchirrous tefti- 
 cle, is attended with a hardnefs altogether unufual in 
 the real hernia humoralis, or inflamed tefticle. 
 
 A fchirrous tefticle, in the courfe of its progrefs, 
 puts on fuch a variety of appearances, as renders it 
 difficult, by defcription, to give an adequate idea of it. 
 In general, however, the accefllon and progrefs of the 
 difeafe is this : 
 
 An unufual degree of hardnefs, attended with fome 
 enlargement of the teftis, is the firft indication of the 
 difeafe. The parts are not at firft difcoloured, nor is 
 there any material degree of pain. In a gradual man- 
 ner, the tumor acquires a larger fize. At firft, it is 
 fmooth and equal, but on becoming larger, it alfo be- 
 comes harder and knotty or unequal on the furface : 
 flight pains are felt in every part of it ; and if it be 
 not fufpendcd, the patient complains of iineafmefs in 
 his back. 
 
 When the conftitution Is found, the difeafe will oc- 
 cafionally remain in this fituation for a great length 
 of time ; and in fome inftances, by moderate diet, 
 keeping an open belly, fufpending the tumor proper- 
 ly, and avoiding violent exercife, it has not only been 
 prevented from increafing, but, in a gradual manner, 
 has been difcuffed. This favourable termination, 
 however, it muft be owned, is exceedingly rare ; for 
 inftead of remaining ftationary, the difeafe in general 
 becomes worfe. It acquires a larger fize j becomes 
 
i 20 0/ the Sarcocck. Chap. XXVII. 
 
 ragged, and more unequal on its furface ; and the 
 pain, which at firfh was trifling, becomes more fevere, 
 darting, in fmart flings, through every part of the 
 tumor. 
 
 The inequalities on the furface of the tumor by de- 
 grees increaie. In fome inflances, a confiderable 
 quantity of ferum is extravafated into the tunica vagi- 
 nalis, which, to thofe who are not verfant in the treat- 
 ment of difeafes of this kind, gives the tumor the ap- 
 pearance of a common hydrocele ; and at other times,, 
 inflead of fuch depofitions into the vaginal coat of the 
 tefticle, partial collections of matter take place through 
 the whole body of the tumor. Thefe by degrees in- 
 creafe, and the fcrotum, which till then had been gra- 
 dually diftending, at laft burfts, and a difcharge takes 
 place from the various collections in the body of the 
 tumor, of a thin, fetid, bloody matter. 
 
 In fome inltances, the fpermatic cord becomes hard 
 and enlarged foon after the commencement of the dif- 
 eafe ; but this does not commonly happen till the tu- 
 mor has acquired a confiderable fize, and moll fre- 
 quently, I have obferved, not till matter has formed 
 in it. 
 
 On the teflis increafmg In bulk, this afTedion of 
 the cord alfo becomes worfe. From being at hril on- 
 ly nightly tumefied, it gradually turns more hard and 
 fwelled ; it becomes fo painful, that the patient can- 
 not bear to be touched, and knotty or unequal 
 through the whole extent of it. 
 
 The difcharge from the openings in the fcrotum 
 flill continues ; but although the quantity of matter 
 is increafed, the fize of the tumor is not thereby di- 
 minifiied. It rather continues indeed to increafe, the 
 edges of the fore become hard, Hvid, and retorted, 
 and fungous excrefcences pulh out from different 
 parts of it. 
 
 Whatever was the flate of the patient's health on 
 the firft attack of the difeafe, in this advanced ftate of 
 it, it is always much impaired. He now becomes 
 
Chap. XXVII. Of the Sarcocele, 1 2 1 
 
 emaciated, of a pale, wan complexion, and the difeafe, 
 which in this ftage, is a real cancer of the moll ma- 
 lignant nature, turning dill more virulent, by the pain 
 becoming more tormenting, the patient is at laft car- 
 ried otf in much mifery. 
 
 Such, in general, is the progrefs and event of this 
 dreadful difeafe, if not interrupted by the extirpation 
 of the teftis, before it has gone too far. I have alrea- 
 dy obferved, that it exhibits a great variety of fymp- 
 touis. Thofe I have enumerated occur moft fre- 
 quentlv ; but no defcription cim convey a clear idea 
 of all the appearances tliat it aifumcs. 
 
 In fome, as I have obferved above, it remains ap- 
 parently in an indolent inaftive ftate, for a great 
 length of time, even for years ; and in others, it pro- 
 ceeds fo rapidly, that in the fpace of a few months, I 
 have known it pafs through all the changes I have 
 enumerated. 
 
 Nor is any age, temperament, or line of life, ex- 
 empted from it : it happens equally to the opulent 
 and to the moft indigent ; and I have met with it in 
 all ages, from the fixteenth to the feventieth and 
 eightieth year, but not fo frequently in early youth, 
 as in more advanced ftages of life. In a great pro- 
 portion of ca'es, the difeafe begins in the body of the 
 teftis, afie<^ing the whole of it equally ; but in fome, 
 it makes its firft appearance in the epididymis, and 
 occafionally even in the fpermatic cord. It has been 
 a prevailing opinion, indeed, that a fchirrous hard, 
 nefs, tending to cancer, never begins in the epididy- 
 mis, and that the tefticle is always firft affedled. 
 
 This is certainly in general the cafe, but every prac- 
 titioner muft at times have met with inftances of can- 
 cer beginning in the epididymis, and fometimes even 
 in the fpermatic cord, and fpreading from thence to 
 the neighbouring parts. I might here infert different 
 cales which have fallen within my own obfervation ; 
 but Mr. Pott's collection furniflies a fufficient number 
 of well marked examples.* 
 
 * Treatifc on the Hydrocele, cafes 4», 48, and 491 
 
122 Of the Sarcocsk. Chap. XX VIL 
 
 In almofl; every cafe of fwelled tefUcle from gonor- 
 rhoea, the epididymis is not only affeded before the 
 teflicle, by the inflammation fpreading from the ure- 
 thra, along the vas deferens ; but the fwelling, when 
 it begins to yield, always firft removes from the tefli- 
 cle, leaving in general, a hardened ftate of the epidi- 
 dymis, which for the mod part, continues in fome 
 degree during life. But as the hardnefs produced in 
 this manner is entirely the effeft of infianmiation up- 
 on a membranous or vafcular part, fo here, as in oth- 
 er parts of the body, of a fimilar texture, we feldom 
 find that hardnefs induced by inflammation terminates 
 in cancel*. 
 
 The contrary however, of this has been inculcated ; 
 and it has even been faid, that the hernia humoralis 
 produced by gonorrhoea, and that tumor of the teftis 
 which we fometimes meet with from lues venerea, are 
 frequent caufes of farcocele ; which in various inftan- 
 ces has done harm, by tending to prevent a trial of 
 mercury, the only remedy which in tumors of the 
 teftis arifmg from this caufe, has ever as yet proved 
 of any real utility. 
 
 But, although tumors of the teflis, from a venereal 
 caufe, feldom terminate in this manner, yet I will not 
 go fo far as to fay that they never have done fo ; for 
 I know, that a hardened flate of the teflis and epidi- 
 dymis produced originally from a venereal taint, does 
 in fome inflances, degenerate into the worfl fpecies of 
 farcocele. That is, that although tumors in this part, 
 arifmg from lues venerea, are mofl frequently cured 
 by mercury, yet occafionally and in particular confli- 
 tutions, the peculiarities of which, however, we are 
 not acquainted with, they do certainly end in fchirrus 
 of the worfl kind, a difeafe which might never proba- 
 bly have appeared, if the original venereal taint had 
 not afted as an exciting caufe of it. We know that 
 a predifpolition to difeafes will remain long in a latent 
 (late in the fyflem, without any evident fymptom be,- 
 ing excited, till the application of fome particular , 
 
Chap. XXVII. Of the Sarcocek. 12^ 
 
 ftimulus brings it into a£tion. In the fame manner, 
 a venereal affection of the teftis, or even that hardnefs 
 of the epididymis that remains after an inflammatory- 
 tumor of thele parts from gonorrhoea, will in fome 
 confliitutions, terminate in farcocele, akhough in a 
 great proportion of cafes it is otherwife, and no dif- 
 treisful confequence refults from them. 
 
 I have dwelt the longer upon this, from a contrary 
 dodrinc having been ilrenuoufly inculcated by one 
 whofe authority is defervedly great, and whofe obfer- 
 vation in this cli'eafe has led to the conclufion he en- 
 deavours to ellabiifli.* But, as the refult of my ex- 
 perience has been eAa6tly what I have flated, I could 
 not avoid fpeaking of it in the manner I have done. 
 
 In the treati'e to which I allude, we are told, that 
 hernia humoralis is never productive of farcocele. If, 
 on this fubje6l, Mr. Pott's idea is juft, it ought un- 
 doubtedly to be received ; but, if it is not, it may cer- 
 tainly do harm, by rendering both patients and practi- 
 tioners more remiis in cafes of farcocele proceeding from 
 this cau^e, than they otherwife would be ; as, by con- 
 tinuing ftill to expect that a mercurial courfe may ac- 
 complifli a cure, they may allow the difeafe to go too 
 far before extirpation is advifcd. 
 
 In every doubtful cafe, when lues venerea is fufpe£l:- 
 ed to be the caufe of the tumor, bloodletting, when 
 the pulfe is full, an open belly, a cooling diet, a hori- 
 zontal pofture, a proper fufpenfory bandage, and a 
 well directed courfe of mercury, will commonly re- 
 move it. But, when thefe means are employed with- 
 out advantage ; and efpecially if, during their applica- 
 tion, the tumor, inflead of decreafmg, becomes grad- 
 ually worfe, as foon as, from its increafe, there appears 
 to be any rifk of its advancing too far to admit of be- 
 ing extirpated, it ought, without further hefitation, to 
 be removed, whatever the caufe may be by which it 
 was at firft produced. 
 
 • Mr. Pott, Treatife on the Hydrocele, Sec. p. 331. 
 
1 24 Of the Sarcccck, Chap. XXVII. 
 
 . Among other caufes which authors have mentioned 
 of farcocele, is the hydrocele of the tunica vaginalis. 
 From quantities of a fcrous fluid being frequently found 
 in the vaginal coat of a fchirrous teflicle, it has been 
 fuppofed, that the water, in fuch cafes, 'was the origi- 
 nal caufe, and not the eifeO: of the difeafe in the tef- 
 tis. There is much reafon, however, to think, that 
 in thefe coUcclions of water in the tunica vaginalis, in 
 which the tcftis is found difeafed, that the hardened 
 ftate of that organ ought to be confidered as the orig- 
 inal difeafe, and not the water which furrounds it. 
 
 Colleftions of water are, no doubt, often met with, 
 even in a real farcocele ; but this we are to confider 
 entirely as a diflerent ftage of the fame difeafe : for, 
 although the true farcocele is not at firft attended with 
 any colleclion, either of blood or ftrum, it is natural 
 to fuppofe, that an enlarged or hardened ftate of the 
 teftis muft have feme influence, both on the quantity 
 and appearance of the fluid with which the tunica va- 
 ginalis is always provided. 
 
 If it either excites an augmented fecretion, or a di- 
 minifhed abforption of this fluid, a dropfical fwelling 
 muft take place ; and every fuch collection combined 
 with a fchirrous tefticle, has been very properly term- 
 ed a hydro-farcocele. 
 
 That the teftis, by remaining long immerfed in the 
 ferum even of a true hydrocele, is frequently altered 
 in its texture, there is no reafon to doubt. Thus, on 
 laying open the tunica vaginalis in a common hydro- 
 cele, the teftis is very commonly of a more pale ap- 
 pearance than in a ftate of health. 
 
 In feme cafes, it is much diminiflicd, and, in others, 
 confiderably enlarged ; but all fuch enlargements, 
 when connected v/ith a real hydrocele, are of a foft, 
 harmlefs nature, and never give pain. In this ftate, 
 the teftis Ihould never be extirpated. 
 
 This is a point, I may remark, which it is of much 
 importance to afcertain : for, on the idea of this en- 
 largement of the teftis, frequently connected with, aod 
 
Chap. XXVir. Of the Sarcoccle. 125 
 
 perhaps produced by immerfion in the water of a hy- 
 drocele, being truly fchirrous, the operation of caftra- 
 tion has been often advifed, and unfortunately pradif- 
 ed. In circumflances of doubt, the means of diftinc- 
 tion between the mild and malignant variety of en- 
 larged tefticle, by* which we fhould in general be di- 
 rected, are thefc : when either the body of the teflis 
 or epididymis, or both, are hard and enlarged previ- 
 ous to any collection of fcrum in the tunica vaginalis, 
 fuch collections as afterwards take place ought not to 
 be confidcred as conftituting a fimple hydrocele. If 
 the tumor has been accompanied with pain, and if, 
 upon difcharging the ferum by inciuon, the teftis, be- 
 lides being enlarged, is hard or ulcerated -on its fur- 
 face, extirpation fhould be immediately advifed ; but, 
 on the contrary, when the water of a hydrocele is 
 known to have been collected while the tefticle re- 
 mained found, and of its natural fize, whatever en- 
 largement it may be found to have acquired on laying 
 the fac open, if the teftis is neither of a fchirrous hard* 
 nefs, nor aft'edted v^ith pain or ulceration, we ought 
 unqueftionably to proceed as in a cafe of fimple hy- 
 drocele ; for, this kind of enlargement will be rarely 
 found to excite future uneafmefs, and will confequent- 
 ly feldom or never render extirpation neceifary. 
 
 In judging of the probable termination of a fchir- 
 rous tefticle, different circumftances require attention : 
 the a,ge and habit of body of the patient, the duration 
 of the difeafe, and the ftate it is in at the time. 
 
 Thus, whatever treatment is to be adopted, more 
 fuccefs may be reafonably expected in a young heal- 
 thy perfon, than in the reverfe ; particularly if extir- 
 pation of the teftis is to be advifed. In patients that 
 are otherwife in good health, the chance of fuccefs 
 from the operation is commonly confiderable, provi- 
 ded the difeafe is not too far advanced ; whereas, in 
 old or infirm people, and in habits attended with pale, 
 wan complexions, with indigeftion, and other fymp. 
 
1 26 Of the Sarcccek. Chap. XXVII. 
 
 toms of obftrucled vifcera, whatever flate the difeafe 
 may be in, Httle or no advantage is Ukely to accrue 
 from any operation. 
 
 The complexion, of itfelf, I muft obferve, does not, 
 in this difeafe, merit much attent:on ; for, I have 
 fcarcely met v/ith an inflance of th€ true farcocele, ev- 
 en in the early and mofl fimple (lage of the difeafe, in 
 which a pale complexion did not take place. It feems 
 to be, in a great meafure, the effect of that anxiety 
 and dread for the final event of the difeafe, to which 
 patients, with tumors of this defcription, are particu- 
 larly liable ; but it is materially different from that 
 wan, fickly countenance, often accompanied with a 
 flight tinge 'of bile, that we meet with in the advanced 
 ftate of the difeafe, when attended with obftructions 
 of any of the abdominal vifcera. 
 
 With refpecl to the duration of the difeafe, if it has 
 already fubfifted for a confiderable time without mak- 
 ing progrefs, there will be reafon to think that it is of 
 a mild nature, and that the fyftem is not fo much af- 
 fefted as if its progrefs had been great and rapid ; and, 
 laftly, the flate of the tumor at the time is of much 
 importance in forming a prognofis of the event. As 
 long as the teftlcle is only fomewhat hard and enlarg- 
 ed, without the formation of matter, and without any 
 difeafe of the cord, if the conftitution is otherwife 
 healthy, there will be much caufe to hope for a fa- 
 vourable event from any operation that is advifed. 
 
 But, on the contrary, when the difeafe is fo far ad- 
 vanced, that colledions of matter have formed, either 
 upon the furface of the tefticle, or in its more inter- 
 nal parts, as in this flate there will be caufe to fufpedl 
 that the conflitution has fuft'ered from abforption, fo 
 there will be lefs caufe to hope that the operation will 
 prove fuccefsful, than in the more early flages of the 
 difeafe. And this is more remarkablv the cafe, when 
 ulcerations have taken place on the furface of the tu- 
 mor ; for we know well that abforption is much 
 more apt to occur from tumors in a flate of ulcera- 
 
Chap. XXVII. Of the Sarco£eIe, 1 27 
 
 tion, than from matter to which the air does not get 
 accels. 
 
 In whatever ftate, however, the tumor may be, there 
 is always reafon to hope for more fuccefs from the 
 operation while the fpermatic cord is yet found, than 
 when it has become difeafed ; for, as loon as the cord 
 is much affected, the chance of fuccefs from any 
 means that can be attempted, will be proportionally 
 lefs. The cord, indeed, may, towards its under ex- 
 tremlt)'-, be difeafed, even in the fame manner with 
 the teliis itfclf, without leflening the chance of benefit 
 from the operation; but, whenever the difeafe has 
 fpread fo far up the cord as to render it doubtful 
 whether the parts affeded can be all removed by the 
 knife or not ; and efpecially, if there is reafon to think 
 that the cord is difeafed within the boundaries of the 
 abdomen, inflead of there being, in fuch circumftan- 
 ces, any advantage to be expected from the operation, 
 every attempt towards the removal of the parts below^ 
 will, for certain, tend to aggravate the fymptoms, and 
 haften the death of the patient. 
 
 When a fchirrous or cancerous tumor is fo fitu- 
 atcd, that it can be entirely removed, the operation 
 ought immediately to be advifed ; but when the dif- 
 eafe has advanced fo far as to render this impofliblc, 
 in whatever part of the body it may be feated, no at- 
 tempt of this kind fhould be made, the fact being now 
 clearly afcertained, that canerous atlections are always 
 rendered worfe by extirpation, when all the difeafed 
 parts cannot be removed. 
 
 It is of much importance, however, to obferve, that 
 the fpermatic cord freqently becomes full and thick, 
 merely by the weight of the tumor, without being in 
 any other refpeft difeafed. A fulnefs of this kind, 
 when the cord itfelf is not painful, and when no knots 
 or inequalities have formed upon its furface, ought 
 not to prevent the operation, when in other rcfoedls, 
 it appears to be neceffary ; for, a mere enlargement 
 of the cord very frequently occurs, either from a vari- 
 
123 Of the Sarccccle. Chap. XXVII. 
 
 cofe date of the velTcls, or from a watery depofition 
 in the cellular fubflance of the part, when it is not in 
 any other manner difeafed.* But, when the cord, at 
 the fame time that it has become enlarged, hard, and 
 knotty, adheres to the neighbouring parts, is painful 
 to the touch, or ulcerated, thefe, if the difeafe extends 
 over the whole procefs, up to the abdominal mufcles, 
 are circumftances which, with every prudent pradti- 
 tioner, will at all times forbid the operation of cailra- 
 tion. 
 
 It has indeed, been propofed, in this flate of the 
 cord, to enlarge the opening in the external oblique 
 mufcle, fo as by diil'edion, to trace the difeafed parts 
 even into the cavity of the abdomen, with a view to 
 remove them entirely. But, although theoretical wri- 
 ters may attempt to amufe their readers with fuch pro- 
 pofals, they will never be feriouily thought of by prac- 
 titioners whofe opportunities for obfervation enable 
 them to think and aft for themfelves. 
 
 It is unnecelTary here to enumerate either internal 
 medicines or external applications, as none have been 
 employed with advantage for the removal of this dif- 
 eafe. Cicuta and belladona, fo much celebrated in 
 cancer, have no effect in arrefting its progrefs, or in 
 mitigating its fymptoms. It is on the extirpation of 
 the difealed parts that we alone rely for a cure : hence, 
 it is a point of the firfi: importance, to afcertain the pe- 
 riod of the difeafe at which the operation fliould be 
 propofed. 
 
 I have already obferved, that occafionally we meet 
 •Avith a fchirrous enlargement of the teflis, with which 
 ♦ patients walk about for a great length of time, with 
 little or no inconvenience. Such inflances, however, 
 are rare ; for by much the greatell proportion prove 
 to be of a malignant nature, and proceed rapidly to a 
 flate of pain and hazard. I may therefore obferve, 
 
 * Of the point here inculcated, fome Cn^lar proofs are recorded by 
 Mr Pott, in his ulcful coUcclion of cafes. Sec TrcatiJc on the Kydrocele, 
 Cafes xxi:ix. xl. xlix. and l. 
 
Chap. XXVII. Of the Sarcoceie. 129 
 
 that, whenever a fchirrous or hardened ftate of the 
 tefticle does not yield to the means ufually advifed for 
 it, fuch as moderate evacuations of blood, when thefe 
 are indicated, a cooling diet, a lax belly, the ufe of a 
 fufpenlory bandage, and efpccially when mercury, 
 which, on the chance of the difeafe being venereal, is 
 very commonly tried, are all ufed without advantage, 
 v/c may, in fuch circumftanccs, always have much 
 caufe to fufpeft that the difeafe is of the word kind. 
 When more inveterate fymptoms appear, when the 
 tumor, which, till now, was in a hard indolent ftate, 
 becomes painful, and increafes in bulk, no further de- 
 lay (hould be advifed. For, however improper it 
 would be to remove a hardened teftis, which, for a 
 confiderable time, had remained indolent, without 
 pain or increafe, it would be equally unpardonable in 
 any praditioner to advife the operation to be delayed, 
 when matters are fo far changed, that the tumor is 
 attended with much pain, and daily becoming larger. 
 In fuch circumflances, the fooner the difeafed parts 
 are removed, the greater will be the chance of a re- 
 covery ; fo that not a day' fliould be loft : for, what- 
 ever the opinion of the late Mr. Sharpe on this point 
 may have been, as well as of fome others who appear 
 to have copied from him, it has long been a fixed 
 maxim with the moft experienced furgeons, that, in 
 all cafes of cancer, the rifk of a relapfe after the ope- 
 ration, is commonly in proportion to the duration of 
 the difeafe.* 
 
 The extirpation of the tefticle being refolved on, 
 the method of doing it is this : the patient muft be 
 laid on a table of a convenient height, with his legs 
 hanging down, and firmly fecured by two afTiftants on 
 
 • The opinion of the late Mr, Sharpe, on this point, was fingular in a 
 Bian of fuch extcnfive experience. He confidered the rifle of a rclapfc, af- 
 ter the extirpation of cancerous tumors, to be greater in the more early 
 periods of the difeafe, than in their more advanced ftates. Critical Inqui* 
 ry, 4th edit. p. 108. 
 
 Vol. III. K 
 
130 Of the Sarcoccle, Chap. XXVIl. 
 
 each fide ; one at each arm, and another fupporting 
 each leg. The parts being pre\'ioufly Ihaved, if tha 
 tumor is large, an afliftant mud be employed to fecure 
 it ; if only, however, of a moderate fize, the furgeon 
 will do it beft himfelf. With one hand, therefore, he 
 Jhould grafp the fwelling, fo as to keep it firm, and 
 with a fcalpel in the other, an incifion fhould be made 
 along the whole courfe of it, beginning at leaft an inch 
 above the part where the cord is to be cut, and con- 
 tinuing it through the Ikin and cellular fubflance, to 
 the inferior part of the fcrotum. The eafieft method 
 of doing it, both for the furgeon and patient, is by 
 one continued ftroke of the knife, as it is both more 
 quickly and more neatly performed in this manner, 
 than in the ufual way of pinching up the ikin between 
 the finger and thumb, before cutting it ; and there is 
 no kind of difficulty or rifk in doing it in this manner. 
 
 The fpermatic cord being thus laid bare, the fur- 
 geon, with the finger and thumb of one hand, fhould 
 raife it from the parts beneath, fo as to be enabled to 
 pafs a broad waxed ligature round it ; which is eafily 
 done with a large curved needle, or even with a blunt 
 probe, with an eye at one end. With this ligature, a 
 running knot fhould be made upon the cord, about 
 half an inch above where it is to be divided. 
 
 The cord being at this part cut acrofs with the fcal- 
 pel, the tefticle is then to be entirely removed, by dif- 
 fering the cord and it from above downwards, fo as 
 to feparate them as eafily as pofTible from the furround- 
 ing parts, without injuring the found Ikin with which 
 they were covered. Different inftruments have been 
 propofed for facilitating the feparation of the teflis from 
 the contiguous parts ; but none with which we are 
 acquainted anfwers the purpofe fo well, or with fuch 
 expedition as a fcalpel. 
 
 When the difeafed parts are removed, any arteries 
 of the fcrotum that have been divided, fhould be firfl 
 fecured with ligatures, by means of the tenaculum. 
 This being done, the fpermatic artery and vein fhould 
 
Chap. XXVII. Of the SarcQcele. 131 
 
 be gently feparated from the nerve with which they 
 are in contact, and, by the aid of a tenaculum, (hould 
 be tied with a fmall Hgature of waxed filk. By in- 
 cluding the nerve in the ligature, as is commonly 
 done, we render this the moft painful part of the op- 
 eration, whila no advantage whatever is gained by it. 
 
 The ligature previoufly pafTed round the cord, (hould 
 be untied ; but it fhould not be withdrawn. Leil the 
 ligatures of the fpermatic artery and vein fliould give 
 way, this ligature (liould be allowed to remain during 
 the firll eight or ten days of the cure, and, being per- 
 fedly loofe, no harm can be done by it. It is meant 
 merely as an additional fecurity, and to ferve as a kind 
 of tourniquet, in the event of any hemorrhage taking 
 place ; fo that, in circumftances fuch as we are now 
 confidering, it ought always to be left loofe. There 
 is, in fadl, no more necellity for allowing this ligature 
 to remain tied, than for leaving a tourniquet firmly 
 applied upon any of the extremities after the operation 
 of amputation ; and yet, inftead of one ligature, fuch 
 as this, it has been the practice with many to apply 
 two, about half an inch diilant from each other ; and 
 thefe they leave firmly tied upon the whole fubftance 
 of the cord during the cure of the fore.* 
 
 There is, however, no necelTity for this precaution, 
 as all manner of rifk may be prevented, by fecuring 
 the blood veflels in the manner I have pointed out. 
 I have often done the operation in this way, and no 
 hazard has ever enfued from it. By leaving the liga- 
 ture at the upper part of the wound untied, it may be 
 made ufe of, as I have already obferved, to comprefs 
 the cord, in the event of the blood vefTels burfting out 
 again ; but, when the ligature upon the fpermatic ar- 
 tery and vein is properly applied, this will never hap- 
 pen ; and when it occurs from negled: or mifmanage- 
 ment, any fevere hemorrhage may always be prevent- 
 ed by the ligature left for that purpofe. 
 
 • Even the late Mr. Sharpe gives thefe direiStions. Vide Trcatife on 
 the Operations of Surgery, loth edit. p. j j. 
 
 K 2 
 
132 Of the Sarcocele, Chap. XXVII. 
 
 On the arteries being tied, the edges of the cut 
 fhould be laid together, and fecured with adhefive 
 plafter, when the retraclion is inconfiderable ; and, 
 with the interrupted future, when it appears from the 
 retradion that takes place to be neceilary. At the 
 fame time, care fliould be taken to Icatte the ends of 
 the Hgatures employed for fecuring the blood veffels, 
 hanging out at the edges of the wound, to admit of 
 their being withdrawn, when, in the courfc of the cure, 
 they appear to have become loofe. The whole fcro- 
 tum (hould be covered with a pledget of foft linen, 
 fpread with faturnine cerate ; and a culhion of tow, 
 covered with old linen, being laid over it, the whole 
 fhould be fecured with a fufpenfory bag, or the T 
 bandage. 
 
 At the end of the fecond or third day, the dreflings 
 fhould be removed : it is eafily done, when the parts 
 are covered in the manner I ha\e advifed, with cerate ; 
 and it always keeps the patient more comfortable than 
 when the firfl; dreffing is long delayed. For the fame 
 reafon, the dreflings fhould be renewed daily. In the 
 courfe of eight or ten days, the ligatures commonly 
 feparate, and are eafily taken away. About the fame 
 period, the ligature pafled beneath the fpermatic cord 
 may be withdrawn ; and by the fourteenth or fifteenth 
 day, the cure, when conduced in this manner, is for 
 the mofl part complete. 
 
 Hitherto we have been fuppofmg that the tegu- 
 ments covering the tefhicle are found, in which cafe 
 none of them fhould ever be taken away ; but, when 
 the fkin has become thin and inflamed, and efpecially 
 when any of it is in a ftate of ulceration, all fuch parts 
 of it fhould be removed along with the tefticle. In 
 fuch circumfl:ances, the beft method of doing the op- 
 eration is this : inftead of a longitudinal cut along the 
 courfe of the teiliclc, the firfl incifion fhould be car- 
 ried in a flraight line to the under extremity of the 
 fpermatic cord, from whence two femilunar incifions 
 fhould be continued to the under part of the fcrotum, 
 
Chap. XXVII. Of the Sarcocek, 133 
 
 and in their courfe, be made to mclude all difeafed 
 parts of the fkin. 
 
 The remainder of the operation fhould be finifhed 
 in the manner that I have defcribcd, and the (kin in- 
 cluded in the two femilunar cuts not be difledted off 
 by itfelf, but removed along with the teflicle. 
 
 Even where a large portion of the teguments have 
 been removd, the fore may be covered with fkin ; nor 
 fhould this ever be omitted, when we find it can be 
 done ; for it not only haftens the cure, but ferves as 
 a more firm protedion to the end of the fpermatic 
 procefsj feptum fcroti, and contigQous parts, than the 
 new fcarf ikin, with which alone they would other- 
 wife be covered. But when the remaining teguments 
 will not flretch fo much as to admit of their being 
 retained either with plafters or futures, the cure mufl 
 neceflariiy be conduced in the ufual way, by drefling 
 with pledgets of any emollient ointment, till a cica- 
 trix is induced. The advantages however, that we 
 derive from being able to cover the fore entirely with 
 fkin, are fo great, that every operator fliould keep it 
 anxioufly in view ; for, befides thofe I have mention- 
 ed, it faves a great deal of pain and confinement, to 
 which the patient muft otherwife fubmit. It admits, 
 indeed, of a cure in the fourth part of the time com- 
 monly required when the edges of the fkin cannot be 
 kept together. 
 
 From the defcrlptions ufually given of caflration, 
 we would be induced to confider it as one of the moft 
 fmiple, as well as the moft eafy in furgery ; and it 
 muft be admitted, that in the early ftages of a farco- 
 cele, fcarcely any difficulty ever attends it. But it is 
 right that the younger part of the profcffion fhould be 
 informed of what all practitioners of experience know, 
 that fcarcely any operation is productive of more per- 
 plexing occurrences in the advanced periods of the 
 difeafe. 
 
 When the fpermatic cord is fo much difeafed, that 
 "we are obliged to divide it near the abdominal muf- 
 
134 Of the Sarcocele. Chap. XXVII. 
 
 cles, if the upper part of it is not previoully fecured 
 with a ligature, it is apt to retract within the abdo- 
 men, fo as to render it impoflible to fecure it in any 
 other manner than by dividing the abdominal muf- 
 cles. Of this I have now been prefent at two inftan- 
 ces, in both of which the cord retracted fuddenly with 
 a fniart jerk, inflantly on being divided. 
 
 In one of thefe cafes, no ligature had been applied, 
 as the afliftant imagined that he could fecure the cord 
 between his finger and thumb till the fpermatic artery 
 could be tied, but in which he was miftaken ; and in 
 the other, the ligature not being tied fufficiently tight, 
 it flipped off from the end of the cord ; and in both 
 inftances, the patients died of the hemorrhage. Ex- 
 ternal preflure was the only remedy that could be em- 
 ployed ; but although in both inftances it gave, from 
 time to time, a temporary check to the difcharge, it 
 did not, in either cafe, prove effedlual ; fo that after 
 various returns of the hemorrhage, the patients were 
 at laft carried oft' by inanition. 
 
 In all cafes, therefore, where the cord muft be cut 
 in the upper part of it, a ftrong ligature ftiould be 
 previoully firmly tied, as far as poffible above the part 
 in which the divifion is to take place. It fhould be 
 applied with a running knot, and left of fuch a length 
 as to admit of the ends of it hanging freely out of the 
 wound. Being made with a running knot, it may be 
 eafily undone, whenever it may be fuppofed that no 
 hemorrhage will occur on its being withdrawn ; and 
 if the end of the ligature is twice paffed through the 
 firft noofe, it will be fufftciently firm. 
 
 The pain attending this mode of applying the liga- 
 ture, is, no doubt, much more fevere than when the 
 nerve is avoided ; but in the fituation to which I al- 
 lude, where the cord is cut near to the abdominal 
 mufcles, this cannot with fafety be done, and ftiould 
 not therefore be attempted. 
 
 In confiderable enlargements of the teftis, the tu- 
 mor is apt to prefs fo much upon the feptum fcroti, 
 
Chap. XXVII. Of the Sarcocek. 135 
 
 and in fome Inftances, adheres to it fo firmly, that the 
 cavity of the tunica vaginalis of the oppofite fide is 
 fometimes opened in the courfe of the operation. Of 
 this I have been prefent at difi'erent inftances : in fome 
 no inconvenience enfued from it ; but in others, In- 
 flammation to an extenfive degree, was induced in the 
 correfponding tefticle. With fufficient caution, how- 
 ever, in the removal of the tumor, all this may be 
 prevented ; for, however large it may be, the dilTec- 
 tion may be always accompUfhed without perforating 
 the feptum. When it is perceived, however, that an 
 opening is by accident made in it, in order to prevent 
 that inflammation of the teftis which free accefs of air 
 very feldom fails to induce, I would advife the divid- 
 ed parts to be neatly and gently drawn together with 
 a ligature, in fuch a manner as to admit of its being 
 eafily withdrawn in the courfe of the cure. By this, 
 we alfo prevent blood and matter from finding accefs 
 to the tunica vaginalis. 
 
 But the moft diftrefsful part of this operation arifes 
 from that enlarged ftate of the arteries of the fcrotum, 
 which takes place in every inftance where the tumor 
 has acquired a great bulk, and from which practition- 
 ers occafionally meet with more embarraflfment than 
 is ufually experienced in any other operation. Inftead 
 of one, two, or three arteries, very inconfiderable in 
 fize, which in the firft ftages of the difeafe, are all that 
 we perceive ; in the more advanced ftates of it, we 
 fometimes meet with fix, eight, or even more, and all 
 or many of them, of fuch a fize as to require imme- 
 diate attention. 
 
 In this period of the difeafe, the patient is com- 
 monly weak and delicate ; fo that not being able to 
 bear the lofs of much blood, his ftrength would fink, 
 if arteries of the fize which thefe often acquire were 
 allowed to bleed during the remainder of the opera- 
 tion. During the removal of the tumor, one or more 
 afTiftants fhould be employed for the fole purpofe of 
 putting a ftop to the difcharge, by placing a finger 
 
13^ Of the Sarcocele, Chap. XXVII* 
 
 upon every arten^, as foon as they perceive it to be 
 cut ; nor Ihould the preflure be removed till the dif- 
 feQion is finifhed, and the fiirgeon in readinefs to fe- 
 cure the bleeding veflel with a tenaculum and liga- 
 ture. This being done over the whole furface of the 
 fore, he next prc^ceeds to tie the fpermatic artery, and 
 to finilh the operation in the manner I have men- 
 tioned. 
 
 From want of this attention, I have known fuch 
 quantities of blood loft, as have either proved quickly 
 fatal, or induced fuch debihty and relaxation, as the 
 patient never recovered from ; and as I have in differ- 
 ent inftances known even furgeons of experience fail 
 in the proper management of this part of the opera- 
 tion, I think it right to fay, that the younger part of 
 the profeffion cannot be too much on their guard in 
 performing it. 
 
 Befides the common form of farcocele, of which I 
 have thus given an account, we find, that in workers 
 among foot, the teftis is liable to be attacked with 
 cancer that firft begins in the fcrotum. 
 
 It firft appears on the anterior and under part of 
 the fcrotum, fometimes in the form of a warty excref- 
 cence, and in others of a foul, fuperficial ulcer, with 
 hard retorted edges. From the fufpicious fituation of 
 the fore, and from the appearances which it exhibits 
 at firft, it is often fufpecued to be venereal ; but no 
 advantage is derived from mercury, nor from any 
 dreflings that are employed. If not prevented by ear- 
 ly extirpation, the ulcer fpreads over the fcrotum, and 
 from thence to the teftis, fpermatic cord, and inguinal 
 glands J giving to the parts that it attacks all the or- 
 dinary and characleriftic marks of cancer. 
 
 This variety of cancer appears obviouily to be pro- 
 duced by foot ; for it is found, that, befides chimney 
 fweeps, thofe who are employed in manufadlures in 
 which foot enters as an ingredient, are occafionally 
 feized with it. And it alfo appears, that the foot afts 
 altogether locally in producing it j for, when the fore 
 
Chap, XXVII. Of the Sarcocele. 137 
 
 is extirpated early, that is, foon after it has appeared, 
 and before it has fpread over any great extent of fur- 
 face, the difeafe feldoni returns, either there or on any 
 other part. 
 
 As no other remedy has been difcovered, for none 
 that I have either tried or heard of has any influence 
 in curing the fore, I would therefore advife the difea- 
 fed parts to be extirpated as early as poflible. This, 
 while the ulceration is confined to the fcrotum, is ea- 
 fy both to the patient and furgeon, when compared 
 with the operation of caftration, which mufl always 
 take place when the tcflis becomes difeafed, and is 
 therefore a ftrong inducement for our infifting that no 
 time fliould ever be loft in putting it in pradice, 
 
 I may further obferve, that arfenic, cauftic, red pre- 
 cipitate, corrofive fublimate, and other irritating ap- 
 plications, produce the fame cffeds in this as in other 
 varieties of cancer. 
 
 When applied fo as to remove the difeafed parts 
 entirely, they perform with much more pain, and in 
 a much more tedious manner, what may be more 
 neatly done by the fcalpel at once : while, fo far as I 
 have obferved, none of them are productive of any 
 other advantages, at the fame time that, by the irrita- 
 tion which they excite, they very frequently do much 
 harm. 
 
 ]\Iany accounts have been communicated to the 
 public of this and other varieties of cancer being cur- 
 ed by efcharotics of different kinds, and chiefly by ar- 
 fenic, which appears to form the bafis of a great pro- 
 portion of the remedies of this clafs, that have been 
 employed for the cure of this difeafe. But, while all 
 of thefe, as well as the internal ufe of hemlock, and of 
 every other medicine I have known employed, have 
 failed in every inftance, they have very commonly 
 had the effedl of amufmg the patient with hopes of a 
 recovery, till it has been too late even for the extirpa- 
 tion of the difeafed parts to prove fuccefsful. 
 
13^ Of the Sarcocek, Chap. XXVII. 
 
 I have, therefore, no hefitation in afferting, that the 
 operation fhould be advifed in the early ftages of the 
 difeafe, and that no other remedy, with which we are 
 yet acquainted, fhould ever be relied on. 
 
 Befides thofe afFedions of the tefles and their cov- 
 erings, that I have defcribed, there is another, that 
 feems to be pecuUar to warm climates. It is met with 
 frequently on the coaft of Africa, and in the Weft In- 
 dies, in fome inftances in Europeans, but chiefly in 
 negroes. 
 
 An uniform, firm, colourlefs fwelling attacks the 
 whole fubftance of the fcrotum. It is feldom, for a 
 confiderable time at firft, accompanied with pain ; but, 
 when it paifes from the cellular fubftance of the fcro- 
 tum to the teftes themfelves, which, in fome inftances, 
 happens, it, in this ftate, always excites a great deal of 
 diftrefs. 
 
 In the early ftages of the difeafe, the external ap- 
 plication of aftringents, accompanied with a courfe of 
 mercury, has, in lome inftances, proved ufeful. But, 
 when the tumor has become large, a cure has never 
 been obtained of it. In this fituation the patient ob- 
 tains no relief, but from a proper application of afuf- 
 penfory bag, and, in fevere degrees of pain, from largo^ 
 dofes of opium. 
 
Seft. I. Of the Phymojis. 139 
 
 CHAPTER XXVIII. 
 
 OF THE DISEASES OF THE PENIS. 
 
 SECTION I. 
 
 Of the Phymojis, 
 
 THE glans penis is naturally provided with a cov- 
 ering termed the preputium j formed by an 
 elongation and doubling of the fkin. This in a heal- 
 thy Hate is in general of fuch dimenfions as to pafs 
 eafily over the glans, but by difeafe it is frequently 
 prevented from doing fo ; and when the prepuce has 
 got forward, and cannot be drawn back over the glans, 
 the difeafe thereby produced is termed a phymofis. 
 
 Phyir.ofis is induced by whatever tends to fwell the 
 glans, or excite inflammation and ftridure in the pre- 
 putium : hence it is a frequent confequence of gonor- 
 rhoea vi'ulenta, and lues venerea ; and it fometimes 
 occurs from want of cleanlinefs, particularly in thofe 
 who are naturally liable to a plentiful exfudation of 
 vifcid nucus between the glans and preputium. 
 
 Whe-e the difeafe is flight, and not of long dura- 
 tion, fonenting the parts in any warm emollient de- 
 coftion. commonly gives relief ; or what anfwers bet- 
 ter for fich purpofes than any decodion, is warm milk ; 
 this, together with the ufe of emollient poultices, with 
 a view to relax the conftrifted preputium, often an- 
 fwers fo eftedually as to render other applications un- 
 neceflTaiy. 
 
 At tie fame time that fomentations and poultices 
 are advifed, a weak faturnine folution fliould be injed- 
 ed frcni time to time between the prepuce and glans. 
 
I40 Of the Phymofu, Chap. XXVIII. 
 
 with a fyrlnge, in order to wafh away any matter which 
 by its acrimony might tend to protract the difeafe. 
 
 When the parts are much inflamed, bloodletting 
 often proves ufeful. When the fuperficial veins of the 
 penis can be opened, any blood to be difcharged fliould 
 be taken from one of them by the lancet ; but when 
 they do not appear confpicuous, taking blood from the 
 arm will anfwer as well as from any other part : local 
 bloodletting with leeches would be here particularly 
 indicated ; but when the difeafe has arifen from lues 
 venerea, the bites of thefe animals almofl: conftantly 
 terminate in troublefome fores. Together with a dis- 
 charge of blood proportioned to the ftrength of the 
 patient, gentle laxatives ihould be prefcribed, a low 
 diet, and abflinence from exercife. 
 
 When, however, it is found, that even a due perfe- 
 verance in thefe means does not remove the difeafe, 
 and efpecially if chancres are confined under the pre- 
 puce, which might injure the glans by the matter dif- 
 charged from them not getting a proper vent, in that 
 cafe it becomes neceffary to remove the ftrifture by an 
 incifion carried along the whole courfe of th^ prepu- 
 tium. 
 
 As the fkin of the prepuce is exceedingly Ux, it is 
 almofl impofTible to cut it with neatnefs and accuracy 
 in the ordinary way, either with a fcalpel or bi^oury ; 
 and v\^hen done in this manner, the fkin yields b much 
 before the inflrument, as always to render the opera- 
 tion tedious and painful : neither are the probe fcilTars 
 well calculated for doing it properly, as the pats are 
 commonly fo much thickened by inflammaticn, that 
 they cannot be rightly cut with fciflars. 
 
 Thefe inconveniencies being obvious, many inven- 
 tions have been propofed for doing the operatio)i more 
 eafily. In Plate LXVIII. figures i. 2. and 3. is re- 
 prefented an inflrument which I made for this pur- 
 pofe feveral years ago, and it anfwers the intention 
 very efFeclually, and with much eafe. 
 
Se£l. I. Of the Phymofis, X4I 
 
 It confifts of a diredor, fig. 2. with a fmall curve 
 at its extremity, to which a Iharp pointed biftour)'', 
 fig. I. with a narrow blade, is fo exactly adapted, as 
 in fig. 3. that the cutting part of it is entirely conceal- 
 ed in _ the groove of the director, which ought to be 
 about a quarter of an inch longer than the blade of 
 the knife. 
 
 The knife being inferted into the director, fo as to 
 be covered by it entirely, the inftrunient in this ftate 
 is to be pafl'ed between the prepuce and glans on one 
 fide of the penis, till the director is found by the fin- 
 ger to have, reached the upper end of the preputlum. 
 The operator is now to keep the director firm with 
 one hand, and with the other is to pufli the knife for- 
 ward, lb as to make its point pafs through the pre- 
 puce ; and the director being withdrawn, the opera- 
 tion is finiflied by drawing the knife forward, fo as to 
 make it divide the prepuce through its whole length 
 along the fide of the penis. 
 
 In this manner the preputium Is preferved^ in a tenfe 
 flate, while the divifion is going on, by which means 
 the operation is accompliflied with eafe : and, by di- 
 viding the preputium on one fide, we more readily 
 avoid the large veins of the penis, at the fame time 
 that the matter proceeding from the cut is more eafi- 
 ly difcharged, than when the operation is done on the 
 back part of the penis. 
 
 The prepuce being thus divided, the parts fliould 
 be bathed with warm water, fo as to wafh off any ac- 
 rid matter with which they may be covered ; and this 
 being done, the fore fhould be covered with foft lint ; 
 and a" comprefs of old linen being laid over it, the 
 whole may be eafily retained by a fmall linen bag 
 adapted to the fize of the penis, to be fecured by two 
 ftraps pinned to a circular bandage made to furround 
 the body. This bag muft indeed be always removed 
 when the patient makes v/ater ; but this is eafily done ; 
 and it retains the dreflinsfs not onlv more efieduallv, 
 
143 Of the Paraphpmfis. Chap. XXVIH. 
 
 but with more eafe to the patient, than is done either 
 with adhefive plafters or any other form of bandage. 
 
 In the after dreffings of the fore, care fliould be 
 taken to infert a piece of foft Hnt between the divided 
 prepuce and glans, otherwife troublefome adhefions 
 are apt to take place. I have met with feveral inftan- 
 ces of this, which gave much diflrefs to the patients, 
 and which with due care and attention in drefling the 
 fores, might eafily have been prevented. 
 
 It is fcarcely neceffary to obferve, that when any 
 venereal infeftion fubfifls in the conflitution, the fore 
 produced by this operation will not readily heal, if 
 the patient be not put under mercury. In fuch cir- 
 cumftances, therefore, if mercury has not been previ- 
 oully given, it ought always to be advifed immediate- 
 ly on the operation taking place. 
 
 In fome cafes of phymofis, the preputium is fo long 
 that the operation of circumcifion anfwers the purpofe 
 better than a longitudinal cut. And it is eafily done, 
 by taking away all the fuperabundant portion of the 
 prepuce by one flroke of a fcalpel. It fometimes, 
 however, happens, when the operation is done in this 
 manner, that the remainder of the preputium con- 
 tracts fo powerfully, as to produce a good deal of dif- 
 trefs ; which can only be obviated by due attention to 
 the after treatment of the fore, and making ufe of 
 emollients, inftead of aflringent applications during 
 the cure. 
 
 SECTION II. 
 
 Of the Faraphpiofis. 
 
 BY the term paraphymofis is meant a morbid re- 
 traftion of the preputium, producing flridturc 
 behind the glans penis. This difeafe, like the former, 
 is a frequent fymptom in the venereal difeafe : but it 
 
Sed. II. Of the Paraphymofis, 143 
 
 will arlfe from whatever tends to produce, either a 
 preternatural fulnefs in the glans, or a conftridion of 
 the prepuce ; and more efpecially from fuch caufes as 
 induce a complication of both. 
 
 In the incipient ftate of paraphymofis, we may oft- 
 en with due dexterity and attention bring the prepuce 
 over the glans, by pufhing the glans gently back with 
 the thumb of each hand, while with the fingers we 
 draw the prepuce eafily forward. In the more ad- 
 vanced ftate of the difeafe, however, no attempt of this 
 kind fhould be advifed, as it is in its commencement 
 only that it ever fucceeds ; and when it does not prove 
 ufeful, it is apt to do harm, by inducing an increafed 
 degree of irritation in the parts to which the prelfure 
 is applied. 
 
 As the paraphymofis feems to be more frequently 
 induced by an enlargement of the glans than by any 
 original affection of the prepuce, fo the ftriclure in the 
 prepuce is not here fo completely relieved by emollient 
 fomentations, as it commonly is in phymofis, where 
 the difeafe is moft frequently produced by a ftridlure 
 of the prepuce alone. In paraphymofis, indeed, warm 
 emollients feem rather to do harm, as they tend evi- 
 dently to increafe the fwelling in the glans, by which 
 the ftriclure in the prepuce is always proportionally 
 increafed. 
 
 Nothing in general anfwers fo well here as fatumine 
 appUcations. The fwelling, indeed, will often fubfide 
 by being frequently immerfed in a cold folution of 
 faccharum faturni, when all other remedies fail. But, 
 when the penis is evidently much fvvelled and inflam- 
 ed, together with this application to the part, the pa- 
 tient fhould be kept cool ; gentle laxatives fliould be 
 prefcribed, and blood be taken from one of the fuper- 
 ficial veins of the penis. 
 
 By due perfeveraiice in thefe means, and keeping 
 the patient on low diet, the ftridure is frequently re- 
 moved. But, when the difeafe proceeds to increafe, 
 by the fwelling iu the glans becoming more confider- 
 
144 Of the Paraphymofis. Chap. XXVIIL 
 
 able, and the ftriclure of the prepuce increafmrr, the 
 preputium becomes cedcmatous, and unlefs relief be 
 foon obtained by a complete removal of the ftridlure, 
 gangrene of the glans very commonly enfues. 
 
 When, therefore, none of the remedies I have men- 
 tioned anfwer the purpofe, we fhould endeavour to re- 
 move the ftriclure by an operation ; and the eafieft 
 method of performing it is, with the flioulder of a lan- 
 cet, or a fmall fcalpel or biftoury, to make a deep fcar- 
 ification on each fide of the penis, directly behind the 
 glans ; taking care to make each cut of about half an 
 inch in length, and of fuch a depth as effectually to 
 divide the prepuce juft at the fpot where the ftridure 
 is moft confiderable. 
 
 The parts fhould now be allowed to bleed freely, 
 as ^is circumftance of itfelf in general affords relief ; 
 and as foon as the flow of blood is over, a pledget of 
 any emollient ointment being applied to the fores, and 
 a foft well made poultice being laid over the whole, if 
 the fcarifications have been carried entirely through 
 the ftridure, nothing further will be neceffa'ry than 
 dreffing the parts daily with the fame ointment with 
 which they were at firft covered : but, if the fcarifica- 
 tions have not been made of a fufficient depth, it may 
 afterwards be neceffary to renew them ; \^'hen care 
 muft be taken that they are effedually done. 
 
 In the phymofis, I advifed the patient to be put un- 
 der a mercurial courfe whenever there is reafon to fuf- 
 pect that he is infected with lues venerea ; and the 
 fame precaution, it is evident, is equally proper in pa- 
 raphymofis. 
 
Se6t. III. Amputation of the Pails, I45 
 
 SECTION III. 
 
 Of A?nputat'w}i of the Penis, ^c, 
 
 THE penis, like other parts of the body, is h'able 
 to dircafes, which in fome inflances render am- 
 putation neceffary. 
 
 Thus, in fome inflances, it is attacked with gangrene, 
 and in others with cancer, in both of which amputa- 
 tion is very commonly requifite. 
 
 I have elfewhere entered fully into the confideration 
 both of mortification and cancer.* Referring, there- 
 fore, to the obfervations that I had there occafion to 
 fuggeft, I fhall at prefent only advert to the mode of 
 amputating the penis when it becomes fo difeafed as to 
 render this operation neceffary. 
 
 A circular incifion fliould be firft made through the 
 found fkin at the upper end of the difeafed parts, when 
 the flvin being drawn back by an affiftant, the body 
 of the penis fhould be cut through by one ftroke of 
 the fcalpel, care being taken to remove every part that 
 appears to be difeafed. 
 
 This being done, fuch arteries as bleed freely fhould 
 be carefully fearched for, and fecured with ligatures. 
 In general, two, and fometimes three arteries are met 
 with J and they fliouId all be fecured in this manner. 
 But even after the principal arteries have been tied, a 
 confiderable oozing of blood ufually continues from 
 the furface of the fore, which we fometimes flop by 
 fprinkling the whole with flarch or gum arable in fine 
 powder ; but when this does not anfvver, a fmall filver 
 canula being paffed into the urethra, and retained with 
 a bandage, any farther difcharge of blood may be ea- 
 fily flopped by flight compreffion with a narrow roU- 
 
 • Vide Chap. I. ScO. IV. aad Cijap. V- Sctft. VIII. 
 
 Vol. III. L 
 
14^ Amputailon of the Penis. Chap. XXVlH. 
 
 er on the parts that remain. A flight degree of com- 
 preilion anfwcrs the purpofe, fuch a degree of it, in- 
 deed, as does not hurt the parts on which it is made ; 
 and as the tube inferted into the urethra need not be 
 long, it is eafily retained during the whole courfe of 
 the cure, without either inconvenience or diftrefs. 
 
 In Plate LXVI. fig. 4. is reprefented a tube which 
 I have in different inftances ufed for this purpofe. It 
 is eafily kept in its fituation by fixing it with two lig- 
 atures, one on each fide, to a narrow roller round the 
 penis. 
 
 Heifler, as well as others, being afraid of the he- 
 morrhagy produced by amputating the penis, advife 
 it to be done with a flrong ligature, A ligature be- 
 ing applied with firmnefs above the difeafed parts, they 
 are thereby made to fall off in the courfe of fix or eight 
 days ; but whenever a part can be eafily removed with 
 the fcalpel, it is done with much more eafe and expe- 
 dition than in any other manner. 
 
 Others, again, have faid, that no danger is to be 
 dreaded from any difcharge of blood that can ever en- 
 fue from amputating the penis ; but this I know from 
 experience is not the cafe. In the courfe of a few 
 months, I had occafion to perforin this operation three 
 different times in the Royal Infirmary here ; and, in 
 the firfl, I was perfuaded by a gentleman who had 
 found it in one cafe to fucceed, not to fecure the ar- 
 teries with ligatures, but to truft to compreffion alone. 
 This was accordingly done ; but unfortunately, in the 
 courfe of an hour or two after the operation, fuch a 
 profufe hemorrhagy fupervened as terminated in the 
 patient's death. 
 
 In the next, I was refolved to fecure every branch 
 of an artery that could be laid hold of. Three differ- 
 ent arteries were accordingly tied, and no hemorrhagy 
 enfued. In the third operation, two branches of an 
 artery were fecured ; but a plentiful oozing ftill con- 
 tinuing from the fore, the filver tube above mention- 
 ed was introduced into the urethra, and a flight com- 
 
 ■%, 
 
Se£l. III. A?npuiation of the Penis. 147 
 
 preflion being made upon it, the difcharge was imme- 
 diately flopped. In no other inftance of my perform- 
 ing this operation did any dangerous hemorrhagy take 
 place, and 1 have done it in a great many. 
 
 When all the arteries, for we frequently meet with 
 three or four, have been fecured in this manner, the 
 parts fliould be covered with pieces of foft lint fprink- 
 led with ftarch or gum arable in powder ; and a com- 
 prcfs of linen, with a hole in it large enough to pafs 
 over the canula in the urethra, being laid over it, and 
 the T bandage being employed to retain it, all the 
 dreflings may in this manner be fecured ; while the 
 after treatment of the fore fliould be fimilar to that 
 of wounds in any other part. 
 
 In proceeding to this operation, It ought to be kept 
 in view, that the prepuce is frequently fo much en- 
 larged and ulcerated, as to give caufe to fufpeft that 
 the glans as well as the reft of the penis is difeafed, 
 when in reality they are perfedly found. I was once 
 prefent at an operation, where the previous appear- 
 ances were fuch as gave no reafon to doubt of the 
 glans being difeafed ; the prepuce, with part of the 
 penis, was accordingly taken off; when it afterwards 
 appeared that the glans might have been faved, as the 
 dil'eafe was found to be confined to the prepuce alone. 
 
 In every cafe, therefore, where we are not abfolute- 
 ly certain of the glans being affeded, all the difeafed 
 preputlum fliould be firfl renioved ; and the flate of 
 the parts below being examined, if they are found to 
 be fo much difeafed as to render it proper to remove 
 them, it can be then done with as much eafe as if they 
 had been taken off along with the prepuce ; while, on 
 the contrary, when they appear to be found, the fur- 
 geon as well as the patient will have much caufe to 
 rejoice. 
 
 It fometimes happens, that the frenum penis is fo 
 fliort as to excite much uneafmefs when the parts are 
 in a ftate of eredion. But as no danger enfues from 
 L 2 
 
143 Ampuiaiion of the Penh. Chap. XXVIII. 
 
 a divlfion of this ligament, whenever it proves trouble- 
 fome, it ought to be cut acrofs ; and it is eafily done 
 with probe pointed fciflars : after the frenum is divid- 
 ed, a bit of foft lint fliould be inferted between the 
 lips of the wound, otherwife the parts newly feparated 
 will be apt to reunite. 
 
 In fome inflances, the urethra in male children i$ 
 incomplete, and terminates before it reaches the point 
 of the yard. In others no external opening can be 
 difcovered, while in many the urethra terminates in a 
 fmall opening, not large enough to admit a fmall pin 
 head, at fome diftance from the end of the penis. 
 
 When no opening is difcovered, if the urine is found 
 to flop at any particular part, the introduction of a 
 fmall trocar from the point of the yard along the courfe 
 that the urethra ought to take, and carrying it for- 
 ward till it meets with the urine, will give immediate 
 relief ; and by the ufe of fmall bougies, the fides of 
 the paflage may be rendered callous, and a clear 
 opening preferved. But when any opening is difcav- 
 ered, although it Ihould not be properly placed, if it 
 affords a temporary paffage to the urine, it is better to 
 delay the operation till the patient is advanced in life ; 
 and on an opening being then made with a trocar in 
 the manner I have mentioned, a piece of flexible ca- 
 theter of refina elaflica may be introduced, not only 
 for preferving the paffage free and pervious, but for 
 carrying off the water till a cure is obtained. In the 
 earlier periods of childhood, the fmallnefs of parts 
 through which a catheter ought to pafs, renders the 
 ufe of this inflrument altogether inadmiffible. 
 
 Befides the affedions of the penis that we have been 
 juft confidering, fiftulous openings frequently form in 
 the urethra, and they always give much diftrefs. Thefe- 
 however, as well as the treatment of flones impacted 
 in the urethra, will fall to be confidered hereafter. 
 
Se£l:» L Of the Stone, 149 
 
 CHAPTER XXIX. 
 Of the stone. 
 
 SECTION I. 
 
 General Remarks on Urinary Calculi. 
 
 PARTICLES of Hone have been known to form 
 in almoft every cavity of the body, but more 
 frequently in the organs of urine than in other parts. 
 
 The blood, as well as the fecretions which it af- 
 fords, are, by experiment, found to contain a large 
 proportion of earth : when this earthy part of our 
 fluids is in the ufual quantity, and when not feparated 
 by difeafe, it continues to circulate along with the 
 other parts of which thefe fluids arc compofed ; and 
 in this fl;ate no harm ever enfues from it. Various 
 caufes, however, may concur to produce a depofition 
 of this earthy matter from the blood and its fecre- 
 tions. 
 
 I. We know, that every liquid can diflblve and 
 keep fufpended a certain quantity, and no more, of 
 thofe fubftances of which it is a menilruum ; and it 
 is likewife known, when a greater proportion than 
 this is added, that a feparation and coniequent depo- 
 fition takes place of all the additional quantity. In 
 like manner, we may fuppofe, if the ladeal veflTels 
 ever abforb a greater proportion of earthy matter from 
 the contents of the inteliines, than the quantity of flu- 
 ids in the circulating fyftem can keep fufpended, that 
 this fuperabundance of earth muft necelTarily feparate 
 from the reft ; and the depofitions thus produced are 
 much more likely to occur in the bladder and kid- 
 neys than in other parts, from the urine containing a 
 larger proportion of earth than any other fecretion. 
 
150 Of the Stone, Chap. XXIX, 
 
 2. Independent of other caufes which miy tend to 
 induce a fuperabundant quantity of earthy matter in 
 the blood, fuch articles of food as contain a large pro- 
 portion of earth have been fuppofed to be more pro- 
 ductive of it than others : but unlefs fuch quantities 
 of earth as are contained in food, be conveyed in a 
 ftate of the mofl perfect folution, any effect that may 
 refult from it will not be important. There is much 
 reafon, however, to think, that a long continued ufe, 
 either of water, or of wines abounding with earth in 
 a diffolved ftate, has a confiderable tendency to pro- 
 duce that ftate of the blood to which I allude ; of 
 which indeed, I could produce various facts that could 
 not admit of difpute. 
 
 3. Thofe who are much accuftomed to the ufe of 
 folid food, will be more liable to the formation of a 
 large proportion of earthy matter in the blood, than 
 thofe who by a free ufe of liquids are in the habit of 
 preferving a more plentiful and more diluted ftate of 
 the fecretions. And accordingly, in thofe who fre- 
 quently void particles of fand, and even fmall calculi, 
 I have known more advantages derived from a con- 
 tinued and plentiful ufe of diluent drinks, than from 
 any other remedy. A hberal ufe of watery fluids 
 may, no doubt, operate to much advantage, by wafti- 
 ing away particles of fand and ftone already formed 
 and lodged in fome of the organs of urine ; but they 
 feem hkewife to prove ufeful, merely by their diluent 
 properties in preventing their formation, 
 
 4. A fuperabundance of earthy matter being once 
 produced in the blood, various circumftances may 
 concur to form depofitions of it in the different cavi- 
 ties : of thefe a fedentary life is, perhaps, one of the 
 moft remarkable ; and hence it probably is, that fuch 
 people are found to be moft liable to calculous com- 
 plaints, whofe occupations require the leaft bodily ex^ 
 ertion. 
 
 It muft indeed, be allowed, that ftone in the blad^ 
 der is frequently met with amongft indigent and in-? 
 
Sea. I. Of the Stone. 151 
 
 duftrious labourers ; whofe neceflities, at all times, 
 prevent their indulging in indolence. In fuch inftan- 
 ces, however, it may be fuppofed, that the very coarfe 
 articles of food, with which people in this line of life 
 are chiefly nourifhed, will tend to impregnate the 
 blood with fuch a large proportion of earth, as mull 
 neceflarily produce eflecls not to be obviated, even by 
 the beneficial influence of a continued and regular 
 courfe of exertion. 
 
 5. Whatever influence a predifpofitlon in the fyf^ 
 tem may have in the formation of calculus, and in its 
 fubfequent increafe of bulk, the introduction of any 
 fubfl:ance that can ferve as a nucleus, will almofl: cer- 
 tainly produce a (lone, in whatever cavity it is lodg- 
 ed. Thus, a particle of fand, of blood, or coagulable 
 lymph, may in confequence of fpafm or inflammation, 
 be confined in the pelvis of one of the kidneys, or in 
 the cavity of the bladder, and may foon acquire fuch a 
 fize, from the conflant addition of earthy matter that 
 it receives, as to make it impofllble for the urine to 
 carry it off: and urinary calculi, thus begun to be 
 formed, will acquire, fooner or later, a confiderable 
 bulk, according to the quantity of earth with which 
 the urine is impregnated. Thus inft:ances have oc- 
 curred, of flones becoming large, in the fpace of a 
 few months from the firfl obvious fymptoms which 
 they produce ; while at other times, they have been 
 known to remain in the bladder for a great many 
 years, without arriving at any fize of importance. 
 
 When fpeaking of nuclei, it is necefl'ary to remark, 
 that their eft'efl; in the formation of calculi, in the uri- 
 nary paffages efpecially, appears to be fo great, that it 
 may be doubted whether a Itone is ever known to 
 form in thefe parts without the intervention of this 
 caufe ; for, however large the quantity of earth con- 
 tained in urine may be, it would probably all flow off 
 by the urethra, if it was not detained by the acciden- 
 tal introdudion or formation of a nucleus, 
 
1^2 Of the Stone, Chap. XXIX. . 
 
 Nuclei of different kinds, fuch as hairs, needles, 
 mulket and piflol bullets, pieces of bougies, and a 
 variety of other articles, have been met with in the 
 centre of urinary calculi ; but particles of blood, or of 
 coagulable lymph, are moft frequently found to pro- 
 duce them. 
 
 By the difference of food ufed at different periods 
 of the difeafe ; by the ftone being formed flowly or 
 more quickly ; and perhaps, by the intervention of 
 other caufes which are not always known, and which 
 if known, could not be eafily explained ; it common- 
 ly happens, that the different lamellse of which hu- 
 man calculi are compofed, vary confiderably both in 
 colour and confiftence ; a crufi of a foft friable na- 
 ture being frequently known to cover one of a tex- 
 ture equal in hardnefs to the moft folid marble ; while 
 this again is found to furround a ftratum not firmer 
 than a piece of dough. 
 
 Whatever may be the Immediate caufe of this dif- 
 ference of confiftence in ftones, and even of different 
 parts of the fame ftone, is of little importance in prac- 
 tice : but we know from experience, that the fymptoms 
 produced by calculi formed of hard compaQ: materi- 
 als, are in general more fevere than fuch as arife from 
 thofe of a fofter texture ; and we likewife know, that 
 the furface of ftones being fmooth or ragged, has 
 much more influence than any other circumftance in 
 the violence of the fymptoms which they produce : 
 much variety too, it may be remarked, is. met with in 
 human calculi with refpeft to the fmoothnefs of their 
 furfaces ; fome being perfectly polifhed, while others 
 are covered with hard fharp points. 
 
 The violence of fymptoms in this difeafe, Is com- 
 monly in proportion to the fize of the ftone ; ftones 
 of the greateft bulk being for the moft part attended 
 with the moft fevere pain. This, however, is not al- 
 ways the cafe ; for inftances fometimes occur of the 
 moft fevere fymptoms being induced by fmall ftones ; 
 whiljl in others, ftones of a confiderable fize have 
 
 J 
 
Sea. I. Of ihe Stone. 153 
 
 been known to fubfifl for a great length of time with- 
 out inducing much pain : but in general it is other- 
 wife, and the fymptoms are moft frequently mild or 
 fevere, according as the flone by which they are pro- 
 duced is fmall or large. 
 
 When a flone has acquired fuch a fize that it can- 
 not pafs off from the bladder, the patient becomes lia- 
 ble to fymptoms which froni their commencement 
 give much uneafmefs, and which, in the event, com- 
 monly terminate in the mofl afllicting fcenes of diflrefs 
 to which the human frame is liable. 
 
 One of the firfl fymptoms of flone, is an uneafy 
 fenfation at the point of the yard, which for fome time 
 is only difcovered on the patient taking violent and 
 jolting exercife, or immediately after voiding urine. 
 This pain by degrees becomes more frequent and 
 more fevere. The patient has a flrong propenfity to 
 pafs urine frequently, and commonly voids it in fmall 
 quantities, perhaps even drop by drop. 
 
 When flowing in a full flream, it often flops fud- 
 denly ; and this it is moft apt to do when a confider- 
 able quantity is collected, and when of courfe the 
 patient's defire for voiding it is Urongefl. Nor does 
 the preflure ufually made by the patient anfwer any 
 good purpofe : for, as the interruption to the flow of 
 urine proceeds from the weight of the flone bearing 
 againfl the neck of the bladder and orifice of the ure- 
 thra, nothing will produce a free i*eturn of it but an. 
 alteration in the fite of the flone, which more readily 
 happens from the patient changing the poflure of his 
 body, and particularly by the pelvis being more or 
 lefs elevated, than by all the preifure that he can em- 
 ploy for forcing it out. 
 
 The urine of calculous patients is often perfectly 
 clear, but mofl commonly thick, and dcpofites a mu- 
 cous fediment ; and not unfrequently, when the dif- 
 eafe is violent, and the paroxyfms frfequent In their 
 return, it is tinged with blood. When the flone is 
 large, a dull uneafy fenfation takes place about the 
 
154 Of the Stone, Chap. XXIX. 
 
 neck of the bladder ; and the irritation produced by 
 it frequently excites a tenefmus, or a conftant and 
 painful defire to go to ftool. 
 
 All thefe fymptoms are commonly increafed by ex- 
 «rcife, particularly by riding on horfeback ; and from 
 a long continuance of pain, and from that want of reft: 
 which frequent returns of the paroxifms induce, the 
 patient's ft:ate of health by degrees becomes impaired ; 
 and unlefs the ftone is removed, it commonly hap- 
 pens that his mifery is only terminated by death. 
 
 When all or moft: of the fymptoms that I have 
 enumerated, occur in the fame patient, there can be 
 no great reafon to doubt of the caufe by which they 
 are produced ; and we know with certainty that they 
 proceed from calculus, when fragments of ftone, or 
 fundry fmall fl:ones, continue to pafs from time to 
 time along with the urine : but when this does not 
 occur, we can never with certainty know whether the 
 fymptoms arife from ftione or not ; for inftances fre- 
 quently happen, of all the fymptoms ufually produced 
 by ftione in the bladder, arifmg from an ulcer or tu- 
 mor either in the bladder itfelf, or in its neck, or even 
 from tumors on the contiguous parts when they prefs 
 either on the bladder or on its neck. 
 
 Pra£titioners accuftomed to this branch of pra£tice, 
 will in general be able to judge from the fymptoms, 
 whether a ftione actually exifts in the bladder or not ; 
 but the only certain means by which it can be afcer- 
 tained, is through the intervention of a found or curv- 
 ed probe ; different fizes of which are reprefented in 
 Plate LXIX. By pafting this inftirument into the 
 bladder, in the manner I fhall prefently mention, if it 
 touches a ftione, fuch a fenfation is thereby communir 
 cated to the operator, as gives ample convidion of 
 the real caufe of the difeafe. 
 
Sea. II. Of the Stone. 155 
 
 SECTION II. 
 Of Sounding or Searching for the Stone. 
 
 BEFORE defcribing the operation of founding, it 
 will be proper to give an anatomical dcfcription. 
 of fuch parts as are concerned in it ; and to this I 
 fhall add an account of thofe parts that are mod im- 
 mediately injured by the various operations of lithoto- 
 my : thefe are, the kidneys, ureters, urinary bladder, 
 pelvis, veficulse feminales and their dudls, proflate 
 gland, urethra, penis, fome of the mufcles of the penis, 
 and part of the abdominal mufcles. 
 
 A minute defcription of thefe parts would lead to 
 an extenfive difcuiTion, inconfiftent with the nature of 
 this undertaking ; and as fuch a defcription is not ne- 
 ceflary, I fliall only give fuch an account of the parts 
 as may ferve to render intelligible the defcription to be 
 afterwards given of the operations to be performed on 
 them. 
 
 The kidneys are two glandular bodies lying in the 
 back part of the abdomen, on the upper part of the 
 pfose mufcles ; the right being feated immediately be- 
 low the great lobe of the liver, and the left under th^e 
 fpleen ; and they are both, I may remark, almoll com- 
 pletely covered by the flight curvatures of the inferior 
 falfe ribs. They are fupplied with blood veflbls, term- 
 ed the emulgent arteries and veins, dire6tly from the 
 trunks of the aorta and vena cava. The ufe of thefe 
 organs is to feparatc the urine from the blood, which, 
 as foon as it is fecreted, is carried by means of two 
 canals or tubes, one from each kidney, termed the 
 ureters, direftly to the vefica urinaria. The ureters, 
 after leaving the kidneys, proceed obliquely downwards 
 behind the fpermatic velfels, over the os facrum ; and 
 palling in between the bladder and reftum, they are 
 jnferted into the former near to its neck, at a fmall 
 
156 Of the Sfotif. Chap. XXIX. 
 
 diftance from one another ; and after piercing the ex- 
 ternal coat of the bladder, they run obliquely for a 
 ihort fpace between it and the more internal covering 
 of that organ before penetrating its cavity : a conftruc- 
 tion well calculated for preventing a reflux of lyrine to 
 the kidneys. 
 
 The pelvis is a kind of box or bafon, formed by a 
 Conjundion of the os facrum, os coccyx, and oiTa in- 
 nominata. The cavity formed by a particular combi- 
 nation of thefe parts, being intended for the protec- 
 tion of the bladder, and fome other organs, is every 
 where furrounded with bone, or with ftrong ligaments, 
 except at its upper and inferior parts, where alone the 
 pelvis is accefTible, being here covered with foft parts 
 only. The cavity of the pelvis is chiefly occupied by 
 the bladder, which, when in a dillended ftate, fills it 
 entirely, and even afcends confiderably above its brim. 
 
 The bladder, or receptacle of the urine, is a mem- 
 branous bag compofed of different coats, one of which 
 is evidently mufcular, with its fibres running in differ- 
 ent direftions. The human bladder is of an irregular 
 oblong figure. The fuperior part of it has common- 
 ly been termed its fundus, or bottom : the oppofite 
 extremity, lying at the bottom of the pelvis, is termed 
 the cervix or neck ; and the intermediate fpace, its 
 middle or body. The bladder is every where nearly, 
 though not exadly, of the fame diameter, except at 
 its fundus, where it is fomewhat contracted ; and again 
 near to its neck, where it dilates confiderably, extend- 
 ing back towards the coccyx. 
 
 The fuperior part of the bladder is covered with the 
 peritonaeum ; and it therefore lies, along with the oth- 
 er abdominal vifcera, within the abdominal cavity ; 
 but the under part of it is not covered with that mem- 
 brane. The anterior under part of the bladder is con- 
 nected by cellular fubflance to the pubes ; laterally, 
 it is fixed by productions of its external covering to 
 the other bones of the pelvis ; and pofteriorly, it is in 
 male fubjeCts firmly connected with the rectum, from 
 
3e<a. II. Of the ^one. tsf 
 
 the entrance of that gut into the pelvis, till within a 
 little of its terminarion in the anus, when the neck of 
 the bladder and commencement of the urethra fepa- 
 rate a little from the gut, leaving a fpace that is filled 
 with fat and cellular fubftance. 
 
 In females, the uterus, in an unimpregnated ftate^ 
 lies altogether in the cavity of the pelvis, immediately 
 behind the bladder ; and the vagina, in which the os 
 tincEe terminates, lies diredly behind the urethra, and 
 before or upon the inteflinum redlum, to which it is 
 firmly attached. 
 
 The neck of the bladder terminates in the com- 
 mencement of a cylindrical membranous canal, the 
 urethra, which comes off at nearly a right angle from 
 the anterior part of it. The urethra, at its commence- 
 ment, is furrounded by the proflate, a gland of a flat 
 pyramidal fliape, with its bafe towards the bladder, 
 and its apex pointing to the perinazum ; its fuperior 
 lamella being conneded with the pubes, and its infe- 
 rior part \^^th the anterior and under part of the rec- 
 tum. 
 
 The urethra continues to be efitircly membranous 
 for a jQiort fpace after it leaves the apex of the proflate 
 gland ; and this part of it keeps in clofe contatt with 
 the offa pubis, till it paffes out from below the arch 
 formed by thefe bones, which it does, by making a 
 curve in its progrefs to the perineum. This curva- 
 ture in the urethra it is material to be well acquaint- 
 ed with, particularly in the operation of founding. A 
 good anatomift will in genei"al pafs a ftaff with eafe, 
 while thofe not verfant in the anatomy of the parts 
 concerned, are not only apt to fail entirely, but are 
 fure to give much unnecclfary pain. 
 
 The commencement of the urethra, that I have jufl 
 defcribed, is termed the membranous part of it ; which, 
 before it has proceeded an inch from the extremity of 
 the proflate gland, is furrounded by a cellular kind 
 ot body, termed the corpus fpongiofum urethras, which 
 here forms a kind of protuberance, termed the bulb 
 
158 Of ihe Stone. Chap. XXlX. 
 
 of the urethra ; and which afterwards proceeds along 
 in a more diffufed ftate to the extremity of the penis, 
 where, by expanding again, it terminates in the for- 
 mation of the glans penis. 
 
 The reft of the penis is formed of the preputium, 
 which, as I have already had occafion to obferve, is 
 merely a doubling of the fkin ; and of two round cav- 
 ernous bodies, termed the corpora cavernofa penis, 
 which originate by two crura or legs from part of the 
 OS ifchium and pofterior part of the pubes on each 
 fide ; and having united near the fymphyfis pubis, 
 they thus form the principal part of the body of the 
 penis, and are continued to the glans, with which they 
 are connected, but with which the cellular or caver- 
 nous parts of thefe bodies have no direct communica- 
 tion. 
 
 By the jun6lion of the two cavernous parts of the 
 penis, which are nearly round, a kind of hollow is 
 formed both above and below. In the former of thefe, 
 or in that vacuity which runs along the back part of 
 the penis, the principal veins of the penis run ; and 
 the urethra is protected by the latter. The obvious 
 ufe of the urethra is to ferve as a paflage for the urine 
 and femen ; the receptacle of the former I have al- 
 ready defcribed, and I fhall now mention thofe of the 
 latter. The femen, after being fecreted by the teftes, 
 is by two very fmall tubes, termed vafa deferentia, 
 lodged in the veficul^e feminales, which are found to 
 be two cellular kinds of canals, contorted in fuch a 
 manner as when diftended to refemble the inteftines 
 of a fmall fowl. They are feated on the pofterior part 
 of the neck of the bladder, below the entrance of the 
 ureters, and lie in clofe contact with the redluni ; and 
 the femen is again difcharged from thefe receptacles 
 by two excretory dufts, which terminate in two points, 
 at a part which, from its figure, has been termed the 
 caput gallinaginis, fituated on the inferior fide of the 
 urethra, nearly about the middle of the proftate gland ; 
 and a little below the entrance of thefe canals from the 
 
Seel. IL Of the Stone. 159 
 
 veficulae feminales, the two excretory du£ts of the 
 proflate gland empty themfelves into the urethra. 
 
 The niufcles that are cut in the lateral operation of 
 lithotomy, now commonly praftifed, are the eredores 
 penis, acceleratores urince, tranfverfales perinasi, and 
 levator ani. The ereclor penis arifes fi'om the tube- 
 rofity of the ifchium ; and, after covering almofl com- 
 pletely the crus penis of the fame fide, it is inferted 
 by a tendinous expanfion into the fuperior part of the 
 penis, near to where it joins with its fellow of the op- 
 pofite fide. 
 
 The accelerator urinse arifes by flefhy fibres from 
 the fphinder ani and contiguous foft parts ; and after 
 covering the membranous part of the urethra, it is in- 
 ferted into the middle of the bulb, where it joins with 
 a fimilar mufcle of the oppofite fide : part of thefe 
 mufcles, too, run along the crura penis, and are after- 
 wards loft ill the ligamentous covering of the corpora 
 cavernofa. The tranfverfales perina:i are two thin 
 narrow mufcles, which originate from the firm mem- 
 branous covering of the tuberofity of the ifchium, 
 and, after ftretching direclly inwards, are inferted into 
 the bulb of the urethra. 
 
 Befides thefe mufcles, which all fuffer more or lefs 
 in the lateral operation of lithotomy, the levator ani 
 mufl: neceffarily be cut in the fame operation ; and in 
 the high operation for the flone, part 6f the mufculus 
 tranfverfalis abdominis, of the redlus, and pyramidalis, 
 are alfo cut. 
 
 Almoft all thefe parts are furnifhed with blood by 
 branches from the internal iliac arterv ; and thofe vef- 
 fels which run mod hazard of being cut in the lateral 
 operation for the (tone, are, the arteria pudica interna, 
 and the pudica externa ; for, the former fupplies not 
 only the parts about the anus, but the bulb of the 
 urethra and the corpora cavernofa ; and the latter, to 
 wit, the pudica externa, fupplies a great part of the 
 bladder, the proflate gland, and veficulcc feminales. 
 
i6o Of the Stone. Chap. XXIX. 
 
 Having thus premlfed all that Is neceflary for our 
 purpofe, of the anatomy of thefe parts, I fliall now 
 proceed to the operation of founding. 
 
 For the purpofe of difcharging water collected in 
 the bladder, a curved filver tube is made ufe of, nam- 
 ed a catheter, different forms of which arc delineated 
 in Plates LXXI. and LXXII. But for the difcovery 
 of a (lone in the bladder, a folid inflrument made of 
 fleel is preferable, as the fenfation communicated by a 
 firm fubflance is more diflincl than when an inftru- 
 ment of filver, or any other fofter material, is employ- 
 ed. In females, the urethra runs almoft in a ftraight 
 line ; fo that an inflrument, either perfectly ftraight, 
 or nearly fo, fuch as is reprefented in Plate LXXI. fig. 
 3. is more eafily introduced than one with a large 
 curvature : but in male fubjects, the turn made by 
 the urethra, when it pafles up between the redum and 
 pubes, is fo confiderable as to preclude entirely the 
 introdudion of a ftraight inftrument, unlefs much vi- 
 olence is ufed. By preferving the penis at an acute 
 angle with the body, the courfe of the urethra may 
 indeed be rendered fo ftraight, that a ftraight probe 
 may be eafily introduced, till it reaches this turn to- 
 wards the farther extremity of the perinasum ; but the 
 curvature made by the urethra at this place, renders 
 it necelfary to employ an inftrument with a corre- 
 fponding degr«r£ of convexity. 
 
 The curvatures commonly given to thefe inftru- 
 ments are either too great or not confiderable enough. 
 Either extreme renders it difficult to obtain a paflage 
 into the bladder : for when the ftaft' is made with toa 
 'much convexity, befides being more difficult to intro- 
 duce, it gives much unnecefiary pain, by ftretching 
 and even tearing the urethra; nof can an inftrument" *^: 
 with much convexity, be fo eafily managed, when in ■ 
 the bladder, as when the curvature given to it is lefs. * 
 In Plate LXIX. founds are reprefented of various 
 fizes, and with fuch degrees of curvature, as by expe-- 
 rience I have found to anfwer bettej than any other. 
 
Sea. II. Of the Stone, l5i 
 
 They are taken from the natural curvature of the 
 urethra, the inflruments from whence they are deline- 
 ated having been exadly adapted to that paffage, after 
 the furrounding parts were removed. 
 
 The patient to be founded (liould be laid upon a 
 bed, with his head raifed on a pillow, and his thighs 
 fo me what elevated and fcparated from each other, in 
 which pofition the mufcles of the abdomen are put in 
 a (late of relaxation. The furgeon, if he employs his 
 right hand to pafs the ftaff, fliould (land on the left 
 fide of the patient, and the found fliould be of a fize 
 proportioned to the paffage intended to receive it. 
 Having previoufly brought it to the heat of the pa- 
 tient's body by immerfion in warm water, and having 
 dipped it in fine oil, he is now to grafp the penis with 
 his left hand ; and, having introduced the end of the 
 found into the urethra, with its concave fide towards 
 the abdomen of the patient, he mufl pulh it eafily on 
 with his right hand, while he continues with his left 
 to draw the penis gently forward upon the inftru- 
 ment. 
 
 The found beine; in this manner carried a fufiicient 
 length, it will commonly flip eafily into the bladder ; 
 but, occafionally, we meet with difficulty in pafTmg it 
 tlirough that part of the urethra that is furrounded by 
 the proflate gland, the inflrument being apt to flop 
 when it comes to this part of the paffage ; and here I 
 mufl remark, that any force employed for pufhing it 
 further, fhould be applied with much caution. That 
 part of the urethra immediately anterior to the prpf- 
 tate gland being entirely membranous and unfup- 
 ported, if the I'ound at this part meets with obflruc- 
 tion, and if flill puflicd forward with much force, 
 much mifchief mufl neceflarily enfue. In this man- 
 ner the point of the inftrument is often forced entire- 
 ly through the urethra ; by which, inflead of getting 
 into the bladder, it forms an artificial paffage, either 
 between the bladder and pubes, or between the blad- 
 
 VoL. III. M 
 
1 62 Of the Stone, Chap. XXIX. 
 
 der and rectum ; an occurrence that always excites 
 fevere diftrefs ; and which, there is reafon to fear, is, 
 either from ignorance or inattention, much more fre- 
 quent than it ought to be. 
 
 In order to guard againil the dreadful confequences 
 that refult from this, as foon as it is found that the 
 inflrument does not pafs eafily along, the forefinger 
 of the left hand, being dipped in oil, fnould be intro- 
 duced into the redum, when, by ftretching the parts 
 and elevating the point of the ftaff, while at the fame 
 time the inflrument is pufhed gently forward, we 
 commonly procure an eafy entrance into the bladder. 
 By depreiling the handle of the found, we alfo elevate 
 the point of it, and in this manner its entrance into 
 the bladder is fometimes accomplifhed ; but in gene- 
 ral the introduction of the finger into the rectum an- 
 fwers the purpofe. 
 
 Sounding is undoubtedly a very nice operation ; 
 and dexterity in performing it can only be acquired 
 by much practice. Every fludent, therefore, ought 
 to embrace all opportunities of praftifmg it, firft on 
 the dead fubjeft, and afterwards on the living ; for 
 every candid practitioner mufl acknowledge, that he 
 has, in different inflances, found the introduction of a 
 catheter, or of a found, both difficult and uncertain : 
 but when the parts concerned are not inflamed, fwel- 
 led or ulcerated, the operation does not often mifgive 
 in the hands of an expert furgeon. 
 
 The ftaff being introduced, the operator (hould lay 
 hold of the handle Avith one hand ; and if any part of 
 it comes in contact with the flone, the bufmefs of 
 founding is accomplifhed ; and we are thus rendered 
 certain of the nature of the difeafe : but if the flone 
 is not foon difcovered, it may commonly be found by 
 moving the inflrument, fo as to make its point pafs 
 eafily from one fide of the bladder to the other. 
 When the flone, hov/ever, is fmall, and has fallen in- 
 to that part of the bladder that lies below the entrance 
 of the urethra, the flafF is apt to pafs over it. With 
 
 1 
 
Sea. II. Of the Stone. i6^ 
 
 a view to obviate this difficulty, the finger of the left 
 hand may be again introduced into the redlum, fo as 
 to elevate that part of the bladder in which the flone 
 lies concealed. If, again, even this attempt fliould 
 fail, the patient's body fliould be put into a different 
 pofiure ; and no fituation will, in general, anfwer fo 
 well as lowering the head and upper part of the body, 
 while, at the fame time, we raife the pelvis. In this 
 manner a ftone, if not contained in a particular cyft, 
 which it rarely is, may be moved from the projedlion 
 at the neck of the bladder towards its fundus, where it 
 will be more readily llruck with the found. But 
 when, even by this pofture of the body, we do not 
 fucceed, every variety of pofition ought to be tried : 
 the patient's head may be elevated, and the pelvis de- 
 prefl'ed ; he may be made to ftand ered ; or, what I 
 have fometimes known to fucceed after other attempts 
 had failed, he may be made to fland upon his feet, 
 with his body bending forward. 
 
 It fometimes, however, happens, when the ftone is 
 fmall, and the capacity of the bladder large, that our 
 firfl attempt in founding fails entirely ; but when the 
 fymptoms of flone are ftrongly marked, and whea 
 fchirrofity and ulceration of the parts, which might 
 give rife to thefe fymptoms, are not found to exift, we 
 ought not to reft fatisfied with one, or even with two 
 trials. I have known a Hone difcovered on the third 
 or fourth founding, which had efcaped the inflrument 
 in all the preceding trials. 
 
 When a flone is ftruck with the ftaff, the fenfation 
 it communicates to the operator is fo peculiar, as to 
 render it impoffible for any to be deceived in it by 
 whom it has ever been felt ; but with thofe who 
 have not been accuflomed to this operation, a harden- 
 ed flate of the bladder communicates fuch a fenfation 
 through the flafF, as frequently proves the caufe of de- 
 ception. This has even happened with pradirioners 
 of much experience and obfervation : it is reported of 
 
 M 2 
 
1 64 Of the Stone. Chap. XXIX. 
 
 the moft celebrated lithotomift of this, or perhaps any 
 other country, that, in the courfe of his pratlice, which 
 indeed was very extenfivc, three patients were cut by 
 him in whom no flones were difcovered, and where a 
 fchirrous or hardened ftate of the bladder had given 
 rife to the miftake.* With praditioners of experi- 
 ence, however, this can never happen but from inat- 
 tention ; for I will venture to affirm, that a perfon ac- 
 cuflomed to the fenfation communicated by a ftone, 
 can never, if he attends to what he is doing, be de- 
 ceived by the application of the found to a fchirrous 
 or any other tumor. 
 
 There being the lead hazard, however, of fuch a 
 misfortune as the one I have mentioned, namely, that 
 of a patient being made to undergo all the pain and 
 rifk of the operation of lithotomy, when no flone has 
 exifled, is a point of fuch a ferious nature, and fraught 
 with fuch confequences, both to the patient, praftition- 
 er, and art of furgery, as ought to excite the moll ac- 
 curate attention to this part of the operation. 
 
 SECTION III. 
 General Remarks on the Operation of Lithotomy, 
 
 THE prefence of a ftone in the bladder being af- 
 certained in the manner I have mentioned, the 
 means to be employed for the relief of the patient, is 
 the next objedt of confideration. 
 
 The public have at different periods been amufed 
 with encomiums on the Hthontriptic powers of differ- 
 ent articles, particularly of lime water, and of eauftic 
 alkali in a diluted ftate, and more lately of aerated al- 
 kaline water ; but although fome human calculi are 
 foluble in all of thefe liquids, yet none of them can 
 
 •' The late Mr. Clicfclden. 
 
Sea. III. Of the Stone, 165 
 
 be conveyed In fuch a ftate to the bladder as to be 
 much depended on. Many indeed have obtained re- 
 lief from the ufe of thefe remedies : the pain has, by 
 their means, been rendered Icfs fevere, and the pa- 
 roxyfms lefs frequent ; but we have not one authenti- 
 cated inflance of a (tone in the bladder being diffolv- 
 ed by the ufe of thefe, or any other remedy. 
 
 As the conftituent principles of thefe and other II- 
 thontriptic medicines, render them liable to very ma- 
 terial changes in their circulation from the flomach 
 to the bladder, it has been propofed to convey them 
 directly into the bladder itfelf, in order to bring them 
 into immediate contact with the ftone ; and machines 
 have, accordingly, been invented for the purpofe : but, 
 after a great many trials have been made with reme- 
 dies of this clafs, it feems now to be admitted, that no 
 folvent, powerful enough to have any effect upon a 
 ftone, can be injefted into the bladder, but with the 
 greateft hazard of injuring that organ. But as fome 
 pradlitioners Hill continue to think favourably of it, I 
 have given a delineation, in Plate LXXIV. fig. 1. of 
 a machine by which liquids may with eafe be thrown 
 into the bladder. Every attempt, however, of this 
 kind is now in general laid afide ; and as no depend- 
 ence is to be placed upon the lithontriptic powers of 
 any medicine taken by the mouth, the only refource we 
 have is, the removal of the ftone by a chirurgical ope- 
 ration. In this manner, if his conftitution is found, 
 the patient may again enjoy as good health as he did 
 before he was attacked with the difeafe ; and unlefs 
 the operation is performed, the remainder of a mife- 
 rable life will probably be cut ftiort by the frequent 
 returns of pain and fever, to which people in this fitu- 
 ation are conftantly liable. 
 
 We ought, however, to remember, that although a 
 great proportion of thofe who are cut for the ftone 
 recover and do well, yet a confiderable degree of dan- 
 ger always attends the operation ; fo that, before ad- 
 vifing any perfon to fubmit to it, fuch circumftances 
 
i66 Of the Stone. Chap. XXIX. 
 
 ought to be confidered with attention, as can beft en- 
 able us to form a juH: prognofis of the event. 
 
 By experience it is found, that children more rea- 
 dily recover from this operation than adults ; and it 
 is likewife obferved, that old people, from the fifty- 
 fifth to the feventieth year, whofe conflitutions are not 
 impaired, run lefs rifk from it than men in the full 
 vigour of life. This may poffibly arife irom the in- 
 flammatory fymptoms which ufually fucceed to this 
 operation, being more apt to proceed to a dangerous 
 height in young plethoric people than in older pa- 
 tients ; and we know from experience that more dan- 
 ger is to be dreaded from inflammation after this ope- 
 ration than from any other caufe. But at whatever 
 period of life the patient is, if he is otherwife healthy, 
 more fuccefs is to be expedted, than if his conftitution 
 had been previoufly impaired by frequent returns of 
 the difeafe ; efpecially when it has continued fo long 
 as to produce ulceration in any part of the bladder. 
 
 In an ulcerated ftate of the bladder, if the patient is 
 advanced in years, he could not expert much enjoy- 
 ment of life, even although he were to recover from 
 the operation : in this fituation, therefore, a prudent 
 practitioner would rather decline to operate : inflead 
 of it, he would rather advife a plentiful ufe of mucil- 
 aginous drinks ; an occafional ufe of the warm bath ; 
 together with dofes of opiates proportioned to the de- 
 gree of pain. By thefe means the violence of the 
 pain is fometimes mitigated, and the patient is there- 
 by faved from the diftrefs of a fevere operation, the 
 effedls of which, in a conftitution fuch as I have men- 
 tioned, frequently prove fatal. 
 
 But even in thefe circumftances, if the patient is 
 young, if he is fuffering much from the difeafe, and 
 if not fo weak as to render it probable that the quan- 
 tity of blood ufually loft in the operation may irre- 
 parably injure his health ; I would decidedly advife 
 the operation. His chance of recovery will, undoubt- 
 edly, be lefs than if his health had otherwife been un- ^ 
 
 I 
 
Sea. III. Of the Stone. 167 
 
 impaired ; but, if he is lucky enou<:^h to furvive the 
 operation, he may enjoy life with comfort and eafe. 
 
 The operation being refolved on, the next point to 
 be determined is the befl method of doing it. From 
 the anatomical defcription that I have given of the 
 parts with which the human bladder is furrounded, it 
 appears, that there are only two points at which it can 
 with propriety be laid open. A confiderable part of 
 the fundus of the bladder I have fhown to be covered 
 with the peritonaeum ; fo that to open it here, would 
 be attended with imminent danger, from the certainty 
 of expofmg the abdominal vifcera, not only to the ef- 
 fects of the atmofphcre, but to the irritation of the 
 urine, on finding accefs to the cavity of the peritonae- 
 um by the wound in the bladder. The poflerior part 
 of the bladder I have fliewn to be either immediately 
 . covered with bone, or internally connecled with parts 
 which it would be highly improper to injure ; and 
 thefe particularly are, the redum ; the veficulce femi- 
 nales ; and the vafa deferentia and ureters. 
 
 The only parts of the bladder, therefore, which can 
 with a chance of fafety be cut into, are, that portion 
 of the anterior part of it, lying immediately below the 
 peritonreum, and which, when in a ftate of diflention, 
 is raifed fomewhat above the pubes ; where an inci- 
 fion direclly above the brim of the pelvis will lay that 
 part of it bare where it is not covered with the perito- 
 naeum, and where, accordingly, an opening into it 
 may be made : and, again, that portion of the blad- 
 der that we term its neck, which may be opened lat- 
 erally by an incifion in the perinceum, without any 
 danger of wounding other parts of importance. 
 
 It is in one or other of thefe parts that any opening 
 into the bladder can be made with fafety. Some prac- 
 titioners, indeed, have attempted to cut into it at the 
 poflerior part of its neck, or even into the body of it 
 at once ; but the hazard of wounding parts of much 
 importance is here fo great, that for this and other 
 reafons to be mentioned hereafter, every operation of 
 
t6S Of the Stone, Chap. XXIX, 
 
 this kind is now laid afide. We fliall prefently, how- 
 ever, enter more fully into the difcullion of this point, 
 by giving a detail of the various means that have been 
 propofed, from the time of Celfus downwards, for the 
 purpofe of extrading flones from the bladder ; and 
 this I Ihall do in the order of time that thefe opera-t 
 tions were introduced into pradtice. 
 
 The diftrefs and mifery that urinary calculi excite, 
 were probably experienced in the earliefl; ages of the 
 world. Relief, we may therefore fuppofe, would be 
 fought for, by the removal of the ftones, as foon as 
 fuch a knowledge of anatomy was obtained as could 
 juflify the attempt. We find accordingly, from the 
 writings of Hippocrates, that even at this early period, 
 the operation for the ftone was frequently performed ; 
 but as it was then folely praftifed by a particular fet 
 of men termed lithotomifts, we have received no ac- 
 count from this author of their method of doing it. 
 Celfus is the firfl who defcribes the method of oper- 
 ating at the time when he lived ; and it was done by 
 making an opening in the body of the bladder, direft? 
 ly upon the (lone itfelf. From the fmall number of 
 xnftruments ufed in this method of cutting, it has been 
 termed the operation by the leffer apparatus. 
 
 SECTION. IV. 
 
 Of the Operation of Lithotomy by the LeJJer Apparatus. 
 
 THE perfon to be cut being properly fecured, (the 
 ealieft and beft method of effeding which, I 
 fhall defcribe in Section VII.) the furgeon muff dip 
 the fore and middle fingers of his left hand in oil ; and 
 having introduced them into the redum of the patient, 
 he is to fearch for the (lone, and pufh it forward to- 
 wards the perinosum, fo that it may be felt between 
 the fcrotum and anus. In order to facilitate this part 
 
Sea. IV. Of the Stone, 169 
 
 of the operation, and to get the ftone properly fixed, 
 either the furgeon or an afliftant fhould prefs with his 
 right hand upon the under part of the abdomen, at 
 the fame time that the furgeon himfelf is pufhing the 
 ftone forward with his fingers in the reftum, in which 
 manner it is to be preffed forward below the pubes, 
 and fecured on one fide of the perinseum, between 
 thefe bones and the anus. This being done, we are 
 direfted by Celfus to make a femilunar cut through 
 the fkin, cellular fubflance, and mufcles ; beginning 
 on one fide of the anus, and carrying the cut direftly 
 over the centre of the tumor formed by the projetlloii 
 of the ftone. The bladder being thus laid bare, a 
 tranfverfe inclfion is made through the coats of it di- 
 redlly upon the ftone ; when the ftone, if it is fmall, 
 may probably be turned out by preflure from behind 
 with the fingers in the rtftum ; but if it is large, and 
 does not come away eafily, we are defired by Celfus 
 to take the affiftance of a hook for fcooping it out. 
 
 This operation, with a few variations, continued, fo 
 far as we know, to be the only method of cutting for 
 the ftone, till the beginning of the fifteenth century, 
 when another method of operating, to be hereafter 
 defcribed, was propofed, and very generally adopted. 
 Long after this period, however, this operation of Cel- 
 fus was ftill continued by many ; and the eafe with 
 which it is accompliftied, not only from the fmall num- 
 ber of inftruments with which it is done, but from lit- 
 tle or no anatomical knowledge being requlfite, pre- 
 ferved it in conftant ufe with itinerants, who continu- 
 ed, even to a late period, to praftife it in different parts 
 of Europe, under the name of the operation upon the 
 gripe.^ 
 
 This method of cutting for the ftone is Indeed fo 
 eafily performed, particularly in early infancy, that, 
 even in thefe times, many of our well informed prac- 
 titioners have a ftrong partiality towards it. At fo 
 late a period as the time of Heifter, we find it was 
 much in repute, infomuch that Heifter himfelf per- 
 
170 Of the Stone, Chap. XXIX. 
 
 formed it frequently ; but a wrong reprefentatlon has 
 commonly been given of the parts that are cut in it ; 
 for it has been commonly fuppofed, that by cutting di- 
 rectly upon the ftone, the bladder itfelf muft alone be 
 wounded, while all the neighbouring parts of impor- 
 tance arc imagined to efcape unhurt ; a circumftance 
 that would recommend it Ilrongly, if, on experience, 
 it was found to be the cafe. This, however, is far 
 from being fo ; as all who will make the experiment, 
 will readily perceive. 
 
 A flrict attention to the anatomy of the parts, might 
 at once indeed convince us of the difficulty, if not of the 
 abfolutc impoffibiUty, of cutting from the perinasum di- 
 rectly upon a ftone in the bladder, without deftroying 
 either the vafa deferentia, veficulye feminales, or ex- 
 cretory duels of thole receptacles ; the deftru£lion of 
 which would produce the ufual effects of caftration 
 with as much certainty as a total extirpation of the 
 teftes themfelves. Thefe parts are all placed upon 
 the under and back part of the bladder ; and as they, 
 as well as the ureters, are immediately connefted with 
 that part of the bladder that is cut in this operation, 
 it is perhaps impoliible to perform it without dividing 
 one or all of them. 
 
 As I had once a favourable opinion of this opera- 
 tion, I thought that in fome inftances it might be ufe- 
 fully employed, if, on experience, it fhould appear that 
 thefe parts could be avoided with the fcalpel. I ac- 
 cordingly put it frequently in practice on dead fub- 
 jects ; but although in all of them it was done with 
 every pofTible attention, it was conftantly found either 
 that the veficuiae feminales were divided, or that their 
 excretory ducts were cut acrofs. This, however, was 
 not all ; for although in fome inftances the urethra 
 was not touched, yet in others it was found to be com- 
 pletely laid open before the fcalpel reached the blad- 
 der. In every inftance where the operation is perform- 
 ed in the manner directed by Celfus, the urethra muft 
 neceflarily be cut, before the inftrument reaches the 
 
Sea. IV. Of the Stone. 171 
 
 bladder. For it is altogether impofTible to make a 
 tranfverfe incifion into the bladder, in the manner ad- 
 vifed by Celfus, without previoufly palling through 
 part of the urethra ; the fartheft extremity of that ca- 
 nal being always puflied forward by the fingers in the 
 rectum, in fuch a manner as to render it impollible to 
 avoid it in this method of performing the operation. 
 
 But in mod of the trials that I made upon dead 
 fubjects, for this purpofe, I attempted what I confider 
 as a material improvement of Celfus's method. A 
 tranfverfe or femilunar incifion through the teguments 
 and mufcles, I believe to be better adapted than any 
 other, for giving a free paflage to the (tone ; but as 
 the bladder is compofed of a very dilatable membra- 
 nous fubllance, there is no neceflity for a tranfverfe 
 cut being made in it. After laying the bladder bare, 
 therefore, by a femicircular cut along the courfe of 
 the flone, inflead of continuing the fame kind of in- 
 cifion with which the operation commenced, a longi- 
 tudinal cut was made directly on the centre of the 
 ilone, in order to avoid with as much certainty as pof- 
 fiblc all thofe parts that fliould not be injured. Even 
 with this precaution, however, although the urethra 
 was avoided, fome of the other parts I have mention- 
 ed were always divided ; fo that although they may 
 by accident, perhaps, be avoided once in a great num- 
 ber of times, I am confident that even the mofl: expert 
 anatomid would feldom be able to make an opening 
 into this part of the bladder, fufficient for extrading a 
 flone of a moderate fize, without dividing either the 
 veficulse feminales, the vafa deferentia, or their excre- 
 tory du£ls. In fome infi:ances, too, the entrance of 
 the ureters into the bladder is fo low down, as to ren- 
 der them liable to be cut in this operation. This, how- 
 ever, is a rare occurrence ; but it has in fome inftan- 
 ces happened. 
 
 Another important objedion to this operation is, 
 that the bladder being pufhed forward, and divided at 
 a part that mufl afterwards recede from the wound iii 
 
1/3 Of the Stone, Chap. XXIX. 
 
 the teguments, much rifk mud be Incurred of the for- 
 mation of fmufes, by the urine infmuatlng into the 
 neighbouring parts ; and we have to add to this, that 
 in general this operation mufl be confined to the early- 
 periods of infancy. The readings of Celfus with which 
 we are furniihed, limit the performance of this opera- 
 tion to the age of ten, or from that to the fourteenth 
 year ; but this mufl furely be confidered as an error 
 in the late editions of that work, as this mode of op- 
 erating is unqueftionably better adapted for the earlieft 
 periods of infancy, than for the more advanced flages 
 of it, infomuch that it may always be done with more 
 or lefs eafe, in proportion to the thicknefs of parts 
 about the rectum and bladder ; and this, again, de- 
 pends in a great meafure on the age of the patient. 
 "We are told, indeed, of fome practitioners who per- 
 formed this operation on people of every age, of eve- 
 ry habit of body, and whether corpulent or not. Such 
 accounts, however, have never appeared to be au- 
 thentic. 
 
 Among other improvements of this operation of 
 Celfus, the ufe of forceps for extracting the ftone, was 
 perhaps the greatefl ; but neither this, nor any other 
 advantage it can receive, can obviate the difficulties 
 I have mentioned. We find accordingly, that, about 
 the beginning of the 1 6th century, fome time between 
 the year 1500 and 1520, a new method of operating 
 for the ftone was propofed at Rome, by Johannes de 
 Romanis, as we are afterwards informed by one of 
 his pupils, Marianus, and whofe name has been com- 
 monly given to it ; this being termed the methodus 
 mariana, or lithotomy by the greater apparatus, from 
 the great number of iliftruments that at firft were em- 
 ployed in it. 
 
 K^' 
 
Sea. V. OftheSione, 173 
 
 SECTION V. 
 
 Of Liihoiomy by the Greater Apparatus, 
 
 BY this operation a palTage is made into the blad- 
 der, by cutting into the urethra at the bulb ; at 
 which a variety of inftruments were introduced, for 
 the purpofe of dilating the paffagc to fuch a fize as 
 might eafily admit of the extratlion of the ftone. 
 
 For a confiderable time after this operation was 
 propofed, a number of inventions were brought forth, 
 for the fole purpofe of rendering the dilatation of the 
 urethra and adjacent parts more eafy. Thefe it is 
 unnecefTary to enumerate, as an account of the ope- 
 ration, as it was lafl pratlifed in its mofl improved 
 ftate, will ferve to communicate all that is neceffary 
 to be known concerning it. 
 
 The patient being fecurcd, and placed upon a table 
 in the manner to be defcribed more particularly in 
 Sedion VII. a grooved ftafl' was then paffed through 
 the urethra into the bladder ; the handle of the in- 
 ftrument being carried over the right groin, while its 
 convex part was made to pufli out the urethra on 
 the left fide of the perinceum. In this pofition the 
 ftaff v/as prefer ved by an alTiflant, who like wife fuf- 
 pendcd the fcrotum ; while the operator, with a fcal- 
 pel in his right hand, made an incifion from the very 
 bottom of the fcrotum to within a (inciter's breadth of 
 the anus, carrying it along the left fide of the peri- 
 nicum, within a very little of the rapha. 
 
 The ikin, cellular fubftance, and mufcles, being thus 
 divided, the urethra itfelf was now opened in its bulb, 
 by cutting direftly into the groove of the ftaff ; and 
 the incifion was completed by carrying the knife along 
 to the extremity of the urethra, at the commencement 
 of the proftate gland. 
 
 Various indruments were at one period in ufe, 
 termed dilators, and male and female ccndudors, for 
 
1/4 Of the Stone. Chap, XXIX. 
 
 the purpofe of finlfliing the operation, by dilating fuch 
 parts as were not cut ; and the timidity of fome ope- 
 rators was fuch, that they dilated, Itretched, or lace- 
 rated almoft all that part of the urethra that lies be- 
 tween the bulb and proflate gland ; a degree of cau- 
 tion by no means ncceffary, and which, by the vio- 
 lence which this dilatation did to the parts, was fure 
 to produce very diflrefsful confequences. Other prac- 
 titioners, however, performing the operation fo far in 
 the fame manner, hnifhed the other parts of it in a 
 different way. They liril introduced a blunt gorget 
 into the bladder, by running its beak along the groove 
 of the flaff, and puihing it forward, fo as to force a 
 paffage through the proilate gland ; and this being 
 done, the forefinger of the left hand was pufhed along 
 the gorget, and with it the paffage was further dilat-j^. 
 ed, till the opening was fuppoied to be fufficiently 
 large for the ftone to pafs through it. 
 
 The opening into the bladder being in this manner 
 completed, the flone was extracted in the manner I 
 fhall hereafter point out, when treating of the lateral 
 operation., in Section VII. by the ufe of different for- 
 ceps adapted to the fize of the parts ; and on extract- 
 ing the ftone, all thofe parts that were not cut in the 
 previous fteps of the operation, were of necellity great- 
 ly lacerated. 
 
 Although this operation was long practifed, it is li- 
 able to many objections. Of thefe, the number of 
 inftruments ufed in it is mentioned as one : but, in 
 the improved ftate of the operation, that I have de- 
 fcribed, this objection is entirely removed, no more 
 inftruments being ufed in it than are daily employed 
 in the molt fimple method of performing the lateral 
 operation ; namely, a fcalpel, a gorget, and forceps 
 for extracting the ftone. But the material objections 
 to which it is liable are, that by beginning the inci- 
 fion too near to the fcrotum, much more of the ure- 
 thra is cut than is neceffary : by not dividing the 
 proftate gland with the fcalpel, the parts are fo much. 
 
Sea. V. • Of the Stone. 175 
 
 lacerated, firll by the forcible introdu6l:ion of the 
 blunt gorget, and then by the extraftion of the ftone, 
 as muft be the caufe of much irreparable mifchief : 
 and laflly, by the parts not being freely divided, we 
 might frequently find it impofiible to extract large 
 {tones by this operation, which, in the lateral method 
 now praOifed, might pafs with eafe. In other re- 
 fpedts, however, this operation poflefied much merit, 
 and it required only to be improved in a few circuni- 
 ftances, to become the real lateral operation of mod- 
 ern practitioners . Thefe, however, it is unnecellary 
 to enlarge upon here, as they will be afterwards par- 
 ticularly pointed out in the defcription to be given of 
 the lateral operation. 
 
 After this operation had been practifed for thirty 
 or forty years, fome of the inconveniencies that refult 
 from it fuggeiled the idea of what was afterwards term- 
 ed the high operation ; an appellation which it deriv- 
 ed from the bladder being cut into above the ofla 
 pubis. 
 
 About the year 1561, Franco, a French fiirgcon of 
 this name, publifhed a treatife on hernias ;* and here 
 •we find the firfl: account of the high operation. It 
 was firfl fuggefled to Franco by accident ; for hav- 
 ing, as he informs us, met with a large ftone in a child 
 two years of age, which he could not polTibly extradt 
 by the operation then practifed in the perinseum, he 
 was induced to open the bladder above the pubes : 
 but although the ftone was extracted, and the child 
 recovered. Franco never performed the operation 
 again ; and he even advifes it not to be done by oth- 
 ers, from the great danger which he thinks will at- 
 tend it. 
 
 The next account we find of it is by Roffet, in a 
 publication on this and other fubjects, publifhed at 
 Paris in the year 1590. But it does not appear that 
 he ever performed the operation himfelf ; nor was it 
 
 * Traitc tres ample des Hcrnies, par Pierre Franco. 
 
iy6 Of the Stone. Chap. XXtX.- 
 
 any where much pradifed till fome time after the 
 commencement of the prefent century, when it was 
 adopted and keenly patronifed in London by Mr. 
 Chefelden and Mr. Douglas. 
 
 During the twelve or fifteen years immediately fub- 
 fequent to the year 1720, the high operation was fre- 
 quently performed both in London, Edinburgh, and 
 other parts of Europe ; but the lateral operation, with 
 the improvements upon it by Rau, being then more 
 generally known, the fuperior advantages it was found 
 to poffefs very quickly procured it a preference ; and 
 fince this period the high operation has never been 
 generally praftifed, either in this or any other coun- 
 try ; but I fhall now proceed to defcribe the method 
 of doins: it. 
 
 t) 
 
 SECTION VI. 
 
 Of the High Operation for the Stone, 
 
 I HAVE already made it appear, that the fundus of 
 the bladder, or that part of it lying highefl in the 
 {Delvis, is covered with the peritoneum ; fo that at 
 this part no opening, it is evident, can be made in it 
 with fafety, as the operator would not only incur the 
 rifk of wounding the inteftines, but the urine would 
 be apt to efcape into the abdomen. It is the anterior 
 part of the bladder, namely, that part of it that lies 
 between the middle of it and its neck, that ought to 
 be opened in this operation : but this part of the blad- 
 der is feldom fufficiently elevated, and as one com- 
 mon efFeft of the ftone in the bladder is to induce a 
 diminifhed or contracted ftate of it, this circumftance 
 of itfelf is a very important objeftion to this opera- 
 tion ; for unlefs the bladder can contain a large quan- 
 tity, at leaft a pound and a half in an adult, it ought 
 not to be attempted. 
 
Sed. VI. Of the Stone, 177 
 
 Various methods have been propofed for diftending 
 the bladder. Some ha\'^ faid that it may be done by 
 throwing air into it with bellows ; and others have 
 advifed a quantity of wa'er to be injected immediately 
 before the operation, and to retain it by forming a 
 ligature on the penis. Both of thefe methods, how- 
 ever, are apt to do harm by diftending the bladder 
 too fuddenly ; and we are even told by fome, that it 
 has been burft by this kind of treatment. Means, 
 therefore, of a more harmlefs nature fhould be at- 
 tempted ; and it may be done without running any 
 riflv of hurting the bladder, merely by the patient be- 
 ing accudomed, for a confiderable time before the 
 operation, to retain his urine as long as poffible ; and 
 as foon as it is found that he can retain a fufficient 
 quantity, by paffing a ligature upon the penis ten or 
 twelve hours before the operation, and caufing him to 
 drink plentifully of any diluent drink, we may be al- 
 moft certain of producing an eafy and fufficient de- 
 gree of diftention. 
 
 This being done, the patient muft be laid upon a 
 firm table, about three feet four inches in height ; at 
 the fame time that his legs and arms fhould be fecur- 
 ed, not with ligatures, but with the hands of aflift- 
 ants. In order to guard as much as poffible againfl 
 any injury being done to the bowels, the patient fhould 
 be laid with his head confiderably lower than his bo- 
 dy, and his thighs and buttocks raifed. By this fitu- 
 ation, too, the ftone, which would othersvife fall into 
 the neck of the bladder, where it could not be very 
 accefhble, is brought more contiguous to the intend- 
 ed opening, and is thereby more eafily laid hold of, 
 either with forceps or the fingers. 
 
 The patient being thus properly fecured, an incifion 
 is to be made with a round edged fcalpel, diredly 
 upon one fide of the linea alba, beginning about four 
 inches above the offa pubis, and ending at the fym- 
 phyfis of thefe bones : even the linea alba itfelf may 
 Vol. III. N 
 
178 Of the Sme. Chap. XXIX. 
 
 be cut with fafety ; but is is better to avoid it, as the 
 incifion is more eafily made in foft parts than in ten- 
 dons or ligaments. The Ikin and cellular fubftance 
 being freely divided, the redti and pyramidales muf- 
 cles come fuccefiivcly into view : in general, the in- 
 cifion may be carried on merely by feparating thefe 
 mufcles from one another ; but no harm could be 
 done by fome of their fibres being cut. 
 
 A fufficient opening of the exlernal parts being in 
 this manner obtained, the operator fiiould now fearch 
 with his fingers for the bladder, which he will com- 
 monly difcover immediately above the pubes. With 
 the fingers of his left hand he fiiould now prefs back 
 the peritonaeum, with the inteflines contained in it, 
 and with the fame fcalpel with which he performed 
 the preceding fleps of the operation, he fliould pene- 
 trate the bladder itfelf in its moft prominent part. 
 This opening into the bladder fhould at once be made 
 fo large as to admit two of the fingers of the opera- 
 tor's left hand ; which being introduced, the incifion 
 fhould be enlarged to the length of three inches, by 
 running a probe pointed biftoury along one of the 
 fingers, down towards one fide of the neck of the 
 bladder. The inflant that the fingers are introduced 
 into the bladder, the ligature upon the penis fliould 
 be taken off, fo that the water contained in it may be 
 difcharged by the urethra, otherwife the whole will be 
 difcharged by the wound, and part of it might lodge 
 among the contiguous mufcles. 
 
 The incifion being in this manner completed, the 
 operator ought to fearch with his fingers for the ftone, 
 and if poffible, it fhould be extracted without the af- 
 fiftance of inftruments : but if this does not fucceed, 
 forceps mufl, no doubt, be employed. One great ad- 
 vantage tlKit we derive from this operation is, that as 
 the extraftion of the flone does not require much 
 force, fo it is here rarely known to break : but when 
 this misfortune takes place, the pieces will be more 
 eafily removed with the fingers alone, than with any 
 
Sed. VI. Of the Stone. 179 
 
 of the fcoops commonly employed. The ftones be- 
 ing removed, the upper part of the wound in the teg- 
 uments fhould be drawn together, either with ftrong 
 adhefive plafters, or with the twifted future, care be- 
 ing taken to leave at lead an inch and a half in the 
 under part of it open, in order to difcharge any urine 
 that may be thrown out from the wound in the blad- 
 der into the contiguous parts. It might even be prop- 
 er to keep the whole external incilion open till the 
 wound in the bladder is reunited ; but as the bowels, 
 fupported now by the peritonjeum only, would be apt 
 to protrude at this opening, and as this would prove 
 not only troublefome but highly dangerous, it ought 
 by all means to be guarded againft. 
 
 With this view, the bowels fliould be kept open 
 with gentle laxatives, and the patient during the whole 
 courfe of the cure fhould be kept with his head and 
 upper part of the body low, and the pelvis elevated. 
 
 The parts injured in this operation are not any 
 where nearly furrounded with bone ; fo that large 
 flones can be extrafted with more eafe in this than in 
 any other way : and as the wound in the bladder is 
 made far from its neck, fiftulous openings are not fo 
 apt to enfue from it as from incifions in the perina^um. 
 Thefe are two advantages that we derive from this 
 operation ; but the objeftions to it are various. 
 
 I. When the bladder does not admit of fuch dif- 
 tention as to be raifed above the pubes, it is almoft 
 impolTible to make an opening into it without divid- 
 ing the peritonaeum. From this much danger would 
 undoubtedly enfue ; air would find accefs to the whole 
 furface of the alimentary canal ; the bowels would 
 protrude, and urine would efcape into the cavity of 
 the abdomen. 
 
 Many, indeed, affert, that no danger enfues from 
 the protrufion of the bowels ; that the wound heals 
 with the fame eafe, and that the patients recover equal- 
 ly well as if this did not happen. No pradition- 
 
 N 2 
 
i8o Of the Stone. Chap. XXIX, 
 
 er, however, In thefe times, will give credit to this, 
 and it is accordingly a very important objcftion to the 
 high operation. 
 
 2. As the urine is apt to find accefs between the 
 peritongeum and abdominal mufcles, as well as be- 
 tween the bladder and pubes, troublefome fmufes are 
 apt to form in the cellular fubftance of thefe parts, and 
 as no vent can be made for the matter, they always 
 terminate in much diftrefs. 
 
 3. It has been obferved, when the habit of body is 
 not entirely good, that a cure cannot be obtained eith- 
 er of the wound in the bladder, or external teguments. 
 This, it will be faid, may be alleged as an objedfon 
 to every important operation ; but it has been com- 
 pletely efhabliflied by obfervation, that degrees of dif- 
 eafe in the conftitution prove highly detrimental in the 
 high operation for the itone, which in the ufual meth- 
 od of operating in the perina;um give much lefs caufe 
 of alarm. 
 
 4. This operation is confined almoft entirely to pa- 
 tients under thirty years of age : for although it was 
 at one period frequently pradifed on older people, and 
 although no particular reafon can be given why it 
 ought not to fucceed in more advanced ages, yet we 
 learn from almoft every author who has written upon 
 it, particularly from Middleton, Smith, Douglas, and 
 Heifter, that a very fmall proportion only recover of 
 fuch as have pafled their thirtieth year. 
 
 It is perhaps for one or other of thefe reafons that 
 the high operation has fallen into difufe, and that it 
 has not been much praftifed for a great length of time 
 in almoll any part of Europe. But although this 
 method of operating is attended with hazard, and is 
 frequently followed with diftrefsful confequences, yet 
 there is reafon to think, that, in particular circum- 
 ftances, it might be pra6:ifed with advantage. 
 
 The mofl material objection, to the modern or lat- 
 eral method of performing this operation, arifes from 
 the bruifing of the foft parts againfl the contiguous 
 
 f 
 
 i 
 
Sea. VI. Of the Stone. i S i 
 
 bones in the extraftion of a large ftone ; which is fo 
 much the cafe, that we may confider the rilk in that 
 operation to be almoft in proportion to the fize of the 
 ftone. When a ftone is fmall and eafily extraded, 
 the proportion of deaths in the lateral operation is ve- 
 ry fmall : but whenever the ftone is of fuch a fize as 
 to weigh feven, eight or ten ounces, it is perhaps one 
 of the mofh dangerous operations to which a patient 
 can fubniit. In different inftances, too, the ftone has 
 been fo large, that it could not be taken out by the 
 lateral operation ; nay, fome cafes are on record, in 
 which it became necelfary to perform the high opera- 
 tion, after the operator had failed in extrading the 
 ftone by the ufual method of cutting in the peri- 
 naeum.* 
 
 When, therefore, from the long continuance of the 
 difeafe ; from the fenfe of weight about the neck of 
 the bladder ; and particularly when from the touch by 
 the finger in ano, we have reafon to fufpe«5t the ftone 
 to be large, it ought to be an objecl of confideration, 
 how far it may be proper to avoid the lateral, and in 
 certain circumftances, to employ the high operation. 
 The circumftances to which I allude, rcfpecl the age 
 of the patient, the foundnefs of his conftitution, and 
 the poilibility of diftending the bladder fo as to raife 
 it above the brim of the pelvis. Thefe circumftances 
 are favourable where the ftone is large ; and v. hen it 
 is known to be fo, the high operation, although lefs 
 advantageous in the general run of calculous cafes 
 than the lateral method of cutting, may be praclifed 
 with a greater probability of fuccefs than any other 
 with which we are acquainted. 
 
 Having now faid all that is neceflary refpeding the 
 apparatus altus, we ftiall proceed to the conftderailon 
 of what has ufually been termed the lateral operation. 
 
 * We find that it happened to Htifter. Vide Heifter's Surgery, p. a. 
 Sea. V. Chap. CXLII. 
 
i8a Of the Stone, Chap. XXIX, 
 
 SECTION VII. 
 
 Of the Lateral Operation, 
 
 IN the operation of lithotomy, as it was formerly 
 praclifed by the great apparatus, the external in- 
 cifion was made in nearly the fame part that it is now 
 in the lateral operation ; but the two methods of ope- 
 rating are materially different in every other circum- 
 ftance. 
 
 The original invention of the lateral operation is 
 due to a French ecclefiaftic, commonly known by the 
 name of Frere Jacques. This operator firfl: appeared 
 at Paris in the year 1697, when, by the fuccefsful 
 event of a few cafes, he vvas defnxd to operate upon 
 a great number. But it foon appeared to practition- 
 ers of difcernment, that the fame he had acquired 
 would not probably be of long duration. For with a 
 very imperfe6t knowledge of the anatomy of the parts 
 concerned in the operation, a bad afforlment of inflru- 
 ments, and a total negledt of his patients after the 
 operation, it was fcarcely poffible that much fuccefs 
 could refult from his method. His manner of operat- 
 ing was as follows : 
 
 The patient being properly fecured, either upon a 
 table or on a bed, a common folid ftaff was introduc- 
 ed into the bladder by the urethra, and the handle 
 being carried over the right groin, the convex part of 
 it was made to elevate the teguments and other parts 
 on the left fide of the perinseum. 
 
 With a flraight biftoury he now made an incifion 
 through the fkin and cellular fubftance, beginning be- 
 tween the anos and tuberofity of the ifchium, and 
 proceeded upwards along the left fide of the perinas- 
 um, at a fmall diftance from the rapha, till it extend- 
 ed at leafl one half of the courfe of the perinseum. 
 "With the fame knife he now went on along the direc- 
 
Sea. VII. Of the Stone. 183 
 
 tion of the ftaff, to divide the parts between the exter* 
 nal incifion and the bladder, which he alio opened 
 with the point of the fame knife with which the other 
 fteps of the operation had been done. At this open- 
 ing in the bladder he firfl introduced the index of his 
 left hand, in order to difcover the fituation of the 
 ftone J and having withdrawn the ftaff, he laid hold 
 of the ftone with forceps, and performed the extrac- 
 tion in the ufual manner. The patient was now car- 
 ried to bed, and no farther attention was paid to him 
 by the operator, who never applied any dreftings, as 
 he trufted the fubfcquent management of every cafe 
 to the nurfe or other attendants. 
 
 In confeqiience of this unpardonable negle6l, and 
 by frequently cutting parts in the courfe of the opera- 
 tion which he ought to have avoided, a great propor- 
 tion of thofe on whom he operated died ; no lefs, we 
 are informed, than twenty-five of fixty.* Hence Jac- 
 ques foon fell into difrepute ; and although he after- 
 wards made many improvements in his method of 
 operating, particularly in ufmg a grooved ftaff inftead 
 of a folid one, and in being more attentive to the fub- 
 fequent management of his patients, yet his reputation 
 in Paris never gained ground ; nor do we find that 
 his method was ever attended with much fuccefs, eith- 
 er in Holland, or in the various parts of Germany, 
 where he afterwards praclifed. 
 
 For with fo much inattention did he proceed, that 
 although he profefTed to cut direftly into the body of 
 the bladder, without injuring either the urethra or 
 proftate gland ; yet in the dilfeclion of fuch bodies as 
 died of the operation, it was found, that in many th« 
 proftate gland was divided, together with the veficu- 
 las feminales. In fome inftances, the bladder was cut 
 in two or three different parts ; in others the redlum 
 was divided ; and it even frequently happened, that 
 
 '* Vide Morand Opufcules de Chirurgic, partie li. p. 5 4« 
 
1 84 Of the Stone. Chap. XXIX. 
 
 the bladder was entirely feparated from the urethra.* 
 We need not wonder, therefore, that this practition- 
 er, as well as his method of operating, foon fell into 
 difcredit. Biit although this was a confequence that 
 necefTarily enfued from the ill fuccefs that atteneded his 
 praftice ; yet the world, we nuifl admit, is much in- 
 debted to Jacques, for having laid the foundation of 
 the lateral method of cutting for the Hone, which, in 
 its prefent improvtd ftate, is practifed with fo much 
 fuccefs over all Europe. 
 
 Rau was the firll who endeavoured to improve this 
 operation of Frere Jacques, which he did by ufmg a 
 ftafF with a deep groove, by which he was enabled to 
 continue the incifion into the bladder with more cer- 
 tainty than can be done with a fhaft' entirely folid. But 
 Rau, afraid of wounding the proilate gland, introduc- 
 ed a refinement into his method of cutting, which, in 
 the event, proved extremely hurtful, and was proba; 
 bly the caufe of its being aftervv'ards laid afide. For, 
 inftead of dividing the urethra and proftate gland, by 
 which the extradion of the flone would have been 
 made eafy, he difl'eded with much caution by the fide 
 of the proftate, till the convex extremity of the ftafF 
 was difcovered in the bladder itfelf. At this part an 
 incifion was made into it, and the ftone thereafter ex- 
 traded, in the manner then praclifed for cutdng with 
 the great apparatus. 
 
 By this method of operating, the redum and vefi- 
 culas feminales were in great danger of being injured ; 
 the ftone was extraded with difficulty ; and from the 
 depth of the incifion, the urine did not pafs eafily off 
 by the wound, fo that troublefome fmufes frequently 
 enfued. t 
 
 * For a particular account of Frcre Jacques's method of operating, fee 
 Dr. Lifter's Journey to Paris ; the works of Dionis, Mcri, Collet, Saviard, 
 and Morand. 
 
 f Rau himfclf kept this method of operating as much concealed as pofi 
 fible. But an account of it was publidicd after his death, by Albinus ; 
 who, by aiCflJng frequently at his operations, became perfecfUy mafter of 
 the manner of performing it. Vide Index fiippcUctSlilis anatomicae, &c. 
 JLug. Batavorum. 
 
Se<a. \1I. Of the Stone. 1 85 
 
 Thefe inconveniencies prevented this operation of 
 
 Rau from ever being generally received, and fuggeft- 
 
 ed to our countryman, the celebrated Chefelden, the 
 
 lateral method of cutting as it is now, with a few al- 
 
 . terations, very univerfally praftifed. 
 
 As this operation of Mr. Chefelden is defcribed by 
 many writers in furgery, it is not here neceflary to en- 
 ter into a detail of it : I (hall now, therefore, proceed 
 to defcribe the lateral operation in its prefent improv- 
 ed (late. 
 
 I'hat the patient may not find it neceflary to go 
 foon to ftool after the operation, feveral flools fliould 
 be procured by a purgative on the preceding day ; 
 and with a view to difcharo-e the contents of the rec- 
 turn more entirely, an injection fhould be given a few 
 hours before the operation is performed. 
 
 When the bladder is in a collapfed ftate, it is liable 
 in this operation to be cut in different parts by the 
 gorget ; the patient ought therefore to be defired to 
 drink plentifully of fome diluent liquor, and to retain 
 his urine for feveral hours before being laid upon the 
 table : in fome, however, the irritation produced by 
 the difeafe is in fuch a degree as entirely to prevent 
 this voluntary retention of urine ; in which cafe the 
 penis Ihould be fiightly comprefTed with a broad fillet 
 for fome hours before the operation ; and we leflen 
 or remove the irritation by a large dofe of opium. 
 
 Thefe circumftances being adjufted, and the perin- 
 fEum and parts about the anus being fliaved, the pa- 
 tient is now to be laid upon a table for the operation. 
 The moft convenient height for this table is three feet 
 two inches. It ought to be perfectly firm ; and, that 
 there may be fufficient fpace for the patient, it fhould 
 be about three feet eight inches long, and two feet and 
 a half wide. 
 
 The patient fliould be completely and properly fe- 
 cured, and the following is perhaps the befl method 
 of domg it : let a noofe be formed in the double of a 
 piece of broad firm tape, five feet in length : the pa« 
 
1 86 Of the Stone. Chap. XXIX, 
 
 tient's wrlfts being paffed through this noofe, he fliould 
 be defired to take a firm hold of the outfide of the an- 
 kle of the fame fide, when, by different turns of the 
 tape round the hand, ankle and foot, his hand is to be 
 firuily fecured in this polition ; and this being done 
 on one fide, the hand and foot of the oppofite fide are 
 to be firmly tied together in the fame manner. 
 
 The operator fhould now introduce a grooved flafF, 
 of a fize proportioned to the parts through which it is 
 to pafs. Different fizes of thefe ftaffs are reprefented 
 in Plate LXIX ; the artifl who makes them fliould 
 round off the edges of the grooves, otherwife they are 
 apt to injure the urethra ; and the extremity of the 
 groove fhould be perfectly free and open, otherwife it 
 is difficult to difengage the gorget after it has paffed 
 into the bladder. As the groove is only neceffary in 
 the convex part of the ftaff, and from that to its point, 
 the handle of the inftrument, down to the commence- 
 ment of the convexity, fliould be entirely folid, fo as 
 to admit of the penis being preffed upon it without be- 
 ing hurt, either by the hand of the aflifl;ant, or by a 
 piece of tape, which may be fometimes neceffary, as I 
 have already advifed, for preventing the urine from 
 being difcharged. 
 
 I may here remark, that more attention fliould be 
 given to the length of the fl:aff than is commonly done. 
 Staffs are in general too fliort ; fo tliat when, in the 
 courfe of the operation, the handle is preffed down 
 upon the groin by the affiftant, the point is very apt 
 to flip entirely out of the bladder ; a circumfliance to 
 be guarded againfl; with all poffible attention, and it 
 cannot with luch certainty be done as by making the 
 ftaff always of a fufficient length. 
 
 The fl:one being again diflinctly felt, not only by,; 
 the furgeon himfelf, but by* his aflifl:ants, the patient-^ 
 muff now be placed in that pofture in which he is to 
 be kept during the remainder of the operation. ^The 
 table intended to be ufed fliould be perfectly level ; 
 but, that the patient may lie upon it with as much eafe 
 
Sea. VII. Of the Stone. 187 
 
 as pofTible, a pillow may be put under his head, and, 
 that the pelvis may be higher than the abdomen, there 
 Ihould be at lead two pillows under his buttocks, which 
 fhould be made to projed an inch or two over the end 
 of the table. 
 
 A due elevation of the buttocks, is highly important, 
 although feldom attended to by the operator ; indeed, 
 the very reverfe is often advifed, the head and upper 
 part of the body being generally kept higher than the 
 pelvis. This, however, can arife from inattention on- 
 ly ; for we may by the leafl reflexion be convinced, 
 that the more eredl: the body is kept, the greater will 
 be the preffure of the inteftines upon the bladder ; and 
 if, by this preffure, the fundus of the bladder is forced 
 down upon its neck, the rifk of its being wounded 
 mull be great indeed. 
 
 Of fuch patients as have died of this operation, I 
 have, in different inflances, found on diffection, that 
 the bladder was wounded in three different parts : in 
 its cervix, as is always the cafe when the gorget is of 
 a proper length ; in its fide confiderably above the 
 cervix ; and, again, in the fundus or upper part of it. 
 Now, this can never happen, if the diredions I have 
 given are kept in view ; for when the bowels are pre- 
 vented from falling upon the bladder, by the buttocks 
 being raifed above the reft of the body, and if, at the 
 fame time, the bladder is properly diftended with 
 urine, it muft be altogether impoffible, in the ufual lat- 
 eral operation, to injure it in^an improper part. But 
 if this precaution of having the bladder diftended dur- 
 ing the operation is negleded, at the fame time that 
 the bowels, by an elevated pofture of the upper part 
 of the body, are allowed to fall into the pelvis, the 
 bladder muft be fo completely collapfed, and its fun- 
 dus puftied fo much down upon its neck, as muft fre- 
 quently be the caufe of much unneceffary hazard. 
 
 Befides the cafes to which I allude, in which the 
 bladder was after death found to be wounded in dif- 
 ferent parts, we find a very candid acknowledgment 
 
i88 Of the Stone, Chap. XXIX. 
 
 made by a celebrated lithotomift, of his being once fo 
 unfortunate in the lateral operation, that a confidera- 
 ble portion of the fmall guts pafTed immediately out at 
 the wound.* 
 
 This would certainly have difconcerted many oper- 
 ators : but, fortunately for the patient, the operation 
 was in this cafe completely finilhed ; the bowels were 
 reduced and a perfed cure was obtained. Mr. Brom- 
 field endeavours to account for this protrufion of the 
 bowels in a different manner ; but I am much inclin- 
 ed to believe, that it happened from the pelvis not 
 having been fufficiently raifed above the reft of the 
 body, and from the bladder having been in a collapf- 
 ed ftate at the time the incifion was made in it. For 
 this author, it muft be remarked, inftead of ordering 
 the bladder to be diftcndcd at the time of operating, 
 defires exprefsly that it may be emptied immediately 
 before the operation.! 
 
 Matters being adjufted in the manner I have advif- 
 ed, with refped to the patient, an aififtant on each fide 
 is to fecure his legs and arms : one muft prevent him 
 from moving the upper part of his body ; another 
 muft lay hold of the ftaff ; and a fifth is required to 
 hand the necefiary inftruments to the operator. 
 
 The furgeon, after having again felt the ftone with 
 the ftaff, is now to make the hand of it pafs over the 
 right groin of the patient, fo that the convex part of 
 it may be diftinguifhed on the left fide of the perinae- 
 um : in this pofition it may be exa6Hy preferved by 
 the affiftant, who with his right hand ftiould lay hold 
 of the handle of the ftaff, while with his left he ele- 
 vates and fiipports the fcrotum. 
 
 The thighs of the patient being fufficiently feparat- 
 ed by the alliftants, and the furgeon being feated be- 
 tween the patient and the window, in fuch a manner 
 that the light may fall diredly upon the perinaeum, 
 
 * Vide Mr. Bromfield's Chlrurgical Obfervations and Cafes, Volume H. 
 page 264. 
 t Page aa8, Vol. II. 
 
Sea. VII. Of the Stone. i8$ 
 
 an incifion is now to be made with a common round 
 edged fcalpel through the fkin and cellular fubftance, 
 at leaft four inches in length in a full grown perfon, 
 and fo in proportion in fmaller fized people ; begin- 
 ning a little to the left fide of the rapha, nearly an inch 
 below the termination of the fcrotum, and proceeding 
 along the fame fide of the perinaeum, till it runs at an 
 equal diftance between the tuberofity of the ifchiuni 
 and the anus, which lafl it ought to pafs at lead aa 
 inch. 
 
 As the fuccefs of the operation depends in a great 
 menfure on this part of it being properly performed, 
 it ought at all times to be done with the utmoft atten- 
 tion. From timidity or inattention, this external in- 
 cifion is commonly made too fhort : inftead of four 
 inches, I have often feen it, even in the largeft adult, 
 fcarcely two. In confequence of this, the mufcles, and 
 other parts below, are not properly divided ; the op- 
 erator has not freedom to profecute the other fteps of 
 the operation ; and if the ftone is large, the parts 
 through which it has to pafs muft be much more bruif- 
 ed and lacerated than if they had been freely cut with 
 the knife ; and as no harm can enfue from the exter- 
 nal incifion being free and ample, it ought in every 
 inllance to be fo. Much hazard may enfue from the 
 divifion of the teguments and mufcles being fmall j 
 but none from their being largely laid open. 
 
 By this firft ftroke of the fcalpel, the fkin and cel- 
 lular fubftance (hould be freely divided, fo as to bring 
 the fubjacent mufcles completely in view ; when, by 
 a continuation of the incifion, the ereftor penis, accel- 
 erator urinse, tranfverfalis perins^i and levator ani 
 fliould be cut.* 
 
 • Soon after *he flrrt edition of this work was publiflied, my friend 
 Dr. Monro, in convcrfing on the lateral operation of litliotomv, obfcrved, 
 that I had dclircd mufcJes to be cut which mi^ht be avoided ; and know- 
 \ng that Sharpe, Camper, and others who wrote upon this operation, footi 
 after that important improvcm< nt was iniroducetl, of cutting the proflatc 
 gland with the K<^ro;et of Hawkins, inflcad of the fcalpel, were of opinion, 
 that the cxtcnfivc divifion that I have advifcd of thefe parts was uanecei- 
 
19© Of the Stone, Chap. XXIX* 
 
 As no danger enfues therefore from a free divifion 
 of thefe parts, and as a large opening not only facili- 
 tates the extraction of the Hone, but admits of any 
 blood veiTel that is cut being eafily fecured with a lig- 
 ature, which can never be done when the incifion is 
 fmall, it ought in every inflance to be large. In gen- 
 eral, the arteries with which thefe mufcles are fuppli- 
 ed are not fo large as to render ligatures neceffary j 
 
 fary, I fliall here fliortly mention the reafons that have made me differ 
 from authorities of fuch refpeiStability. 
 
 That this operation may be performed without dividing more mufcles 
 than the tranfverfah"s pcrinasi and levator ani, is well known ; but it is not 
 what may be done, but what ought to be done, that In all important op- 
 erations demands our attention ; on the point in queftion,my opinion has 
 alwavs been, that all thofe mufcles fliould be cut that are apt to be brulf- 
 ed or torn in extraiSling the ftone : now, this is fo clearly the cafe with 
 the eredtor penis and accelerator urinns, that few will doubt of the pro- 
 priety of dividing them who have infpedted them in patients dying after 
 the extrafting of large flones: wlienever a ftone has been large and difii- 
 cult to extraifb, T have always found thefe mufcles much contufcd, often 
 lac-;rared, and commonly in a ftate of mortification. Whereas, when com- 
 pletely cut acrofs, this does not fo readily happen; the divided ends of 
 the mufcles retraA; they are thereby faved from the violent prefTure of 
 the forceps and flone ; and the operation is finillied with much more eafe 
 than it otherwife poflQbly could be. 
 
 Having long oblerved this to be the cafe ; knowing that no danger could 
 enfue from dividing them, for it is daily done with impunity to a much 
 greater extent in fululous or fmuous ulcers of thefe parts, and finding up- 
 on trial that the more freely they v/ere cut, the more fuccefsful the oper- 
 ation commonly proved, I have therefore long been in the practice of do- 
 ing it : my operations indeed have proved fuccefsful nearly in proportion 
 to the freedom with which thefe parts have been divided, at the fame 
 time that the wounds have healed more kindly than when fmall openings 
 have been made. 
 
 Neither has this divifion of thefe parts any influence on the diredlion 
 of the external cut, which ought to be in the line that I have mentioned, 
 beginning nearly an inch below the terminatian of the fcrotum, a very lit- 
 tle to the left of the rapha, and proceeding obliquely along the fame fide 
 of the perinreum, till it runs at an equal diftancc between the tuberolity 
 of the ifchium and the anus. 
 
 If the fkin and cellular fubftance have been freely divided, they retradl 
 fo much, that all the mufcles that I have mentioned may be cut with cafe : 
 this indeed is not often done ; by which, flones even of no great bulk arc 
 extradled wth difficulty to the operator, and with perfedt torture to the 
 patient ; by which lives are often brought into hazard, and even loft, 
 which otherwife might be faved. 
 
 I have infifted the more upon this, as I conceive it to be one of the mofl 
 important points in this very interefting operation ; one on which the fuc- 
 cefs attending it mufl at all times in a great meafure hinge; and particu- 
 larly from my having witnefTed more difaflrous confequcnces from a tim- 
 idity in regard to it, that is, from the mufcles not being freely divided, 
 than from all other failures on the part of the furgeon. 
 
Sea. VII. Of the Stone, 19! 
 
 but whenever they prove to be fo, and efpecially when 
 the patient is weak and emaciated, the larger arteries 
 ihould be immediately fecured before the furgeon pro* 
 ceeds to the other flops of the operation. 
 
 In proceeding to finifli the operation, furgeons not 
 unfrequently open the urethra higher than it ought to 
 be cut, and pafs the knife into the fubftance of the 
 bulb itfelf. But this adds greatly to the hazard of the 
 operation : for, the blood veflels of the bulb are not 
 only large, but finufes are much more apt to form in 
 it than in other parts of the penis, by which the cure 
 of the wound is rendered much more tedious when 
 this part is divided ; and not being necellary, it ought 
 always to be avoided. When, therefore, the incifion 
 of the mufcles is finifhed, the operator ought to fearch 
 for the flaff with the index of his left hand ; and hav- 
 ing found it, he fliould pufh the point of his finger 
 along the courfe of it till he palTes the bulb, when, 
 with the edge of his knife turned towards the groove 
 of the rtalF, he fliould divide the membranous part of 
 the urethra in its whole courfe, from the bulb to the 
 proflate gland ; and the finger being thus ufed as a 
 dire£tor, while by means of it the redlum is complete- 
 ly guarded, this incifion of the urethra may be made 
 with entire fafety. There is in general, indeed, fuch 
 a quantity of cellular fubflance between the urethra 
 and redum, that in this part of the operation the gut 
 cannot poffibly be hurt, if the furgeon is not either 
 very unfleady or inattentive : and by means of the 
 precaution I have advifed, of keeping the forefinger 
 of the left hand always between the knife and the in- 
 tefline, it may in this manner be in every inftance very 
 certainly avoided. 
 
 The incifion of the urethra being finifhed, the prof- 
 tate gland, which we readily difcover with the finger 
 at the bottom of the wound, is next to be divided. 
 In the hands of an expert furgeon, the operation 
 might be finiflied with the fame fafety with the fcal- 
 pel as with any other inflrument : for, by continuing 
 
I9« Of the Stone, Chap. XXIX. 
 
 the inclfion of the urethra, and carrying on the fcal- 
 pel fo as to divide the proftate gland laterally, if the 
 finger is ftill continued between the knife and the rec- 
 tum, no rifk could enfue from it : but as this part of 
 the operation is performed entirely by feeling, without 
 the aflillance of the eyefight ; and as many operators 
 are not fo much accultomed to this, as, in fuch cir- 
 cumftances, to be fufficiently fteady, the redtum might 
 be often injured were the fcalpel to be commonly em- 
 ployed for completing the operation. 
 
 This inconvenience, however, of wounding the rec- 
 tum, may with certainty be avoided, by ufmg a cut- 
 ting director, or gorget, as it is termed, inftead of a 
 fcalpel : this alteration of the gorget was lirfl propof- 
 ed by Mr. Hawkins of London : in Plate LXXI. fig, 
 4. a view is given of this ; and in the fame Plate, and 
 likewife in Plates LXX. LXXII. and LIX. and LX. I 
 have delineated different improvements that have been 
 propofed upon this inftrument of Mr. Hawkins. 
 
 The gorget of Mr. Hawkins is contracted too much 
 at the cutting part of it, by which it does not divide 
 the proftate gland fufficiently. Were we to ufe a gor- 
 get much wider in the cutting part of it, the divifion 
 of the proftate gland might indeed be made extenfive 
 enough ; but it is not done by the gorget in common 
 ufe, fo that the divifion of this gland is commonly too 
 fmall, either for the extraction of a (tone, or even for 
 the introdudion of the forceps, without much lacera- 
 tion ; a circumftance that in every inftance fhould be 
 guarded againft. 
 
 The gorget in ordinary ufe, while it is too narrow 
 in the cutting part of it, is too wide behind ; a form 
 which the leaft reflection muft Ihew to be not only un- 
 neceffary but hurtful ; for, after the divifion of the 
 proftate gland, the only ufe of the gorget is to ferve 
 as a conductor to the forceps ; and as this purpofe is 
 anfwered equally well by a director that does not ex- 
 pand to near the extent of the gorget, it is obvioufly 
 improper to have this inftrument fo wide as it is com- 
 
Sed. VII. Of the Stone. 193 
 
 monly made. But farther, the impropriety of this 
 conftruction is ftill more evident, when we compare 
 the fize of the common gorget with the parts through 
 which it has to pafs : for it is obvious, that it mufl 
 greatly injure the urethra ; the back part of the inftru- 
 ment being fo wide and deep, as to render it impofli- 
 ble to pafs it, without much laceration. 
 
 The cutting diredor, Plate LXX. fig. 2. as well as 
 the gorget, Plate LXXI. fig. 2. will be found to pof- 
 fefs all the advantages of the common gorget, without 
 any of its inconveniencies : the cutting part of both 
 expands more than that of the common gorget, fo that 
 they divide the proilate gland more freely ; and as 
 the blunt part of them is much contracted, they do 
 not lacerate the urethra on being puflied forward. 
 To thofe who have never ufed thefe inftruments, and 
 who thereby may have a partiality for the common 
 gorget, thefe inltruments may perhaps appear not to 
 be Sufficiently wide for conducing the forceps : this, 
 however, is not the cafe ; and it will foon be found, 
 that they are not only more eafily introduced than the 
 common gorget, but that they anfwer equally well for 
 conducting cither the finger or forceps. 
 
 It has been objected to thefe inftruments, that they 
 will not make fuch a free divifion of the mufcles as is 
 done by the common gorget. This, however, pro- 
 ceeds from prejudice in favour of an inftrument with 
 which pratlitioners are as yet better acquainted, and 
 which has indeed been defer\^edly much employed ; 
 but it is thrown out without due refleftion on its im- 
 port. I have already endeavoured to inculcate the 
 neccflity of a free divifion of the teguments and muf- 
 cles in this operation ; but whoever confiders this 
 point with attention, will fee, that this ought to be 
 done with the fcalpel alone, and that it fhould not de- 
 pend in any degree upon the gorget : all that fhould 
 be left for the gorget or cutting direftor to do, is to 
 divide the proftate gland with a fmall portion of the 
 
 Vol. III. Q 
 
194 Of the Stone, Chap. XXIX* 
 
 neck of the bladder. Some practitioners, indeed, have 
 recommended inflruments for carrying the incifion in- 
 to the body of the bladder ; but this is a very hazard- 
 ous attempt, and not in any refped: neceflary : for as 
 foon as the proftate gland and neck of the bladder are 
 divided, the forceps are palied with eafe ; and ths 
 bladder itfelf is fo eafily dilated, that it readily yields 
 to the paiTage of the flone, however large it may be. 
 What I wifh to have underflood, is, that it is^not the 
 fize of the wound in the bladder that renders the ex- 
 tradion of flones eafy or difficult ; and that it is on 
 the previous incifion of the mufcles and proflate gland 
 that this almoft entirely depends. 
 
 The membranous part of the urethra being divided 
 by the fcalpel in the manner I have advifed, the nail 
 of the index of the left hand iliould be introduced in- 
 to the groove of the flaff, to ferve as a conductor to 
 the point or beak of the cutting director or gorget. 
 The furgeon having no further occafion for the fcal- 
 pel, muft now lay it afide ; and having paifed the 
 point of the director or gorget along his finger into 
 the groove of the flaff, he is now to take the handle 
 of that inflrument from the afTiftant, and having raif- 
 ed it from the groin of the patient in which it lay, he 
 mufl with his left hand preferve it firm in this fitua* 
 tion, while with his right he puflies on the cutting di- 
 rector or gorget till it has paffed freely into the blad- 
 der ; a point of the operation that he knows is accom* 
 plifhed when the urine is perceived to rufh with free* 
 dom out at the wound. In executing the firfl part of 
 the operation, the furgeon fhould be firmly feated j 
 but in pafling the gorget or diredor into the bladder^ 
 as likewife in extrading the flone, he fhould fland 
 immediately before the patient, as in this poflure thefg 
 fleps of it are more eafily performed. 
 
 It is a point, I may remark, of the firfl importance 
 in this operation, to raife the fta£f to a proper height 
 before pufliing on the gorget. The handle of the 
 ftafl' fhould form nearly, though not entirely, a right 
 
Sea. VII. Of the Stone, 195 
 
 angle with the body of the patient ; and if kept fuf- 
 ficiently firm in this pofition, the gorget or director 
 inay be puflied on with fafety, as the beak of the in- 
 ftrument, if this direction of the flaff is continued, can 
 fcarcely efcape from the groove in which it runs. But 
 if the elevation of the ftalf is either much more or lefs 
 than this when the gorget is puflied forward, the point 
 of the gorget, inflead of pafling into the bladder, mufl 
 be forced out of the groove, and pafTing between the 
 redum and bladder, or between the bladder and 
 pubes, it muft here do a great deal of harm. I have 
 known even expert furgeons, from an unpardonable 
 degree of inattention, fall into this error with regard to 
 the height of the flaff. Younger practitioners, there- 
 fore, cannot be too much on their guard againfl it. 
 
 Even the greatefl attention, however, to the eleva- 
 tion of the ftaff, will not of itfelf prove fuflicient. The 
 furgeon ought previoufly to fee that the director or 
 gorget is exa£lly fitted to the groove intended to re- 
 ceive it ; for if not properly adapted to each other, 
 the gorget will not run eafily, and may therefore be 
 very readily puflied out of the groove of the ftaff. 
 
 With the view of rendering this part of the opera- 
 tion fafe, different inventions have been propofed for 
 fixing the beak of the gorget in the groove of the 
 flaff, fo as to prevent it from getting out till it has 
 paded into the bladder : but all of thefe gives fome 
 difficulty in pafling the initrument ; and befides, they 
 do not appear to be neceffary, as no operator can pof- 
 fibly go wrong, but from grofs mifconduct or inatten- 
 tion. 
 
 As foon as the gorget has freely entered the blad- 
 der, the flaff fhould be withdrawn ; and this being 
 done, the next flep in common pradice is, to intro- 
 duce the forceps immediately ; but as the flone may 
 be frequently felt with the finger, and as no other 
 method ferves fo effectually to difcover its real fitua- 
 tion, this precaution of introducing the finger into the 
 o 2 
 
196 Of the StoiK, Chap. XXIX* 
 
 bladder ought never to be omitted. Ijttle additional 
 pain is given by the introduction of the finger, and if 
 the operator is lucky enough to difcover the ftone, he 
 is thereby inftruded \\\t\\ much certainty of the bed 
 direftion for the forceps. 
 
 The fituation of the ftone being in this manner dif- 
 covered, or if, upon trial, it is found that the fmger 
 will not reach it, forceps, proportioned to the fize of 
 the patient, are to be palled into the bladder along 
 with the gorget or director, while the latter is imme- 
 diately thereafter to be withdrawn. 
 
 In an operation of fuch importance as this, the niofl 
 trifling circumftance merits attention ; for the more 
 obvious and leading parts of it may be performed in 
 a mafterly manner, and yet the whole may fail from 
 want of attention to the lefs important Iteps of it. 
 Even the method of withdrawing the cutting director 
 or gorget, is a matter that requires attention ; much 
 more, hideed, than it commonly meets with. After 
 the forceps are introduced, the gorget fliould be flow- 
 !y withdrawn in the exa£t direftion by which it was 
 entered ; for if turned in any degree either to one 
 •fide or another, it muft neceflarily make another in- 
 cifion, not only in the proftate gland, but in ail the 
 ^ther parts through v/hich it is made to pafs ; the im- 
 propriety of which is too obvious to require further 
 animadverfion. 
 
 If the ftone has been previoufly difcovered by the 
 finger, it is commonly eafily laid hold of with the 
 forceps ; but when the finger has not been able to 
 reach it, it is in fome inftances with much difficulty 
 met with. The forceps muft neceiTarily be introduced 
 {hut, that is, with their blades as near to each other 
 as their form admits of j for, with a view to prevent 
 them from laying hold of the bladder, they fhould be 
 fo conftrufted as not to meet at any part except at 
 their axis, by at leaft the tenth part of an inch. But 
 as foon as they have entered the bladder, they fhould 
 be gradually opened ; and in this expanded ftate 
 
Sea. VII. Of the Sione. 197 
 
 fhould be eafily moved about, with their handles 
 fometimes depreffed and fometimes elevated, till the 
 ftone is difcovered, when it fhould as quickly as pof- 
 fible be laid hold of. It frequently, however, hap- 
 pens, even with expert furgeons, efpecially when the 
 ilone is fmall, that it is not readily difcovered by the 
 forceps. In fuch inflances, we fometimes meet with 
 it near to the fundus of the bladder j but it is mofl 
 frequently found concealed in the under and back 
 part of it, near to its neck, in that bag that I have 
 mentioned as being formed by the natural prefTure of 
 the urine. When it is difcovered in this fituation, 
 nothing will bring it fo readily into contact with the 
 forceps, as elevating this part of the bladder by in- 
 troducing the finger into the redum. 
 
 In general, flraight forceps, fuch as are reprcfented 
 in Plate LXXV. fig. i. and 2. are preferred to thofe 
 that are much crooked, delineated in fig. 3. For 
 they not only aft with more power in extrading the 
 ftone, but ferve equally well with the others for find- 
 ing it. Every operator, however, fhould be provided 
 with all the varieties of forceps now in ordinary ufe. 
 
 When the ftone is difticult to difcover, the furgeon 
 is apt to allege that it proceeds from its being con- 
 tained in fome preternatural bag or cyft ; and when 
 laid hold of with the forceps, and an unufual degree 
 of llrength is required to extrad it, this is commonly 
 faid to arife from the ftone adhering to the coats of 
 the bladder. That the weight of a ftone will fome- 
 times form a partial cavity for itfelf, by prefling that 
 part of the bladder on which it lies into the neigh- 
 bouring foft parts, there is no rcafon to doubt ; and 
 in fome inflances the bladder is found fo much con- 
 traded round a Hone, as to form almofl two diftind 
 bags. This, however, is rare ; and the adhefion of 
 ftones to the bladder, I believe to be flill lefs frequent, 
 if it ever takes place. Stones have indeed been fre- 
 quently found covered with the coagulable part of the 
 blood, which in fome inftances becomes fo firm and 
 
198 Of the Stone. Chap. XXIX. 
 
 tough, as to have the appearance of an organized 
 membrane ; but we are perfectly unacquainted with 
 any procefs of nature by which an adhefion can be 
 produced between the bladder and a ftone contained 
 in it. 
 
 It cannot pofTibly happen by any communication of 
 blood veiTels betwixt the bladder and ftone ; and it is 
 equally improbable that it can be produced merely 
 by agglutination ; for, by the intervention of the 
 urine, with which the bladdefis conftantly moiften- 
 ed, fuch an effed muft be with certainty prevented. 
 
 But it is not reafoning alone that militates againft 
 this opinion. For although fuch an occurrence has 
 been frequently mentioned by authors, yet we do not 
 meet with one authenticated inftance of any firm ad- 
 hefions betwixt the bladder and ftones contained in it 
 being difcovered after death. I am therefore led to 
 conclude, that this idea is entirely void of foundation ; 
 and that it has probably arifen from the mifconducl 
 of operators, who, by making the external incifion too 
 fmall, or not dividing the mufcles and proftate gland 
 fufficiently, have experienced much difficulty in ex- 
 trafting a ftone of even a moderate fize, and who, to 
 efcape cenfure, have fuggefted the poflibility of ftones 
 adhering to the internal coat of the bladder. 
 
 When the ftone is laid hold of with the forceps, 
 the operator, before he proceeds to extract it, ought 
 to introduce his finger into the bladder, in order to 
 difcover whether it is properly fixed in the forceps or 
 not. This in various inftances proves ufeful, for on 
 finding that a ftone of confiderable length is laid hold 
 of in fuch a manner as to have its longeft diameter 
 made to prefs in a tranfverfe diredlion with refpecl to 
 the opening in the bladder, much pain and laceration, 
 which would undoubtedly occur from extracting it in 
 this direction, may be eafily prevented, either by turn- 
 ing the ftone with the point of the finger, when this 
 can be done, or by letting it flip altogether out of the 
 forceps, and again endeavouring to lay hold of it in a 
 
Sea. VII. Of the Stone, 199 
 
 more favourable pofition. When the operator is cer- 
 tain that this is properly done, he is then to extract 
 the ftone in a very flow and gradual manner. The 
 forceps lliould be very firmly held in both hands, his 
 right being applied towards the extremity of the han- 
 dles, and his left near to their axis. 
 
 In common practice, if the ftone does not coma 
 readily away, the force made ufe of is applied fo as to 
 dilate the parts equally in every direction. The ftone 
 is made to move not only upwards and downwards, 
 but laterally ; and, by fome, even a rotatory motion 
 is given to it. Nothing, however, can be more de- 
 ftructive than this to the parts through which the ftone 
 muft pafs, while at the fame time it is evidently ill 
 calculated for facilitating the extradion. 
 
 Inftead of moving the ftone in this manner, the 
 prefTure ought to be made almoft entirely downwards ; 
 not directly from the fymphyfis of the pubes towards 
 the anus, but in the courfe of the external wound, 
 which ought, as I have already obferved, to run at an 
 equal diftance between the anus and tuberofity of the 
 ifchium. As it will be admitted, that the force em- 
 ployed in extracting a ftone muft prove more ufeful 
 when exerted upon parts that are foft and of a yield- 
 ing nature, than when applied immediately upon a 
 bone ; fo, whoever attentively confiders the anatomy 
 of the parts concerned in this operation, will fee the 
 propriety of the advice I have given. The opening 
 into the pelvis is at this place fo narrow, that a very 
 flight examination muft render it evident, that in ex- 
 tracting a ftone, no advantage can be derived from 
 lateral prelfure. If, again, the ftone is forced upwards, 
 it muft prefs againft the bones of the pubes ; for this 
 direction nothing intervenes between thefe bones and 
 it, except the urethra, and a fmall portion of cellular 
 fubftance : and if directed towards the anus, it mufl 
 prefs the redum againft the point of the coccyx, 
 which will not only give much immediate diftrefs, but 
 muft even add greatly to the hazard of the operation. 
 
200 Of the Stone, Chap. XXIX. 
 
 The rotatory motion which in this operation is 
 fometimes given to a ftone, unites all thefe difadvan- 
 tages ; but by can-ying the preflure downwards in the 
 courfe of the wound, fo as that it may fall between 
 the anus and ifchium, every inconvenience of this 
 kind is avoided, and a more extenfive dilatation is ob- 
 tained than can be procured in any other direction. 
 
 By gradual preflure in this direftion, the ftone, if 
 not uncommonly large, will for the moft part be ex- 
 tradled at laft ; but when, in the courfe of the extrac- 
 tion, the operator meets with much refiftance to the 
 ftone, he fhould examine the ftate of the divided 
 parts, and if any part of the mufcles that ought to 
 have been cut are ftill found entire, they fhould be 
 Immediately divided ; and the eafieft method of doing 
 it, is to fecure the ftone in the forceps with the left 
 hand, while with a fcalpel in the other, a complete, 
 divifion of the mufcles is accompliftied. 
 
 With a view to prevent the forceps from prefllng 
 fo much upon the ftone as might break it, fome pro- 
 pofah have been made for rendering the degree of 
 preflure fteady and certain. Of thefe the beft feems 
 to be what is reprefented in Plate LXXVI. fig. 3. in 
 which, as foon as the ftone is laid hold of, it is pre- 
 ferved in the fame pofition by means of a fcrew that 
 pafl'es from one of the handles of the forceps into the 
 other. This, however, I confider as a very unnecef- 
 fary addition to forceps ; for when a ftone is fmall, 
 no furgeon of experience will apply great force to exf 
 tra6l it ; and when of a large fize, it will be more for 
 the patient's advantage that it ftiould break than be 
 extracted entire. 
 
 I have fpoken already of the hazard arifmg from 
 the extraftion of large ftones. It is indeed fo confid- 
 erable, as to warrant this conclufion, that, casteris pa- 
 ribus, the hazard attending lithotomy may be confid- 
 ered as correfponding to the fize of the ftone to be 
 extracted. In healthy fubjefts, when the ftone is 
 fmall, and the operation properly performed, fcarcely 
 
Sea. VIT. Of the Strme. 20l 
 
 one in twenty die ; but although a few have recover- 
 ed from whom flones of a large fize have been taken, 
 yet whenever the flone has exceeded feven or eight 
 ounces in weight, not above one in ten recover. 
 
 This is accordingly a very important circumftance, 
 and worthy of our mofl ferious attention ; and although 
 the breaking of a ftone in the courfe of extraction, is 
 in other refpefts difagreeable, yet, with a view to ob- 
 viate the dreadful confequences of tearing out a large 
 ftone, when in the courfe of an operation it is found 
 to be uncommonly large, and that it cannot be taken, 
 out but with much hazard to the patient, might it not 
 be more eligible, either to endeavour to break it with 
 the forceps already introduced, or to withdraw thefe, 
 and to introduce others more fit for the purpofe ? In 
 Plate LX XVIII. fig. i. is delineated forceps of this 
 kind, originally invented by Andreas a Cruce, and 
 fmce improved by Le Clat and others : by means of 
 the long and ftrong teeth with which they are fur- 
 niflied, and efpecially by the intervention of the fcrew 
 for comprefiing their handles, almoft any ftone may 
 be broken into fmall pieces ; and this being effefted, 
 the diiierent pieces fall to be extracted with common 
 forceps. 
 
 In fuch circum fiances, however, or when a ftone has 
 broken by accident in the courfe of an operation, the 
 utmoft care is neceffary in order to extract every frag- 
 ment ; for, if the fmalleft particle is left, if it be not 
 afterwards waflied oft" with the urine, it may prove 
 highly detrimental, by ferving as a nucleus for the 
 formation of another ftone. After all the larger pie- 
 ces have been extracted with the forceps, a fcoop re- 
 prefented in Plate LXXVIII. fig. 2. proves fometimcs 
 ufeful for taking out the fmaller particles ; but for this 
 laft purpofe, nothing anfwers fo well as injefting large 
 quantities of tepid water into the bladder, either with 
 a fyringe or bag and pipe. This may be done with 
 ejitire fafety, and it commonly anfwers the purpofe fpr 
 which it is employed. 
 
202 Of the Stone. Chap. XXIX. 
 
 When a ftone is found to have a fmooth polifhed 
 furface, it is the common opinion that others muft re- 
 main in the bladder, as this fmoothnefs is fiippofed to 
 arife from the friclion of other ftones ; while a rough 
 unequal furface is fuppofcd to denote the exiftence of 
 one (tone only. No dependence, however, fhould be 
 placed on thefe circumftances ; for we daily meet with 
 inftances of a finglc {iowo. with a fmooth furface ; and 
 of ftones that are rough and unequal leaving more than 
 one in the bladder. As foon, therefore, as one ftone 
 is extracted, the operator, inftead of trufting to exter- 
 nal appearances, fhould firft fearch the wound with 
 his fijiger, as far as it will reach, and then, either with 
 common forceps, or with the thick cui-ved inftrument 
 reprefented in Plate LXXII. fig. i. which may be term- 
 ed a fearcher, and which anfwers the purpofe better ; 
 and as long as any ftones are difcovered, the forceps 
 ihould be repeatedly introduced till the whole are tak- 
 en out. 
 
 In the courfe of this operation, fome blood veflels, 
 as I have already obferved, are unavoidably divided ; 
 but when the incifion is kept fufficiently low in the 
 perinseum, and when therefore the bulb of the urethra 
 is avoided, there is feldom much rilk to be dreaded 
 from any hemorrhagy that enfues. It fometimes, 
 however, happens, that thofe branches of the internal 
 iliac artery that fupply the parts lying anterior to the 
 proflate gland, are fo confiderable, as to pour out a 
 good deal of blood : but as a free difcharge during 
 the operation is the beft preventive of inflammation, a 
 fymptom more to be dreaded than any other arifmg 
 from Hthotomy, nothing in general ihould be done, 
 except in very weak habits of body, to put a ftop to 
 the hemorrhagy till all the ftones are extracted ; when, 
 if it ftill continues, any artery that appears fhould be 
 fecured with a lisjature ; and if the external incifion 
 has been made large in the manner I have advifed, 
 this part of the operation does not prove fo difficult 
 as is commonly imagined. In different inftances, I 
 
Sea. VII. Of the Stone. 203 
 
 have palled a ligature upon an artery almoft as deep 
 as the proftate gland ; and when a large veffel has 
 been cut, the advantage derived from this efteftual 
 method of fecuring it, is of itfelf a very important ar- 
 gument for making the external incifion in every in- 
 ftance free and extenfive. 
 
 When, however, the divided veffel cannot be fecur- 
 ed with a ligature, we are then to endeavour to flop 
 the hemorrhagy by preffure ; and for this purpofe a 
 firm roller introduced at the wound would commonly 
 anfwer ; but in order to avoid any flop to the flow of 
 urine, inflead of a folid roller, a filver canula covered 
 with foft linen may be employed. Of this inflrument 
 I have given a reprefentation in Plate LXXVllI. fig. 3. 
 
 Not\\'ithflanding, however, of every precaution, 
 fome of the deep feated arteries, divided in the opera- 
 tion, continue fometimes to pour out a great deal of 
 blood, and which, inflead of palling off by the wound, 
 is, in fome inllances, colle6led in great quantities in 
 the cavity of the bladder. As foon as this is perceiv- 
 ed, means fliould be employed for removing the blood ; 
 and the mofl eifeftual are, to extract as much of it as 
 poffible, by a proper ufe of a fcoop, Plate LXXVIII. 
 fig. 2. and afterwards by injefting warm water at the 
 wound, to wadi off the remainder. In this manner 
 very large colleclions of blood may be removed ; and 
 when, as has fometimes happened, means of this kind 
 have not been employed, the coagulum has at lafl be- 
 come fo firm, and has filled the cavity of the bladder 
 fo much, as to prevent entirely all further depofition 
 of urine. In this cafe the belly becomes pained and 
 fwelled ; fever takes place j and death itfelf very com- 
 monly fucceeds. 
 
 With a viev/ to prevent this unfortunate iffue with 
 as much certainty as poliible, every patient fliould, 
 iunnediatcly after the operation, be laid in fuch a pof- 
 ture as may v/ith moll certainty tend to difcharge any 
 blood that may fail into the bladder. Inflead of lay- 
 ing the head low, and the buttocks high, as is com- 
 
204 Of the Stone. Chap. XXir. 
 
 monly done, the pelvis fhould be lower than the rcfl 
 of the body ; by which the wound is kept in a depend- 
 ing poilure, which ferves to allifl the diicharge of any 
 blood that the arteries may pour out. As foon as the 
 flow of blood is flopped, the patient ihould be untied, 
 and a piece of foft lint being infertcd between the lips 
 of the wound, the thighs fhould be laid together, in 
 which pofition he fliould be carried to bed ; and an 
 opiate being given, he fhould for fome time be left en- 
 tirely to the charge of an experienced nurfe. No 
 drefling anlwers fo well as dry lint ; for as the urine 
 is conflantly pafTmg off by the wound, and as the parts 
 are thereby kept wet, which makes them apt to fret, 
 a frequent renewal of drefTmgs becomes neceffary ; 
 and nothing is either more eafily appHed or removed 
 than a piece of diy lint. 
 
 When the flone has not been difficult to extract, 
 the patient generally remains free from much pain j 
 and he frequently falls into reft, and fleeps during the 
 firft three or four hours after the operation : but when 
 the ftone is large, and much violence has been done 
 to the parts in taking it out, fevere pain in the under 
 part of the belly often fupervenes in the fpace of an 
 hour or two from the operation ; and it commonly 
 proves, when not fpeedily removed, to be one of the 
 moft alarming fymptoms that takes place. When 
 merely fpafmodic, ho\vever, which in fome inftances 
 appears to be the cafe, it is commonly foon removed 
 by the ufe of warm fomentations to the belly, or by 
 emollient anodyne injedions thrown into the redum. 
 
 When by the ufe of thefe remedies, the pain is found 
 to abate, little or no anxiety need be entertained on 
 account of it ; but when, inftead of becoming lefs vi- 
 olent, it proceeds to increafe, and efpecially when the 
 belly becomes hard and tumefied, and the pulfe full 
 and quick, much danger is to be dreaded. As thefe 
 fymptoms almofc conftantly proceed from inflamma- 
 tion, blood fliould be taken in quantities proportioned 
 to their violejice ; emollient injections fliould be con- 
 
Sea. Vri. Of the Sion.\ 205 
 
 tinued ; and If the local application of heat to the ab- 
 domen, either by warm flannels, or by warm water 
 contained in a bladder, does not anfwer, the patient 
 fhould be immediately put into a femicupium. In. 
 fuch circumllances, indeed, I have experienced more 
 advantage from this than from any other remedy ; for 
 it not only conveys the heat more diredly and more 
 fully to the parts affedted, but a free difcharge of urine 
 by the wound is alfo more commonly procured by it 
 than in any other manner, fo that much relief is often 
 obtained from it. 
 
 A due perfeverance in thefe means, with a proper 
 life of opiates, a low diet, and a free ufe of diluent 
 drinks, will frequently remove very alarming fymp- 
 toms. But, in fome inftances, all our efforts prove 
 fruitlefs : the pain and tenfion of the abdomen con- 
 tinue to increai'e ; the wound, inftead of putting on a 
 florid, healthy appearance, remains floughy and pale, 
 which feldom fails to precede the moft alarming fymp- 
 toms ; the pulfe becomes quick and feeble, and death 
 clofes the fcene. But, w^hen matters terminate happi- 
 ly, the wound by degrees becomes red and of a heal- 
 thy afpeft : the urine, in fome infl:ances, pafl'es by the 
 urethra from the firft ; but in moft cafes it comes 
 away by the wound for the firft two or three weeks : 
 the pain in the belly gradually abates ; and any fynip- 
 toms of fever which prevailed at firft, are in a fhort 
 time entirely removed. 
 
 The period at which a complete cure of the wound 
 is accompliflied, is exceedingly various, and depends 
 on the health of the patient : in fome few cafes of 
 young healthy boys, I have known it completely cica- 
 trifed in lefs than three wrecks ; but in others, not till 
 the fixth, feventli, or eighth week. In fome inftan- 
 ces, again, although a great part of the fore may heal 
 rapidly, yet a fmall opening will remain, at which the 
 urine continues to be difcharged, and, the edges be- 
 coming callous, a real fiftula is produced, that cannot 
 be cured but by another operation j the manner of 
 
2o6 Of the Sionc, Chap. XXIX. 
 
 performing which I fliall prefently have occafion to 
 mention. Indeed the prevention of fiftulous openings 
 depends much on proper attention in drefling the 
 wound. If care is taken to introduce the Hnt fuffi- 
 ciently within the hps of the wound, till granulations 
 fill it up at bottom, there will feldom be any rifk of 
 fiftulous fores. The wound ought not, however, to 
 be crammed, either with lint or any other drcfling ; 
 for in this cafe the edges muft either inflame, or ac- 
 quire a morbid hardnefs. In other refpects, the treat- 
 ment fliould be nearly fuch as is known to anfwer in 
 fimilar wounds in other parts. It is proper, however, 
 to obferve, that nothing removes that excoriation of 
 the buttocks with fuch certainty, which fometimes 
 proves troublefome after this operation, from their be- 
 ing kept conftantly wet with the urine, as frequent 
 bathing with brandy or lime water. 
 
 Where the confiitution is enfeebled, incontinence 
 of urine is apt to fucceed to this operation ; for the 
 removal of which nothing proves fuccefsful till a re- 
 covery of ftrength has taken place. A light invigo- 
 rating diet, together with the ufe of the cold bath and 
 Peruvian bark, are therefore our principal remedies. 
 But, in order to obviate the immediate difagreeable 
 effect of a conftant difcharge of urine, different inftru- 
 ments have been invented. Some of thefe have in 
 view the compreflion of the penis, in order to prevent 
 the urine from being difcharged ; and others, while 
 they are fo formed as to be concealed within the pa- 
 tient's breeches, are meant to ferve as receptacles for 
 the urine on its paffing from the urethra. 
 
 In Plate LXXVII. fig. i. is reprefented the moft I 
 convenient form of the firft of thefe ; and in fig. 2. 
 of the fame Plate, as well as in Plate LV. fig. 2. are 
 delineated receivers, which by experience have been 
 found to anfwer the purpoie of the latter both with 
 cafe and certainty ; and they may alfo be ufed in all 
 cafes of incontinence of urine, whethei- arifing front 
 this operation or any other caufe. 
 
Sea. Vn. Of ihc Stotie. 207 
 
 While from the fliortnefs of the urethra In women, 
 they are lefs liable to the ftcne than men, the opera- 
 tion of lithotomy with refped: to them, is, on the fame 
 account, much more fnnplc, and of courfe more eafily 
 performed, and accompanied with lefs hazard. It can- 
 not be done by cutting from the perina^um, in the 
 fame manner as in male fubjefts ; for, as the urethra 
 and bladder lie immediately above the vagina, any 
 opening made into them from the perlnteum, would 
 pafs through the vagina, fo as to wound it both above 
 and below. There is no necefiity, however, for hurt- 
 ing the vagina, as the urethra may be divided from 
 one end to the other, without any rifk of touching it. 
 
 The patient being placed upon a table, and fecured 
 in the manner I have already advifed for male fubjects, 
 a grooved ftaff, fuch as is reprefented in Plate LXX. 
 fig. 5. is to be introduced into the bladder, by paiTmg 
 it along the urethra, which lies between the nympha;, 
 immediately below the clitoris ; and the operator, 
 keeping the flaff firm with his left hand, mufl: with his 
 right introduce the beak of the cutting dIre£tor, fig. i. 
 of the fame Plate, or of the gorget, fig. 2. Plate LXXI. 
 into the groove, and then pulli it eafily along till it has 
 fairly entered the bladder. The fl:aff is now to be 
 withdrawn, when the operator, as in male fubjects, 
 fhould introduce his finger along the direftor ; and. 
 having difcovered a ftone, fliould proceed to extra<^ 
 it in the manner I have already advifed. 
 
 By the old method of cutting in females, namely, 
 with the greater apparatus, no inclfion was made into 
 the urethra, but different inft:ruments were ufed for 
 dilating it ; and this being done, the forceps were em- 
 ployed for extrading the Itonc. In this manner, how- 
 ever, the parts were much lacerated ; the patient fuf- 
 fered a great deal of unneceffary pain, and the blad- 
 der was commonly deprived of all power of retention. 
 I have therefore no helitation in giving a preference to 
 the method of operating that I have pointed out, in 
 
2o8 Of the ^ione. Cliap. XXIX. 
 
 which the urethra is cut through its whole length, in- 
 jflead of being lacerated or torn. 
 
 As the bladder in females lies immediately above, 
 and quite contiguous to, the vagina, it has been pro- 
 pofed, that, inllead of laying open the urethra, as I 
 have advifed, an opening fliould be made directly into 
 the bladder from the vagina, at which the forceps are 
 to be introduced for extrading the (tone. One cafe 
 of this kind is recorded by BulFiere ;* and, more late- 
 ly, other three are related by the late Mr. Gooch, in 
 which this method of extraftion was fuccefsfully em- 
 ployed.! It has never, however, been generally 
 adopted ; and as various objections occur to it, I do 
 not fuppofe that it will ever be frequently praO:ifed. 
 
 By cutting into the bladder through the vagina, 
 parts are injured, which by the other method are 
 avoided : the ftone, when it does not lie diredtly up- 
 on the vagina, is with difficulty laid hold of ; it can- 
 not be fo eafily extracted as when drawn along the 
 courfe of the urethra ; fiflulous openings mufl proba- 
 bly occur more frequently after this method of oper- 
 ating than after the other ; and if the woman Ihould 
 afterwards become pregnant, the cicatrix formed in 
 the vagina would produce pain, obftruction, and per- 
 haps laceration in the time of delivery. 
 
 One great advantage derived from the lateral oper- 
 ation, in its prefent improved ftate, both in males and 
 females, is, that no laceration takes place if the ftone 
 be not remarkably large ; in which cafe, no precau- 
 tion can altogether prevent it : but, in a great propor-j 
 tion of cafes, if the parts are freely divided in the] 
 manner I have advifed, all the rifk attending lacera*i 
 tion, and which I have endeavoured to point out as 
 the mod hazardous part of this operation, is avoided 
 with certainty. 
 
 * Philofopliical Tranfadtiona for the year 1669, p. 106. 
 
 t Vide Cafes and Remark* ia Surgery, volume ii. p. 182, by Benjamiu 
 Gooch. 
 
Sed. VII. Of the Stone, 409 
 
 I have thus defcribed the various means which 
 hitherto have been employed by praditioners, for ex* 
 trading ftones from the bladder ; and from what has 
 been faid, it appears, that the lateral operation is, in 
 ordinary cafes, greatly preferable to every other. It 
 ftands indeed fo eminently fuperior to the others for 
 general ufe, that it does not appear neccffary to draw 
 any farther comparifon between them ; but, as I have 
 already obferved, particular cafes fometimes occur, ill 
 which the high operation may with propriety be em- 
 ployed inftead of it : I have already in ftrong terms 
 pointed out the rifk of extrading a large flone by the 
 lateral operation ; and T have Ihown, that ftones of 
 any magnitude that the bladder can contain, may be 
 taken out by the high operation. When, therefore, 
 it is with tolerable certainty known, that a ftone is 
 imcommonly large, and when the high operation is in 
 other refpeds admiflible, it ought certainly in every 
 fuch inftance to be preferred : for although where 
 ftones are large it may be better to break them into 
 fmall pieces in the manner I have advifed, than to 
 lacerate the parts by taking them out entire ; yet the 
 pradice is only proper when the operator unexped- 
 edly meets with a large ftone after the bladder has 
 been cut into ; fo that wherever it is previoufly known 
 that a ftone is large, much advantage may be derived 
 from a judicious choice, on the part of the operator, 
 of his method of operating. 
 
 In the diredions that I have given for performing 
 the lateral operation, the didates of experience are 
 ftridly adhered to, and I have recommended nothing 
 that is not either at prefent very generally adopted, 
 or that I have not myfelf put in pradice. 
 
 Many propofals have been made by individuals for 
 the improvenient of the operation of lithotomy, par- 
 ticularly of the lateral method of performing it ; but 
 a minute detail of all that has been fuggefted upon 
 the fubjed, is incompatible Vvith the nature of this 
 
 Vol. III. P 
 
2IO Of the ^ lone. Chap. XXIX, 
 
 work ; nor could it ferve any pUrpofe, but to bring 
 into view fome particular modes of pradice, which 
 were either never generally followed, or which, if 
 adopted, have fallen again into difufe. 
 
 The moft remarkable of thefe propofed improve- 
 ments of the lateral operation, are thofe of three French 
 furgeons, Monfieur Foubert, Monfieur Thomas, and 
 Frere Cofme. The two firft, invented inflruments 
 for penetrating the body of the bladder, without 
 wounding the urethra. The bladder beincj diftended 
 with urine, and an incifion made through the fkin and 
 cellular fubftance, a cutting inftrument of a particular 
 conftruction is then puflied pad the urethra into the 
 fide of the bladder ; and an opening being made of a 
 fufficient fize, the ftone is extracted in the ufual man- 
 ner. One material advantage expefted from this is, 
 that by the urethra and proftate gland being avoided, 
 that inability to retain the urin^e, and other trouble- 
 fome confequences, which fometimes enfue from in- 
 juries done to thefe parts, are not fo apt to occur 
 when the body of the bladder alone is wounded. But, 
 independent of other objections to which this method 
 of operating is Hable, the wound in the bladder being 
 fure to recede froni the wound in the teguments as 
 foon as all the water contained in it is difcharged, will 
 probably prevent it from being ever adopted ; for the 
 urine, not finding a free paffage by the wound, muft 
 pafs into the contiguous parts, where it mufl always 
 excite very diftrefsful confequences. 
 
 So that although this method of cutting directly 
 into the neck or body of the bladder, is at firft viewj 
 extremely plaufible, yet the leaft reflection on the con- 
 fequences that it would excite, muft at once bring 
 conviction of the rifk that would refult from it. 
 
 The operation of Frere Cofme is, in efte(ft, the 
 {fame with the lateral operation, as it is now common- 
 ly pradtifed. The parts that are cut in it are exactly 
 the fame, only they are divided in a different manner, 
 'After the ftaff is laid hare in the ufual manner, the 
 
Sea. VII. Of the Sme. Sii 
 
 beak of the inftrument, fig. i. Plate LXXVI. is Intro- 
 duced into the groove ; and being puflied forward till 
 it reaches the bladder, the fpring E is then prelTed 
 down, fo as to raife the knife from its fheath, when 
 the operation is finifhed by withdrawing the inftru- 
 ment in fuch a direction as may divide the neck of 
 the bladder and proftate gland, in the fame manner as 
 is done by the common gorget : after this, the other 
 fteps of the operation are to be completed, in the 
 manner direfted above with forceps. 
 
 Mofl of the other deviations from the eftablifhed 
 mode of pradice, hitherto propofed by furgeons, con- 
 fift, either in feme improvements of the cutting gor- 
 get of Mr. Hawkins, or in a preference which fome 
 pra6litioners Itill continue to give to the knife. I have 
 already obfcrved, that Mr. Hawkins* gorget does not 
 fpread fujBiciently at the cutting part of it, and that it 
 is wider and deeper behind than it ought to be, by 
 which it is liable to tear and otherwife injure the ure- 
 thra more than is neceffary. This inconvenience, 
 however, is removed by the cutting director that I 
 have ventured to recommend, as delineated in Plate 
 LXX. and in a great degree by the gorget, fig. i. and 
 2. Plate LXXI. 
 
 In regard to the preference given by fome to thq 
 fcalpel, not only to the diredor, but to the cutting 
 gorget, I have only to obferve, that an expert furgeon 
 of fteadinefs, and pofl'efling a minute knowledge of the. 
 anatomy of the parts, may with eafc and fafety per- 
 form the operation with the knife alone ; but I mufl 
 alfo remark, that, when the fcalpel only is employed, 
 the danger of wounding the reftum would in common 
 pradice be very great, fo that the gorget or cutting 
 direftor, by either of which the gut is completely de- 
 tended, ought to be commonly preferred. 
 
 In the courfe of this fe6tion, I have endeavoured to 
 deliver all that is worth recording of modern pradice 
 in the operation of lithotomy : I am not confcious of 
 p 2 
 
212 Of the ^mc. Chap. XXIX. 
 
 having omitted any improvements of importance ; and 
 I hope it will appear that I have propofed fome that 
 are not generally l^nown, or which, if known, are not 
 commonly praclifed. 
 
 The operation of lithotomy being one of the' mofl 
 important in the department of furgery, I have been 
 induced to extend this fection to a great length : it 
 may therefore prove acceptable, to ftudents efpecially, 
 to have fuch circumftances enumerated in a more 
 concife manner, as particularly merit their attention, 
 
 1. I have already in ftrong terms pointed out the 
 propriety of an abfolute certainty being attained, of 
 a ftone exifting in the bladder, before the operation 
 of lithotomy is propofed : and I have endeavoured to 
 fhow, that no fymptoms, hov.ever ftrongly marked, 
 afford fufficient evidence of the prefence of calculus ; 
 the operation of founding, or touching the ftone with 
 a ftaff, being the only certain means we have of judg- 
 ing of its exiftence. 
 
 2. Before proceeding to the operation, a confider- 
 able quantity of urine fliould be allowed to collect in 
 the bladder ; the reftum fliould be emptied by an in- 
 jection, and the buttocks fliould be raifed above the 
 reft of the body : the external incifion fliould be more 
 extenfive than is commonly advifed. In full grown 
 adults, inftead of the.ufual length of an inch and half, 
 or two inches, it fliould be at leaft three inches and a 
 half long ; care being taken to commence the cut at 
 the inferior edge of the pubes, and to continue it in 
 an oblique diredion, till it has pafled the anus, at an 
 equal diftance between the end of the reftum and the 
 tuberofity of the ifchium. 
 
 3. As the chief refiftance to the extraction of the 
 ftone, proceeds moft commonly from the mufcles 
 covering the urethra, thefe ought to be freely divided : 
 no danger can enfue from this, and much advantage 
 is derived from it. 
 
 4. But, although a free divifion of the mufcles is 
 of much importance, there is no neceflity for cutting 
 
Sea. VIL Of the Stone, 213 
 
 fo much of the urethra as is commonly done : it does 
 not facilitate the extraftion of the ftone, and it makes 
 the operation more hazardous than v hen the mem- 
 branous part of it only is divided. The incifion be- 
 ing carried through the teguments and mufcles, fo as 
 to leave the ftaff covered by the urethra only, the op- 
 erator fhould infert the index and middle finger of his 
 left hand into the bottom of the wound, by which 
 means the redum is completely protefted ; and this 
 being done, an opening fliould be made in the urethra 
 with the point of the fcalpel, very near to the prollate 
 gland, from whence the incifion fhould be extended 
 upwards to the bulb, but no farther. This, I may re- 
 mark, fhould be done by one flroke of the knife, and 
 Jiot by repeated incifions, as is commonly done ; for 
 iby this means a rugged unequal wound is produced. 
 In the firft part of the operation, the edge of the knife 
 fhould be applied in fuch a manner as to cut from 
 above downwards, as in this manner the incifion is 
 accomplifhed both with eafe and fafety ; but in divid- 
 ing the urethra, the back of the knife ought to be 
 turned down, while the edge of it penetrates the ure- 
 thra, and runs along the fulcus of the flaff. In this 
 manner we cannot polfibly hurt the redum ; which is 
 too frequently done in the ufual method of perform- 
 ing this part of the operation. 
 
 5. We have now to divide the proflate gland, with 
 a fmall portion of the neck of the bladder. This, I 
 have obferved, may be done with eafe and fafety, 
 with the fcalpel alone, by a good anatomift, accuftom- 
 ed to operate and whofe hand is perfedly fteady ; but 
 as the proflate gland mufl be divided in fuch a direc- 
 tion as to avoid the rectum, with which it is conned- 
 ed behind, and likewife the excretory dufts of the ve- 
 ficula; feminales which terminate here, much accura- 
 cy is required to get it accomplifhed, and it can only 
 be done with fafety to thefe parts by a lateral cut 
 through this gland. A very fmall variation in the 
 
214 Of the Stone. Chap. XXIX. 
 
 direction of the fcalpel, might be produclive of much 
 danger ; and few praditiontrs being pofl'efl'ed of fuch 
 equal fleadinefs as the certain prevention of this re- 
 quires, a knife conftrudted in fuch a manner as to 
 protect the rectum, at the fame time that it divides 
 the proftate gland properly, ought certainly to be pre^ 
 ferred. The gorget of Mr. Hawkins is polfefled of 
 all thefe advantages ; but I have likewife fhown, that 
 it is attended with fome difadvantages. Thefe, how- 
 ever, are obviated by the cutting direftor that I have 
 defcribed, as well as by the gorget, Plate LXXI. fig, 
 1. and 2. which make a more clean and ample cut 
 than the common gorget, at the fame time that they 
 do not tear the urethra, as is done by the gorget of 
 Mr. Hawkins, from its expanding too much behind. 
 
 6. After the ftone is laid hold of with the forcepSj^ 
 it Ihould be extracted flowly ; not by a rotatory mo- 
 tion, or by prefTure applied equally in ajl directions ; 
 but by endeavouring to ftretch the parts along the 
 courfe of the wound, in a line diredly between the 
 anus and tuberofity of the ifchium. Moderate lateral 
 preffure may likewife have fome influence ; but no 
 force fhould ever be applied towards the upper part 
 of the wound ; for nothing can be gained by doing 
 fo, and it muff always do harm, by preffing the ure- 
 thra againft the pubes. When, in the courfe of ex- 
 traction, it is found, that the paflage of the ftone is 
 impeded by fome of the mufcles not being freely di- 
 vided, this ought ftill to be done, by the operator 
 keeping the ftone firm in the forceps with one hand, 
 while with a fcalpel in the other, he cuts what is ne- 
 ceflary ; or, the forceps may be held by an affiftant, 
 while this additional cut is going on. 
 
 7. The ftone being extradted, foft dreflings fhould 
 be applied to the wound ; and the patient fhould be 
 laid in bed, with his head and upper part of his body 
 raifed higher than the pelvis, fo that any blood pour- 
 ed out from the wound, may be freely difcharged, in* 
 
Sea. VIII. Of the Stone, 2 1 $ 
 
 (lead of lodging In the bladder, which otherwife It 
 might do. 
 
 Having thus enumerated fuch points in this opera- 
 tion as particularly merit attention, I (hall now pro- 
 ceed to confider the operation of nephrotomy. 
 
 SECTION VIII. 
 Of Nepbrotoniy, 
 
 WHEN flones are impafled In the kidneys, fo 
 that they cannot pafs off with the urine, they 
 give rife to a train of very diftrefsful fymptoms, which 
 at laft almofl: conftantly terminate in the death of the 
 patient. 
 
 The feverity of the pain is frequently indeed fo great, 
 as to have induced practitioners to fuggcft an operation 
 for extracting the {tones. This conlifts in a cut made 
 through the common teguments and mufcles, imme- 
 diately above the kidney, with an opening into the 
 kidney itfelf, of a fufficient fize to afford a free paffage 
 for gi flone of an ordinary fize. 
 
 But we are to remember, that, however marked the 
 fymptoms of ftone in the kidney may appear to be, 
 that it is impoffible to judge of it with precifion. We 
 know that ftone in the kidney occafions pain in the 
 region of the kidney, together with ficknefs and vom- 
 iting, and a difcharge of urine, fometimes mixed with 
 blood, at other times with mucus, and in fome inftan- 
 ces with purulent matter. We alfo know, however, 
 that the fame fymptoms are not unfrequently induced 
 by other caufes, particularly by inflammation and con- 
 fequent fuppuration of the kidney. Many inftances, 
 indeed, have occurred of the moft: violent nephritic 
 fymptoms fubfifting for a great length of time, where 
 ftones were fufpeded as the caufe ; but where the kid- 
 ney has been found, on diffedion, to be completely 
 
5 1 6 Of the Stone, Chap. XXIX. 
 
 fuppurated, and as it were entirely difiblved, a quan- 
 tity of purulent matter being all that it contained ; 
 feveral cafes of which have fallen within my own ob- 
 fervation. 
 
 Even in calculus of the bladder, a difeafe lefs am- 
 biguous than nephritis calculofa, the fymptoms are 
 never fo diftincl and cbarafteriftic as to render the op- 
 eration of lithoton-y advifable, if a ft one be not dif- 
 covered by the found. But in difeafes of the kidney 
 fufpeclcd to proceed from flone, we are deprived of 
 this means of diflindion ; fo that it might not unfre- 
 quently happen, that, after laying the kidney open, no 
 ftone would be found. This is, therefore, a very im- 
 portant objedtion to the operation in queftion. 
 
 But it is to be farther obferved, that the kidneys lie 
 at a great depth : although not entirely covered by 
 the inferior falfe ribs, yet that thefe ribs proje6t fo 
 much over them, as to itand much in the way of an 
 operation ; and that, in corpulent people, the kidneys 
 are fcarcely acceflible. 
 
 Hence, it is impoflible t(3 make an opening into the 
 kidney with fo much accuracy and precifion, as the 
 near Contiguity of the neighbouring large blood vef- 
 fels would require ; and whoever attempts the opera, 
 tion of nephrotomy, even on the dead body, will find 
 it difficult, or perhaps impoffible, to cut into the pel- 
 vis of the kidney, without opening fome of the large 
 blood veflels that belong to it : the great and imme- 
 diate danger from fuch an occurrence, is too obvious 
 to require to be farther mentioned. 
 
 When, indeed, the inflammation induced by a ftone 
 in the kidney, terminates in an abfcefs, and when the 
 matter thus collecled forms a tumor in which a fluc^ 
 tuation is diflinguifhed, little or no danger can enfue 
 from laying it open : and in fuch an event, the ftone 
 that produced the tumor will either be difcharged 
 along with the matter ; or it may, if it can be lai4 
 hold of, be afterwards taken out with fafety^ 
 
Sea. IX. Of the Stone. 217 
 
 The ftone being thus taken out, the opening through 
 which it paffcd, if the patient recovers, will either heal 
 by the ufual means employed for abfcefles in other 
 parts ; or the mod unfavourable termination that can 
 probably happen, will be a fiftulous fore, through which 
 a mixture of pus and urine will continue to be dif- 
 charged. 
 
 Upon the whole, we may therefore conclude, that 
 when not direded by the appearance of a tumor to 
 the part that ought to be opened, the uncertainty of 
 the ground upon which we proceed when we under- 
 take this operation ; the difficulty of performing it ; 
 and the very imminent danger that attends it, will 
 more than counterbalance any advantage that can be 
 derived from it ; fo that the operation of nephrotomy 
 will never probably be received into general pradice, 
 however much it may be recommended by fome, who, 
 in order to raife a reputation which they might not 
 otherwife obtain, will fometimes ftcp forward and pro-" 
 pofe with confidence what no pradlitioner of character 
 would think right to attempt.* 
 
 SECTION IX. 
 Of Stones in the Urethra. 
 
 PATIENTS liable to calculous complaints frequent- 
 ly pafs fmall ftones with their urine. When 
 thefe ftones are fmooth and not very large, they ufu- 
 ally come off with little difficulty ; and in fome cafes 
 flones even of a confiderable fize are paffed without 
 exciting much pain. But when an angular or rough 
 
 * For further information on the fub'ieifl of nephrotomy, fee Rofletut 
 de Partu C.-vfarco, cap. vii. fcift. 4. Philofophical TranfaAions for the year 
 1696. Schcnklus Obfcrvat. Med. lib. iii. Juncker's Confpetfl. Chirurg. tab. 
 93. Edinburgh Medical Eflays. Memoires de I'Academie Royalc de 
 tUirurgie dc Paris. And Mcry's Obfervativni fur la Maniere de Tailler, 
 
2i8 Of the Stone. Chap. XXIX. 
 
 ftone is pufhed into ihc urethra, if not fo fmall as to 
 pals otF with the hrll flow of urine, it never fails to 
 create a great deal of diflrefs. 
 
 Pain is the firll fyniptom produced by a ftone lodg- 
 ed in the urethra ; and to this fucceeds inflammation, 
 tumefaction of the parts, and always a partial and fre- 
 quently a total fuppreiTion of urine. In fome inftan- 
 ces, when a ftone in this fituation is long neglected, 
 this fuppreflion and confequent tumefaction terminate 
 in a rupture of the ure'dira ; in confequence of which, 
 the urine efcapes into the contiguous cellular fubftance, 
 and very troublefome fwellings arife not only in the 
 body of the penis, but frequently in the fcrotum, and 
 through the whole courfe of the perina^um. 
 
 The treatment fuited to fuch tumors will be point- 
 ed out when we co\m to treat of fiftulous fores in 
 thef^ parts ; fo th^t I fliall now only relate the eafieft 
 and moft efl.'eclual means of extratting ftones from the 
 urethra. 
 
 When a ftone has been long fixed at one particular 
 part without yielding in any degree, and when the 
 pain and inflammation that it excites are confiderable, 
 it ought to be cut out in the manner I ftiall hereafter 
 advil'e j but on firft paffmg down from the bladder to 
 the urethra, we frequently fucceed by more gentle 
 means. 
 
 Whether or not the urethra itfelf is poflfefiTed of any 
 contractile power, is a point not to be eafily afcertain- 
 ed ; but the mufcles with which it is immediately con- 
 nected, are, in common with other mufcular parts, fub- 
 jed to the influence of ftimuli ; and as nothing with 
 which we are acquainted, can be fuppofed to give a 
 more powerful ftimulous to a fenfible part than the 
 irritation of a rough or angular ftone, fo we may fair- 
 ly conclude, that when once a ftone is impacted in the 
 urethra, its farther paflage along that canal will be 
 impeded by a fpafmodic contraction of the contiguous 
 mufcles. One very important indication, therefore, 
 in the treatment of this malady, is, the removal of 
 
Sea. IX. Of the Stone, 21^ 
 
 fpafm ; and when we keep this idea in view, and con- 
 tinue to perfifl in the ufe of proper remedies, we fel- 
 doni fail to bring oif fuch ftones as have been lodged 
 in the urethra, without the aid of any chirurgical op- 
 eration. But, inftead of the application of means cal- 
 culated for the removal of fpafm, the ordhiary prac- 
 tice of furgeons is the direct reverfe, and is therefore 
 apt to produce a very oppofite effeft. 
 
 An attempt is commonly made to pufh the flone 
 forward at once with the fingers. It is obvious, how- 
 ever, that until the fpafm by which the obftrudion is 
 partly produced is removed, every trial of this kind 
 will rather tend to incrcafe the complaint. For this 
 reafon, therefore, no preflTure fhould be employed till 
 the moft elfedual means have been ufed for removing 
 the fpafm produced by the (lone. With this view, 
 the patient, if he is plethoric, ought to lofe a confid- 
 erable quantity of blood by the lancet ; or, if he is 
 thin and emaciated, a proportional quantity fliould be 
 difcharged by leeches, diredly from the pained part, 
 A quantity of warm oil (liould be repeatedly injected 
 into the urethra, in order to lubricate the paifage. 
 The patient fliould be immerfed in a warm bath ; and 
 a full dofe of laudanum (hould be given about an hour 
 bef(M"e going into the bath. 
 
 Together with thefe remedies, a plentiful ufe of di- 
 uretics, and diluent drinks, is commonly prefcribed ; 
 but, inflead of proving ufeful, they almoll conilantly 
 do harm. For, when the urine ruflies out with vio- 
 lence, if it does not carry the flone freely out of the 
 urethra, it tends to fix it more firmly than before ;. 
 and the pain thus produced, w'll always increafe the 
 inflammation, tenfion and fpafm of the parts alfefted : 
 fo that whatever has much effect in increafing thq 
 quantity of urine, fhould be carefully avoided. 
 
 A proper quantity of blood having been difcharg- 
 ed ; the patient having remained for a fufficient length 
 of time in the warm bath ; and the opiate having be^ 
 gun to operate j the parts will thus be as completely 
 
mo Of the Stone, Chap. XXIX. 
 
 relaxed as poflible ; and this is the period when fome 
 attempt Ihould be made for extradling the ftone. Va- 
 rious inftruments have been contrived for this pur- 
 pofe, particularly long fmall pliers or forceps, conceal- 
 ed in a canula of a fize correfponding to that of the 
 urethra ; but as none of thefe have ever proved ufe- 
 ful, and as they often do much harm, by tending to 
 increafe the irritation in the urethra, I do not think it 
 neceflary to delineate any of them. 
 
 Inftead of ufnig thefe inftruments, the furgeon 
 fhould at firft endeavour by gentle prelfure to pufii the 
 ftone forward along the urethra, and by continuing to 
 move it eafily in different directions, and perfevering 
 for a confiderable time, we often fucceed in bringing 
 it off, when otherwife it muft have been cut out. 
 
 It frequently happens, however, that ftones of fuch 
 a fize and figure get into the urethra, as cannot by 
 any means be made to pafs off. When a ftone, thus 
 fixed in the paflage, is of fuch a form as to admit of 
 the urine being difcharged, a patient, rather than fub- 
 mit to an operation, will fometimes allow it to remain ; 
 by which the ftone, in a fhort time, commonly obtains 
 an increafe of fize by a depofition of earthy matter 
 from the uripe : of this I have met with various in- 
 ftances, in which the ftones became very large, and 
 in which the urethra was fo much dilated as to form 
 an extenfive pouch or cavity correfponding to the fize- 
 and figure of the ftone. But when the ftone, inftead 
 of allowing any of the urine to pafs, fills up the ure- 
 thra entirely, it becomes neceffary to remove it by an 
 operation, as foon as the means that I have advifed 
 have been found to prove of no avail. 
 
 This operation confifts in cutting diredly upon the 
 flone, and extracling it either with a fcoop, or with 
 fmall forceps ; but the methods of effeding this ought 
 to vary according to the part of the urethra in which 
 the ftone is fixed. When a ftone is fituated near to 
 the beginning of the urethra, and contiguous to the 
 bladder, it has been advifed to pufh it again into the 
 
Sed:. IX. Of the Stone* 22 1 
 
 bladder by means of a ftaff : but as it might there 
 probably acquire a larger fize, and would confequent- 
 ly render the patient liable to all the diftrefs and haz- 
 ard arifmg from a ftone in the bladder, this is a prac- 
 tice by no means to be admitted, as the ftone may be 
 extraded with much more eafe from any part of the 
 urethra, and with much lefs hazard to the patient, 
 than is always incurred by the more formidable oper- 
 ation of cutting into the bladder. 
 
 When, therefore, an operation is neceflary for ex- 
 tracting a flone fixed in the urethra near the neck of 
 the bladder, the method of performing it is this : 
 
 The patient fliould be laid upon a table, and fecur- 
 ed in the manner I have direded for lithotomy : and 
 an affiftant fufpending the fcrotum and penis, the fur- 
 geon, after oiling the firft and fecond fingers of his 
 left hand, fliould introduce them into the anus, and 
 by means of them ought to prefs firmly upon the parts 
 immediately behind the flone ; which will not only 
 enable him to lay it bare with more eafe, but will be 
 the furefl method of preventing it from being puflied 
 into the bladder by the neceffary preffure of the knife. 
 This being done, an incifion fliould be made through 
 the common teguments and urethra, fo as to lay the 
 ftone completely bare ; which may now be either turn- 
 ed out by a due degree of preffure applied with the 
 fmgers in the re6tum ; or, if this be not fufficient, it 
 may be taken out either with a fcoop, or with fmall 
 forceps. 
 
 The after treatment is the fame here as I have ad- 
 vifed in the operation of lithotomy. 
 
 When, again, a ftone has paffed farther on in the 
 urethra, in order to extract it the fkin fliould be drawn 
 as much as pofTible pafl it, either in a backward or 
 forward direction ; and the flone being now fecured 
 in its fituation by preffure, a longitudinal cut is to be 
 made upon it, directly through the fkin, cellular fub- 
 ftance, and urethra, of a fufficient fize to admit of its 
 being extracted, either with the fcoop or forceps. The 
 
222 Of the Stone. Chap. XXIX^ 
 
 edges of the wound are now to be completely cleared 
 of fabulous particles, and the fkin allowed to regain 
 its natural fituation ; by which means, if the opera- 
 tion has been properly done, the wound in the ure- 
 thra will be entirely covered with fkin that has not 
 been injured ; a circumftance that tends to render the 
 operation much lefs formidable than it otherwife would 
 be ; for the wound in the urethra is thus fo well pro- 
 tected, that it commonly heals by the firft intention. 
 
 It fometimes indeed happens, when the operation is 
 done in this manner, that in voiding urine, part of it 
 efcapes at the wound, and infmuates into the contigu- 
 ous cellular fubftance. This, however, is a rare oc- 
 currence, and the inconveniencies that arife from it are 
 cafily obviated, by laying open any colledion of urine 
 that takes place during the cure. 
 
 When a ftone fixes near to the point of the yard, in 
 that part of the urethra running through the glans ; 
 if it is fo near as to be fcen, it may frequently be tak- 
 en out with fmall diifecling forceps : and in order to 
 facilitate the extraction, when it cannot be otherwife 
 done, the end of the urethra may be dilated with the 
 point of a biftoury : but when this fails of fuccefs, an 
 incifion muft be made upon the ftone in the manner 
 I have advifed where the urethra is covered vi^ith fkin. 
 Soft drefhngs fliould be applied to the wound ; and 
 when the cure is nearly completed, a hollow bougie, 
 a fhort filver tube, or a catheter of elaftic gum, fhould 
 be pafled into the urethra, in order to preferve it of a 
 proper fize. 
 
 The moft perplexing fituation in which a ftone can 
 be fixed in the urethra, is juft behind the fcrotum ; 
 f(5r if the ftone is either forced into the fcrotum, or if 
 it becomes ncceftary to make an opening into it with 
 a fcalpel, the urine is apt to collect in it, from which 
 a great deal of diftrefs never fails to enfue. 
 
 In order, therefore, to obviate this inconvenience, 
 as fuon as a ftone is difcovered in this fituation, we 
 
 ii 
 
S^a. IX. Of the Sionc. 243 
 
 fhould endeavour, with all poffible attention, either to 
 get it carried farther along the urethra, or, if this can- 
 not be done, to pulh it back into the perinjeum with 
 a (laif : but when this is found to be impra6licable, 
 and that the ftone mull be extraded, an incifion 
 fliould be mide in the urethra, by beginning the cut 
 at the under part of the fcrotum, immediately to one 
 fide of the feptum, and proceeding upwards till the 
 ftone is diflinftly felt, when it mult be laid bare and 
 taken out in the manner I have»already advifed. 
 
 By making the incifion from below upwards, any 
 urine that efcapes from the urethra finds a free paf- 
 fage J and if the opening is fufficiently large, the ftone 
 may in this manner be extracted eafily : during the 
 operation, the teftes fhould be as much protected as 
 poflible : and on the ftone being removed, the drcflings 
 fliould be applied in fuch a manner, that the fore may 
 heal from the bottom ; for this being neglected, and 
 the teguments allowed to heal before every vacancy 
 is filled up, purulent matter, and perhaps urine, will 
 very probably colled, and may thus give rife to trou- 
 blefome fmufes. 
 
 When urine continues to be difcharged for any 
 length of time at a preternatural opening of the ure- 
 thra, whether the confequence of the operation of li- 
 thotomy or of any other caufe, if the calculous diathe- 
 fis prevails, ftones of a large fize will frequently form 
 in the cellular fubftancc contiguous to the opening. 
 I have met with feveral inltances of this : in fome the 
 ftones were fiuall, and eafily taken out ; but in others, 
 where they fpread and occupied a confiderable por- 
 tion of the cellular membrane, they were very difficult 
 to remove.* The treatment here confifts folely in 
 making a free incifion along the courfe of the calcu- 
 lous concretions j in turning them out, either with a 
 
 • A very remarkable cafe of this nature is recorded hv Gooch. Sed 
 Cafts and PraClical Rcuiiiiks iii Surgery, vol. ii, p. Z74, by Benjamin 
 Oooch. 
 
224 Of the Stone. Chap. XXIX. 
 
 fcoop or fmall forceps ; and in drefling the wound 
 properly, fo as to induce a firm adhefion of the parts 
 beneath, before the teguments are permitted to heal. 
 In females, the urethra is fo fliort, and dilates fo 
 readily, that fmall flones feldom flop in it : they are 
 moft commonly carried off by the flow of urine that 
 brings them into it ; but when they happen to fix in 
 it, they are eafily turned out, merely by infinuating 
 the end of a blunt probe behind them, and then pul- 
 ling them forward : or, when this docs not fucceed, it 
 may always be done with fafety, by laying open the 
 extremity of the urethra with a fcalpel, fo far as to 
 admit of the introduction of fmall foixeps. 
 
 1 
 
Chap. XXX* Inccnthwice of Urine, I25 
 
 CHAPTER XXX. 
 
 OF INCONTINENCE OF URINE. 
 
 INCONTINENCE of urine may arife from various 
 caufes ; but being frequently conneded with cal- 
 culous complaints, and in fome inflances the confe- 
 quence of the operation of lithotomy, I am hence in- 
 duced to fpeak of it here. 
 
 1. It may arife from irritation about the neck of 
 the bladder, produced by the fri(9:ion of ftones con- 
 tained in it. Thus we know, that inability to retain 
 urine is a frequent fymptom of ftone in the bladder ; 
 and we cannot fuppofe it to proceed from any other 
 caufe than the conllant ftimulus communicated by the 
 llone to the coats of the bladder. For, were it always 
 produced, as has been fuppofed, by a total lofs of 
 power in the fphincter veficec, the difeafe would fel- 
 dom or never admit of a cure. But we know well, that 
 incontinence of urine, depending upon flone in the 
 bladder, is often removed entirely by the operation of 
 lithotomy : and we likewife know, that it is often 
 much relieved, even when the ftone remains in the 
 bladder, by the ufe of thofe remedies that moft effec- 
 tually remove irritability ; particularly by a plentiful 
 ufe of mucilaginous drinks, and a free ufe of opiates. 
 By a continued ufe of thefe remedies, indeed, this va- 
 riety of the difeafe is commonly removed with more 
 certainty than by anv other means, extradion of the 
 ftone excepted ; which, when thefe fail, is to be kept 
 in view as the only refource upon which we are to de- 
 pend. 
 
 2. Incontinence of urine is a frequent effect of pal- 
 fy ; and it would appear, that the fphincler of the 
 
 Vol. III. O 
 
226 Incontinence of Urine. Chap. XXX, 
 
 bladder fometimes lofes its contra£tile power, while 
 the natural tone of#he inufcle termed detrufor urinse, 
 which conflitutes the chief part of the body of the 
 bladder, remains entire. In this variety of the difeafe, 
 the obflinacy of the paralytic affeclion with which the 
 conftitution is attacked, commonly renders fruitlefs 
 every attempt to remove it. But the moft obvious 
 remedies to be employed for it, are, tonics, particular- 
 ly Peruvian bark, chalybeates, and efpecially the cold 
 bath general and local. The local application of cold 
 to the perinasum has frequently a powerful influence : 
 cloths wet with vinegar and cold water, or with a 
 ftrong folution of faccharum faturni in vinegar, prove 
 fometimes ' ufeful ; but the moft efFedlual method of 
 applying cold, is by dafhing water upon the loins, pe- 
 rinasum and fundament. 
 
 3. Incontinence of urine is not an unfrequent efFe£t 
 of laceration in the operation of lithotomy in male 
 fubjeds ; and in the fame operation, and by violence 
 done to the parts in delivery, m. females. It ought, 
 however, to be remembered, when in the lateral ope- 
 ration much laceration is produced, that in general it 
 proceeds from the mufcles not having'been divided 
 with fufHcient freedom by the knife ; and according- 
 ly, except in cafes of large flones, incontinence of 
 urine feldom fucceeds to this operation when proper- 
 ly performed. 
 
 As the difeafe in this cafe depends upon nearly the 
 fame caufe as that which I mentioned laft, namely, on 
 a lofs of power in the retaining parts, the fame reme- 
 dies are proper ; and by due perfeverance, particular- 
 ly in the ufe of cold bathing, many are at laft very 
 completely cured of this variety of the difeafe. But 
 it fi-equently happens, in all the varieties of the dif- 
 eafe, that no relief is obtained from any remedy what- 
 ever ; in which cafe, it becomes an objedl of import- 
 ance to prevent the urine from incommoding the pa- 
 tient, which never fails to happen, if means are not 
 employed to prevent it. 
 
 A 
 
Chap. XXX. Incontinetice of Urine, iij 
 
 When it proceeds from either of the la ft mention* 
 ed caufes, namely, from a paralyfis of the iphincter of 
 the bladder, or from laceration, comprellion of the 
 urethra anfwers the purpofe ; as the preffure can be 
 fo modified as to be applied and removed at pleafure* 
 Nuck invented the firll inftrument for this purpoie of 
 which any defcription is given. The jugum, or yoke, 
 as it is termed, Plate LXXVII. fig. i. is an improve^ 
 mcnt upon this ; and, when properly fitted, it anfwers 
 the purpofe exceedingly well. When lined with quilt* 
 ed filk or velvet, it fits eafily on the penis, and by 
 means of the fcrew, the preffure can be made fuffi- 
 ciently tight. For women another invention is necef- 
 . fary, as the preffure muft be applied through the va- 
 gina. Peffaries of refma elaftica, and of fponge, have 
 been propofed for it, but thofe of ivory or lignum 
 vitse anfwer better ; in Plates LXXIV. and LXVl. are 
 reprefented peffaries of difi'erent kinds. 
 
 Peffaries fhould all be finely polifhed, and dipped 
 in oil immediately before being introduced. After 
 b-ing paffed into the vagina, the peffary fliould be 
 placed directly acrofs, fo as to prefs with as much ef- 
 fect as poffible againft the urethra. 
 
 This method of obviating the inconveniencies arifmg 
 from incontinence of urine, by preffure, is not, how- 
 ever, applicable when the difeafe proceeds from irri- 
 tation about the neck of the bladder ; for the conti- 
 nual defirc to pafs water, with which patients in fuch 
 circumflances are tormented, renders every attempt 
 to fupprefs a complete difcharge of it totally inadmif- 
 fible. It is therefore a point of the firft importance 
 to diftinguifli between the different caufes of this fymp- 
 tom ; for it is obvious that a remedy that may be well 
 calculated for one variety of the difeafe, may prove 
 highly prejudicial in others. 
 
 Whenever it is found that preffure upon the ure- 
 thra is improper, or that it does not anfwer, relief may 
 commonly be obtained from a machine properly fit- 
 0^2 
 
228 Tncontincnce of Urine. Chap. XXX. 
 
 ted to fei*ve as a refervoir for the urine. The inftru- 
 ments formerly referred to, reprefented in Plates LV. 
 and LXXVII. have been often ufed, and commonly 
 with much advantage. They ftiould be made fo as to 
 apply as clofely as poflible to the parts on which they 
 reft ; and when properly fixed to a circular bandage 
 round the body, they remain fufficiently firm, and at 
 the fame time admit of every necefl'ary change of pof- 
 ture in ordinary exertions of the body. The laft of 
 thefe inftruments, namely, the one delineated in Plate 
 LXXVII. fig. 2. proves ufeful only in men ; but the 
 other, Plate LV. fig. 2. may be employed for women 
 alfo. 
 
Chap. XXXI. Suppreffton of Urine, 229 
 
 CHAPTER XXXI. 
 
 OF SUPPRESSION OF URINE. 
 
 THE fubjeft of the preceding chapter, namely, ia- 
 continence of urine, proves always troublefome 
 and inconvenient ; but the difeafe that we are now to 
 confider, proves in every inftance, very alarming, and 
 often ends in the death of the patient.* 
 
 A fuppreffion of urine may be the effeft of various 
 caufes, and in the method of cure a nice difcrimina- 
 tion of thefe is neceflfary. 
 
 I. In the preceding chapter we have feen, that in- 
 ■continence of urine is often produced by the fphinder 
 of the bladder becoming paralytic, while the detrufor 
 urina: ftill retains its power of contradion. In like 
 manner, a fupprellion of urine frequently occurs in 
 palfy, and feems to proceed from lols of power in the 
 body of the bladder, while the fphinder {till preferves 
 its ufual power of retention. 
 
 Although this variety of the difeafe is often con- 
 nected with palfy of all the under part of the body, 
 yet it is frequently induced by the pernicious cuftom 
 of remaining too long, efpecially when drinking free- 
 ly of diuretic liquors, without voiding urine ; by 
 which the bladder is fometimes fo far over diftended, 
 that it lofes entirely all power of contraction. 
 
 The catheter proves here commonly a very certain 
 remedy when employed early, and it fhould always be 
 advifed as foon as it is found that the urine colleded 
 
 * It is that variety of the difeafe to which I alhide, in which the urine 
 is colleoled in the bladder, but which the patient is unable to difcharge. 
 When fupprcfl'ion takes place from a morbid (late of the kidneys, a vari- 
 ety of the difeafe is produced, that no cliirurgical operation can relieve 
 fo tliat it does not fall to be tonlidered here. 
 
230 Supprejfioti of Urine. Chap. XXXL 
 
 in the bladder cannot be paiTed. For although the 
 ufe of this inftrument fliould never be advifed where 
 it can with fafety be avoided, yet as in the circuui- 
 ftances we are now confidering, delay never fails to 
 prove dangerous, the urine (hould always be drawn off 
 as foon as the itoppage excites irritation. At the com- 
 mencement of the di'eafe, it is for the mod: part eafi- 
 ly done ; while long delay, by exciting fwelling and 
 inflammation about the neck of the bladder, never fails 
 to render it both more difficult and more painful, and 
 in fome inflances even impoflible to pafs the catheter. 
 The method of paffing the catheter, both in male and 
 female fubjefts, is the fame with the operation of 
 founding for the (lone, already defcribed in Chapter 
 XXIX.Sedionll. 
 
 2. A fuppreffion of urine is frequently produced in 
 the laft months of pregnancy, by the preffure of the 
 uterus on the neck of the bladder. So completely in- 
 deed is the urine fometimes obftrucled by this, that 
 not a fmgle drop can be difcharged but with the aid 
 of a catheter ; and as this Inftrument is in females 
 commonly introduced with eafe, it fliould always* be 
 done as foon as the urine cannot be otherwife avoided. 
 Delay in ufmg the catheter is often the caufe of much 
 diftrefs. In different inftances, the bladder has from 
 this caufe alone been diftended to fuch a degree as to 
 lofe the power of contraction ; and in a few cafes, it 
 has even burft entirely : we fliould not therefore hefi- 
 tate to advife the catheter to be employed, on finding 
 that the bladder is in any degree diftended beyond its 
 ufual fize. 
 
 3. Tumors in the vagina and neighbouring parts, 
 when they become large, are apt to comprefs the ure- 
 thra fo much as to induce a total fuppreffion of urine ; 
 and a prolapfus uteri is often attended with the fame 
 effea. 
 
 The method of treatment beft calculated for remov- 
 ing a prolapfus uteri, as likewife the means of cure 
 commonly employed in tumors in the vagina, will be 
 
Chap. XXXI. Suppreffion of Urine, 23 j 
 
 the fubje^s of different chapters ; only it miift be re- 
 membered, that till thefe views are accompliflied, the 
 urine (hould be regularly drawn off with the catheter, 
 whenever it is collected in large quantities. 
 
 The very irritable (late of the parts about the neck 
 of the bladder that often prevails in fuppreffion of 
 urine, renders it neceffary in fome inftances to ufe the 
 catheter often. Inflead of this, fome praditioners 
 have advifed the common catheter to be allowed to re- 
 main in the bladder a confiderable time at once, fo as 
 to admit of the urine being difcharged as foon as it is 
 fecreted : but this is a practice that ought not to be 
 admitted ; for the irritation arifmg from a long con- 
 tinuance of a catheter in the bladder, commonly does 
 more harm than we ever experience from a frequent 
 ufe of it. When it is wiflied, however, to allow a 
 catheter to remain in the bladder, either for this pur- 
 pcfe, or for wounds in the urethra, the hard filver 
 tubes in common ufe ought not to be employed : thofe 
 that are prepared with refma elaflica, anfwers the in- 
 tention better, and I have found by experience, that 
 they do not diffolve in the urine : in one cafe a tube 
 of this refm was kept in the bladder twenty-two days 
 without being hurt by the urine. 
 
 4. A ftoppage to the flow of urine is not an unfre- 
 quent effe£l of an enlarged ftate of the proflate gland, 
 and of obftructions in the urethra in virulent gonor- 
 rhoea. The treatment beft fuited to thefe affedlions 
 will form the fubjed of part of the enfuing chapter. 
 
 Suppreffion of urine induced by (tones impacted in 
 the urethra, has been already confidered in Sedion 
 IX. of Chapter XXIX, where the remedy was point- 
 ed out. 
 
 5. But the mod alarming variety of the difeafe, is 
 that which proceeds from inflammation about the neck 
 of the bladder, inducing pain and fwelling to fuch a 
 degree, as often make it impoffible to pafs the cathe* 
 ter. 
 
232 SupprcJJton of Urine. Chap. XXXI, 
 
 Suppreffion of urine from this caufe is not an un- 
 frequent confequence of inflammation in gonorrhoea 
 proceeding backwards along the urethra : it is fome^ 
 times, although not often, induced, by an unguarded 
 ufe of ftimulating injections ; and as the bladder is 
 equally liable with other parts of the body, to the in- 
 fluence of every caufe that excites inflammation, what^ 
 ever excites inflammation in other parts will very rea- 
 dily do fo here. 
 
 In whatever way inflammation may be induced, the 
 means of cure fhould be nearly the fame : blood 
 ihould be difcharged from the arm in quantities pro- 
 portioned to the ftrength of the patient, and a confid- 
 erable number of leeches fhould be applied to the pe- 
 rinseum as near as poflible to the feat of the difeafe, 
 and allowed to bleed freely. Opiates fhould be giv- 
 en in large dofes ; injections of warm water or r^iilk, 
 whether by themfelves or combined with opiates, 
 Ihould be repeatedly thrown into the reftum ; and the 
 whole body fhould be immerfed in the warm bath. 
 By thefe means, when the inflammation is not violent, 
 the fupprefTion will in fome inftances be removed be- 
 fore any diflrefsful fymptoms take place. But when 
 thefe remedies do not prove effectual ; when the blad- 
 der becomes painfully diftended ; and when every at- 
 tempt to introduce the catheter has failed, other means 
 of relief fhould be employed. In fuch circumilances, 
 puncturing the bladder is the only remedy on v/hich 
 we can with certainty depend : being an operation of 
 fome nicety and hazard, arifmg not fo much from the 
 difficulty of doing it, as from the confequences that 
 fometimes refult from it, and the flrid confinement 
 that for a confiderable time it entails upon the patient, 
 it ought never to be advifed till the other remedies I 
 have mentioned have been tried in vain ; at the fame 
 time, however, I think it right again to obferve, that 
 it fhould never be long delayed after our other rjieans 
 of relief have been found to fail. 
 
Chap. XXXI. Supprefflon of Urine. 233 
 
 The bladder may be pundured in various ways : it 
 may be done a little above the pubes : the membra- 
 nous part of the urethra, and proftate gland may be 
 cut, and an opening made in the neck of the bladder. 
 An opening may be made from the perinscum, direct- 
 ly into the body of the bladder ; and a pundure may 
 be made in the back part of the bladder by paffing a 
 trocar into it from the redum. As the method of 
 punduring the bladder, after dividing the membra- 
 nous part of the urethra and proftate gland, is obvi- 
 oufly more hazardous than any of the others, it is now 
 very defervcdly laid afide, fo that it is not neceflary 
 to fpeak of it farther. We have, therefore, only to 
 confider the other three modes of operating. 
 
 In puncturing the bladder above the pubes, we are 
 directed by authors, firft to make an incifion, two 
 inches in length, through the common teguments and 
 mufcles, and then to perforate the bladder with a tro- 
 car. But there is no neceflity for this extenfive divi- 
 fion of the teguments and mufcles ; for the operation 
 may be done with equal fafety and with lefs pain to 
 the patient, by pufliing a trocar at once through the 
 fkin, mufcles, and bladder ; and it may be entered 
 any Vvhere from the height of half an inch to an inch 
 and half above the pubes, and at half an inch or there- 
 by on either fide of the linea alba. Some advife the 
 trocar to be paffed obliquely downwards, with a viev/ 
 to prevent the back part of the bladder from being 
 hurt ; but we ad with more fafety, and guard with 
 more certainty againft this injury to the bladder, by 
 making ufe of a ihort canula, and pafllng the trocar 
 nearly in a horizontal diredion ; for, in paiTing it ob- 
 liquely down towards the centre of the pelvis, the 
 bladder, on being left empty, v/ould, in a great pro- 
 portion of cafes, Idc apt to flip off from the end of it, 
 by which the urine would be extravafated, and lodge 
 in the contiguous parts. As foon as the trocar has 
 piercecf the bladder, the ftilette fliould be withdrawn, 
 and the canula fecured in its fituation with pieces of 
 
234 SuppreJJion of Urine. Chap. XXXI. 
 
 ribbon or tape conneded with it, tied to a circular 
 bandage, palfed round the body. , 
 
 The length of the canula ul'ed in this operation is,* 
 I may remark, a point of the lirll importance, and 
 merits particular attention ; for much inconvenience 
 would arife from its being too fliort, while a long ca- 
 nula, as I have already obferved, is apt to injure the 
 back part of the bladder. Of this we have an inllance 
 on record, in which the end of the canula was found, 
 after death, to have penetrated not only the back part 
 of the bladder, but even the reclum.* 
 
 In corpulent people, the canula may require to be 
 two, three, or even more inches in length, according 
 to the quantity of fat between the Ikin and bladder ; 
 but in thin patients, I know from experience, that an 
 inch and half is fufTicient. 
 
 The canula, it mud be remembered, fliould be re- 
 tained in its fituation till the caufe of the obftru«5lion 
 is fo far removed, that the urine can be pafl'ed in the 
 ufual manner ; but it has been very properly remark- 
 ed,! that a canula cannot be kept above ten or four- 
 teen days in the bladder, but with the rilk of contract- 
 ing a calculous cruft, that renders its extraction both 
 r difficult and painful. The canula, therefore, fhould 
 be taken out and cleaned, from time to time. This 
 has commonly been done, by paffing a firm probe of 
 a fufficient thicknefs through it into the bladder, upon 
 M'hich the canula is again returned, on being cleared 
 of the incruftadon. Inftead of a probe, however, I 
 have employed a tube that anfwers better. This tube 
 is made to fit the diameter of the canula exa6lly, but 
 at the fame time to pafs eafdy through it ; and it has 
 this advantage over a probe, that in the event of its 
 proving difficult to return the canula of the trocar, as 
 fomecimes is the cafe, the tube may be retained ; and 
 being nearly of the fame diameter, it anfwers the pur- 
 
 * vide Shnrpe's Operations of Surgery, Chap. XV. » j 
 
 f Vide Critical Enijuir y, &c. by Mr. Sharpe, Chap. IV. { 
 
Chap. XXXI. Supprejfton of Urine. . 235 
 
 pofe equally well. Of this tube, and the mode of 
 applymg it, I have given a delineation and defcriptioa 
 in Plate LVI. and in Plate LVIl. I have delineated a 
 very neat apparatus for punduring the bladder above 
 the pubes, by Dr. Monro. 
 
 In punduring the bladder from the perinseum, the 
 patient fliould be placed upon his back on a firm ta- 
 bic ; and his thighs being feparated, and properly fe- 
 cured by airiftants, an incifion fliould be made of an 
 inch and half in length, beginning at the commence- 
 ment of the membranous part of the urethra, and pro- 
 ceeding towards the anus, in a Hne parallel to, but at 
 leafl half an inch diftant from, the rapha perin^ei. In 
 this manner the fkin and cellular fubftancc (hould be 
 freely divided ; which puts it in the power of the op- 
 erator not only to introduce the trocar with more eafe, 
 but to avoid the urethra with more certainty than he 
 otherwife could do. 
 
 This being done, as the bladder is always much dif- 
 tcnded when this operation is neceffary, it is eafily dif- 
 tinguifhed with the finger at the bottom of the wound : 
 but, whether it is felt by the finger or not, we flioulJ 
 not hefitate to pulh in the trocar a little above, and 
 to the left of the proftate gland, which, when the parts 
 have been freely divided, is eafily difcovered ; and if 
 the point of the trocar is pafTed up towards the pubes, 
 there can be no danger of hurting either the ureters 
 or vafa dcferentia, which fome have been afraid of in 
 this operation ; and at the fame time there muft be an 
 abfolute certainty in this diredion, if the trocar is car- 
 ried to a fufficient depth, of its reaching the bladder. 
 
 It has been alleged, and with fome reafon, that in 
 this part of the operation the furgeon muft be at a lofs 
 to know when the inftrument has reached the blad- 
 der ; and feveral inventions have been propofed, to ob- 
 viate this inconvenience. In Plate LXXIII. fig. 5. is 
 reprefented a very fimple contrivance for this purpofe ! 
 * it confifls of a trocar, with a canula of the ulual form, 
 and a deep groove in the (tilette, fo that urine begins 
 
236 Supprcjfion of Urine. Chap. XXXI. 
 
 to flow along the groove, immediately on ihe inflru- 
 ment having entered the bladder. As foon, therefore, 
 as in this manner we know that the trocar has pafled 
 to a fufficient depth, the fl:ilette Ihould be withdrawn ; 
 when the canula fliould be fecured by two pieces of 
 tape, conneded with two rings upon its brim, being 
 firmly tied to a circular bandage round the body : 
 and if one of thefe tapes is tied behind immediately 
 above the facrum, and the other directly above the 
 pubes, the canula will not be eafily difplaced. 
 
 It is equally neceffary here as when the operation is 
 done above the pubes, to change the canula, or at lead 
 to clean it from time to time ; and in this fituation 
 too, fo long as a canula is employed, the urine may 
 be retained and drawn off at pleafure, by a plug of 
 cork being fixed in it. 
 
 In perforating the bladder from the re6lum, the pa- 
 tient fhould be placed upon his back, and fecured with 
 afllflants in the manner 1 have pointed out : the fur- 
 geon now inferts the forefinger of his left hand into 
 the reftum, and having carried the point of it about 
 an inch above the proflate gland, where the bladder 
 in this diftended ftate of it is eafily felt, a curved tro- 
 car about two inches and a half in length, ffiould be 
 pafled along the finger, and puflied at this prominent 
 part of the bladder, in an oblique direction upwards 
 till it reaches the urine. In this fituation, the canula 
 muft either be retained by being fixed with pieces of 
 fmall tape to a circular bandage round the body, or a 
 tube of refina elaftica fliould be inferted through it, 
 and left in the opening till the urine paflfes off by the 
 urethra. 
 
 This operation has now been frequently praftifed, 
 but it is liable to fo many important objeftions, that 
 I do not fuppofe that it will ever be generally adopted. 
 It is eafily performed, but this is almofl the only cir- 
 cumflance that tends to recommend it. The chief 
 objections to it are, the rifle incurred by it, of wound- 
 ing either the ureters, vafa deferentia, or veficulse fe- 
 
Chap. XXXI. Supprejion of Urine, ^2>7 
 
 minales, while, at the fame time, it forms a paffage, 
 by which the fseces may find accefs to the cavity of 
 the bladder, that would either foon end in the death 
 of the patient, or leave him in a date of very mifera- 
 ble exiftence. Much irritation and diftrefs mull alfo 
 enfue from a canula being left in the reclum during 
 the cure, that is, till the urine pafles off by the natur- 
 al conduit of the urethra, which, in fome inftances, 
 does not happen in lefs than a year or two, while in 
 others the ftoppage continues during life. Mr. Wel- 
 don, who has written an ingenious treatife on this fub- 
 ject, indeed fays, that the canula may be withdrawn 
 foon after the operation, and the lirine allowed to pafs 
 off by the opening.* But, befides the very uncom- 
 fortable ftate to which this would reduce the patient, 
 by having his urine at all times pafling oif by the rec- 
 tum ; the opening would often be apt to heal from 
 time to time, by which the operation might be fre- 
 quently to renew. 
 
 I have thus defcribed the different modes that have 
 been propofed of punduring the bladder. In appre- 
 ciating the merits of each, I was at one time of opin- 
 ion, that doing it from the perinseum was the beft ; 
 and in the former editions of this work, I freely faid 
 fo. I now, however, think it right to fay, that farth« 
 er experience has convinced me that I was wrong. 
 Every method of performing this nice operation, is at- 
 tended with difficulties. I have already enumerated 
 thofe that chiefly apply to the mode of doing it from 
 the re6lum. To the perforation above the pubes, it is 
 objected, that the cavity of the abdomen may be pierc- 
 ed with the trocar ; that the bladder may be injured, 
 by being fufpended for a confiderable time upon the 
 canula ; that it may even flip off from the end of the 
 canula, by which all the urine will efcape, and lodge 
 in the pelvis ; that the end of the canula may injure 
 
 • Vide Obfervations on the different modes of pundluringthe bladder, 
 by Walter Wtldoii, furgcon. 
 
>•*&« 
 
 238 SiipprcJJton of Urine, Chap. XXXL 
 
 the back part of the bladder ; and that the. urine, in- 
 iinuating into the cellular fubftance of the contiguous 
 parts, may terminate in various diflrefsful fymptoms. 
 
 It may be obferved, however, in anfwer to thefe dif- 
 ficulties, that where the operation is properly conduc- 
 ed, few or none of them ever occur. It can feldom 
 or never be neceffary to pundlure the bladder, till it is 
 fo much diftended with urine, as to be confiderably 
 raifed above the pubes ; in which fituation, there is 
 no rifk of pufliing the trocar into the abdomen. A 
 fuppreflion of urine may no doubt happen, where the 
 bladder, by difeafe, is fo much contraded, that this 
 degree- of diftentioif cannot, confjftently with the fafe- 
 ty of the patient, be permitted. I conclude, however, 
 that this is uncommon, as I have never yet met with 
 it ; and v/herever it takes place, the difeafed fhate of 
 the bladder will give little or no chance to the opera- 
 tion, wherever it may be performed. I know from 
 experience, that the bladder is not apt to be hurt by 
 being fufpended on the canula ; and I conclude that 
 this may, in fome meafure, happen, from thofe attach- 
 ments that commonly take place in this difeafe, be- 
 tween the bladder and contiguous parts, as the effect 
 of the inflammation, with which a fuppreffion of urine 
 is for the mofl part attended, Thofe adhefions of the 
 bladder to the contiguous parts, may alfo in fome 
 meafure tend to prevent the bladder from flipping off 
 from the canula ; but this accident can never poffibly 
 happen, if the trocar is not introduced with too much 
 obliquity downwards. Neither vnll the back part of 
 the bladder be hurt by the canula, if the direftions I 
 have given, in regard to the length of it, are kept in 
 view^, and if the blunt filver flopper, Plate LVI. fig. 3. 
 is always kept in it, except when the patient is voiding 
 urine. 
 
 That difl:refsful fymptoms may enfue, from the urine 
 finding accefs to the contiguous cellular fubfl:ance, 
 none will doubt, but I have now much reafon to think 
 that it is an uncommon occurrence in this operation. 
 
Chap. XXXI. Supprefflon of Urine. 239 
 
 In perforating from the perinceum, to which at one 
 time I gave the preference, the urine is ftill more apt 
 to efcape from the wound, into the contiguous cellu- 
 lar fubltance ; although this is by no means the moil 
 important objedion to the operation being done in that 
 fituation. The chief danger here, arifes from the near 
 contiguity of very important parts, the urethra, prof- 
 tate gland, ureters, vaffe deferential, and veficulas fe- 
 minales, which being all near the neck of the bladder, 
 and therefore apt to inflame, whenever the urine is 
 long fupprelfed, they muft necefTarily be more fevere- 
 ly injured, by the trocar paffing near them, and by 
 their being freely expofed to the air, by the deep in- 
 cifion in the previous fteps of the operation, than the 
 upper part of the bladder can poffibly be, in perforat- 
 ing above the pubes, and accordingly more danger is 
 found to attend it. 
 
 I an\ therefore of opinion, on a comparative view 
 of the advantages and difadvantages of thefe feveral 
 operations, that punfturing the bladder above the 
 pubes is the bed. I have only further to obferve, be- 
 fore leaving the fubject, that in whatever way the op- 
 eration is done, it ihould not be long poflponed after 
 the bladder becomes painfully diflended : I have often 
 indeed been led to think that more danger has enfued 
 from delay in this fituation, by which the bladder has 
 appeared to be entirely deprived of its tone, than we 
 almofl ever meet with from the mod untoward occur- 
 rence in any of thefe modes of operating. 
 
 In the operation of lithotomy in females, I men- 
 tioned reafons that appear to be conclufive againll 
 the method of cutting into the bladder from the vagi- 
 na ; but they do not apply with equal force againft 
 the propriety of puncturing the bladder in this part. 
 On the contrary, whenever there is caufe for perform- 
 ing this operation in women, it cannot be done in any 
 other way, either with fuch eafe or certainty, as from 
 the vagina. When the bladder is much diflended 
 with urine, it is eafily difcovered by the finger in the 
 
240 Svppvejfton of Urine, Chap. XXXl, 
 
 vagina ; and from thence it may with fafety be pier- 
 ced with a trocar. The forefinger of the left hand 
 being pafled into the vagina, the point of the trocar 
 fliould be conduced upon it, and pufhed through the 
 vagina into that part of the bladder firlt difcovered by 
 the finger ; for here the ureters run no rifk of being 
 wounded, which farther back they certainly would do. 
 The trocar being freely paiTed into the bladder, and 
 the urine all evacuated, the canula fliould be left in 
 its place, and continued as long as the caufe fubfifts 
 by which the fupprefiion was produced. That the 
 tube may be firmly fecured, it fnould be of a fuffi- 
 cient length for palling out at the vagina, and to ad- 
 mit of its being tied to the T bandage, with tapes at- 
 tached to it. 
 
 I think it here, however, proper to obferve, that in 
 whatever way the bladder is punclured, and v>hether 
 in male or female patients, if tubes of filver irritate 
 and excite pain, as is very apt to be the cafe, that this 
 may in moA: inilances be prevented by leaving in the 
 palfage a tube of elaitic refin. 
 
Chap. XXXII. Obftruaiom, ^a 441 
 
 CHAPTER XXXII. 
 
 OBSTRUCTIONS IN THE URETHRA. 
 
 IN the preceding fe6lion, when treating of the cauf- 
 es of fuppreflion of urine, obftruclions produced 
 by chips, of which caruncles are fuppofed to be the 
 moll frequent, were fpoken of as the niofl: frequent 
 and mod remarkable. 
 
 But although I have particularly mentioned the 
 term caruncle, by which is meant a tlefliy excrefcence 
 arifmg from the membrane of the urethra, J do not 
 tvifli it to be fuppofed that I confider it to be a fre- 
 quent occurrence. That fuch excrefcences are fome- 
 times met with towards the extreuiity of the yard, 
 there is no reafon to doubt ; but as I have often dif- 
 fecled thefe parts, in patients who had long laboured 
 under fymptoms fuppofed to proceed fn*m caruncles 
 in the back part of the urethra, and as caru'icles were 
 not difcovcred in any of tliem, I am therefore of opi- 
 nion that their exiftence in the more remote parts of 
 the urethra is very uncommon. I have often obferv- 
 ed this kind of produfftion, within a quarter of an inch 
 of the extremity of the urethra, efpccially where the 
 glans and prepuce have been covered wi:h warty ex- 
 crefcences of a funilar nature ; but from having never 
 found them fpread farther up the canal, although it 
 is not a proof that they never occur in other parts of 
 it, yet this, together with fome obiervations of a fimi- 
 lar nature by Dionis, Saviard, Mr. Prtit, and others, 
 IS fufficient authority for the opinion I have advanced, 
 that caruncles in the more remote parts of the urethra 
 are rarely met with. Daran indeed often fpeaks of 
 them ; and he no doubt had more pradice in difeafos 
 Vol. in. R 
 
242 Ohjlrudious in Chap. XXXII. 
 
 of this clafs than perhaps ever fell to the fliare of any 
 other individual : but if his works are read with atten- 
 tion, it will appear that his detail is very inaccurate ^ 
 for he evidently confounds other caufes of obftruftion^ 
 particularly flriclures and cicatrices of old ulcers, 
 with, and niiflakes thein for, caruncles. 
 
 Pra(5litioners in former times, as well as many in 
 more late periods, have doubted fo little of the fre- 
 quent occurrence of caruncles, that almofl every in- 
 ftance of obflrufted urethra fucceeding to a clap has 
 been attributed to this caufe. What I have here fet 
 forth will tend to fet this however in a difierent view ; 
 and I fhall now proceed to enumerate the different 
 caufes by which obftrudlions in the urethra may be 
 produced. 
 
 1 . Although I have fald that caruncles are rarely 
 met with in the fuperior part of the urethra, yet they 
 fometimes form towards the extremity of this canal : 
 they muft therefore be mentioned as one caufe of 
 thefe obftruclions. I muft again obferve, however, 
 that where caruncles, or carnofities as they are fome- 
 times termed, are met with, they are always of the 
 fame nature with thofe warty excrefcences that fre- 
 quently form upon the prepuce and glans as a confe- 
 quence of gonorrhoea. 
 
 2. Ulcers in different parts of the urethra have been 
 known to produce very complete obftrudions. 
 
 On opening the bodies of thofe who at the time of 
 death laboured under gonorrhoea, ulceration has very 
 feldom been difcovered ; and this gave rife to the opi- 
 nion that ulcers of the urethra never take place in 
 gonorrhoea. We now know indeed that very great 
 quantities of matter may be furnifhed by parts mere- 
 ly inflamed, and not in a ftate of ulceration. But we 
 alfo know, that parts remaining for any confiderable 
 length of time fo highly inflamed as to furnifh much 
 pus, are very ^pt to become ulcerated ; and if this 
 happens in other parts of the body, we may conclude 
 that the fame caufe will induce the fame eifeds in the 
 
Chap. XXXII. the Urethra. 243 
 
 urethra. Accordingly, there is no reafon to doubt of 
 ulcers arifing in the urethra from inflammation alone ; 
 but it is iikewife certain, that they are fometimes, met 
 with in the urethra from the fame caufe by which 
 chancres are produced in the glans, namely, from the 
 mechanical effecls of the veneral poifon, independent 
 of the intervention of any degree of inflammation. 
 
 The excretory duels of the diff'erent glands in the 
 urethra, particularly of the proflate gland, as alfo the 
 duels of the veficul^ feminales, and the other parts 
 about the verumontanum, have commonly been fup- 
 pofed to be particularly obnoxious to the effecls of the 
 venereal virus ; and ulcerations are accordingly faid 
 to be more frequent in thefe parts than in others. The 
 refult of my obfervation, however, has been, that ul- 
 cers feldom occur in any part of the urethra, but 
 more frequently towards the extremity of the urethra 
 than in other parts of it, and that they rarely form 
 farther back than an inch or fo from the point of the 
 yard. 
 
 3. Diflfedlion has fhewn, that a mere contraded 
 (late of the urethra is to be confidered as the moft 
 frequent caufe of obftrudion. In fome, the ftriclure 
 is confined to one point, while in others different parts 
 of the paffage are difeafed. At one period, I was in- 
 duced to think that ftridures in the urethra were more 
 frequently produced by ulceration than in any other 
 way ; but I have now reafon to think, that they pro- 
 ceed more frequently from that thickened ftate of the 
 membrane of the urethra that gonorrhoea is apt to 
 excite. 
 
 Aflringent injeclions are mentioned by many as a 
 frequent caufe of flridlures. Irritating injeclions, when 
 improperly applied to parts already in a flate of in- 
 flammation, may no doubt do harm ; and, by increaf- 
 ing the inflammatory ftate of the urethra, may in this 
 manner produce ftriclures : but this is not the fault 
 of the remedy, but of the improper ufe of it. Similar 
 R 2 
 
244 VbftrtiBions in Chap. XXXIL 
 
 obje£lions might with equal reafon be adduced againft 
 the ufe of every medicine with which we are acquaint#. 
 ed ; for few remedies are more fafe in their operation, 
 or more effedual in the cure, than aftringent injec- 
 tions in gonorrhoea. Obftinate claps indeed are often 
 cured by injedions that cannot be removed in any 
 other way. 
 
 4. Tumors in the cellular fubflance furrounding 
 the urethra, or in any of the glands connected with it, 
 very frequently produce obllruclions in the courfe of 
 it : and inflammation, whether at firft produced by 
 gonorrhoea, or in any other way, when it terminates 
 in fuppuration, mud be apt to induce them. In fuch 
 cafes, indeed, as foon as the matter collected in the 
 abfcefs is difcharged, the obflruQion produced by it 
 is in general removed : in fome inftances, however, 
 this does not happen ; for in different cafes I have 
 found, that the compreflion produced by the tumor 
 has induced fuch firm adhefion between the fides of 
 the urethra, as to obliterate the canal entirely. In 
 which cafe, as a total Hop is put to the natural dif- 
 charge of urine, it burfts out in the perinasum, where 
 one or more openings, communicating with the ure- 
 thra, are found between the feat of the difeafe and the- 
 proftate gland. 
 
 5. Of all the caufes of obftruclion, none are fo fre- 
 quent as a fulnefs or enlargement of the corpus fpon- 
 giofuin urethrse. On dilfeding the penis of fuch as 
 have laboured long under obftrudions, a partial en- 
 largement or thickening of the fubftance of the ure- 
 thra, often appears to be the caufe, and it frequently 
 proceeds fo far as to obllru£l the paffage entirely. 
 
 In fome, the ftoppage is confined to a particular 
 point : in others, it is of confiderable extent ; while 
 not unfrequeritly it attacks different parts of the canal> 
 leaving intermediate parts perfedlly found. 
 
 6. Having thus enumerated the caufes that mofl 
 frequently produce obftrm^ions in the urtthra, I fhall 
 
Chap. XXXII. tie Urethra, 245 
 
 now endeavour to point out the treatment befl calcu- 
 lated for their removal. 
 
 When the obflruftion is produced by the preflure 
 of a tumor, our practice muft depend on the kind 
 Jind nature of the tumor. Accordingly, when the tu- 
 mors are hard and indolent, they ought to be extir- 
 pated whenever it can be done with fafety. But al- 
 though this may be done when they do not penetrate 
 deep, yet when the proftate gland, or any of the parts 
 about the neck of the bladder, are found to be enlarg- 
 ed, the removal of thefe cannot pofTibly be attempted. 
 In fuch defperate cafes, cicuta has been often ufed ; 
 but feldom, I believe, with advantage. In an ulcerat- 
 ed ftate of the parts, a plentiful ufe of uva urfi has 
 been known to give relief, and fome advantage has 
 occafionally been derived from a gentle courfe of mer- 
 cury. The effeft, however, of mercury, in all affec- 
 tions of this kind is by no means certain ; and in the 
 diftrefs that this variety of the difeafe excites, we are 
 frequently reduced to the neceflity of trufting entire- 
 ly to the relief which opiates give, and to a plentiful 
 ufe of mucilaginous drinks. 
 
 When, again, the tumors proceed from inflamma- 
 tion, if they are not foon difcuffed, the mofl elfeftual 
 means (hould be employed for bringing them to fup- 
 puration. 
 
 Thefe having been enumerated in Chapter I. it is 
 not necefl'ary to repeat them, and as foon as the for- 
 mation of matter is accomplifhed, it ought to be dif- 
 charged. In other parts of the body, when an in- 
 flammatory tumor is likely to terminate in fuppura- 
 tion, we confider it as good practice not to open the 
 abfcefs till pus is thoroughly formed ; but in this fitu- 
 ation, as much diflrefs would enfue from delay, the 
 abfcefs fliould be opened as foon as there is caufe to 
 imagine that the prefTure upon the urethra would be 
 diminifhed by doing fo ; and this mufl always be the 
 cafe when a fluduation of matter is evidently difcov- 
 ered. In all fuch cafes, we remove the obflrudioft 
 
24^ Ohjlrud-iom in Chap. XXXII. 
 
 In the urethra with more certainty by difcharging the 
 matter contained in the abfcefs than by any other 
 means. If, on laying the colleclion open, however, 
 if is found that the itoppage in the urethra is not re- 
 moved, bougies fliould be immediately employed. By 
 pafTmg a bougie of a proper fize along the urethra, 
 and allowing it to remain for two or three hours dai- 
 ly, any flricture produced by the preflure of the ab- 
 fcefs will foon be removed. 
 
 It fometimes happens, where abfceffes in this fitua- 
 tlon have been of long duration, that the urine burfts 
 into the cellular membrane of the perina?um and oth- 
 er contiguous parts, and from thence forms one or 
 more external openings. One of the mofl diflrefsful 
 fituations is in this manner induced, to which the hu- 
 man body is liable, a difeafe of which we fhall more 
 particularly confider in fpeaking of fiflula in perinaeo. 
 In the other cafes of obflruded urine, proceeding from 
 caruncles when they happen to occur ; from ulcers, 
 and the cicatrices which they produce ; from ftrifture 
 and contraction of the urethaa ; or from an enlarged 
 and thickened ftate of the corpus fpongiofum urethrse, 
 we depend almoft entirely on a proper application of 
 bougies, a, remedy that proves chiefly ufeful by its 
 mechanical adion on the obftrucled part. It has been 
 alleged, indeed, by many, particularly by Mr. Daran. 
 and Mr. Sharpe, that, in removing caruncles and oth- 
 er caufes of obftruftion, bougies prove more ufeful 
 by what they term their fuppurative quality, than by 
 any other property : by which they mean to fay, that 
 bougies may be compofed of fuch materials as will in- 
 duce a fuppuration upon the caruncles to which they 
 are applied ; and that this fuppuration, if continued 
 for a fufficient length of time, will ultimately deftroy 
 all the difeafed parts.* 
 
 * For Mr. Daran's account of this matter, fee his Treatife on Difeafes, 
 of the Urethra : and Mr. Sharpe's account of It may be feen in his Cri- 
 tical Enquiry, chap. vi. Although Mr. Sharpe is clearly of opinion, that 
 tjjie principal advantage derived from bougies proceeds from their influ-^ 
 
Chap. XXXII. the Urethra. ii^y 
 
 This idea, although founded on inaccuracy, contin- 
 ues with many ftiil to prevail : little argument, how- 
 ever is required to fhew that bougies a6t chiefly by 
 their mechanical prlTure, and not by the fuppuration 
 which they excite. Among other reafons that might 
 be given as proofs of this, I fhall only mention the 
 following. 
 
 1 . Thofe who allege that bougies prove ufeful only 
 by inducing fuppuration, are obliged to afl'irm that ob- 
 flruclions to the pafTage of urine arife mofl: frequent- 
 ly from caruncles in the urethra ; and that the fuppu- 
 ration produced by the bougies, tends to deflroy, or 
 as it were to diifolve, them ; but although thefe ex- 
 crefcences may fometimes prove the caufe of obftruc- 
 tions, yet, as I have already endeavoured to fhew, 
 they are very rarely met with. It mufl therefore fol- 
 low, if this idea of the caufe of the difeafe is ill found- 
 ed, that the fuppofed modus operandi of the remedies 
 employed in it muft likewife be erroneous ; for every 
 practitioner who gives attention to this branch of his 
 profeflion, mud acknowledge, that bougies prove 
 much more frequently ufeful than the caufe upon 
 which they have been fuppofed chiefly to operate is 
 found to exifl. Indeed, the general utility of bougies 
 in obflrudions of the urethra, mufl be acknowledged 
 by all who have ufed them, while fcarcely any advan- 
 tage is derived from any other remedy. 
 
 2. But although we fhould allow that caruncles are 
 frequently formed in the urethra, we cannot admit 
 that fuppuration induced upon them would have much 
 influence in removing them, 
 
 cnce in inducing fuppuration, yet, whenever he argues on this with accu» 
 racy, he is obliged to acknowledge, that by their preflure alone they prove 
 ufeful : for he fays, " Tliat though I have a great opinion of the good ef- 
 fcdls produced by the fuppuration, yet I believe alfo, that bougies oper- 
 ate by diftending the urethra ; and I will go fo far as to give it as my 
 judgment, that even the cures done by Mr. Daran are wrought partly by 
 diftcntion, and partly by fuppuiation'; though he himfclf afcribes theni 
 to fuppuration only." Vide page 171, fourth edition, loc. cit. 
 
248 Ohjiruaiom in Chap. XXX 11. 
 
 We know, that in other parts of the body, warts 
 and other hard excrelcences cannot be carried off 
 merely by matter being formed upon them ; and we 
 cannot fuppofe that in this there is much dift'erence 
 between warts in the urethra, and thofe wliich form 
 in other parts of the body. 
 
 3. It has been faid, that thefe bougies, while they 
 a«3: by inducing fuppuration, have likewife fome influ- 
 ence as efcharotics ; and that manv of Mr. Daran*s 
 bougies, the compofition of which was kept fecret, 
 were evidently poflefled of this property. Mr. Daran, 
 in order to render the operation of his remedy as myf- 
 terious as poflible, did indeed allege, that his bougies 
 "Were endowed with many virtues : but no candid prac- 
 titioner will fay, that bougies pofleffed of a degree of 
 cauflicity fufficient to deflroy warts, can with propri- 
 ety be palled into the urethra ; for, if of fuch a ftrength 
 as to corrode thefe excrefcences, they would neceflari- 
 ly injure the whole of the urethra to which they are 
 applied. Indeed, the mildeft materials we can employ 
 frequently ftimulate too much : for, upon withdraw^ 
 ing any bougie that has remained long in the urethra, 
 it is almoft always found covered with purulent mat- 
 ter. It is this indeed I imagine, that firfl: fuggefted 
 the idea of bougies acling by inducing fuppuration ; 
 which, however, is to be confidered only as a neceffa-n 
 ry effetl of a ftimulus applied to a fenfible membrane, 
 being in no refpe£t eifential to the cure of the difeafe 
 for which the bougie is ufed. 
 
 • 4. But without having recourfe to the fuppurative 
 or efcharotic effects of bougies, the advantages com- 
 monly derived from them may, as I have already en- 
 deavoured to Ihew, be eafily explained upon the prin- 
 ciple of mechanical prelfure alone. 
 
 I have thus thought it proper to confider the adion 
 of bougies with minutenefs ; for till the opinion is ex^ 
 ploded of medicated bougies, as they are termed, be- 
 ing neceflfary, much mifchief may be done, by forming 
 them of irritating or even of efcharotic materials, as is 
 
Chap. XXXII. the Urethra. 249 
 
 fometlmes the cafe, inftead of rendering their compo- 
 fition mild and inoffenfive, as in every inflance it ought 
 to be. 
 
 The opinion that I have endeavoured to eftablifh 
 being admitted, namely, that bougies (hould operate 
 folely by mechanical prelTure, it muft necelTarily fol- 
 low, that, in the formation of bougies, much will de- 
 pend on their being of a proper confiftence ; neither 
 too hard nor too foft. When too foft and comprefli- 
 ble, they cannot aft with advantage againft the ob- 
 ftrutting caufe, and againft which preflure is intended 
 to be applied ; and when too hard, they are apt to 
 crack, and are neither introduced into, nor retained in 
 the urethra, with fo much eafe as when formed of a 
 proper confiftence : bougies ought likewife to have a 
 fmooth poliftied furface, to facilitate their introduc- 
 tion ; and laftly, they ought, as I have already remark- 
 ed, to be compofed of very mild materials, fo that they 
 may excite as little irritation a$ poflible. 
 
 Various formulae have been given for bougie plaf* 
 ters ; and of thefe the following are perhaps the beft,, 
 No. I. 5o« Emplaft. Diachyl. fnnp. ^iv. 
 Cer. puriflT. 3ifs. 
 01. Oliv. opt. 3iii. 
 No. 2. 5>- Tniplaft. commun. 
 
 Sperm at. Cet. aa ^iv, 
 
 01. Oliv. opt. ^fs. 
 Mlnii, 5fs. M. 
 No. 3. 5" Eniplaft. commun. Jvi. 
 
 Cerx flavas purift". 
 
 Spermat. Cet. aa ^ii, 
 
 01. Oliv. opt. l\. 
 
 Antimon. crud. pp"- ^fs. M. S. A. 
 Any of thefe prefcriptions afford a good compofi- 
 tion for bougies. They require to be ilowly melted, 
 and the different articles to be well mixed together. 
 No. I. is the fimpleft, and perhaps the beft ; the red 
 lead in No. 2. and antimony in No. 3. being added 
 chiefly for the purpofe of affording a variety of col- 
 
250 OhJlruBiom in Chap. XXXII. 
 
 our. No. 4. is a compofition for bougies recommend- 
 ed by Mr. John Hunter ;* and No. 5. by Mr. Sharpe.f 
 No. 4. Take oil of oHves, three pints j 
 Bees wax, one pound ; 
 Red lead, one pound and a half. 
 Let them be boiled together on a flow fire for fix 
 hours. 
 
 No. 5. Igo. Diachyl. cum pice Burgund. Jii. 
 Argent, viv. ^i. 
 Antimon. crud. pp"- 5fs. 
 The quickfilver to be previoufly diflblved in balfam 
 of fulphur, or in honey, and added to the plafter 
 when melted in a moderate heat. 
 
 Any of thefe compofitions, when boiled to a pro- 
 per confidence, will anfwer for the formation of bou- 
 gies, which is done in the foUov/ing manner : while 
 the liquid fliil continues warm, let a piece of fine old 
 linen be dipped in it, taking care with a fpatula to 
 cover the whole. If the melted Hquor be of a proper 
 heat, no more of the plafter will adhere to the linen 
 than is neceflary ; but as air bubbles are apt to arife 
 and produce inequalities on the furface of the cloth, 
 the fpatula made ufe of fhould be fomewhat warmer 
 than the plafter, and by means of it the whole fliould 
 be made fmooth. The plafter might indeed be fpread 
 entirely with the fpatula ; but this is not only attend- 
 ed with more trouble, but it does not cover the cloth 
 with fufficient equality. 
 
 The cloth being fufficiently cold, may be immedi- 
 ately formed into bougies, and the whole fliould, in 
 the firft place, be cut into the number that is meant 
 to be made. The moft exact method of doing this is 
 bv means of a fliarp pointed knife, direfted by a rule. 
 The pieces Ihould be eleven inches in length for bou- 
 gies of a full fize ; but they fliould likewife be kept of 
 all the variety of lengths for llridures of diiierent 
 heights in the urethra. 
 
 * See Treatife on the Venereal DIfcafe, p. 137. 
 •j- Sec Critical Encjuiry by baniuci Sharpe, F. R. S. 
 
Chap. XXXII. ihe Urethra. 251 
 
 A variety of diredions have been given for the form 
 of bougies. Some advife them to be made nearly of* 
 an equal thicknefs to within an inch of their fmallefl 
 end, and to taper from that to the point, while a great 
 proportion of them are made to taper to within an inch 
 or two of the point, and the reft of them are cylindri- 
 cal. I once thought that this laft form of bougie was 
 the beft ; but after a long courfe of experience in this 
 branch of bufmefs, I am now convinced, that bougies, 
 which taper equally from one end to the other, arc 
 the beft, and that this form anfvvers equally well for 
 every variety of fize. They are introduced more ea- 
 fily, and with lefs pain than any of the others ; the 
 linen fliould therefore be cut in fuch a manner as to 
 give this form to the bougies. When rightly fprcad, 
 and the linen fufficiently fine, a well fhaped bougie 
 will be formed of a flip of about five-eighths of an 
 inch broad at its largeft end, and fomewhat more than 
 three-eighths at the fmalleft end. This forms a bou- 
 gie of a middle fizc ; for particular purpofes they muft 
 be confiderably larger, and for others not fo large by 
 a great deal. 
 
 The flips of linen are now to be rolled up as neatly 
 as pofTible with the fingers ; and in order to give them 
 a fmooth polilhed furface, they fhould be fmartly roll- 
 ed between a piece of fmooth hard timber and a plate 
 of fine poHfhed marble : this being continued till the 
 whole are rendered perfedlly fmooth and firm, and 
 their points being properly rounded, in order to facil- 
 itate introdudion, they are in this ftate to be kept for 
 ufe. 
 
 Thefe direftions will convey an idea of the method 
 of preparing bougies, but no furgeon can ever become 
 fo expert in forming them as artifts daily accuftomed 
 to prepare them in large quantities. I muft here, 
 however, remark, that bougies, properly prepared with 
 refina elaftica, are preferable in many circumfianccs 
 to fuch as are made with any kind of plafter. They 
 not only prove much more' durable, but more force 
 
i52 Ohjlrucliom in Chap. XXXIL 
 
 can be employed with them, and as they do not break 
 or crack by continuing in the urethra, they remain in 
 it with lefs pain and inconvenience than any other bou- 
 gie that has yet been invented. 
 
 Catgut has frequently been ufed as a bougie ; but 
 after various trials being given to it, I do not find that 
 it anfwers the purpofe : it cannot be made fufficiently 
 fmooth ; and it fometimes fwells fo much as to excite 
 a good deal of irritation ; and lead, which was one of 
 the firfl articles ufed for bougies, is fo firm that it al- 
 ways creates much pain, while it is fo apt to break, 
 that difierent inftances having occurred of this, it has 
 now been long laid afide. 
 
 We come now to the application of the bougie. A 
 bougie muft be chofen adapted to the fize of the paf- 
 fage through which it is to pafs, and well covered with . 
 fine oil : the penis being firmly grafped and extended I 
 with one hand, the end of the bougie muflbe inferted 
 into the urethra with the other ; and being pufhed 
 forward with caution, it is in this manner to be car- 
 ried on till it meets with the caufe of obflruftion ; 
 when, if a moderate force makes it pafs, our objecl is 
 fo far accomplifhed : but if, after different attempts, 
 it cannot be eafily carried forward, it fhould be imme- 
 diately withdrawn ; and at next trial, which, in order 
 to avoid any riflv of inflammation, fhould not be made 
 for two or three days, a bougie with a fmaller point 
 ihould be employed. 
 
 Much nicety is required in this part of the opera- 
 tion ; for, by proceeding flowly, with due care and 
 caution, eveiy riflv may be avoided of injuring the ure- 
 thra, at the fame time that the object in view may be 
 cften accompliflied with more certainty than when 
 much force is employed. As foon as we reach the 
 caufe of obfliruclion, if a bougie of the fmalleft fize is 
 employed, infl:ead of pufliing it on with force, as to a 
 certain degree may be done with a catheter, it anfwers 
 the purpole with more certainty to twirl it between 
 the finger and thumb, fo as to make it prefs moder- 
 
Chap. XXXII. the Urethra, ^55 
 
 ately upon the part that It ought to pafs. But, on 
 the other hand, ahhough mifchief has often accrued 
 from too much force being ufed with bougies, and al- 
 though every praclitioner (hould therefore be warned 
 of the danger ; yet, when much refiftance is met with, 
 they muft neceffarily be preffed on with firmnefs, ijF 
 this, however, is done with caution, and in a proper 
 diredion, which experience alone can teach, it may 
 very commonly be accomplilhed. It often happens, 
 indeed, unlefs a tolerable degree of force is employed, 
 that bougies will not pafs, and no benefit will therefore 
 be derived from them ; for unlefs they are made tq 
 pafs the point of obftruction, they cannot operate widi 
 advantage. 
 
 This, I muft obferve, is a point of much importance, 
 and ought to be kept in view. For although no un- 
 neceffary force fhould be ever employed, yet we com- 
 monly meet with too much timidity j for, in ordinary 
 practice, if the bougie meets with unufual refiftance, 
 and if it cannot, on the firft or fecond attempt, be in- 
 troduced, the cafe is commonly confidered as defper- 
 ate, and no further trials are made. I can from much 
 experience, however, fay, that few cafes occur, in 
 which bougies, by a frequent repetition of cautious 
 trials, may not be introduced. Even where I have 
 been convinced that the paftage of the urethra has at 
 a particular point been entirely obliterated by the fides 
 of it adhering to each other, and where the urine has 
 long been voided by openings in the perin^sum, the 
 bougie, with a due degree of force properly applied, 
 has at laft proved fuccefsful. 
 
 In fome inftances, bougies with fmall points will 
 pafs, when others of a larger fize will not penetrate ; 
 but, in general, when the obftruciion is found to be 
 unufually firm, thofc of a middling fize are preferable 
 to fuch as have fmall points : for bougies of this form 
 are apt to bend if thay do not pafs forward at once j 
 and as foon as the point vields in any degree, the bou- 
 gie ftiould be withdrawn, as it cannot afteivv^ards be 
 
254 ObJIruaions in Chap. XXXIL 
 
 pufhed forward ; for if more force is employed, in- 
 ftead of being carried farther into the urethra, it be- 
 comes twifted, and excites pain in the extraftion.* 
 
 By different cautious trials, the bougie will for the 
 mofl part be made to pafs the different points of ob- 
 ftru6lion ; and this being done, as bougies have fome- 
 times flipped entirely into the urethra, and even into 
 the bladder itfelf, this ought to be carefully guarded 
 againft, by a piece of cotton thread connected with the 
 extremity of the bougie, being either tied round the 
 penis behind the glans, or to a circular belt pafled 
 round the body. 
 
 Certain regulations have been held forth by authors 
 for the time that bougies fhould be kept in the ure- 
 thra : but with fome patients they excite a good deal 
 of pain, while with others they give little or none ; 
 and as it is the degree of pain that they induce which 
 ought to regulate the time that they remain in the ure- 
 thra, nothing decifive, it is evident, can be faid with 
 refpeft to it. When they excite much pain, they 
 ihould neither be allowed to remain long at once, nor 
 fhould they be ufed above once in two or three days : 
 but when they can both be eafily introduced and re- 
 tained in the urethra, they fhould be inferted often ; 
 for as it is by their preffure alone that they prove ufe- 
 ful, and as this mufi be continued for a certain length 
 of time, according to the caufe of the obftruftion, the 
 more conftantly the bougie is ufed, the more quickly 
 a cure will be performed ; and with the fame view it 
 fhould be gradually increafed in fize, till the largelt 
 can be inferted that the urethra will admit. 
 
 When bougies excite irritation, they fliould never 
 be employed but when the patient can confine himfelf 
 to his apartment ; but with many the diltrefs that they 
 induce is fo inconfiderable, that they can walk eafily 
 
 • with a view to give more firmnefs to bougies, Mr. Deafe, an inge- 
 nious furgeon of Dublin, recommends their being formed upon catgut. 
 Vide Obfervations on the diflfcrent Method* of treating the Vcucreal Dif- 
 cafe, by WiUiam Dcale, Dublin. 
 
Chap. XXXII. the Urethra, 255 
 
 with bougies of the largefl: fize inferted along the whole 
 courfe of the urethra. I always advife, however, the 
 patient to remain at reft while a bougie is in the ure- 
 thra. 
 
 Nothing certain can be faid. of the length of time 
 that bougies fliould be ufed, as this muft be always 
 regulated by their effects ; which, again, will in a great 
 meafure depend on the nature of the obftrudion. 
 This, however, I can with freedom propofe, that they 
 (hould be continued, not only while any difficulty in 
 paffmg water remains, but for a confiderable time 
 thereafter. 
 
 In the ufe of bougies, care fhould be taken not ta 
 pufh them into the bladder : for, even when prepared 
 of the beft materials, a portion of the compofition may 
 crack and fall off ; and if this (hould not pafs off with 
 the urine, it may be the caufe of much diftrefs, by 
 ferving as a nucleus for a ftone. 
 
 Flexible catheters of various kinds have been in- 
 vented for the purpofe of remaining in the urethra, 
 and for anfwering both the intention of catheters and 
 bougies. Various methods of forming thefe inftru- 
 ments have been propofed ; but the moft convenient 
 of any that I have feen, is either a tube of relina elaf- 
 tica, or one of flexible filver wire, wrapped fpirally 
 round a fteel probe of a proper length and thicknefs ; 
 and this being neatly covered with fine linen fpread 
 with bougie plafter, and the probe upon which it was 
 formed being withdrawn, the inftrumcnt is thus com- 
 pleted ; only it muft be afterwards furnifhed with a 
 filver wire or cleanfer, in a fmiilar manner with other 
 catheters. Thefe inftruments, however, do not prove 
 fo ufeful as was once expected ; but when it is ever 
 neceffary to allow a catheter to remam long in the 
 urethra, one of this flexible form anfwers the purpofe 
 exceedingly well. It muft, however, be remembered, 
 that as thefe catheters are covered with plafters, they 
 fhould not be allowed to remain long in the bladder. 
 
^5^ Objlruaions in Chap. XXXIL 
 
 for the fame reafon that bougies ought not to be in- 
 ferted into it. When it is neceflary to leave a flexi- 
 ble catheter in the bladder, thofe that are compofed 
 of refina elaflica fliould be employed, as the adhefive 
 property of this fubflance prevents it from cracking 
 and falling off, as plaflers of every kind very com- 
 monly do. 
 
 When fpeaking of the formation of bougies, I have 
 faid, that as it is chiefly by mechanical preffure they 
 prove ufeful, fo a proper confiftence is the principal 
 circumfl:ance to be kept in view in their compofition. 
 This, I mufl; again fay, fliould be our leading objeft 
 in the employment of bougies : but when there is rea- 
 fon to think that chancres, or venereal .ulcerations, 
 exifl: in any part of the urethra, as nothing would 
 cicatrife the ulcers fo quickly as a local application of 
 mercury, a large proportion of quickfilver extinguifli- 
 ed in honey may with advantage be added to the 
 compofition, as in the formula given above. No. 5. 
 As mercury in this fl:ate excites little or no irritation, 
 it may be ufed with freedom. Red precipitate in fine 
 powder has alfo been advifed as a proper ingredient 
 in bougies, not only to be applied in this manner to 
 ulcers in the urethra, but with a view to corrode oth- 
 er caufes of obfl:ruction : this, however, is a practice 
 that ought to be laid afide, as the precipitate is very 
 apt to fl;imulate and inflame the membrane of the 
 urethra. 
 
 I have thus entered fully into the confideration of 
 the ufe of bougies. Indeed, too much attention can- 
 not be given to a praftice from which fuch important 
 advantages may be derived : for by a proper applica- 
 tion of bougies, almofl: every caufe of obfl:ruci:ion that 
 I have enumerated may be either cured, or at leaft 
 greatly relieved ; and were it not for the advantages 
 derived from bougies, almofl: every cafe of ob(lru6;ion 
 would terminate in the. moil complete degree of 
 mifery. 
 
Chap. XXXII. ihe XJtethr.a. 257 
 
 Before concluding the fubject, I mud not omit to 
 mention the effed of bougies in fome cafes of trouble- 
 fome gleets. Whenever this kind of difcharge is kept 
 up by an excoriation or flight ulceration of the ure- 
 thra, or by any of the common caufes of flridure, as 
 is fometimes the cafe, no remedy proves fo effeftual as 
 bougies ; and even in ordinary cafes of gleet, proceed- 
 ing from a relaxed flate of the excretory duds open- 
 ing into the urethra, nothing proves more certain- 
 ly ufeful than the compreflion induced by bougies. 
 Whether they operate by affording fupport to the re- 
 laxed membrane of the urethra, or by inducing fome 
 degree of inflammation upon the parts affetted, 1 know 
 not ; but in many inltances of obilinate gleet, bougies 
 have been found to anfwer, when other remedies have 
 failed. 
 
 Hitherto I have confidered obflruftions of the ure- 
 thra in male fubjeds only ; but the fame difeafe alfo 
 occurs in women : even in females, bougies are oftea 
 ufed with advantage ; but in women, tumors of fuch 
 a fize fometimes form in the urethra, as cannot pofli- 
 bly be cured by this remedy ; and as the urethra iti 
 females is not only fhort, but much wider than in 
 men, thefe tumors may in them be often removed, 
 either with ligatures or with the fcalpel. Nay, we 
 know from experience, that a tumor adhering even to 
 the bladder itfelf, may, in women, be taken off with 
 fafety. In fuch cafes, there is a neceffity for laying 
 the urethra open ; which may be done at either of the 
 fides, and without any rifk of wounding the vagina ; 
 and if an incifion is here made with freedom, any tu- 
 mor fituated even near to the neck of the bladder, 
 may be fo far pulled down as to admit of the applica- 
 tion of a ligature ; and whenever this "can be done, 
 the attempt may be made without hazard. 
 
 A remarkable inftance of this is related by Mr, 
 Warner, where a tumor of the fize of a turkey's ^^^^ 
 produced from the internal membrane of the bladder. 
 
 Vol. III. S 
 
258 OhJlruEl'iom In Chap. XXXII* 
 
 was extirpated with a ligature, and with mofl com- 
 plete fuccefs.* When fuch tumors are not fo large as 
 totally to ob(lru£l the urine, or to be productive of 
 much dillrefs, a prudent practitioner would rather de- 
 cline to meddle with them. But when the reverfe of 
 this is the cafe, and when the urine is paffed with dif- 
 ficulty, neceflity points out the propriety of this ope- 
 ration ; and it mufl be comfortable for a patient, in a 
 fituation that would otherwife be defperate indeed, to 
 know that a remedy can with fafety be employed from, 
 which a cure may be obtained. 
 
 It has been advifed even by practitioners of reputa- 
 tion, when obftructions of the urethra proceed from 
 caruncles, or carnofities, as they are termed, to deflroy 
 them with lunar cauftic ; and inftruments have been 
 invented for applying the caufhic to the difeafed parts, 
 Plate CXV. jfigs. i. 2. and 3 : but the rifk of injuring 
 the contiguous parts, even when the cauftic is guard- 
 ed in the mod cautious manner, is evidently fo great, 
 as muft for ever prevent the pradtice from getting in- 
 to general ufe. 
 
 This I flill venture to predict, notwithftanding all 
 that has been faid by Mr. Everard Home in recom- 
 mendation of the ufe of cauftic : Mr. Home has no 
 doubt removed obftruCtions in the urethra with cauf- 
 tic ; but he has fo frequently failed, after putting pa- 
 tients to fevere pain, and after the moft complete tri- 
 als were given to his plan, that wherever it has fuc- 
 ceeded, I have much reafon to believe that due perfe- 
 verance in the ufe of common bougies would have 
 anfwered equally well ; while no rifk, and not the 
 twentieth part of the pain, would have been the effeCl 
 of their application : the cleareft proof, indeed, that 
 can be given of the inefficacy and danger of the ufe 
 of cauftic in obftruCtions of the urethra, is obtained 
 J|"om its having been laid afide after being put fully 
 
 ^ Vide Cafca and Remarks io Surgery, by Jofeph Warner. 
 
Chap*XXXn. the Urethra, 259 
 
 to the tefl: of experience more than a century ago, as 
 well as from the practice being ftill confined almoft 
 entirely to the hands of Mr. Home ; no praditioner 
 of experience of whom I have heard, either in Lon- 
 don, here, or elfewhere, having been induced to adopt 
 it, after all the trials that have been made with it : 
 this I have been led to fay from the baneful influence 
 which I have much reafon to believe would refult 
 from the ufe of cauftic in difeafes of the urethra, were 
 the pradice ever to be generally adopted ; and I fpeak 
 to its inefficacy, not from doubtful fpeculation, but 
 from ample experience. 
 
 S Z 
 
1 
 
 t6<y Of the Fiftula • Chap. XXXIII. 
 
 CHAPTER XXXIII. 
 
 OF THE FISTULA IN PERIN^O, 
 
 BY the term fiftula in perinsco is meant, a finuou* 
 ulcer of this part, communicating moft frequent- 
 ly with the urethra only, but in fome inftances direct- 
 ly with the body of the bladder. The term, however, 
 is not fhridlly confined to this acceptation ; for it is al- 
 fo applied to fome ulcers of this part that communi- 
 cate with the fcrotum and penis. 
 
 The term fiflula fliould with propriety be reftrifted 
 to that variety of fmus in which the edges of the fore 
 have become hard and callous ; but cuftom now ap- 
 plies it indifcriminately to every ulcer that is not fuper- 
 ficial, but which lies deep, and difcharges its contents 
 by one or more narrow openings in the external teg- 
 uments. 
 
 In confequence of the latitude given to the mean- 
 ing of the term fiftula, many appearances are exhibit- 
 ed under this general denomination of fiftula in peri- 
 naeo. In fome, a fingle opening is met with in the 
 teguments of the peringeum or penis, difcharging mat- 
 ter mixed with urine : this, in fome inftances, is not 
 pven accompanied with hardnefs or inflammation of 
 the contiguous parts, but in others, inftead of this 
 fimple form of the difeafe, along with one or more ex- 
 ternal openings communicating with the urethra, at 
 which all, or at leaft the greateft part, of the urine is 
 pafTed, the parts contiguous to thefe openings are 
 much difeafed. In fome they are found merely hard 
 or callous, without much enlargement ; but in others 
 they are not only hard, but much fwelled, inflamed, 
 and painful. In a fev/, this hardnefs and enlargement 
 is confined to a fmall fpace ; but moft frequently. 
 
Chap. XXXIII. in Perlnao, s6i 
 
 when the difeafe has been of long continuance, it ex- 
 tends nearly from the anus to the fcrotum, reducing 
 the whole perina^um to a ftate of callofity. In many, 
 the malady does not ftop here : the fcrotum, and even 
 the penis, becomes difeafed ; and when the urine at 
 laft efcapes into the cellular fubftanCe of thefe parts, 
 particularly when it lodges in the fcrotum, it never 
 fails to excite a great deal of mifchief. 
 
 In confidering this difeafe, the caufes by which it 
 may be produced, firft merit attention. They are in 
 general as follow : 
 
 1. AVounds and other injuries of the urethra and 
 bladder, in whatever manner they may be produced. 
 
 In the old method of performing lithotomy by the 
 apparatus major, the parts were fo much bruifed and 
 lacerated, that the wound feldom healed kindly, and 
 frequently became fillulous ; but when the operation 
 is well performed, according to the prefent improved 
 method, this feldom happens. From fome caufe or 
 other, however, it happens in a few inflances, that the 
 urine does not flow freely by the penis ; and finding 
 a ready pafl'age by the wound, it continues to come 
 off in this manner, till the edges of the fore becoming 
 callous, the difeafe in queftion is produced. In fome, 
 a direft communication is kept up between the neck 
 of the bladder and the fore ; but in others, the urine 
 paffes firfl into the urethra, and from thence is dif- 
 charged by the wound in the perinasum. 
 
 Filtulous openings are fometimes the confequence 
 of incifions made into the urethra, for the purpofe of 
 extrading (tones that lodge in it. 
 
 2. Inflammation in any part of the urethra, by 
 whatever caufe it may be induced, if it terminates in 
 an abfcefs, is very apt to corrode the membrane of 
 this canal, and to produce a fmuous opening, at which 
 the urine is difcharged. This, I may remark, is not 
 an unfrequent confequence of virulent gonorrhoea : 
 for wh^n the infiammation fprcads along the perinse- 
 um towards the anus, if it be not quickly removed by 
 
262 Of the Fijiula Chap. XXXIII. 
 
 bloodletting, and fuch other means as are employed, 
 it is very apt to terminate in fuppuration. 
 
 Abfcefles that form originally in the foft parts about 
 the anus, are alfo known to give rife to it, by exciting 
 inflammation and ftriclure, terminating in fuppuration, 
 in the cellular fubftance connefted v^^ith the urethra. 
 
 3. The feveral caufes enumerated in the laft Chap- 
 ter inducing obftruftion of the urethra, by impeding 
 the free difcharge of the urine, frequently give rife to 
 the difeafe now under confideration ; and according- 
 ly we find that fiflulous fores in the perinseum are 
 very commonly connected with an obftructed Hate of 
 the urethra. 
 
 As the difeafe may thus be induced by various cau- 
 fes, it is neceffary to have thefe in view in the courfe 
 of the cure. In order, however, to render this very 
 perplexing branch of practice as obvious and fimple 
 as poffible, it is necelfary to remark, that the diS'erent 
 caufes that I have enumerated, tend to the produdion 
 of the difeafe by two general effefts only : 
 
 1. By the formation of a paffage dire6lly into the 
 urethra or bladder, either by external violence, or by 
 the deftruclion of part of the membrane of the ure- 
 thra, as a confequence of ulcers feated in it, or of mat- 
 ter colleded in abfcelfes tending to abrade i^s fub- 
 ftance ; this, we fuppofe, may occur, independently 
 of any obftruction to the paifage of the urine. 
 
 2. By the fole influence of obftructions in the urci- 
 thra : thefe, by putting a ftop to the free evacuation 
 of urine, at firfl induce a fulnefs and tenfion of the 
 urethra, which, if not quickly removed, very com^ 
 nionly terminates in a complete rupture of this canal. 
 
 In the treatment, therefore, of this difeafe, we are 
 to be directed by one or other of thefe general effects ; 
 and it is to be remarked, that in no difeafe is it of 
 more importance to difliinguifli accurately between the 
 caufes by which it is induced. When the opening in 
 the urethra has been produced by previous obftrucr 
 tion, no external application, nor any remedy diredt« 
 
Chap. XXXIII. in Pcrinae. 263 
 
 ed to the fyflem, will have any efFed ; while a proper 
 and long continued ufe of bougies, by removing the 
 obftruftion, will feldom fail. And, on the other hand, 
 when the difeafe has not originated from obftrudion, 
 but has been induced by a fimple opening in the ure- 
 thra, bougies are not only very unneceflary, but fre- 
 quently do harm. This, I muft obferve, is a diftinc- 
 tion not fufficiently attended to in pradice. Affec- 
 tions of this kind are commonly treated with bougies 
 only, whatever may have been the caufe by which 
 they were induced ; but we (hall foon make it appear 
 that this muft frequently be wrong. 
 
 In the cure of hftulous fores of thefe parts, it is a 
 matter of the firft importance to diftinguifh between 
 fuch as are merely local, and thofe that are connedted 
 with any general difeafe of the fyftem. For however 
 well our means of cure might be direded to the topi- 
 cal management of the fores, if the patient at the fame 
 time laboured under lues venera, fcrofula, or fcurvy, 
 no permanent cure could be expeded, if the difeaf<j 
 of the conftitution were not to be removed. 
 
 Where a filtulous fore is produced by ftridlures ii^ 
 the urethra, bougies is the only remedy we can truft j 
 and when properly applied, they very commonly fuc- 
 ceed. They ought to be continued till the ftridures 
 are entirely removed, when the urine being freely and 
 eafily paffed, the fores which the ftrictures had induc- 
 ed, very commoly heal ; but when they do not heal, 
 the cure is for the moft part found to be checked by 
 the edges of the fores having become hard or callous ; 
 and till this ftate of the parts is removed, no progrefs 
 towards amendment is to be looked for. 
 
 We are therefore to deftroy thefe callous edges of 
 the fore, as foon as it is found that the bougies do not 
 fucceed ; and the method of doing it this : the patient 
 muft be laid upon a tiible, in nearly the fame pofture 
 as in the operation of lithotomy ; and a ftaff being in- 
 troduced into the urethra, and made to pafs the open- 
 ing at which the urine is difcharged, it is in this fitua- 
 
264 Of the Fijiula Chap. XXXIII. 
 
 tion to be held firm by an affiflant ; while the furge- 
 on, introducing a fmall probe or diredor at the exter- 
 nal opening of the fore, and cutting upon it in the di* 
 reOiion of the finus, is thus to lay it open through its 
 whole length, till it terminates either in the urethra, 
 or, if neceffary, in the bladder itfelf. 
 
 When more fmufes than one are difcovered, they 
 muft all be laid open in the fame manner. In fome 
 inftances, we meet with difl'erent fmufes in the cellu- 
 lar membrane, leading from one opening in the ure- 
 thra ; while, in others, there are as many openings in 
 the urethra as external fores or finufes. This, howev- 
 er, is uncommon : but this is not a matter of import- 
 ance, as the fame method of treatment anfwers equal- 
 ly well in both j for whether the different fmufes orir 
 ginate from one common opening in the urethra, or 
 not, they ought all to be laid open from one end to 
 the other. 
 
 In general, this fimple divifion of the fmufes would 
 prove fufficient ; but when any of the parts through 
 which they run, have become uncommonly hard, a 
 fmall portion of the difeafed parts, contiguous to the 
 fores, Ihould be removed with the fcalpel. This, how- 
 ever, is not always neceifary, as the inflammation and 
 confequent fuppuration, induced by the mere divifion 
 of the fmus, very commonly removes every flight de- 
 gree of callofity ; but when the hardened parts are ex- 
 tenfive, and too coniiderable to be removed in the 
 courfe of the fubfequent fuppuration, fuch a propor^ 
 tion of them fhould be cut off with the fcalpel, as might 
 not probably be removed in this manner. This, how- 
 ever, is a point on which nothing decifive can be faid ; 
 for the neceflity of removing a portion of thefe difea- 
 fed parts, and the quantity to be removed, mufl:, in all 
 fuch cafes, be left to the judgment of the operator. 
 
 After all the fmufes have been freely divided, the 
 {lafF fliould be withdrawn, and the divided parts gentr 
 ly feparated, by the introdudion of foft lint fpread 
 with any emoUient ointment, in order to prevent theiy 
 
Chap. XXXIII. in Pcrlnao. 16^ 
 
 immediate reunion. But although fome eafy applica- 
 tion fnould for this purpofe be inferted between the 
 lips of the wound, it ought to be done with caution ; 
 for {luffing or cramming the fores, as is fometimes 
 done, always does harm, and often renders all the oth- 
 er fteps of the operation abortive. The fores are now 
 to be covered with a pledget of emollient ointment ; 
 and>proper compreffes being applied over it, the T 
 ban^ge fliould be employed to retain them. 
 
 About twenty-four hours after the operation, the 
 outward coverino^s fliould be removed, and an emol- 
 lient poultice applied over the dreffings ; and as foon 
 as a free fuppuration has taken place, the whole fliould 
 be removed, and light eafy dreilings continued till the 
 fores are healed, by a proper adhefion of the parts at 
 the bottom of each. 
 
 A very important part of the cure is found to con- 
 fift in the dreffings being duly applied. Indeed, reg- 
 ular dreffings are of fuch importance, that, without 
 this attention, all the previous fteps of the operation 
 avail nothing. It is chiefly, indeed, by more attention 
 being given to this in private praQ:ice, than can eafily 
 be done in hofpitals, that we prove more fuccefsful 
 with private patients in the treatment of fores of this 
 defcription. 
 
 I have not yet mentioned the ufe of bougies, nor of 
 the catheter, as a necefl'ary part of the treatment fub- 
 fcquent to the operation ; and in this I fliall pcffibly 
 appear to be Angular ; for we are commonly advifed 
 to keep a bougie confl:antly inferted from the time of 
 the operation, excepting at the time of voiding urine, 
 when a catheter is advifed to be employed ; and in 
 order to avoid the trouble of withdrawing the one, 
 and inferting the other, fome praditioners advife a 
 flexible catheter to be kept in the urethra from the 
 firft. 
 
 The advantages fuppofed to accrue from the ufe of 
 bougies here, is the prevention of any undue contrac- 
 tion of the urethra j and by the catheter it is meant 
 
a66 Of the Tijlula Chap. XXXIII. 
 
 to prevent the urine from pafllng off by the fore dur- 
 ing the cure. Thefe motives, for ufmg both the one 
 and the other, are plaufible ; and they have accord- 
 ingly been generally adopted. I am free to confefs, 
 too, that, following the example of others, I have oft- 
 en employed both the catheter and bougie ; but I can- 
 Bot fay that I ever did fo with advantage, and I have 
 often feen them do much harm. By diftending the 
 urethra, the fores do not fo readily heal ; and if the 
 Catheter does not pafs fully into the bladder, part of 
 the urine, in coming off, almoil conftantly paffes be- 
 tween it and the urethra, fo as to get accefs to the 
 wound, by which it does more harm to the fore, than 
 if no catheter had been ufed : and, again, if a cathe- 
 ter is paffed entirely into the bladder, and kept long 
 in this fituation, it almoft conftantly does harm, by 
 inducing pain, inflammation, and fwelling about the 
 neck of the bladder. 
 
 But whoever will go freely into a different practice, 
 and will endeavour to cure this kind of fore without 
 the aid of thefe inftruments, will foon find that they 
 are not neceffary ; and that the wound in the urethra, 
 from the operation that I have defcribed, is in general 
 more eafily cured, without the affiftance either of bou- 
 gies or catheters, than when they are employed ; for 
 inftead of forwarding the cure of the fore, they uni- 
 formly tend to retard it, by tearing open fuch adhe- 
 fions as nature, if left to herfelf, would have made al» 
 together complete. 
 
 This, I muft again remark, is a point of much im- 
 portance, and merits all poffible attention. The ufe 
 of the bougie, in all fuch cafes, is at prefent fo univer* 
 fal, that the cure of a fiftula in perinseo by an opera- 
 tion, is almoft never attempted, but where bougies are 
 at the fame time employed ; but, from much experi- 
 ence in this branch, I am now convinced that many 
 more would be cured, if the bougie and catheter were 
 Jooth laid afide. 
 
Chap. XXXIII. in Perinao. aSy 
 
 In real obftruclions of the urethra, bougies, as I 
 have faid, are almofl: the only remedy to be trufted ; 
 but they are of no farther ufe after thefe obftruclions 
 are deftroyed : when, therefore, a fiftulous opening 
 remains after the obftruftions are removed, or, when 
 no ftrifture or obftrudion exifts, the operation that I 
 have defcribed ought alone to be depended on ; and 
 in this part of the cure bougies ought never to be em- 
 ployed. 
 
 But it is faid by thofe who patronife the ufe of the 
 bougie and catheter, that if the urine is allowed to pafs 
 out by the fore, the cure will be thereby, if not alto- 
 gether prevented, at leaft much retarded. To this it 
 may be anfwered, that after the operation of lithoto- 
 my, we do not find the cure retarded although the 
 urine comes at all times into immediate contaft with, 
 and during the firft days after the operation pafles con- 
 ftantly off by the wound. In what manner this is ef- 
 fected, I fhall not at prefent determine ; but that the 
 fad is fo, no pradlitioner will deny : and from all the 
 experience that I have had, openings in any other part 
 pf the urethra, require no more ailiftance from bou- 
 gies or catheters, than they do in that part of it which 
 is divided in lithotomy ; and every lithotomift, I be- 
 lieve, would fpurn at the idea of keeping a catheter 
 conftantly in the bladder after this operation, in order 
 to prevent the urine from pafllng off by the wound. 
 
 It happens, indeed, in a few cafes of lithotomy, that 
 a contracted ftate of the urethra is produced by the 
 cicatrix of the fore : in this fituation, after the parts 
 are firmly united, bougies prove fometimes ufeful by 
 removing the ftridure ; and in particular inltances, 
 where the fore does not heal, by the urine continuing 
 to pafs by the wound, in confequence of ftridures or 
 adhefions in the urethra, the bougie is employed with 
 advantage even during the progrefs of the cure. But 
 thefe arc rare occurrences, and no practitioner has ev» 
 er recourfe to bougies, till fome degree of obftrudion 
 
263 ' Of the Fijlula Chap. XXXIIL 
 
 has actually taken place-: in the fame manner they 
 iliould never be employed in this operation, till the 
 propriety of ufmg them is pointed out by the forma- 
 tion of fome deijrce of obftrufticn. 
 
 When the parts of which the perinasum is formed 
 have become hard and otherwife difeafed, before any 
 operation fuch as I have defcribed is advifed, we are 
 commonly directed to a long continued ufe of poulti- 
 ces ; mercurial fridions ; and the ufe of refolvent gum 
 plafters. So far, however, as I have obferved, Httle 
 or no advantage is derived from this ; for any fuppu- 
 ration which it excites, is, in general partial, io that it 
 has little effe6t in removing the hardnefs for which it 
 was employed. 
 
 And, again, when the hardened parts are extenfive, 
 and when no relief is obtained from the difcutient 
 remedies that I have mentioned, we are in general ad- 
 vifed to cut them entirely av/ay with a fcalpel. There 
 is no neceffity, however, for this meafure ; for al- 
 though it may be proper to remove the edges of the 
 fores when they have become callous, there is never 
 any good caufe for extirpating all the difeafed parts : 
 it would frequently be a painful and cruel operation ; 
 and as it could feldom be of any real advantage, it 
 ought rarely, or never to be practifed. 
 
 When, again, a preternatural opening is formed in 
 the urethra, either by external violence or the abrafion 
 pf its fubftance by abfceffes feated in it, a different 
 courfe of treatment becomes neceffary. When pro- 
 duced by an abfcefs in the perin?2um, or in any part 
 of the urethra, a free difcharge fhould be given to the 
 matter ; every part of the cellular fubftance in which 
 it is Jbund to lodge {hould be laid open ; and warm 
 fomentations and poultices Ihould be applied to fuch 
 inflammatory tumors as have not fuppurated. In this 
 manner, fores, which if negledled, would prove high- 
 ly diftrefsful, are often made to heal eafily ; but when 
 even by thefe means the fores do not unite, and con- 
 
Chap. XXXin. in Perinao, 269 
 
 tinue to difcharge matter, and efpecially when their 
 edges become hard and callous, the finufes muft: be 
 laid open, and every other part of the cure condudled 
 in the manner that I have ah"eadv advifed. 
 
 This kind of fore when produced by wounds of the 
 urethra, requires a fimilar method of cure. By the 
 removal of extraneous matter, and by the ufc of poul- 
 tices to abate inflammation, a cure will often be ac- 
 compliflied without any other alliftance ; but, when 
 the Itate of the fores requires it, they ought to be laid 
 open, and treated in every refped like other cafes oi 
 fiftula. 
 
 The moft diftrefsful variety of this kind of fore, is 
 that in which the urine pafles off diredly from the 
 body of the bladder without communicating with the 
 urethra. This variety of the difeafe, I may remark, 
 is readily diftingu idled from the other by the urine 
 drilling off infenfibly and at all times ; whereas, when 
 the external opening does not communicate direftly 
 with the bladder, and when the urine paffes firit 
 through part of the urethra, the patient has common- 
 ly the power of retention in full perfection ; by which 
 his fituation is much more comfortable than when the 
 urine is conftantly paffmg off. But although this va- 
 riety of the difeafe is eafily diftinguifhed from the oth- 
 er, it is not fo readily cured ; for the fmufes from 
 whence the urine is difcharged communicate diredly 
 witii . the bladder, and nothing tends to remove them 
 but laying them open to the bottom. 
 
 When, therefore, a patient diftreffcd with this kind 
 of fore, finds his fituation to be fuch as to make the 
 pain and rifk of fuch an operation an eligible alterna- 
 tive, it ought certainly to be advifed, as the only means 
 from which any relief is ever likely to be derived. 
 
 As the intention and principle of this operation are 
 the fame as of that in which the urethra only is con- 
 cerned, all that need be faid in regard to the mode of 
 performing it is, that a fluff fliould be introduced into 
 
270 Of the Fi/iula in Pennao. Chap. XXXIIL 
 
 the bladder ; the different fmufes fhould be laid free-" 
 ly open to the bottom ; their edges, if callous, Ihould 
 be removed to fuch a depth as can be done with fafe- 
 ty, and the wounds thus produced fliould be lightly 
 dreffed, in the manner I have already pointed out. 
 
 In this manner, a great proportion of this variety 
 of fore may be cured, provided the means are employ- 
 ed in due time, and duly perfifted in : but in long 
 continued fillulous fores of thefe parts, where the fur- 
 rounding cellular membrane has become much hard- 
 ened, and otherwife dil'eafed ; and efpecially, when 
 the fyftem is tainted with fcurvy, fcrotula, or lues ve- 
 nerea ; it mufl be acknowledged that no means with 
 which we are acquainted will prove at all times fuc- 
 cefsful. 
 
Chap. XXXIV. Of Hemorrhoids^ l^c, i-]\ 
 
 CHxVPTER XXXIV. 
 
 pF HAEMORRHOIDS, OR PILES. 
 
 THE term hcEinorrhoids, or piles, was at one time 
 applied to ever)^ evacuation of blood from the 
 veins running upon and in the neighbourhood of the 
 redum ; but a mere diftcntion of thefe veins, when 
 productive of pain, now receives the fame denomina- 
 tion. 
 
 As long as the difeafed parts of the veins remaii¥ 
 diftendcd, and do not difcharge any part of their con* 
 tents, the piles are named cascae or blind ; but whea 
 they burft and difcharge blood, they are termed aperC 
 or open. 
 
 It frequently happens, that a difcharge of blood ujv 
 on going to ftool is the firft warning or appearance of 
 this difeafe : for although in fome inflances it is oth- 
 erwife, yet when the parts of the veins chiefly affecled 
 lie high in the reftum, the pain or uneafmefs which 
 they excite is for the moft part inconfiderable, owing 
 to the veins in this fituation being furrounded with, 
 parts which from their foftnefs readily yield to their 
 diftention ; whereas, when the difeafe occurs at the 
 end of the gut, as the inteftine is here furrounded with 
 a firm mufcular covering, the fpliindler ani, a good 
 deal of refiftancc is thereby given to the formation o£ 
 ha^morrhoidal tumors, and they accordingly in this 
 fituation almoft always excite a great deal of diftrefs. 
 
 When piles are fo fituated as to be within view, if" 
 they have begun to dil'charge blood, one or more 
 fmall openings are obfcrved, from whence the blood 
 is poured out : when the parts have not been previ- 
 oufly much diftendcd, thefe openings appear to be the 
 mouths or outlets of veins j and the openings from 
 
37a Of Hamorrhcids, Chap. XXXIV. 
 
 whence the blood proceeds, are each of them obferv- 
 ed to be feated upon a fmall protuberance arifing from 
 the internal coat of the gut. In general, thefe tu- 
 mors, when they difcharge freely, are fmall, being 
 feldom larger than an ordinary pea ; but when any 
 obftrudion occurs to the difcharge of their contents, 
 they gradually increafe, till in Ibme inftances they 
 arriv^e at the fize of pigeons or pullets eggs, when by 
 the pain, irritation, and tenefmus, which in fuch a 
 (late they always excite, much diftrefs and mifery are 
 produced by them. Even when the tumors at lafl 
 burft: and difcharge their contents, if they have previ- 
 Gufly become large, they do not disappear entirely : 
 on the contrary, they ftill continue of nearly the fame 
 fize ; they aflume a livid appearance ; and inflcad of 
 being foft or elaflic, they are firm and of a flelhy con- 
 fiflence. 
 
 As long, however, as hsemorrhoidal tumors remain 
 fhut, they are foft and yielding to the touch, infomuch 
 that by preflure they can commonly be much dimi. 
 nifhed ; their colour is flill more livid than that of the 
 apert kind, and they are commonly more painful : for 
 although they do not ufually become large before 
 burfling ; yet when they lie deep, and are thickly 
 covered with firm unyielding parts, the tumors are in 
 fome inflances of fuch a fize, as almoll entirely to ob- 
 ftrucl the pafliige of the faeces ; and as a tenefmus is 
 a common fymptom in this flate of piles, the diftrefs 
 produced by the frequent inclination to go to flool, 
 together with the difficulty of the evacuation, never 
 fail to induce a great deal of mifery. 
 
 Thefe tumors have commonly been fuppofed to pro- 
 ceed from a mere dilatation of the hsemorrhoidal 
 veins. In the incipient ftate of the difeafe, while they 
 remain fmall and circumfcribed, this m.ay frequently 
 be the cafe ; but whenever they become large, they 
 will almofl conftantly be found to be connefted with 
 an effufion of blood into the contiguous cellular fub- 
 itance. 
 
Chap. XXXIV. * cr Piles. 273 
 
 As long as piles remain fmall, foft, and compeffif 
 ble, we may conclude, that the blood ftill remains 
 within the cavities of the veins ; but v.henever they 
 become large, and of a firm flefliy confiftence, the 
 blood, as I have juft obferved, uill, in almofl every 
 inflance, be found effufed into the neighbouring parts. 
 
 Various conjedures have taken place on the nature 
 of the ha^morrhoidal difcharge : but the mod prevail- 
 ing opinion is, that it is commonly of a critical na- 
 ture ; that it is induced by the prefence of fome pec- 
 cant or morbific matter in the fyftem ; and that there- 
 fore it would, in general, be improper to put a (top 
 to if. 
 
 It does not, however, require minute inveftigatioa 
 to fhew, that this reafoning is ill founded : for were 
 we even to allow, that the piles commonly appear 
 without the intervention of any evident occafional 
 cacfe, and that they are in reality connected with fome 
 morbific humor in the blood, in what manner can we 
 fuppofe this difeafed matter to be feparated and dif- 
 charged by the htemorrhoidal flux ? Now that the cir- 
 culation of the blood is well underltood, it will be dif- 
 ficult for the fupporters of this opinion to give a fatif- 
 faclory anfwer to this quedion. But, independent of 
 this, we know that piles are very commonly induced, 
 perhaps in nineteen cafes of twenty, by an obvious 
 caufe ; and that the removal or prevention of this, 
 when effeded in due time, almoft conflantly prevents 
 or cures the difeafe. In a great proportion of cafes, 
 piles will be found to proceed from compreffion upon 
 the ha^morrhoidal veins ; by which the blood contain- 
 ed in them being impeded in its progrefs to the heart, 
 dilatations of thefe veins, and fubfequent efFufions, are 
 confequences that necellarily enfue. 
 
 The moil frequent caufes of this compreffion are, 
 large collections of hard faeces in tlie redum ; the 
 prefiure produced upon the neighbouring parts, in 
 
 Vol. III. T 
 
^74 Of Hanhdrrholds, Chap. XXXIV* 
 
 pregnancy, by the gravid uterus \ and laRly, tumors, 
 of whatever nature they may be, which, from their 
 fituation, comprefs the hscmorrhoidal veins. Thus 
 piles are not an unfrequent effeQ: of fchirrous tumors 
 in the rectum, and of fimilar aifedions of the proftate 
 gland and bladder ; and I have fometimes traced them 
 as the confequence of fwellings in the mefenteric 
 glands, which alfo a£t by obllructing the refluent vef- 
 fels in their courfe from the rectum. 
 
 When tumors in the contiguous parts are found to 
 produce the difeafe, the means of cure muft be direft- 
 ed particularly to the removal of thefe. When preg- 
 nancy is the caufe, gentle laxatives, and a frequent 
 recumbent pofture, will often afford relief; but noth- 
 ing will remove the difeafe till delivery takes place. 
 And, again, when piles have been induced by coftive- 
 nefs, a regular ufe of gentle aperients, fuch as cream 
 of tartar and oil of caftor, will very commonly pro- 
 cure relief. But when the parts inflame and become 
 painful, fuch remedies muft be employed as are known 
 to be moft powerful in removing, or even preventing 
 the effects which thefe fymptoms ufually induce. If 
 much fever prevails, blood fhould be difcharged in 
 proportion to the ftrength of the patient ; and it an- 
 fwers beft when taken by means of leeches applied as 
 near as poffible to the feat of the pain : nay, I often 
 apply them upon one or more of the hjemorrhoidal 
 tumors, and very commonly with much advantage : 
 the pained parts fhould be frequently bathed with a 
 mild folution of faccharum faturni ; and the patient 
 fhould be kept upon a low, cooling regimen. 
 
 I here think it proper to mention two remedies that 
 I have often ufed with advantage in cafes of piles. 
 The one is an ointment compofed of equal parts of 
 oak galls finely powdered, and hogs lard or butter : 
 this commonly gives more relief in external hsemor- 
 rhoidal fwellings, than any of the fulphur ointments 
 fo frequently employed; and when the feat of the 
 
Chap. XXXIV. e>r Piles, iy^ 
 
 pain is internal, and cannot be reached by an oint- 
 ment, injeftions of a ftrong intufion of galls may be 
 ufed inftead of it. The other is a remedy that I firft 
 employed on the fuggefton of our late jultly celebrat- 
 ed profclfor Dr. Cullen ; balfamum copaibae. This 
 medicine, given to the extent of fifty, fixty, or eighty 
 drops, morning and evening, not only removes the 
 pain fo frequently produced by piles, but very com- 
 monly anfwers as an eafy and certain laxative. 
 
 Warm emollient fomentations and poultices fome- 
 times give relief in piles, but as they tend, when long 
 continued, to excite relaxation in the contiguous parts, 
 by which very large defcents of the gut are produced, 
 they (hould in every inftance be foon laid afide. 
 
 By the ufe of one or other of thefe remedies, all 
 the ordinary fymptoms of piles will in general be re- 
 moved : but there are fome ftates of the difeafe that 
 can only be relieved by a chirurgical operation ; and 
 thefe particularly are, frequent returns of profufe eva- 
 cuations of blood from the ha^morrhoidal veffels, and 
 the piles becoming fo large as to induce much pain, 
 irritation, and even obftruclion in the under part of 
 the reftum. 
 
 When frequent returns of h^emorrhagy have weak- 
 ened the fyftem too much ; and when bloodletting, 
 gentle aperients, and a proper regimen, do not prove 
 effectual, our next refource is to put a flop to the dif- 
 charge by the direct application of preiTure to the 
 mouths of the bleeding veffels. In flight cafes of piles, 
 this may frequently be done by a tube of filver wrap- 
 ped properly round with foft linen, being pafTed into 
 the rettum ; or a piece of fheep's gut, tied at one ex- 
 tremity, being pufhed into the anus, and a quantity of 
 water or any other fluid being conveyed into the open 
 end of it, which ought to be of a length to admit of 
 two or three inches hanging out at the redum, almofl 
 any neceffary prefTure may thus be applied, merely by 
 
 T 2 
 
27^ Of Hamorrhoids, Chap. XXXIV, 
 
 pufhing the water into the upper part of the gut, and 
 fecuring it there with a ligature.* 
 
 In various cafes I have proved fuccefsful with this 
 remedy, where others have failed, and in fome inftan- 
 ces I have derived advantage from cold aftringent in'- 
 fufions and folutions being thrown into the rc£tum, 
 fuch as infufions of red rofe leaves, walnut-tree leaves, 
 and oak bark, and folutions of alum, and even of fac- 
 charum faturni, and white vitriol. When thefe rem- 
 edies do not fucceed, there is often reafon to think, 
 either that the veifels from whence the blood is dif- 
 charged lie too high in the abdomen to admit of their 
 being afted upon in this manner, or if near the end 
 of the gut, that they are of a confiderable fize : in the 
 one cafe, we truft entirely to perfeverance in the means 
 that have already been mentioned ; particularly to the 
 effecl of a low regimen, gentle aperients, and the in- 
 ternal ufe of alum, kino, and other aftringents ; while 
 in the other, if the bleeding veffel can pofiibly be per- 
 ceived, it ought at once to be fecured with a ligature. 
 To thofe who' are not accuftomed to the application of 
 this remedy, it may appear to be of a hazardous na- 
 ture, but when properly applied, I can, from much 
 experience of the effects of it, venture to fay, that it 
 never does harm, while it feldom fails to acl with cer- 
 tainty in the cure. The ligatures may be applied ei- 
 ther with the crooked needle or tenaculum ; but the 
 latter fhould perhaps in every inftance be preferred, as 
 with it the ruptured veffels alone can be tied without 
 including any of the contiguous parts, which cannot 
 be done when we employ the crooked needle. 
 
 I have already obferved, that in fome in (lances, the 
 tumors produced by piles become very large. As 
 long, however, as they are not painful, or very incon- 
 
 * Mr. Eromfield, when treating of the extratSlion of the flone in women, 
 advifes the urethra to be dilated by means of w;;ler contaiiuxl in the gut 
 of a fowl. In jnfticc to Mr. Uronifield, I mufl: obferve, that the pra(5lice 
 here recommended is taken from this hint. 
 
Chap. XXXIV. or Piles. 277 
 
 venient, they ought not to be touched ; but whenever 
 they become fo large as to obftrud the paffage of the 
 fseces, they ought if poflible to be removed : when 
 fituated near to the verge of the anus, this may com- 
 monly be eafily done ; and even when an inch or more 
 up the reclum, they may frequently be brought com- 
 pletely in view by prefTure, fimilar to what is employ- 
 ed on going to ftool. 
 
 Various methods have been in ufe for removing 
 thefe tumors, namely, ligatures, excifion^ and even 
 the potential and aftual cauteries. Neither of the lat- 
 ter, however, fliould be ever employed ; fo that the 
 methods by ligature and excifion arc thofe that we 
 have to confider. 
 
 When a hemorrhoidal tumor is attached by a fmall 
 root, and when therefore a ligature is eafily applied, 
 we are commonly advifed to take it off in this man- 
 ner ; and on the contrary, when it adheres to the gut 
 by an extenfive furface, we are defired to diffed it oft' 
 with a fcalpcl. The very reverfe, however, fliould be 
 adopted ; for when the tumors are fmall, and attach- 
 ed by narrow necks, and when there is therefore no 
 reafon to be afraid of any hemorrhagy that may enfue 
 from removing them by excifion, as the fcalpel may 
 in this cafe be ufed with fafety, it ought undoubtedly 
 to be preferred, as the eafiefl and fpeedieft: method of 
 finifliing the operation ; but v/henever they are. large, 
 and when there is reafon therefore to fufpecl that the 
 arteries that fupply them with blood are large, the lig- 
 ature ought certainly to be employed, as the only fafe 
 means of removing them. No good reafon has ever 
 been given for confining the ufe of the ligature to tu- 
 mors with fmall necks ; for although in thefe it is 
 more eafily applied, yet with due care and attention, 
 even fuch as have broad extenfive attachments may 
 be removed in this manner. 
 
 A needle armed with two firm waxed ligatures be- 
 ing introduced through the middle of the tumor at 
 
278 ■ Of Hamorrhoids, or Piles. Chap. XXXIV. 
 
 its bafe, and the ends of one of them being firmly tied 
 round one half of the tumor, vvhilft the other half of 
 it is fecured by the other ligature, the whole may in 
 this manner be removed with as much certainty as 
 when the bafe is narrow. If the ligatures have been 
 properly applied, the tumor will commonly fall off in 
 the fpace of three days : in fome inflances, they drop 
 off in forty-eight hours, or even in lefs 5 but in gen- 
 eral three days are required. When the fcalpel is em- 
 ployed for the removal of thefe tumors, the parts 
 ihould be afterwards dreffed with foft lint, covered 
 with any emollient ointment ; but when taken off with 
 ligatures, no dreffing is neceffary. 
 
 In the ufe of ligatures for this purpofe, when more 
 than one is contained in the fame needle, their being 
 of different colours tends to prevent confufiou. 
 
Chap. XXXV. CondylomatQus Eurcfccnces* 279 
 
 CHAPTER XXXV. 
 
 OF CONDYLOMATOUS EXCRESCENCES, AND SIMILAR. 
 AFFECTIONS ABOUT THE ANUS. 
 
 THE parts about the anus are liable to excrefcen- 
 ces, termed condylomata, fici, and criiliE. The 
 ^iftinttions, however, which thefe names import, are 
 of no moment ; for thefe tumors are all of the fame 
 nature, and are cured by the fame means. 
 
 We fometimes meet with them in the cavity of the 
 gut itfelf ; but moll frequently they are confined to 
 the parts exterior to the fphinder. They are of dif- 
 ferent degrees of hardnefs, being in fome in (lances not 
 much firmer than the parts with which they are con- 
 ne«^ed, and in others they refemble the firmeft fchir- 
 rus. Their colour is allb very various : in fome they 
 "are of a pale white, and in others of different fhades 
 of red. In fome inftances, a fingle excrefcence or two 
 is only met with ; but in others they cover almofl the 
 whole parts contiguous tjb the anus. In fome, they 
 never become larger than ordinary warts ; and the 
 difeafe, even in its mofl advanced llage, is found to 
 confifl; of a number of thefe, either adhering together, 
 or lying in clofe contadt. But in others, the tumors 
 are from the beginning broad and flat, being frequent- 
 ly of the Ihape and magnitude of fplit garden beans. 
 
 Thefe excrefcences, on their firfl formation, feem 
 all to be productions of the cuticle ,; but when of long 
 duration, they commonly adhere to the fkin itfelf, and 
 in fome inftances even proceed to the depth of the 
 contiguous mufcles. 
 
 As long as they create no uneafmefs, they fliould 
 never be touched ; and it frequently happens that they 
 never become fo large as to require much attention ^ 
 
sSo Condjlomatous Excnfcences. Chap. XXXV",- 
 
 while In fome they excite fo much diftrefs, that we are 
 obliged to remove them immediately. 
 
 In fuch as are foft, rubbing them from time to time 
 with crude fal ammoniac, or walhing them with a 
 ftrong folution of that fait, or with fpirit of hartfliorn, 
 will frequently remove them. The pulvis fabinse, too, 
 in fine powder, often anfwers the purpofe, as well as 
 red precipitate of mercur}', particularly when mixed 
 with equal parts or thereby of calcined alum ; but all 
 of thefe remedies are flow in their operation ; and when 
 the tumors are hard and v/arty, they have little or no 
 efFe*^:. • When they do not, therefore, fucceed, v/e em- 
 ploy either the fcalpel or lunar cauftic : but when the 
 patient will fubmit to the fcalpel, it ought always to 
 be preferred ; for no danger can arife from it, as the 
 parts to be removed are not fupplied with large blood 
 Veflels. All the difeafed parts Ihould be completely 
 removed ; and dry lint being applied to the fores, they 
 fall afterwards to be drelfed like wounds produced in 
 any other way. 
 
 When the fears of a patient, however, prevent him 
 from fubmitting to this operation, cauftic muft necefr 
 farily be employed : but in the ufe of this remedy, 
 much attention is neceffary, to prevent it from fpread- 
 ing to the gut ; for mifchief might enfue were it to be 
 diredly applied to it. 
 
Chap. XXXVI. Of a Prolapfus Am, 28 1 
 
 CHAPTER XXXVI. 
 
 OF A PROLAPSUS ANI. 
 
 A PROTRUSION of any part of the reaum be- 
 yond its ufual Umits, Is termed a proh\pfus ani. 
 In fome inflances, the difplaced portion of gut is in- 
 confiderable, but in others it falls down to a great 
 length. 
 
 The fphlnder ani and neighbouring parts, whilft lit 
 full (trength, fervc as a bafe or fupport to the fuperior 
 part of the gut : A^hatevcr, therefore, tends to induce 
 any morbid debility of thefe, will neceffarily have fome 
 influence in the formation of a prolapfus ani. 
 
 The mofl common caufe, however, of this protru- 
 fion of the gut is, frequent and violent exertions ex- 
 cited in the reclum itfelf by fome irritating caufe about 
 its extremity ; thus producing what we commonly 
 term tenefmus : a frequent ufe of aloctics is faid to be 
 very apt to excite irritation in the reQum, although, 
 from much obfervation, I am now inclined to doubt 
 of the truth of it ; but I have much reafon to think, 
 that the fmall worms termed afcarides, by lodging 
 chiefly in the under part of the redlum, and by thus 
 producing irritation, have, in different inflances, in- 
 duced deicents of the gut. Habitual coflivenefs, hcS* 
 morrhoidal fwellings, and in fliort every caufe that: 
 ftimulates the reftum to over exertion, will alfo be apt 
 to produce it. 
 
 The reclum often remains unreduced for a great 
 length of time, and no bad ccnfequences enfue : hence 
 it is evident, that this portion of gut will bear more 
 expofure to the air than the other parts of the intef- 
 tincs ; but we ouG^ht not from this to be ever induced 
 to allow any part of it to remain long down, without 
 attempting to reduce it. By many, we are defired, 
 before reducing the gut, to foment it well with emol- 
 lient and antifeptic decoclions j and the operator is 
 
282 Of a Prolapfus Ani, Chap. XXXVI, 
 
 direfted to cover his fingers with oiled or waxed linen 
 before any prefTure is applied to it. Thefe previous 
 fteps, however, are not neceflary. We fhould inftant- 
 ly indeed endeavour to return the prolapfed parts, 
 without allowing them to be expofed to fuch injuries 
 as might enfue from the delay in fomenting them ; 
 and as we can handle the parts with more exadnefs 
 when the fingers are bare, than when covered with 
 oiled or waxed gloves, thefe ought never to be em- 
 ployed ; but when any covering is judged to be ne- 
 celfaiy, a piece of foft oiled cotton cloth anfwers the 
 purpoie better than any other. 
 
 The patient being put into bed, and laid upon one 
 fide, or upon his face, which anfwers better, with his 
 buttocks elevated above the reft of his body, the fur- 
 geon fhould now prefs firmly, though equally, with 
 the palm of his hand upon the under part of the pro- 
 truded gut. By a continuance of this kind of pref- 
 fure, the gut is in general eafily reduced ; but when 
 this does not fucceed, we feldom fail by pufhing up 
 the fuperior part of the gut with the fingers, while the 
 palm of the other is made to fupport the inferior part 
 of it. When, indeed, the prolapfed portion of gut 
 has previoully become much inflamed and fwelled, no 
 means of redudion will fucceed till thefe are remov- 
 ed. In this fituation, therefore, before preflure is em- 
 ployed, it may be proper to difcharge a quantity of 
 blood in proportion to the ftrength of the patient, par- 
 ticularly with leeches, from the neighbourhood of the 
 anus ; the gut fhould be fomented with a weak folu- 
 tiort of faccharum faturni, moderately warm ; and 
 when, by thefe means, the fwelling is nearly, or per- 
 haps entirely removed, the prolapfed parts will be ea- 
 fily reduced in the manner I have already advifed. 
 
 We feldom, indeed, find it difficult to reduce pro- 
 trufions of the redum ; but it is often no eafy matter 
 to retain them after they are replaced : for the fphinc- 
 ter ani, by repeated defccnts of the gut, often becomes 
 fo relaxed that it does not retain it j fo that a protru- 
 
Chap. XXXVI. Of a Prolapfus Anl 283 
 
 fion takes place, not only on going to ftool, but often 
 on every attempt to walk, or to fit in an erect poflure- 
 
 When the gut thus falls readily down, much bene- 
 fit may be derived, from a proper bandage. On the 
 protruded portion of gut being replaced, if a thick 
 comprefs of linen is apphed directly upon the anus, a 
 proper application of the T bandage over the whole 
 proves often ufeful. But in Plate LXXVII. fig. 3. I 
 have delineated a trufs originally invented for this 
 purpofe by the late Mr. Gooch,* by which the parts 
 may be more completely retained than with any other 
 bandage, while at the fame time the patient may be 
 allowed more freedom than he could otherwife poffi- 
 bly venture on. 
 
 The parts that protrude upon going to flool being 
 immediately replaced, an operation that the patient 
 himfelf can often accomplifh, this trufs fliould be di- 
 rectly applied ; and with a view to ftrengthen the 
 fphindter ani and neighbouring parts, the debility of 
 which is often to be confidered as thefole caufe of the 
 defcent, the patient fhould be advifed to the ufe of 
 fteel, bark, cold bathing, and dafhing cold water up- 
 on the buttocks and under part of the back : confid- 
 erable advantage has alfo been experienced, from a 
 frequent ufe of aflringent injedions, particularly infu- 
 fions of galls and oak bark ; and when a fmall pro- 
 portion of opium is added to the liquor, the irritabili- 
 ty in the redtum, which is often to be confidered as 
 the original caufe of the difeafe, is thereby more effec- 
 tually removed than in any other way. I have fome- 
 times ventured to add a fmall quantity of aliim, and 
 faccharum faturni, to thefe injections ; but in general, 
 any addition of a faline nature is here inadmiflible, 
 from the irritation that fuch remedies commonly give 
 to the gut. 
 
 By one or other of thefe means, the difeafe may ei- 
 ther be entirely cured, or at leaft fo far palliated as to 
 obviate every inconvenieijce from its continuance. 
 
 * vide Cafes and Pra<SUcal Remarks ia Surgery, &c. vol. IL by B. Gooch. 
 
384. Of an Imperforated Anus, Chap. XXXMI. 
 
 CHAPTER XXXVII. 
 
 OF AN IMPERFORATED ANUS. 
 
 AN imperforated anus is not an uncommon oc- 
 currence, fo that every midwife fhould examine 
 with attention the ftate of this and other natural paf- 
 fages immediately after birth. 
 
 In fome, the end of the reclum is fomewhat prom- 
 inent where the anus ought to be, being only covered 
 with fkin and a fmall quantity of cellular membrane : 
 hut in others, no veftige of the redum is perceived ; 
 and the fkin retains its natural appearance, without 
 being any where elevated betvreen the fcrotum and 
 point of the coccyx. 
 
 In fome, the redum terminates within an inch of 
 the ordinary feat of the anus ; in others, it has reach- 
 ed no farther than the top of the facrum. In fome it 
 has been known to terminate in the bladder j and in 
 (Others, in the vagina. 
 
 When the affiflance of a furgeon is required, as 
 death mud enfue if a proper vent be not obtained for 
 the fiEces, no time fhould be lofl in deliberation. If 
 the end of the gut is found to be covered with fkin 
 only, and if a protuberance is formed by the faeces 
 pu.lhiiig it forward, all that the furgeon can do, is with 
 a i'calpel or lancet to make an opening of a fufficient 
 fize ; but when this kind of direction is not met with, 
 more difficulty and danger is to be dreaded. 
 
 When the gut is deep, an incifion of an inch in 
 length fhould be made diredly on the fpot where the 
 anus ought to be ; and this fhould be continued with 
 gradual and repeated ftrokes of the fcalpel, in the di- 
 re£lion that the redum ought to take ; not in a direct 
 courfe through the axis of the pelvis j for in that di- 
 
Chap. XXXVII. Of an Imperforated A ?nis, 285 
 
 reclion the vagina or bladder, or perhaps both, might 
 be injured ; but backwards along the coccyx, where 
 the rifk oi \younding any part of importance is Icfs. 
 The bed director is the finger of the operator. The 
 forefintrer of one hand being inferted into the wound, 
 and palled towards the coccyx, the furgeon, with the 
 fcalpel in the other, ihould diflcct gradually in this di- 
 redion, either till he meets with faeces, or till the fcal- 
 pel has reached at leafl the full length of his finger ; 
 and if, after all, the faeces are not reached, as death 
 mufi: enfue if more be not attempted, I would advife 
 a long trocar to be pulhed forward upon the finger, 
 in fuch a diredlon as the operator thinks will moil 
 probably meet with the gut. 
 
 In this manner many lives have been faved which 
 would othcrwife have been loft. I myfclf have had 
 two fuch cafes ; in both of which the gut lay deep, 
 and in both I was fortunate enough to form an anus, 
 which for many years has continued to anfwer the 
 purpofe fufficiently. But in both it was exceedingly 
 difficult to preferve the palTage fufficiently wide : for 
 as foon as the doffi's of Hnt and other tents employed 
 for preferving the paiTage w^re withdrawn, a very 
 ftrong contraction took place, by which the opening 
 was occafionally nearly obliterated. Sponge tent, 
 gentian root, and other fubftances that fwell by moif- 
 ture, were at different times employed ; but thefe uni- 
 formly gave fo much pain and irritation, that they 
 could not be continued. They are commonly, indeed, 
 recommended in fuch cafes ; but all who have ever 
 employed them in parts fo exquifitely fenfible as the 
 return, will foon be convinced of the impropriety of 
 the advice. 
 
 Doffils of foft lint moiftened In oil, and rolls of bou- 
 gie plafter of a proper fize, were found to Irritate Icfs, 
 and to anfwer better than any other application ; and 
 for the purpofe of dilating the pailage, when, at dif- 
 ferent tiuies during the cure, it was found to have be- 
 
286 Of an Imperforated Anus. Chap. XXXVtl^ 
 
 come too ftrait, the method I have already advifed 
 (when fpeaking of piles) of comprelTmg blood vefl'els 
 in the reclum by introducing a Iheep's gut, fliut at 
 one end, into it, and forcing water up by the other, 
 was employed with advantage. But upon the whole, 
 although this part of the cure may appear to thofe 
 who have not met with fuch cafes, to be fimple and 
 eafy, it is found to be much otherwife in pra6lice. 
 Indeed, no cafe in which I was ever concerned, gave 
 fo much perplexity and trouble, either to the patient 
 or myfelf, as each of thofe I have mentioned ; for al- 
 though in both, the openings were at firft made fufii- 
 ciently large, yet nothing but continued attention for 
 the fpace of eight or ten months, prevented the necef- 
 fity of a frequent repetition of the operation. When 
 the fkin alone is to be cut, it is a fimple matter indeed ; 
 for in this cafe nothing is in general neceffary but the 
 introduction of a doffil of foft lint for a few days into 
 the opening. But when the redum lies deep, I am 
 inclined to think, from the event of thofe cafes, that 
 although ultimately, a complete cure may commonly 
 be obtained after a free difcharge of fseces is procured, 
 that much care and attention on the part of the oper- 
 ator will always be required for a confiderable time 
 after the operation ; and in general we may fuppofe, 
 that the difficulty will be in proportion to the depth 
 of the cut. 
 
 Even where the gut terminates in the bladder or 
 vagina, the operation fhould be advifed : for, as in the 
 one cafe, all the fseces mufl be emptied into the blad- 
 der, there would be much rifk of fuch accumulations 
 being formed in it as would foon put a total flop to 
 the difcharge by the urethra ; and in the latter, where 
 the rectum terminates in the vagina, much diflrefs 
 would enfue from it, which a fuccefsful ifTue of this 
 operation alone could prevent. 
 
 When it unfortunately happens that no paffage is 
 obtained for the farces by any of the means that I have 
 
Chap. XXXVII. Of an Imperforated Anus, 287 
 
 mentioned, might not we attempt an opening above 
 the pubes, with the view of reaching the under extrem- 
 ity of the colon, or perhaps on the right fide, fo as to 
 reach the caput coli, for the purpofe of making an ar- 
 tificial anus ? It is true, that the chance of fuccels from 
 fuch a meafure would not be great ; and, even admit- 
 ting that the attempt fhould fucceed in the mofl com- 
 plete manner, the difcharge of faeces from the open- 
 ing would always prove troublefome and very uncom- 
 fortable ; but the melancholly idea of leaving a child 
 in fuch a Hate, to die in much pain, muft prove fo 
 highly diftrefsful, both to the parents and operator, as 
 •would incline me rather to advife even the doubtful 
 and defperate remedy I have mentioned. 
 
288 OftheFiJlulu Chap. XXXVIIL 
 
 CHAPTER XXXVIII. 
 
 OF THE FISTULA IN ANO. 
 
 E 
 
 VERY finuoas ulcer in the neighbourhood of* 
 the re6tuni is termed a fiflula in ano. This is 
 the mofl accurate and niofl fiinple idea that can be 
 given of the difeafe : for although, in different inftan- 
 ces it aifumes a variety of appearances, and akhough 
 the defcriptions given of thefe have tended to render 
 this part of chirurgical pathology extremely perplex- 
 ed, yet whoever uill attentively confider all the civ- 
 cumftances tl;^^t relate to it, will lind, that the fiftula 
 in ano is of a nature as determined and fixed as any 
 difeafe that falls within the province of furgery. 
 
 Several varieties of this ulcer are defcribed by au- 
 thors : an external opening contiguous to the anus, 
 communicating with an internal ulcer, but without 
 any connection with the re£lum, is termed an incom- 
 plete uflula : when the ulcer has tv/o outlets, one ex- 
 ternal, and the other opening into the gut, the fiftula 
 is faid to be complete ; and again, when it communi- 
 cates with the gut only, without any external open- 
 ing, it is termed an internal or occult fiftula. 
 
 This difeafe has been likewife diftinguifiied into fim- 
 ple and compound. When the parts through which 
 the fmus runs are hard and tumefied, or when a com- 
 munication is difcovered between the ulcer and the 
 bladder, vagina, os facrum, and other contiguous parts, 
 the fiftula is faid to be of a complicated or compound 
 nature ; and it is termed a fimple fiftula, when all the 
 neighbouring parts are found. 
 
 In the commencement of the difeafe, the contigu- 
 ous parts are very commonly found ; but whenever 
 the ulcer has been of long duration,- not only the parts 
 
Chap. XXXVIIL in Ano. 289 
 
 about the anus, but even the perinccum and buttocks, 
 frequently become difeafed. This may depend on dif- 
 ferent caufes, but it appears rnofl frequently to pro- 
 ceed from the matter of the abfcefs or fmus not find- 
 ing a proper vent, and from its being allowed there- 
 fore to fpread along the contiguous cellular fubftance* 
 
 Thus, we fometimes find, that the perinsL'um and 
 part of the buttocks have become hard, with various 
 finufes running in different parts of them ; and when 
 the matter is (harp and acrid, inftanccs occur of the 
 OS facrum becoming carious, and of the bladder and 
 vagina being corroded fo as to have the contents of 
 the redum emptied into them. This laft ftage of the 
 difeafe is not, however, often met with j and it would 
 probably never occur, if the difeafe were properly 
 managed from the beginning, by a free difcharge be- 
 ing given to the matter. 
 
 In enumerating the caufes of this difeafe, it may be 
 remarked, that v/hatever tends to produce matter 
 abdut the anus, may be confidered in this light. Thus 
 the piles, condylomatus tumors in the neighbourhood 
 of the reclum, !->ardened fseces collefted in the extre- 
 mity of the gut, and, in Ihort, whatever can excite ir- 
 ritation and inflammation of thefe parts, will occafion- 
 ally terminate in fuppuration ; and, if the matter thus 
 produced be not ablorbed, or if the fore arifing from 
 the burRing of the abfcefs, does not foon heal, a fmu- 
 ous ulcer will very readily form. I may alfo remark, 
 that abfceffes in thefe parts frequently fucceed to fevers 
 and other difeafes of the conititution. 
 
 The circulation being more languid here than in 
 other parts, every inflammatory tumor that forms in 
 it is not only more apt to fuppurate, but the fores that 
 enfue heal with difficulty. They always excite much 
 diflrefs, and require much caution and attention, in 
 the treatment. We have it commonly in our power, 
 however, with proper management from the fuft ap- 
 pearance of inflammation about the anus, to preveuE 
 
 Vol. III. U 
 
29C Of the Tijlula Chap. XXX Vni. 
 
 much of that pain and mifery, that thefe tumors, when 
 neglected, are ultimately fure to induce. 
 
 As foon as this kind of tumor has advanced fo far 
 as to make it probable that fuppuration will enfue, 
 every means that can accelerate the formation of mat- 
 ter fhould be advifed : and as nothing anfwers this 
 purpofe with more certainty than a continued applica- 
 tion of heat, warm emollient poultices, fomentations, 
 and the fleams of warm water, are chiefly to be truft- 
 ed. By a due application of thefe remedies, the tu- 
 mor may in general be made to fuppurate quickly ; 
 and as foon as matter is formed, it ought to be dif- 
 charged by a free incifion in the moil depending part 
 of it* 
 
 In this ftage of the difeafe, much more depends up- 
 on the abfcefs being freely and timoufly laid open, 
 than is commonly imagined ; for if this is long delay- 
 ed, or if the opening is not made of a fize fufficient 
 for difcharging all the matter, it is thus allowed to 
 pafs into the contiguous cellular fubllance, fo as to 
 feparate, not only the fl-iin but all the under part of 
 the rectum, from the mufcles and other parts with 
 which they naturally lie in contact : and in this man- 
 ner, inflead of a fmiple fore, which, when the abfcefs 
 is rightly treated, is all that we ought to meet with, 
 the whole under part of the gut is in fome inilances 
 entirely feparated from the furrounding parts, and a 
 variety of fmufes form in different direftions, either 
 along the perineum, or by the fide of the gut, and in 
 fome inflances among the mufcles of the hips. 
 
 With a view, therefore, to prevent thefe diflrefsful 
 confequences, as foon as an abfcefs in this fituation 
 is found to contain matter, it ought, as I have obferv- 
 ed already, to be opened by a free incifion ; by which 
 means, and with due attention to the fubfequent treat- 
 ment of the fore, if the conflitution is otherwife found, 
 a fpeedy cure may in general be expelled. 
 
 The matter being difcharged, doflils of lint are 
 commonly crammed into the fore, with a view to pre- 
 
Chap. XXXVIII. in Am. 291 
 
 vent, as it is faid, the parts which have been newly- 
 divided from adhering too foon. This, however, is a 
 very erroneous pradice : for extraneous fubflances of 
 every kind, by the irritation that they give to the rec- 
 tum, ahnoft always do mifchief ; and, if the opening 
 is of a fufficient fize, there is no necelTity for this pre- 
 caution, as the conftant difcharge of matter from the 
 fore, proves in general fufficient for preferving it of a 
 fize adequate to the quantity produced ; and this I 
 may remark is the principal objeft we have in view 
 from the operation. 
 
 Inflead of irritating the parts, therefore, by the in- 
 troduction of dollils, as foon as the matter of the ab- 
 fcefs has been freely difcharged, the fore (hould be 
 merely covered with foft lint fpread with any mild 
 ointment, and an emollient poultice applied over the 
 whole. 
 
 Any hardnefs that did not difappear during the fup- 
 puration, will thus be foon removed, and a cure will 
 in general be quickly obtained. 
 
 It mod frequently, however, happens, that the aid 
 of furgery is not defired in this firft and very fimple 
 ftate of the difeafe ; nor till the abfcefs has burft of 
 itfelf, and perhaps at an improper part ; and till of 
 courfe much mifchief is produced, by the matter hav- 
 ing infmuated into the furrounding cellular fubftance : 
 in this fituation, one or more finufes are commonly 
 met with, forming, according to their duration differ- 
 ent degrees or ftages of the real fiflula in ano. 
 
 When, in this llate of the difeafe, the advice of a 
 pratlitioner is defired, the firft objed he fhould have 
 in view, is to difcover with accuracy the courfe of 
 the finufes ; for nothing can with propriety be done 
 till this is accompHflied. When the finufes difcharge 
 their contents by external openings, the direclion in 
 which they run is for the mod part eafily difcov- 
 ered : if they run along the perin^eum, or fpread 
 among the mufcles of the hips, a probe, introduced 
 u 2 
 
292 Of the Fijlula Chap. XXXVIII. 
 
 in the ufunl manner will readily pafs along the whole 
 of them : but when any of the finuies follow the di- 
 reftion of the gut, the forefinger of one hand, after 
 being well oiled, fliould be introduced into the rec- 
 tum, at the fame time that the probe is entered at the 
 wound with the other : by this means we not only 
 prevent the gut from being much injured by the probe, 
 but if any communication has taken place between the 
 gut and the fmus, it is in this manner eafily difcover- 
 ed, by the point of the probe pafTmg from the fmus, 
 and being found in the gut with the finger. In a few 
 cafes, however, even when we know that the fmus 
 communicates with the gut, the probe does not pafs 
 eafily from one to the other ; but with due perfever- 
 ance we always fucceed ; and if the probe is rightly 
 managed, it may always be done without riik of hurt- 
 ing the gut. 
 
 As our knowing with certainty, whether the fmus 
 communicates with the gut or not, is of much import- 
 ance in the cure, nothing fliould be omitted that may 
 enable us to determine the point with precifion. 
 When air or faeces are difcharged by the fmus, or 
 when water or any other fluid inje£ted into it is re- 
 turned by the anus, the exiflence of fuch a commu- 
 nication cannot be queftioned. 
 
 The abfence, however, of thefe tefls, does not im- 
 ply that no communication takes place between the 
 gut and the finus : for we know that the pafTage of fae- 
 ces from the rectum into fores of this defcription, does 
 not always happen ; and we may eafily fuppofe it pof- 
 fible for an opening between the finus and the gut, 
 to be fo formed as to prevent the pafiage of liquids 
 from one to the other. 
 
 When, by a repetition of cautious trials with the 
 probe, or with injections of warm water into the fores, 
 the courfe of the different finufes is difcovered, the 
 method of cure is next to be determined. In a pre- 
 ceding part of this work, the method of curing fmu- 
 
Chap. XXXVIII. in Ano. 293 
 
 fes has been pointed out:* but from the nature and 
 fituation of the parts in which this variety of the dif- 
 eafe is feated, fome peculiarities occur in regard to the 
 cure. 
 
 Aftringent injections, paftes and ointments of the 
 fame nature, have at different times been recommend- 
 ed for putting a flop to the difcharge of thefe fmufes. 
 But the cauftic property of tliefe remedies is by no 
 means fuited to the irritability of the parts in which 
 this difeafe is feated ; nor have they by experience 
 been found to anfwer the intention for which they 
 were propofed : they have now, therefore, very uni- 
 verfally fallen into difcredit. 
 
 I have elfewhere fhown, that the leading objed to 
 be kept in view in the treatment of fmufes, is the de* 
 ftruftion or annihilation of the cavities from whence 
 the matter is difcharged. With a view to this, dif- 
 ferent means have been advifed. Where prelfure can 
 be employed, the fides of fmufes are, in fome inflan- 
 ces made to adhere by means of it ; but in the fiftula 
 in ano, this method of cure is inadmiffible, as in this 
 fituation no regular or equal prefl'ure can be applied. 
 
 This being the cafe, and knowing that adhefion 
 readily takes place between contiguous parts in a ftate 
 of inflammation, we endeavour to make thofe parts 
 inflame that we wifh to adhere to each other. It is 
 perhaps indeed a doubtful point, whether animal fub- 
 ftances can be made to adhere permanently by any 
 other means than through the intervention of inflam- 
 mation. 
 
 For the purpofe of exciting this inflammatory or 
 adhefive flatft of a fmus, fo neceffary for the reunion 
 of its fides, different means may be employed. It 
 may be accomplifhed either by the introdudion of a 
 cord of cotton or filk along the courfe of the fore, or 
 by laying the finus open through its whole length, fo 
 as to convert it as nearly as pofllble into the ftate of 
 a recent wound. 
 
 * Vide Chapter V, Sc«5Vion V. 
 
294 OftheFiJiuIa Chap. XXXVIII. 
 
 In other parts of the body, I have advifed the ufe 
 of a cord, or feton as it is termed, in preference to 
 every other method of cure ; as by means of it, we 
 have it in our power to excite ahnoft any degree of 
 inflammation, without any of the difadvantages that 
 fometimes enfue from the extenfive cicatrix of a large 
 wound. In the fiftula in ano, however, the feton 
 cannot be employed ; for the irritation that it would 
 excite, would prove too fevere a flimulus for the rec- 
 tum, with which it would at all times be in immedi- 
 ate conta6l. 
 
 As in this fituation, therefore, aflringent and efcha- 
 rotic injections and paftes cannot be employed with 
 fafety, as preflTure is inadmiffible, and as cords of even 
 the fofteft materials would excite a very infupportable 
 degree of irritation ; we are under the neceffity of 
 employing the only other remedy by which a due de- 
 gree of inflammation can be induced, namely, a free 
 and extenfive incifion along the whole courfe of the 
 fmus, commencing at one end of it, and terminating 
 at the other. 
 
 Having thus endeavoured to afcertain the proper 
 method of cure, we fhall now proceed to defcribe the 
 eafielt and mofl efl'eclual manner of putting it in prac- 
 tice. 
 
 The courfe of the different fmufes having been dif- 
 covered by a previous fearch in the manner I have 
 advifed, as it is of importance to have the alimentary 
 canal, and particularly the re£lum, emptied, a purge 
 fhould be given on the preceding day, and a glyfter 
 an hour or two before the operation. 
 
 The operation is often done while the*[)atient ftands 
 with his back to a clear light ; but it anfwers better 
 to place him upon a table, in the fame manner as is 
 done for the operation of lithotomy, with his legs bent 
 and kept afunder by an afliftant on each fide. 
 
 The patient being firmly fecured in this fituation, 
 the furgeon, after dipping the forefinger of his left 
 hand in oil, fliould pafs it as far as it will reach into the 
 
Chap. XXXVIII. inAuo, 295 
 
 re£tum : with his right hand, he muft now enter the 
 point of the probe pointed biftoury, at the external 
 opening of the fore ; and having pafled it along the 
 whole length of the finus, till he feels the point of it 
 through the opening in the gut, upon his finger in the 
 anus ; (for I am here fuppofing that a communication 
 takes place between the fmus and the rectum ;) he is 
 now to pufii the point of it in upon his finger ; by 
 means of which, he not only proteds the oppofite fide 
 of the gut, but by thus direding the point of the in- 
 ftrument, he cuts fleadily, and the fmus is in this 
 manner laid open with much eafe from one end to 
 the other. This being done, if any other external 
 openings are perceived, the finger fhould be again 
 paiTed into the redum, and every fore that is met with 
 ihould be laid open in the fame manner. The biftou- 
 ry to which I allude is delineated in Plate LXIV. fig, 
 2. and 4. 
 
 By many it is fuppofed, that every external open- 
 ing that occurs here, communicates with a feparate 
 and diftincl fmus ; and fome have gone fo far as to 
 fay, that thefe again are commonly found to commu- 
 nicate by fepaiate openings vidth the gut. This, how- 
 ever, is feldom or never the cafe ; for I have very 
 univerfally found, that all the external fmufes com- 
 municate with one common fore or abfcefs, and that 
 this, in a great proportion of cafes, perhaps in ninety- 
 nine of every hundred, communicates with the rec- 
 tum by one aperture only : and at any rate, the means 
 to be employed, are in both cafes the fame» Whe- 
 ther the external or internal openings communicate 
 with one or with more abfcefles, they fliould be laid 
 freely open from one end to the other. 
 
 In almoft every inftance, however, we find, that 
 when the principal fmus is laid open through its whole 
 courfe, from the entrance of the knife to the aperture 
 in the reftum, the others are found to run no farther 
 than into fome part of the fore, without communicat- 
 
296 OftheFiJlula Chap.XXXVIIL 
 
 ing diredly with the gut ; fo that their entire divifion 
 is eafily and quickly accomplifhed. 
 
 I have dehred, in fcarching for the different finufes, 
 that this part of the operation may be accurately done ; 
 fo that it may be known with certainty, whether the 
 fores communicate with the gut or not : if a commu- 
 nication is difcovered, the knife fhould enter by this 
 opening from the fmus into the gut ; for the opening 
 is commonly at the mod fiiperior point of the fmus, 
 and it is likewife proper that the knife fliould be made 
 to pafs in fuch a direction that the aperture into the 
 gut may form a part of the incifion : for if this fhould 
 not be done, httle or no advantage might be derived 
 from the operation ; the parts would not readily ad- 
 here at this point j and the faeces getting accefs to the 
 cellular fubftance behind the gut, would be apt to 
 give rife to a new collection of matter. 
 
 It frequently happens, however, that no direfl: com- 
 munication can be difcovered between the finus and 
 reOium ; in which cafe the hflula, as I have already 
 remarked, is faid to be Incomplete : but in the meth- 
 od of cure, the treatment is nearly the fame as when 
 fuch a communication takes place ; only with this 
 difference, that in the latter, the point of the bifloury 
 paffes into the gut at the aperture found In it ; where- 
 as, in the other, an opening nuift be made in it at the 
 fuperior part of the fnius, by pufhing the point of the 
 bifloury againfl the finger in the rectum ; and this 
 being done, the operation is to be finiflied in the man- 
 ner I have mentioned, by drawing the point of the in- 
 ftrument out at the anus, fo as to divide the finus 
 through its whole length. 
 
 In the courfe of this operation, the fphin£ter ani is 
 always divided if the fiflula penetrates to any confid- 
 erable height in the rectum : but this is not of fuch 
 importance as at firfl fight might be imagined ; for 
 although fome degi'ee of inability to retain the fasces 
 frequently enfues for a (hort while after the operation, 
 yet experience fhows that the parts in general recover 
 
Chap. XXX\niI. in Ano. ic^y 
 
 their tone very completely, infomuch that Tx-ant of re- 
 tention is fcarcely ever at laft mentioned by the pa- 
 tient, as any of the inconveniencies that enfue from it. 
 
 Various inftruments have been propofed for eftecl- 
 ing this operation ; but none of them anfwer the pur- 
 pofe with fo much eafe and fafety as the probe point- 
 ed biftoury. A razor, with a probe point, Plate XCI. 
 fig. I. may be ufed in nearly the fame manner; but 
 the biftoury is pofTefled of all the advantages attend- 
 ing the razor, and as it can be directed with more 
 fteaJinefs, it ought to be preferred. 
 
 Some have objected to this mode of operating, that 
 in the cafe of an incomplete fiftula, the point of the 
 biftoury, on being pufhed through the gut will be apt 
 to hurt the finger in the rectum ; and likewife, that 
 it can never be applicable where the fmus runs far- 
 ther up the rectum than the finger can reach ; and 
 with a view to obviate thefe inconveniencies, different 
 iuftrumcnts have been propofed, paiticularly a direc- 
 tor and fcalpel. 
 
 I'he diredor, which ought to be large, being paflk 
 ed into the rectum, the finus or fiftula is advifed to be 
 laid open through its whole length, by a fcalpel being 
 made to run along the whole courfe of it from the 
 external opening of the finus. This, I mufl obferve 
 however, is a practice net to be imitated : the hazard 
 attending it is evidently indeed fo great, that it has 
 feldom been attempted, nor will it probably be ever 
 recommended but by fuch writers as copy from one 
 another. The parts chiefly ailected by the operation, 
 lie fo contiguous to organs that ought not to be in- 
 jured, particularly to the bladder, that we fnould nev- 
 er on any account attempt to lay finufes in this fitua- 
 tion open, unlefs the finger is previoufiy introduced 
 to ferve as a guide for the biftourv ; and for the fame 
 reafon the inltrument fhould never be carried faither 
 than the length of the finger. Fiftulous fores do not 
 commonly penetrate deeper here than the length of 
 the forefinger : in fome cafes, however, they go to a 
 
298 Of the Fijlida Chap. XXXVIII. 
 
 greater depth : they have even been found to pafs to 
 the very fuperior part of the os facrum, and acrofs the 
 pelvis in a direction between the reclum and bladder. 
 In every fuch inftance, however, all that an operator 
 fliould attempt, is to lay the under part of the fore 
 completely open, fo as to procure as free and eafy a 
 difcharge to the matter as pofiible ; for any advantage 
 to be derived from the incifion being carried to a 
 greater depth than the finger can reach, would feldom 
 if ever compenfate the hazard of the attempt : and 
 whenever the fmufes are confined to the under part of 
 the gut, no other direftor than the finger is required ; 
 for whoever has done the operation in the manner I 
 have advifed, will find that the redum is eafily pierc- 
 ed with the probe pointed biftoury, and that it may 
 be done without hurting the finger previoully pafTed 
 into the gut. 
 
 It is alleged by fome, that danger may occur from 
 fmufes in this fituation being cut freely open : trou- 
 blefome h^morrhagies, they think, may happen, from 
 the hsemorrhoidal arteries and veins being cut ; fo that 
 it has been propofed to open the fmufes with ligatures : 
 by inferting one end of a piece of pliable filver or lead 
 along the courfe of a finus, pufhing it into the redum, 
 drawing it out at the anus, and twifting the ends of it 
 together, the contained parts are thus directed to be 
 gradually compreffed and divided. But this being 
 not only more painful, but alfo more tedious, than 
 the method of dividing thefe parts with a biftoury, 
 and as we have few inftances of the hasmorrhagy that 
 enfues from this operation being fevere, the latter is 
 very univerfally preferred : the late Mr. Deifault of 
 Paris, a furgeon of much eminence and refpedtability, 
 conceived, indeed, a partiality for the method of cur- 
 ing this difeafe with a ligature, formed of lead or fil- 
 ver wire, and he contrived a very ingenious apparatus 
 for palfmg the lead ; but for the reafons that I have 
 given, there is no reafon to fuppofe that it will ever 
 be much employed by others. 
 
Chap. XXXVIII. in Am, 299 
 
 The different finufes being laid open with the bif- 
 toury, much care is required in applying the dreffings, 
 for on this the fuccefs of the operation in a great mea- 
 fure depends. Some, however, are fo inattentive to 
 this, as to fuppofe that every thing neceifary is done, 
 when the divifion of the parts is completed ; but this 
 is fo far from being the cafe, that I may freely affert, 
 that a cure will feldom be obtained, if much atten- 
 tion be not given to the fubfequent treatment of the 
 fores. 
 
 The parts, however, ought not to be much cram- 
 med with drefllngs ; nor ihould any thing be employ- 
 ed that is not perfectly mild, and incapable of excit- 
 ing much irritation. Dry lint is almoft the only ap- 
 plication that practitioners ufe, but it is ill fuited for 
 the purpofe. One of the moft diftrefsful fymptoms 
 that enfues to this operation, is diarrhoea, attended 
 with tenefmus, or a frequent defire to go to (tool. In 
 fome, the divifion of the fmufes alone appear to excite 
 this ; but it very commonly may be traced as a con- 
 fequence of the after management of the fores : for 
 every application that is not perfedly mild, and efpe- 
 cially if forcibly pulhcd to the bottom of the wound, 
 is furc to induce a very diilrefsful degree of irritation 
 in the end of the gut ; and as this almoft always ex- 
 cites a frequent discharge of faeces, that not only tends 
 to reduce the ftrength of the patient, but to interrupt 
 the cure of the fores, it becomes highly neceifary to 
 avoid it. 
 
 With this view, inftead of dry lint, I have long been 
 in the praftice of ufmg fine thin old linen dipped in 
 oil or fpread with any fimple mild ointment ; by which 
 we with certainty avoid that diftrefsful irritation which 
 dry applications to fuch fores never fail to induce. 
 After the wounds, therefore, have been cleared, a very 
 fmall pledget of this kind of linen, thinly covered with 
 fimple liniment of wax and oil, ftiould with the end 
 of a probe be gently inferted between their edges ; but 
 not to fuch a depth, or with fuch force, as to give any 
 
300 Of the Fiftula Chap. XXXVIII. 
 
 kind of uneafinefs. This being done, and a cufliion 
 of fine tow, covered with a comprefs of foft linen, be- 
 ing applied over the parts, and fccured \Yith a T band- 
 age, the patient fhould be carried to bed ; and the 
 dreliings being renewed, either after every ftool, or, 
 when thefc are not frequent, once in the twenty-four 
 hours, the fore will in general fill up from the bottom, 
 and will at laft cicatrize in the fame manner as wounds 
 in any other part. This kind of fore fliould indeed 
 be managed in every rcfpccl like fimilar fores in oth- 
 er parts of the body : for although fomething myite- 
 rious or peculiar has commonly been fuppofed to exiil 
 in fores about the anus ; yet this is by no means the 
 cafe : they are of a nature exactly fimilar to fores in 
 other parts, and are to be cured at all times by the 
 fame means. They fhould be lightly and eafily drelT- 
 ed, in the manner I have advifed. No injections 
 fliould be ufed, as is often done with a view to cleanfe 
 the parts. They are not more neceffary here than in 
 any other fore, and I have conftantly feen that they 
 do harm. They not only irritate and inflame the parts 
 to which they are applied, but if ufed v/ith much force, 
 the liquor is apt to find its way into the contiguous 
 cellular fubftance, and in this manner to form new 
 finufes. They Ihould in no inllance therefore be em- 
 ployed. 
 
 I have already obferved, that, by perfeverance in 
 this mild courfe of treatment, a cure will, in general, 
 be obtained. But in fome inilances it is otherwife ; 
 and inftead of a good difcharge, and red frefh granu- 
 lations, with v/hich the wound in a healing flate ought 
 to be covered, the parts become foft, flabby, and un- 
 healthy, and the matter is thin, fetid, and perhaps mix- 
 ed with blood. If, on a minute infpeftion of the fore, 
 any part of a finus is found to have efcaped notice, 
 and if matter is found to lodge in it, a certain and al- 
 mofl: immediate advantage will be derived from laying 
 it open to the bottom. The moll frequent caufe of 
 failure indeed in this operation is want of attention to 
 
Chap. XXXVIIT. in Ano. 301 
 
 this very neceflary point ; in the firfl place, by due 
 pains not being taken to difcover the finufes in the time 
 of the operation, and a delire afterwards to perform 
 the cure by any other means rather than put the pa- 
 tient to the pain of another operation, or candidly to 
 avow our own error, which in every inflance fhould 
 freely be done. I readily own, that when I firft fet- 
 tled in bufmefs, I fell into this error, in diilerent in- 
 flances : by not fearching with fuflicient pains after 
 the firft incifion was made, finufes efcaped notice that 
 might have been difcovered : but having long been 
 cbnvinced, that a patient had better be kept much 
 longer on the table, fo as to have all the parts exam- 
 ined in th*^ moft accurate manner, than to incur the 
 rifk of a fecond operation, I now fpend fo much time 
 upon this, that in the courfe of thelc eighteen or twen- 
 ty years, fcarcely an inftance has occurred with me, 
 out of fome hundred cafes, of the operation being from 
 this caufe to be repeated : 1 own, however, that more 
 time is for this purpofe fpent on the operation than is 
 commonly done. 
 
 It fometimes, again, happens, that the cure of the 
 fore is retarded, not by any fault in the operation, but 
 by real difeafe of the lyftem : in this cafe, if the pa- 
 tient is found to labour under lues venerea, fcrofula, 
 or fcurvy, the remedies appropriated to the exifting 
 difeafe fliould be prefcribed ; or if the conftitution is 
 merely relaxed or Vv'eakened, whether by fever or any 
 other caufe, the natural tone of the fyllem (hould be 
 reftored, by a nourifliing diet, a proper allowance of 
 wine, and refidence in good air. 
 
 When treating of ulcers in Chapter V. I have en- 
 deavoured to inculcate the utility of iifues in every va- 
 riety of fore ; but in no variety of the uileafe does this 
 remedy a£l with more advantage than in the fiftula in 
 ano, efpecially when the difcharge has been of long du- 
 ration. Different inftances, indeed, have occurred to 
 me, in which, vhere iffues are not inferted, the patient 
 tvas obvioufly injured by curing the difeafe : other dif- 
 
302 OfibeFiJlula Chap. XXX VIIL 
 
 eafes of a more alarming nature were induced by it ; 
 while in fome I have not been able to obtain a perma- 
 nent cure of the fmus till an ifl'ue was inferted : I am 
 now therefore fo much convinced of the utility of if- 
 fues, that whenever the difeafe has been of long dura- 
 tion, and the difcharge copious, I feldom advife the 
 operation till an iilue is inferted. 
 
 Hitherto, I have been fuppofmg, that the difeafe has 
 not advanced farther than to produce finufes along the 
 courfe of the re£tum, and parts immediately contigu- 
 ous. We fliall now proceed to confider it in its more 
 advanced ftages. 
 
 The firft of thefe that I fliall notice, is that in which 
 the parts lying contiguous to the fores, have been fep- 
 arated or detached from each other, by a mere effu- 
 fion of matter into the furrounding cellular fubftance. 
 This, to a certain degree, is the cafe in every fmus ; 
 but when fmufes about the anus have been of long du- 
 ration, the matter which they produce, if it does not 
 find a free outlet, fpreads in fome inftances fo exten- 
 fively among the contiguous parts, as to feparate, not 
 only all the fkin and other teguments from the muf- 
 cles underneath, but to detach all the under part of 
 the reftum from the cellular fubftance with which, in 
 a (late of health, it is firmly conneded. Of this I 
 have now met with various inftances. 
 
 In this ftate of the difeafe, two modes of operating 
 have been advifed ; either to take away a confiderable 
 portion of the teguments, fo as to give free vent to the 
 matter ; or, if this does not prove fuccefsful, to extir- 
 pate all the inferior part of the re£tum that is found 
 to be feparated from the contiguous parts. 
 
 Thefe operations, however, not only give fevere 
 temporary pain, but much fubfequent diitrefs ; and as 
 all the advantages that arife from them may be attain- 
 ed in a more eafy manner, they ought undoubtedly 
 to be laid afide. To take away any large portion of 
 the teguments about the anus, mull of itfelf be ex- 
 tremely painful J and to extirpate the extremity of 
 
Chap. XXXVIII. in Am. 303 
 
 the reclum, would, in a great proportion of cafes, be 
 produftive of more mifery than could ever be induced 
 by a continuance of the difeaie ; for, befides the diffi- 
 culty and pain that in this fituation would arife from 
 the paflage of hard f?eces, it would be impoflible for 
 tho patient to retain liquid (tools. 
 
 This diflrefsful operation, however, need never be 
 put in practice ; for I know from various trials, that 
 a fnnple divifion of the gut will with jnore certainty 
 accomplifn a cure : all that ought to be done there- 
 fore is, to lay the detached portion of gut open from 
 one end to the other in the manner I have already 
 pointed out in cafes of fnnple fmus : and if this does 
 not allow the gut to apply equally to the contiguous 
 parts, another incifion Ihould be made on the oppo- 
 lite fide of it ; by which means all fuch parts of it as 
 were feparated or detached from the furrounding muf- 
 cles will now be equally applied to them ; no part of 
 it will be puckered or unequal ; and ii; the neighbour- 
 ing bones and other parts are found, and the conftitu- 
 tion not difeafed, a cure will foon be obtained by ad- 
 hefion again taking place between the gut and parts 
 that lie behind it. 
 
 Upon the fame principles that in this fituation we 
 advife a divifion of the rectum, when the matter has 
 paffed between the fkin and mufcles of the perinscum, 
 or of the hips, the bag in which it is contained fliould 
 be freely laid open from one end to the other ; and if 
 one incifion is not fufficient, another fliould be made 
 without delay : the fame drellings fliould be applied 
 here that I have already advifcd where the finus runs 
 behind the re6tum. 
 
 Hitherto I have fuppofed that the fiftula or finus 
 difcharges its contents by one or more external open- 
 ings in the neighbourhood of the anus : this, howev- 
 er, does not always happen ; and the matter, inftead 
 of being difcharged by an external opening, is in fome 
 inflances, firft emptied into the gut, and afterwards 
 difcharged, either by itfelf, or mixed with faeces on the 
 
504 Of the Tijlida Chap. XXXVIII. 
 
 patient going to flool. This, as I have already obferv- 
 ed, forms what has been termed an occult fillula, or, 
 according to French authors, une fillule borgne. 
 
 As the ufual and mo(t certain characleriltic of fif- 
 tula, namely, an external opening difcharging matter, 
 is here wanting, fome attention is required to afcertaiii 
 its exiftence, as well as to prevent it from being con- 
 founded with other difeafes. Thus, matter difcharg- 
 ed from abfcefles in the upper part of the alimentary 
 canal, has, in fome inftances, been fuppofed to proceed 
 from an occult fiflula in the neighbourhood of the 
 anus ; and vice versa, pus collefted in and difcharged 
 from an impoflhume near to the anus, has, merely 
 from want of attention, been fuppofed to originate 
 from difeafe in the upper part of the gut ; and upon 
 this fuppofition, remedies have been prefcribed with- 
 out effect, when a complete cure might have been ob- 
 tained by very fimple means. 
 
 The diftinction, however, between thefe difeafes is, 
 in general, fufficiently evident. When matter colleft- 
 ed in the fuperior part of the gut, is at laP: difcharged 
 by ftool, it is commonly thoroughly mixed with, and 
 feems to conftltute a part of, the fseces, and no pain 
 takes place near to the anus. But in the cafe of an 
 occult fiilula, the matter difcharged by ftool is not 
 mixed with the faeces ; on the contrary, they always 
 appear diftinct and feparate ; on minute inveftigation, 
 fome degree of hardnefs, fvvelling, or difcoloration, is 
 always difcovered near to the fundament ; and in this 
 fpot a confiderable degree of pain is felt on prelTure. 
 
 Various means have been propofed in cafes of oc- 
 cult fiftula, for difcovering the fite of the abfcefs. By 
 fome we are advifed to pafs a curved probe up the 
 rectum ; and to fearch with the point of it till the 
 opening is difcovered, when by pufhing it forward, it 
 may pafs into the abfcefs :* others, again, advife a 
 thick firm tent to be pufhed into the redum, fo as to 
 
 • vide Dioiiis — Courfc of Operations, Demonftr. ir. 
 
Chap. XXXVIII. in Am. 305 
 
 obftrucl every means of communication between the 
 fmus and gut ; and by this they fuppofe, that the 
 matter of the abfcefs may be made to colledl in fuch 
 quantities as evidently to point out its fituation. Nei- 
 ther of thefe methods, however, are neceflary, nor is 
 it piobable that they would often fuccecd. 
 
 Whenever an abfcefs is feated near to the verge of 
 the anus, however fmall it may be, it may be eafily 
 difcovercd : for, fome degree of hardnefs, a fmall tu- 
 mefaftion, and moft frequently fome difcoloration, is 
 obferved at fome part contiguous to the extremity of 
 the gut ; and whenever this mark is perceived, and 
 efpccially if prefl'ure excites much pain, there will be 
 no caufe to doubt of this being the feat of the abfcefs. 
 
 In fuch circumftances, what are we to do ? We 
 ought here to have the fame objedt in view, as if the 
 matter had been difcharged by an external opening : 
 for the difeafe is in reality the fame, and differs only 
 in this fmgle circumftance from the moil frequent 
 variety of fiflula, that the matter is in this cafe firfl 
 thrown into the reftum, before it can be difcharged, 
 inftead of coming freely off by one or more external 
 outlets near to the anus. And as the two varieties of 
 the difeafe are very nearly the fame, fo the means ne- 
 ceffary for their removal are very fmiilar. 
 
 As foon as we have determined to perform the op- 
 eration, the point of a lancet fliould be plunged into 
 the tumefied or difcoloured fpot ; and upon the point 
 of the inflrument reaching the abfcefs, which is at 
 once known by a difcharge of pus taking place, as the 
 difeafe is thus reduced to the ft ate of a fimple, com- 
 plete fiftula, the operation is to be finiflied in the fame 
 manner as I have already advifed for that variety of 
 the difeafe ; by the introduction of the finger of the 
 left hand into the anus, paffmg the probe pointed bif- 
 toury in at the wound newly made, and on its poin( 
 being difcovered by the finger in the redum, by draw- 
 ino; it out in fuch a manner as to divide the abfcefs or 
 
 Vol. III. W 
 
3o6 Of the Fiftula Chap. XXXVIII. 
 
 fmus through its whole length ; and the fubfequent 
 treatment of the fore is alfo the fame as in other cafes 
 of fiftula. 
 
 All that has been as yet faid relates to the mildeft 
 and moft fimple ftages of filtula ; the parts chiefly 
 affefted being fuppofed to be in no other way difeaf- 
 ed, than by having an abfcefs feated in them, either 
 occult, or with one or more external fmufes running 
 into it. But when by neglecl, or improper treatment, 
 the matter collected hi fuch abfceffes does not find a 
 free vent, the contiguous parts inflame, become pain- 
 ful, and in a gradual manner acquire much morbid 
 hardnefs or callofity. 
 
 In fuch circumftances, various remedies have been 
 advifed : as a previous ftep to any operation, it has 
 been propofed by fome to diffolve this hardnels or cal- 
 lofity, by the ufe of mercury, aided by fuppurative or 
 emollient poultices. Others advife the hardened parts 
 to be deftroyed with cauftic ; but the opinion that 
 has till of late moft generally prevailed, is, that all the 
 callous parts fhould be extirpated with the fcalpel. 
 
 But whoever has had opportunities of becoming 
 acquainted with this branch of practice, will know, 
 that it is perfedly impoflible to dilfolve or diflipate 
 any callofity that has been of long duration, either by 
 poultices, mercurials, or other difcutients ; and it 
 luckily happens, that a cure may in general be ob- 
 tained by means of a more gentle nature than the 
 deftruclion of the hardened parts, whether by cauftic 
 or extirpation : when the parts cannot be preferved 
 but at the hazard of the patient's life, they ought 
 undoubtedly to be removed ; but as neceftity alone 
 jfhould point out the propriety of fuch a painful and 
 violent meafure, it ftiould never be advifed when our 
 views can be accompllftied in a milder manner. 
 
 I have endeavoured to fhew, and indeed the fa£l is 
 obvious to all who will be at the trouble of obferving, 
 that the callous ftate of the parts that often takes place 
 where the difeafe has been of long duration, is uni- 
 
Chap. XXXVIII. in Ano, 307 
 
 formly the effedt of the matter not findhig a free vent, 
 and of its being thereby forced to difperfe among the 
 contiguous mufcles ; by which, pain, inflammation, 
 and hardnefs, are fucceflively and neceilarily pro- 
 duced. 
 
 If this is a true flate of the matter, and all prafti- 
 tioners of experience will probably admit that it is fo, 
 it mufl be obvious, that there can be no need of luch 
 violent remedies as thofe I have mentioned, namely, 
 the removal of the difeafed parts either with cauftic or 
 the fcalpel : the means of relief to be employed here, 
 are merely fuch as will afford a free outlet to the mat- 
 ter, whilft they alfo ferve to induce and preferve a 
 difcharge of matter in the fubltance of the difeafed 
 parts, and which ] am inclined to confider as the mod 
 effectual method hitherto difcovered for the removal 
 of all fuch morbid callofities. 
 
 Through the whole of this chapter, I have avoided 
 the ufe of the word fchirrus ; and I am here particu- 
 larly anxious to have it remarked, that I have done 
 fo : for in real fchirrus, the remedy I have now point- 
 ed out, namely, the excitement of fuppuratlon in the 
 fubftance of the difeafed parts, would probably prove 
 highly pernicious, by forcing quickly forward to a 
 ftate of cancer, a tumor, which, if left to itfelf, might 
 probably have remained indolent for a great length of 
 time. It is therefore evident, that an accurate diflinc- 
 tion between real fchirrus, and other hard tumors, is 
 a point of much moment. Every hard tumor that 
 from experience is known to be apt to degenerate in- 
 to cancer, I would denominate fchirrus. Now, we 
 know very well, that cancers rarely attack tumors that 
 are not glandular : fo that to every indurated fwelling 
 of the cellular fubftance, and other foft parts not evi- 
 dently glandular, a different appellation fliould be giv- 
 en : all of thefe may, with propriety enough, be de- 
 nominated callous tumors. 
 
 Thofe hard tumefactions, therefore, feated in the 
 cellular fubftance near the anus, as they never appear 
 w 2 
 
3o8 Of the Tijhila Chap. XXXVIII. 
 
 to degenerate into cancer, I have termed callofities : 
 the moil effeclual remedy that I have tried for the 
 removal of thefe, is a free fuppuration induced in 
 them ; and the beft: method of eftedling this, is by 
 laying every fmus that can be difcovered, freely open 
 from one end to the other ; and when the finufes are 
 not numerous, it proves even uieful to make one, 
 two, or more deep incifions along the whole extent of 
 the induration. By carrying the incifion to the full 
 depth of the indurations, fuch a plentiful flow of mat- 
 ter enfues to the inflammation that they induce at firfl, 
 as commonly acts with much advantage in the cure. 
 
 Indeed none can imagine how highly beneficial this 
 practice proves, but thofe who have experienced the 
 benefit that enfues from it : in various inflances, I 
 have known it fiicceed completely where the total re- 
 moval of the difeafed parts had previoufly been judg- 
 ed to be indifpenfable. Where the difeafe has been 
 of long duration, the remedy muft indeed be long per- 
 fifled in ; that is, a plentiful difcharge of pus mufi be 
 long preferved, either in the incifions firfl made, or, 
 if thefe heal too quickly, in others made to fucceed 
 them. 
 
 In fome inflances, thefe incifions do not eafily fup- 
 purate ; their edges inflame, become painful, and dif- 
 charge a thin fetid matter. When this proceeds from 
 lues venerea, or any other difeafe of the confl:itution, 
 this mufl be firfl removed, before the incifions will 
 yield good matter. But when the fyftem is otherwife 
 healthy, and when there is therefore reafon to ima- 
 gine that the untoward ftate of the fores proceeds 
 merely from irritation, or fome other local affeftion, 
 in fuch circumflances, Avarm poultices prove highly 
 ufeful : by their emollient properties, they tend to re- 
 move irritation with more effect than any other reme- 
 dy ; and I have elfcwhere fhewn, that nothing ads 
 with fuch certainty in the formation of good pus. 
 
 In every cafe, therefore, of fiftula, attended with 
 much hardnefs and tumefaction of the contiguous 
 
Chap. XXXVIII. in Atio. 309 
 
 parts, inftead of removing the hardened parts either 
 with cauflic or the knife, the pradice I would advife 
 is this : the finus or fiflula lliould be treated in the 
 fame manner as if no hardnefs exifted ; that is, it 
 fhould be laid freely open from one end to the other : 
 if more finufes are difcovcred, thefe fhould alfo be 
 laid open ; and if the hardnefs in the contiguous parts 
 extends either laterally, or in any other direftion be- 
 yond the courfe of the finufes, one or more deep in- 
 cifions fliould be made along the whole length of it: 
 and by preferring thefe incifions in a fuppurative (late 
 till the hardnefs is difcufled, they may then be allow- 
 ed to heal from the bottom in the fame manner with 
 wounds or ulcers induced by any other caufe. 
 
 By this management alone, when the conftitution 
 is otherwife healthy, the very word variety of fiflula 
 may be cured with more certainty, and with much 
 more comfort to the patient, than by the extirpation 
 of the hardened parts. Indeed, fcarcely any cafe, I 
 think, can occur, of the parts being in fuch a flate as 
 to render it proper to remove ihem, if they have not 
 been long and almoft entirely feparated from the fub- 
 jacent mufcles, with which, in a healthy flate, they 
 ought to be connected. This, again, can never take 
 place, but from very grofs mifmanagement : when we 
 do, however, meet with it, and when the hardened 
 parts are fo much detached from the others, that they 
 would not probably adhere again, neceflity points out 
 the propriety of cutting them oft'; and in external ul- 
 cerations of thefe parts, when the edges of the fores 
 have become hard and reverfed, the cure may be pro- 
 moted by removing the difeafed parts ; but in no oth- 
 er inflance ought this pradice to be attempted ; for 
 all the advantages faid to be derived from it, may be 
 obtained with much more eafe and fafety from the 
 method of cure I have here pointed out. 
 
 The only other fymptoms connected with fiflula in 
 ano, to which I have not yet adverted, are fuch aS 
 
310 Of the Fijluh Chap. XXXVIII. 
 
 atife from afFedions of deep feated parts ; namely, 
 fuch as proceed from difeafe of the os coccyx, os fa- 
 crum, bladder, and parts about the loins. 
 
 It fometimes happens, that the matter collefted hi 
 fiftulous fores about the anus, by being allowed to 
 fpread among the neighbouring parts, comes at laft 
 even to injure the bones themfelves ; but inftances 
 likewife occur of difeafes of the bones being the pri- 
 mary affedlion, and of its giving rife to, inllead of be- 
 ing produced by, fmufes about the reftum. Thus, 
 collections of matter on the pfose mufcles, originating 
 in fome inftances, from caries of the lumbar vertebrae, 
 inftead of falling down and pointing, as they com- 
 monly do, in the upper and forepart of the thigh, are 
 fometimes found to follow the courfe of the inteftines, 
 and to difcharge their contents at the fide of the rec- 
 tum. A fevere bruife, too, upon the hips and conti- 
 guous parts, by injuring the os coccyx, has in fome 
 inftances produced the fame effedt. 
 
 But the moft diftrefsful circumftance that ever ac- 
 companies fiftula in ano, is the formation of a pafl'age 
 between the rectum and bladder. This fometimes 
 happens indeed, where no fmus or abfcefs had previ- 
 oufly appeared about the anus ; but it more frequent- 
 ly fucceeds to ulceration in thefe parts, and by thefe 
 being improperly treated, than to any other caufe. 
 The fymptoms by which the exiftence of this dread- 
 ful malady is with moft certainty known, are, in the 
 firft place, an unufual, dark brown, thick fediment, 
 being obferved in the urine, which by degrees becomes 
 of a darker colour, and of a more offenfive faecal 
 fmell ; air is frequently difcharged in confiderable 
 quantities by the urethra, both before and after void- 
 ing urine ; and in the latter ftages of the difeafe, the 
 urine does not get a free vent from the bladder. 
 
 The exiftence of thefe fymptoms, ferves fufficiently 
 to afcertain the nature of the difeafe ; but hitherto we 
 have not been able to difcover any means of removing 
 
Chap. XXXVIII. in Ano. 3 1 1 
 
 it. So that all who have yet been attacked with it 
 have at laft fallen viftims, after dragging on, twelve, 
 eighteen months, or perhaps a few years of a mifera- 
 ble exiftence. 
 
 In the event of any of the bones of the coccyx, fac- 
 'rum, or lumbar vertebras, becoming carious, from the 
 matter in this difeafe having been allowed to penetrate 
 and to corrode them, all that art can do is to preferve 
 a free vent for the difcharge ; to keep the parts clean ; 
 to extradl any pieces of lool'e bone that may be diff 
 covered ; and to flrengthen the conftitution by a nou- 
 rifhing regimen, with a view to enable it to fupport 
 the long continued difcharge to which it may proba- 
 bly be expofed : fome few have in fuch circumflances, 
 and with fuch a plan of management, been fortunate 
 enough to obtain cures, by fuch pieces of bone as were 
 fpoiled being at lad thrown off, and by the parts be- 
 ing then induced to heal. This, it mufl be confelfed, 
 however, is a rare occurrence ; and all that, in this 
 fituation, we have rcafon to expect, is to be able to 
 palliate the moil diftrefsful fymptoms. 
 
 I have thus concluded what it was my intention to 
 offer on the fiftula in ano ; and as it is a very diftrefs- 
 ful as well as a frequent difeafe, and efpecially as it was 
 never till of late defcribed with accuracy, I have hence 
 been induced to confider it more minutely than I oth* 
 erwife fliould have done. What I have endeavoured 
 to fliew, and to which I ftill wifti to excite the atten- 
 tion of the younger part of the profellion, is, that a 
 fnius or fiftula, is a difeafe of the very fame nature in 
 the neighbourhood of the anus, as in any other part 
 of the body ; and therefore, that the method of cure 
 ought to proceed upon the fame principles here as in 
 fmiilar affections of other parts. Till the late improve- 
 ments made in the treatment of this difeafe, and till 
 the true nature of it was underftood, much confufion 
 fubfifted in the method of conducing the cure. Ex- 
 cept in the mod trifling cafes of fuperftcial finufes, it 
 
312 Of ihe Fijiula Chap. XXXVIII. 
 
 was never Imagined that a fimple incifion could an- 
 fvver : nothing lefs than a total deftrudion or removal 
 of the difeafed parts was fuppofed to be fufficient. 
 
 But it will now, 1 hope, appear, that this is very 
 rarely neceflary ; and when a cure is practicable, that 
 it will be more readily accompliflied by the means I 
 have pointed out, namely, by a mere divifion of the 
 fmufes, than by any other that has yet been propofed. 
 It will fometimes happen, indeed, that, in cafes of an 
 inveterate nature, none of the means that I have men- 
 tioned will fucceed ; but, in all fuch cafes, no advan- 
 tage would be derived from more violent remedies, 
 and much diftrefs would certainly be induced by them. 
 
 I have already obferved, that the beft form of knife 
 that I have yet feen for fiftula in ano, is one or other 
 of the biftouries, delineated in Plate LXIV. Thofe 
 who are not accuftomed to ufe this bifloury, are apt 
 indeed to fuppofe, that it cannot penetrate the re£tum 
 but with much rilk of injury to the finger of the op- 
 erator, previoully palled into the gut ; but this is fo 
 far from being the cafe, that in none of the cafes in 
 which I have operated, and they now amount to feme 
 hundreds, has my finger ever been hurt : with a view, 
 however, to obviate this difficulty, a very neat and 
 fnnple invention has for fome years pad been ufed by 
 many, and of which I have given a figure in Plate 
 CXIV. fig. 2. and 3. and the mode of applying it will 
 be feen in the explanation of the Plate. The probe 
 pointed bifloury, however, when properly formed, di- 
 vides the gut in a great proportion of cafes with per- 
 fedl cafe, and with no hazard, as I have endeavoured 
 to fliew either to the patient or operator ; but where 
 the parts meant to be cut are of confiderable thicknefs, 
 as is the cafe when the finus does not run contiguous 
 to the rectum, I have fometimes found it difficult to 
 perform the operation with a biftoury of any form. 
 The difficulty, however, does not confifl; in palling the 
 inftrument from the finus into the redum, which, with 
 
Chap. XXXVIII. in Ano, 3 1 % 
 
 the common crooked biftoury, is in every cafe eafily 
 done, if the probe pointed part of it is properly made, 
 but in turning the point of it down, fo as to divide the 
 parts from the opening at which it entered, to the un- 
 der part of the gut : by cutting flowly and dehberate- 
 ly, I have always been able to do it ; but in one cafe, 
 a biftoury of confiderable ftrength broke while I was 
 making the cut ; and in different inftances I have 
 known this happen with others : this has made me 
 wifh to have an inllrument for this operation dill more 
 perfeft than the biftoury : many have been propofed, 
 but none that has yet appeared anfwer fo well as the 
 biftoury : I am at prefent ufmg fciffars of a particular 
 conftruftion ; but I cannot as yet fpeak of them with 
 fuch certainty from experience, as to render it proper 
 to lay them before the public, which, however, I ftiall 
 do at fome future period, if the trials that I mean to 
 give them fliall juftify the opinion I have formed of 
 them : I may here, however, fliortly obferve, that they 
 confift of two cutting blades, which, after being intro- 
 duced feparately, the one into the fmus, and the other 
 on the finger previoufly pafled into the reftum, are 
 joined at their axis by a moveable pin, in which ftate 
 being able to aft like common fciffars, the operation 
 is finiihed by a fmgle cut. 
 
314 General Obfervations Chap. XXXK 
 
 CHAPTER XXXIX. 
 
 OF FRACTURES, 
 
 SECTION I. 
 
 General Obfervations on Fra&ures. 
 
 SOME praftitloners denominate every folutlon of 
 continuity in a bone, a fracture ; but the term may, 
 with more propriety, be confined to divifions in bones 
 produced by external violence. Thus, we do not fay 
 that a bone is fractured, the parts of which are fepa- 
 rated from each other by the effect of internal difeafe ; 
 while we fay that it is fractured when this happens 
 from a fall, a blow, or a bruife. 
 
 Fradtures are of various kinds, and are diflinguifli- 
 ed by different names. A bone may be fractured ei- 
 ther dire£tly acrofs ; in an oblique direction ; or lon- 
 gitudinally : hence the terms, tranfverfe, oblique, and 
 longitudinal fractures. When a bone is fplit, we fay 
 that it is fplintered. 
 
 When the teguments remain found, a fracture of a 
 bone is denominated fimple ; and we term it com- 
 pound when the fracture communicates with a wound 
 in the fliin and other correfponding foft parts. By 
 fome a fracture is faid to be compound when a bone 
 is broken into different parts ; and thofe fra£tures they 
 term complicated, that are accompanied with wounds 
 in the correfponding foft parts. This fubdivifion, 
 however, of fractures, feems to be unneceffary : for 
 unlefs a bone is fplintered, no effential difference arifes 
 merely from its being broken at one or two parts ; 
 whereas the flighted communication between a frac- 
 ture and a wound in the furrounding foft parts, chang- 
 
Se6t. I. on FraHurcs, 315 
 
 cs the nature of it fo entirely, as often to induce much 
 danger where no alarming fymptoms would otherwifc 
 have been dreaded. 
 
 The exiftence of fracture is, for the mod part, eafi- 
 ly difcovered, by manual examination. A fradlure of 
 a lingle bone, where there is only one in the fradured 
 limb, and the fradture of both bones when there are 
 two, as well as fradures accompanied with extenfive 
 wounds of the contiguous foft parts, are eafily difcov- 
 ered : but in fimple fractures, where only one bone 
 of a limb has fuftered, it is often difficult to judge with 
 any degree of precifion ; particularly where the con- 
 tiguous parts have become tenfe and painful. Infuch 
 cafes, our opinion muft be formed by a minute atten- 
 tion to different circumftances ; the age and habit of 
 body of the patient ; the fite of the fuppofed frafture ; 
 the fituation of the limb when the injury was receiv- 
 ed ; and, laftly, the attending fymptoms. 
 
 In old age, bones are more eafily fra£lured than In 
 earlier periods of life. In infancy, bones will rather 
 yield than break on the application of a moderate force ; 
 whilfl in old age they become fo brittle, that even the 
 largeft are frequently broken by very trifling falls and 
 bruifes. 
 
 Different difcafes induce this brittle flate of the 
 bones ; particularly lues venerea. Of this I have met 
 with various inflances. In fome of thefe, the largeft 
 and hardeft bones were broken, folely by the ordina- 
 ry adtion of the mufcles of the limb. This I have al- 
 fo known happen in fea fcurvy : bones that have been 
 fractured and long united, are apt to feparatc in ad- 
 vanced ftages of fcurvy, the callus being either diffolv- 
 ed or rendered too foft for the purpofe of retaining 
 them together. 
 
 Befides thefe general difeafes of the body, the bones 
 themfelves are liable to a diCeafe that renders them foft 
 and flexible. This is u'uaily termed mollifies oflium. 
 In fome, this goes no farther than to produce that flate 
 of the bones that I have mentioned, in which they are 
 
3i6 General Obfervations Chap. XXXIX. 
 
 apt to be fractured by flight falls and fimilar accidents : 
 but in others, it has been known to proceed to fuch a 
 height, that every bone in the body has become crook- 
 ed and diftorted. I have feen a fkeleton in which the 
 condyles of the knee joints were turned up fo as to 
 touch the pubes, and in which every other bone was 
 crooked in nearly a fimilar degree. 
 
 In judging therefore of the probability of a fraclure 
 from the degree of violence that has been applied, thefe 
 circumftances merit attention : for it is evident, that 
 in old age, and in thefe difeafed flates of bones, a de- 
 gree of force will produce fradure, which in other 
 circumftances it could not poflibly do. 
 
 The (ite of a fuppofed fra6lure is alfo to be taken 
 into confideration. Bones are more apt to be broken 
 in thofe places where they are hard and brittle, as in 
 the firmer parts of all the long bones, than towards 
 their extremities, where they are of a more foft and 
 yielding texture ; and bones that he deep under the 
 cover and protection of mufcular parts, as in the thighs, 
 are not fo frequently fra6tured as thofe of the arms 
 and legs that are not fo w^ell prote6led. 
 
 Further, the fituation of a limb when an injury is 
 inflifted, is an obje£t of inquiry. Thus, a very incon- 
 fiderable weight pafling over a bone lying on an une- 
 qual furface, will readily produce a fradure ; while 
 the fame bone, equally fupported, will bear a heavy 
 load without being much injured. 
 
 In forming an opinion of the probability of a bone 
 being broken, we ought, laftly, to take into confider- 
 ation the fymptoms that ufually accompany fradtures. 
 Thefe are, pain, fweUing, and tenfion in the contigu- 
 ous parts ; a more or lefs crooked and diftorted ftate 
 of the Hmb ; a crackling or grating noife on the parts 
 being handled ; and lofs of power to a certain degree 
 in the injured limb. 
 
 It is true, that the mere fracture of a bone is not 
 neceflarily attended with much pain ; for the bones, 
 not being fo plentifully fupplied with nerves as the 
 
 \ 
 
Sect. I. on FraSlures, 317 
 
 fofter parts of the body, they are therefore of a lefs ir- 
 ritable nature. But pain arifes from two circumftan- 
 ces with which fraduies are ufually attended ; the 
 contiguous foft pa;ts being bruifed and otherwife hurt, 
 in the firft place by the force producing the injury, 
 and afterwards by the difplaced ends of the bones. 
 For the mod part the pain indeed is not very fevere : 
 but in fomeit is fo violent as to induce the mod alarm- 
 ing fymptoms ; fpafmodic twitchings of the mufcles 
 of the limb ; high degrees of inflammation ; fever ; 
 general convulfions and delirium ; and if the caufe 
 by which thefe fymptoms are induced be not foon ob- 
 viated, they fometimes even terminate in death. In 
 general this is preceded by mortification of the parts 
 contiguous to the fradture ; but in fome thefe fymp- 
 toms prove fatal, without any tendency to gangrene 
 being perceived. 
 
 When the force by which a frafture is produced 
 has been extenfively applied over a limb, we may read- 
 ily fuppofc that the fevereft fymptoms may be induced 
 by this caufe alone ; but in general we find, when the 
 pain, tenfion, and convulfive twitchings of the muf- 
 cles are fevere, that they chiefly arife from the adjoin- 
 ing membranes, mufcles, and other foft parts being 
 torn, punftured, or comprefied, by the ends of the 
 fractured bones : and although this may happen in 
 fraftures of every defcription, yet it will neceflarily be 
 more frequent in thofe that are fo oblique as to admit 
 of the bones pafllng eafily over each other, than in 
 tranfverfe fractures, where the parts, on being replac- 
 ed, more readily remain in their natural fituation. 
 
 The other diagnoftic fymptoms of fracture that I 
 enumerated, namely, a grating noife on the parts be- 
 ing handled, and difliortion and lofs of power to a cer- 
 tain degree in the injured limb, muft necefl'arily take 
 place in every frafture. They are indeed much more 
 evident in fome fra(^nrcs than in others ; but in all, 
 they may be difcovered where the parts are not much 
 fwellcd, excepting in the cafe of a longitudinal or fplin- 
 
3i8 General Obfcrvaiions Chap. XXXIX. 
 
 tered fradure. A bone may be fpllt in this direftion 
 without any of thel'e fymptoms taking place : for un- 
 lefs the divided parts be completely feparated from 
 each other, neither diftortion nor crackling will be 
 perceived on handling them ; nor will the bone be 
 rendered altogether incapable of performing its ufual 
 functions. In fuch cafes, we judge of the probability 
 of a fracture, from the violence of the injury, the fe- 
 verity of the fymptoms, and other circumflances al- 
 ready enumerated. 
 
 Bcfides thefe leading fymptoms of fractures that 
 take place immediately on the injury being inflicted, 
 there are others which occafionally occur from the 
 firft, and fome that we are to confider as confequen- 
 ces rather than fymptoms. Of the firft, the moll re- 
 markable are, that great degree of ecchymofis which 
 in fome cafes appears inftantaneoufly, from the ends 
 of a fractured bone having penetrated a contiguous 
 artery or vein ; and the wound or laceration of the 
 teguments in compound fractures. 
 
 The moft important confequences of fra£tures are, 
 ftiffnefs and immobility of the injured limb ; diftortion 
 of the parts chiefly affe6ted, either from a fulnefs or 
 thicknefs remaining in the contiguous mufcles or lig- 
 aments ; an exuberancy of callus ; a contracted ftate 
 of the contiguous joints ; or a marafmus or wafting 
 of the limb itfelf. All thefe we ftiall confider more 
 particularly in fpeaking of the treatment of fractures. 
 
 In judging of a fracture, and of the probable event 
 of it, various circumftances are to be confidered : par- 
 ticularly the age and habit of body of the patient ; the 
 fituation of the bone, and the part of it that is injur- 
 ed ; the nature of the attending fymptoms ; the cir- 
 cumftances with which the fracture may be compli- 
 cated ; and the kind of fracture. 
 
 With refpeCt to the firft of thefe, namely, the age 
 and habit of body of the patient, wc all know that 
 they are points of much importance in the cure of ev- 
 ery injury ; and in none more than in natures. Thus 
 
Se£t. I. on ¥ra6lures. 319 
 
 in youth, particularly in infancy, fradures are more 
 quickly cured than in old age ; and in found confti- 
 tutions, more readily than in thofe that arc difeafed. 
 1 have obferved above, that the bones fometimes be- 
 come brittle in lues venerea ; and it may here be re- 
 marked, that the exiilence of lues venerea and fcurvy, 
 is particularly adverfe to the reunion of fradlured parts. 
 I have met with foine exceptions to this, where frac- 
 tures have urited readily even in advanced ftages of 
 lues venerea : but this is uncommon ;. and where lues 
 venerea has attacked the bones, a firm callus feldoni 
 forms till the virus is eradicated. 
 
 In fpeaking of the effe£l of age on the cure of frac- 
 tures, although I admit that the divided parts of bones 
 unite more fpccdily in infancy than in old age, yet I 
 think it right to remark, that they do not reunite with 
 more certainty. By many we are told, that in ad- 
 vanced periods of life, the union of fraclured bones 
 is often not to be accomplilhed. I have never, how- 
 ever, feen an inftance of this, although I have had the 
 management of many fractures even in extreme old 
 
 The fituation and part of the injured bone, are both 
 circumftances that merit attention. Thus we know, 
 that fra£lures of the fmall bones of the arms and legs, 
 of the feet and hands, and of the ribs, in general heal 
 eafily ; while fraftures of the larger bones, particular- 
 ly ot the femur and humerus, are managed with more 
 difficulty. In the lafl, indeed, one principal caufe of 
 the cure proving tedious, is the difficulty of retaining 
 the ends of the bone together. 
 
 When any of the large bones are fradured near to 
 their extremities, we find the danger is greater, and 
 the profped of a complete cure much lefs, than when 
 they are broken near to their middle : for here the 
 fhortnefs of one end of the bone makes the retention 
 difficult ; and the fymptoms that enfue from fraclures 
 m this fituation are apt to be particularly fevere, not 
 OTily from the contiguity of the capfular ligaments of 
 
320 General Obfervatlons Chap. XXXIX. 
 
 the joints, which may thus be injured, but from the 
 numerous tendons that are inierted into thefe parts of 
 the bones j which may not only be lacerated and 
 bruifed, but even torn from their infertions. Befides, 
 the ends of bones are not only foft, but even fpongy 
 or cellular in their texture, by which fractures in thefe 
 parts do not unite fo equally ; the parts more fre- 
 quently exfoliate, and matter is more apt to form in 
 them : hence when fradured they are more tedious 
 in the cure, and give rife to more troublefome fymp- 
 toms, than fnnilar accidents in the harder parts of 
 bones. 
 
 It is alfo proper to remark, that fraftures near the 
 extremities of bones are frequently productive of ftift' 
 immoveable joints, unwieldy limbs, pains and fwell- 
 ings ; which, in various inftances, even under the beft 
 treatment, continue obftinate for a great length of 
 time, and in fome cafes even during the life of the pa- 
 tient. 
 
 We are in general led to fuppofe, that thefe confe- 
 quences arife folely from mifmanagement, either on 
 the part of the furgeon or of the patient. That in 
 fome inftances, this is the cafe, no perfon will doubt. 
 The ends of a fraftured bone may be improperly plac- 
 ed from the hrft by the pratlitioner, or they may be 
 afterwards mifplaced by the patient ; and in either cafe 
 we may conceive tliat all the fpmptoms I have men- 
 tioned will take place. But in juftice to the profef- 
 fion, 1 muft obferve, that they more frequently arife 
 from the fituation and nature of the fracture than 
 from any other caufe. l>Ior is it furprifmg that it 
 (hould be fo. When v/e conlider the various circum- 
 ftances with which fraftures are often accompanied ; 
 the degree of violence required to break a large bone ; 
 the fe\ ire. contufion of the contiguous foft parts which 
 this muft produce ; and the laceration of nerves, muf- 
 cles, and ligaments, that muft occur from the fpiculje 
 of fradured bones ; we fhould rather expect that th 
 
Seel. I. o'n FraHuresi 321 
 
 would more frequently induce diftrefsful confequen- 
 ces than we aftually find to be the cafe. 
 
 In forming a judgment of the nature and probable 
 event of fradures, the fymptoms merit particular at- 
 tention. If the fymptoms are moderate, when com- 
 pared with the violence that the parts have fuffered, 
 our prognofis fhould be proportionally favourable : 
 but when the attending fymptoms are fevere, particu- 
 larly if the pain is uncommonly violent, and the fwell- 
 ing and tenfion confiderable, however trifling the force 
 may have been by which the fracture was produced, 
 the cafe will probably be difficult to manage, and un- 
 certain in the event. In fuch circumftances, there- 
 fore, even in fimple fradtures, our prognofis fhould be 
 guarded. 
 
 The circum.flances with which a fradure may be 
 complicated, are likewife of importance ; and unlefs 
 they are duly weighed, no accurate judgment can be 
 formed of the event. The contiguous mufcles and 
 other foft parts may be feverely contufed ; fome of 
 the ligaments and tendons of the injured part may be 
 ruptured, or even torn from their infertions ; and the 
 frafture may be combined with a diflocation of one 
 or both of the contiguous joints. Thefe accidents in 
 every inftance aggravate the danger. 
 
 The laft confideration on this fubjed refpeds the 
 kind of fradure. The greateft difference is obferved 
 between the event of a fmiple and of a compound 
 fradure. A great proportion of cafes of fimple frac- 
 ture are of a mild nature from the firfl ; and with 
 very ordinary attention, complete cures are obtained : 
 but in compound fractures, the fmallefl external 
 wound communicating with the injury in the bone, 
 will often produce the greatefl danger. I do not mean 
 to fay that this always happens ; on the contrary, we 
 know that even the worfl cafes of compound frailures 
 will, with proper attention, often terminate in a fa- 
 vourable manner : but every practitioner verfant in 
 this branch of bufinefs, will allow, that this is feldom 
 
 Vol. III. X 
 
32a General Obfervatms Chap. XXXlX^ 
 
 the cafe ; and that even under the befl: management 
 fuch cafes are fo apt to go wrong, as to warrant the 
 opinion that I have given of them, and to render it 
 proper in ahnoft every inflance to give a guarded 
 prognofis. 
 
 Various indications have been propofed for the cure 
 of fractures ; and thofe we are defired to have partic- 
 ularly in view, are, extenfion ; counter extenfion ; 
 coaptation, or replacement of the fractured parts ; de- 
 ligation, in fo far as is neceflary for retaining them ^ 
 pofition of the injured part j and prevention or re- 
 moval of bad fymptoms. 
 
 The fubjeft, however, may be fimplified, and the 
 indications with propriety reflricted to three : to re- 
 place the parts of the bone that have been moved from 
 their natural fituation ; to retain them in this fitua- 
 tion as long as may be neceflary ; and to obviate fuch 
 fymptoms as may fupervene during the cure. 
 
 In fome few favourable cafes, where the bones are 
 fraftured directly acrofs, they are either not moved 
 out of their natural fituation, or the alteration is fo 
 inconfiderable that they are eafily replaced. But when 
 the bones of a limb are broken in an oblique direction, 
 they are apt to pafs one another fo as to produce much 
 deformity and pain. The contiguous mufcles are thus 
 feverely injured, and excited to violent adtion : hence 
 the malady is increafed by every exertion ; and noth- 
 ing will remove it but an artificial replacement of the 
 diftorted bones. 
 
 To accomplifh this, various methods have been pro- 
 pofed. In former times it was done by much violence 
 and force ; by what was termed extenfion and counter 
 extenfion : but we now know that our purpofe may 
 be accomplifhed in an eafier manner, with lefs pain to 
 the patient, and lefs trouble to the operator. 
 
 As long as it was imagined that much force was 
 neceffary, the liinb was extended by one or more af- 
 fiitants pulling at each end of it 5 and when this was 
 not fufficient, diifferent machines were employed fof 
 
Sed. I. on Fractures. 323 
 
 it. This force was in general applied while the limb 
 was ftretched out or extended, by which it became 
 much more difficult to reduce the difplaced ends of 
 the bone : for in this manner all the contiguous muf- 
 cles were put into a£lion ; nor could the bones be re- 
 placed till this was overcome by the application of a 
 fuperior force. The mifchief that this would often 
 produce, it is eafier to imagine than exprefs. 
 
 When it is confidered, that in the reduction of frac- 
 tured bones, the chief refiflance arifes from the action 
 of the correfponding mufcles, the propriety of placing 
 the limb in fuch a pofture during the operation, as 
 may favour the relaxation of thefe mufcles, is fo evi- 
 dent, that we now refled with furprife, that it fhould 
 have been left to the practitioners of the prefent age 
 to propofe it. For, whatever may have been the opi- 
 nion of a few, it is certain, that till lately it was the 
 general practice to keep every limb in an extended 
 pofition while any attempt was making to replace the 
 fradured bones, and that it is chiefly to the late Mr. 
 Pott we owe the prefent improved ftate of this impor- 
 tant branch of chirurgical pradice. 
 
 If in the treatment of fractures, we take care to re- 
 lax all the mufcles of the limb, it is furprifmg with 
 what eafe the ends of the bones may in general be re- 
 placed. When a limb is laid completely in this re- 
 laxed poflure, the furgeon will in mod cafes be able 
 to replace the bones without any alliftance : but whea 
 this does not fucceed, a flight degree of extenfion may 
 be employed, by the upper. part of the hmb being 
 kept firm by one afllfl:ant with his hands placed be- 
 tween the fradture and the contiguous joint, while the 
 under part of it is gently extended by another ; care 
 being fliill taken, however, to keep the mufcles as 
 much relaxed as poflible. 
 
 As it is of much importance, in replacing the frac- 
 tured parts of a bone, to do it with accuracy, the moft: 
 minute attention fliould be given to this part of the 
 operation. Every inequality depending upon any por- 
 X 2 
 
324 General Ohfcrvatiom Chap. XXXIX# 
 
 tion of a difplaced bone, fhould, as much as poffible, 
 be removed, fo as to render the injured part fimilar 
 to the correfponding found limb ; which, for the pur- 
 pofe of a more attentive examination, ihould be plac- 
 ed as near to it as the conveniency of the operator 
 will permit. 
 
 The neceflity of attention to this part of the treat- 
 ment will particularly appear from this, that when the 
 fraclured bones are not properly reduced at firft, the 
 limb mufl either remain always diftorted, or be put 
 right during a future flage of the cure, when it will 
 necelTarily be done with more pain to the patient, and 
 more trouble and perplexity to the furgeon. 
 
 The bones being put right, our next obje£l is to re- 
 tain them as long as may be neceifary in this fituation. 
 This we do with fpllnts and bandages, and placing the 
 limb in fuch a ftate of relaxation as will admit of its 
 refting with eafe, and without being diflurbed, till the 
 cure is completed. In treating of fradtures of parti- 
 cular bones, the pofture in which they fhould be pla- 
 ced, and the bandages beft adapted for their retention, 
 will be defcribed. I may merely obferve at prefent, 
 that no bandage fhould be more tightly applied than 
 merely to retain the bones in their fituation ; and that 
 this may, for the mofl part, be eafily done, if the limb 
 is kept in a relaxed pollure. 
 
 The time required for the firm reunion of fractur- 
 ed bones depends upon various circumftances : upon 
 the fize of the bone, and the weight that it has to 
 fupport ; on the age and habit of body of the pa- 
 tient ; and on the cure having proceeded with more 
 or lefs interruption, from the limb having been kept 
 more or lefs fleadily in its fituation, as well as from 
 the attending fymptoms of fweiling, pain, and inflam- 
 mation, having been mild or fevere. In a healthy 
 middle aged patient, where no untoward fymptoms 
 have occurred, and when the injured parts have been 
 retained exactly in their fituation, a cure of a fractur- 
 ed femur, or of the bones of the leg, will be accom- 
 
Sed:. I. on FraSiurcs. 325 
 
 plifhed in two months ; of the humerus and bones of 
 the fore-arm, in fix weeks ; of the clavicles, ribs and 
 bones of the fingers and toes, hands and feet, in three 
 weeks. In infancy and childhood, fraftures in all 
 thefe parts heal more quickly, while in old age this 
 uniting proccfs goes on more flowly, and therefore 
 requires more time to accomplifh. 
 
 In fimple fradures, to which thefe general obferva- 
 tions more particularly apply, the pain, tenfion, and 
 other fymptoms, are in general moderate, and ufually 
 fubfide entirely in the courfe of a few days, if the 
 bones are properly retained in their fituation ; but in 
 fome cafes, inflead of diminidiing, they become daily 
 more violent, fo as to be produftive of much diftrefs 
 to the patient, as well as trouble and embarraflment 
 to the praftitioner. 
 
 When the mufclcs and other foft parts of the limb 
 have not been much contufed, no remedy fhould be 
 advifed merely with a view to the prevention either 
 of tenfion or pain : but when much violence has been 
 done to the limb, thefe fymptoms fhould be guarded 
 againfl by the early ufe of allringent applications, fuch 
 as folutions of faccharum faturni, of crude fal ammo- 
 niac, and fpiritus Mindereri ; and when thefe fail, by 
 a free appHcation of leeches over the injured parts. 
 Indeed, the prad:ice of taking away blood by leeches 
 proves in every inflance fo highly ufeful, that I always 
 advife it when the tenfion is confiderable, or whenever 
 the pain continues fevere after the bones have been 
 replaced. In every frafture, inflammation is the 
 fymptom which, in the firft place, we have moft rea- 
 fon to dread ; and as nothing tends with fuch cer- 
 tainty to prevent or remove it as local bloodletting, it 
 fhould never be omitted at firft when the furrounding 
 foft parts are much injured : nor fliould it aftei*wards be 
 delayed when it appears to be neceflary ; for this reme- 
 dy proves always moft efte£i:ual when employed early. 
 
 Befides the mimediate advantage of relieving the 
 pain in the injured part, nothing prevents with fuch 
 
326 General Obfervations Chap. XXXIX. 
 
 certainty the troublefome confequences of contufion 
 in cafes of fraclure, as the early application of leeches. 
 Of thefe confequences, the mofl remarkable are, deep 
 feated abfcelfes, which in fome inflances form within 
 the cavity of the bone itfelf, and in others in the fur^ 
 rounding cellular fubftance ; long continued pains, re- 
 fembling rheumatifm, ftretching over the injured limb; 
 a thickened enlarged ftate of the periofteum and oth- 
 er foft parts ; a fhifF contrafted ftate of the contigUf 
 ous tendons ; an exuberancy of callus j and an un- 
 wieldy ilate of the whole member. 
 
 It is well known to every furgeon of experience, 
 that all of thefe confequences are apt to fucceed to 
 fractures accompanied with much contufion ; and no- 
 thing proves more perplexing to furgeons, or more dif- 
 trefsful to patients ; for when they are not foon remo- 
 ved, they are very apt to prove permanent ; and for 
 the moll part this is laid to the charge of mifmanage- 
 ment in the reduction of the fracture. 
 
 In many inftances thefe confequences no doubt pro- 
 ceed from the extremities of the fradtured bone not 
 being properly replaced, or not retained with exaft- 
 nefs afterwards : but they more frequently proceed 
 from the inflammation that fucceeds to contufion. It is 
 therefore evident, that early local bloodletting is in fuch 
 circumftances moil likely to prove ufeful. When 
 fwelling and pain in a fractured limb have continued 
 long, the mod effectual relief is obtained from fric- 
 tions with emollient oils, and from tepid bathing in 
 warm fea water, and in the waters of Buxton, Bath, and 
 Barreges. But in the early ftages of fra£lures, nothing 
 removes the pain with fuch certainty as a plentiful dif- 
 charge of blood froui the injured parts. 
 
 We are fometimes difappointed in the cure of frac- 
 tures, by the limbs remaining unfeemly from an over- 
 growth of callus. This is not indeed a frequent oc- 
 currence, but every practitioner mufl have met with 
 it : being mod apt to take place where the fymptoms 
 of inflammation have been fevere, I have regularly or- 
 
Sedi. I. en Fradures. "^if 
 
 dered local bloodletting, for the prevention and remo- 
 val of this exuberancy of callus, and commonly with 
 much advantage ; but, in fome cafes, the tendency to 
 form callus is fo great, that it can fcarcely be check- 
 ed. The application of ardent fpirits, and other af- 
 tringents, is here fuppofed to prove ufeful : and I have 
 in fome inftances derived advantage from continued 
 gentle preflure, applied by means of a thin plate of 
 lead adapted to the form of the part, and retained with 
 a proper bandage : but as neither this nor any other 
 remedy ■will prove fuccefsful in every cafe, and as pa- 
 tients are apt to regret nothing fo much as difappoint- 
 ment in obtaining a complete cure of a fracture, our 
 fafeft courfe, as Toon as the callus begins to be luxu- 
 riant, is to acquaint the patient with the probable 
 event ; and he muft be very unreafonable indeed, if 
 he afterwards repines at what the utmoft care and at- 
 tention could not prevent. 
 
 Among the confequences that fometimcs refult from 
 fradlures, there is one that merits more particular con- 
 fideration, namely, the difficulty of obtaining an union 
 between the ends of the fradlured bones, by which 
 they remain loofe and detached long after they (hould 
 have been firmly united. 
 
 This may proceed from various caufes : from con- 
 ftitutional difeafes, fuch as rickets, fcurvy, or lues ve- 
 nerea ; from the ends of the fractured bones not be- 
 ing kept fleadily in contact till completely united ; 
 from a portion of a mufcle, tendon, or ligament, fall- 
 ing between the ends of the fradured parts, fo as to 
 prevent them from being placed in contact ; and in 
 fome, from a bone being broken in different parts, and 
 the intermediate detached pieces being fo fmall as to 
 prevent them from adhering, even when kept in clofe 
 contad. 
 
 It has been obferved, too, that a ftate of pregnancy 
 proves inimical to the recovery of fradtured bones. 
 This has not indeed fallen within my obfervation ; but 
 it appears to be the general opinion of pradlitioners, 
 and different inllances of It are upon record. 
 
328 General Obfervatiom Chap. XXXIX, 
 
 When this want of union proceeds from any gen^ 
 eral difeafe cl the fyfliem, this difeale mull be remov- 
 ed by the remedies that experience has (hewn to prove 
 mofl effectual ; for no atterition on the part of the 
 furgeon will be of any avail till this is accompli flied ; 
 and as much m.iichief is often prevented by an early 
 application of remedies, they fliould always be advifed 
 as foon as the caufe is found to exift. It would even 
 be a prudent precaution, where a patient at the time 
 of receiving a fradlure is known to labour under any 
 conflitutional difeafe, to advife an immediate applica- 
 tion of remedies ; by which means cures might be 
 often quickly accomplifhed, which otherwife are pro- 
 tracted to a great length. 
 
 When a cure is interrupted by the fra£lured ends 
 of bones not being kept in their fituation, they fliould 
 be replaced and retained with as much accuracy as 
 pofTible ; and when the injury is flill recent, often, in- 
 deed, for the fpace of two or three weeks, a perfect 
 union may thus be accompliilied. 
 
 But where fractured bones have remained for any 
 confiderable length of time difunited, the oiTeous mat- 
 ter by which they lliould have been knit together be- 
 comes hard, fmooth, and totally unfit for the purpofe, 
 infomuch that no advantage could be derived from 
 their being replaced. Of this I have met with vari- 
 ous inftances, where the ends of the fradured bones 
 were become perfectly fmooth, and moved on each 
 other with nearly the fame eafe and freedom as the 
 bones of any of the joints. 
 
 In this fituation, when the inconvenience which it 
 excites is inconfiderable, the patient flioukl be advifed 
 to fubmit to it, particularly in fractures of the fmall 
 bones, fuch as thofe of the fingers and toes, the bones 
 of the metacarpus and metatarius, the clavicles, and 
 ribs, rather than to any operation for effecting a cure ; 
 but in the large bones of the extremities, where much 
 firmnefs is required, and where this kind of injury de- 
 flroys the ufe of the limb, as we may be able by an 
 
Seel:. I. on FraBures, 329 
 
 operation to reftore it, we ought perhaps in every in- 
 ftance to propofe it. By making an incifion through 
 the furrounding foft parts, fo as to lay the ends of the 
 bones bare, and removing a fmall portion of each of 
 them, either with a common faw, or with the head of 
 a trepan, we reduce them to the Itate of a recent frac- 
 ture ; when, by taking care to retain them in a pro- 
 per fituation, we may in due time accomphfh a cure. 
 
 The operation is no doubt painful and tedious ; for 
 the incifion muft be extenfive, in order to admit of a 
 free application of the inftruments ; and it requires to 
 be conduded with caution, that the large blood veflels 
 of the limb may be avoided : but it may be done with 
 perfedl fafety by any perfon accuftomed to the opera- 
 tive part of furgery.* 
 
 Nor fhould we be deterred from propofing this 
 method of cure, from any apprehenfion about the va- 
 cancy that may be produced by the removal of the 
 ends of the bones : for if the limb is kept lleadily in 
 its fituation, and if the conftitution is healthy, nature 
 will not probably fail in fupplying the deficiency. 
 Thus, many indances are upon record, even of entire 
 bones being regenerated ; and, in a lefler degree, the 
 powers of nature on this point muft have fallen with- 
 in the obfervation of every praditioncr. 
 
 A bone is often broken in different parts, and a 
 cure notwithftandinci: obtained : but when the detach- 
 ed parts are fo fmall that the circulation will not pro- 
 bably be kept up in them, as they will thus be ren- 
 dered incapable of furnilTiing the fccretion by which 
 their reunion fliould be accompliflied, it would be bet- 
 ter to remove them at once, than to impede the cure 
 by any attempt to fave them. Accordingly, in all 
 compound fradurcs, where the injured bone is already 
 laid bare, it is the beft pradice to remove all fuch de- 
 tached portions as might not probably unite with the 
 icmaining parts of the bone. But in funple fractures, 
 
 Vide While's Cafes in Surgery, where two inflances of tliis arc rcr 
 ccrdcd. 
 
330 General Ohfervatlons Chap. XXXIX. 
 
 where the fkin remains entire, as we cannot judge 
 with fuch certainty of the nature and extent of the in- 
 jury, nor of the probability of our being able to pre- 
 ferve the loofe portions of bone, we fhould endeavour, 
 in the firft place, to accomplifh a cure in the eafieft 
 manner, by placing the parts in fuch a pofition as will 
 moft readily admit of their reunion : but when this 
 does not fucceed, when the ends of the bone remain 
 loofe long after they fliould have been united, and if 
 one or more detached pieces are difcovered, thefe are 
 to be confidercd as extraneous bodies, and ought ac- 
 cordingly to be removed, either with the fingers or 
 forceps, at an opening made through the foft parts for 
 this purpofe. 
 
 Experience enables me to recommend this pradice 
 with confidence. I have met with various cafes in 
 which cures were judged to be imprafticable, from no 
 union being formed between the ends of bones that 
 had been long fradured, and in which I proved fuc- 
 cefsful at laft, by the removal of fome loofe fragments. 
 
 But the moft perplexing caufe of failure, in the 
 treatment of fractured bones, is a portion of a mufcle, 
 ligament, or fome other foft part pailing between them. 
 We judge that this is the cafe, when the pain and ten- 
 fion of the injured part have been more fevere than 
 ufual from the firil ; when particular movements of 
 the limb occafion fevere pain and twitchings of the 
 mufcles that ferve to move it ; and vi^hen the ends of 
 the fradured bone do not unite at the ufual time. 
 
 As foon as there is reafon to think that the cure is 
 prevented by this caufe, we fhould endeavour to re- 
 move the portion of interpofing membrane or mufcle, 
 by putting the limb into every variety of pofture. But 
 when this does not fucceed, as may fometimes be the 
 cafe, and when the bones ftill remain loofe long after 
 the ufual period, we ought, without further hefitation, 
 to make an incifion upon the fradured part. When 
 the injury has not been of long duration, a cure will 
 be accomplifhed merely by bringing the ends of the 
 
Se£t. I. on FraSlures. 331 
 
 fraftured bone Into contaft ; but when this meafure 
 has been long delayed, and when the offeous matter 
 poured out by the fractured extremities of the bone 
 has become hard, a fmall part of it fhould be remov- 
 ed either with a faw or fome fharp inflrument, fo as 
 to convert the injury once more into the ft ate of a re- 
 cent fradure ; otherwife jio advantage will be gained 
 by the operation. 
 
 Befides thefe caufes that I have mentioned, which 
 tend to impede the cure of fractures, it may not be 
 improper to remark, that the eft'ufion of much blood 
 round the injured bone, is v^ry apt to do harm. In 
 cafes of fimple fracture, the larger blood veflels are 
 feldom injured ; and blood effufed from fmall arteries 
 is for the moft part foon abforbed, and no bad confe- 
 quences enfue from it. But inftances fometimes oc- 
 cur, even in fimple fraftures, of large blood veflels 
 being cut by the fliarp fpiculse of the bone. When 
 the quantity of blood thrown out is confiderable, the 
 tumefadion of the limb becomes fo great, that it is 
 neceflary to lay it open in order to fecure the injured 
 veflel with a ligature : but where the fwelling does not 
 arrive at any alarming height, we rather truft to the 
 natural contractility of the artery, for ftopping the 
 hemorrhagy, and to the powers of the abforbents, for 
 removing the blood already eft'ufed. In fome fuch 
 cafes, where blood has remained long in contadl with 
 a fra£lured bone, the power of forming callus appears 
 to have been deftroyed by it ; the periofteum feparates 
 for a confiderable ^pace from each end of the bone ; 
 and on laying the parts open, no union is found to 
 have taken place ; the fpiculee produced by the frac- 
 ture remain equally (harp as at firft ; and, for the mofl: 
 part, a thin fetid fanies is difcharged from the fore. 
 
 In this fituation, a cure will not be obtained till 
 thofe parts of the bone which have been denuded of 
 the periofteum have exfoliated ; and, as exfoliation is 
 in general a tedious procefs, I would rather advife the 
 removal of the denuded bone with a faw j by which 
 
332 Of Fraaures of the Chap. XXXIX. 
 
 a more expeditious and more certain cure would be 
 obtained. 
 
 Having premifed thefe general obfervations, we pro- 
 ceed to the confideration of fractures of particular 
 bones. 
 
 SECTION II. 
 
 Of Fradures of the Nofe, 
 
 THE arch formed by the bones of the nofe, pre- 
 vents them from being fo frequently fractured 
 as they otherwife would be. They are neceffarily, 
 however, liable to every variety of fratture when ex- 
 pofed to much violence. 
 
 Befidcs the ufual fymptoms of fra£lures, injuries of 
 this kind in the bones of the nofe are apt to impede 
 refpiration ; they hurt the fpeech and fenfe of fmell- 
 ing ; polypi and tedious ulcers fometimes enfue from 
 them ; and they are more hazardous than fraftures of 
 other bones, from their contiguity to the brain. Thefe 
 fraftures, therefore, require very accurate attention. 
 
 When we have afcertained the nat-ure and extent 
 of the fradure, our next objeft is to replace, with as 
 much accuracy as poffible, fuch parts of the bones as 
 are difplaced. When any part of them has been raif- 
 ed above the level of the reft, it muft be prefled into 
 its fituation with the fingers ; while fuch parts of them 
 as may have been forced into eitb-^r of the noftrils, 
 muft be elevated with the end of a narrow fpatula, or 
 any other inftrument of a fmiilar form. Any portion 
 of bone that is quite loofe, and nearly feparated from 
 the reft, fliould be removed immediately, whether it 
 be raifed up or forced into the noftril ; but whatever 
 adhei-es firmly to the remaining portion of bone fliould 
 be replaced. 
 
 If the bones are properly replaced, they will for the 
 moft part remain in their fituation without aftiftance. 
 
Sed. III. Bones of the Face, 333 
 
 If the foft parts have been injured, they mufl: bedrefT- 
 ed in th6 ufual way ; and whether they are hurt or 
 not, we jfhould endeavour to prevent inflammation by 
 the ufe of faturnine applications, and by local blood- 
 letting when the violence of fymptoms feems to re- 
 quire it. 
 
 But when the parts that have been replaced do not 
 remain firm in their fituation, fomething mufl be done 
 to retain them. If they fall into the noftrils, we fuc- 
 ceed beft by the introduftion of tubes of fuch a fize 
 into them, as may preferve the fraftured bones in their 
 fituation. The form and fize of thefe tubes are delin- 
 eated in Plate XXVI. fig. 2. If the tubes are cover- 
 ed with foft lint, fpread with any emollient ointment, 
 they may be kept in the noftrils as long as is neceifa- 
 ry : while, on the contrary, if any part of the bone is 
 raifed above the reft, it muft be kept down by a pro- 
 per application of a double headed roller. If the teg- 
 uments are injured, the fore muft be firft dreflTed ; care 
 being taken in doing it to prevent deformity as much 
 as pofTible : a comprefs of foft old linen muft be next 
 applied ; and over the whole an equal preflure with 
 the bandage I have juft mentioned. 
 
 In this manner a cure may be obtained of almoft 
 every injury of this part, unJefs the bones have been 
 fo much fliattered, that their reunion cannot be accom- 
 pliftied : in which event, all that art can do is to ex- 
 trad the detached pieces, and to co-operate as much 
 as polTible with nature in healing the remaining fore. 
 
 SECTION III. 
 Of rradurcs of the Bones of the Face. • 
 
 WHEN treating of fradures of the fkull, in 
 Chapter X. thofe of the upper part of the 
 face were confidered. At prefent, therefore, I have 
 ©nly a few obfervations to oficr on fradures of the fu- 
 
334 Of Fraaures of the Chap. XXXIX. 
 
 perior maxillary and cheek bones, being thofe which 
 form the moft prominent parts of the fides of the face. 
 
 The vicinity of thofe bones to the eyes and nofe, 
 and the fituation of the antrum maxillare, make frac- 
 tures in this part highly important. When fradures 
 ftretch toward the eyes, they are apt to induce fevere 
 degrees of inflammation ; and when they penetrate the 
 antrum, they not only prove tedious, but commonly 
 occafion much deformity : for when the anterior part 
 of that cavity is laid open, and any portion of the bone 
 removed, the face becomes flat, and the teguments 
 puckered, notwithfl:anding all that can be done to pre- 
 vent it. 
 
 In all fuch injuries, therefore, we fhould with the 
 greatefl: care replace any portion of bone that may be 
 fraftured, fo as to favour its reunion with the refl: ;■ 
 and any wound that accompanies the frafture, fhould 
 be dreiled with much attention, that deformity, as far 
 as poflible, may be prevented. 
 
 After the bones are replaced, which may be done 
 with the fingers where there is no wound, and with 
 forceps or a narrow fpatula when the parts are laid 
 open, a piece of adhefive plafl:er will anfwer better 
 than any bandage for retaining the drefllngs. Blood- 
 letting, and an antiphlogiftic regimen, mud be advif- 
 ed to obviate inflammation of the eye or contiguous 
 parts, which otherwife might enfue. The remaining 
 part of the cure, namely, the reunion of the fractured 
 parts of the bone, mufl be left to nature. 
 
 When a frafture penetrates the antrum maxillare, 
 the matter which collefts in that cavity cannot be pro^ 
 perly evacuated from any opening that may take place 
 on the prominent part of the cheek. In confequence 
 of this, I have known fmuous ulcers formed that have 
 conthmed open for a great number of years. They 
 can only be healed by giving a free vent to the mat- 
 ter, by an opening made in the moft depending part 
 of the cavity, in the manner I have advifcd in Chap. 
 XIV. Sea. V. 
 
Sed. IV. inferior Maxillary Bcnes. 335 
 
 SECTION IV. 
 
 Of Fradures of the inferior Maxillary Bones, 
 
 ALTHOUGH the bones of the under jaws are 
 very ftrong and compadt, yet fractures of one, 
 or even of both, are not unfrequent. This feems to 
 arife from blows and other injuries to which thefe 
 bones are expofed, being moft apt to fall upon their 
 anterior flat furfaces, where they are lefs capable of 
 refifting violence than in any other part.. 
 
 "We judge of the e.xiftence of a fradure in the jaw, 
 by the deformity that it occafions ; by the crackling 
 of the bone when handled ; by inability to move the 
 jaw ; by the violence of the injury, and degree of pain 
 with which it is accompanied. When both jaws are 
 broken, the injury becomes obvious ; as in this cafe a 
 confiderable feparation takes place at the fradlured 
 part : but even where one bone only is fradured, it 
 may always with due attention be difcovered. 
 
 The fite of the fraclure being afcertained, our next 
 objeft is to replace the bones with as much care as 
 poUible : this we do by placing the patient in a pro- 
 per light, having his head firmly fecured, and the fin- 
 gers of one hand prefTmg upon the infide of the jaw, 
 while the other hand is employed externally in remov- 
 ing any perceptible inequality of the bone. One of 
 the teeth is commonly feated in the courfe of the frac- 
 ture ; and in this fituation acting as an extraneous 
 body, and thus tending to retard the cure, it fliould 
 be a general rule to take it out immediately : but 
 \vhen any of the teeth not feated in the courfe of the 
 fradlure, are' forced out of their fockets, it maybe 
 right almofl: in every inftance to replace them, and to 
 endeavour to fix them, by tying them to the contigu- 
 ous firm teethi 
 
■ 1 
 
 336 Of Fraaures of the Chap. XXXIX. 
 
 This being done, our next object is to retain the 
 fraftured bones in their fituation till they are firmly 
 reunited. For this purpofe, a variety of fplints have 
 been invented, both of paftcboard and other materials ; 
 but as a comprefs and bandage, either of foft old linen 
 or cotton, anfwers the purpofe with equal certainty, 
 and as it fits with much more eafe to the patient, it 
 fhould always be preferred. The parts being kept 
 firm by an afliftant, a thick comprefs fliould be laid 
 over the chin, and be made to extend from ear to ear 
 along each jaw ; and over the whole a four headed 
 roller fhould be applied in the manner I (hall mention 
 when treating of bandages. In ufing this bandage, it 
 fhould not be made fo tight as to give much uneafi- 
 nefs, or to endanger the circulation, at the fame time 
 that it fhould be applied in fuch a manner as to keep 
 the fractured parts of the bone in clofe contadt. 
 
 During the cure, the patient fliould be kept perfeft- 
 ly quiet. He fhould be fed entirely on fpoon meat. 
 He fhould be enjoined neither to fpeak or laugh, nor 
 to ufe his jaws in any manner of way. To prevent 
 the bones from being difplaced, which is apt to hap- 
 pen from frequent infpeftion, the bandage fhould be 
 applied with fuch attention, that there may be no oc- 
 cafion to move it often. In compound fracture of this^ 
 part, there is indeed a neceffity for moving the band- 
 age daily, as the fore cannot otherwife be drefled. It 
 fhould always be done, however, with the utmofh at- 
 tention, an afTiftant taking care to fupport the parts 
 with his hands during the whole time. 
 
 The management of a fracture of one or both jaw 
 bones is exactly fimilar ; only where .both bones are 
 broken, flill more attention is required than vvhen one 
 only is fractured. In a fracture of one of the bones, 
 the patient may be allowed to eat foft meats, and to 
 fpeak with freedom, in the fpace of three weeks : but 
 where both bones have fufFered, this fhould not be 
 permitted till five or fix weeks have elapfed. 
 
Sed. V. Clavicles mui Ribs» 337 
 
 SECTION V. 
 Of Fradures of the Clavicles and Ribs. 
 
 THE clavicles and ribs are more liable to fraftures 
 than any other bones. This proceeds, not on* 
 ly from the flender ftruclure of ihefe bones, but from 
 the pofition in which they are placed, with their flat 
 fides expofed to every injury that may be applied to 
 them. 
 
 A fracture of the clavicle is in general eafily dillin* 
 guifhed. On the correfponding arm being fmartly 
 moved, a grating noife is produced by the ends of the 
 bone rubbing againfl each other ; the ends of the 
 fractured part readily yield to preflure ; and, in gen- 
 eral, the end of the bone connected with the humerus, 
 is pulled to fome diftance from the other by the weight 
 of the arm. The motion of the humerus is impeded, 
 and fome degree of fwelling, accompanied with more 
 or lefs pain, takes place over the injured part. 
 
 In almoft every inflance of a fra61:ured clavicle, the 
 end conneded with the fternum is higher than the oth- 
 er, which has fuggefted an idea that has Very univer- 
 fally prevailed in the method of cure* Thtf height of 
 this part of the bone is fuppofed to proceed from its 
 having ftarted or rifen out of its natural fituation : in 
 the redudion, therefore, of the fradure, much pains 
 is commonly taken to prefs it down, and very tight 
 bandages are employed to prevent it from rifmg dur- 
 ing the cure. It will, however, be found, that this 
 part of the bone rifes very little out of its natural fitu- 
 ation, and that the appearance of its doing fo proceeds 
 almoft entirely from the other end of the bone being 
 dragged down by the caufe I have mentioned, name- 
 ly, by the weight of the arm. At any rate, no ad- 
 vantage is obtained from this pradice : for a force 
 
 Vol. III. Y 
 
338 Of Fraaures of the Chap. XXXIX. 
 
 that would be necefTary for prefling dowft the end of 
 the bone, cannot be applied without the effeft of cut- 
 ting the teguments, by prefling them againft that part 
 of it that is fuppofed to be raifed ; while our purpofe 
 is fully anfwered by raifmg the arm, and fupporting 
 it at a proper height. The deprefled portion of the 
 fractured clavicle is thus raifed and brought into con- 
 ta£l with the upper part of it. In fome cafes, indeed, 
 of oblique fractures, it may be impofllble to bring the 
 ends of the bone in every point exaftly oppofite to 
 each other : but this may be always fo far accomplifh- 
 ed as to enable us to avoid deformity, and to render 
 the bone fufficiently flrong. 
 
 When the ends of the bone are brought into con- 
 taft, our object is to retain them in this fituation till 
 they are united ; and, as I have obferved above, this 
 can only be done by affording a proper fupport to 
 the arm. 
 
 The arm is ufually fupported by a fling hung round 
 the neck, adapted to the length of the arm, and every 
 where equally applied to it. But the leather cafe re- 
 prefented in Plate XCVI. fig. i. anfwers the purpofe 
 with more eafe and neatnefs. It fupports the fore- 
 arm and elbow joint more equally and more fecurely : 
 this lafl, I may remark, is a point of no fmall impor- 
 tance ; for if the elbow is allowed to drop, the hu- 
 merus and fcapula will both fall down, by which the 
 ends of the fraftured clavicle will again be feparated. 
 
 We are commonly directed, in the cure of fra£lures 
 of this bone, to have the fhoulders drawn back and 
 the head raifed ; and inflruments are defcribed for 
 effecting thefe purpofes. No general rule, however, 
 of this kind can be given : for in fome cafes the frac- 
 tured parts of the bone are kept exactly together when 
 the head is bent down upon the breaft ; while in oth- 
 ers, it is better accomplifhed when the head and fhoul- 
 ders are raifed. 
 
 In other points, fractures of the clavicle mufl be 
 treated like fimilar injuries in other parts of the body. 
 
Sed. V. Clavicles and Ribs* 339 
 
 When fevere pain takes place, bleeding with leeches 
 becomes proper ; but in general, the fymptoms arif* 
 ing from fradures of this bone are of fo litile impor- 
 tance, that the common faturnine applications prove 
 fufficient. When the fradure is accompanied with a 
 wound, any fplinters of bone that may be difcovered 
 nmfl be removed, and the wound itfelf dreffed in the 
 ufual way. It is proper, however, to remark, from 
 the vicinity of the fubclavian artery, that the removal 
 of any portion of the clavicle may be attended with 
 danger, and ought therefore to be managed with cau- 
 tion. 
 
 When the ends of the fraftured part are properly 
 fupportcd, they will in general be firmly united in the 
 fpace of a fortnight ; but the correfponding arm fliould 
 never be ufed with freedom till the end of the fourth 
 or fifth week. 
 
 We difcover fradures of the ribs by the feat of the 
 pain, and by prefl'ure with xht fingers. For the mofl 
 part, the attending fymptoms are moderate ; the pain 
 mduced by the fracture is inconfiderable, no fever oc- 
 curs, and the patient loon gets well : but hi fome in- 
 flances the pain is fevere from the firfl ; the breathing 
 becomes difficult, attended with cough and perhaps a 
 fpitting of blood ; and the pulfe is quick, full, and 
 fometimcs oppreflfed. 
 
 It will readily be underllood, that a fradured rib 
 cannot of itfelf induce any of thefe fymptoms : but in 
 fome inflanccs the ribs are not only fractured, but 
 pulhed inwards, by which the pleura and lungs are 
 not only comprefTed but lacerated ; from which we 
 may eafily perceive, how pain, opprefTed breathing, 
 and fever, fliould be induced ; and from which alio 
 we may account for the emphyfematous fwellings de- 
 fcribed in Chapter XXI. Settion V. 
 
 In all cafes of fradtured ribs, it is a fafe and proper 
 pradice to difcharge a quantity of blood proportioned 
 to the ftrength of the patient. If any inequality is 
 Y 2 
 
340 Of Fraaurcs Chap. XXXIX. 
 
 difcovered, by one end of- the rib having rifen above 
 the other, we (liould endeavour by moderate equal 
 prefTure to replace it ; and to prevent it from rifmg, 
 a broad leather belt (hould be applied and drawn as 
 tight as the patient can eafily bear it. When the belt 
 is properly lined, either with quilted cotton or flannel, 
 it fits with eafe even when tolerably tight ; and it 
 ought to be continued for feveral weeks after the ac- 
 cident. 
 
 Even where the fymptoms have at firfl been fevere, 
 they commonly fubfide upon the patient being freely 
 bled and kept quiet and on a low regimen : but where 
 the oppreflfed breathing is kept up by air efcaping 
 from a puncture in the furface of the lungs, or by 
 blood difcharged from a ruptured artery into the ca- 
 vity of the chefl, or when the pain is prevented from 
 fubfiding by the fractured rib being forced in upon 
 the pleura ; it becomes neceflary to make an opening 
 with a fcalpel. Where a portion of rib is merely 
 forced inwards, the opening fhould be made direftly 
 upon the injured part ; and on the rib being laid bare, 
 the deprefled part of it fhould be raifed, either with 
 the fingers, forceps, or a fpatula. When the fymp- 
 toms proceed from air or blood colle£led in the cavi- 
 ty of the cheft, an opening fhould be made to dif- 
 charge them, in the manner that I have mentioned in, 
 Chapter XXI. Section III. and V. 
 
 Fractures of the r'lhs fhould in every inftance be 
 treated with attention ; but particularly where a ten- 
 dency takes place to phthifis pulmonalis, when the 
 irritation produced by a fradured rib is very apt to 
 do harm. 
 
Scd. VI. of the Sternum, 341 
 
 SECTION VI. 
 
 Of Fradurcs of the Sternum. 
 
 THE fupport which the ftcrniim receives from the 
 ribs, and the degree of ehiiticity of which it is 
 polTelTed, render it lefs liable than it otherwife would 
 be to be hurt by external violence. It muft necefla- 
 rily, however, be injured by great degrees of force. 
 In fome cafes it is fradured without being difplaced ; 
 in others, it is not only broken, but at the fame time 
 beat in upon the pleura. 
 
 A fimple fradure of the fternum is to be confider- 
 ed in the fame light with fimilar injuries done to the 
 ribs, and to be treated in the fame manner. But 
 more danger is apt to enfue from any portion of this 
 bone being forced into the chefl, from the vicinity of 
 the large blood veflels of the breaft, while the fymp- 
 toms with which it is accompanied are nearly the 
 fame ; namely, pain in the injured part, cough, op- 
 preffed breathing, a quick and fometimes an oppreiT- 
 ed pulfe. 
 
 By fome we are told, that the deprcffed portion of 
 bone may be raifed by defning the patient to make 
 deep infpirations ; by placing a barrel or a drum un- 
 der his back, and keeping him lying for fome time in 
 this poflure ; and by the application of adhefive plaf- 
 ters over the correfponding teguments ; when, by ele- 
 vating the foft parts, the bone beneath, it is faid, may 
 frequently be raifed along with them. 
 
 It is not poffible, however, to fuppofe, that much 
 advantage is to be derived from any of thefe means : 
 they may more likely, indeed, do harm ; nor would 
 I have mentioned them here, had it not been with a 
 view to caution the younger part of the profefiion, 
 who, finding thefe modes of practice recommended 
 
342 Of Fraclures of Chap. XXXIX. 
 
 by all the older writers, might have been induced to 
 adopt them without weighing their import. As the 
 (kin is no where very intimately conneded with the 
 bone beneath, it is not probable that any portion of 
 deprefled bone will ever be raifed by the external ap- 
 pHcation of adhefive plafters ; while, by advifmg deep 
 infpirations, or laying the patient upon his back over 
 a convex body, we would often do harm, by forcibly 
 pufhing the lungs againil the deprefled portion of 
 bone. 
 
 When it therefore happens, that the pain, cough, 
 opprefled breathing, and other fymptoms, do not yield 
 to bloodletting and other parts of an antiphlogiftic 
 courfe, fome other method of cure fhould be attempt- 
 ed. An incifion fliould be made upon the injured 
 part, of a length fufficient to admit of a free examin- 
 ation of the bone ; when the deprefled piece may be 
 raifed with a levator, if the opening will admit an in- 
 ftrument ; or when the opening in the bone is not 
 fufficiently large for this, a perforation may be made 
 with the trepan, in the manner I have advifed in 
 Chapter X. in fmiilar injuries done to the fkull. 
 
 I know that many will judge this to be hazardous ; 
 but when a patient is in danger, either from a portion 
 of deprefled rib or of the flernum, and which cannot 
 otherwife be raifed, I would never hefitate in advifmg 
 it. If the operation is performed with caution, the 
 bone may be raifed with fafety ; and this being done, 
 the fore muft be treated in the ufual way. By this 
 being neglefted, either from timidity on the part of 
 the operator, or from any other caufe, many have di- 
 ed of phthifis pulmonalis, who otherwife might have 
 been faved. 
 
Sed. VII. the Vertebra^ ^a 343 
 
 SECTION VU. 
 
 0/ Fractures of the Vertebra, Os Sacrum, Coccyx, and 
 OJfa Innotnmata. 
 
 FRACTURES of the vertebrse may be produced 
 by falls and blows ; but we meet with them more 
 frequently from gun(hot wounds, than from any oth- 
 er caufe. 
 
 For the mofl part, they terminate fatally : for al- 
 though many have furvived fuch fradures a great 
 length of time, yet they generally linger and die of the 
 confequences. The fpinous and oblique procefles of 
 the vertebrae may indeed be broken without immedi- 
 ate danger ; but very commonly the force by which 
 this is efteded, gives fuch a fhock to the fpinal mar- 
 row, as at laft terminates in the death of the patient : 
 and a fradure that extends through the body of a ver- 
 tebra, will probably, in every inftance, prove fatal. 
 
 We judge of the exiftence of this fraclure, by ex- 
 ternal examination ; by the force with which it was 
 effedled ; by the feverity of the pain ; and by the parts 
 lying below the injured vertebra becoming paralytic 
 when the fpinal marrow has been injured. 
 
 When any of the external parts of the vertebrae 
 are loofe, we may in general replace them with our 
 fingers ; and, confinmg the patient as much as poflible 
 to one pofture, we may, by means of the napkin and 
 fcapulary bandage, retain them in their fituation till 
 they unite with the reft of the bone. 
 
 Where this cannot be done, a patient is in general 
 left to his fate, as it is not fuppofed that we can with 
 fafety lay any of the vertebras bare, for the purpofe of 
 replacing fuch parts of them as may be deranged :• 
 but wherever the fpinal marrow appears to be com- 
 preffed, and where there is reafon to think that the 
 comprelfion is produced by the depreflion of a portion 
 
344 Of Fradurcs Chap. XXXIX. 
 
 of bone, as we know from experience that every fuch 
 cafe will terminate fatally if the caufe of compreliion 
 be not removed, it would furely be better to endeav- 
 our to raife it, than leave the patient to certain mifery 
 and death. By laying the injured parts freely open, 
 we may be enabled to raiie that portion of bone by 
 which the compreffion is produced ;. while, in fuch 
 circumllances, it cannot add to the hazard of the pa- 
 tient, even allowing the attempt to prove abortive. 
 
 In a cafe where lymptoms of paralyRs were induced 
 by a muiket bullet lodged in the fubflance of one of 
 the vertebrae, a complete recovery was obtained by ex- 
 trafting the bullet. A portion of deprefled bone 
 might often be removed with equal eafe and fafety ; 
 and there is reafon to fuppofe that limilar effeds would 
 often refult from it. 
 
 In fradures of the os facrum, the method of treat- 
 ment mufl be nearly fimilar to what I have advifed in 
 fradures of the vertebrse ; only, where the injury is 
 feated near to the under part of the bone, as well as 
 in fradures of the coccyx, when any part of it is preff^ 
 ed inward, we may in fome cafes be able to replace it, 
 by pufhing it out with the finger of one hand intro- 
 duced into the anus, while we co-operate outwardly 
 with the other. 
 
 Where any of the ofla innominata are broken, if 
 the injury is deeply feated, the patient ought to be 
 placed in that pofture in which he finds himfelf in 
 greateft eafe, and confined as much as poflible to this 
 fituation, till the bones have time to unite. Blood- 
 letting, and an attentive regimen, fuited to his ftrength 
 and to the violence of the fymptoms, may prevent 
 the inflammation that ufually fupervenes from becom- 
 ing fevere. 
 
 In more external fradures of thefe bones, we are 
 often enabled to replace fuch parts of them as have 
 been forced out of their fituation, and with the afiift- 
 ance of a proper bandage, we may alfo be able to re- 
 tain them till a cure is completed, I have now feen 
 
Setl. VIII. of the Scapula. 345 
 
 different inPcances of a confiderable portion of the ile- 
 um being frattured and feparated from the reft, and 
 of a cure being accompliihed, by replacing the detach- 
 ed parts, and retaining them with a broad roller paff- 
 ed feveral times round the pelvis and upper part of 
 the thigh. 
 
 With refpeft to the application of this bandage, no 
 particular dire£tions can be given : it muft depend en- 
 tirely on the judgment of the praQitioner ; who will 
 apply it in the way that he thinks will make it anfwer 
 the purpofe of fixing the bones in the fecureft manner. 
 
 SECTION VIII. 
 
 Of FraSlurcs of the Scapula, 
 
 THE fcapula, from its fituation, is not fo liable to 
 be fradured as other bones ; but every prafti- 
 tioner muft have met with it. It may be fradured 
 either in the thin plate, of which it is moftly compof- 
 ed ; or in one or other of its procefl'es. 
 
 As the motion of the arm depends mucli on a found 
 and entire (tate of the fcapula, and as fractures of any 
 part of it are diiiicult to cure, they very commonly 
 produce a ftiff unwieldy ftate of the corrcfponding 
 arm, which in fome degree often continues during the 
 life of the patient. 
 
 Fraclures of this bone are difcovered by the feat of 
 the pain ; by the violence of the injury ; by manual 
 examination ; and by ftiffnefs and immobility in the 
 correfponding arm. We are told, that fradures of 
 the fcapula are apt to be accompanied with emphyfe- 
 matous fwellings ; but they can only appear vvhen a 
 fplinter of the bone is forced into the lungs : when 
 this takes place, air will no doubt efcape ; and if it 
 paifes into the cellular fubftance, emphyfematous fwell* 
 ings will neceffarily occur. 
 
34^ Of Fraaures Chap. XXXIX. 
 
 In fradures of the fcapula, our firft objed Is to re- 
 place the fradlured parts of the bone with as much ex- 
 aftnefs as poflible : in doing fo, we are much afllfted 
 by relaxing the raufcles of the injured part. By raif- 
 mg the head and fhoulders we relax the mufcles of 
 the back ; and if, at the fame time, the humerus is 
 fupported, the deltoid mufcle will be fo much relax- 
 ed, that any fradlured portion of the fcapula will be 
 more eafily replaced. It is always however more dif- 
 ficult to retain the bones during the cure, than to re- 
 place them : for the detached portion being in gener- 
 al fmall, we can feldom retain it with a bandage. A 
 proper application of a long roller is perhaps the beft 
 method of doing it ; and in ufing this bandage, we 
 fhould ftill take care to have the head and fhoulders 
 fupported, and the arm fufpended, fo as to keep all 
 the mufcles of the injured part as much as poflible re- 
 laxed. 
 
 As all fractures are apt to excite inflammation, I 
 have elfewhere obferved, that this fymptom fliould at 
 all times be guarded againfl:. No where is it more 
 neceflary to attend to this than in fraftures of the fca- 
 pula, where inflammation is particularly apt to pro- 
 ceed to an alarming height. Bloodletting fliould 
 therefore be freely praftifed ; particularly local blood- 
 letting with leeches, or cupping and fcarifying ; a rem- 
 edy that I confider as more effeftual than any other 
 for the removal of inflammation, wherever it is feated. 
 
 SECTION IX. 
 Of Fra&ures of the Humerus. 
 
 IT'RACTURES of this bone are eafily difcovered, 
 as no part of it is thickly covered with foft parts ; 
 oblique fractures become evident to the fight, but ev- 
 
Se£l. IX. of the Humerus. 347 
 
 en thofe that are perfedly tranfverfe become immedi- 
 ately obvious on the llighteft manual examination. 
 
 In the redudion of fractures of this bone, we do 
 not find that much extenfion is required ; but that it 
 may be done with eafe, the mufcles of the arm fliould 
 be put as much as pollible into a flate of relaxation ; 
 this we do by moderately bending the elbow, while 
 the limb is raifed nearly to a horizontal direction, and 
 not carried fo much forward as to put the latiilimus 
 dorfi, infcrted into the back part of it, on the flretch, 
 or too far back to ftretch the pectoral mufcle. 
 
 The patient being properly placed, and the arm put 
 in this fituation, the furgeon will in general be able to 
 replace the bones without any afliflance ; but when 
 extenfion is neceflary, it may be applied by one aflift- 
 ant grafping the arm between the fradure and joint of 
 the fhoulder, and another above the elbow. 
 
 In this manner the fradured parts of the bone are 
 to be replaced ; and with a view to fecure the fradur- 
 ed parts in their fituation, a firm fplint, fuch as is re- 
 prefented in Plate LXXXI. figs. 5. and 6. fhould be 
 placed on the outfide of the arm, and another along 
 the infide of it, each of them covered with foft flan- 
 nel, to prevent them from galling the Ikin ; and while 
 thefe are fecured by one alliflant, and the fore-arm 
 fupported by another, a flannel roller fhould be appli- 
 ed over the whole, of fuch tightnefs as to fupport the 
 ends of the frattured bone, without interrupting the 
 circulation of the limb. 
 
 The fore-arm fhould be fupported in a fling, fuch 
 as is reprefented in Plate XCVI. fig. i. and the pa- 
 tient may be either put to bed or allowed to fit, as is 
 mofl agreeable to himfelf. It may not, however, be 
 improper to remark, that it anfwers better to have the 
 arm in a hanging pofition than laid horizontally on a 
 pillow ; particularly in oblique fraftures of this bone, 
 in which the weight of the limb has a confiderable ef- 
 fect in pi-eventing the ends of the bone from over lap- 
 ping or palTmg each other. Even in bed, therefore, 
 
34^ Of Fraaures of the Chap. XXXIX. 
 
 where there is any danger of this, the patient fliould 
 be placed in fuch a manner that. his arm may hang, 
 inftead of being laid in the ufual way upon a pillow. 
 In tranfverfe fraclures, this precaution is not fo necef- 
 fary, as the ends of the bone, if once replaced, ferve 
 in ibme meafure to fupport each other. But even in 
 thefe, it is the bell practice to fupport the fore-arm in 
 fuch a manner that it may have fome effect in pulling 
 the under part of the humerus gently downwards. 
 
 When no urgent fymptom takes place, fuch as much 
 pain and fwelling of the arm, the bandage fliould not 
 be moved for feveral days : but about the feventh or 
 eighth day, it is proper in every fracture to remove 
 all the coverings, in order to fee whether the bone . is 
 perfectly in its place or not ; for at this period, any 
 accidental difplacement may be eafily put right, and 
 a cautious inl'pedion may be made with fafety. 
 
 I have advifed a roller to be employed for fractures 
 of this bone ; and perhaps it is the only inftance in 
 fractures of the large bones of the extremities in which 
 it fhould be preferred to the twelve tailed bandage. 
 But whoever has ufed them both will find, that in fim- 
 ple fradtures of the humerus, the roller is not only 
 more eafily applied than the other, but that it anfwers 
 the purpofe better. 
 
 Fractures of the humerus commonly heal more 
 Jdndly than fimilar injuries of any other bone ; and 
 when properly managed, they feldom leave either lame- 
 nefs or diftortidn of the arm. When no interruption 
 occurs to the cure, cither from fevere pain, fwelling, 
 or inflammation, or from accident or mifmanagement, 
 the bone will in general be firmly united in lefs than 
 a month ; but the limb Ihould not be ufed with free- 
 dom till fix or feven weeks have elapfed. 
 
 1 
 
SqO:. X» Bones of the Fore- Arm. 349 
 
 SECTION X. 
 
 Of Fradures of the Bones of the Fore-Arm^ 
 
 THE bones conipofing the fore-arm are two in 
 number, the radius and uhia. Being much ex- 
 pofed to injuries, they are very Hable to fractures. 
 When both bones are broken, the nature and feat of 
 the injury at once become obvious ; but when one 
 bone only is fraftured, efpecially the radius, as the 
 firmnefs of the uhia keeps it on the ftretch, and pre- 
 vents it from being difplaced, we do not fo eafily per- 
 ceive the injury : the feat of the pain points out the 
 injured part ; and when either of the bones is fraclur- 
 ed, a grating noife will be heard if the furgeon grafps 
 the limb firmly above and below this part, and endeav- 
 ours to move it in different directions. 
 
 In this examination, it is of much importance to 
 diftinguifh the direction of the fracture with as much 
 exactnefs as pofilble, particularly if near to the wrift ; 
 for upon this the chance of our making a perfeO: cure 
 in a great meafure depends ; and in this fituation, 
 whether both bones or only one of them is broken, 
 much attention is required to prevent the ftiff uneafy 
 ftate of the arm from continuing long after the bones 
 are united : patients indeed often complain of this, in 
 fome cafes during life ; and I think it more frequent- 
 ly happens when the radius is broken by itfelf than 
 when the ulna only is fractured, owing, I fuppofe, to 
 the radius having a rotatory motion independent of 
 the other, by which it is not fo eafily kept in its fitu- 
 ation. And as there is nothing for which praftition- 
 ers are more apt to be blamed than for thole inconve- 
 nicncies that fucceed to fradures, we ought in every 
 inifance to be as much as poflible on our guard againft 
 them. 
 
350 Of Fractures ofihe Chap. XXXIX.- 
 
 On the feat of the injur}'^ being difcovered, {i any 
 part of either of the bones is difplaced, we ought, as- 
 foon as it can be done, to put it right. The patient 
 being properly feated, and the mufcles of the arm re- 
 laxed by gently bending the joints of the wrift and 
 elbow, the fore-ann fhould be extended to fuch a de- 
 gree, by one affiftant grafping it above the fradure, 
 and another below, as is juft fufficient to allow the 
 furgeon to replace the bones. This being done, one 
 of the fplints reprefented in Plate LXXXl. fig. 3. 4. 
 or 5. covered with foft flannel, and of a length tO' 
 reach from the elbow to the tops of the fingers, and 
 of fuch a breadth as to incafe rather more than one 
 half of the arm and hand, fhould be placed along the 
 ulna. Another fplint not quite fo broad mufl be 
 placed along the courfe of the radius ; vihen both 
 mufl be fecured either with a flannel roller or a twelve 
 tailed bandage, with fuch tightnefs as may prevent the 
 bones from flipping out of their place, but without 
 impeding the circulation, or exciting any degree of 
 pain. In all fimple fraftures of thefe bones, the twelve 
 tailed bandage, and fimple roller, may be ufed with 
 perhaps equal propriety. 
 
 In applying the fplints, the pahii of the hand fhould 
 be turned towards the breaft, this being not only the 
 mofl convenient pofture in which the arm can hang 
 while in a fling, but the befl in which it can at all 
 times be placed, even when the patient is in bed : for 
 in this fituation the palm of the hand can neither be 
 turned up nor down ; that is it can neither be put in- 
 to a prone nor a fupine poflure, without giving that 
 rotatory motion to the radius that I have mentioned, 
 and which tends more than any other to difplace any 
 part of this bone that may be fraftured. It fhould 
 therefore be avoided j and I know of no way in which 
 it can with fuch certainty be done, as fecuring the 
 arm with fplints in the manner I have mentioned : it 
 fhould now be hung in the fling reprefented in Plate 
 XCVI. fiiT. I. and allowed to remain in the leather 
 
Seft. X. Bones of the Fore- Arm, 351 
 
 cafe during the night, or in any fmall box of a fimi- 
 lar conflru^iion, and of a fi^e jufl fufficient to receive 
 the arm when placed upon its fide, but without per- 
 mitting it to turn either one way or another. 
 
 In fpeaking of the fplints, I have advifed them to 
 be of a fufficient length for (tretching along the whole 
 courfe of the arm from the elbow to the top of the 
 fingers. The under fplint ought more efpecially to 
 be of this length ; for the arm not only refts with 
 more eafe and equality upon a long fplint, but it ferves 
 to cover the fmgers, by which they are prevented more 
 effedually than in any other manner from moving ; a 
 circumftance of much importance in every fradure of 
 the fore-arm : for when a free motion of the fingers 
 is permitted, it not only tends to keep up inflamma- 
 tion and pain, but is often the caufe of the bones 
 being again difplaced, when othenvife they might 
 have been kept in contact. 
 
 A partial diflocation of the bones forming the joint 
 of the wrift, is not an unfrequent concomitant of frac- 
 tures of the radius ; from a combination of which, 
 there is always much rifk of fliffnefs being left in the 
 joint, and of a painful permanent fwelling over the 
 under part of the arm : with this the patient fhould 
 always be made acquainted ; for even under the befl: 
 management, a difl'ocation of the wrift, accompanied 
 with a frafture of the contiguous bones, commonly 
 ends in this manner : for the method of reducing the 
 diflocation, I muft refer to the enfuing Chapter ; and 
 I have already pointed out, in the firft Sedion of this 
 Chapter, what I conceive to be the beft method of 
 preventing and removing inflammation ; which I have 
 there (hewn to be the moft frequent caufe of that 
 ftiff immoveable ftate in which fradured hmbs ai'e of- 
 ten left. 
 
 The olecranon, or upper end of the ulna, is fome- 
 times fra£lured without any injury being done to the 
 reft of the bone ; this part of the bone being particu- 
 
352 Of Fraaures of the Chap. XXXIX. 
 
 larly apt to fufl'er from falls and bruifes upon the el- 
 bow. 
 
 In this cafe, in order to keep the fradured parts in 
 contadt, the fore-arm muft be extended : and with a 
 view to preferve the arm in this fituation, a long fplint 
 fhould be laid along the forepart of it, from the up- 
 per part of the humerus to the tops of the fingers ; 
 and this being fecured with a roller, the arm fhould 
 be allowed to hang by the fide, to which it fhould be 
 fixed with one or two ftraps. 
 
 It is proper, however, to remark, that it fhould not 
 be long kept in this fituation, otherwife a fliffnefs of 
 the elbow-joint would enfue : with a view to the pre-- 
 vention of this, the bandage and fplint fhould be re- 
 moved about the eighth or tenth day ; when the fore- 
 arm being for fome time moved flowly backward and 
 forward, and the joint rubbed with any emollient oil, 
 the arm fhould be again fecured as before. A cau- 
 tious and daily repetition of this, while it prevents a 
 ftiff joint, does not retard the cure. 
 
 SECTION XI. 
 
 Of Fra&ures of the Bo?ies of the Wrtfl, Hands, and 
 Fingers* 
 
 THE bones of the wrifl being fmall, round, and 
 fomewhat moveable, readily yield to any ordi- 
 nary force that may be applied to them. On this ac- 
 count, they are feldom fractured, except by fhot from 
 firearms, or a heavy weight paffing over them. 
 
 Thefe bones are fo fmall that when fradured, they 
 are not eafily retained in fitu^ and do not therefore 
 unite fo readily as bones of a larger fize. For this 
 reafon, as well as from the contiguity of numerous lig- 
 aments and tendons, which gives rife to high degrees 
 of inflammation, a complete anchylofis, or great ftiff- 
 
Sea. XL Bones of the Wri/i, ^c. 353 
 
 nefs of the joint, often fucceeds. v^fter replacing the 
 bones, thefe confequences are with moft certainty 
 guarded againft, by a copious difcharge of blood from 
 the injured parts by means of leeches ; and this being 
 done, the arm and hand (liould be well fupported by 
 a fplint beneath, and another above,, in th^ manner 
 advifed in the lafl fe6lion. 
 
 In fradlures of the metacarpal bones, after being re- 
 placed with accuracy, a firm fplint, either of timber 
 or flrong pafteboard, (liould be applied over the whole 
 palm of the hand and infide of the arm, from the ends 
 of the fingers to the joint of the elbow, in order to 
 keep the hand in a flate of extenfion, as the flexor 
 mufcles of the lingers cannot be bent without altering 
 the pofition of thcfe bones : and that this may with 
 certainty be done, the long fpUnts mentioned above, 
 fecured with a fnnilar bandage, fhould be applied over 
 the whole. 
 
 Fra£lures of the bones of the fingers are frequent ; 
 but when properly treated, they readily unite, and the 
 fingers become equally ufeful as before. 
 
 The befl fplint for a fradured finger is a piece of 
 firm pafteboard fitted to it with accuracy, and foften- 
 ed in water till it is eafily moulded to the form of the 
 part. The finger being ftretched out and the bone 
 replaced^ this fplint iliould be applied along the whole 
 length of it, and fecured with a narrow roller. In or- 
 der to prevent the injured parts from being difturbed, 
 a large fplint, either of the fame kind of pafteboard, 
 or of a thin piece of wood glued upon leather, as is 
 reprefented in Plate LXXXI. figs. 3, 4, 5, or 6, fhould 
 be applied over the infide of the hand ; and the fin- 
 gers being ftretched upon it, another roller fhould be 
 put over the whole, to fecure the fingers and hand, fo 
 as entirely to prevent motion. 
 
 With a view to preferve the motion of the finger 
 joints, the bandage and fplints fliould be removed 
 about the tenth or twelfth dav j when all the joints 
 
 Vol. III. Z 
 
354 Of Fraaurcs of the Chap. XXXIX* 
 
 being frequently bent and extended, the whole fhould 
 be tied up as before : and this being repeated daily, 
 the fplints may with fafety be removed at the end of 
 the third week ; when, by this piece of attention, the 
 motion of the finger will be found complete, unlefs 
 more than one bone has been broken, and at the fame 
 time feverely fplintered. 
 
 SECTION XII. 
 
 Of Fractures of the Femur or Thigh Bone* 
 
 WE meet with fraclures in every part of the fe- 
 mur ; but more frequently in the middle 
 than in any other part of it : next to this, that part of 
 it which we term the neck of the femur, is mod apt 
 to be fradured. 
 
 Fractures of all the under part of this bone are for 
 the mofl part eafily diftinguiflied, by the ufual grating 
 noife produced by the ends of it being forcibly rub- 
 bed together ; by the limb being much Ihortened if 
 the fradure is oblique, or the ends of the bone dif- 
 placed where the fradure is tranfverfe ; by much pain 
 and tenfion over the injured part ; and by the limb 
 being rendered unable to fullain the weight of the 
 body. 
 
 It is often difficult, however, to diflinguifh fraftures 
 of the neck of the femur from diflocations of this 
 bone ; but a due attention to the following circum- 
 ftances will enable us for the mod part to avoid mif- 
 takes in regard to this, which are always attended with 
 ferious confcquences. 
 
 In a great proportion of cafes, perhaps in ninety- 
 nine of every hundred, the head of the femur when 
 diflocated is pufhed inwards and downwards, owing to 
 the brim of the acetabulum being not fo deep in this 
 
Sed. XII. Femur or TJj'igh Bone. 355 
 
 part as in others ; while in fradures of the neck of 
 the femur, the bone has in every inftance that I have 
 feen of it been drawn upwards, and the leg thereby 
 rendered fhorter by three or four inches, in confe- 
 quence of the powerful exertion of the glutasi mufcles 
 on a bone deprived of its ordinary fupport. In all 
 fuch cafes, therefore, the trochanter is found to be 
 much higher than the trochanter of the other thigh ; 
 and the knee and points of the toes turned inwards ; 
 while in thofe diflocations of the thigh joint that I have 
 mentioned, the leg is much lengthened, the head of 
 the bone is found in the groin, and the trochanter is 
 difcovered on the forepart of the thigh, while a cor- 
 refponding vacancy is perceived where the trochanter 
 and head of the bone Ihould be, and the toes are turn- 
 ed outwards. 
 
 In every frafture, a grating noife is difcovered on 
 the ends of the bone being rubbed againft each other ; 
 and in all fractures of the neck of the femur, we ob- 
 ferve, that the leg and thigh may be turned with much 
 more eafe from one fide to another, that is, the knee 
 and foot may be moved witli more eafe outwards or 
 inwards, than when the head of the bone is diflocated. 
 I may Hkewife remark, that, in diflocations, the tumor 
 formed by the head of the bone and trochanter to- 
 gether, mud aKvays be larger than in fradlures, where 
 the tumor is formed by the trochanter alone. 
 
 In no part of furgery are practitioners more apt to 
 be difappointed than in the treatment of fractures of 
 the thigh, particularly where the neck of the bone is 
 broken. This proceeds from various caufes ; all of 
 which fliould be kept in view in forming a prognofis 
 of the event. 
 
 1. The thigh bone is fo thickly covered with muf- 
 cles and other foft parts, that it is often difficult to dif- 
 cover the direction in which a fracture runs. 
 
 2. We muft often, therefore, be uncertain whether 
 the bones are rightly replaced or not j for where the 
 
 z 2 
 
^^6 Of Fraaures of the Chap. XXXIX. 
 
 courfe of a fracture cannot be afcertained, we can nev- 
 er be fure whether this is rightly done or not. 
 
 3. But even where the reduction of the fradure 
 can be accompUfhed, we know from daily obfervation 
 that it is difficult to retain the different parts of the 
 bone in their fituation with fuch exadtnefs as to pre- 
 vent deformity. For when the fradure is either in 
 the neck of the bone, or runs obliquely in any other 
 part of it, it is fo difficult to prevent the fraftured parts 
 of it from being difplaced merely by the ordinary ac- 
 tion of the mufcles, that the limb for the mod part be- 
 comes much fhorter than the other ; for in all fuch 
 cafes, if the different parts of the bone cannot be fo 
 placed and retained as to fupport each other, the un- 
 der part of it will very certainly be'drawn upwards. 
 
 In all thefe fraftures too, other caufes concur to 
 render it difficult to retain the fraftured parts of the 
 bone in their fituation. They are more eafily afted 
 upon than fradures of other bones by every exertion 
 of the body ; particularly by fneezing, coughing, and 
 laughing ; nor can the pofture of the body be in any 
 way altered without moving the thigh. 
 
 Till of late, pradtitioners were often difappointed in 
 their endeavours to reduce fra61:ures of the femur ; 
 chiefly ov/ing to the pofition in which the limb was 
 put during the operation. The body being placed ei- 
 ther upon the floor, on a table, or in a bed, the limb 
 was then extended, by which all the mufcles of the 
 limb were put upon the flretch ; and as the extenfion 
 was continued till the different parts of the bone were 
 replaced, when this was difficult, the mufcles were 
 often either violently torn afunder, or fo much weak- 
 ened as not to be afterwards fit for ufe ; for fome of 
 the mufcles of the thigh being among the ftrongefl of 
 the body, a very confiderable force was required to 
 overcome their refiffance. But if the mufcles of the 
 limb are relaxed, by making the thigh form an obtufe 
 angle with the body while the joint of the knee is 
 moderately bent, it is furprifnig with what eafe we 
 
Seel. XII. Femur or Thigh Bone. 357 
 
 may, in mod cafes, place the fra£lured end of the 
 bone in its fituation. The caufe of refiftance is thus 
 ahnofl entirely removed ; fo that if much tenfion or 
 fwelling have not taken place, the ends of the bone 
 may in general be eafily brought in contadl, by one 
 affiftant fecuring the upper end of it, while the under 
 part of it is fupported and gently drawn down by 
 another, the furgeon in the mean time being employ- 
 ed in putting the fradured parts together with as much 
 accuracy as poflible. 
 
 Fradures of the neck of this bone are particularly 
 difficult to reduce ; for the mufcles being here exceed- 
 ingly ftrong, and running in various direftions, they 
 cannot be relaxed fo completely as thofe in other parts 
 of the limb. But even here we may, for the mofl 
 part, fucceed in the manner I have mentioned, the 
 body being fecured by one affiftant, while moderate 
 extenfion is made by another at the under part of the 
 thigh. Praditioners ought, however, to be provided 
 with inftruments for more powerful extenfion when 
 more lenient meafures do not fucceed. Different in- 
 ftruments are delineated for this purpofe in Plates 
 LXXXVII. LXXXVIII. and LXXXIX. but none of 
 them fliould ever be employed till other more gentle 
 means have failed. 
 
 It is not, however, in replacing the bones, but in 
 retaining them when replaced, that we moft frequent- 
 ly fail. In tranverfe fradures of this bone, the prac- 
 tice is eafy. After the fradured ends of it are brought 
 in contact, they would for the moft part fupport each 
 other with fufficient firmnefs even without a bandage, 
 if the patient fiiould be confined to a proper pofture ; 
 but to prevent any rifk from fudden exertions, the 
 parts fhould be as firmly fecured with fplints and a 
 proper bandage, as is confiftent with a free circulation 
 through the reft of the limb. 
 
 For this purpofe two fplints are reprefented in Plate 
 LXXXI. fig. 4. and 6. One to reach from the top 
 of the hip joint to a little below the knee, and of 
 
358 Of Fraaures of the Chap. XXXIX. 
 
 a breadth fufficient to cover at leaft one half of the 
 thigh ; the other to reach from the groin to a little 
 below the knee, and in breadth to cover about a third 
 part of the thigh. Of thefe, covered with foft flan- 
 nel, the longeft laid upon a twelve tailed flannel band- 
 age, is to be placed upon a thin pillow nearly as long 
 as the thigh. The patient being previoufly laid on a 
 firm hair mattrefs fupported by firm fpokes of timber, 
 fo that the hmb may' not fmk or yield, his knee being 
 moderately bent, and the bones accurately fet, the pil- 
 low with the bandage and fplint above it ought to be 
 placed fo that the fplint may reach from the hip joint 
 along the outfide of the thigh to the knee. That this 
 pofliure of the leg and thigh may be eafily preferved, 
 the patient fliould not be laid diredly upon his back, 
 but turned fomewhat towards the injured fide ; and 
 the knee and leg raifed rather higher than his body. 
 
 The limb being thus placed in the pollure in which 
 it is to be kept, the fiiort fplint mentioned above muft 
 be laid along the infide of the thigh from the groin 
 to the knee, when the twelve tailed bandage, previouf- 
 ly placed beneath the other fplint, muft be applied 
 with fuch tightnefs as to make an equal degree of 
 preflfure over the whole thigh. 
 
 As the cure would be much interrupted, and might 
 even at laft be incomplete, were any part of the drefl- 
 ings to yield, it is a right precaution perhaps in every 
 cafe, to infert a long fplint of firm timber beneath the 
 pillow, and to fecure it in its fituation with two broad 
 flraps firmly buckled on the upper part of the limb. 
 
 To obviate the motion of the limb, in confequence 
 of involuntary ftartings, the pillow fhould be fixed to 
 the bed by flraps ; and to prevent injury or uneafmefs 
 from the weight of the bedclothes, two or three hoops 
 fixed in a frame fhould be placed over the thigh. 
 
 When no untoward fymptoms occur, the limb 
 mi'Sjht be left in this fituation till the cure is complete ; 
 but left the bones fhould by accident be difplaced, and 
 cfpecially if the limb fhould fwell and become painful. 
 
Se£b. XII. Femur or TJj'igh Bone. 359 
 
 the bandage fhould occafionally be undone, and the 
 upper fplint removed, with a view to admit of the parts 
 being accurately examined ; and the twelve tailed 
 bandage admits of this, without difturbing the limb. 
 When pain, fwelling, or much inflammation, fuper- 
 vene, it may be proper to apply leeches and other rem- 
 edies to the injured parts ; but when this does not hap- 
 pen, and when the bones remain in their fituation, the 
 fplint fliould be immediately replaced and fecured with 
 the bandage as before. 
 
 In healthy adults, when no interruption occurs to 
 It, the cure is in general complete in the courfe of fix 
 weeks ; but violent exertion of every kind fliould be 
 avoided till the eighth or tenth week has pafled over. 
 
 I have advifed the limb to be placed in fuch a pof- 
 ture as tends with mofl effed to relax. the mufcles that 
 belong to it. But although this may be highly pro- 
 per at fnfl, there is no neceflity for the fame poflure 
 being continued during the whole courfe of the cure. 
 It often indeed proves hurtful, as the limb, when kept 
 invariably in one pofture for fix or eight weeks, as is 
 too frequently done, is very apt to become fliff and 
 unwieldy, fo as afterwards to give much uneafmefs 
 and diftrefs. In a fimple frafture, the patient may, 
 at the end of a fortnight, be allowed to turn more to- 
 wards his back, and the joint of the knee may be 
 fomewhat llretched out. If this is done with caution, 
 it may be repeated daily ; that is, the leg may be al- 
 ternately ftretched out and bent ; by which the mo- 
 tion of the whole limb will be much more free and 
 entire at the end of the cure than we ufually fmd it to 
 be : but where the bones of a limb are broken in fev- 
 eral parts, and into fmall pieces, the limb fhould not 
 be raifed nor moved in any manner of way till five or 
 fix weeks have elapfed j and then only with much 
 caution. 
 
 In a great proportion of cafes in which cures are 
 practicable, this courfe of treatment will prove fuccefs- 
 ful. It will never fail in tranfverfe fradlures, if all the 
 
360 Of Fraaurcs Chap. XXXIX. 
 
 parts of It meet with proper attention : but although 
 it will often fucceed even where the bone is broken 
 obliquely ; yet it mufl be confefled, that cafes fome- 
 times occur in which it fails entirely ; the ends of the 
 bone flip pad each other, and the limb becomes much 
 fliorter than it ought to be, notwithllanding all our 
 eftbrts to prevent it. 
 
 An elFeclual method, indeed, of fecuving oblique 
 fractures in the bones of the extremities, and efpeciaU 
 ly of the thigh bone, is perhaps one of the greatefk 
 defiderata in modern furgery. In all ages, the diifi- 
 culty of this has confefl'edly been great ; and frequent 
 lamenefs produced by fliortened limbs arifmg from 
 this caufe, evidently fliows that we are (till deficient 
 in this branch of practice. 
 
 The treatment of fractures being one of the mod 
 important branches of furgery, and to prevent lame- 
 nefs, one of our firft objects, nmch ingenuity has been 
 fhown in the invention of means for anfwering this 
 purpofe : it has been propofed, and by many attempt- 
 ed, in fractures of the thigh, to fecure the patient's 
 body, at one fixed point, with different bandages, to 
 the upper part of the bed, and by an axis in peritro- 
 chio at the foot of the bed, to make fuch a degree 
 of extenfion as might be fully equal to the purpofe of 
 retaining the fradtured bones. But all who are ac- 
 quainted with the fretful, irritable Itate, in which pa- 
 tients with fractures commonly are, and with the pain 
 that tight bandages always excite, will know, that al- 
 though propofals of this kind may appear to advant- 
 age in theoretical difquifitions, they will never proba- 
 bly be of real utility. And accordingly none of them 
 have ever been in general praftce. 
 
 The invention of the late Mr. Gooch, of Norwich, 
 is the one that promifed to prove mod ufeful in oblique 
 fractures of the thigh. This'inftrument is delineated 
 in Plate LXXXIII. a^d in an improved date by the 
 late Dr. John Aiike% in Plate LXXXIV. 
 
Sea. XIIL of the Patella. 361 
 
 A broad firm ftrap of leather, lined with quilted 
 cotton or fofc flannel, is placed on the upper part of 
 the limb, where it is firmly fecured with buckles. A 
 fimilar ilrap is put round the under part of the thigh, 
 and made to rell chiefly on the condyles of the femur. 
 Two or three fteel fplints, conne£lcd with the (traps, 
 pafs from one to the other in fuch a manner, that by 
 means of them the ftraps can be forced afundcr, and 
 retained at. any dift:ance during the cure. 
 
 For a more particular account of this apparatus, the 
 explanation of the Plates may be confulted. 
 
 In fome cafes, however, the pain, fwelling, and In- 
 flammation, are fo confiderablc, as to preclude the 
 application of the moft fimple bandage. After thefe 
 fymptoms are relieved by local bloodletting and other 
 remedies, Mr. Gooch's method, or Dr. Aitken*s, may 
 be adopted where the fradured bones cannot other- 
 wife be retained ; if not, the cure mufl: be conducted 
 in the ufual way, with the hazard of the ends of the 
 bone palfing each other, and of the limb being fome- 
 what liiortened. But in this event, under the circum- 
 fl:ances I have meniioncd, although the patient may 
 regret his misfortune, he cannot with jufl:ice blame 
 the furgeon. 
 
 SECTION XIII. 
 
 Of FraBitres of the Patella. 
 
 THE patella or knee pan is liable to fra£lures from 
 falls and bruifes upon the knee. Tranfverfe 
 fradures of this bone are mofl: frequent : we alfo meet 
 with longitudinal fractures, and in fome cafes it is 
 broken into three or four different pieces. 
 
 In fradures of the patella, we are defired to make 
 a guarded progncfis ; for by mofl: writers, it is faid, 
 that they almoft conilantly terminate in a fliff joint. 
 
362 Of Fraaiiru Chap. XXXIX 
 
 owing, as is fuppofed, to the callus forming in too great 
 quantity, and finding accefs to the cavity of the joint. 
 I have not found, however, that fractures of this bone 
 are fo apt to produce flifF joints as we are led to ex- 
 pe£l. In various cafes that have fallen under my 
 care, fcarcely any degree of ftifi'nefs remained after 
 three or four months had elapfed ; nor is it probable, 
 when permanent lamenefs enfues to fraftures of this 
 bone, that it proceeds from fuperabundancy of callus. 
 I rather think that it proceeds from the inflammation 
 that ufually takes place ; or from the knee being kept 
 too long in an extended immoveable pofture. From 
 a dread of feparating the frattured parts of the bone 
 before they are firmly united, the leg is ufually pre- 
 ferved in an extended pofture for eight, or perhaps 
 ten weeks ; a much longer period than is neceffary, 
 and by which alone even the foundefl joint would be 
 apt to become flilf and immoveable. 
 
 In the treatment of fradlures of this bone, in what- 
 ever direction they may run, the leg jQiould be extend- 
 ed, in order to relax the only mufcles with which it 
 is connefted, thofe forming the ligament inferted into 
 it. With this view, the patient fhould be placed up- 
 on a bed rendered fo firm that it will not yield during 
 the courfe of his confinement ; a precaution highly 
 requifite in all fractures of the lower extremities, where 
 long confinement to bed is almoft always neceifary, 
 and where unequal finking of the body is often the 
 fource of much uneafinefs to the patient, and may 
 even be the caufe of feparation of the newly replaced 
 bones. 
 
 This being done, a long firm fplint of timber, thick- 
 ly covered with foft wool, or with feveral plies of fine 
 flannel, fliould be placed beneath the thigh and leg, 
 from the upper part of the one to the extremity of 
 the other ; and to this the limb fhould be fecured by 
 two ftraps between the ankle and knee, and one or 
 two between the knee and top of the thigh. This 
 will effedtually preferve the leg in a fi:ate of extenfion ; 
 
 n 
 
Sea. XIII. of the Patella, 363 
 
 and it does it in the eafiefl: manner when the fplint is 
 fufficiently broad and properly covered with flannel 
 and wool in the manner I have mentioned. 
 
 The different parts of the fractured bone are now 
 to be brought as near together as pofTible with the 
 hand ; but no bandage is yet to be applied to them. 
 Our great objed at firft is to prevent inflammation ; 
 for which purpofe as much blood fliould be taken 
 from the joint with leeches as the patient can proper- 
 ly bear ; and for two or three days, or as long as 
 much pain, fwclling, or tenfion, continue, faturnine 
 and other afliringent applications fliould be ufed for 
 renioving them. 
 
 This being accompliflied, we again examine the 
 fl:ate of the bone ; and if the diflcrent parts of it are 
 all either entirely or nearly in contaft, they ought not 
 to be difl:urbed. The joint may be covered with a 
 large pledget of faturnine cerate, by which it will be 
 kept foft and eafy ; and a hooped frame fhould be 
 employed to fupport the bedclothes. 
 
 But if the different parts of the bone, infl:ead of 
 being nearly in contaft, are found feparated to any 
 confiderable extent, we ought flrfl: to replace them, 
 and then endeavour to retain them as far as this can 
 be done with bandages. 
 
 In longitudinal fra<5lures of the patella, this is eafi- 
 ly done ; for in this direction we meet with no refifl:- 
 ance, and the parts are eafily retained by moderate 
 prefl'ure, either with the common uniting bandage, or 
 with flips of leather fpread with glue or adhefive plaf- 
 ter. But in tranfv^erfe fraftures of this bone, as that 
 part of it that remains connecled with the extenfor 
 mufcles of the thigh is apt to be drawn forcibly up- 
 wards, we cannot always replace it but with a force 
 that would excite pain, fwelling and inflammation. 
 
 It is not neceitary, however, that the diflcrent 
 pieces of bone be kept in exadl conta£l. Where it 
 can be eafily done, it ought always to be advifed ; but 
 I know from the refult of ftveial cafes where this was 
 
2,64 Of Fradures Chap. XXXIX. 
 
 Impracllcable, that a cure may be obtained, and the 
 joint be equally firm and ufeful as it was before, even 
 although the Separated portions of bone cannot be 
 kept within an inch of each other. We fhould not 
 therefore be anxious about this ; and inftead of ufing 
 much force for drawing the bones into contad, no 
 more fhould be employed than the patient can eafily 
 bear. 
 
 Various bandages have been invented for drawing 
 the divided parts of a fractured knee pan together ; 
 but alinoH: all of them have been formed upon erro- 
 neous principles. They are made to prefs equally 
 upon the upper and under portion of the bone : 
 whereas the leaft reflection on the anatomical ftruc- 
 ture of the parts mufl render it obvious, that no ad- 
 vantage can be derived from much prefTure on the 
 inferior part of the bone, which always remains in its 
 natural fituation ; and therefore, that our force fhould 
 be entirely applied to that part of it that remains con- 
 nedled with the ligament of the extenfor mufcles, by 
 the adlion of which, particularly cf the re£lus mufcle, 
 this portion of the bone is drawn upwards. 
 
 In Plate LXXXVI. a bandage is reprefented, from 
 which, while it fits eafily upon the parts to which it 
 is applied, every advantage may be derived that this 
 kind of afliflance can give : it confifls of two circular 
 (traps of firm leather, A B, lined with foft flannel, 
 with two perpendicular flraps C E, that pafs from one 
 end to the other, and a femilunar firm comprefs G j 
 with another (trap of a greater length D, reaching 
 from the point of the toes to the buckle on the upper 
 circular flrap round the thigh, as is more particularly 
 reprefented in fig. 3. of the fame plate. 
 
 The leg being extended and raifed to a proper 
 height for relaxing the extenfor mufcles of the thigh, 
 the upper edge of the under circular flrap A fhould 
 be applied to the under part of the inferior portion of 
 the bone, fo as to fupport it in its natural fituation 
 without forcing it farther up. The flrap muft be 
 
Sea. XIII. of the Patella. 365 
 
 then tightly buckled ; and the upper half of the bone 
 being pulled gently though firmly down, the femilu- 
 nar comprefs F in fig. 2. mud be applied round the 
 upper end of it, when the upper circular flrap muft be 
 alfo buckled. By means of the two perpendicular 
 flraps and buckles, we now make a gradual firm ex- 
 tenfion, which will not move the under circular (trap 
 if it was previoufly made fufficiently tight ; but which 
 will draw the other down if it has not been made too 
 tight. This will, in fome degree, draw down the up- 
 per part of the bone, by gently pulling the femilunar 
 comprefs previoufly applied to the upper part of it ; 
 but it will be more cffe6:iially done by the (trap D 
 made fufRciently tight by fixing it to the correfpond- 
 ing buckle in the upper circular (trap B. 
 
 In this manner the diflerent parts of the bone may 
 be made to approach each other as far as this can 
 with propriety be done ; but for the reafons I have 
 given already, the prelTure fliouid never be carried fo 
 far as to endanger the excitement of pain, inflamma- 
 tion, or fwelling. 
 
 The limb being fccurcd in the manner I have men- 
 tioned, the bandages fliould not be removed till the 
 twelfth or fourteenth day, if pain and inflammation 
 do not render a more early removal neceflary. But 
 about this period, the bandage fliould be removed, 
 when the limb may be moderately bent ; ?.nd this be- 
 ing cautioufly repeated every fecond or third day, no 
 interruption will be given to the cure, while the mo- 
 tion of the joint will be preferved ; which it feldoni 
 or never is when this piece of attention is omitted. 
 
 The joint of the knee is liable to another injury, fo 
 fimilar in its effcfts, as well as in the method of cure, 
 to fractures of the patella, that I think it right to men- 
 tion it ; namely, a feparation, by external violence, of 
 the ligament or tendon of the reftus mufcle from the 
 patella. The ufual efiect of a fmart ilroke, or a fe- 
 vere fall, upon the forepart of the knee, is a frafture 
 f>f this bone j but where a perfon carrying a heavy 
 
366 Of Fraaures of the Chap. XXXIX, 
 
 burden upon his back, fjills with his knee much bent, 
 a rupture of the tendon more frequently happens : at 
 leaft I have met with it in feveral inftances from this 
 caufe, in which the tendon, after feparating from the 
 bone, retracted to the diftance of two or three inches. 
 The treatment that I have advifed for a fradlure of 
 the patella proves equally fuccefsful here ; only it will 
 be underltood, that in this cafe no advantage can be 
 obtained from pulling down the retracted tendon : 
 for not being connected with any part of the bone, it 
 cannot be laid hold of; fo that we have to truft en- 
 tirely to the extended pofture of the limb. But al- 
 though the tendon and bone cannot be brought clofe 
 to each other, yet a cure may always be accompliflied 
 in the manner I have mentioned. 
 
 SECTION XIV. 
 
 Of Fraaures of the Bones of the Leg. 
 
 IN fractures of the leg, only one bone is often brok- 
 en ; but a frafture of both is more frequent. In 
 this cafe the feat, as well as the direction of the frac- 
 ture, are readily perceived. When one bone only is 
 broken, the nature of the injury is difcovered with 
 more difficulty. This, however, is of little import- 
 ance ; for v/hen one of the bones remains entire, it 
 ferves fo eli'eftually to fupport the other, that Httle 
 more is neceffary than confinement till the fractured 
 bone is united. 
 
 Fractures are more frequent near the joint of the 
 ankle than in other parts. A great proportion indeed 
 of fractures of the fibula are leated an inch or two 
 above the under extremity of this bone, this being the 
 wreaked part of it. 
 
 The fame general principles that I have propofed 
 in the management of fractures of the thigh bone. 
 
Sed. XIV. Bones of the Leg. 367 
 
 prove applicable in fra6lures of the leg : in replacing 
 the bones, the niufcles of the limb Ihould be relaxed ; 
 and we do it in the mod effedual manner by bending 
 the joint of the knee, and flightly extending the foot. 
 The leg being put in this pofition, the bones are for 
 the mod part eafily replaced ; and with no more ex- 
 tenfion than can be eafily given by one alTiftant at the 
 upper end of the limb, and another at the ankle. 
 
 This being done, and the patient placed in fuch a 
 manner that the injured leg may be laid upon its out- 
 fide, with the knee bent, the fplints, figs. 3. 5. or 6. 
 Plate LXXXI. fliould be applied and retained with the 
 twelve tailed bandage ; the fplint on the outfide of the 
 leg reaching from a little above the knee to beneath 
 the ankle, with a view to prevent the motion of eith- 
 er of thefe joints, by which the bones are very apt to 
 be difplaced. 
 
 Whether the fplints are of firm pafteboard, or fuch 
 as are reprcfented in Plate LXXXI. they would for 
 the moft part, prove fuiFicient : but when the patient 
 is either refllefs, or troubled with fpafmodic affections 
 of the mufcles of his leg, an additional fplint of wood, 
 fliaped to the form of the leg, reprefented in figs. i. 
 and 2. of the fame plate, fliould be appHed along the 
 outfide of it ; and if it is flightly excavated and filled 
 with foft wool or tow, it fits with eafe, while it pre- 
 vents, with certainty, the ends of any of the bones 
 from falling down. We fix it with ilraps and buc- 
 kles, and the leg, when drefl'ed in this manner, has 
 the appearance reprefented in Plate LXXXV. fig. 2. 
 
 I have already obfervcd, that after the drefTings are 
 applied, the leg fliould be laid upon its outfide, with 
 the knee bent, and the foot fupported with a turn of 
 a roller, as reprefented in the figure jufl mentioned. 
 The intention of this is to relax the mufcles of the 
 limb ; by which the patient lies with more eafe, while 
 the bones are lefs liable to be difplaced, than where 
 tJie mufcles are fully flretched out, as till lately was 
 ahnoft the univerfal cuftom. 
 
358 Of Fradures cfthe Chap. XXXIX 
 
 But although the leg (hould be placed in fuch a 
 pofture as may tend molt clTeclually to relax the muf- 
 cles ; yet the knee fhould not be more bent than this 
 requires : for when this joint is kept long much bent, 
 it proves almoft equally irkfome to the patient as 
 when the leg is fully llretched out. The knee fhould 
 not therefore be more bent, nor fliould the patient be 
 laid more towards his fide, than is juft neccflary for 
 allowing the leg to be placed upon its outfide. 
 
 Some people, however, cannot fleep when lying on 
 either fide ; and fome practitioners think, that frac- 
 tures of the leg heal more eafily when the patient is 
 laid on his back, and the limb placed upon the gaf- 
 trocnemii mufcles, with the toes upwards. In fuch 
 cafes the patient may be placed upon his back, and 
 yet the curved pofition of the leg retained. This may 
 be done in difterent ways ; but the eafieft method is, 
 to raife the leg, and fupport it upon a frame, at a 
 proper height above the level of the body. This ad- 
 mits of the limb being placed in the pofture I have 
 advifed, and with any necefl'ary degree of curvature. 
 
 Even where a fractured leg is placed on the out- 
 fide, it proves to be a pleafant variety to have the pof- 
 ture altered ; and with fuch a frame it can be eafily 
 done. 
 
 A limb placed in this fituation is reprefented in 
 Plate XCV. fig. 2, and the fame variety of pofture is 
 admiflible in fradtures of the thigh. The patient may 
 from the firfl be placed with his leg curve'd in this 
 manner ; or he may afterwards turn upon his back, 
 and the cure be completed while he remains in this 
 pofture, or he may alternately change from one to the 
 other. The inconveniency ufually complained of, 
 from the leg refting* upon the heel when ftretched 
 out, is avoided by an excavation or opening in the 
 bottom of the frame foF receiving the heel, or it may 
 be done by allowing the heel to project over the edge 
 of the frame altogether. No change of pofture, how- 
 ever, fhould be permitted for the firft ten or twelve 
 
Se6l. XIV. Bones of the Leg, 369 
 
 days. About this time the patient may be turned with 
 caution upon his back, and the leg moved from one 
 pofition to the other, CiU'e being taken to preferve it in 
 the fame degree of curvature. 
 
 In fradures of the leg, where the fibula only is In- 
 jured, it is apt to pafs unnoticed, and to be confider- 
 ed as a fprain of fome of the niufcles : but as very 
 ferious confequences are apt to eiilue from this mif- 
 take, it ought to be flriclly guarded agalnft. 
 
 When treating of fradures of the clavicle, I had 
 occafion to mention an appearance which, of itfelf, is 
 extremely fimple and of eafy treatment ; but which, 
 from want of attention to the caufe of it, has often 
 been produ6lIve of much perplexity both to patient 
 and praditioners ; I mean what is commonly termed 
 the rifing end of a bone ; and as this frequently oc- 
 curs in the leg, I think it proper to mention it here. 
 
 When the bones of the leg are broken diredly 
 acrofs, they fomctlmes ferve to fupport each other fo 
 efFeftually that neither of them are difplaced. In fuch 
 circumflances, no inequality appears in the limb, if it 
 be not from fome temporary fwelling of the foft parts. 
 But when both bones are not only fradlured but dif- 
 placed, the under part of them, or that portion con- 
 nected with the foot, is almofl always drawn down, 
 and towards the back part of the leg ; by which an 
 unequal prominency is produced by the projeding end 
 of the upper portion of bone, or that part of it which 
 ftill remains conneded with the knee. 
 
 It is this that is termed the rifing end of the bone ; 
 and in reducing fuch fraftures, much pains is com- 
 monly taken to force this part of the bone into con- 
 tad with the other. It is obvious, however, that the 
 upper part of the bone does not rife, but that the in- 
 ferior portion falls, or is drawn down, and out of its 
 natural fituation, by the weight of the foot, as well as 
 by the contraction of the mufcles on the back part of 
 the leg : hence no advantage can be gained by any 
 
 Vol. III. A a 
 
370 Foot and Tecs. Chap. XXXIX. 
 
 preflurc made upon the fuperior part of the bone, 
 while much harm is often done by it, by bandages 
 being fo tightly tied over it as to cut all the teguments 
 with which it is covered ; and thus forming a com- 
 pound fracture of what othervvife would have remain- 
 ed of the moft fmiple kind. 
 
 The upper part of the bone never rifes out of its 
 natural fituation ; fo that any inequality in the form 
 and appearance of the leg, muft be produced in the 
 manner I have mentioned, namely, by the inferior por- 
 tion of the bones being drawn out of the fituation 
 which they ought to occupy : fo that inftead of forc- 
 ing down the upper part of the bone, our fole objefb 
 fhould be to raife the inferior part of it, fo as to bring 
 them into contact ; and by fupporting it in this fitu- 
 ation, to endeavour with as much certainty as pofli- 
 ble to effect their reunion. In this manner a cure 
 may be often accomplifhed, which could not be ob- 
 tained in any other way. 
 
 SECTION XV. 
 
 Gf FraBures of the Bones of the Foot and Toes. 
 
 FRACTURES of the bones of the foot and toes 
 are to be managed nearly in the fame manner 
 with fimilar injuries ^f the hands and fingers. All 
 portions of difplaced bone muft be put into its natural 
 fituation with as much accuracy as pollible ; and we 
 endeavour to retain them by fplints fitted to the form 
 of the part, fupported with different turns of a roller. 
 In fradtures of the bones of the foot, a large fplint 
 ftiould be applied over the fole, fo as to fupport the 
 whole of it ; and no freedom fhould be permitted in 
 the motion either of the foot or ankle during the cure ; 
 for nothing tends more to difplace a fradured portion 
 of bone than the adion of the contiguous mufcles." 
 
Sed. XVT. Of Compound Fraclures, 371 
 
 SECTION XVI. 
 
 Of Compound Fra&urcs. 
 
 S the term compound fra6lure has been applied 
 to injuries of different kinds, I think it right to 
 define with precifion the meaning that I wifh to affix 
 to it. A fraclure of a bone, communicating with an 
 external opening or wound in the corrcfponding tegu- 
 ments, I denominate a compound fraclure. It is not 
 the circumftance of a fractured bone being accompa- 
 nied with a wound in the contiguous foft parts, that 
 conftitutes a compound frafture : this may happen 
 with a frafture of the moft fimple nature, tjnlefs the 
 external opening communicates with the fraclure of 
 the bone, the fradlure is not affecled by it, even al- 
 though the wound is extenfive ; while the fmalleft 
 punclure pafTmg dire6lly to the fubftance of a fraftur- 
 ed bone, adds difficulty to the method of cure, and 
 hazard to the event. 
 
 Compound fradures are produced, not only by ex- 
 ternal violence, but frequently by the bones in fmiple 
 fradtures being, in the courfe of the cure, pufhed 
 through the corrcfponding teguments. In fome cafes, 
 this happens from a bone being fo very obliquely 
 fradlured that it terminates in a (harp point ; while in 
 others it is the evident effeft of too tight a bandage, 
 applied with the view, as we have feen in Seft. XIV. 
 of bearing down the upper end of the fradlured bone. 
 But in whatever way a compound fra£lure is produ- 
 ced, the confequences that refult from it are nearly 
 fimilar. The admiffion of air to a fra6lure adds evi- 
 dently to the rilk that attends it ; and whether this 
 takes place as an immediate effedl of external violence, 
 or as the confequence of preffure upon the ends of 
 the bone, no difference is perceived in the effeds that 
 refult from it. 
 
 A A 2 
 
T^yi Of Compound Fradures. Chap. XXXIX. 
 
 Various reafons might be adduced to prove that it 
 is the admiflion of air alone that renders compound 
 fra£lures more hazardous than others. I may fhortly 
 mention, however, one of the mofl obvious proofs of 
 it. The worfl variety of fimple fradlure, where the 
 bone is broken in the mofl obhque manner, and where 
 it is difficult or perhaps impoflible to retain it in its 
 fituation, will continue to do well, and to excite no 
 fevere fymptoms, as long as the fkin remains entire : 
 but if, by any accident, the point of the bone is pufh- 
 ed through the teguments, from that moment the pain 
 becomes more fevere ; the inflammation, which be- 
 fore perhaps was trifling, becomes now confiderable ; 
 fever takes place ; the limb is apt to be attacked with 
 fevere fpafmodic twitchings ; and to thefe gangrene 
 or extenfive fuppurations frequently fucceed. 
 
 In the treatment of compound fradures, our firft 
 obje£t is to reftrain profufe hemorrhagies when they 
 take place, by a proper application of the tourniquet : 
 our next is to confider, whether we fhould attempt to 
 fave the limb, or recommend immediate amputation. 
 
 From the difficult treatment and uncertain event of 
 compound fractures, practitioners have been very uni- 
 verfally difpofed to confider the amputation of the 
 fradured limb as necefi'ary. At all times indeed in- 
 dividuals have oppofed this general opinion. Among 
 others, Mr. Bilguer of Berlin wrote decidedly againft 
 it ; and he afferts, that amputation is feldom or never 
 neceflTary, and that a greater number of patients would 
 recover if this operation were entirely exploded. 
 
 To me it appears that both opinions are in the ex- 
 treme ; and that they have been formed without that 
 attention to the difcrimination of circumjflances which 
 the great importance of the queflion merits. 
 
 In private praftice, where patients can be kept qui- 
 et and perfectly at reft from the date of the injury, 
 and where due attention can be enfured on the part 
 of the practitioner, as well as of experienced nurfes, 
 compound fractures fhould receive a different treat- 
 
Sed. XVI. Of Compound Fra&iires, 373 
 
 ment from thofe that happen in a field of battle or in 
 an engagement at fea. So many inftances occur, in 
 which, from amputation being objefted to by the pa- 
 tient, from the Hmb being too much fwelled or in- 
 flamed before affiftance is called, or from intention on 
 the part, of the pra£titioner to endeavour to fave the 
 limb, of cures being made, that I am now convinced 
 that in private praftice immediate amputation Ihould 
 never be advifed, unlefs when the bones are fo much 
 fhattered that they cannot reunite ; or where, from 
 the violence of the injury, the texture of the foft parts 
 is completely deftroyed. 
 
 On the other hand, I believe, that it would be a 
 good general rule, both in the navy and army, to am- 
 putate immediately in all cafes of compound fradlure 
 that occur in battle, where the accident is either in the 
 humerus or thigh, or where both bones of the fore- 
 arm or leg are fradlured. In this fituation, the pa- 
 tient is expofed to a variety of hardfliips that tend to 
 aggravate his danger ; while no accommodation can 
 be procured nor attention given to lelfen it. 
 
 In oppofition to this it may be alleged, that com- 
 pound fradures are frequently cured in military hof- 
 pitals. This indeed is the argument on which Mr. 
 Bilguer refts his opinion : but, like every prejudiced 
 inquirer, he ftates it partially. 
 
 I readily admit, as every one accuftomed to the 
 treatment of fractures will do, that cures are fome- 
 times unexpedledly accompliflied under the mofl un- 
 toward circumftances ; but the favourable termina- 
 tion of a few cafes will never invalidate an eftablifhed 
 pradice, founded on the fure bafis of experience and 
 obfervation. 
 
 When an officer of rank and fortune receives a 
 compound fradure, and where circumftances admit of 
 his being foon conveyed to good quarters, with a prof- 
 pe£t of this being his place of refidence during the 
 cure, the cafe muft be bad indeed if we do not at- 
 tempt to fave the limb. But this does not happen in 
 
374 Of Compound Fraditrcs. Chap. XXXIX. 
 
 the ufual routine of military practice ; and I mention 
 fuch cafes only, becaufe the accounts we have receiv- 
 ed of Mr. Bilguer's fuccefs, are .chiefly if not entirely 
 drawn from fuch inftances ; and they therefore afford 
 no general conclufion relative to military and naval 
 pradice. 
 
 Even in private practice, I am far from thinldng 
 that our attempts to fave fractured limbs will always 
 fucceed. I know that they do not ; and in the courfe 
 of much bufmefs, cafes fometimes occur in which the 
 beft conducted meafures fail, particularly where the 
 large joints are injured, and where the long bones are 
 not only fractured but fplintered in different places : 
 but I alfo know from experience, that where at lafl 
 we are obliged to advife amputation, more recover 
 when the operation is delayed, than commonly do 
 where it is performed foon after the accident ; at lead 
 this has been very commonly the cafe in the courfe of 
 my obfervation. Of thofe who have died foon after 
 the operation, either from the fever induced by the 
 extenfive wound ; from the great and fudden change 
 produced in the circulating fyftem by the removal of 
 a limb ; or from the perturbation and violent agita- 
 tion of fpirits which the unexpected lofs of a limb 
 muft always induce, a great proportion has been of 
 thofe on whom the operation was performed immedi- 
 ately after the accident : a patient in this ftate of bo- 
 dy and mind muft be ill fitted for undergoing the fe- 
 verity of fuch an important operation ; and accord- 
 ingly all the caufes that I have enumerated concur to 
 render the fubfequent fever, and every concomitant 
 fymptom, more violent than we commonly find them 
 in patients who have been reduced by confinement 
 and a low regimen, and who, from having full leifure 
 to reflect upon the danger of their fituation, are, from 
 their own conviction of the neceffity of the meafure, 
 very readily induced to fubmit to the operation. 
 
 A patient may indeed be brought fo low as to make 
 the fuccefs of the operation doubtful from this caufe 
 
Se6l. XVL Of Compound Fraffures. 375 
 
 alone : but a practitioner may always guard againfl: 
 this, by propofmg the operation as foon as his attempts 
 to fave the limb prove alDortive, and before the patient's 
 ftrength has declined too much. 
 
 Amputation feems to prove more fuccefsful in the 
 more advanced ftages of compound fradlures than im- 
 mediately after the accident ; and ftill more fo in the 
 advanced ftages of chronic affedlions, particularly in 
 white fwellings of the joints, as I have elfewhere re- 
 marked, than in the more early periods of the difeafe. 
 A point of the greateft practical importance is thus of- 
 fered to our confideration. So far as my obfervation 
 goes, I confider the fact as afcertained ; and if the ex- 
 perience of others leads to the fame conclufion, it will 
 prove the moft convincing argument againft early am- 
 putation. In the courfe of my own experience, I do 
 not recoiled an inftanae of death having enfued from 
 the operation alone, where the difeafe was of fome du- 
 ration for which it was advifed ; and it has often been 
 performed where the patient was greatly exhaufted : 
 whereas many have died merely from the operation, 
 where it has been put in practice foon after the acci- 
 dent. AVhen I fpeak of death as the confequence of 
 the operation, I do not mean fuch inftances of it as 
 occur from hemorrhagies breaking out in the courfe 
 of a fhort time after the patient is laid in bed, as thefe 
 commonly happen from negligence on the part of the 
 furgeon, at whatever period a limb may be amputated ; 
 but fuch as take place about the fecond or third day, 
 and in fome inftances at a later period, from the vio- 
 lence of the fever induced by and commencing foon 
 after the operation. 
 
 When amputation is not performed immediately, 
 or foon after the injury is received, all praditioners 
 agree that it cannot, for feveral days at leaft, and oft- 
 en for a much longer period, be admiftible. Differ- 
 ent caufes may afterwards render it neceflary. 
 
 1. Hemorrhagies under certain circumftances. 
 
 2. Extenfive mortification. 
 
37^ Of Compound Fra6lures, Chap. XXXIX. 
 
 3. The ends of the fractured bones remaining long 
 difunited, while a copious difcharge of matter endan- 
 gers the ftrength of the patient. 
 
 When hemorrhagies take place immediately, we 
 have it always in our power to command them, either 
 by comprefTion alone, or by enlarging the wound when 
 it is too fmall, and fecuring the bleeding arteries with 
 ligatures. Sometimes, however, when no difcharge 
 of importance occurs at firft, profufe hemorrhagies 
 will take place at the end of feveral days. It may be 
 difficult in fome cafes to account for this ; but we cart 
 frequently trace it to the effect of friction ; the coats 
 of an artery being deftroyed by beating or rubbing 
 upon the Iharp edge of a fplintered bone. 
 
 Even in this advanced ftate of the injury, we may 
 frequently be able to fecure the wounded arteries with 
 ligatures. But the limb is fometimes fo much fwelled 
 and inflamed before the hemorrhagy appears, that the 
 original opening will not admit of this ; and on pro-^ 
 ceeding to enlarge it, fuch confufion is met with from 
 effufed coagulated blood between the interftices of the 
 mufcles, as well as through the whole cellular mem- 
 brane of the affected parts, that the divided arteries 
 cannot be all brought into view, but by fuch extenfive 
 incifions as in this (late of the parts would create more 
 hazard than amputating the limb at a proper dillance 
 above : and although it is not frequent, yet inllances 
 happen, where the mofl expert furgeons are obliged 
 in this fituation to amputate. 
 
 Mortification is perhaps the moft urgent motive for 
 amputating in this ftage of compound fradtures. I 
 {hall have occafion, however, to confider this fubjedt 
 more particularly in the chapter on amputation ; and 
 with refpect to the third caufe that I have mentioned, 
 no reunion taking place between the fractured parts 
 of the bone, and a finking of the patient's ftrength 
 from too copious a difcharge of matter, no practition- 
 er of experience will, in this fituation, difpute the pro* 
 priety of amputation. 
 
Sea. XVI. Of Compound FraBures. 377 
 
 It is this ftate of a compound fradlure, when the 
 original inflammatory fever excited by the injury is 
 gone, and before the patient is too much weakened 
 by the difcharge, which of all others I confider as the 
 mod favourable for amputation. The exad time can- 
 not poiTibly be fixed by any general obfervation : it 
 muft depend upon the particular circumftances of ev- 
 ery cafe, and chiefly upon the quantity of the difcharge, 
 and ftrength of the patient ; and thefe again are points 
 which the judgment of the practitioner in attendance 
 can alone decide upon. I may remark, however, that, 
 as long as the patient does not feem to be much hurt 
 by the difcharge, however great it may be, the opera- 
 tion fhould not be advifed ; for, while his ftrength is 
 not much impaired, v/e may with fafety proceed in our 
 endeavours to fave the limb. 
 
 From what has been faid, it will appear, that in pri- 
 vate pra6lice, very few cafes can occur of compound 
 fradlures, in which we fhould not attempt to fave the 
 limbs. 
 
 In the treatment of compound fra£tures, our objeft 
 is the fame as in the management of thofe of the mofl 
 fmiple nature ; namely, to replace the bones that may 
 be deranged, and to retain them till they are united. 
 
 In the hrft place, all extraneous bodies fhould be 
 removed, as well as all thofe fmall pieces of bone that 
 will not probably unite with the reft ; for which pur- 
 pofe, the opening, if too fmall to admit of their being 
 eafily taken out, fhould be enlarged with a fcalpel. 
 And this being done, we in general find^ that the 
 bones are eafily replaced by relaxing all the muicles 
 of the limb in the manner already pointed out in the 
 preceding fcdions of this chapter. Only one excep- 
 tion occurs to this : a fharp point of a bone is, in feme 
 inftances, fo far puflicd through the teguments, that it 
 cannot be replaced by an ordinary fcice ; ?nd to a 
 certain extent, the greater the force is that we apply, 
 the more firmlv the protruded portion of bene is fixed 
 between the fkin and parts beneath. In tliis fituation. 
 
378 Of Compound Fradures, Chap. XXXIX. 
 
 we fhould either faw off the end of the protruded por- 
 tion of bone, or enlarge the wound. 
 
 When a long fliarp point of bone is much protru- 
 ded, we fhould not hefitate to remove it ; for, although 
 it might be reduced, it would not readily unite with 
 the refl of the bone, at the fame time that it would be 
 apt to excite much pain and irritation. When the 
 portion to be taken away is fmall, it may be done with 
 the cutting forceps ufually employed in amputations : 
 but, when it cannot be eafily done in this manner, it 
 may with fafety be taken off with a faw ; a piece of 
 pafleboard, or thin fheet lead being previouHy inf«rt- 
 cd between it and the teguments beneath. 
 
 But when the protruded portion of bone is broad 
 at the bafe, and not of great length, as there will be 
 caufe to hope that it may unite with the reft of the 
 bone if the correfponding parts are brought in conta£t, 
 we ought certainly to endeavour to fave it ; and in 
 general we are able to do fo by enlarging the opening 
 through which it has paffed. If we take care to avoid 
 any large blood veffels and nerves, which thofe ac- 
 quainted with the anatomy of the pares will readily 
 do, no danger will occur from the operation. Inftead 
 of increaling the danger of the patient, it tends often 
 to leffen it, by removing a powerful caufe of pain and 
 irritation, and thus preventing that inflammatory ten- 
 lion to which limbs in this fituation are particularly 
 liable. 
 
 To thofe not accuftomed to manage compound 
 fradiures in this manner, the praftice that I now recom- 
 mend may be fuppofed to be attended with hazard ; 
 and to convert a fmall puncture into an extenfive 
 wound, may often appear to be cruel and unneceffa- 
 ry. But as the admiffion of air has already occafion- 
 ed all the mifchief that can arife from this, we do not . 
 in this manner add to the hazard of the patient ; and 
 it -is generally \yq\\ known, that a free incifed wound 
 heals more readily than a fmall pun6lure. It is the 
 Ikin only that for the moft part we have to cut here j 
 
SecV. XVI. Of Compound Fra6lures, 379 
 
 but even where the bone cannot be eafily reduced 
 without carrying the incifion into the fubflance of the 
 contiguous mufcles, we fhould not hefitate to advife 
 it : only, in this cafe, the opening fliould be made as 
 much as poffible in the direction of the fibres of the 
 mufcles. 
 
 The fplinters of bone, coagulated blood, and other 
 extraneous bodies being removed, any artery that may 
 be cut being fecured with a ligature, and the protru- 
 ded portion of bone replaced, the frafture is, in other 
 refpedis, to be reduced in the manner I have advifed 
 when fpeaking of fimple fractures ; that is, by relax- 
 hig the mufcles of the limb, and extending the bones 
 no more than is juft neceflary. This being done, a 
 pledget of foft lint, fpread with any emollient oint- 
 ment, fhould be laid over the wound, when the limb 
 fhould be placed upon a firm fphnt, and flill kept in 
 a relaxed polture. As it is of much importance that 
 the wound be regularly drelfed without moving the 
 limb, it fhould, if poilible, be fo placed, that this can 
 be done ; and with the fame view, the twelve tailed 
 bandage, in compound fractures of the extremities, 
 fliould be preferred to the roller. 
 
 As it is a point of the utinofl importance to place 
 the limb in fuch a pofhire as will admit of the fore 
 being dreffed without being moved, various inventions 
 have been propofed for rendering this in every cafe 
 practicable. Few of thefe, however, have anfwered 
 the purpofe for which they were intended. The beft 
 that I have feen is a box invented by the late ingenious 
 Mr. James Rae of this place ; of which, with fome 
 improvements made by his fon Mr. John Rae, I now 
 give a delineation. The leg may be laid in it either 
 l")ent or flraight, and a wound, wherever fituated, may 
 be dreffed without altering the pofition of the limb, 
 as will be more clearly underflood from the reprcfen- 
 tation of the inft rumcnt, Plate LXXXIV. fig. 3. 
 
 In whatever fituation the limb is placed, it is an ob- 
 ject of the firft importance to endeavour to prevent 
 
380 Of Compound Fraaures. Chap. XXXIX. 
 
 inflammation ; for, when mortification enfues, it may- 
 be ahnoft always traced to a high degree of inflam- 
 mation ; and to this alfo may be traced thofe exten- 
 five colledlions of matter which often occur in com- 
 pound fra6lures. We are, therefore, from the firfl, 
 to guard againlt the acceflion of this fymptom ; by 
 one or more general bloodlettings, proportioned to the 
 flrength of the patient ; by the application of leeches 
 to the edges of the fore ; by the ufe of opiates ; by 
 gentle laxatives ; a low regimen ; and other parts of 
 an antiphlogiftic courfe. The dreflings fliould be re- 
 moved once or twice daily, according to the quantity 
 of matter ; and inftead of dry lint, pledgets of any 
 emollient ointment, or Goulard's cerate, fliould be 
 preferred ; for I have not found in any ftate of thefe 
 fores that ointments do harm ; and they always fit ea- 
 fily, and are more eafily removed than when dry lint 
 is applied alone. 
 
 Warm emollient poultices are commonly applied 
 at firfl;, and continued for a good many days ; but as 
 they prove always troublefome, and cannot be remov- 
 ed without in fome degree altering the pofl:ure of the 
 limb, I think it better to avoid them till we fee wheth- 
 er or not they become neceflary by the approach of 
 inflammation. In that event, they fhould be immedi- 
 ately employed as the furefl: means of exciting a dif- 
 charge of matter : for, although we would rather wifli 
 the fore to heal by what is termed the firfl: intention, 
 without the formation of matter ; yet this being a rare 
 occurrence in wounds attending compound fraftures, 
 and a plentiful difcharge of good pus being the mofl: 
 certain preventive of mortification, we fliould not he- 
 jfitate in our endeavours to promote it whenever the 
 inflammation becomes fevere. 
 
 As foon, however, as our views are accompliflied, 
 by the inflammation fubfiding, and a free difcharge of 
 matter having taken place, the poultices fliould be laid 
 afide : for when too long continued, they certainly do 
 
Se£l. XVI. Of Compound Fra&ures. 381 
 
 harm, by relaxing the parts too much, and exciting 
 too profufe a difcharge. 
 
 When matter is difcharged from compound frac- 
 tures in too great abundance, befides laying afide the 
 ufe of emollient poultices, the fore fhould be dreifed 
 with aftringents, fuch as foft lint dipped in a folution 
 of faccharum faturni, with a due proportion of bran- 
 dy ; and the patient fhould be fupported with nour- 
 ifhing food, a free ufe of wine, Peruvian bark, and 
 elixir of vitriol. A free vent fnould be procured for 
 the matter ; and when this cannot be obtained by the 
 pofture of the limb, it fhould be done by making a 
 counter opening in a more depending part. The ne- 
 celFity, however, of this, may be often prevented by 
 employing foft lint, or covering the fore with foft: 
 fponge to abforb the matter, and by frequent drefTmgs ; 
 for, although the fores fhould never be more expofed 
 to the air than is necefl'ary, yet whenever the difcharge 
 is copious, there will be more rilk from allowing the 
 parts to be long immerfed in matter, than from a fre- 
 quent renewal of the drefTmgs. 
 
 When the difcharge from compound fradures is 
 exceflive, and cannot be lefl'ened by the means I have 
 mentioned, it will often be found to proceed from a 
 portion of loofe bone that has not been earlier notic- 
 ed. In this fuuation, we fliould examine the fore with 
 as much attention as poffible ; and wherever a piece 
 of loofe bone is difcovered, it ought to be taken out 
 ekher at the fore itfelf, or by a counter opening, if it 
 appears that in this manner it can be more eafily done. 
 In making an examination for this purpofe, the finger 
 alone fliould be employed when the opening is fo large 
 as to give it accefs ; for in this manner we do lefs 
 harm than with a probe ; and at the fame time we dif- 
 cover the real ftate of the parts with jriore precifion. 
 When it is necelfary to ufe a probe, it fliould be done 
 with caution, for much mifchief is frequently done 
 where probes are ufed with freedom. 
 
382 Of Compound FraBures. Chap. XX^ 
 
 If, inflead of producing a difcharge of matter, the 
 inflammation fliould end in gangrene, the hazard be- 
 comes ftill greater than it ever can be from the mofl 
 extenfive abfcefs. Having already, in Chapter I. con- 
 fidered the fubjecl of gangrene, I muft now refer to 
 that part of the work. In a following chapter, I fhall 
 have an opportunity of mentioning the period at which 
 amputation of limbs, attacked with gangrene, fhould 
 be advifed. 
 
 In confidering this fubjeft, fome will fuppofe that I 
 fliould have given more particular directions for fe- 
 curing fractured limbs in their fituation, efpecially in 
 compound fracture ; but, as I know of no method of 
 effecling this with fuch certainty and eafe as the one 
 that I have defcribed, I confider it as unnecelTary to 
 enumerate all the means that have been propofed for 
 it. In particular circumftances, thofe that I have de- 
 fcribed in the eleventh fedion of this chapter, the ma- 
 chines of Mr. Gooch, and Dr. Aitken, may prove 
 ufeful for keeping the fraftured bones extended ; and 
 much advantage may certainly be derived from them 
 in giving a fteady fupport to fraftured limbs, when it 
 is necefl'ary to move a patient from one part to anoth- 
 er : but in common pratlice, I can without hefitation 
 fay, that no advantage is derived from any infl:rument 
 of this kind that I have ever known ufed ; and few, I 
 believe, have paid more attention to this branch of 
 bufmefs than I have often had occafion to do. 
 
 1 
 
Sect. I. General Rsmarks, kc» 383 
 
 CHAPTER XL. 
 
 OF LUXATIONS. 
 
 SECTION I. 
 
 General Remarks on Lu>:atkm. 
 
 A BONE is faid to be luxated where that part of 
 it forming a joint is difplaced. When the tnd 
 of a bone is forced entirely out of its correfponding 
 cavity, the diflocation is faid to Be complete ; and we 
 term it incomplete, where any part of the bone refts 
 upon the edge of the focket. 
 
 Luxations may, with the fame propriety as frac- 
 tures, be divided into fnnple and compound. Where 
 the end of a bone is merely difplaced we term it a 
 fnnple luxation ; but where this is accompanied with 
 a correfponding wound in the foft parts, laying open 
 the cavity of a joint, we fay that the luxation is com- 
 pound. By fome praditioners the term compound is 
 applied to diflocations accompanied v/ith fractures of 
 the contiguous bones, whether the teguments be in- 
 jured or not. We fay, however, with more propriety, 
 that a luxation in fuch circumftances is of a compli- 
 cated nature. 
 
 For the moft part luxations are produced by exter- 
 nal violence, and appear as the immediate confequen- 
 ces of fome confiderable force apphed to the injured 
 parts. They are particularly apt to occur in leaping- 
 and falling ; from blows, and from violent twifls and 
 diftradlions of the diiferent bones of a limb : but they 
 are alfo produced by other caufes ; by a morbid weak- 
 nefs or relaxation of the ligaments and mufcles of a 
 joint, which fometimes occur as the confequences of 
 palfy and long continued rheumatifm j and by the end 
 
:hap. XL. j 
 
 384 General Remarks Chap. 
 
 of a bone being puflied from the cavity in which it 
 was lodged, by matter colleded in it, or by tumors 
 and exoftofes. 
 
 Diflocations produced by external violence, are 
 chiefly the objects of furgery. The fymptoms ufual- 
 ly induced by thefe, are, inability to move the injured 
 limb ; pain, tenfion, and deformity in the part aft'eft- 
 ed ; and in fome cafes inflammation, fubfultus tendi- 
 num, and fever. 
 
 In general, the motion of the limb is impaired in 
 proportion to the extent of the luxation ; but in fome 
 cafes, even the moft partial luxation renders the joint 
 perfeln:ly ftiff and immoveable, and creates the moft 
 exquifite pain on every attempt to move it. This is 
 particularly the cafe fti partial diflocations of the large 
 joints. 
 
 The deformed or altered appearance of a joint, with 
 which luxations are always accompanied, mufl: necef- 
 farily be in proportion to the extent of the injury ; 
 but this is not the cafe with the other fymptoms : for 
 fubfultus tendinum, inflammation and fever, are often 
 excited in a greater degree by partial diflocations, 
 where the ends of bones are not much moved from 
 their fituation, than where they are entirely forced 
 from their fockets, owing to a circumflance that we 
 Diall prefently endeavour to explain. 
 
 The firfl; approach of fweUing in diflocation, is al- 
 ways of the inflammatory kind, and it is a neceflary 
 eft'eft of the violence done to the injured parts. This, 
 however, fliould be difl:inguiflied from a fecondary 
 fwelling to which diflocations are liable, an extenfive 
 tumefadion that in fome cafes fpreads over all the un- 
 der part of the limb, and which feems to originate 
 from a different caufe. Infl:ead of being red, tenfe, 
 and painful, the teguments are pale, foft, and oedema- 
 tous ; owing, I fuppofe, to the lymphatic veflTels of 
 the limb being compreflfed by the end of the difplaced 
 bone. This kind of fwelling is mofl; frequent in dif- 
 locations of the femur and humerus ; in which alfo 
 
Se£l. L on Luxations. . 385 
 
 confiderable numbnefs or diminifhcd fenfibllity is apt 
 to take place from the comprelTion of the nerves of 
 the hmb. 
 
 It is of much importance to dlflingiiifh- diflocation« 
 from other affections of the joints, and to afcertain to 
 what extent the bones are moved from their fituation. 
 In compound luxations the nature of the injury is ob- 
 vious ; and, for the mod part, it is fufiiciently evident 
 where bones are completely diflocated ; but partial 
 diflocations are often not to be difcovered but by the 
 moll: minute examination : they therefore frequently 
 pafs unnoticed, or are confidered as fprains, and con- 
 tufions ; and thus, where, with due attention on the 
 part of the practitioner, a cure might frequently be 
 performed, patients are often rendered lame and mife- 
 rable for life. 
 
 The fymptoms that I have enumerated are com- 
 mon to all diflocations. In fpeaking of particular lux- 
 ations, I (hall have occafion to mention the peculiari- 
 ties of each, and I fliall endeavour to do it in fuch a 
 manner as may with moft certainty prevent thofe un* 
 fortunate occurrences to which I allude. 
 
 In forming a prognofis of the event of luxations, 
 that is, of the pradicability of their redudion, and of 
 the termination of the fymptoms with which they are 
 attended, various circumftances require attention : the 
 form and flruclure of the different joints ; the nature 
 and extent of the luxation, together with the degree 
 of violence by which it was produced, and the circum- 
 ftances with which it may be compHcated ; and, lafl- 
 ly, the duration of the injurv. 
 
 The fkeleton is commonly had recourfe to for a 
 knowledge of the joints ; but although every fludent 
 fhould be acquainted with the articulations in a dry 
 ftate, we fliould by no means reft fatisfied with this. 
 In the treatment of luxations, it is much more necef- 
 fary to have an exact knowledge of the joints in a re- 
 cent ftate ; of the cartilages, ligaments, and tendons. 
 
 Vol. III. B b 
 
385 Gene fa! Remarh Chap. XL. 
 
 with which the bones are conneded, as well as of the 
 contiguous parts in which the heads of the difplaced 
 bones may happen to be lodged : otherwife our ideas 
 of the nature of thefe injuries, and of the means that 
 will mofl: probably prove fuccefsful in the redudion 
 of difplaced bones, mud be very imperfedt. 
 
 I cannot here enter upon a minute defcription of 
 every joint, as it would lead to an extent of difcuffion 
 inconfiflent with the nature of this work. Referring 
 to the proper fources for more particular information, 
 I (hall here only obferve, that it is chiefly thofe joints 
 that are poflefled of much motion in which we meet 
 with luxations. Of thefe, there are two varieties. 
 The one termed the junction by ball and focket, where 
 the head or end of one bone is received into the cavi- 
 ty of another ; and the other termed by anatomifts 
 ginglimus, or the hinge-like joint, from its refemblance 
 to the hinge of a door. In this the joint is formed 
 by different parts of one bone being received into 
 cavities or indentations of another. The former ad- 
 mits of the moft extenfive motion, as is exemplified 
 in the joint of the humerus with the fcapula, and in 
 that of the femur with the ofla innominata ; while the 
 latter does not admit of more than that of flexion and 
 extenfion, as is the cafe in the elbow and knee. In 
 thefe we accordingly find, that this more limited mo- 
 tion to which they are confined, renders them lefs lia- 
 ble to luxations ; while the free motion of the others 
 expofes them to be frequently luxated, as is more par- 
 ticularly the cafe in the joint of the humerus, from the 
 cavity in which the head of that bone is lodged being 
 of no great depth. 
 
 Befides the ufual coverings of teguments, mufcles, 
 and tendons, in common to joints with the reft of the 
 body, every joint poflefled of much motion is provid- 
 ed with what is termed a capfular ligament ; which 
 is a firm fomewhat elaftic fubftance, forming a kind 
 of pouch or bag, that completely furrounds the ar- 
 ticulation, and ferves at the fame time to retain the 
 
Se£l. I. (/n Luxations, 387 
 
 ends of the bones together, and to contain a thin 
 tranfparent fluid, the fynovia, for the purpofe of lubri- 
 cating the cartilages that cover the ends of the bones. 
 Praftitioners are not agreed whether in luxations 
 the capfular ligaments of joints are ruptured or not. 
 As it has appeared on diifedion, in a few inftances, 
 that the ligament was ruptured, fome have concluded 
 that it is the cafe in all ; while others are of opinion, 
 that the ligament always remains entire, except where 
 the luxation has been the confequence of very fevere 
 and unufual degrees of violence. 
 
 , The refult of my obfervation on this point is, and 
 I fpeak from many opportunities of difleding difloca- 
 ted joints after death, that partial luxations may hap- 
 pen without any rupture of the capfular ligament ; 
 but that it is always ruptured in complete luxations 
 produced by external violence ; nay, that the liga- 
 ment is often torn from its infertion round the neck 
 of the bone. Where the head of a bone is gradually 
 pufhed from its focket by the flow formation of a tu- 
 mor within the joint, and where the ligament is per- 
 haps nmch relaxed by difeafe, a luxation may happen 
 without either rupture or laceration : but we cannot 
 fuppofe that fuch a firm fubftance as a ligament in a 
 ftate of health always is, will, without burfling, yield 
 to the fudden impulfe produced by the complete dif- 
 location of the head of a bone, and where the dif- 
 placed bone is in fome cafes almoft inftantaneoufly 
 forced to the diftance of feveral inches from its natur- 
 al fituation. Different inftances are upon record of 
 this opinion being fupported by the diflection of dif- 
 located joints after death ; and were it neceffary, I 
 could add feveral others that have fallen within my 
 own obfervation. 
 
 I mentioned above, that the pain attending partial 
 
 diflocations is commonly very fevere on every attempt 
 
 to move the joints. For the moft part, indeed, it is 
 
 more exquifite than it ufually is where the luxation 
 
 B B 2 
 
3^8 General Remarks Chap. XL. 
 
 is complete ; and we conclude that It proceeds from 
 the capfular ligament being overft retched, and -from 
 the ends of the difplaced bones continuing to act 
 againft it inftead of palling freely through it. 
 
 In judging of a luxation, the diftance to which the 
 head of the difplaced bone is forced, and the degree 
 of violence by which it was produced, require parti- 
 cular attention. When a bone is only partially diflo- 
 cated, although the pain may be very acute, yet the 
 redudion will be accomplilhed both with more eafe 
 and certainty than if the fame bone had been forced 
 completely out of its fituation. And where the joint 
 has not fuffered any extraordinary violence, the in- 
 flammation and other concomitant fymptoms will not 
 prove fo formidable as they commonly do where the 
 capfular ligament and other foft parts have been much 
 flretched, or otherwife feverely injured. 
 
 One of the mod unfavourable circumftances with 
 which a luxation is ever attended, is a fradlure of one 
 or both of the bones forming the joint. Even a frac- 
 ture of the difplaced bone proves always diflrefsful, 
 efpecially if it is broken near to its neck, as in this 
 cafe it can fcarcely be laid hold of for the purpofe of 
 reducing it ; but the riik attending it is much greater 
 when the bone forming the focket into which it Ihould 
 be received is alfo broken : for we know from expe- 
 rience, that fraftures of thefe parts are more apt to 
 excite fevere degrees of inflammation, as well as ex- 
 tenfive fuppurations, than fradures of any of the long 
 bones. And when the focket is broken, there is al- 
 ways much hazard of the joint being rendered fliifi" 
 for life, even when the reduction of the difplaced bone 
 is accompliflied in the eafieft manner. 
 
 A diflocation being more or lefs recent, Is the next 
 point that merits attention ; for we know that luxa- 
 ted bones are, cseteris paribus, more eafdy reduced 
 foon after being difplaced than when much time has 
 elapfed. While the injury is recent, the bone returns 
 with more eafe along the parts which it has juft tra- 
 
Se£l. I. on Luxations, 389 
 
 verfed, than it poffibly can do after lodging feveral 
 weeks or months among the contiguous mufcles ; 
 where the head of it, inftead of being loofe, as is ufu- 
 ally the cafe at firfl, forms a focket for itfelf, and is 
 commonly firmly grafped by fome of thofe mufcular 
 fibres with which it is furrounded. At this period 
 too, the cavity from whence it was diflodged may 
 probably be in fome degree filled up by the contigu- 
 ous foft parts : not that the fynovia ever becomes in- 
 fpiffated, fo as to produce this effed: ; for although 
 this has by many been fuppofed to happen, and vari- 
 ous means have been propofed for preventing and re- 
 moving it, yet we now know that the opinion is ill 
 founded. No infpiffation of this fluid has ever been 
 difcovered by difledion, although ftiff joints, where 
 this ftate of the fynovia was previoufly confidered as 
 the caufe, have often been laid open for the purpofe. 
 But although the cavity of a joint may not be filled 
 up by the efl'edl of any particular aff'edion of the fy- 
 novia, there is much reafon to fuppofe, that in courfe 
 of time it will be diminiflied by the confi:ant adion of 
 the contiguous mufcles ; which will not only force the 
 cellular fubftance, fat, and other foft parts with which 
 it is covered, into it, but may even have fome effeO: 
 in comprcfling the bone itfelf, or the cartilaginous 
 brim with which the bone is ufually covered. 
 
 Thefe are the circumflances in diflocations which 
 more particularly require attention ; but we have alfo 
 to remark, that the patient's age and general ftate of 
 health, have fome influence in the reduftion of a dif- 
 located bone. Diflocations are more eafily reduced 
 at fome ages, and in particular habits of body, than 
 in others. Thus, in advanced periods of life, and in 
 weak delicate confl:itulions, where the mufcles give 
 little refifl:ance, difplaced bones are more eafily moved 
 than in the vigour of youth, and in robufl: habits of 
 body, where the fuperior flirength of the mufcles has 
 a confiderable efled: in preventing it. 
 
390 General Remarks Chap. XL. 
 
 In the treatment of diflocations, the objeds we have 
 in view are, to put the bone that is difplaced into its 
 natural fituation, with as much eafe and expedition 
 as poflible ; to retain it in this fituation till the injur- 
 ed parts have recovered their tone ; and to obviate 
 pain, inflammation, and any other fymptom that re- 
 quires attention. 
 
 Before proceeding to the redu6lion of diflocations, 
 we fliould examine the contiguous foft parts, to fee 
 whether they are in a fit ftate for it or not ; for al- 
 though the fooner the operation is attempted, the more 
 certain will our fuccefs in general be ; yet whenever 
 the furrounding teguments and mufcles are much 
 contufed and inflamed, it is better to allow the pain 
 and fwelling to fubfide before we endeavour to re- 
 duce the bone ; at leafl: I have always been in the 
 practice of this. I never obferved that any bad con- 
 fequences enfued from it ; and I have known much 
 mifchief done by a limb being ftretched while the 
 parts furrounding a diflocated joint have been much 
 fwelled and inflamed. 
 
 In fuch circumftances, therefore, we fhould endea- 
 vour, by local bloodletting with leeches, by the ufe of 
 faturnine applications, a low regimen, and putting the 
 limb in an eafy relaxed poflure, to remove the inflam- 
 mation before any attempt is made for reducing the 
 bone. 
 
 In almofl every diflocation, one bone only is dif- 
 placed : the other bone or bones of which the joint 
 is formed remain in their natural fituation ; and it 
 will be found perhaps univerfally, that it is the bone 
 connefted vi^ith the inferior part of a limb that is forc- 
 ed from its fituation ; the bone forming the upper 
 part of the joint, if it be not fractured, being feldom 
 in any refpecl altered : in the redudion therefore of 
 luxations, the only attention to be given to the upper 
 part of a limb, is to keep it firm and fteady, while we 
 endeavour by the eafiefl and mofl effectual means to 
 replace the inferior part of it. 
 
Sed. I. on Luxations. 391 
 
 A perfon not acquainted with anatomy, might be 
 led to fuppofe that this may always be readily done ; 
 as he will be apt to conclude, that the fame degree of 
 force by which a bone is pufhed out of its place, will 
 with equal eafe replace it. This would no doubt be 
 A. the cafe, were it the bone only upon which we had to 
 * a6t, or if the bone was conneded with inorganic mat- 
 ter only that would not refift the means employed to 
 reduce it : but every joint being either partly furround- 
 ed by, or much connected with mufcles, the contrac- 
 tile power with which thefe are endowed, ads with 
 much force and advantage againft every attempt that 
 can be made for the redudion of the bone ; for they 
 not only draw it beyond the end of the contiguous 
 bone againft which it ought to be placed, but they 
 often pull it out of its natural diredion, and fix it 
 firmly in fome neighbouring cavity, from whence it 
 is diflodged with difficulty ; while the ftimulus create 
 ed by every trial that is made for replacing the bone, 
 is apt to excite a further exertion of the mufcles, and 
 to increafe the difficulty of the redudion. 
 
 It is therefore obvious, that in the redudion of eve* 
 ry diflocated bone, the mufcles with which it is con- 
 neded (hould be put as much as poffible into a ftate 
 of relaxation ; for in this fituation, the refiftance 
 which they give to the force employed for moving the 
 bone is inconfiderable, when compared with what is 
 required for the fame purpofe, when they are kept in 
 a ftate of extenfion. In the one, it is ufually done 
 with eafe, both to the patient and furgeon ; while in 
 the other, that is, while a limb is much ftretched or 
 extended, it is with the utmoft difficulty that a diflo- 
 cated bone can be moved. 
 
 By relaxing all the mufcles of a limb, we may in 
 general obtain a fufficient force for reducing a luxa- 
 tion merely by the hands of affiftants ; but in fome 
 inftances more force is required than can be appHed 
 in this manner : in this cafe, various inftruments have 
 been propofed foi- increafmg our powers of exten- 
 
392 General Remarks Chap, XL. 
 
 / 
 
 fion ; feme of which, and perhaps the moft ufeful, 
 are dehneateJ iii Plates LXXXVII. LXXXVIII. and 
 LXXXIX. 
 
 But whether we find It neceflary to ufe machines of 
 this kind or not, no more force fliould be ever em- 
 ployed than is juft requifite; and it ought always to 
 be applied in a flow gradual way, by which there is 
 much lefs rifk of any harm being done, than when the 
 mufcles of a limb are forcibly and fuddenly ftretched ; 
 and it will alfo be underftood, that the whole force 
 ufed lor the reduction of a diflocated bone, fhould be 
 applied to that bone only, and not to any other part 
 of the limb. 
 
 Befides the refiftance arifing from the aftion of the 
 mufcles, we fometimes meet with much difficulty from 
 the projecling end of a diflocated bone having palled 
 that of a contiguous bone. In this cafe the extenfion 
 is to be made in fuch a direction as will bell obviate 
 this relative fituation of the parts. 
 
 In extending a limb for the purpofe of reducing diflo- 
 cations, the extenfion fhould be carried fo far as to 
 diflodge the difplaced bone, and to bring the end of it 
 on a line with the end of the other to which it is to 
 be oppofed, otherv/ife no advantage v. ill be gained by 
 the operation ; for while any part of one bone projects 
 pad the extremity of the other, no means that we can 
 employ will be able to replace it, unlefs fuch a force 
 is made ufe of, (as has fometimes happened,) as is fuf- 
 ficient for breaking off the projecling part of the bone ; 
 ■while, on the contrary, the redudion is always accom- 
 pliflied in the eafiefl manner, as foon as the difplaced 
 bone is drawn freely pad all the projefting parts of 
 the other ; nay, when the end of a difplaced bone is 
 brought to this fituation, it would be difficult to pre- 
 vent it from paffi^ng inilantaneoufly into its natural 
 fituation ; fo that in the reduction of diflocations, our 
 chief object is to make a fufficient degree of extenfion, 
 when the ordinary action of the mufcles will for the 
 
Seft. r. on Luxations, 393 
 
 mofl; part replace the bone : or when this fails, the 
 nK)fl gentle preiTure will prove fufficient. 
 
 The diflocated bone being reduced, it feldom proves 
 difficult to retain it in its fituation, unlefs it has often 
 been difplaced before : the furefl means of retaining 
 it, is to put the limb into a relaxed pofture, and to 
 fupport the bone that has been jufl replaced with a 
 proper bandage, till the furrounding foft parts have re- 
 covered their natural tone. 
 
 The fymptoms that prove mofl: urgent in difloca- 
 tions, both iDcfore and after the bones have been re- 
 duced, are, pain, inflammation, and fwelling. For the 
 mofl: part thefe fymptoms abate foon after the reduc- 
 tion ; but while any degree of inflammation contin- 
 ues, repeated applications of leeches Ihould be advifed 
 as the mofl: eflcdual remedy : and as this fymptom is 
 to be confidered as the caufe of all the others, as well 
 as of thofe chronic pains to which joints are liable, 
 that have ever been diflocated, it therefore merits par- 
 ticular attention. But this fubjeft having already been 
 fully confidered, when treating of contufions, I mufl; 
 now refer to what was then faid upon it in Chapter 
 II. Seaion IT. 
 
 In the firft part of this fe£tion, I have faid that lux- 
 ations are fometimes combined with fractures of the 
 difplaced bones. When a bone is fradured at a con- 
 fiderable diftance from the luxated joint, we may for 
 the mofl: part be able to reduce the luxation immedi- 
 ately ; and this being done, the fracture fliould be 
 treated in the ufual way : but when a bone is fractur- 
 ed fo near to the luxated joint that it cannot be laid 
 hold of, the cafe is thereby rendered both difficult and 
 uncertain. In the fmaller joints, as in thofe of the 
 fingers and toes, the difplaced portion of bone may in 
 fome inftances be puflied into its fituation ; but in all 
 the larger joints, particularly in the hip joint, and in 
 that of the flioulder, we mufl: firfl: allow the fracture 
 to heal, and the union of the fradured bones to be 
 
Of Luxations of the 
 
 Chap. XL. 
 
 perfe£lly firm, before we can exped to reduce the lux- 
 ation. 
 
 In compound luxations, that is, where joints arc 
 not only luxated but laid open by external injuries, 
 the treatment that I have advifed in compound frac- 
 tures applies with equal propriety : almoft all the ob- 
 fervations indeed that were made upon the one will 
 apply with nearly equal force to the other : fo that at 
 prefent I fliall refer to Section XV. of the laft Chap- 
 ter where the fubjeft was fully confidered. 
 
 I may juil Ihortly obferve, that after the luxated 
 bones are replaced, and the limb laid in a proper pof- 
 ture, our next obje6: is to prevent inflammation : this 
 we do with moft certainty by copious bloodletting, 
 with leeches applied near to the injured parts ; dreff- 
 ing the fores with faturnine cerate, or any mild oint- 
 ment ; moderating the pain with adequate dofes of 
 opiates ; and a low regimen. 
 
 This being done, we have to endeavour to prevent 
 the m.atter of the fore from lodging about the joint, 
 by placing the limb in fuch a manner that it may moft 
 readily run off : if this fails, we fometimes fucceed by 
 dreffing the fore more frequently, and abforbing the 
 matter with a bit of fponge ; or, when the quantity of 
 matter is confiderable, by a counter opening made in 
 a more depending part of the limb. 
 
 When mortification takes place, it is to be treated 
 in the manner I have advifed in Chap. I. Se£l. IV. 
 
 All that I have hitherto faid, relates in general to 
 luxations produced by external violence. When they 
 proceed from the heads of bones being pufhed from 
 their fockets, either by tumors of a flefhy or offeous 
 nature, or by collections of matter, they may almoft 
 in every in fiance be confidered as incurable : when 
 the joint is fo fituated that the difeafed parts can all 
 be removed, this meafure fhould be advifed ; but 
 when this cannot be completely accompliflied, all that 
 art fhould attempt is, to give as free a difcharge as 
 
Sect. II. Bones of the Cranium. 395 
 
 poffible to any matter that may form, and to fupport 
 the conflitution with fuch a diet, as may prevent it 
 from being too much reduced by the difcharge. 
 
 Diflocations are fometimes the confequence of re- 
 laxation of the ligaments and tendons by which the 
 bones in a healthy ftate are kept together. This re- 
 laxation is feldoni fo completely removed as t(^ pre- 
 vent the bones from falling out from time to time ; 
 but the inconveniency may in fome meafure be obvi- 
 ated by fupporting the limb with a bandage ; by en- 
 deavouring to reftore the tone of the relaxed parts by 
 cold bathing ; and, in fome inftances, electricity has 
 appeared to prove ufeful. 
 
 We fliall now proceed to fpeak of diflocations from 
 external violence as they occur in particular parts. 
 
 SECTION 11. 
 
 Of Luxations of the Bones of the Crajiium. 
 
 THE bones of the cranium are frequently feparat- 
 ed from each other at the futures in hydroce- 
 phalus internus. This, however, can feldom become 
 an obje£t of furgery. If fuch colledions (hall ever 
 be removed by medicine, all that art can do further is 
 to fupport the parts with a bandage. 
 
 We alfo find that openings are in fome inftances 
 produced at the futures by external violence, particu- 
 larly by falls from heights. This, however, very com- 
 monly proves fatal. I have only met with one in- 
 ftance of a patient under fuch circumftances recover- 
 ing. All that in this fituation can with propriety be 
 done, is to fupport the parts by gentle preiTure with a 
 proper bandage ; to prefcribe bloodletting and other 
 evacuations according to the violence of the fymptoms ; 
 and to keep the patient quiet, and under proper con- 
 finement during the cure. 
 
39^ Of Luxaiicns cfihs Chap. XL. 
 
 SECTION m. 
 
 Of Luxntions of the Bones of the Nofe. 
 
 ' I iJiE bones of the nofe are fo firmly united, and 
 X ferve fo effectually to fuppoit each other, that 
 they are not often diflocated. 
 
 Thefe bones being thinly covered with foft parts, 
 luxations in any part of the nofe are eafily difcovered 
 by the touch, as well as by the deformity which they 
 produce. 
 
 In the reduction of luxations of thefe bones, the pa- 
 tient fhould be feated oppofite to a proper light, with 
 an affiftant behind fupporting his head ; and the fur- 
 geon (landing before, fliould endeavour to replace the 
 bones with as much accuracy as poffible. In general, 
 this may be done v/ith the fingers alone ; but when 
 one of the bones is puflied inwards, we do it more 
 eafily by pufhing one of the tubes in Plate XXVI. fig, 
 3. up the correfponding noffcril, in order to elevate the 
 depreffed piece ; and if the tube is guarded with fome 
 plies of foft lint, it may be retained m its fituation till 
 there is no longer any rilk of the bone flipping out. 
 
 When either of the bones of the nofe is puflied out- 
 wards, it mufl: firfl: be exaftly replaced, and afterwards 
 retained in its fituation by a proper application of a 
 double headed roller. 
 
 SECTION IV. 
 
 Of Luxations of the Lower Jaw. 
 
 THE lower jaw is conneded by a very beautiful 
 mechanifm with the bones of the head. In each 
 temporal bone there is an irregular oblong cavity, im- 
 
Sed IV. Lozi'er Jaw, 397 
 
 mediately before the external meatus auditorlus. In 
 thefe cavities, the two condyles of the lower jaw are 
 lodged ; and by means of two intermediate loofe car- 
 tilages which move along with the condyles, and w^hich 
 correfpond with the irregular furfaces of the cavities 
 in which they are placed, luch a degree of hrmnefs is 
 given to this joint as would otherwife be inconfiflent 
 with the freedom of motion of which it is pofleifed ; 
 for although the condyles of the jaw arc fecured in 
 their fituation, by different ligaments, as well as by 
 ftrong mufcles, particularly by the ftrong tendons of 
 the temporal mufcles inferted into the coronoid pro- 
 celTes of the jaw ; yet the variety of motions which 
 the under jaw is conftantly performing, would render 
 it very liable to diflocations, were it not for the inter- 
 vention of thefe moveable cartilages ; which admit of 
 every neceffary freedom, while fuch a loofe, extenfive 
 motion is prevented, as muft have happened if the 
 heads of the condyles had been placed in large fmooth 
 cavities without thefe cartilages between them. 
 
 The under jaw cannot be diilocated either upwards, 
 backwards, or laterally : it can only be diflocated for- 
 ward and downward. In every other diredlion, the 
 condyles are fo much furrounded with bone, that they 
 cannot be forced out of their correfponding cavities, 
 as will be readily feen on an examination of the flvcle- 
 ton : but when the mouth is widely opened, as hap- 
 pens in yawning, the condyles are apt to flip too far 
 over the anterior boundaries of thefe cavities. In this 
 manner a diilocation takes place, as we difcover by the 
 chin being thrown forward and dov^nward, while the 
 mouth remains open, at the fame time that much pain 
 is produced by every attempt to clofe it ; nor can the 
 patient fpeak diftiiidly, or fwallow but with much dif- 
 ficulty. 
 
 In fome cafes, one fide only of the jaw is diflocated, 
 that is, one of the condyles remains nearly in its nat- 
 ural fituation, while the other is thrown entirely out* 
 
39^ Of Luxations of the Chap. XL» 
 
 In this cafe, the jaw, inftead of falling direQly down, 
 is pufhed obliquely downwards, and fomewhat to- 
 wards the fide oppofite to that in which it is difloca- 
 ted. 
 
 Befides the fymptoms that I have mentioned of pain 
 on any attempt to clofe the mouth, and difficulty in 
 fpeaking and fwallowing, we are told by all the older 
 writers on this fubjed, and by all who have copied 
 from them, that luxations of the jaw are apt to induce 
 convulfions, and even death. I have never, however, 
 met with an inftance of this, nor is it probable that it 
 will ever happen, unlefs from great mifmanagement 
 on the part of the furgeon. 
 
 A luxation of the jaw being very diftrefsful, and 
 even alarming to thofe who are not acquainted with 
 its nature, immediate affiftance is commonly defired ; 
 and with due attention vi^e can feldom fail to reduce it. 
 
 The patient being firmly feated on a low chair, with 
 his head properly fupported behind, the furgeon (land- 
 ing before, with his thumbs fufficiently guarded, (hould 
 pufh them as far as they will go between the teeth of 
 the upper and under jaws, the under or flat part of 
 the thumbs being applied to the furface of the teeth 
 of the under jaw : the palm of each hand fhould be 
 applied to the outfide, while with his fingers he lays 
 a firm hold of the angles of each jaw. With the fin- 
 gers applied in this manner, he fhould pull the under 
 jaw forward till he finds it move fomewhat from its 
 fituation : and this being done, but not till then, he 
 fliould prefs the jaw forcibly down with his thumbs, 
 and moderately backwards with the palms of his hands ; 
 when, if the difl'erent parts of the operation are right- 
 ly managed, the ends of the bone will immediately flip 
 into their fituation ; upon which the thumbs fhould 
 be inflantly withdrawn. 
 
 In general, we are direfted to prefs the jaw down- 
 wards and backwards : but although this might fuc- 
 ceed in fome inflances where the jaw is diflocated on- 
 
Sed. IV. Lower Jaw. 399 
 
 ly on one fide, yet even there It would often fail ; and 
 it would feldom anfwer when both condyles are out : 
 for, till the condyles are quite difengaged from the 
 bones on which they reft, and which they can only be 
 by puHing the jaw forward, all the force we could em- 
 ploy in pulling them down would be of little avail, as 
 I have often had occafion to obferve. 
 
 I have defired, in prefilng down the jaw, that at the 
 fame time it fhould be prefl'ed moderately backwards : 
 the flighteft force, however, in this diretlion is fuffi- 
 cient ; nay, in fume cafes it is not necefl'ary ; for as 
 foon as the condyles are fufficiently deprefled, they are 
 almoft inflantaneoufly drawn into their natural fitua- 
 tions by the ordinary adion of the temporal mufcles, 
 whether any force be applied for this purpofe or not. 
 
 The treatment that 1 have advifed anfv/ers equally 
 well, whether the jaw be luxated on one fide, or on 
 both ; but where one condyle only is thrown out, the 
 force ufed for deprefllng the jaw fliould be chiefly ap- 
 plied to that fide. 
 
 The luxated jaw being reduced, the patient fhould 
 be advifed to avoid every caufe that might have any 
 efl'ed: in throwing out the bone again ; particularly 
 much fpealdng, gaping, and yawning, as the condyles 
 are apt for a confidcrable time to be turned out by 
 any of thefe aftions. 
 
 In the reduftion of a diflocated jaw, the thumbs are 
 very apt to be bit if they be not well protected, or if 
 they be not inftantly withdrawn on the bones flipping 
 into their fituation. For the moft part, the end of a 
 handkerchief is wrapped round them ; but a covering 
 of firm leather anfwers better, or a cafe of thin iron 
 covered with leather, would be ftill preferable, as it 
 would not occupy fo much fpace. It would pafs far- 
 ther into the mouth, and would thus act with more 
 advantage in forcing down the jaw. 
 
400 Of Luxations Chap. XL. 
 
 SECTION V. 
 
 Of Liixatiojis of the Head* 
 
 THE head is connecled in fuch a manner with thtf 
 atlas or firfl vertebra of the neck, that it moves 
 upon it with eafe and freedom backwards and forwards, 
 the two condyles of the os occipitis being received in- 
 to correfponding cavities in the fuperior oblique pro- 
 cefles of that bone : but the lateral and rotatory mo- 
 tion of the head proceeds from the immediate connec- 
 tion between it and the fecond vertebra of the neck, 
 by means of the proceffus dentatus of that bone ; 
 which palling through the back part of the large cav- 
 ity of the atlas, is fixed, by means of different liga- 
 ments, to the OS occipitis. 
 
 The connection between the head and the firfl of 
 thefe bones is fo firm, that they are not perhaps ever 
 feparated by accident ; at leaft, I have not heard of 
 any inftance of this being difcovered on diffe^ion. It 
 rather appears, that, in luxations of the head, the con- 
 nection is deftroyed between the head and the fecond 
 vertebra, the head being forced with fuch violence for- 
 ward as to -ftretch or rupture the ligaments by which 
 the tooth like procefs of this bone is fixed to the oc- 
 ciput : at leaft, this has been found to be the cafe in 
 different inftances of thefe dillocations, and it alfo hap- 
 pens in thofe who die by hanging. 
 
 In every diflocation of the head, the head falls for- 
 ward upon the breaft ; the patient is inftantly depriv- 
 ed of fenfibillty ; he lies as if he were dead ; and he 
 foon dies if the luxation be not quickly reduced. In- 
 juries of this kind are produced molt frequently by 
 falls from great heights, or from horfeback. 
 
 Luxations of the head, for the moft part, terminate 
 fatally ; but as inftances have occurred where this has 
 been prevented when timous affiftance has been given, 
 
Sed. VI. of the Spine, Os Sacrum, &c. 401 
 
 we have reafon to think, that recoveries would be 
 more frequent if this could be always procured. 
 
 Different means have been propofed for the reduc- 
 tion of thefe luxations ; but whatever requires much 
 preparation is here inadmiflible. In all fuch cafes, 
 our views muft be inftantly carried mto effeft ; and 
 it fortunately happens, that in perhaps every inftance 
 they may be accomplilhed without any preparation. 
 
 The patient being feated on the ground, and fup- 
 ported by an affiftant, the furgeon (landing behind, 
 fhould raife the head from the breafl ; and the aflift- 
 ant being defircd to prefs down the (boulders, the head 
 (liould be gradually pulled ftraight up till the difloca- 
 tion is reduced ; or, if this does not happen with mod- 
 erate extenfion, it may, at the fame time, be gently 
 moved from fide to fide. A fudden noife or crack is 
 heard on the redudion taking place ; and if the pa^- 
 tient be not entirely dead, an immediate and perhaps 
 entire recovery of all his faculties enfues. In fome 
 cafes they have been completely reftored on the head 
 being replaced ; but in others they have remained long 
 impaired, and in fome have always continued fo. 
 
 The redudlion being accomplilhed, the patient 
 fhould be immediately laid in bed. His head (hould 
 be kept elevated, and retained by a proper bandage 
 for a confiderable time in one pofture ; and with a 
 view to prevent inflammation, bloodletting (hould be 
 prefcribed in fuch quantities as his ftrength will bear ; 
 his bowels (hould be opened with proper laxatives j 
 and he (hould be confined to a low regimen. 
 
 SECTION VI. 
 
 Of Luxations of the Spine, Os Sacrum, and Os Coccyx, 
 
 THE vertebrae, or bones of which the fpine is com- 
 pofed, are fo intimately connected, by the pro- 
 cefs ot one bone running into correfponding parts of 
 Vol. III. C c 
 
403 Of Luxations of ihi Chap. XL«, 
 
 another, as well as by flrong ligaments and mufcles, 
 that they are feldom diflocated. They are fo firmly 
 united indeed, that I do not fuppofe that any of them 
 can be diflocated by external violence without being 
 fractured. Befides the means of connection that I 
 have mentioned, the vertebras of the back are much 
 ftrengthened by the fupport which they receive frbm 
 the ribs. 
 
 I never met with a complete diflocation of any of 
 the vertebra ; nor do I fuppofe that it ever happens, 
 even when accompanied with a fradlure, but with im- 
 mediate death : for the force neceifary to move one of 
 the vertebrae from its fituation, muft not only be at- 
 tended with the compreffion, but even with the lacer- 
 ation of the fpinal marrow, while the contents of the 
 thorax or abdomen mufl in a very eflential manner 
 be hurt by it. I do not fuppofe, therefore, that a 
 complete diflocation of any of thefe bones can ever be- 
 come an objeft of furgery. 
 
 We know, however, that one or more of the ver- 
 tebrae may be partially diflocated, and that the patient 
 may furvive. In fome cafes, perhaps, a complete cure 
 may be obtained ; but I believe that it does not fre- 
 quently happen. 
 
 Thefe luxations are ufually produced by falls from 
 great heights ; by violent blows j or by heavy weights 
 pafling over the body. 
 
 They are diftinguifhed, by the body being diftorted, 
 by examination with the fingers, and by the fymptoms 
 which they induce ; which are fuch as ufually occur 
 from compreflion of the fpinal marrow ; particularly 
 a paralyfis of all that part of the body lying beneath 
 the injured part, and either a total fuppreflion of 
 urine, or an involuntary pafling of both urine and 
 faeces. 
 
 There Is reafon to fuppofe, from the niechanifm of 
 the parts, that the vertebrae will feldom or never be 
 diflocated outwards : they are ufually forced direclly 
 forward, or in fome degree to the right or left. On 
 
Se6i:. VL Spine, Os Sacrum, &c. 403 
 
 this account they are extremely difficult to reduce, as 
 the contents of the thorax or abdomen muft always 
 lie between the injured parts and the means that are 
 ufcd for this purpofe. 
 
 Various means have been propofed, and different 
 machines invented, for the redudion of diflocated ver- 
 tebrae. Thefe machines, however, fliould be laid afide, 
 as being not only ufelefs, but dangerous ; for whoev- 
 er has paid attention to the anatomy of the fpine, will 
 fee, that in diflocations of the vertebrae, fcarcely any 
 advantage is to be gained from the application of much 
 force, while much mifchief may evidently enfue from 
 it. 
 
 When one or more of the vertebrae are luxated for- 
 ward, of which we can only judge by an accurate ex- 
 amination with the fingers, the mofl certain method, 
 perhaps, of reducing the difplaced bones is, to bend 
 the body flowly and gradually forward, as far as it can 
 be done, over a calk, or any other cylindrical fubftance 
 of a fufficient fize. If the bone by this pofition re- 
 gains its fituation, the body fhould be immediately 
 raifed ; while the attempt may be repeated when it 
 does not fucceed at firft. 
 
 When the difplaced bone is pufhed much out of its 
 natural fituation, neither this nor any other method 
 will probably fucceed ; but it has certainly done fo in. 
 different inftances of partial diflocations. In bending 
 the body forward, the two vertebras lying contiguous 
 to the one that is puflied forw^ard are fomewhat farther 
 feparated from each other ; by which, the difplaced 
 bone may, either by the compreffion produced upon 
 the abdomen, or by the ordinary adion of the contig- 
 uous mufcles, be forced into the fituation that it form- 
 erly occupied. 
 
 When the diflocated bone, inftead of being puflied 
 
 flraight forward, is forced in any degree to one fide, 
 
 the body while the redudion is attempting, fliould not 
 
 only be bent forward, but fomewhat towards the af- 
 
 c c 2 
 
404 Of Liisailcns Chap. XL# 
 
 feded fide ; by which, the two contiguous vertebrce 
 will be feparated to a greater diftance than they pofli- 
 bly could be by bending it either diredly forward or 
 towards the oppofite fide. 
 
 When any part of the os facrum is luxated, all that 
 can be done is to replace it with as much exaflnefs as 
 poffible by external preifure, and by bending the body 
 forward in the manner I have mentioned. 
 
 The coccyx is more frequently luxated than any 
 of thefe bones, as it is equally liable to the fame kinds 
 of injuries, befides being more expofed to the effects 
 of falls, and to be injured in delivery. 
 
 This bone may be luxated either outwardly or in- 
 wardly. It is apt to be forced outwards in laborious 
 births when much violence is ufed in pulling down 
 the head of a child ; and it has alfo been clifplaced by 
 large colledtions of hard f^aeces in the reclum. We 
 judge of this having happened, from the pain which 
 takes place all over the region of the loins, particular- 
 ly about the junftion of the os coccyx with the facrum ; 
 and from the difplaced bone being difcovered upon 
 examination with the fingers. 
 
 When the coccyx is luxated inwardly either by falls 
 or blows, the patient complains of much pain, and of 
 the fenfation of a tumor or fome other hard body com- 
 preffing the under part of the rectum ; he is hable to 
 tenefmus ; he finds it difficult to pafs his fseces ; and 
 in fome inflances, a fuppreflion of urine takes place. 
 On the finger being introduced at the anus, the dif- 
 placed portion of bone is readily difcovered. 
 
 In outward luxations of the coccyx, we feldom find 
 it difficult to replace the bone by external preffure with 
 the fingers ; but it is often difficult to retain it in its 
 fituation. It can only be done by fupporting the parts 
 with proper comprelfes and bandages, for which pur- 
 pofe the T bandage anfwers better than any other. 
 
 In the redu6lion of an internal diflocation of this 
 bone, the forefinger -of one hand, after being immerf* 
 ed in oil, Ihould be paffed as far as poflible up the rec- 
 
Se£l. VII. of the Clavicks, 405 
 
 turn. By means of it the bone fhould be prefled into 
 its fituation ; while with the other hand we fupport 
 the parts outwardly that correfpond with it. 
 
 As diflocations of thefe bones, particularly of the 
 coccyx, are very apt to excite inflammation^ and as 
 this often terminates in abfceffes that do not readily 
 heal, we fliould omit nothing that may probably tend 
 to prevent it. Bloodletting fliould be prefcribed in 
 proportion to the ftrength of the patient, particularly 
 local bloodletting with leeches, or cupping and fcari- 
 fying ; a lax flate of the bowels fhould be preferved ; 
 and the patient fliould be confined to that poflure in 
 which he is eafiefl, and to a low regimen. 
 
 SECTION VIL 
 Of Luxatio7is of the Clavicles, 
 
 THE- clavicles are joined to the fcapula at the ac- 
 romion, where they give confiderable fupport to 
 the joint of the flioulder ; and their interior ends are 
 fupported by the upper part of the ftemum. 
 
 As the clavicles are not pofTeffed of much flrength, 
 and being tied at their articulations to the contiguous 
 bones by ligaments, they are more expofed to frac- 
 tures than to luxations. In fome cafes, however, they 
 are luxated. This may happen at either extremity of 
 thefe bones, but it is more frequent at their jundion 
 with the flernum than at the acromion ; for the force 
 by which luxations of the clavicles are produced, is 
 for the mofl part applied to the fhoulders, by which 
 their oppofite ends are mofl apt to be pufhed out. 
 
 As the clavicles are thinly covered, luxations of ei-* 
 ther of their extremities are eafily difcovered : they 
 commonly produce a good deal of flifihefs and immo- 
 bility in the correfponding joint of the flioulder j for 
 the neck of the fcapula having lofl its fupport, it is apt 
 
4o6 Of Lnxatiom Chap. XL, 
 
 to be drawn out of its fituation ; by which the motion 
 of every mufcle connected with the joint is necefl'arily 
 affected. 
 
 A diflocation of the clavicle is eafily reduced by 
 moderate prelfure with the fingers, efpecially if the 
 arms and fliouldcrs are at the fame time drawn back ; 
 by which the fpace which the clavicle Ihould occupy 
 may be fomewhat lengthened. It is more difficult, 
 however, to retain the bone in its fituation, as it is apt 
 to be again difplaced on the preffure being removed, 
 by the ordinary action of the flexor mufcles of the 
 arm. 
 
 We derive little advantage here from fupporting the 
 arm. On the contrary, when the end of the clavicle 
 connected with the fternum is difplaced, raifmg the 
 arm does harm, as it tends to pufh the bone farther 
 out of its place. It is, therefore, highly necefi'ary to 
 attend to this difference between the management of 
 fra£tures and luxations of this bone. In the latter, an 
 elevated pofture of the arm does mifchief : in the form- 
 er, it proves ufeful, as I have fhewn in Chapter 
 XXXIX. Seaion V. 
 
 The weight of the fore-arm ought however to be 
 moderately fupported to prevent the flioulder from 
 being too much drawn down. Befides this, the head 
 and ftioulders fhould be fupported, and a moderate 
 preffure made upon the difplaced end of the bone. 
 Various bandages have been propofed for this, partic- 
 ularly the long roller applied in fuch a manner as to 
 form the figure of 8 upon the fhoulders and upper 
 part of the breaft. No advantage, hov/ever, iS gained 
 from this, as the bandage cannot be retained fo firm-^ 
 ly in its fituation as to have any effedt without imped- 
 ing refpiration. The machine reprefented in Plate 
 CI. fig. I. nearly the fame as is commonly ufed for 
 fupporting the head, anfwers the purpofe better than 
 any other ; for while it neceffarily raifes the head and 
 keeps the fhoulders back, the flraps that pafs over the 
 upper part of the breafl may be made to a6t with fome 
 
Sea. VIII. of the Ribs. 407 
 
 force upon the diflocated end of the bone. It is fcarce- 
 ly necelTary to obferve, that the ufe of this machine 
 rfiould be continued for a confiderable time, otherwife 
 the bone is apt to ftart, when the whole is to do over 
 again. 
 
 SECTION VIII. 
 Of Luxations of the Ribs, 
 
 BY many it has been fuppofed that the ribs cannot 
 be diflocated ; and accordingly this variety of 
 luxation has pafled unnoticed by different writers on 
 this branch of furgery. It is only at the articulation 
 of th^ribs with the vertebrae that luxations can hap- 
 pen ; and being conneded with thefe bones by ftrong 
 ligaments, they more frequently break than yield at 
 the joints. 
 
 It will readily, however, appear, by accurate exami- 
 nation of the jundion of the ribs with the vertebras, 
 that they may be diflocated inwards. They cannot 
 indeed be pufhed either upwards, downwards, or back- 
 wards ; but we know from experience, that a ftrong 
 force applied near to their articulations, will rupture 
 their conneding ligaments, and thus pufli them for- 
 ward ; for the fad has been proved by diflfedion after 
 death. 
 
 The fymptoms induced by diflocations will be near- 
 ly the fame with thofe that enfue from fradures of 
 the ribs, namely, pain in the injured part, with diffi- 
 cult refpiration ; and if the end of the bone is puflied 
 into the fubftance of the lungs, emphyfematous fvvell- 
 ings may enfue from it. A diflocation, however, may 
 be diftinguiflied from a fradure, by the pain being 
 mofl: fevere at the articulation, and by no part of the 
 bone yielding to prefl'ure excepting at this very fpot. 
 
4o8 Of Lvxatiom^ &c. Chap. XL. 
 
 I believe It will commonly happen, that the end of 
 a luxated rib, in confequence of its elaflicit)^, wiil re- 
 turn to its natural fituation when the caufe by which 
 the luxation was produced is removed ; but when it 
 does not, the bed method of reducing it will be to 
 bend the body forward over a cafli or other cylindri- 
 cal body, while the vertebrae immediately above and 
 below the rib are prefled inward with as much force 
 as can with fafety be applied to them. After this, a 
 thick comprefs of linen fliould be laid over thefe ver- 
 tebras, and another long one along the moft promi- 
 nent part of the diflocated rib and the two ribs imme- 
 diately contiguous J when, by means of a long broad 
 l*oller paffed two or three times round the body, fo 
 much prefTure may be made upon the vertebree as will 
 retain them in their fituation ; while the prelfure made 
 upon the projecting part of the rib tends to ke^ the 
 end of It in its fituation till the ligaments that were 
 ruptured are again united. 
 
 No bandage fhould be applied with fuch tightnefs 
 as to impede the breathing. The beft method of pre- 
 venting the roller from moving, is by the fcapulary 
 bandage paifed over the fhoulder, and a ftrap con- 
 ne£ted with it behind, carried behind the thighs and 
 fixed to it before. 
 
 No diilocation Is more apt to Induce Inflammation 
 of the contiguous parts, and other difagreeable fymp- 
 toms ; for the prevention and removal of which, noth- 
 ing anfwers fo well as copious bloodletting, preferving 
 the patient cool, and at perfect reft, a low diet, gentle 
 laxatives, and opiates if a cough enfues and becomes 
 troublefome. 
 
Secb. IX. Of Dlflocaiions^ &c. 409 
 
 SECTION IX. 
 
 Of Diflocations of the Humerus at the Joint of the 
 Shoulder. 
 
 THE joint of the fhoulder is formed by what is 
 ufually termed a ball and focket, the round head 
 of the OS humeri being lodijjed in a cavity on the an- 
 terior part of the fcapula. This cavity, however, is fo 
 fuperficial, that in the ikeleton it does not appear to 
 contain above a tenth part of the head of the hume- 
 rus J but in the recent fubject it is much more con- 
 fiderable, by means of a cartilaginous brim ; and a 
 capfular ligament furrounds the whole joint. By this 
 mechanifm, the flioulder enjoys more free motion than 
 other joints ; but by this it is alfo expofed to more 
 frequent luxations ; infomuch, that we meet with 
 more diflocations of the flioulder than of all the other 
 joints of the body. 
 
 The OS humeri is mofi: frequently luxated down- 
 wards dlredly into the axilla, owing to the head of 
 the bone meeting with lefs refiftance in falling into 
 tliis fituation than in any other direction. The head 
 of the bone is fometimes pufhed downwards and for- 
 vard, and lodged beneath the peroral mufcle, when 
 we find it refling on the ribs between the coracoid 
 procefs of the fcapula and the middle of the corre- 
 sponding clavicle. In a few cafes it is diflocated down- 
 wards and backwards : but it can never be luxated 
 upwards without being accompanied with a frafture 
 of the acromion j of the coracoid procefs ; or perhaps 
 of both. 
 
 The head of the bone, as I have already obfen'ed, 
 takes for the mod part that direction in which it meets 
 with the leaft refiftance ; but this alfo depends in feme 
 degree on other caufes, particularly on the part of the 
 joint which received the injury, and on the fituation 
 
41 o Of Dijlocatiom of the Chap, XL. 
 
 of the humerus at the time. Thus, if a blow falls 
 upon the upper part of the joint, while the arm is in 
 a direft line with the body, any diflocation that takes 
 place will be downwards ; while the head of the bone 
 will moft probably be forced downward and inward 
 by any ftroke given to the outfide of the joint while 
 the elbow is flretched back, and vice versa. 
 
 We judge that the humerus is difplaced by the pa- 
 tient being unable to move the arm ; by pain being 
 excited on every attempt to prefs the arm near to the 
 fide ; by the arm being of a different length from the 
 other ; from its being longer or fliorter according as 
 the head of the bone is lower or higher than its nat- 
 ural fituation in the acetebulum ifcapulae ; by the 
 head of the bone being felt either in the armpit, be- 
 neath the perioral mufcle, or backwards below the 
 ridge of the fcapula ; and by a vacancy being difcov- 
 ered beneath the acromion. If the two fhoulders are 
 examined together, which fhould always be done, the 
 found joint will be found round and prominent, while 
 the forepart of the other, if much tumefadion has not 
 taken place, will appear to be fiat, or even fomewhat 
 hollow. This difference in appearance between the 
 two joints appears moft obviouily on viewing them 
 both from above downwards. 
 
 In luxations of long duration, the whole arm is apt 
 to become oedematous, and to be in fome degree de- 
 prived of fenfibility, from the preffure produced upon 
 the nerves and lymphatic veffels of the arm by the 
 head of the bone. All the other appearances I have 
 mentioned, are likewife fo obvioufly induced by the 
 difplacement of the head of the humerus, that fcarcely 
 any of them require to be explained. The head of 
 the bone being thrown out of its natural fituation, 
 muff neceffarily affocl the aftion of every mufcle of 
 the joint : fome will be too much relaxed, while oth- 
 ers are overftretched : the motion of the joint mufl 
 of courfe be confiderably impaired. It is obvious too, 
 that much pain muft be excited by the arm being 
 
Seel. IX. Joint of the Shoulder. 41 1 
 
 prefled down to the fide, as the head of the bone will 
 not only be forcibly rubbed againft fome part of the 
 fcapula, but the foft parts on which it refts muft be 
 greatly compreffed, at the fame time that fome of the 
 contiguous mufcles will be ftretched to a degree 
 which they cannot eafily bear. 
 
 In a fimple diflocation of the humerus, our prog- 
 nofis fhould in general be favourable ; for in recent 
 cafes we feldom fail in the reduction of the bone. In- 
 ftances not unfrequently however occur, in which the 
 operation is difficult ; but this is feldom the cafe where 
 it has been properly conduced from the firfl. In dif- 
 locations, indeed, of long continuance, the mofl ex- 
 pert praditioners often fail ; for in fuch cafes, the 
 head of the bone has often formed a focket among 
 the contiguous parts, from whence it cannot be dii- 
 lodged without tearing afunder fome of the mufcles 
 with which it is furrounded ; and when diflodged, 
 our endeavours may be rendered abortive, by the ca- 
 vity in which the bone (hould be lodged being dimin- 
 ilhed. In all cafes, therefore, of long duration, that 
 is, where the bone has been out of its place for fix 
 months or upwards ; for I have often fucceeded where 
 it has been out two, three, and even four months ; 
 although it may be proper to make fome attempts to 
 replace the dillocated bones, yet none that require 
 great force fliould be much perfiflied in, for the at- 
 tempt muft always be of uncertain fuccefs, while it 
 neceffarily gives a great deal of pain, at the fame time 
 that it is apt to render the motion of the head of the 
 bone in the artificial focket, which it generally forms 
 for itfelf, more fi:iff than it was before. 
 
 In general it is fuppofed, that the humerus is more 
 eafily reduced when the head of the bone is lodged 
 in the axilla than when it is pufhed forward beneath 
 the peftoral mufcle ; but more eafily when lodged 
 beneath this mufcle than where it is forced back be- 
 neath the fpine of the fcapula. The latter I believe 
 
412 Of Di/Jocaiions cfihe Chap. XL. 
 
 to be fo ; but I have not found in the treatment of 
 the others that there is any difference between them. 
 
 In the redudion of a diflocated humerus^ we are in 
 general told, that it is to be done by extenfion, coun- 
 ter extenfion, and the fubfequent application of fuch 
 a force as is fufficient to replace the bone. Thefe 
 three indications, however, may all be comprehended 
 in one. If a fufficient degree of extenfion is applied 
 for dravt'ing the head of the bone on a line with the 
 acetabulum, the furgeon will feldom have any thing 
 farther to do ; for when brought to this fituation, the 
 reduction is almofb in every inftance inflantly com- 
 pleted by the ordinary action of the mufcles. 
 
 All that we have to do by counter extenfion, is to 
 fix the body fteadily while the arm is extending, and 
 to prevent the fcapula from being drawn forward by 
 the force that is necefllu-y for moving the arm ; for if 
 this bone be not fixed, it in fome degi-ee moves for- 
 ward with the humerus, by which the force employed 
 for extending the arm is in fome meafure loft, at the 
 fame time that the cavity in the fcapula in which the 
 head of the bone is to be placed, is thus kept in a 
 ftate of motion, by which the redudtion cannot be fo 
 readily effe£ted. 
 
 This being done, our powers of extenfion are ap- 
 plied to the arm, till the head of the bone is drawn on 
 a line with the brim of the focket ; when, as I have 
 obferved above, it will inftantaneoufly flip into its place 
 by the adion of the contiguous mufcles ; fo that there 
 is no neceffity for the appHcation of any force for this 
 purpofe. Much mifchief has often been done by force 
 applied with this view, as we fhall prefently fee on 
 confidering the different modes of reducing luxations 
 of this joint ; for it is obvious, if the force that is ufed 
 for raifing the humerus is applied before the end of it 
 is drawn pafl the mofi projeding point of the fcapula, 
 that the two bones mufl be thus preffed together fo 
 as to obftruft the redudion. 
 
Sea. IX. John of the Shoulder. 413 
 
 Various modes have been propofcd for the reduc- 
 tion of diflocatcd fhoulJers, infomuch that we feldom 
 meet with two praciitioners who do it in the fame 
 manner : but as one or other of thefe mufl be prefer- 
 able to the reft, and as it is of much importance to 
 have this afcertained, I Ihall offer a few obfervations 
 upon each of them, and fhall more particularly de- 
 fcribe that which to me appears to be the beft. 
 
 I. The humerus is often reduced by preilure with 
 the heel upon the head of the difplaced^ bone. The 
 patient being placed upon the floor, the furgeon alfo 
 fitting upon the floor directly before him, puts the heel 
 of one foot, that of the left foot when he is operating 
 upon the left flioulder, and vice versa, upon the head 
 of the bone ; and laying hold of the fore-arm with 
 both hands, he extends the arm, at the fame time that 
 he endeavours with his heel to pufh up the bone. 
 
 When the head of the bone has fallen dire6lly 
 downward into the armpit, we are direded by fome 
 to place a fmall tennis ball or any other round fub- 
 ftance between it and the heel ; by which the preffure 
 may be continued with more certainty into the bottom 
 of the axilla than where the heel alone is employed. 
 
 This method, however, is liable to three very im- 
 portant objedions. By laying hold of the fore-arm, 
 the joint of the elbow is confiderably ftretched, by 
 \vhich it may be much hurt, while a great part of the 
 force is fpent upon it which ought to have been ap- 
 plied entirely to the os humeri : by extending the 
 fore-arm, feveral of the mufcles of the arm itfelf, as 
 well as the biceps flexor cubiti, are put upon the 
 ftretch ; by which the extenfion is rendered much 
 more difficult than when thefe mufcles are relaxed by 
 the joint of the elbow being properly bent. And, 
 lallly, whether the heel be employed by itfelf or with 
 a ball, it is much more apt to do harm than good ; 
 for if it be not applied with fuch nicety and exadnefs, 
 as to pufli the head of the bone directly tov.ards the 
 fockct, it mud neceffarily force it againlt the neck of. 
 
414 OfDiJlocat'ions of the Chap. XL. 
 
 the fcapula or fome of the contiguous parts, and will 
 thus tend in the mofh effeclual manner to counteradt 
 the extenfion of the arm. 
 
 Befides, in this manner, the arm mud in every in- 
 flance be pulled in a verj'^ oblique direction downwards 
 by the relative fituation of the furgeon and patient ; 
 whereas it fhould in fome cafes be raifed nearly, though 
 not entirely, to a right angle with the body, and kept 
 in that pofition while the extenfion is going on. 
 
 It may be alleged, indeed, that this method often 
 fucceeds, and that it has long been employed by fome 
 of our oldeft and moft experienced furgeons. This I 
 admit : but I alfo know that it often fails, even with 
 thofe who fpeak mod favourably of it ; and that oth- 
 er modes of treatment have in various inftanccs an- 
 fwered, where this had previoufly failed. 
 
 2. Others attempt to reduce this diflocation, by en- 
 deavouringr to force the head of the bone into the 
 focket with a rolling-pin applied beneath it, while a 
 fufficient force is employed for extending the arm, and 
 for fixing the body in its fituation. With a view to 
 prevent the pin from hurting the fkin, we are defired 
 to cover it with flannel, and that part of it which pafl- 
 es into the axilla is directed to be more thickly cov- 
 ered than the reft. 
 
 But however this may in fome inftances fucceed, it 
 ought by no means to be received into pra6lice. It 
 is evidently liable to moft of the objections I have 
 mentioned to the mode of operating with the heel ; 
 particularly to the rifl^ of forcing the head of the hu- 
 merus in beneath the neck of the fcapula, and thus 
 counteracting the force employed for extending the 
 arm. It is obvious, too, even on the principle upon 
 which it is recommended by thofe who pra6tife it, that 
 this, as well as the mode of operating with the heel, 
 cannot be applicable where the head of the bone is 
 lodged either backward, or forward beneath the pec- 
 toral mufcle : for the fole Intention of both is to raifc 
 the head of the bone ; and yet by fome they are ufed 
 
Sedt. IX. Joint of the Shoulder. 415 
 
 indifcriminately, whether the bone is luxated down- 
 wards, backwards, or forward. 
 
 3. The patient being properly placed, the body fix- 
 ed by ailiflants, and the arm extended in the manner 
 I fhall afterwards direct, fome furgeons make ufe of a 
 towel or girth for pulling the head of the bone into 
 the focket. The ends of the girth being tied togeth- 
 er, one end of the double is put over the arm, and 
 carried near to the head of the humerus ; and the oth- 
 er being pafTed over the neck of the operator, he forc- 
 es up the end of the bone by raifnig his neck ; and if 
 this could be done with fufficicnt exaftnefs, jufl when 
 the head of the humerus has cleared the brim of the 
 focket, no harm would arife from this part of the op- 
 eration ; but if the force for elevating the bone be ap- 
 plied before a fufficient degree of extcnfion is made 
 for this purpofe, it muft evidently do mifchief, by 
 locking the head of the humerus and neck of the fca- 
 pula together : fo that this is in fome meafure liable 
 to the fame objedions that I have Hated to the mode 
 of operating with the heel and rolling-pin. 
 
 Thefe were the means ufually employed for reduc- 
 ing luxations of this joint ; but being frequently found 
 to fail, others have at different times been propofed in 
 order to increafe the powers of extenfion. 
 
 4. Of this nature is the ambe of Hippocrates, as 
 it is ufually termed : it is the one that was chiefly em- 
 ployed by ancient praditioners, and in fome parts of 
 Europe it is ftill the only inftrument ufed for this pur- 
 pofe : for this reafon I have given a delineation of it 
 in Plate LXXXVII. fig. i. but I do not by any means 
 advife it to be employed. The powers of which it is 
 pofleffed arc great, but they cannot be properly appli- 
 ed ; fo that they are pernicious in proportion to their 
 extent. It is hable in a tenfold degree to the objec- 
 tion I have Hated above to the three preceding modes 
 of reducing this bone, that of prefling the head of it 
 againft the neck of the fcapula ; by which one or oth- 
 er of them muft frequently be broken, as will readily 
 
41 6 Of Dijlocaiions cf the Chap. XL, 
 
 occur to whoever examines this inftrument with at- 
 tention ; for initead of extending the arm before raif- 
 ing the end of it, the firll action of this inftrument is 
 to raife the extremity of the bone, by which it mufl 
 be fo firmly pufncd in beneath the neck of the fcapu- 
 la, as to counterad with much effeft the power after- 
 wards apphed to extend it. 
 
 5. The method of reducing this joint by means of 
 a ladder has been long known, but I hope not often 
 employed. The diflocated arm being hung over the 
 upper flep of the ladder, to which height the patient 
 mufl be previoufly raifed, and being fecured in this 
 fituation by afliftants, the feat on which he is placed 
 is fuddenly drawn away ; by which the whole weight 
 of the body falls upon the luxated joint and by vv'hich 
 we are told the bone may often be reduced when oth- 
 er means have failed. The top of a high door is fome- 
 times ufed for the fame purpofe. ^Vhether the door 
 or ladder is employed, that part upon which the arm 
 is made to reft fhould be well covered with feveral 
 pHes of foft cloth or flannel. 
 
 6. The patient being laid upon the floor, the bone 
 has in fome inflances been reduced by two or three 
 flout men flanding upon a table, and lifting him fud- 
 denly up by the luxated arm. 
 
 7. Upon the fame principle, it has been propofed 
 to raife the patient by the luxated arm with ropes 
 running over puUies fixed in the ceiling of a high 
 roofed apartment. The jerk produced by the body 
 being fuddenly raifed and let down, has in fome cafes 
 fucceeded where other attempts to reduce the hume- 
 rus had failed. 
 
 This was firft praftifed, I believe, by the ingenious 
 Mr. White, of Manchefler ; and I have known it fuc- 
 ceed in different cafes of old luxations : but thefe me- 
 thods are all liable to great objections. The force is 
 too fuddenly applied ; by which more mifchief may 
 be done to the furrounding foft parts than can be 
 compenfatcd by the redudion of the bone. We know 
 
 
Sed. IX. Joint of the Shoulder, 417 
 
 that mufcles, blood veflfels, and ligaments, will flretch 
 to a confiderable degree, if the extending force be ap- 
 plied in a gradual manner : but we alfo know, that 
 they very readily break when powerfully and fudden- 
 ly ftretched. C3f this we have a remarkable inftance 
 in the burfting of the capfular ligaments of joints, 
 which I believe to happen, as I have endeavoured to 
 fhew, in almoft every cafe of luxation from external 
 violence. This leads us to fay, that any force that is 
 ufed for the redudion of luxations fliould be applied 
 in the mod gradual manner, and that the mode of 
 operating we are now confidering, mufl frequently do 
 harm by tearing and lacerating the foft parts furround- 
 ing the joint. Of this I have have had various inflan- 
 ces even where the teguments have been protected in 
 the mod cautious manner, by covering them with foft 
 flannel, and afterwards with fuin leather, before ap- 
 plying the ropes for extending the arm. 
 
 Befides, in rhefe modes of redudlion, the arm muft 
 be always extended in the fame direction, whether the 
 bone be luxated forward, downward, or backward : 
 whereas the direction in which the arm is extended, 
 fliould vary according to thefe circumftances ; as mull 
 be obvious to whoever attends to the anatomy of the 
 parts concerned in the luxation. Nay in one variety 
 of luxation, irreparable mifchief may be done to the 
 joint, by extending the arm in a direction which, in 
 another, might not only be proper, but neceflary. 
 Where the head of the humerus is puflied forward be- 
 neath the perioral mufcle, or direclly backward, we 
 may readily fuppofe that it may be eafily reduced by 
 pulling the arm upward, as is done when the body is 
 fufpended by a pully in the manner I have mention- 
 ed ; while much harm may be done by it, where the 
 head of the bone is lodged in the axilla, and puflied 
 beneath the neck of the fcapula. In this cafe, the 
 end of the humerus is often fo firmly wedged between 
 the fcapula and ribs, that one or other of thefe bones 
 
 Vol. hi. D d 
 
41 8 Of Dijlocatiom of the Chap. XL. 
 
 would neceflarily break by the fudden application of 
 much force in this direction ; and it can only be pre- 
 vented by extending the arm fomewhat obliquely 
 downward till the head of the humerus is quite difen- 
 gaged. 
 
 8. A machine has been invented for conjoining the 
 power of the ambe, with the mode of operating we 
 have juft been confidering ; in which the patient's 
 body is nearly fufpended by the diflocated arm, and 
 is fuddenly raifed and let down again while the ope- 
 rator endeavours with the lever of the ambe to elevate 
 the head of the bone. The invention is ingenious, 
 and the inftrument is evidently powerful ; but if our 
 objedtions to thefe two modes of operating, taken 
 feparately, are well founded, they are no lefs fo when 
 they are combined. The powerful action of the lever 
 muft be hazardous in proportion to the uncertainty of 
 its application. While the body is quickly rifmg and 
 falling, the lever cannot poflibly be applied with ex- 
 aclnefs to the end of the bone ; and if made to a6t 
 with much force before the head of the humerus is 
 cleared of the fcapula, one or other of thefe muft ne- 
 celfarily give way. 
 
 9. When the more fimple methods of reducing 
 luxations have failed, ropes and pullies have fome- 
 times been employed. Of thefe, different forms may 
 be feen in Plate LXXXVIII. figure 1 ; in Scultetusj 
 Plate XXII. fig. I ; and in Plate X. fig. 7. of Defa- 
 gulier's Experimental Philofophy. With one or oth- 
 er of thefe, any degree of force may be applied that 
 can ever be required for this purpofe. 
 
 10. But when recent cafes are properly managed, 
 luxations may in almoft every inftance be reduced 
 without any afTiftance from machinery. I often fuc- 
 ceed by the moderate extenfion 1 am able to make of 
 the arm with one hand, while the other is employed 
 in prefTmg back the fcapula. This, however, requires 
 all the mufcles of the arm and fore-arm to be as much 
 relaxed as poffible ; which we accomplifh by bending 
 
Se£t. IX. yoint of the Shoulder. 419 
 
 the elbow moderately, raifing the arm to a height 
 fomewhat lefs than a right angle with the body, and 
 preferving it in fuch a diredion as to prevent either 
 the pectoral or extenfor mufcles of the arm from be- 
 ing flrctched. When the arm is in this fituation, we 
 often find luxations eafily reduced which had previ- 
 oufly refilled the greatell force ; for in this manner 
 we not only relax the mufcles of the arm, but the 
 capfular ligament of the joint ; by which the head of 
 the bone returns more readily by the opening at which 
 it was forced out than it otherwife poffibly could do. 
 For when the ligament is much ftretched, it will grafp 
 the neck of the bone, by which our being able to re- 
 turn it will necefl'arily be rendered more uncertain. 
 
 More force, however, is fometimes required than 
 can be applied in this manner ; and the following is 
 a method by which I have never yet failed in recent 
 luxations. The patient is feated upon a chair, and. 
 his body fecured by a long broad belt pafled round it, 
 and given to alhllants, or tied round a poll : a firm 
 band of leather, four or five inches broad, and lined 
 with flannel, as is reprefented in Plate LXXXVIII. fig. 
 3. is now tied round the arm immediately above the 
 elbow. The three ftraps or cords connected with this 
 band being given to alllftants, they are defired to ex- 
 tend the arm in the relaxed pofition I have mentioned, 
 and in a flow equal manner, while another afiiftant 
 ftanding behind is employed in keeping the fcapula 
 firm. The furgeon himfelf (lands moft conveniently 
 on the outfide of the arm : his bufinefs is to dired: the 
 afTiflants in the degree of force they are to employ, 
 and to point out the diredion in which the arm is to 
 be extended ; he may alio fupport the fore-arm and 
 retain it bent at the elbow, in the manner I have men- 
 tioned. As foon as the head of the bone is drawn 
 clearly pafl the brim of the focket, the extenfion of 
 the arm fliould be fomewhat relaxed, when the re- 
 dudion will for the moft part be accompliflied by the 
 £> JD 2 
 
420 Of DijOocaiions of the Chap. XL. 
 
 action of the mufcles of the joint ; or it will be readi- 
 ly effected by moving the arm gently in different di- 
 rections. A crack is heard on the bone flipping in ; 
 the patient finds immediate relief; and the anterior 
 part of the fhoulder acquires its ufual prominent form. 
 
 The diredion in which the arm is extended, muft 
 depend upon the fituation of the head of the bone : 
 that in which it will meet with the leaft refiftance is 
 always to be preferred. When the head of the bone 
 is pufhed forward, and lodged beneath the pectoral 
 mufcle, the arm fnould be raifed to a right angle with 
 the body, and the fame direftion will anfwer where 
 it is pufhed backward ; but in the mod frequent kind 
 of luxation of this joint, where the head of the bone 
 is lodged in the armpit, the arm fhould uniformly be 
 drawn fomewhat obliquely downward : if extended 
 when raifed to a right angle with the body, it would 
 be drawn againft the neck of the fcapula, by which 
 much pain would be excited, and the reduction fruf- 
 trated. Of this I have feen many inftances, as every 
 practitioner muft: have done. 
 
 It fhould be a general rule in the treatment of eve- 
 ry luxation, to vary the direction in which the exten- 
 fion is made as foon as any confiderable refiftance is 
 met with ; but in luxations of the humerus, attention 
 to the obfervations I have juft throv/n out will for the 
 moft part prove fufficient. 
 
 In reducing luxations of this joint, it has been the 
 prevailing practice to prefs the fcapula forvvard and 
 downward : nearly the reverfe of this, however, fhould 
 be adopted. By prefling the fcapula downward, we 
 force it againft the head of the humerus, the very 
 thing we ought moft carefully to avoid : and by forc- 
 ing it forward, it is evident that the end of the hume- 
 rus will not be fo eafily drawn out from beneath it, as 
 when the afliftant is defired to pull it backward in the 
 manner I have mentioned. 
 
 II. The mode of treatment I have juft been de- 
 fcribing, will fucceed in almoft every inftance of recent 
 
Sea. IX. Joint of the Shoulder. 421 
 
 luxation ; and it will feldom fail even in cafes of long 
 {landing, where the redudion of the diflocated bone 
 is prafticable : but when a greater force is required 
 than can be applied in this manner, the inftrument 
 reprefented in Plate LXXXIX. may be employed. It 
 was invented by the late Mr. Freke, of London ; and 
 it anfwers the purpofe of extenfion better, and with 
 more exadnels, than any that I have feen. It is de- 
 lineated exadly from the plate given of it by Mr, 
 Freke ; but it admits of fome improvements. The 
 ftrap A A which paiTes over the flioulder, prefles 
 down the fcapula, and thus impedes the rctludion of 
 the bone : it fliould therefore be either entirely wanting, 
 or made with a flit to pafs over the arm fo as to draw the 
 fcapula back : in which cafe, inftead of pafling oblique- 
 ly downwards to be fixed in the floor, it fliould pafs 
 flraight acrofs, and be fixed in a poft on a line with 
 the flioulder. 
 
 I have already obferved, that the ufe of a lever in 
 raifmg a luxated humerus is both unneceflTary and dan- 
 gerous : the lever of this inftrument, therefore, infliead 
 of being moveable, fliould be fixed fo as only to ferve 
 as a fupport to the arm ; or if it ever is ufed as a lev- 
 er, it fliould be managed with the utmofl caution. 
 The principal advantage that we derive from this in- 
 ftrument, is our being able, by means of it, to apply 
 any force that may be necefl'ary in the nioft gradual 
 manner ; an objed of the firfl: importance in the re- 
 duction of luxations : it alfo extends the arm in any 
 diredion we may judge proper ; by which it can at 
 once be adapted to any variety of luxation. 
 
 Swelling, pain, and inflammation, when they occur 
 as confequences of luxations of the arm, are to be re- 
 moved by the remedies ufually employed in fuch ca- 
 fes, but chiefly by local bloodletting with leeches. 
 
 The round head of the biceps flexor cubiti, which 
 pafles through the joint of the Ihoulder, and is lodged 
 in a groove in the head of the humerus, is apt to be 
 feparated from this bone when it is forced far out of 
 
422 Of Luxations of the Chap. XL. 
 
 its natural fituatlon, and thus induces a flift' unwieldy 
 ftate of the arm : for the moft part it returns imme- 
 diately to this groove on the diflocation being reduc- 
 ed ; fo that there is commonly caufe to fufpect that it 
 conthiues to be difplaced when any unufual pain, (lift- 
 nefs or tenfion remain. The moft certain method of 
 replacing it is to move the arm from time to time in 
 every variety of way ; and we know that it is replac- 
 ed, by an inftantaneous removal of the diftrefs. 
 
 The glenoid cavity of the fcapula being very fuper- 
 ficial, the head of the humerus is apt to fall out again, 
 even after it has been completely replaced ; particu- 
 larly when it has been frequently luxated. The moft 
 certain method of preventing this is to fupport the 
 arm in a fling, as is reprefented in Plate XC-VI. fig. 2, 
 till the parts recover their tone. Blifters applied to 
 the flioulder, and pumping cold water over the joint, 
 have alfo proved ufeful for this purpofe. 
 
 SECTION X. 
 
 Of Luxations of the Fore-arm at the foint of the 
 Elbow* 
 
 THE bones of the fore-atm at the elbow are more 
 frequently diilocated upward and backward than 
 in any other direction : they can fcarcely be luxated 
 laterally or forward, if the injury be not at the fame 
 time accompanied with a fradure of the olecranon or 
 top of the ulna, as will be readily perceived on ex- 
 amining the connection of that procefs with the cavi- 
 ty in the pofterior part of the os humeri. 
 
 As the joint of the elbow is not deeply covered 
 with foft parts, luxations of the bones are eafily dif- 
 covered as long as fwelling and tenfion have not 
 taken place. When thefe iymptoms occur to any 
 extent, it is often difficult to diftinguifh either the na- 
 
Sed. X. Fore-arm at the Elbow, 423 
 
 ture or extent of the injury with which they are con- 
 ne£led. When the luxation is backward, the olecra- 
 non is felt on the back part of the arm, and the con- 
 dyles of the humerus are pufhed forward. When the 
 olecranon is broken off, and the ulna and radius pulh- 
 ed forward, they are alfo apt to be drawn upward on 
 the anterior part of the humerus, when the condyles 
 of that bone are difcovered behind. The extent of 
 the joint is fo confiderable from one fide to the other, 
 that the bones compofing it can never be completely 
 luxated laterally, unlefs the foft parts with which they 
 are covered are much lacerated. In whatever way 
 they are difplaced, the joint becomes immediately ftiff 
 and immoveable. 
 
 In the reduction of thefe diflocatlons, the patient 
 ihould be feated on a chair of a convenient height, 
 and the arm firmly fecured by an affiftant : when the 
 bones are luxated backward, the fore-arm fliould be 
 moderately bent, in order to relax the flexor mufcles : 
 while in this pofition it fliould be flowly and gradual- 
 ly extended ; and if care be taken to increafe the cur- 
 vature of the elbow in proportion as the extenfion is 
 made, we fcldom or never fail to complete the reduc- 
 tion. Where the olecranon is broken off", and the 
 ends of the radius and ulna puflied forward and drawn 
 up upon the humerus, we are under the neceflity of 
 extending the arm while in a fl:raight pofition, as in 
 this cafe the heads of thefe bones are puflied back up- 
 on the anterior part of the humerus on the leafl: at- 
 tempt to bend them. The extenfion fliould be con- 
 tinued till the ends of both bones are pulled fomewhat 
 lower than the mofl: depending point of the humerus, 
 when they will either regain their fituation by the ac- 
 tion of the mufcles, or be eafily forced into it. 
 
 In lateral diflocations of thefe bones, the extenfion 
 muft: alfo be continued till they have clearly pafl'ed the 
 end of the humerus, when by moderate lateral pref- 
 fure they will for the mofl; part be eafily replaced. 
 Of whatever kind the diflocation may be, the extenfion 
 
424 Of Luxations cj the Chap. XL. 
 
 fliould be made by afliftants grafping the arm imme- 
 diately above the wrifl ; and while they are thus em- 
 ployed, much advantage may be gained by the fur- 
 geon preffing down the heads of the bones. 
 
 In two cafes of diflocation of thefe bones, where 
 their heads were drawn up upon the back of the hu- 
 merus, the reduction was not accomphfhed, although 
 a great force was applied, not only in pulling at the 
 under part of the arm, but in pufiiing down the heads 
 of the difplaced bones. In one of them, where the 
 olecranon was pufhed through the teguments, that part 
 of the bone was fawn off, by which the reduftion was 
 effected : in the other, this expedient was not advifed ; 
 and the practitioner finding all his efforts to reduce 
 the bones prove abortive, the limb vv^as amputated. 
 As the extenfion in both was applied w^hile the arm 
 was flretched out, and as I have never failed in fimi- 
 lar cafes where the arm was bent, I conclude, that in 
 the one the arm would have been faved, and in the 
 other the joint preferved entire, if this practice had 
 been adopted. 
 
 The reduction being completed, the fore-arm fiiould 
 be kept in a relaxed pofition, by keeping the elbow 
 moderately bent. 
 
 Thefe bones, w^hen reduced, do not readily fall again 
 out of their place ; but it is proper in this, as in every 
 cafe of luxation, to preferve the limb as much at reft 
 as poffible till the injured parts have recovered their 
 tone. 
 
 The bones of the fore-arm are alfo liable to be dif- 
 located in their connection with each other. At the 
 joint of the elbow a projecting part of the radius is 
 lodged, and moves in a correfponding cavity of the 
 ulna ; and below, a portion of the ulna is received by 
 a fimilar cavity in the radius. Inftances have occur- 
 red of thefe bones being feparated from each other at 
 both thefe points of connection ; but any feparation 
 of this kind is more apt to happen at the wrift than at 
 the elbow. It is known to have occurred, by all the 
 
Se6t. XI. Bones of the Wriji. 425 
 
 ufual figns of luxations : by pain, fwelling, and diftor- 
 tion in the injured part ; by the motion of the joint 
 being impaired ; and by manual examination. 
 
 In general, the difplaced bone is eafily put into its 
 fituation ; but for the moll part we find it difficult to 
 retain it. The mofl certain method of efl'ecling this, 
 is, to put a long firm fplint along the outfide of the 
 arm from the elbow down to the points of the fingers, 
 and another of the fame length on the infide ; the 
 whole to be Iccured with a flannel roller, and the arm 
 hung in the fling reprefented in Plate XCVI. fig. 2. 
 By this we prevent the rotatory motion of the radius, 
 and the pronation and fupination of the hand ; and if 
 this is guarded againlt for a fufficient length of time, 
 a cure may at lafi be expe£led, while want of atten- 
 tion to this is frequently the caufe of the joint at the 
 wrill remaining fliifl:' for life ; of which I have met 
 with various inllances. 
 
 SECTION XI. 
 
 Of Luxaiions of the Bones of the WriJi, 
 
 THE bones of the wrift are not fo frequently lux- 
 ated as might be expedled from the fmallnefs of 
 their fize, owing to their being firmly connected by 
 ligaments ; as well as to the flrength which they de- 
 rive from the whole tending to form a kind of arch ; 
 the convex part of which being on the outer or back 
 part of the hand, where it is mofl: expofed to injuries, 
 is particularly well calculated for preventing any of the 
 bones from being difplaced. 
 
 Degrees of force, however, are fometimes applied 
 to them which they are unable to refill. From their 
 form, it will appear, that they will mofl; readily be dif- 
 located outward. The three fuperior carpal bones, 
 which form a kind of projeding head, that is lodged 
 
426 Of Luxations of the Chap. XL. 
 
 in a fuperficlal cavity in the under extremities of the 
 ulna and radius, may cither be diflocated at this joint, 
 or they may be feparated from the five inferior bones 
 of the wrift. In fome inftances, one or more of thefe 
 bones are feparated from each other ; and in others 
 they are diflocated at their connexion with the bones 
 of the metacarpus and the fuperior bone of the thumb. 
 
 As thefe bones are not thickly covered with foft 
 parts, the nature of the injury becomes immediately 
 obvious : but in fome cafes, where perhaps a fmgle 
 bone is only partially difplaced, if the parts be not ex- 
 amined with attention, the fymptoms that occur are 
 apt to be attributed to a fprain ; and the real caufe of 
 them being overlooked, a permanent lamenefs is thus 
 induced, which with much eafe might have been pre- 
 vented. Of this I have met with various inftances. 
 Similar occurrences, however, may always be prevent- 
 ed by an early and attentive examination of the injur- 
 ed parts. 
 
 In reducing luxations of thefe bones, we are in gen- 
 eral defired to ftretch the arm and hand upon a table, 
 and while they are in this pofition, to pufli them into 
 their fituations : but it is better to have the arm and 
 hand fupported by two alTiftants, as in this fituation 
 the furgeon gets ready accefs to both fides of the wrift. 
 The affiftants fliould be deftred to keep the parts fuf- 
 ficiently firm, but not to ftretch them ; and when in 
 this fituation, the furgeon will feldom find it difficult 
 to pufli the bones into their places. They muft be 
 retained by fplints and bandages in the manner men- 
 tioned in the laft feftion ; and as diflocations of thefe 
 bones are very apt to induce inflammation of the lig- 
 aments and other contiguous foft parts, repeated ap- 
 plications of leeches ihould be advifed as the moft cer- 
 tain preventive. 
 
Se£t. XIL Metacarpus and Fingers. 427 
 
 SECTION XII. 
 
 Of Luxations of the Bones of the Metacarpus and 
 Fingers. 
 
 WE have feen in the lafl fedion that the meta- 
 carpal bones may be diflocatcd at their junc- 
 tion with the bones of the wrifl ; and they are fome- 
 times difplaced at their under extiemities, where they 
 are connefted with the bones of the fingers. They 
 are not fo frequently luxated, however, as at hrfl: view 
 might be expected ; probably from the joint of the 
 wrift being fo moveable, that the whole hand readily 
 yields to any force that is applied to it. 
 
 The bones of the fingers and thumb are alfo fome- 
 tlmes luxated ; but we likewife confider the mobility 
 of thefe bones as the principal reafon of their being 
 lefs frequently diflocated than many of the largefl: and 
 flrongcfl bones that are more firmly connected to- 
 gether. 
 
 Diflocations of thefe bones are eafily difcovered by 
 all the ufual fymptoms of luxations ; but particularly 
 by the deformity v.'hich they produce, which in this 
 fituation is always confpicuous. 
 
 When any of the metacarpal bones are difplaced at 
 their connection with the bones of the wrift, the bed 
 method of reducing them is, by keeping the arm ftea- 
 dily fixed, and pulhing them from above downward, 
 while the hand remains loofe and moveable. When 
 the firft phalanx of any of the fingers is moved from 
 its junction with the correfponding metacarpal bone, 
 it is to be replaced by one affiftant fi.xing the hard, 
 while another draws down the diflocated finger, which 
 fliould be done by grafping the firft phalanx only, in 
 order to prevent the other joints of the finger from be- 
 ing hurt. Diflocations of all the other joints of the 
 
428 Of Luxations of the Chap. XL. 
 
 fingers, as well as of the thumbs, are to be managed 
 in the fame manner. 
 
 In the reduclion of thefe diflocations, the bone fhould 
 not be pulled down till it is fomewhat raifed or eleva- 
 ted from the contiguous bone ; for as all the bones of 
 the fingers and thumbs, as well as thofe of the meta- 
 carpus, are thicker at their extremities than in any 
 other part, thefe projections are apt to be forced againfl 
 each other when the extenfion is made in a ftraight 
 direclion. In this manner the greateft force has fre- 
 quently been employed in vain ; nay, fingers have been 
 amputated where this alone prevented luxations from 
 being reduced, and in which a very inconfiderable force 
 would have proved fuccefsful, if the difplaced bone 
 had been fomewhat feparated from the other before 
 any force was applied for extending it. 
 
 SECTION XIII. 
 
 Of Luxations of the Femur at the Hip foint, 
 
 THE focket or acetabulum, formed by the ofla in- 
 nominata, for lodging the head of the thigh 
 bone, is fo deep ; the brim of the focket in a recent 
 fubjedt contracts fo much about the neck of this bone ; 
 the head of the bone is fo firmly tied down to the bot- 
 tom of the focket by a ftrong ligament ; and it is fo 
 confined by ftrong mufcles, that we would not a pri- 
 ori fuppofe that it could be luxated by external vio- 
 lence : we would rather imagine that it would break 
 at the neck where it is weakeft, than that the head of 
 it fliould ever be forced from its focket : this opinion 
 has accordingly been adopted by many in all ages. 
 For a confiderable time I was difpofed to favour it, 
 from having obferved feveral cafes which at firft were 
 fuppofed to be luxations, but which proved to be frac- 
 tures of the neck of the femur. In the courfe of the 
 
Sea. XIII. Femur at the Hip Joint. 429 
 
 lad few years, however, I have feen feveral cafes in 
 which I was convinced that the thigh bone was luxa- 
 ted. The nature of the fymptoms gave reafon to im- 
 agine that they arofe from luxations j and they were 
 proved to do fo by the patient's being inftantancoufly 
 and completely relieved, and rendered quite able to 
 walk, on the head of the bone being replaced j which 
 in a frafture of the bone could not happen. 
 
 In treating of fradures of the thigh bone, the cir- 
 cumftances by which fraftures of the neck of it may 
 mod readily be dillinguiflied from luxations, were 
 mentioned : 1 fhall therefore refer for this part of 
 our fubjed to the eleventh Seftion of the preceding 
 Chapter. 
 
 It is faid by authors, that the head of the femur 
 may be luxated in various directions, namely, upward 
 and backward, upward and forward, downward and 
 backward, downward and forward, and I may adddi- 
 redlly downward. That all of thefe may happen, I 
 cannot take it upon me to deny ; but I believe few 
 pradiitioners have met with an inltance of the firft and 
 third. The fecond variety, where the head of the 
 bone paffes up upon the os pubis, may happen ; as 
 may likewife the laft, where it is forced directly down ; 
 but I have never feen any variety of this luxation if it 
 be not that in which the head of the femur is pufhed 
 downward and forward, and lodged in the foramen 
 ovale. All praftitioners admit, that the bone is mod 
 frequently dillocated in this diredion ; and an exam- 
 ination of the il-celeton, as well as of the recent fubjeft, 
 will {how why it fliould be fo. The brim of the fock- 
 ct over all the upper and back part of it, is not only 
 ftronger, but more elevated than the red of it. It 
 falls away as it defcends ; and on the anterior under 
 p:\rt of it there is a confiderable vacancy in the bone, 
 the fpace being filled with a ligament only ; and as 
 tiiis opening is fuiTicicntly large to admit the head of 
 the femur, we eafily fee how luxations lliould be mod 
 apt to occur here. 
 
43^ 0/" Luxations of the Chap. XL. 
 
 Every luxation of the femur mufl be productive of 
 lamenefs, and of pain, tenfion, and other fymptoms 
 with which other luxations are accompanied. When 
 the head of the bone palTes upward and backward, the 
 leg muft be much fliorter than the other ; infomuch 
 that the points of the toes only will touch the ground 
 when the patient is {landing upon the other foot ; the 
 great trochanter of the thigh bone will be higher than 
 in the other fide ; the knee and foot turned inward ; 
 and a good deal of pain nmll be induced by every at- 
 tempt to turn them out. 
 
 When the femur is luxated upward and forward, 
 the leg muft be fhortened ; the head of the bone will 
 be felt refling above the os pubis in the groin ; the 
 great trochanter will be on the upper and anterior part 
 of the thigh near the groin, while a vacancy is difcov- 
 ered in that part of the hip which it ought to occupy ; 
 the knee and toes will be turned outwards ; and if the 
 diflocation be not foon reduced, pain, tenfion, and in- 
 flammation, will occur in the fpermatic cord and tef- 
 tis, from the prelTure made upon the cord by the head 
 of the bone. 
 
 If ever this bone is luxated downward and back- 
 ward, the leg will be confiderably longer than the oth- 
 er ; the knee and toes will be turned inward ; and the 
 great trochanter will be much lower than the fame 
 protuberance of the other limb. When the head of 
 the bones pail'es directly downward, the leg will alfo 
 be longer than the other, and the trochanter will like- 
 wife be lower ; but the knee and toes will retain near- 
 ly their natural iituation ; only every attempt to move 
 them will be productive of pain. 
 
 In the moll frequent luxation of the femur, the \Qg 
 appears to be confiderably longer than the other ; the 
 knee and points of the toes are turned outward, nor 
 can they be moved either farther outward or inward 
 but with much pain : all the muicles in the internal 
 part of the thigh are tenfe and painful ; the femur can- 
 not be felt on the outfide farther up than the middle 
 
Sea. XIII. Femur at the Hip Joint. 431 
 
 of the thigh ; a vacancy is difcovered in the ufual feat 
 of the great trochanter, which is found farther dowa 
 and on the anterior part of the thigh, while the head 
 of the femur is plainly felt a litde below the groin ; 
 being feated, as I have obfervcd above, in the foramen 
 ovale. 
 
 In luxations of the femur, the difficulty and uncer- 
 tainty of reducing them has been confidered as fo great, 
 that in general we have been advifed to give a very 
 doubtful prognofis of the event. In cafes of long du- 
 ration, this iliould always be done : for befides other 
 caufes which add to the difficulty of rcdudion, the 
 muicles here are fo ftrong that they refill, in the mod 
 powerful manner, every attempt to diflodge the head 
 of the bone after it has been long fixed among them : 
 by contrading round the neck of the bone, they muft 
 even be torn afunder before it can be reduced : but in 
 recent luxations we have not this difficulty to encoun- 
 ter ; and we know that with proper management the 
 bone may in almofl every inftance be reduced. 
 
 The redu6lion of this bone is commonly attempted 
 by pulling the limb downward j and it feems to be an 
 opinion very univerfally received, that any force we 
 employ ffiould be applied in this direction. Some ad- 
 vife the limb to be drawn directly down from the part 
 in which the head of the bone is lodged ; others de- 
 fire it to be pulled exaiStly in a line with the hip joint, 
 while others turn the knee fomewhat inward. The 
 patient being placed upon his back, and properly fc- 
 cured, the limb is extended in one or other of thcfe 
 diredions, either till the reduclion is accomplilhed, or 
 till fuch a force is applied as makes the operator afraid 
 of doing harm were he to proceed farther. 
 
 It muft be allowed, that diflocations of the femur 
 have in various inftances been reduced in this manner : 
 it might often fucceed where the head of the bone is 
 forced upwards ; but I may without hefitation affiert, 
 that even in this cafe the redudion might be effe£ted 
 with lefs force in a different manner j and in a great 
 
432 Of Luxatlom cf the Chap. XL, 
 
 proportion of cafes, where the head of the bone is 
 lodged in the foramen ovale, or where it is forced di- 
 rectly downwards, that we muft neceflarily fail entire- 
 ly by confining the line of extenfion to any of the di- 
 rections I have mentioned. 
 
 In whatever way the head of the femur is luxated, 
 it muft pafs over fome inequalities or prominent parts 
 of the contiguous bones : thefe it muft again pafs over 
 before it is reduced ; at leaft this muft be the cafe if 
 we wifh it to return by the fame route, arid it will be 
 admitted in the treatment of luxations to be a good 
 general rule, to endeavour to replace the bone by the 
 opening at which it pafled out. But where the limb 
 is only pulled downward in the ufual way, the head 
 of the bone will be forced againft the projedting brim 
 of the focket, if the diflocation is upward ; or it will 
 be drawn to a ftill greater diftance from the joint 
 where the bone is diflocated either dire£tly downward, 
 or lodged in the foramen ovale in the upper and inner 
 part of the thigh. Wherever the head of the bone 
 may be lodged, it ftiould be completely raifed above 
 any projecting part of the contiguous bones before 
 any other attempt is made for reducing it. As this 
 will remove the principal impediment to the reduction, 
 if the mufcles of the limb are at the fame time relax- 
 ed, it will eafily be drawn into the focket when the 
 diflocation is upward, or puflied into it where the head 
 of the bone is already beneath it. 
 
 In the moft frequent variety of this luxation, where 
 the head of the bone is puflied downward and for- 
 ward, I have fucceedcd in the fol-ov^'ing manner : the 
 patient is laid upon his back acrofs a bed, and firmly 
 fecured by tv/o or three affiftants : a broad ftrap, or 
 table cloth, properly folded, is pafTed between his 
 thighs, and over the g;roin on the found fide, and giv- 
 en to two other aififtants : a fimilar ftrap is paifed 
 round the luxated thigh as near as polfible to the head 
 of it ; the ends of which muft be given to an afiiftant 
 ftanding on the oppofite fide : the belt reprefented in 
 
Se£^. Xin. Femur at the Hip yolnti 433 
 
 Plate LXXXVITI. fig. 3. being previoufly fixed upon 
 the under part of the thigh, the flraps conne£ted with 
 it are given to an alliftant or two, while the knee is 
 fupported by another affiftant with the leg moderately 
 bent. The thigh is now to be moderately (Iretched 
 by the aiTiftants who have the charge of the flraps at 
 the under part of it ; but the extenfion fliould not be 
 carried farther than what may be confidered as necef- 
 fary for drawing the head of the bone down to the 
 under part of the foramen ovale ; and this may be al- 
 ways done with a moderate force. The ftrap round 
 the top of the thigh muft now be firmly pulled by 
 thofe who have the charge of it ; who, (landing fome- 
 what higher than the patient, fliould draw the thigh 
 upward and inward *, and the extenfion fhould be con- 
 tinued in this direftion till there is reafon to fuppofe 
 that the head of the bone is clearly raifed from the 
 foramen in which it was lodged. At this time the 
 perfon who has the charge of the knee fhould be defired 
 to move it fomewhat inward, and to pufli the head of 
 the bone upward and obliquely outwgj'd : he will do 
 this with the greatefl certainty of fuccefs, if he fecures 
 the knee with one hand, and the foot with the other, 
 at the fame time that he takes care to keep the leg jufl 
 fo much bent as may relax all the flexor mufcles with- 
 out flretching the extenfors. If the different afTiflants 
 perform their parts properly, the firfl attempt will an- 
 fwcr ; but if any of them have failed, particularly if the 
 head of the bone has not been fulTiciently raifed from 
 the hollow in the foramen ovale before being pufhed 
 upwards, the attempt muft be repeated. 
 
 As the head of the bone may for the mofl part be 
 felt outwardly, the furgeon may in general afccrtain 
 ■with certainty whether it is fufficiently raifed or not. 
 If he finds it rife eafily, the force may be continued 
 till it appears to be about an inch higher than when it 
 was fird applied ; while, on the contrary, if it yields 
 with difliculty, there will be reafon to fufped that 
 
 Vol. III. E e 
 
434 Q/" Lunations Chap. XL. 
 
 fome part of the head of the bone is fixed or locked 
 in the upper part of the foramen ovale ; m which cafe 
 the force in this diredion fhould be difcontinued, and 
 the other affiftants at the knee being direded to in- 
 creafe the extenfion downward, it will afterwards be 
 more eafily raifed. 
 
 In whatever diredion the bone may be diflocated, 
 the point requiring moft of our attention, is the raif- 
 ing the head of the bone fufficiently before any attempt 
 is made to force it into the focket. This being ac- 
 compliflied, a very flight force will in general draw 
 it down when the diflocation is upward ; and when 
 diflocated downward, whether it is fomewhat back- 
 ward or diredly on a line with the focket, it will be 
 eafily puflied up. 
 
 In this manner recent luxations of this joint may for 
 the mofl: part be reduced ; and the fame treatment is 
 perhaps the befl: even in luxations of long duration. 
 In thefe it will fometimes fail ; but it will fucceed, I 
 believe, as frequently as any other that has yet been 
 propofed, whil^q it is not productive of the dreadful 
 pain that commonly enfues from the ufe of thofe ma- 
 chines that have been invented for a greater extenfion 
 of the limb. When any additional force, however, 
 is judged neceflary, it may either be obtained by a 
 proper application of Mr.Freke's machine, reprefented 
 in Plate LXXXIX. of Mr. Petit's in Plate LXXXVII. 
 fig. 2. or of the pullies and ropes reprefented in Plate 
 LXXXVIII. fig. 2. 
 
 It (hould be remarked, however, that this kind of 
 aflifl:ance can never be applicable where the luxation 
 is downward. Extenfion of the limb having been 
 confidered as neceflary in every variety of luxation, it 
 has often been indifcriminately employed, whether the 
 head of the bone was placed above or below the fock- 
 et : it is obvious, however, that it is in the former 
 only that it can ever prove ufeful ; and in the latter, 
 that much miichief may enfue from it. 
 
Sea. XIV. of the Pafella, J^^$ 
 
 The violent diftenfion of the. mufcles, and exten- 
 five laceration of the articular ligaments, with which 
 luxations of this bone muft always be accompanied, 
 render much care and attention neceffary long after 
 the reduction is accomplifhed. Local bloodletting 
 with leeches, or cupping and fcarifying, proves parti- 
 cularly ufeful here, and fliould be repeated more or 
 lefs frequently according to the violence of the fymp- 
 toms, and age and habit of the patient ; and till the 
 parts may be fuppofed to have recovered their tone, 
 the patient (hould be kept as much at reft as pofiible. 
 
 By many it is imagined that the femur may be par- 
 tially luxated ; and the appearances which are fup- 
 pofed to arife from what is termed a fubluxation of 
 this bone are dcfcribed by authors : of thei'e, howev- 
 er, I have taken no notice, as it is not my opinion 
 that this bone can ever be partially luxated. The 
 head of it is fo round, and the brim of the focket fo 
 narrow, that whoever examines them will be convin- 
 ced that it cannot happen. The head of the bone 
 may, in a gradual manner, be pufiied out of the ace- 
 tabulum by a tumor at the bottom, but I do not fup- 
 pofe that it can ever occur from external violence. 
 
 SECTION XIV. 
 Of Luxatiofis of the Patella, 
 
 THE patella may be either partially or completely 
 luxated, and it may be difplaced either upward 
 or downward, outward or inward : it may alfo be 
 luxated by itfelf, or it may be difplaced along with 
 the tibia and fibula in luxations of thefe bones. It 
 cannot, however, be completely luxated in any direc- 
 tion, if it be not accompanied with a rupture of the 
 ligament by which it is tied to the tibia, or of the ten- 
 
 E E 2 
 
43^ Of Luxatiom of the Chap. XL* 
 
 don of the rectus mufcle connected to the upper part 
 of it ; and it will be more readily diflocated inwardly 
 than in any other direction, owing to the internal 
 condyle of the femur being fomewhat lefs prominent 
 than the other : for as this bone is placed in fome de- 
 gree between thefe condyles, it will neceflarily be moft 
 eafily forced out at that fide where it meets with the 
 kafl: refiftance. 
 
 Luxations of this bone are, for the moft part, eafi- 
 ly difcovered, as it is thinly covered with foft parts : 
 but when it has been long difplaced, it is apt to in- 
 duce fo much tumefaction, not only about the joints 
 but over all the contiguous parts, as to be diftinguifh- 
 ed with difficulty. Even the moft partial luxation of 
 the patella always gives confiderable lamenefs and 
 much pain on every attempt to move the joint. 
 
 In the redu6tion of a luxated patella, the patient 
 fhould be placed either on a bed or on a tabic, and 
 his leg fliould be ftretched out and kept in this pof- 
 fure by an affiftant^ The furgeon fhould now lay 
 hold of the bone, and endeavour to pufti it into its- 
 fituation ; but inftead of puftiing it diredly forward,. 
 it ftiould firft be fomewhat railed, otherwife we are 
 apt to force it againft the condyles of the femur or 
 head of the tibia. The beft method of effetting this 
 is to prefs down the fide of the bone moft diftant from 
 the joint ; by which the oppofite fide of it v^ ill be 
 elevated, when a very moderate force will prefs it in- 
 to its place. When the patella is drawn out of its 
 fituation by the tibia and fibula being difplaced along 
 with it, it cannot be replaced till the redudion of 
 thefe bones is accompliflied. 
 
Sea. XV. Tibia and Fibula, 437 
 
 SECTION XV. 
 
 Of Luxations of the Tibia and Fibula at the foint of 
 the Knee, 
 
 THE tibia is the only bone of the leg that is im- 
 mediately concerned in the joint of the knee ; 
 but as this bone cannot be diflocated without drawing 
 the fibula along with it, I think it right to mention 
 them together. 
 
 As more ftrength is required in the knee than in 
 any other joint of the body, the bones of which it is 
 chiefly formed, the femur and tibia are connecl:ed to- 
 gether by the ftrongeft kind of articulation, namely, 
 by ginglimus or the hinge like joint : the furfaces of 
 the two bones are very extenfive, and they are firmly 
 tied together by ilrong ligaments : there is alfo reafon 
 to fuppofe, that the moveable cartilages placed be- 
 tween the end^ of thefe bones have fome influence in 
 lefl"ening the fridion of the joint, and in thus render- 
 ing it more firm than it otherwife would be. 
 
 The great ftrength of this joint is the reafon of its 
 being lefs frequently diflocated than any other in the 
 body '. it cannot indeed be completely diflocated but 
 by the application of fo much force as will not only 
 rupture the teguments which cover it, but the ftrong 
 ligaments and tendons which tie the bones together. 
 As this requires a very unufual degree of violence, 
 thefe bones are feldom forced entirely paft each other ; 
 and the fame reafon even prevents them from being 
 often partially luxated. When either a complete or 
 partial luxation, however, is produced, it may happen 
 nearly with equal eafe on either fide ; but the bones 
 will be more readily forced backward than forward, 
 owing to the flexor mufcles and tendons of the leg 
 being much fl:ronger than the extenfors. 
 
433 Of Luxaficns of the Chap. XL» 
 
 The mofl: partial luxation of this joint is readily dif- 
 tinguifhed, not only by the violent pain which it ex- 
 cites, and the lamenefs with which it is attended, but 
 by the deformity which it produces, and which is al- 
 ways obvious on comparing both knee joints together. 
 When the patella is diflocated at the fame time with 
 the tibia and fibula, it will, for the moll part, be re- 
 duced along with thefe bones ; but when this does 
 not happen, it may be afterwards replaced in the man- 
 ner I have mentioned in the laft feclion. 
 
 Luxations of this joint are to be reduced by fixing 
 the thigh with fufficient firmnefs, and extending the 
 leg till the ends of the bones are entirely clear of each 
 other ; when the tibia and fibula will be eafily repla- 
 ced. In paitial luxations, the degree of extenfion ne- 
 ceflary for this will be inconfiderable ; but where the 
 bones are completely difplaced, more force will be re- 
 quired. It is fcarcely necefl'ary to obferve, that the 
 mufcles of the leg fliould be as much relaxed as pof- 
 fible while the force for extending it is applying. 
 
 Scarcely any joint is fo apt to fuffer from inflam- 
 mation as that of the knee ; fo that in all fuch inju- 
 ries as this, where the furrounding foft parts ai'e fo 
 liable to inflame and become painful, the mofl ftricl 
 antiphlogiftic courfe becomes requifite ; local blood- 
 letting (hould be prefcribed, and repeated according 
 to the violence of the fymptoms and flrength of the; 
 patient ; and the limb Ihould for a confiderable time 
 be kept at perfetl reft. 
 
 The upper as well as the under end of the fibula 
 is fometimes forcibly feparated from the tibia. As the 
 fymptoms which this excites are fimilar to thofe which 
 occur from fprains of the mufcles, the nature of the 
 injury is often overlooked. It may almoft always, 
 however, be diftinguifhed by attentive manual exami- 
 nation. The only method of obtaining relief is by re- 
 placing the bone, which for the mofl part is eafily 
 done, and retaining it with a proper bandage till the 
 parts have recovered their tone. 
 
Sea. XVI. Foot ai the Ankk» 439 
 
 SECTION XVI. 
 Of Luxations of the Foot at the Joint of the Ankle, 
 
 THE joint of the ankle Is formed by the upper part 
 of the aflragalus or firft bone of the foot, being 
 received into a cavity in the under end of the tibia ; 
 which is bounded externally by the end of the fibula 
 projeding a confiderable way paft the end of the tibia. 
 
 The aftragalus may be diflocated either backward 
 or forward, outward or inward, but it is more fre- 
 quently puflied inward than in any other diredlion. 
 The great ftrength of the tendo achillis prevents it 
 from flipping eafily backward, and it has alfo fome ef- 
 fe£l in preventing it from going forward. It cannot 
 be puflied outward without breaking the projeding 
 end of the fibula. 
 
 Diflocations of this joint are in general eafily difcov- 
 ered by the pain and lamenefs which they produce, as 
 well as by the obvious alteration which they occafion 
 in the appearance of the foot. When the aflragalus 
 is puflied forward, the foot appears to be lengthened 
 and the heel fliortened ; when puflied backward, the 
 foot is fhortened and the heel lengthened ; and when 
 luxated, either outwardly or inwardly, there is always 
 a preternatural vacancy on one fide of the joint, and 
 a prominency on the other. 
 
 In the reduction of this luxation, the patient fhould 
 be placed either upon a table or on a bed, and the leg, 
 with the knee bent, fliould be firmly fecured by an af- 
 fiflant or two. The foot is now to be put into that 
 fituation which tends moft eft'edually to relax all the 
 mufcles that belong to it ; and being given to an af- 
 fiflant, he mufl be defired to extend it in that direc- 
 tion till the moft prominent point of the aflragalus has 
 clearly paffed the end of the tibia, when the bone will 
 either flip into its place, or may be eafily forced into it. 
 
440 Of Luxaticns cfthe Chap. XL. 
 
 As the upper part of the aftragalus is not perfeclly 
 round, but rather fomewhat hollow, this joint is more 
 apt to be partially luxated than any other formed by 
 a ball and focket, as this in fome meafure is : partial 
 luxations of it, however, are eafily reduced. 
 
 Befides the antiphlogiftic courle that I have advifed 
 after all luxations of the large joints, it is particularly 
 necelTary in luxations of the ankle to keep the limb 
 for a confiderable time at the moil perfect relt, efpe- 
 cially where the under extremity of the fibula is brok- 
 en, by the foot being forced outward ; for, as the (la- 
 bility of the joint depends in a great meafure on this 
 bone, if it be not either rightly replaced or retained in 
 its fituation, till the cure of the frafture is eftefted, it 
 may afterwards continue weak during life, or be atr 
 tended with ftiffnefs and a great degree of pain. The 
 weaknefs that fucceeds to this kind of injury, if it be 
 not removed by thefe mcafures, will be mod effeclu- 
 ally obviated by a firm fplint of thin iron connected 
 with the fhoe, and applied along the outfide of the 
 leg ; or by an inftrument invented by the late Mr, 
 Gooch, reprefented in Plate XCIV. fig. 4. 
 
 SECTION XVII. 
 
 Of Luxations of the Os Calcis and other Bo7ies of the Foot* 
 
 THE OS calcis, which is the largefl bone of the foot, 
 is fometimes diflocated laterally, where it is con? 
 nedled with the aftragalus. It is prevented from be- 
 ing pufhed forward by the other bones of the foot ; 
 and the tendo achillis, which is inferted into a large 
 rough procefs of this bone which projects backward 
 and forms the heel, prevents it from being luxated in 
 this direction. 
 
 The aftragalus and os calcis are fometimes luxated 
 at their junction with the os naviculare and os cuboi- 
 
Sea. XVII, Os Cakis, Eff^r. 441 
 
 des ; and as this joint, if it may be fo termed, is at no 
 great diftance from the ankle, this variety of luxation 
 has, in feme inftances, been miftaken for luxation of 
 the ankle. The foot may at this part be pufhed either 
 outward or inward, or be forced diredly downward : 
 it will rarely be luxated upward, as it can fcarcely be 
 expofed to external violence in fuch a direftion as 
 could have this effed. 
 
 Luxations of any of thefe bones are readily difcov- 
 ered by the pain and lamenefs with which they are al- 
 ways attended ; as well as by the alteration which they 
 produce on the fliape of the foot. 
 
 The OS calcis, when completely difplaced, is more 
 difficult to reduce than alinofl any other bone of the 
 foot : it can only be done by fixing the leg and foot 
 in fuch a pofitlon as tends mod etfedlually to relax 
 the different mufcles that belong to them ; and while 
 they are in this pofition, by endeavouring to force the 
 bone into its fituation ; and this will be more readily 
 done, if during the operation the foot is extended. 
 
 In luxations of the afiiragalus and os calcis with the 
 OS naviculare and os cuboides, as the anterior part of 
 the foot is apt to be drawn towards the heel, it be- 
 comes neceiTary to extend it to fuch a degree as may 
 clear the bones on the oppofite fides of the joint of 
 each other ; for till this is done, the reduction cannot 
 take place, while the bones will immediately flip into 
 their fituation as foon as they are drawn pafl each 
 .other. 
 
 The other three bones of the tarfus, ufually terme4 
 the cuneiform bones, as well as the metatarfal bones, 
 and the bones of the toes, are all liable to be luxated, 
 and they may be difplaced almoft in every direftion. 
 But it is not neceffary to fpeak of the method of re* 
 ducing them ; for the obfervations that I had occafion 
 to make on diflocations of the bones of the hand are 
 equally applicable here : fo that I fhall now refer to 
 what was faid on that fubjecl in the twelfth Sedion of 
 this Chapter. 
 
442 Of Dijioricd Limbs, Chap. XLI. 
 
 CHAPTER XLI. 
 
 OF DISTORTED LIMBS. 
 
 LIMBS may be diilorted in various ways, and by 
 difierent caufes ; either from a morbid ftatc of 
 the bones, or from a contracted ftate of the mufcles, 
 or the bones and mufcles may both be affeded. In 
 fome cafes, diftortions are owing to original malcon- 
 formation ; in others, they arife in infancy, and in 
 fome, at more advanced periods of life. 
 
 For a confiderable time after birth, the bones are 
 foft and pliable, and are eafily affected by the poftures 
 of the body. The bones of the legs are apt to be 
 crooked by children being made to walk too early. 
 This alfo is the effect of fome difeafes, particularly of 
 rickets, which foften the bones fo much that they ea- 
 fily yield to the pofture of the body, as well as to the 
 ordinary aQion of the mufcles. But the mofl fre- 
 quent caufe of diftorted limbs is that contraction of 
 the flexor mufcles of the leg and fore-arm, which is 
 often induced by an inflamed ftate of the knee and el- 
 bow, and of which we have a very common example 
 in thofe cafes of white fweUing to which thefe joints 
 are more particularly liable. As the Hmb lies in great- 
 eft eafe while the mufcles are relaxed, the patient nat- 
 urally keeps it always bent ; and when this pofture is, 
 long continued, it almoft conftantly terminates in fuch 
 a contracted ftate of the flexor tendons, as keeps the 
 under part of the limb at an angle with the fuperior 
 part of it : of this we meet with daily inftances in the 
 leg ; where from this caufe alone a patient is often al^ 
 together deprived of the ufe of his limb. 
 
 As it has been a prevailing opinion among practi- 
 tioners, that little advantage is to be derived from any 
 remedies that we can employ for diftorted limbs, they 
 have feldom made any attempt to cure them : in con- 
 
Chap. XLI. Of Dijioried Limbs, 443 
 
 fequence of which, this branch of" pra£llce has been 
 ahnofh uiiiverfally trufled to itinerants or to profefl'ed 
 bonefetters. In this, however, we are wrong ; and 
 in faying fo, I can fpeak with confidence, founded on 
 much experience : having early in Hfe obferved the 
 mifery to which patients with diflorted Hmbs were re- 
 duced, I was refolved to make fome attempts for the 
 relief of fuch as might apply to me, however fmall the 
 chance might be of fucceeding ; and in various inftan- 
 ces I have had the fiitisfaftion of relieving, and in 
 fome cafes of curing completely, patients who had 
 been lame for feveral years, and where it was not ex- 
 pected that any thing could be done for their advan- 
 tage. Where an anchylofis is formed by the ends of 
 two bones forming a joint having adhered together, it 
 would be in vain to make any attempt to remove it, 
 unlcfs the inconvenience attending it were uncommon- 
 ly great : in which cafe, if it were the patient's defire, 
 this might be a reafon for amputating the limb ; or in 
 particular indances, it might be removed by taking 
 out the ends of the bones forming the joint, and al- 
 lowing the newly divided ends of them to unite to one 
 another : but when the fhitfnefs of a joint depends on 
 a contracted ftate of the mufcles and tendons that ferve 
 to move it, by much the mod frequent caufe of dif- 
 torted limbs, we may almoft in every inftance aflbrd 
 relief by more fimple means ; and where a limb is 
 crooked by a bone being bent, whether it may have 
 happened from improper management during child- 
 hood, or as the effect of rickets or any other difeafe, 
 w<f may very commonly, by timous attention, either 
 remove it entirely, or render it much lefs confiderable. 
 Where a limb is diflorted from a fliff contracted 
 ftate of the mufcles and tendons that belong to it, a 
 h'iti^ ufe of emollients, with moderate gradual exten- 
 fion, is the remedy from which I have derived moft 
 advantage, and which never in any inftance does harm. 
 Thofe who have not been in the practice of ufmg 
 emollients for this purpofe, may imagine, that they 
 
444 ^f Di/lorted Limbs. Chap. XLI, 
 
 will not penetrate to the depth of the mufcles and ten- 
 dons ; and when I firfl: employed them, I muft own, 
 that I did not expert they were to do fo in any re- 
 markable degree : but, knowing no other remedy that 
 was likely to lubricate fo effectually parts that were 
 become lliiF, I was refolved to give them a complete 
 trial ; and I was foon convinced of their utility : when 
 the Treatife on Ulcers was firft publifhed, I had occa- 
 fion to mention this, and fince that period very ample 
 opportunities have occurred of employing the fame 
 remedy with advantage. 
 
 In order, however, to gain this end, emollients mufl 
 be ufed with great freedom. All the contracted muf- 
 cles and tendons, from their origin to their infertion, 
 niufl be v/ell rubbed for at lead half an hour three 
 times a day ; and the limb fhould be kept conftantly 
 moifl with, or as it were immerfed in, the emollient, 
 by being covered with flannel well foaked in it at ev- 
 ery repetition of the frictions. "While the frictions, are 
 applying, the limb- fliould be flowly, though firmly, 
 extended to as great a degree as the patient can eafily 
 bear ; and the inftrument reprefented in Plate XC. 
 may be afterwards applied, in order to prevent the 
 mufcles from contracting. 
 
 It is neceffary, however, to remark, that this exten- 
 fion fhould not be made quickly : by doing fo, much 
 harm has been done, infomuch that joints have become 
 pained and inflamed, where there was not previoufly 
 any other difeafe than fliffnefs of the flexor mufcles ; 
 while it may be done with the utmoft fafety in the 
 gradual manner I have mentioned. In the one way, 
 mdeed, feveral months may be required for effecting 
 what a greater force might accomplifh in as many 
 weeks ; but the latter muft always be attended with 
 pain and hazard, while with the other we proceed with 
 eafe and fafety. 
 
 Even where extenfion is not neceffary, the effects of 
 emollients are often confpicuous. We frequently meet 
 with fliff joints, particularly in the ankle, without any 
 
Chap. XLI. Of Dijlorted Limbs. 445 
 
 contra£Hon or diftortion of the limb. In this cafe, 
 emollients alone, if duly continued, will commonly 
 relax them fufficiently. 
 
 Every kind of greafy application proves ufeful here, 
 but animal fats anfwer better than vegetable oils. The 
 greafe of gcefe and ducks and other fowls anfwers 
 well ; alfo hogs lard, and the oil obtained from boil- 
 ing recent bones of beef and mutton in water. Butch- 
 ers ufually keep this oil in quantities : when properly 
 prepared, it is quite pure and tranfparent, and has no 
 fmell. 
 
 When the diftortion of a limb proceeds from a bone 
 being bent, if this is not of long duration, and efpe- 
 cially when it occurs in childhood, we may frequent- 
 ly remove or lefTcn it by conftant prefiurc gradually 
 increafed on the convex fide of the limb, till the bone 
 is brought into its natural diredtion. 
 
 This kind of deformity often occurs in patients la- 
 bouring under rickets ; but we find it moit frequent 
 in new born children, either from original malconfor- 
 mation, or from fome fingularity in the fituation of 
 the child while in the womb. It is moft frequent irt 
 the legs, when it alfo affedts the dire£lion of the feet 
 and ankles. When the bones of the leg are bent out^ 
 ward, the foot is turned inward ; and, vice versa, th^ 
 foot is turned outward when the leg is bent inwards 
 Patients affefted in this laft manner are called valgi j 
 and vari when the feet are turned inward. 
 
 Thefe diftortions of the feet and ankles, have been 
 fuppofed to originate in almoft every inftance front 
 malconformation in the bones forming the joint of 
 the ankle ; and the means that have been propofed 
 for removing them, have been meant to produce an 
 alteration of that i(Mnt : thev mav in fome cafes arife 
 from this caufe, but I have fcarcely met with it. At 
 firft view of the difeafe, we are indeed apt to imagine 
 that the fault lies chiefly in the ankle ; but it will be' 
 very univerfally found, as I have juft obferved, to pro- 
 ceed fromt the form of the leg. When the leg is bent 
 
446i Of Dijloried Limhs. Cliap. XLI, 
 
 outward, the toes are turned inward, and the fide of 
 the foot downward ; or, if the curvature of the leg is 
 confiderable, the fole of the foot will be turned near- 
 ly altogether upward, while the top of the foot will 
 refl on the ground on every attempt to walk : and, on 
 the contrary, when the bones of the leg are bent in- 
 ward, the toes and fole of the foot will be turned out- 
 ward and upward. 
 
 Whoever will examine with attention the efFed pro- 
 duced upon the foot by the bones of the leg being 
 .curved in the manner I have defcribed, will find, that 
 the maladies we are now confidering muil necefl'arily 
 refult from it ; and although it may occafionally hap- 
 pen, that the joint of the ankle is atFe£ted by a long 
 continuance of the diflortion, yet in almoft every in- 
 ftance, the difeafe will be found to proceed originally 
 from the caufe I have mentioned : fo that in the cure, 
 our views ihould be chiefly direfted to this afl'eclion of 
 the leg. By removing the curvature of the bones, the 
 foot will gradually regain its natural fituation, while 
 all our endeavours will fail, if we only attempt to al- 
 ter the direction of the ankle joint. 
 
 When the foot and toes are turned inward, folely 
 from a malconformation of the ankle joint, we ought 
 no doubt to endeavour to give the joint a better direc- 
 tion ; but as I never met with an inftance of this, I 
 mufl: leave the particular mode of effecting it to thofe 
 who may happen to fee it. The befl method of ap- 
 plying preffure to the bones of the leg when bent, is 
 by fixing a firm fplint of iron in the flioe, on the con- 
 cave fide of the leg ; and if the head of the fphnt be 
 made to reft againft the correfponding condyle of the 
 femur, and the other end of it on the foot, an eafy 
 gradual preffure may be made upon the oppofite fide 
 of the leg, by one or two broad ftraps paffed round 
 both the leg and the fplint. If the fplint is covered 
 with foft leather, and properly fitted to the parts, it 
 gives no uneafinefs ; and by drawing the ftrap fur- 
 rounding it with the leg tighter from time tq time. 
 
 I 
 
Chap. XLI. Of Dijloried Lmhs, 447 
 
 the preiTure Is increafed in the gradual manner I have 
 mentioned. In Plate XCIV. figs. i. 2. and 3. an ap- 
 paratus is reprcfented ; which in different cafes, where 
 the curvature of the I'^g was very confiderable, and 
 where the fole of the foot was turned ahiioft entirely 
 upwards, anfwered the purpofe completely. It proves 
 fometimes fufficient to fix the fmall end of the fplint, 
 in the (lioe, and the broad flat pad at the top on the 
 condyle of the femur. A fplint for this purpofe is re- 
 prcfented in fig. 2. This gives it two fixed points, 
 by which we have it in our power to make any necef- 
 fary prefTure with the flraps paffed round the leg : but 
 in fome inftances, as was the cafe in two of thofe to 
 which I allude, the fole of the foot could not be kept 
 fo much down as to admit of this, without fixing the 
 fhoe to a frame, as is reprefented in fig. 3. for in all 
 fuch cafes the fole of the foot (hould be kept as much 
 as poflible in a natural fituation, otherwife the preflure 
 made upon the leg for removing the curvature in the 
 bones is apt to give a wrong diredion to the joint of 
 the ankle, by the under end of the fplint being necef- 
 farily made to reft on it. 
 
 I have thus given a general view of the nature of 
 this affedion, and of the management beft adapted for 
 removing it : but whether limbs are diftorted from a 
 contrafted ftate of the mufcles that belong to them, 
 or from a curvature in the bones, much variety muft 
 occur in the application of the remedy, particularly in 
 the manner of applying the extenfion. The treatment, 
 indeed, that fuits one cafe beft, is feldom exadly ap- 
 plicable to another : it muft therefore be varied ac- 
 cording to the judgment of the practitioner. 
 
 Other means have been propoicd for removing cur- 
 vatures in bones : of thefe the beft I have feen is an 
 invention of a late ingenious artift of this place, Mr. 
 Gavin Wilfon, who was long much employed in this 
 branch of bufinefs. In Plate XCIII. fig. i. and 2. I 
 have reprefented one of Mr. Wilfon's inftruments for 
 diftortions of the leg. 
 
44^ Of Di/loriiom *Chap. XLIL 
 
 CHAPTER XLII. 
 
 OF DISTORTIONS OF THE SPINE. 
 
 j'TP'HE fpine may be diftorted in various directions ; 
 
 1 outwardly, inwardly, and laterally ; and in fome 
 
 cafes it happens in all of thefe directions in the fame 
 
 perfon. This fometimes arifes from external violence ; 
 
 but more frequently as a fymptom of a delicate frame. 
 
 Befides the deformity which thefe diftortions pro- 
 duce, they are apt to injure the health, by comprefling 
 the abdominal and thoracic vifcera, and inducing pa- 
 ralytic affections of the lower extremities, in confe- 
 quence of the preiTure which they produce on the 
 nerves of thofe parts. They occur in all ages ; but 
 more frequently about puberty than at any other pe* 
 riod, and more commonly in girls than in boys. In 
 general, their. effects are obferved before the caufe is 
 fufpefted ; for there is feldoni much pain in the dif- 
 torted part. 
 
 When diflortion of the fpine occurs during infancy, 
 the patient appears to be fuddenly deprived of the ufe 
 of his limbs ; but at more advanced periods, he com-^ 
 plains firfl of feeblenefs and languor, and of numbnefs 
 or want of feeling in the under extremities. By de- 
 grees this want of fenfibility is found to increafe ; and 
 he is often obferved to (tumble and to drag his legs 
 inflead of lifting them cleverly, nor can he fland ere6t 
 for any length of time but with much difficulty. At 
 laft he lofes the ufe of his legs entirely, which become 
 altogether paralytic ; and when the fpine is diftorted 
 forward, fo as to comprefs the thoracic and abdomi- 
 nal vifcera, he becomes diftrefied with dyfpncea, or 
 ■with complaints in the fl;omach and bowels, according 
 to the part of the fpine that is difcafcd. 
 
 In fome the lofs of power in the extremities takes 
 place in the courfe of a few days from the lirft ap- 
 
Chap. XLIi. of the Spine. 449 
 
 proach of the difeafe ; and it fometimes becomes gra- 
 dually lefs, although it never is, fo far as I have ob- 
 ferved, entirely removed. 
 
 On the deformity being difcovered, we fometimes 
 find that one of the vertebra only is difplaced : fome- 
 times two or more are affedted ; and in fome cafes it 
 appears to arife folely from a thickening of the liga- 
 ments connedting the vertebrae together, without any 
 particular affedion of the bones. When one of the 
 Vertebrce only is difplaced, the patient is ufually more 
 completely deprived of the power of his limbs than 
 when two or more of them are difplaced, owing per- 
 haps to the angle being more acute, and confeqiiently 
 the prcflure on the medulla fpinalis more confiderable 
 when one bone only is thrown out of the range. This 
 alio accounts for the paralytic fymptoms being in fome 
 inftances lefs remarkable in more advanced ftages of 
 the difeafe than they were at firft ; for although one 
 bone only may be difplaced at firft, yet one or both 
 of the contiguous vertebras almoft conftantly yield at 
 laft ; and the difference arifmg from this is fo great, 
 that patients almoft always linger and die in the courfe 
 of a year or two, often in lefs time, when one bone 
 only is deranged ; while they live for a great length 
 of time, frequently as long as if no fuch circumftance 
 had occurred, when the curvature of the fpine be* 
 comes more extcnfive. 
 
 As diftortions of the fpine often proceed from deli- 
 cate weakly patients indulging too much in particular 
 poftures, every habit of this kind fhould be avoided 
 on the firft appearance of the difeafe. If the patient 
 has been accuftomed to lean much to one fide, the re- 
 verfe of this fhould be advifed ; and that the body 
 may lie as much as pofTible upon an equal furface dur- 
 ing fleep, he ought to ufe a hair mattrefs laid upon 
 boards inftead of a bed of feathers or dov;n. 
 
 By attention to thefe points ; by the ufe of an invi- 
 gorating diet ; the cold bath, bark, and other tonics ; 
 the difeafe has been in fome cafes prevented from ad- 
 
 Voi.. III. F f 
 
450 Of Dl/loriions of the Spine, Chap. XLII. 
 
 vancing fo far as it otherwife probably would have 
 done : but where any of the bones have been affecled, 
 I have never feen an inflance of a complete cure being 
 obtained. Mr. Pott, to whofe obfervations upon this 
 fubject we are much indebted, fpeaks highly of the ef- 
 fect of ifl'ues placed as near as pdflible to the tumor. 
 He advifes an iffue to be opened with cauftic on each 
 fide of the tumor, large enough to admit a kidney 
 bean, and the bottom of the fore to be fprinkled from 
 time to time with powder of cantharides. This I have 
 praclifed in various cafes, and in fome inftances with 
 obvious good effects : but in all of thcfe there was 
 reafon to fuppofe that the feat of the difeafe was in 
 the ligaments only, and not in the bones of the fpine. 
 When they have appeared to prove ufeful where the 
 bones have been affected, I conclude that the mitiga- 
 tion of fymptoms has arifen from the caufe I have 
 mentioned, the preffure upon the fpinal marrow be- 
 ing leflened in the progrefs of the difeafe. 
 
 Various machines have been invented for the re- 
 moval of diftortions of the fpine by preffure : all of 
 thefe, however, do harm, and ought never to be ufed. 
 It muff at once appear, to whoever is acquainted with 
 the anatomy of thefe parts, and with the nature of 
 this difeafe, that the difplaced bone is never to be for- 
 cibly pufhed into its fituation ; and if this cannot be 
 done, it is obvious that no advantage is to be derived 
 from the practice, while it is evident that much harm 
 may enfue from it. 
 
 In all diftortions of the fpine, it is an object of the 
 firft importance to fupport the head and ffioulders. 
 If this is negleded, the weight of the head tends al- 
 moft conftantly to increafe the curvature. The collar 
 ufually employed for this purpofe anfwers nearly as 
 well as any other. In Plate CI. fig. i. a reprefenta- 
 tion is given of one with fome improvements, by 
 which both the head and ffioulders may be very ef- 
 fectually fupported ; and in fig. 3. another is deline- 
 ated for fupporting the ffioulders only. 
 
Chap. XLIII. Of Necrofis. 45 1 
 
 CHAPTER XLIIL 
 
 OF NECROSIS. 
 
 TILL lately little was imderftood of this very fin- 
 gular difeafe : not from its being new, or that 
 it has only lately made its appearance, for it feems to 
 depend on caufes that have probably exifted equally 
 in all ages ; but from its having been confounded 
 with other difeafes, from which however it is widely 
 different. 
 
 We meet with many detached obfervations on this 
 difeafe, in the works of Hildanus, Chefelden, Gooch, 
 Hunter and others, but my friend ]\Ir. Ruffell was the 
 firft who gave a regular fyftematic account of it : the 
 defcription indeed that he gives of it is fo full, clear, 
 and perfpicuous, that fcarcely any thing new is left 
 for others to add to it.* 
 
 The term necrofis, is derived from the Greek word 
 nekros, mortuus ; in allufion to one of the moll re- 
 markable circumftances of the difeafe, which confifts 
 in the fpontaneous death of one bone, and the rcpro- 
 du(5tion of another, the laft of which is in part form- 
 ed before the other can feparate. 
 
 The old bone, which feparates, and commonly 
 comes away either diflblved in the form of matter, or 
 In one or more pieces, is termed the fequcftra, and it 
 is always furrounded by and included in the new one, 
 fo that the new bone mud be larger in circumference, 
 though not longer than the other. This being the 
 cafe, we would naturally fuppofe that thofe tendons 
 of mufcles which were originally inferted into that 
 
 • Vide a Praiflical EfTay on a certain difeafe of the bones, termed 
 Necrofis, illuftrated with lix plates, by James RujTclI, F. R. S. furgeon, 
 Edinburgli. 
 
 F F 2 
 
452 Of Necrofts. Chap. XLIII. 
 
 portion of the old bone that is now deftroyed, would 
 completely lofe their influence : but it is quite other- 
 wife ; for we find, that they poliefs their relative fitu- 
 ation in the newly formed bone, into which they are 
 inferted by the oihfication of a gelatinous fluid poured 
 forth around them. The new bone which is thus 
 produced, appears to be poflclfed of all the eflfential 
 properties of the original. It is not indeed fo regular 
 in its external appearance, nor internal ftruclure, for 
 it is not lamellated, but it can fet out oflific granula- 
 tions ; it may exfoliate, and it performs all the func- 
 tions peculiar to an original bone. 
 
 From all the experiments and obfervations that have 
 hitherto been made on the fubjeft, it feems to be pro- 
 bable that the periofleum is no way concerned in the 
 production of the new bone ; that it does not furnifli 
 granulations for its increafe ; that defliruction of the 
 marrow does not naturally follow an attack of necro- 
 fis ; but that this procefs never takes place without a 
 previous fl:ate of inflammation. 
 
 The fymptoms attending necrofis are the following : 
 Firft, there is a deep feated pain in the limb ; and in- 
 flammation and fuppuration take place : the matter 
 thus formed difcharges itfelf in one or more openings 
 in the moil prominent parts of the limb, and thefe 
 openings communicate with fmufes that commonly go 
 to the depth of the bone : the matter for the mofl 
 part is good, though copious, and it cannot be in- 
 creafed in quantity by prefiiire. 
 
 The fequefl:ra is not always difcovered by the probe, 
 and the fore fometimes heals without the former be- 
 ing thrown off" ; at other times, however, when the 
 inflammation is fevere, the fequefl:ra is thrown oflf 
 quickly, which commonly excites a temporary lofs of 
 power of the whole limb : but in general the inflam- 
 mation is flight ; the procefs of feparation goes on 
 flowly ; and the patient retains the motion and ufe of 
 his limb. 
 
Chap. XLIII. Of Necrcfts. 453 
 
 In the courfe of the difeafe, the fores frequently 
 heal and break out again, and holes form in the new- 
 ly formed bone correfponding with the fmous open- 
 ings on the furface : it has been found, that in this 
 difeafe even joints are regenerated, and in that cafe 
 the cartilage is always larger than in the original fe- 
 queftra ; this has taken place in the lower jaw, where 
 new fockets are formed for the teeth which have been 
 retained. 
 
 The progrefs of necrofis is always tedious ; in fome 
 it will be over in the courfe of a few months ; but in 
 a great proportion of cafes it goes on for two or three 
 years. 
 
 We chiefly meet with necrofis in infancy and early 
 youth, and more frequently in the lower jaw and in 
 the bones of the leg than in any other part of the 
 body. 
 
 ITie mofl obvious predifpofmg caufes of necrofis 
 are lues venerea, and a fcrofulous diathefis ; and in 
 fome inflanccs we can trace the exciting caufe to an 
 external accident, as a blow or a bruife. 
 
 The difeafes for which necrofis may be miflaken 
 are the following : caries of a bone produced by in- 
 flammation or colledions of matter without expofure 
 to the external air ; and it may be miftaken for the 
 exfoliation of an external lamella of a bone : but in 
 the latter the internal furface is fmoother, the matter 
 is thin and fetid, and the granulations lefs firm and* 
 more extenfive than in necrofis. 
 
 The danger arifing from necrofis is In a great mea- 
 fure to be eifimatcd from the degree of inflammation 
 and fever that takes place : it feldom proves danger- 
 ous, and where thefe fymptoms are moderate, the pa- 
 tient is able in a great proportion of cafes to conduct 
 his ordinary bufinefs without confinement ; but when 
 he becomes heftic, as fometimes happens, immediate 
 amputation of the limb is perhaps the only remedy to 
 be trufl:ed. 
 
454 Of Necrofis. Chap. XLIII. 
 
 In the cure of necrofis, no general treatment proves 
 of any avail, and there is reafon to think, \vhen the 
 fequeilra feparates eafily, that the interference of art 
 fhould never be advifed. If it be not indeed in cer- 
 tain circumftances, it is perhaps our beft practice to 
 do nothing in the whole courfe of the difeafe but to 
 obviate particular fymptoms. 
 
 When the pain is fevere, local bloodletting and the 
 general effects of antiphlogidic remedies, as I have al- 
 ready obferved, are to be chiefly depended on. When 
 matter is formed and is found to lodge in any of the 
 foft parts of the limb, it ought to be difcharged by 
 fmall openings, and the ftrength of the patient re- 
 quires to be fupported by due attention to a well re- 
 gulated diet, as otherwife it is apt to fmk by the long 
 duration of the difeafe. 
 
 In this manner a cure is frequently obtained with- 
 out any farther affiftance from art, that is, the fequef- 
 tra either diifolves and comes away infenfibly in the 
 matter difcharged from the fore ; or it comes ofl:' in 
 one or more pieces ; or the irritation that it excites 
 becomes inconfiderable, and the fores at laft heal, 
 while the fequeftra ftill continues furrounded with the 
 newly formed bone. The limb is larger than the oth- 
 er, and commonly fomewhat deformed by the inequal- 
 ities on the furface of the bone ; but under thefe in- 
 conveniencies the patient fometimes efcapes without 
 •much pain, and with little or no injury to his confti- 
 tution. 
 
 It fometimes, however, happens, that the fequeftra 
 does not come away, while at the fame time it creates 
 fo much irritation, that fever takes place, by which, 
 and by a profufe difcharge of matter from the fores, 
 the health of the patient is brought into hazard : in 
 this fituation, an attempt jfhould either be made to re- 
 move the fequeftra by a chirurgical operation, or im- 
 mediate amputation of the limb ftiould be advifed. 
 
 If any part of the fequeftra appears, it may be right 
 to endeavour to fave the limb by taking it away j but 
 
Chap. XLIIL Of Vecrofis. 455 
 
 where no part of the old bone is dlfcovered, under 
 all the uncertainty of the exacl fituation and flate in 
 which it may be, together with the rifk of increafing, 
 by this operation the ftate of irritation over the whole 
 limb, it will probably, in the courfe of further expe- 
 rience, appear to be our bed pradice, in fuch circum- 
 ftances, to advife the limb to be amputated. 
 
 The operation for removing the fequeflra is done 
 in the following manner : a longitudinal incifion is 
 made through all the foft parts covering the difeafed 
 bone : in this manner the bone mud be laid complete- 
 ly bare, but if the teguments are found, no part of 
 them fhould be removed. 
 
 If the fequeflra is difcovered by any holes in the 
 newly formed bone, and if thefe are very near to one 
 another, an opening fufficiently large for taking it out 
 may be made with a large fcalpel or a fliarp chifel 
 and mallet ; but it fhakes the limb lefs, and gives Icfs 
 pain to the patient, to do it with reiterated applica- 
 tions of the trephine, and afterwards to cut out with 
 a firm fcalpel, fuch fmall portions of the bone as the 
 faw may have left. In the event of no opening in the 
 new bone being met with, fmall holes may be drilled 
 in it with the perforator of a trepan. In this manner 
 the ftate of the fequeftra may be difcovered, when by 
 the operation that I have already defcribed, with the 
 head of the trepan, an opening may be made in the 
 new bone of a fufficient fize for removing the other. 
 This, however, as I have already obferved, is an ope- 
 ration neceflarily attended with uncertainty and haz- 
 ard, fo that in a great proportion of cal'es, it will pro- 
 bably be found to be a fafer practice' to amputate the 
 limb. 
 
 After the fequeftra is removed, mild dreflings fliould 
 be applied : emollient poultices and an antiphlogiftic 
 regimen prove ufeful, while fymptoms of inflamma- 
 tion take place ; by which, and a due attention to 
 regimen, the fore will heal eafily, when the health is 
 
45^ Of Necrofts, Chap. XLIII, 
 
 othervvlfe good : the cure however proves always te- 
 dious, bemg fcldom completed in lefs than fix months, 
 and as the limb fhould be kept during the whole pe- 
 riod at perfect reft, and as much as poflible in the 
 fame pofition, the confinement is necelTurily of the 
 moft diftrefsful nature. 
 
 This, together with the uncertainty and hazard of 
 the operation for removing the fequeftra when no 
 part of it appears, makes me conclude, as I have ob- 
 ierved already, that in all fuch circumftances it is per- 
 haps our beft pradice rather to amputate the limb. 
 
Seel. I. Remarks on Amputat'tGn* 457 
 
 CHAPTER XLIV. 
 
 OF AMPUTATION. 
 
 SECTION I. 
 
 General Remarks o?i the Operation of Ampidaiicn, 
 
 Y the term amputation, we ufually underftand 
 the removal of the whole or part of a hmb. We 
 fpcak of the extirpation of a tumor ; of the mamma ; 
 of a teftis : but we fay the amputation of a leg and 
 of an arm. 
 
 The mutilation, produced by this operation, renders 
 it one of the mod dreadful in the pradice of furgery ; 
 yet as the only means by which life can be faved, it is 
 frequently neceflary. It is an operation, however, fo 
 repugnant to humanity, fo diflrefsful to the unfortu- 
 nate fufl'erer, and in fome circumftances fo fraught 
 with danger, that nothing but a clear convidion of 
 this neceility can warrant our propofing it in any cafe. 
 
 The operation, indeed, is not difficult : every prac- 
 titioner accullomed to handle inflruments may perform 
 it. But to diftlnguifh with precifion the cafes which 
 require it, from thofe Vvhich might do well under a 
 different treatment, and to determine the particular 
 periods of each when it ought to be performed, are 
 circumftances which require more deliberation than 
 perhaps any other in furgery : I fhall therefore enu- 
 merate the caufes which may render amputation ne- 
 ceflary, before proceeding to defcribe the method of 
 performing it. 
 
458^ Of Caufes that render Chap. XLIV. 
 
 SECTION II. 
 
 Of the Caufes ivhich may render Amputation neceffary. 
 
 THIS operation may be rendered neceflary by va- 
 rious caufes ; all of which may be comprehend- 
 ed under the following heads. 
 I. Bad compound fractures. 
 
 I. Extenfive lacerated and contufed wounds. 
 
 3. A portion of a limb being carried off by a cannon 
 ball, or in any other manner, if the bones are un- 
 equally brokeYi and not properly covered. 
 
 4. Extenfive mortification. 
 
 5. White fwellings of the joints. 
 
 6. Large exoftofes, whether they are confined to 
 joints, or fpread over the whole bone or bones of 
 a limb. 
 
 7. Extenfive caries, accompanied with bad ulcers of 
 the contiguous foft parts. 
 
 8. Cancer, and other ulcers of an inveterate nature. 
 
 9. Various kinds of tumors. 
 
 1 o. Particular diflortions of a limb. 
 
 II. Necrofis. 
 
 Each of thefe caufes I fliall confider in the order in 
 which they are mentioned. 
 
 In Chapter XXXIX. Sedion XVI. I had occafion 
 to fpeak particularly of compound fractures : I fhall 
 at prefent therefore only remark, as the fubftance of 
 what was then fully pointed out, that in the army and 
 navy, v/here ordinary patients cannot be duly attend- 
 ed, and where they muft be much jolted, and often 
 removed from place to place, immediate amputation 
 fhould be advifed in all cafes of bad compound frac- 
 tures. Cafes will often indeed occur even in the worfl 
 fituations, in which it will be improper to amputate 
 the limbs. Thus, where little violence has been done, 
 and where the bones have been broken fo much in a 
 
Seel. II. Amputation necejfary. 459 
 
 tranfverfe direftion, that when replaced they fupport 
 each other with firmnefs, and efpecially if one bone 
 only is broken, it would no doubt be a fevcre, and 
 often an unneceflary nieafure, to propofe the removal 
 of the limb. But whenever much violence has been 
 done to a limb ; when the bones are broken in fuch 
 a manner that they do not, even when exadly replac- 
 ed, fupport each other firmly, and when the ilefhy 
 parts that cover them are much torn ; in all fuch fit- 
 uations, I confider it as a good general rule to advife 
 immediate amputation. Unlefs the operation, how- 
 ever, can be performed foon after the accident, it can- 
 not again be admiflible for a confiderable time ; for 
 whenever a limb has become fwelled and inflamed, it 
 can never, but with the utmofl danger, be taken ofl' 
 till thefe fymptoms fubfide. 
 
 In private praftice, however, where the patient can 
 from the fi)fl be placed in an eafy comfortable fitua- 
 tion, from which he need not be removed till his cure 
 iv5 completed ; where he can be kept perfectly quiet, 
 and have all the advantages of good air, a proper reg- 
 imen, and the alliftance of able practitioners, very few 
 cafes will occur in which immediate amputation Ihould 
 be advifcd. The only caufe, as I have elfewhere ob- 
 ferved, which in fuch circumftances can render imme- 
 diate amputation proper, is the bones of a limb, togeth- 
 er with the mufcles and other foft parts with which it 
 is covered, being fo fhattered and bruifed that there 
 will be no chance of the limb being rendered ufeful 
 by any attempt that might be made to fave it : in fuch 
 eircumftances, it fliould be removed immediately ; but 
 this not being done, the operation, as I have obierved 
 above, fliouId be delayed, till the fwelling, inflamma- 
 tion, and fever induced by the accident, are removed. 
 
 Although early amputation, however, is feldom ne- 
 ceffary in private praftice, yet, in the after treatment 
 of compound fraftures, it is fometimes proper : 
 
 I. In confequence of profufe hemorrhagies which 
 cannot be otherwife flopped. Thefe fometimes hap* 
 
460 Of Caufes that render Chap. XLIV. 
 
 pen from one or more arteries being cut by the ends 
 of the fracbured bones, as well as from other caufes. 
 
 2. In confequence of extenfive mortification. This 
 we fliall have occafion to confider more particularly 
 in fpeaking of mortification as one of the general caul- 
 es of amputation. 
 
 And, 3. By the ends of the fractured bones remain- 
 ing long difunited, attended with the difcharge of fuch 
 large quantities of matter, that the patient runs fome 
 rifk of finking under it. 
 
 I have elfevvfhere obferved, that the union of frac- 
 tured bones is fometimes prevented by a loofe portion 
 of bone being left which ought to have been remov- 
 ed ; and nothing more readily keeps up a profufe dif- 
 charge of matter : but when all fuch pieces of bone 
 have been removed ; when no union takes place ; or 
 when the difcharge dill continues in fuch quantities as 
 to weaken the patient notwithitanding of all that can 
 be done to prevent it ; fuch as preferving the limb 
 fteadily in one pofture, regular dreffing of the fore, a 
 nouriiliing diet, and a plentiful ufe of bark ; nothing 
 vvill in fuch circumftanccs fo certainly fave the patient 
 as the removal of his limb. 
 
 1. I mentioned extenfive laceration and contufed 
 wounds as the fecond general caufe of amputation. 
 Wounds not accompanied with fraftures of the con- 
 tiguous bones are feldom fo bad as to require ampu- 
 tation in any ftage of them : but when a limb is fo fe- 
 verely lacerated or contufed as to have all the large 
 blood velfels that belong to it deftroyed, fo as to leave 
 no ground of hope that the circulation can be preferv- 
 ed in it, immediate amputation iliould be advifed, 
 whether the bone is fafe or not. As in fuch circum- 
 ftances no effort on the part of the practitioner could 
 fave the limb ; and as wound,s of this defcription are 
 more apt to terminate in mortification than any other, 
 the fooiier the operation is performed the better. 
 
 It will alfo happen in lacerated and contufed wounds, 
 that amputation may be afterwards neceifary, although 
 
Sed. II. Amputation necejfary, 461 
 
 it did not appear to be fo at firft. In this refpe£l they 
 are limilar to compound fradures, and the Tame ob- 
 fervations will apply to them. Hemorrhagies may 
 occur which cannot be flopped ; extenfive mortifica- 
 tion may take place ; and fuch large quantities of 
 maft^ VQSff form, that the patient will not be able to 
 bear up under the dilcliarge. In any of thefe events, 
 we have to confider the removal of the Hmb as the on- 
 ly remedy. 
 
 3. The removal of a portion of a limb by a cannon 
 ball or other violence, was mentioned as the third gen- 
 eral caufe of amputation. 
 
 This is one of thofe cafes which many contend can 
 never require amputation : for the limb being already 
 removed, it will be better, they allege, to endeavour 
 to heal the fore, than to add to the pain and danger 
 of the patient by an operation. The argument is plau- 
 fible, but it will not bear examination. 
 
 In wounds of this kind, the bones are commonly 
 much fhattered, and even fplintered ; and the mufcles 
 and tendons are left of unequal lengths, and much 
 lacerated and contufed. In this fituation it is allowed 
 by all, that the feparate pieces of bone, as well as the 
 fliarp ends of the remaining bone, fliould be removed, 
 toccether with the rapeed extremities of the mufcles 
 and tendons. Now all this could feldom, I believe, 
 be done in lefs time than the operation of amputation ; 
 while by amputating above the injured part, and cov- 
 ering the bone with found mufcles and Ikin, we di- 
 miniih the fore fo much that it would probably heal 
 in a third part of the time that the original wound 
 would require ; at the fame time that the patient will 
 have a good ftump, which in the other method never 
 could be the cafe : with me this lafl argument of it- 
 felf Vv'ould be fufHcient for advifmg the operation un- 
 der the circumflances we are confidering : for, as I 
 do not fuppofe it would add to the danger, any addi- 
 tional momentary pain it might occafion, would be 
 amply compenfatcd by the advantage he would after- 
 
462 Of Caufcs that render Chap. XLIV. 
 
 wards derive from it. When the praftitioner has it 
 in his power, the operation fhould be advifed immedi- 
 ately ; for, however neceflary it might be, many pa- 
 tients would not afterwards have fufficient firmnefs of 
 mind to fubmit to it ; and, from ignorance of the ad- 
 vantages to be derived from it, would prefer prefent 
 eafe, to future conveniency and advantages, however 
 great they might be. 
 
 4. Mortification is the next caufe we have to con- 
 fider by which amputation may become neceflary. 
 They w^ho are determined to oppofe the pradice of 
 amputation as much as poffible, affect to confider it as 
 unnecefl'ary even in mortification : all the lelfer degrees 
 of it, they obferve, may be cured ; and when very ex- 
 tenfive, the patient, they allege, will commonly fall a 
 facrifice to the difeafe, whether the operation is per- 
 formed or not. This opinion, however, is fo direclly 
 contrary to fa£l:, and to the experience of every un- 
 prejudiced practitioner, that I need not attempt to re- 
 fute it : for although it w^ould be highly improper to 
 advife the removal of a limb in flight degrees of gan- 
 grene ; yet when mortification has fpread fo extenfive- 
 ly as to defliroy all or even a great proportion of the 
 foft parts of a limb, an occurrence too frequently met 
 with, what remedy could be employed inftead of it ? 
 As I know of none, and as I never heard of any that 
 in any way could prove ufeful, I fliall conclude, that 
 in mortification proceeding to fuch an extent as I have 
 mentioned, amputation of the limb becomes indifpen- 
 fable. 
 
 But although this do£trine will be generally admit- 
 ted, yet practitioners are not agreed with refpeft to 
 the period of mortification at which the operation 
 fliould be performed. Some contend, that in almofl: 
 every cafe of gangrene, and efpecially where it pro- 
 ceeds from external violence, the limb fliould be am- 
 putated as foon as mortification is evidently formed, 
 and while it continues to fpread : others are of o])In- 
 ion, that amputation fliouId never be advifed till the 
 
Se£t. II. Afiiputation neccjfary. 463 
 
 gangrene is not only flopped, but till the gangrenous 
 parts are feparated from the found. 
 
 Thofe who advife immediate amputation obferve> 
 that by taking the limb ofl' above the difeafed part, we 
 may prevent the progrefs of the mortification, and may 
 thus fave the patient. Although the argument is fpe- 
 cious, it does not appear to be well founded ; and fo 
 far as my obfervation goes, I would fay that it is a 
 practice fraught with danger, and ought univerfally to 
 be difcarded : for however attentive we may be in am- 
 putating at a part of the limb that appears to be found, 
 even the mod experienced practitioner will be liable 
 to be deceived. The (kin may be perfedly found, and 
 may be free from pain, inflammation, and fwelling ; 
 and yet the deep feated mufcles, and other parts con- 
 tiguous to the bone, may be in a ftate of gangrene. 
 Of this I have feen various inftances : but even where 
 the whole divided parts are found to be entirely found, 
 if the operation is performed while mortification is ad- 
 vancing, the difeafe feldom fails of feizing the flump ; 
 at lead, I never knew an inftancc of the contrary, and 
 I have unfortunately been concerned in different cafes 
 where this pradice was adopted. On converfing with 
 practitioners, who, from peculiarity of fituation, have 
 much employment in thofe accidents which are moft 
 apt to terminate in gangrene, 1 alfo find that their ex- 
 perience tends to fupport this opinion : it was alfo 
 the decided opinion of the late Mr. Sharpe, and Mr. 
 Pott, and of every modern practitioner of obfervation.* 
 I think it right to mention this, as attempts have of 
 late years been made by fome fpeculative practitioners 
 to introduce a contrary practice ; which if admitted, 
 there is much reafon to fufpeCt would prove extreme- 
 ly hurtful, although from its proving fo univerfally 
 
 • Mr. Pott's words upon this point arc very ftronj^ : " I have more 
 * tlian once fctii tlie cxptriincnt made of amputating after a gangrene 
 " lias been begun ; but I never law it fucceed : it has always hurried the 
 " patient ■» dcftruCtion." Vide Remarks on Fradures, &c. 
 
464 Of Caufes that render Chap. XLlV* 
 
 unfuccefsful, there is reafon to hope that it will foon 
 be laid afide, even by thofe who at prefent patron- 
 ize it. 
 
 I would not think it neceffary, however, to delay 
 the operation fo long as is advifed by fome, and par- 
 ticularly by Mr. Sharpe ; who thinks that it Ihould 
 never be performed till the feparation of the mortified 
 parts is coniiderably advanced.* As Mr. Sharpe was 
 a man of much experience, his obfervation may prove 
 to be well founded ; but fo far as I have yet feen, I 
 would confider it as fufficient to wait till the mortifi- 
 cation is completely flopped, but not much longer : 
 in this manner, v^e feem to reap all the advantages 
 which the caution that I have adviicd can give ; and 
 the earlier after this that the mortified parts are remov- 
 ed, the more readily we prevent the fyftem from fuf* 
 fering by the abforption of that putrefcent matter which 
 a gangrenous mafs univerfally yields. 
 
 The opinion that I have given relates to every vari- 
 ety of gangrene. In whatever w^ay it may have arif- 
 en, the practice fhould be the fame : for although fome 
 ftrefs has been commonly laid upon the circumftance 
 of its proceeding from an internal or external caufe, 
 yet no utility is derived from this. The operation 
 fhould in no inftance be advifed till the period I have 
 mentioned ; and at that time, whatever may have been 
 the caufe of the difeafe, no delay fhould be admitted. 
 
 tj. In mentioning white fwellings of the joints as a 
 caufe of cftnputation, I mufl refer to Chapter II. Sec- 
 tion III. § I o, for the management of the difeafe, as 
 well as for a more particular account of thofe fymp- 
 toms that more efpecially indicate the operation. At 
 prefent I have only to obferve, that as long as there 
 is the leaft reafon to hope that by any means the limb 
 may be faved without hazard to the patient, the ope- 
 nition fliould never be advifed. As a farther motive 
 for this, I may remark, in addition to what I have in 
 
 • vide Treatife on the Operations of Surgery, Chapter xxxvii. 
 
Sed. II. Amputation necejfary, 465 
 
 various parts of this work done already, that amputa- 
 tion, more frequently fucceeds, that is, a greater pro- 
 portion recover from the operation when it is delayed 
 till the patier^t is confiderably reduced by the difeafe, 
 than when it is performed in the more early part of 
 it. The caufe of this may be nearly the fame as what 
 I have given in Chapter XXXIX. Section XVI. when 
 advifing late amputation in fome circumilances of 
 compound fractures. 
 
 6. In Chapter II. Se6lion III. I entered upon the 
 confideration of the various kinds of exoflofis ; fo that 
 at prefent I have only to remark, that when a difeaf- 
 ed portion of bone cannot be taken out in the manner 
 I have formerly advifed, and when the tumor is eith- 
 er hurting the patient's health or has become unfup- 
 portable from its fize or any other circumftance, am- 
 putation of the limb, when no particular reafon pre- 
 vents it, fhould be advifed as the only remedy. 
 
 7. The next caufe that I have mentioned of ampu- 
 tation, is an extenfive caries attended with ulcers of 
 the contiguous parts. AVhen fpeaking of caries, in 
 the feventh Sedlion of Chapter V. I pointed out the 
 different means employed for the cure of the difeafe, 
 that is, for promoting an exfoliation of the difeafed 
 part of the bone. In addition to what I had then oc* 
 cafion to fay, it may be obferved, that although an 
 extenfive caries is in general confidered of itfelf as a 
 fufficient reafon for amputating a limb, yet it certain- 
 ly Ihould be admitted under much reilridlion. How- 
 ever extenfive a caries may be, even although it occu- 
 pies the whole length of a bone, it may be in many 
 inftances removed ; and we have many on record of 
 deficiencies produced in this manner being amply fup- 
 plied by a regeneration of bone : fo that where the 
 conditution is found, and more efpecially when the 
 patient is young, a carious bone will feldom of itfelf 
 be a fufficient motive for removing a limb, at leall the 
 chance of faving it by removing the difeafed bone 
 
 Vol. III. G g 
 
456 Of Caufes that render Chap. XLIV.. 
 
 fhould firfl be given. But when a carious bone is con- 
 oined with deep and extenfive ulcers of the corre- 
 fponding foft parts, which might give much caufe to 
 fufped that a cure would not be obtained even al- 
 though the difeafed bone fliould be taken out, ampu- 
 tation fhould be preferred ; for in this fituation, be^ 
 fides the difficulty of healing the fores, the formation 
 of any confiderable quantity of bone would be very 
 uncertain, and therefore the rifk fhould not be in- 
 curred. 
 
 8. The next caufe to which we have to advert, by 
 which amputation may become necelfary, is cancer, 
 and other ulcers of an inveterate nature. 
 
 When fpeaking of cancer in Chapter V. Sedion 
 VIII. I endeavoured to fhow, that no dependence is to 
 be placed either upon internal medicines or outward 
 applications for a cure ; and that the removal of the 
 difeafed part is alone to be trufted. It mufl be ac- 
 knowledged that cancer does not frequently occur in 
 the extremities : but every practitioner muft have feen 
 it on different parts of them ; and wherever it appears, 
 the removal of the difeafed parts with the knife fhould 
 be advifed immediately. They may be often taken 
 away without amputating the limb ; but when the dif- 
 eafe has attacked the ligaments or bones, and efpe- 
 cially when the fore is extenfive, nothing but the re- 
 moval of the limb above the parts difeafed ought to 
 be trufted. In fuch circumitances, I have known at* 
 tempts made to fave the limb, but never with fuccefs. 
 Even the removal of the limb will fometimes fail ; 
 but I have known it anfwer where the difeafe had re- 
 turned after being removed in the ufual way. 
 
 Befides cancer, other ulcers may, in particular clr- 
 cumftances, render amputation neceffary : where an 
 extenfive ulcer, not induced by any general alfedion 
 of the fyftem, is hurting the health of a patient ; and 
 when, inftead of yielding to the ufual remedies, it be- 
 comes more extenfive and more inveterate, as it might 
 at laft proceed io far as to endanger life, wc ought 
 
Se£l:. II. Amputation nece[faryi, 467 
 
 rather to advife the limb to be taken off. Such ulcers 
 as are ufually termed phagadenic, fometimes ternunate 
 in this fatal manner : but this termination is mod fre- 
 quent in fniuous ulcers ; fuch as arife from deep feat- 
 ed abfcefles, where the matter has found accefs be- 
 tween the interftices of the large mufcles, and where, 
 notwithftanding all our endeavours, the difcharge con- 
 tinues to be fo proful'e as to endanger the life of the 
 patient. 
 
 9. Various kinds of tumors may render amputa- 
 tion neceflary. 
 
 Encyfted tumors feldom lead to this neceflity ; but 
 in fome inilanccs where they are deep feated, origin- 
 ating pei;haps from the periolleum, when they are al- 
 lowed to remain till they acquire a great bulk, all the 
 contiguous parts come to be fo much injured, that 
 nothing but the removal of the limb will anfwer any 
 good purpofe. In fome cafes, by long continued pref- 
 lure from the tumor, the contiguous bones not only 
 become carious, but are altogether diifolved ; at the 
 fame time that the cellular fubftance, and even the 
 mufcles of the limb, become fo much difeafed as to 
 give no caufe to hope that we could be able to fave 
 them. ► 
 
 We fometimes find a portion of a limb confiderably 
 enlarged, with an uniform hardnefs in fome parts, and 
 in others 3. degree of foftnefs that gives caufe to fuf- 
 pedl that a' fluid is collected beneath. The (kin at 
 hrfl retains its natural colour ; but at laft acquires a 
 livid hue. The commencement of the difeafe is not 
 attended with pain ; but at laft it not only becomes 
 painful, but extremely troublefome from its weight. 
 It ufually begins without any evident caufe, and often- 
 in people who are otherwife healthy : at firft the fwell- 
 ing commonly appears on the inferior part of a limb, 
 and proceeds gradually up till it occupies the whole 
 of it. 
 
 o G 2 
 
468 Of Caufes that render Chap. XLIV. 
 
 This kind of fwelling is at firfl: often miflaken for 
 common oedema or anafarca ; and feems to be fo far 
 of this nature, that it is evidently produced by efFu- 
 fion into the cellular fubflance : but inflead of being 
 of the ferous kind, the effufed fluid is found to be 
 tinged with blood, and of an acrimonious nature ; at 
 leaft this has been the cafe in all that I have known 
 opened : and it has likewife happened, that the mat- 
 ter has never been difcharged in fuch quantities as to 
 have much influence on the fize of the tumor, the 
 fwelling ufually remaining of nearly the fame bulk 
 after the operation as it was before : hence no advan- 
 tage is derived from it ; on the contrary, the opera- 
 tion very commonly does harm. A painful fore is 
 produced ; and it always accelerates the progrefs of 
 the tumor. Indeed, nothing that I have ever known 
 employed has any eftecl in retarding it ; fo that I con- 
 lider amputation as the only refource, whenever the 
 tumor has become fo large as to give much uneafi- 
 nefs. Whether it will always prove effectual or not, 
 I cannot pretend to fay ; but hitherto I have met with 
 jio inftance of the difeafe returning where amputation 
 was performed on a found part of the limb. 
 
 SwelKngs of the aneurifmal kind have alfo been 
 confidered as a caufe which, in particular fituations, 
 may give rife to amputation. This has originated 
 from the operation for the aneurifm having failed in 
 different inflances when performed upon the crural 
 artery, and from the amputation of the limb having in 
 fimilar affedtions faved the life of the patient. When 
 an aneurifm in the ham or the thigh is large, and has 
 been of fuch long duration as to hurt the texture of 
 the foft parts, as well as to injure the bone, which ef- 
 fufed blood is apt to do, it will no doubt be better to 
 amputate the Hmb than to niake any attempt to fave 
 it : but in fuch a cafe, it is not the aneurifm for which 
 amputation is advifed, but a morbid (late of the parts, 
 induced by the difeafe being allowed to continue too 
 long before any eifedual meafure is adopted. In the 
 
Sed. II. Atnputation necejfarj, 469 
 
 commencement, and for a confiderable time thereaf- 
 ter, of tlie femoral or poplitean aneiirifm, I fhould 
 never advife the amputation of a limb : for different 
 inftances are on record of limbs being faved by the 
 operation for the aneurifm, even where the artery was 
 injured in the fuperior part of the thigh : but where 
 fuch an extenfive oedematous fwelling is induced all 
 over the under part of a limb, as to leave no room to 
 hope that it could again be reftored to ufe, even al- 
 lowing the operation for the aneurifm to fucceed, it 
 will no doubt be better to amputate immediately than 
 to attempt the operation. 
 
 The aneurifm to which I allude, is that which pro- 
 ceeds from a dilatation of the artery, and in which the 
 coats of the veflel have burft, fo as to produce a con- 
 fiderable effufion of blood into the furroundiug cellu- 
 lar fubftance, probably before any proper affillance is 
 defired. This w-ill feldom happen but with the poor- 
 efl clafs of people j and therefore this difeafe, in the 
 ftate we are now fpeaking of, is chiefly found in hof- 
 pitals. At full it is always attended with a flrong 
 pulfation ; but in its latter ftages the fwelling becomes 
 fo large, that the beating of the artery is fcarcely, if at 
 all dilcovered ; by which it is apt to be miftaken for 
 a tumor of a different kind : but for the mod part, a 
 due attention to the hiftory of the cafe from the be- 
 ginning, will lead to a knowledge of its real nature. 
 
 The I oth general caufe that I enumerated, by which 
 amputation may become neceffary, is particular dillor- 
 tions of a limb. 
 
 Where a limb is in other refpeds perfedly found, 
 it will feldom happen that any diftortion to which it 
 is liable will be confidered as a fufficient reafon for 
 this operation : but in the courfe of much bufmefs, 
 cafes are fometimes met with in which limbs are fo 
 much diftorted, and produce fo much diftrefs, that 
 patients rather incline to have them removed than 
 fubmit longer to the inconvenience. When in fuch 
 circumflances we are not able to remove the dillor- 
 
47 o General Remarks Chap. XLIV. 
 
 tion by means of a more gentle nature, we are in fomc 
 cafes obliged to comply with the patient's requeft. 
 
 II. Certain flates of necrofis may render amputa- 
 tion neceflary, as may be feen in Chapter XLIII. 
 
 Thefe are the feveral caufes by which the amputa- 
 tion of a limb may be rendered neceflary.- As they 
 are very various, and as the lofs of a member is to 
 every patient an obje£t of much importance, they 
 merit, in every inftance, the utmoft attention from 
 practitioners. Indeed this point of pradice, namely, 
 that of fixing with precifion thofe cafes in which the 
 amputation of limbs (hould be advifed, with the moft 
 fuitable periods for the operation in each, is attended 
 with fuch difficulty, and a furgeon is fo apt to be bla- 
 med if he proceeds to the operation fo long as there 
 is the fmallefl doubt of its being neceffary, that it 
 fhould be held as a fixed regulation with every prac- 
 titioner, never to operate but with the advice of fome 
 of his brethren in confultation, when this can poflibly 
 be obtained. I fhall now proceed to defcribe the me- 
 thod of operating. 
 
 SECTION III. 
 
 General Remarks on the Method of Amputating Limbs. 
 
 SUrgery is not perhaps in any part of it brought 
 to greater perfection than in the method of am- 
 putating limbs. Before the invention of the tourni- 
 quet, this operation v/as attended with fo much haz- 
 ard, that few furgeons ventured to perform it : nay, 
 long after the introduction of this inftrument, the dan- 
 ger attending it was fo great, that more than one half 
 perifhed of all who had refolution to fubmit to it. 
 
 In the prefent improved flate of the operation, I do 
 not imagine that one death will happen in twenty ca- 
 fes ; even including the general run of hofpital prac- 
 
Seft. III. en Amputation* 47 1 
 
 tice : and In private pradice, where due attention can 
 be more certainly bellowed upon the various circum- 
 ftances of the operation, the proportion of deaths will 
 be much lefs. 
 
 The circumftances in this operation that more par- 
 ticularly require attention, are, the choice, when this 
 is in our power, of the part at which a limb fhould be 
 amputated ; the prevention of hemorrhagy during the 
 operation ; the divifion of the (kin, mufcles, and 
 bones, in fuch a manner as to admit of the Hump be- 
 ing completely covered ; the tying of the arteries 
 alone, without including the nerve or any of the con- 
 tiguous parts : fecuring the teguments in a proper 
 fituation, fo as to prevent their retra£lion after the 
 operation ; and a proper fubfequent treatment of the 
 cafe. 
 
 Next to fecuring the patient from lofs of blood, the 
 moft material of thefe is the faving of fuch a propor- 
 tion of the foft parts as will cover the ftump, fo as to 
 heal the fore as nearly as pofTible by the firfl intention : 
 for without this, the wound produced by the removal 
 of a lai^ge limb is always extenfive ; the cure accord- 
 ingly proves tedious ; and the difcharge fo copious, 
 that the patient's health is by this caufe alone irrepar* 
 ably injured. 
 
 The inconveniencles arlfmg from this were fo obvli 
 ous, that various attempts were made, from time to 
 time, to improve this part of the operation. At firfl:, 
 all that was done in amputating a limb, was to cut the 
 foft parts down to the bone by one ftroke of a knife, 
 and afterwards dividing the bone with the faw at the 
 edge of the retraced mufcles. It was afterwards pro- 
 pofed by Mr. Chefelden to divide the foft parts by a 
 double incifion ; to divide the ikin and cellular fub- 
 ftance with a circular incifion ; and then to cut 
 through the mufcles at the edge of the retra£led (kin : 
 by this means the faw was applied higher in the bone, 
 and the flump was better covered both with mufcles 
 
472 General Remarks Chap. XLIV. 
 
 and (kiri. Still, however, an extenfive fore was left ; 
 infomuch that in amputating the thigh, a cure was 
 feldom performed in lefs than three or four months ; 
 often five or fix were required ; and after all, the 
 flumps were commonly pyramidal, by the bone pro- 
 je6ling beyond the foft parts : it often happened too, 
 that another fore was produced by this part of the 
 bone exfoliating, long after the patient confidered 
 himfelf as perfeftly well. 
 
 To prevent this pyramidal or fugar loaf (lump, as 
 it is termed, a bandage or circular roller was employ- 
 ed, with a view to fupport the mufcles and teguments, 
 and to prevent their retradion ; and when properly 
 applied from the upper part of the limb downwards, 
 it in fome degree aniwcred the purpofe, but never with 
 fuch effe6l as to prevent the cure fj-om being tedious. 
 In order to fhorten it farther, it was propofed by the 
 late Mr. Sharpe, in his Treatife on this Operation, to 
 draw the teguments near together by flitches or pieces 
 of tape palTed through them, and tied acrofs the Hump : 
 but the pain and inconvenience arifing from this was 
 fo great, that it never was generally practifed ; and 
 Mr. Sharpe himfelf at lall defifted from it. 
 
 It was now thought impofTible to improve this meth- 
 od of operating, fo as to fhorten the cure, and in place 
 of a pyramidal flump, to give the fore a plain furface. 
 In confequence of this, about forty years ago, differ- 
 ent furgeons attempted to revive v/hat was termed the 
 flap operation ; which had been firft praftifed, upwards 
 of a hundred years ago, by an Englifh furgeon of the 
 name of Loudham. It was done by faving a flap of 
 the mufcles and fkin, in the manner I fhall afterwards 
 defcribe, laying the flap over the flump, and fecuring 
 it in this fituation with proper bandages till it united 
 to the parts beneath. 
 
 As this afforded a thick mufcular cufhion to the 
 flump as well as a complete covering of found fkin, 
 the highefl expectations were formed of it : but the 
 
Sea, III. 071 Jmpufatloti. 473 
 
 objections to it, which I fhall afterwards mention, were 
 fo great, that the utmoft exertions, even of expert fur- 
 geons, to render it more perfed:, have not been able 
 to introduce it to general ufe. 
 
 This failure again excited the attention of practition- 
 ers to the improvement of the common operation of 
 amputation ; and their endeavours have not proved 
 unfuccefsful. By the prefent improved method of 
 operating, fo much of the teguments are faved as com- 
 pletely covers the (lump ; by which, in fome inftan- 
 ces, a cure is obtained by the firft intention without 
 the formation of matter : and in all, unlefs there is 
 fomething particularly bad in the habit of body, or 
 unlefs the inilammation unexpectedly runs to a very 
 unufual height, a cure is completed in the courfe of a 
 few weeks. As I confider the improvement by which 
 thefe ends are efi'eded as one of the molt important 
 in modern practice, I hope to be excufed, if I fliortly 
 ftate the fhare I have had in the introduction of it, be- 
 fore proceeding to defcribc the operation itfelf. 
 
 In the courfe of my education, while attending the 
 hofpital here, as well as the hofpitals of London and 
 Paris, the inconveniencics arifmg from the want of at- 
 tention to the faving of fkin in different chirurgical 
 operations, ftruck me (trongly ; fo that I v/as refolvtd 
 to take every proper opportunity in my own practice, 
 of treating this point with particular attention. 
 
 From the year 1772, when I fettled in bufmefs, I 
 laid it down as a maxim, not to be deviated from, to 
 fave as much fivin and cellular fubftance in the remov- 
 al of tumors, whether cancers or others, when the 
 foundnefs of part admitted of it, as would completely 
 cover the fores ; and in amputating any of the extrem- 
 ities to fave as much of them as would entirely cover 
 the flumps. I firlt performed amputation in the courfe 
 of that year ; and finding the improvement of faving 
 fkin to anfwer even beyond my expectation, (for the 
 cure of a large flump in an amputation of the thigh 
 
474 0?: Amputaiing Chap. XLIV. 
 
 was completed in three weeks,) I did not fail of put- 
 ting it afterwards in practice both in pubhc and pri- 
 vate. The pra£lice was hkewife adopted by my friend 
 IVIr. Hay of this place, and more lately by fome other 
 gentlemen in their attendance at the hofpital ; and ev- 
 er fmce that period, Mr. Hay, I believe, and I, have 
 invariably adhered to it, fome deviations being occa- 
 llonally introduced in the mode of doing it, with a 
 view of rendering it more perfeft ; by which the cures 
 have in every inllance been greatly fhortened. In va- 
 rious' cafes, large flumps which by the ufual method 
 would have required feveral months, were cured in as 
 many weeks : in a few, as was obferved above, the 
 parts united by the firfl intention j and in all, a plain 
 uniform ftump was produced. 
 
 After this had been praclifed for feveral years, Mr. 
 Alanfon of Liverpool, in the year 1779, publiflied 
 fome Obfervations upon Amputation, in which a me- 
 thod of operating is defcribed, v^hich he recommends 
 in the warmefl manner, as anfwering every objeft to 
 be expected from this operation ; and more efpecially, 
 that of curing the flumps in a great meafure by the 
 firfl intention. 
 
 As Mr. Alanfon's mode of operating has of late 
 been very defervedly preferred to every other that was 
 before publifhed, I fhall afterwards give an account of 
 it ; but in the mean time, 1 fhall defcribe that which 
 I have long been accuflomed to praftife, and which, 
 after various trials of every other of which I have yet 
 heard, I itill continue to prefer. In the firfl place, I 
 fhall defcribe the operation as it is performed upon the 
 thigh, and fhall afterwards fpeak of the method of 
 amputating other parts of the extreniities. 
 
Sea. IV. the Thigh, 475 
 
 SECTION IV. 
 
 Of Amputating the Thigh, 
 
 IN amputating either the thigh or leg, the patient 
 fliould be placed upon a table of an ordinary height, 
 with the leg properly fecured and fupported by an af- 
 fiftant fitting before him. The other leg fhould like- 
 wife be fupported, at the fame time that the arms 
 fhould be fecured by an afliflant on each fide, to pre- 
 vent interruptions during the operation. 
 
 The flow of blood to the limb fliould now be flop- 
 ped by the application of the tourniquet, in the man- 
 ner I have mentioned in Chapter VII. and as it is of 
 importance to have the inflrument placed as near as 
 poffible to the top of the thigh, the cufhion placed up- 
 on the femoral artery fhould reach the groin. 
 
 This is neceffary when the operation is to be per- 
 formed on the upper part of the limb ; but it may 
 likewife be done with fafety where it is to be taken 
 off immediately above the knee : and I may here ob- 
 ferve, with refpedt to the mod proper place at which 
 a thigh fhould be amputated, that no more of it fhould 
 be taken away than is rendered neceffary, by the dif- 
 eafe j for the more of it that is left, the more ufeful 
 it proves. 
 
 An alfiftant fhould now be direfted to grafp the up- 
 per part of the limb with both hands, and to draw up 
 the ikin and cellular fubflance as far as pofTiblc. While 
 the parts are in this flate of tenfion, the operator, Hand- 
 ing on the outfide of the patient, fhould divide them 
 with a circular incifion down to the mufcles : this may 
 in general be done with one llroke of the amputating 
 knife, fig. 3. Plate XCVIII. but in large limbs it is 
 eafier done at twice. The afliflant continuing to draw 
 the teguments upwards, the cellular fubflance con- 
 necting them to the mufcles beneath, fhould be divid- 
 
47^ Of Ampuiating Chap. XLIV. 
 
 ed with the edge of the knife till as much of the fl-:in 
 is feparated as the operator thinks will completely cov- 
 er the flump. 
 
 The fkin being ftill drawn tightly upwards, the 
 mufcles fliould be divided clofe to the edge of it down 
 to the bone, by one perpendicular and continued flroke 
 of the knife, beginning with the upper part of the 
 large mufcles on the infide of the thigh, and continu- 
 ing the incifion round through thofe beneath, and on 
 the outfide till it terminates where it commenced. 
 During this part of the operation, fome attention is 
 neceifary to avoid the edge of the retraded (kin ; but 
 it may always be done if the operator is upon his 
 guard, for he may with little difficulty have his eye 
 upon the courfe of the knife from firfl: to laft ; nor 
 can this part of the operation be done with fafety in 
 any other manner. Even where different afliftants are 
 employed to proted the Ikin, it will be apt to be 
 wounded, if the operator does not at every point fol- 
 low the knife with his eye. 
 
 In the ufual method of operating, the bone would 
 now be fawn acrofs at the edge of the retracted muf- 
 cles : but we are more certain of having a good flump, 
 if the mufcles are previoufly feparated from the bone 
 for the fpace of an inch ; and it is eafily done by in- 
 fer ting the point of the amputating knife between them, 
 and carrying it freely round from one fide of the limb 
 to the other. This being done, the mufcles and teg- 
 uments muft be drawn up as far as the mufcles have 
 been feparated from the bbne ; and it is eafily done, 
 either with a bit of flit leather, fuch as is reprefented 
 in Plate XCVIL fig. 4. or with the iron retradors in 
 the fame Plate, fig. 2. and 3. The periofteum fhould 
 now be divided at the place where the faw is to be ap- 
 plied, and it fhould be done with one turn of the 
 knife ; for where much of it is fcraped off, very tedi- 
 ous and troublefome exfoliations are apt to enfue : the 
 knife fhould therefore be carried round the bone di- 
 redly beneath the retradors. At this place the faw 
 
 I 
 
Sea. IV. the TJj'igh. 477 
 
 {hould be applied, and with long fteady flrokes the 
 bone fhould be divided. Thefaw represented in Plate 
 XCVIII. fig. I. anfwers much better than the ufual 
 form of the inftrument with a heavy iron back. In 
 performing this part of the operation, the affiflant hold- 
 ing the leg fhould be diredled to fupport it fteadily ; 
 for if raifed too far, the motion of the faw will be im- 
 peded, while the bone will be apt to be fplintered if 
 it be not fufficiently raifed. Any points or fplinters 
 that may be left, fliould be immediately removed with 
 the nippers, Plate XLIII. fig. 2. 
 
 The retradors ihould now be taken off; and the 
 trunk of the femoral artery being eafily feen, fhould 
 be drawn out with a tenaculum, and a fuflicient hga- 
 ture made upon it before the tourniquet is loofened : 
 but as the mufcular branches of this artery cannot be 
 difcovered as long as they are comprefled, the fcrew 
 fhould be immediately untwifted, fo that the prefl'ure 
 may be entirely removed. All the clotted blood fhould 
 be now removed from the flump with a foft fponge 
 foaked in warm water ; and every artery that can be 
 difcovered fhould be fecured with a ligature, care be- 
 ing taken to leave the ends of the threads of a fufficient 
 length to hang over the lips of the wound. 
 
 The blood veffels being all fecured, and the furface 
 of the wound cleared of blood, the mufclcs and tegu- 
 ments fhould be drawn down till the fkin completely 
 covers the ftump, and fliould be retained in this fitu- 
 ation by an affiitant till a flannel or cotton roller, pre- 
 vioufly fixed round the body to prevent it from flip- 
 ping down, is applied in fuch a manner as to fupport 
 and fix them : tor which purpofe the roller fliould be 
 pafl'ed two or three times, nearly in a circular direc- 
 tion, round the top of the thigh ; and fliould after- 
 wards, with fpiral turns, be brought down near to the 
 end of the flump, of fuch a tightnefs as to prevent the 
 niufcles and fkin from retracing, without comprcfling 
 them fo much as to proAe painful, or to impede the 
 circulation. Here the roller fhould be fixed with a 
 
478 Of Amputating Chap. XLIV., 
 
 common pin, while as much of it is left as will pafs 
 two or three times round the flump, for a purpofe ta 
 be prefently mentioned. 
 
 The ends of the divided mufcles being placed with 
 as much equality as poiTible over the bone, the edges 
 of the fliin mufi: be laid exadlly together, fo as to form 
 a flraight longitudinal line along the centre of the 
 (lump. When only one or two arteries have been fe- 
 cured, the ligatures fhould be left out at the inferior 
 angle of the wound \ but when there are feveral, they 
 fhould be divided between the two angles, to prevent 
 the parts from fuftering by a large extraneous body 
 fixed at any one place. 
 
 While an aiTiftant retains the edges of the divided 
 fkin in contacl, two or three flips of adhefive plafter 
 fhould be laid acrofs the face of the flump, to preferve 
 them in this fituation ; and the whole furface of the 
 flump fliould now be covered with a large pledget of 
 foft lint, fpread with faturnine cerate, or the common 
 calamine cerate of the Difpenfatories : over this there 
 Ihould be placed a foft cufhion of fine tow with a com- 
 prefs of old linen. For the purpofe of retaining them, 
 as well as with the view^ of making gentle preflbre up- 
 on the flump, a flip of linen, of three inches in breadth, 
 fhould be laid over them ; fo as to pafs dire6lly acrofs, 
 and not from above downwards. On being properly 
 placed, the remaining part of the roller fliould be em- 
 ployed to fix it, by pafTmg it two or three times round 
 the flump ; and the preflTure formed by the crofs flrap 
 may afterwards be increafed or diminifhed, by draw- 
 ing it with more or lefs tightnefs, and fixing it with 
 pins to the circular roller. 
 
 In applying the roller, the tourniquet fhould be re- 
 moved, and replaced immediately when the flump is 
 dreffed. If left loofe, it gives no uneafmefs ; and it 
 enables the attendants to check any hemorrhagy that 
 may take place ; a circumflance that merits attention 
 for feveral days after amputation of any of the ex- 
 tremities. 
 
Sea. IV. the Thi^h. 479 
 
 The patient fhould now be carried to bed ; but in- 
 ftead of raifing the flump to a confiderable height with 
 pillows, as is ufually done, it fhould be laid fomewhat 
 lower than the refl of the body : for this purpofe, the 
 bed fliould be previoufly made with a gentle declivity 
 from above downwards, and nothing fliould be put 
 beneath the flump but fuie tow. 
 
 To prevent the patient from moving the limb inad* 
 vertently, as well as to guard in fome meafure againft 
 the eft'ecl: of thofe fpafms which often prove trouble- 
 fome after this operation, I commonly employ two flips 
 of flannel to fix the flump down to the bed. It is ea- 
 fily done, by laying one acrofs near the extremity of 
 the flump, and another near to the root of the thigh. 
 They fhould be pinned to the circular roller round 
 the limb ; and the ends of each of them fhould be 
 pinned to the bed : or they may be tied to it with pie- 
 ces of fmall tape previoufly fewed to the bed, or to the 
 mattrefs, which anfwers better than a feather bed for 
 any patient to be long confined. A bafket or hooped 
 frame fhould now be put over the flump, to protect 
 it from the bedclothes ; and whether the patient com- 
 plains much or not, I make it a conflant rule to give 
 him an anodyne, by which he remains quiet and eafy 
 through the remainder of the day, inflead of being 
 refllefs and diftreffed, which he is otherwife apt to be. 
 
 As hemorrhagies will fometimes happen, even many 
 hours after the operation, the attendant taking charge 
 of the patient fhould be flricl:ly enjoined to examine 
 the flump frequently with the utmofl care ; and on 
 any quantity of blood breaking out, to twift the tour- 
 niquet fufficiently tight, till afliflance is procured. I 
 think it right, however, to obferve, that in general it 
 is the fault of the pra6litioner when this very perplex- 
 ing occurrence takes place ; for it feldom happens 
 when the arteries are fearched for in the time of the 
 operation with that accuracy which the importance of 
 the fituation requires. Indeed, hemorrhagies are lefs 
 frequent after this method of operating, than when the 
 
480 Of Amputating Chap. XLIV. 
 
 mufcles are left uncovered ; and this is one material 
 advantac^e that refults from it : for however attentive 
 a furgeoii may be in fecuring the arteries, the irrita- 
 tion produced upon an extenfive wound, and the 
 fpafms that enfue, very frequently terminate in fatal 
 hemorrhagies. Of this I have known feveral inftan- 
 ces ; while no difcharge of any importance has ever 
 happened in the method of operating, of which I have 
 thus given a defcription. I believe too, as I have eife- 
 where remarked, that fome additional lecurity is de- 
 rived from the uie of the tenaculum : for although 
 thofe who have not been in the habit of ufmg it, are 
 apt to confider it as more uncertain than the needle, 
 yet it is far from being fo. I will not fay that hemor- 
 rhagies will never enfue where the tenaculum is em- 
 ployed ; but it has fo happened in the courfe of my 
 obfervation, that the needle was ufed in every cafe of 
 hemorrhagy that proved fatal. 
 
 Where there is only a trivial oozing of blood, we 
 need not be alarmed ; nor will it be necellary to re- 
 move the dreflings : but whenever the difcharge is fo 
 confiderable as to give caufe to fufpeft that it proceeds 
 from a large artery, nothing but fecuring it with a lig- 
 ature can be depended on. This being done the 
 dreffings mull be renewed in the fame manner as at 
 firft. 
 
 The only other fymptoms that we have reafon to 
 dread, during the firll three or four days after the ope- 
 ration, are fevere fpafmodic affections of the mufcles, 
 and inflammation and tenfion of the flump, with the 
 confequent f:iver which in fome degree fucceeds to 
 every cafe of amputation, but which always proves 
 hazardous when it proceds to a great height. 
 
 When the arteries are tied without including the 
 nerves or any part of the contiguous mufcles, thefe 
 fpafms feldom become troublefome : but when they 
 take place, if laying the limb in an eafy relaxed (rate 
 does not render them moderate, we trull chiefly to 
 opiates for their removal. 
 
Sea. IV. the Thigh. 481 
 
 With a view to prevent inflammation, the patient 
 fliould be confined to as low a regimen as the Itate of 
 his ftrength will permit. In weak emaciated habits, 
 this mult be managed with much difcretion, as the 
 conftitution might be materially hurt by a low diet : 
 but where there is much plethora, with tenfe fibres, 
 together with a ftria antiphlogiftic regimen, the pa- 
 tient fhould be blooded as foon as quicknefs and ful- 
 nefs of pulfe or other fymptoms of fever take place : 
 he fhould take plentifully of diluent drink ; and his 
 bowels fliould be kept open with any of the cooling 
 neutral falts. 
 
 It is proper, however, to obferve, that it is only dur- 
 ing the firft days after the operation that remedies of 
 this kind are in general neceifary. When the inflam- 
 matory fliage is over, evacuations of every kind are to 
 be dreaded ; even laxatives are apt to do harm if car- 
 ried farther than is jufl neceflary for preferving a re- 
 gular fl:ate of the bowels. 
 
 At the end of the fecond day, whatever the previ- 
 ous fymptoms may have been, the fl:ump fliould be 
 examined. Where a free fuppuration is expected, as 
 always happens when the flump is not covered with 
 Ikin, the parts fhould not be looked at till the third or 
 fourth day : but here there is no rcafon for this delay j 
 and the patient is always made more eafy and com- 
 fortable by the removal of the firfl: dreflings. For this 
 purpofe, the ftump fhould be gently fupported by an 
 afllitant, till the laft turns of the roller are undone, 
 and till the crofs flips, tow, and even the large pled- 
 get of ointment next the fore, are removed. In a few 
 cafes the parts are found united by the firfl intention ; 
 but for the mofl part it is otherwife : there is com- 
 monly a fmall quantity of matter over the furface of 
 the flump, chiefly at the inferior angle of the wound ; 
 and the parts are red, tenfe, and painful to the touch, 
 with a fmall feparation or opening between the edges 
 of the divided fl^in, notwithfl;anding the plafliers enx- 
 
 VoL. III. H h 
 
482 Of Amputating Chap. XLIV. 
 
 ployed to rctam them. As in this ftate the plafters do 
 no fervice, they ihould Hkewife be removed ; and it 
 is eafily done when they are thus moiflened with mat- 
 ter. The furface of the flump fliould now be cover- 
 ed with a pledget of the fame ointment as at firfl ; and 
 a culhion of foft tow being laid over it, the crofs flips 
 of linen and the circular roller fliould be again em- 
 ployed J but with no more prelTure than is merely 
 neceflary for fupporting them. 
 
 In this manner the dreflings fliould be renewed dai- 
 ly ; when, by the feventh or eighth day, the inflam- 
 mation and tenfion will in general be fo far diminifli- 
 ed as to admit of the ligatures on the arteries being 
 eafily removed ; at leafl: they may now be gently pul- 
 led daily, and for the mofl: part they yield on the fe- 
 cond or third trial : when allowed to remain longer, 
 they not only prevent the wound from healing, but 
 are apt to be more difficult to remove afterwards. 
 
 As long as the roller is prefer ved clean, it may be 
 allowed to remain ; but as foon as it becomes fuUied 
 with matter, it fliould be removed and another applied 
 in its place j nor fliould it be entirely laid afide till the 
 third or fourth week from the operation. After this 
 period, however, it fliould be removed, as when lon- 
 ger continued it renders the limb fmaller than the 
 other. 
 
 As foon as the fore is obferved to be perfeflly clean, 
 with granulations fprouting in different parts of it, as 
 the pain and tenfion will now be quite removed, we 
 may with fafety venture to complete the cure, by 
 drawing the edges of the wound together with adhe- 
 five plaft:ers. In this fl:ate of the fore no harm ever 
 enfues from it, and it fliortens the cure confiderably. 
 
 By this management, even the largefl: fl:umps will 
 for the mofl: part be healed in three or four weeks ; 
 often in lefs. But it mufl; be remarked^ that although 
 we may in general depend on this in private praftice, 
 where every circumftance that can conduce to the 
 welfare of the patient will meet with attention, and 
 
Sea. IV. ihe TJjigIn 483 
 
 where efpecially we may always obtain a well venti- 
 lated apartment and proper diet ; yet in public hofpit- 
 als, where thefe points are not duly attended to, and 
 where the patient often fuffers more from the bad air 
 that he breathes, than from the operation itfelf, our 
 fuccefs will not in every cafe be fo great. Inftead of 
 the teguments adhering to the parts beneath, large 
 quantities of matter fometimes form between them, 
 which always renders the cure more tedious, and 
 which in fome cafes cannot be accomplifhed but by 
 fending the patient to a .more free air, and by a more 
 plentiful allowance of wine and other cordials than 
 can in general be obtained in hofpitals. But for one 
 inftance of this, in the operation that I have defcribed, 
 I may with fafety affirm, that twenty occur in the 
 ufual mode of conducting it. 
 
 When fpeaking of the time In which (lumps may 
 be expeded to heal, I think it right to obferve, that it 
 fhould not be our objed: to heal the parts in the firft 
 inflance without the formation of matter : it common- 
 ly anfvvers better when done in the more gradual man- 
 ner I have pointed out. When a ftump heals fudden- 
 ly, and the edges of the divided (kin adhere by the 
 firft intention, the teguments are apt to be puckered 
 and uneven, and the ligatures of the arteries are re- 
 moved with difficulty. Of this I have had difierent 
 cafes, when fuch ftrong adhefive plafters were em- 
 ployed, as kept the edges of the (kin in clofe contact : 
 but when the common court plafter is made ufe of, 
 or any other compofition poffiilTed of the fame degree 
 of adhefive property, although the teguments will be 
 prevented from feparating to any confiderable extent, 
 yet they will readily yield to the retraftion that ufual- 
 ly takes place on the acceffion of tenfion and pain. 
 In this manner, a (light feparation is ufual ly produc- 
 ed ; by means of which the ligatures are eafily taken 
 out ; any matter that may form is readily difcharged ; 
 the corners left above and beneath by the teguments 
 H li 2 
 
434 Of Amputating Chap. XLIV. 
 
 being drawn together, are much leffened ; and the 
 ftump is always left fmooth and eqiial : hence thofe 
 flumps which take three weeks or perhaps a month 
 to heal, are ufually of a better form than thofe that 
 heal much fooner. 
 
 The advantages attending a fpeedy cure, and cov- 
 ering the ftump with fkin, are fo great, that they need 
 not be enumerated ; but I thought it right to men- 
 tion the inconveniencies that occur from the union of 
 the divided (kin being too quickly connected, either 
 with adhefive plaflers, or futures, which lafl have In 
 Ibme cafes been employed. 
 
 It will be readily perceived, that the principal dif- 
 ference between this operation and the ufual method 
 of amputating, confifts in the faving as much of the 
 mufcular fubllance of the limb as will completely 
 cover the bone, together with as much fkin as will 
 cover the whole furface of the ftump : but it is pro- 
 per to remark, that we may err in faving more of each 
 of thefe parts than is requifite, and that fome atten- 
 tion is therefore necelTary to guard againfl it. In leav- 
 ing too much mufcular fubftance, we muft neceflarily 
 Ihorten the limb too much, by fawing the bone higher 
 than we otherwife would do j and by faving too much 
 fkin, we render the furface of tlie ftump puckered 
 and uneven. 
 
 With refped to the quantity of mufcular fubftance 
 that ftiould be faved, I have hitherto found, that the 
 direftions given above, in general anfwer the purpofe. 
 By feparating the mufcles from the bone for the fpace 
 of an inch, and fawing it at this height above where 
 it is divided in the ordinary method of amputating, 
 the bone will always be fufficiently covered with iiefh; 
 and a very little experience enables us to judge of the 
 quantity of lldn that fliould be faved for covering the 
 ftump : but even when more is faved than is neccfla- 
 ry for this purpofe, a little attention will enable us to 
 prevent inequalities. By an aftiftant drawing down 
 the teguments, in the manner I haVe direfted, before 
 
Sea. IV. the Thigh, 485 
 
 the roller is applied, as much of them may be pulled 
 down as is juft neceffary ; and if they are kept in this 
 fituation till the application of the roller is finiflied, 
 any inconveniency which might have enfued from too 
 great a quantity will be prevented. 
 
 It will likewife be obferved, that in making the firfl: 
 incifion of the teguments, I have not defired a circu- 
 lar piece of tape to be made ufe of, as is ufually done, 
 to ferve as a direction for the knife. This deviation 
 from the common pra£lice has been long adopted by 
 fome individuals ; but fo far as I know, it was firfl 
 fuggefted by the late Dr. Hunter of London ; and I 
 think it a material improvement of this part of the 
 operation : for bcfides the faving of time, which is 
 always of importance in that ftate of anxiety to which 
 a patient is reduced who is placed upon a table for the 
 purpofe of lofmg a limb, it in reality puts it in our 
 power to make the incifion with more neatnefs, more 
 fpeedily, and with lefs embarraffment, than when the 
 tape is employed. Thofe who have been accuftomed 
 to ufe the tape will at iirft be of a different opinion ; 
 but whoever lays it afide, will fmd, that the circular 
 incifion may be made with more exaftnefs merely by 
 following the knife with the eye ; and I am certain 
 that it may be done in one half of the time. When 
 the tape is employed a good deal of time is loft in en- 
 deavouring to keep the knife exactly in a line with 
 the edge of it ; and if not applied with the utmoft ex- 
 aftnefs, it neceffarily makes the incifion ragged and 
 unequal ; an occurrence I have obferved in different 
 inftances, even with expert furgeons, while I never 
 perceived any inequality where the tape was not made 
 ufe of. 
 
 It has been obje6led to the operation that I have 
 defcribed, that being more tedious than the ufual me- 
 thod of amputating, it muft neceffarily create more 
 pain. The difference in this refpeft, however, is tri- 
 fling ; for it muft be remembered, that the incifion 
 of the fkin, and this is the moft painful part in every . 
 
486 Of Amputating Chap. XLIV- 
 
 operatloR, is the fame in both. The divifion of the 
 cellular fubflance is quickly performed, and little or 
 no pain enfues from it ; and the third incifion, if we 
 may fo term it, or the feparation of the mufcles from 
 the bone, may be performed in the tenth part of a 
 minute. In different inftances, I made ufe of a fcaU 
 pel for feparating the cellular fubftance from the muf- 
 cles beneath, as well as for feparating the mufcles from 
 the bone ; but I now find that both thefe parts of the 
 operation may be done with the common amputating 
 knife, with equal eafe and expedition ; and we fhould 
 avoid multiplying inftruments, wherever the intention 
 can be anfwered equally well with a fmaller number. 
 The knife delineated in Plate XCVIII. fig. 3. is the 
 one I now prefer, after trying various forms of it : it 
 is of a middling fize, fomewhat fliorter than the one 
 in common ufe, and perfedly flraight. The curved 
 knife is ftill ufed by fome praQitioners, but no good 
 reafon has been afngned for it. 
 
 If any furgeon fhould find it difficult to feparate the 
 mufcles from the bone with this knife, the inftrument 
 recommended by Mr. Gooch, and delineated in Plate 
 XCVIII. fig. 4. may be employed. 
 
 I Ihall now defcribe fuch parts of Mr. Alanfon's 
 method of performing this operation as are peculiar 
 to himfelf ; and in order to convey the meaning of 
 the author with exaftnefs, I fnall give it in his own 
 words, from the fecond and lafl edition of his book, 
 page 51. 
 
 *' Apply the tourniquet in the ufual way ; ftand on 
 the outfide of the thigh ; and let an affiflant draw up 
 the (kin and mufcles, by firmly grafping the limb cir- 
 cularly with both hands. The operator then makes 
 the circular incifion as quickly as poffible through the 
 fkin and membrana adipofa down to the mufcles : he 
 next feparates the cellular and membranous attach- 
 ments with the edge of his knife, till as much fkin is 
 drawn back as will afterwards, conjointly with the 
 
Sea. IV. the T/jigb. 487 
 
 following divifion of the mufcles, cover the furface of 
 the wound with the mod perfect eafe. 
 
 " The affiftant flill firmly fupporting the parts as be- 
 fore, apply the edge of your knife upon the inner edge 
 of the mufculous vaftus ifiternus, and at one flroke cut 
 obliquely through the mufcles upwards as to the limb 
 and down to the bone ; or in other words, cut in fuch 
 a direction as to lay the bone bare about two or three 
 fingers breadth higher than is ufually done by the com- 
 mon perpendicular circular incifion : now draw the 
 knife towards you, fo that its point may reft: upon the 
 bone, ftiill attending to keep it in the fame oblique line, 
 that the mufcles may be divided all round the limb in 
 that direction by a proper turn of the knife ; during 
 which its point is kept in contact with, and revolves 
 round, the bone. 
 
 " The part where the bone is to be laid bare, whe- 
 ther two, three, or four fingers breadth higher than the 
 edge of the retracted integuments ; or, in other words, 
 the quantity of mufcular fubft:ance to be taken out in 
 making the double incifion, muft; be regulated by con- 
 fidering the length of the limb, and the quantity of fkin 
 that has been previoufly faveu by dividing the membra- 
 nous attachments. 
 
 " The quantity of fkin faved, and mufcular fubfl:ance 
 taken out, muft: be in fuch an exact proportion to each 
 other, as that, by a removal of both, the whole furface 
 of the wound will afterwards be eafily covered, and 
 the length of the limb not more fliortened than is ne- 
 ceflary to obtain this end. However, it is to be obfer- 
 ved, that the more mufcular fubftance we fave, by ful- 
 ly giving the oblique direction to the knife, inft:ead of 
 dividing the membranous attachments, the better." 
 
 Mr. Alanfon now gives fome directions for the ufe 
 of the retractor ; for fecuring the divided arteries with 
 ligatures ; and for the application of the flannel roller. 
 Afterwards he proceeds thus : " You are now to place 
 the ikin and mufcles over the bone in fuch a direftion 
 as that the wound fliall appear only in a line with the 
 
483 Of Amputating Chap. XLIV. 
 
 angles at each Tide ; from which pohits the ligatures 
 are to be left out, as their vicinity to either angle di- 
 rects : the Ikin is eafily fecured in this pofture by long 
 flips of linen or lint, about two fingers in breadth, 
 fpread with cerate or any other ointment : if the fkia 
 do not eafily meet, it is bed brought into contadt by 
 flips of linen fpread with fliicking plaft:er. Thefe are 
 to be applied from below upwards acrofs the face of 
 the flump, and over thern a foft tovv pledget and com- 
 prefs of linen, the whole to be retained by the many 
 tailed bandage, with two tails or flips to come from 
 below upwards, to retain the dreflings upon the face 
 of the flump.'* 
 
 Mr. Alanfon ufes a knife with a double edge, which 
 he thinks preferable to the one commonly employed. 
 
 As I wifli the author's ideas to be clearly under- 
 flood I think it right to add, that in p. 17, he directs 
 the bone to be laid bare three or four fingers breadth 
 higher than is ufually done by the common perpen- 
 dicular incifion of the mufcles ; that is, that by the 
 oblique direction of the knife, three or four «fmgers 
 breadth of mufcular fubilance fbould be fcooped out. 
 And, in page 21, he obferves, " that a flump formed 
 in the thigh, agreeably to the foregoing plan, if you 
 bring the parts gently forwards after the operation, 
 and then view the furface of the wound, may, in fome 
 degree, be faid to refemble a conical cavity, the apex 
 of which is the extremity of the bone ;" and the parts 
 thus divided, he obferves are obvioufly the befl cal- 
 culated to prevent a fugar-loaf flump.- 
 
 From what has been faid, it will appear, that Mr. 
 Alanfon's method of operating differs chiefly from 
 that which I have advifed above, in the manner of di- 
 viding the rnufcles, and in the after pofition of the 
 fkin. Every furgeon is apt to be partial to that mode 
 of operating which he has been accuflomed to prac- 
 tife J but being ahvays anxious to have this very im- 
 portant operation improved to the highefl pofTible de- 
 gree, I was refolved to give Mr. Alanfon's method a 
 
Sea. IV. fhe Thigh. 489 
 
 fair trial, being hopeful, from the accounts received of 
 it, that I fhould find it anfwer better even than that 
 of which I have fpoken fo highly. I can with truth, 
 however, affert, that it did not anfwer my expedation. 
 The Itumps formed by it are, indeed, much better 
 than can be made by the ufual method of amputating ; 
 but the removal of fuch a large portion of mufcular 
 fubftance, as is done by Mr. Alanfon's oblique inci- 
 fion, produces a hollow, that not only retains the mat- 
 ter, but prevents the ftump from being fo fmooth and 
 equal as when the fkin is fupported by a flat mufcular 
 furface in the manner I have advifed. Mr. Alanfon, 
 who is in the daily pradice of it, may be able to ob- 
 viate thefe difficulties ; but I know that I cannot make 
 fuch a good flump in this manner as I always do in 
 the other method of operating ; nor is Mr. Alanfon's 
 own idea fo completely anfwered by his method of 
 operating. He very properly obferves, page 36, that 
 in the thigh we want a fufficient cufliion between the 
 bone and machine to be ufed in walking ; that the 
 more mufcular fubflance that is faved, the farther will 
 the point of bone on which the preffure principally 
 produces inconvenience, be removed from the furface 
 of the machine ; and likewife, that a more vigorous 
 circulation will be kept up all round the extremity of 
 the bone and flump, which lefTens the danger of ex- 
 foliation. Now, it is obvious, that the end of the 
 bone will not be fo much covered with mufcular fub- 
 ftance when a confiderable portion of the mufcles is 
 removed by the oblique incifion as w^hen they are al- 
 lowed to remain ; nor will the circulation be fo vigor- 
 ous round the end of the bone. 
 
 But admitting Mr. Alanfon's method of operating 
 to be in every point equal to the other, the greater 
 difficulty of performing it is a weighty objedion againfl 
 it. Indeed few, I believe, will be able to divide the 
 mufcles by the oblique incifion without mangling the 
 fkin, even with the explanation given by Mr. Alanfon 
 in the lafl edition of his book. Accordingly we find, 
 
49^ Of Amputatmg Chap. XLIV. 
 
 in page 204, that this actually happened in the hands 
 of an expert furgeon, Mr. Lucas of Leeds, even where 
 the divifion of the mufcles was not begun clofe under 
 the retracted integuments, but a little lower. Nor 
 will this be an uncommon occurrence, if the mufcles 
 are divided with the edge of the knife, as is directed 
 by Mr. Alanfon. I have divided them with the point 
 of the knife, but with dilFiciilty ; for the point cannot 
 be eafily carried round to the height of three or four 
 fingers breadth above the retracled fkin, fo as to make 
 a fmooth equal cut. I do not fee how the edge of the 
 knife can be applied to cut fo obliquely upwards with- 
 out hurting the Ikin ; and yet Mr. Alanfon's words 
 are, " apply the edge of your knife, and at one ftroke 
 cut obliquely through the mufcles," he. He defires, 
 indeed, that the incifion may be finiflied with the point ; 
 but I do not underftand how it can be done without 
 cutting the fkin, if the point be not employed from 
 firfl to laft in the divifion of the mufcles. Indeed, 
 Mr. Alanfon himfelf admits that there is difficulty in 
 this part of the operation ; for in page 1 8, he fays, 
 " that, while one afTiflant continues a firm and Heady 
 elevation of the parts, another fhould attend to prefers'e 
 the fkin from being wounded as the knife goes through 
 the mufcles at the under part of the limb." This, of 
 itfelf, appears to be a material objeftion to this method 
 of operating : for two alliflants, whofe hands are all 
 employed nearly at one point, muft be apt to embar- 
 rafs not only each other but the operator : and befides, 
 it muit often happen, that two afliftants cannot be pro- 
 cured. 
 
 With refpecl to the line of direction in which the 
 wound fliould be clofed, Mr. Alanfon obferves, page 
 ^^j^ if it be formed from above downwards, the cica- 
 trix will generally be found dire6lly oppofite to the 
 bone ; by which, in walking with an artificial leg, the 
 point of preffure muft be upon the new formed fkin ; 
 which he thinks will be avoided by forming the line 
 in the contrary -direction from fide to fide : in which 
 
Sea. IV. the Thigh, 491 
 
 cafe, after the cure is complete, it will be found, that 
 in confequence of the more powerful aftion of the flex- 
 or mufcles, the cicatrix is drawn downwards, and the 
 extremity of the bone is therefore covered with the old 
 fkin ; by which the greateft preflure falls upon this 
 part, and not upon the new formed fkin. 
 
 I have not found, however, that this argument is 
 of much importance ; for this retraction of the flexor 
 mufcles to which Mr. Aknfon alludes, is in a great 
 meafure owing to the cufl:om of elevating the fl:ump 
 after the operation, and may be prevented by keeping 
 it lower than the refl: of the body, in the manner I 
 have mentioned. And befides, the bone is fo well 
 covered with mufcular fubftance, and the cicatrix fo 
 narrow when the operation is rightly done, that I have 
 not met with a fmgle infliance of any inconvenience 
 arifmg from this circumfl:ance mentioned by Mr. Al- 
 anfon : whereas, the lodgment of matter proves always 
 fo troublefome and pernicious, and would in all pro- 
 bability occur fo frequently, were the praftice gener- 
 ally adopted of making a tranfverfe opening inftead of 
 a longitudinal one upon the face of the flump, that 
 this appears to be a fuflicient reafon for preferring the 
 former. 
 
 With a view to prevent that inequality on the fur- 
 face of the flump, which arifes from the retraction of 
 the flexor mufcles of the thigh, I have in fome cafes 
 divided thefe mufcles an inch lower than thofe of the 
 refl of the limb. After dividing the fkin and cellular 
 fubflance with a circular incifion in the ufual way, this 
 is eafily done ; and it prevents this inconvenience in 
 the moft effeftual manner : but it is not necefTary when 
 the flump is treated in the manner I have mentioned. 
 
 Whether others may deem thefe obfervations upon 
 Mr. Alanfon's method of amputating important or 
 not, I cannot determine ; but as they appeared to me 
 to be of confequence, I thought it my duty to offer 
 them. 
 
49* Of Amputating Chap. XLIV. 
 
 It is but juftice, however, to remark, that the pub- 
 lic is much indebted to INIr. Alanfon for his afliduity 
 in endeavouring to improve this very important oper- 
 ation, and for the many ufeful pradical remarks con- 
 tained in his pubhcation. 
 
 SECTION V. 
 Of Amputating the Leg, 
 
 IN amputating the thigh I have obferved, that ag 
 much of the hmb fhould be faved as can be done 
 with fafety ; for the longer the Itump the more utility 
 is derived from it : but in amputating the leg, it has 
 hitherto been a general rule to take it off a little below 
 the knee, even where the difeafe is feated on or near 
 to the ankle, and where accordingly the operation 
 might be performed much lower. The reafon given 
 for this is, that a few inches of the leg being faved, 
 anfwers as a fufficient reft to the body in walking when 
 the limb is inferted into the box of a wooden leg ; and 
 when much more of it is left, that it proves trouble- 
 fome both in walking and fitting, without being at- 
 tended with any particular advantage. 
 
 AVere we to conclude, that the common p^a6i:ice of 
 bending the joint of the knee and refting upon the an- 
 terior part of the leg was necefi'ary, this method of 
 operating a little below the knee would be admitted 
 as the beft : but as we have now had many inftances 
 of patients walking equally well with machines, fo 
 contrived as to admit of the ufe of the knee joint ; as 
 thefe machines, by refembling the human leg, are 
 much more pleafmg to the eye than the wooden ones 
 in common ufe ; and as the operation may be done 
 with much more eafe and fafety to the patient a little 
 above the ankle, I am of opinion that it fliould always 
 
Seel. V. ihe Leg, 493 
 
 be done here whenever It is practicable, Indead of the 
 ordinary place a little below the knee. 
 
 The operation is eafier performed a little above the 
 ankle than at the upper part of the leg, by the parts 
 to be divided being lefs extenftve j for the diameter 
 of the \e.g is here confidcrably Icfs ; and it is done with 
 more fafety by our being able to cover the bone more 
 completely with foft parts, fo as to accomplifli a cure 
 m the fame manner and equally foon as in the thigh : 
 whereas, immediately below the knee, the bones are 
 not only larger, but there is fuch a fcarcity of foft 
 parts, that the cure proves always much more tedious, 
 notwithftanding all our endeavours to promote it ; in- 
 fomuch, that in operating at the ufual place, about 
 four inches beneath the patella, the fore, with all the 
 attention we can give to it, will feldom heal in lefs than 
 ten or twelve weeks ; and in the common method of 
 forming the double incifion, it will even require four 
 or five months : whereas, when the operation is right- 
 ly performed a fev/ inches above the ankle, a cure 
 may, for the moll part, be effeCled in a fortnight or 
 three weeks. 
 
 It is true that a method of amputating beneath the 
 knee has been propofed, by what is termed the flap 
 operation, and by which a cure may be more fpeedily 
 obtained than in the ufual way of operating ; but (till 
 it is tedious, and at the fame time liable to other ob* 
 jeftions, which I fhall have prefently occafionto men- 
 tion. I therefore conclude, that in every cafe that ad- 
 mits of it, amputating a little above the ankle is pre- 
 ferable to operating immediately below the knee. 
 
 We are next to determine the mod proper place 
 for the operation, when we are prevented by the extent 
 of the difea^c in the leg from amputating lower than 
 the ufual place beneath the knee. Where the upper 
 part of the leg is found, it has hitherto been a fixed 
 maxim to amputate below the joint of the knee rather 
 than above it. 
 
494 Of Amputating Chap. XLIV^ 
 
 While pra£lItioners were unacquainted with the 
 prefent improvements on this operation, they feem to 
 have adopted this maxim, chiefly from finding that 
 the body refled more eafily upon the found Ikin on 
 the forepart of the leg than on the (lump of the thigh : 
 but now that the operation, when done above the knee^ 
 may be fo performed that the fore will heal in lefs than 
 one half of the time that is required when the leg is 
 taken off immediately below the joint ; and in fuch a 
 manner that the flump is covered with found fkin, as 
 well as with fome mufcular fubftance, which admits 
 of the patient refling upon it with freedom ; this rea- 
 fon, upon which the practice is chiefly founded, falls 
 to the ground. 
 
 I have obferved above, that the cure of a flump im- 
 mediately below the knee is always tedious, owing to 
 the great extent of bone at this place, and the natural 
 deficiency of foft parts. 
 
 Upon the whole, therefore, I conclude, that ampu- 
 tation immediately below the knee fliould feldom or 
 never be advifed : but as no innovation will at firfl be 
 generally admitted, I think it right to defcribe the 
 method of operating when it is determined to ampu- 
 tate at this part. 
 
 The patient fhould be placed upon a table and fe- 
 cured in the fame manner as in operating above the 
 knee. The tourniquet fhould be applied a little above 
 the knee, with the cufliion upon the artery in the ham. 
 The foot and leg fhould be fecured by an affiflant fit- 
 ting before the patient, while the teguments are drawn 
 up by another affiflant towards the knee. The fur- 
 geon, flanding on the infide of the leg, fliould now 
 with the knife, Plate XCVIII. fig. 3. make a circular 
 cut through the fldn and cellular fubflance down to 
 the mufclcs, fo far down upon the limb, that when as 
 much of the teguments are feparated from the parts 
 beneath as will cover the ftump, the muFcles and bones 
 may be divided immediately below the infertion of the 
 flexor tendons of the leg. The intcroffeous foft parts 
 
Se£t. V. the Leg, 495 
 
 mufl: be divided either with the point of the amputa- 
 ting knife or with the catline, Plate XCVIII. fig. 2. 
 The retradors, Plate XCVIT. fig. 2. and 3. mufl: now 
 be applied fo as to fupport and protect the fkin and 
 other foft parts from the faw employed ior dividing 
 the bones. This being done, and the vefTels fecured 
 in the ufual way with ligatures, the teguments fhould 
 be drawn over the ftump and retained with adhefive 
 plafliers, in the manner I have advifed in amputating 
 the thigh. The practice, indeed, fliould be the fame 
 during the whole courfe of the cure ; only, in the ap- 
 plication of the flannel roller, there is no neceffity for 
 beginning at the top of the thigh : it fliould receive, 
 however, two or three turns above the knee, to pre- 
 vent it from flipping down. 
 
 In feparating the adhcfions of the fkin from the parts 
 beneath, as much of the cellular fubflance fhould be 
 taken along with it as can be got ; otherwife the cir- 
 culation in the fkin itfelf is apt to become fo languid 
 as to prevent it from adhering to the parts on which 
 it is applied. It will be found too, that more attention 
 is necelfary to deflroy the attachments of the fkin in 
 this fituation, particularly on the forepart of the leg, 
 than in the thigh, owing to the cellular fubflance be- 
 ing more condenfed where it lies fo contiguous to the 
 bone, than in the thigh, where the mufcles intervene. 
 And as this flate of the cellular membrane prevents 
 the teguments from retracing freely after they are di- 
 vided ; and as they cannot even be pulled fufficiently 
 up by the afliftant, it is neceffary to fold fuch of them 
 as are feparated from the parts beneath, back upon the 
 found fkin, before the divifion of the mufcles is at- 
 tempted ; otherwife the fl^in will either be cut with a 
 knife, or the mufcles will not be divided fo high as 
 they ought to be. 
 
 Always at this part of the leg, and in a few cafes 
 immediately above the ankle, I have found it necefl'ary 
 to fold the Ikin back in this manner ; but hitherto no 
 inftance has occurred in the thigh, vvhere the operation 
 
49^ OfJmputailng Chap. XLIV. 
 
 might not have been done merely by pulling the teg- 
 uments up, in the manner I have formerly mentioned. 
 
 I have defired above, that in this operation the fur- 
 geon ihould ftand on the infide of the leg : by this, if 
 the knee and foot are turned inwards, i'o as to raife 
 the fibula, the faw may be appUed in fuch a manner 
 to both bones as to divide them nearly together, the 
 fureft method of preventing them from breaking when 
 nearly fawn through : whereas, on (landing on the 
 outfide of the patient, the fibula is more apt to be left 
 to the laft ; at the fame time that the faw is apphed 
 upon the ridge of the tibia, fo as to acl upon its long- 
 eft diameter, by which it is not fo quickly divided. 
 
 In operating above the ankle, that fpot fhould be 
 fixed upon that will leave the ftump of the mofl con- 
 venient length for being fitted with a leather machine 
 refembling the other leg. And I find from obferva- 
 tion, as well as from information obtained from Mr. 
 Wilfon, a late ingenious tradefman of this place, that 
 nine inches from the joint of the knee is the belt 
 length for this purpofe ; for it affords a fuHicient fup- 
 port to the machine, and at the fame time prevents it 
 from being fo heavy and clumfy as when the leg is 
 left of a greater length : for when taken off immedi- 
 ately above the ankle, the flump mufl go down to the 
 very bottom of the machine, which muff therefore be 
 thicker and heavier at the ankle than it otherwife 
 might be ; at the fame time that it will not correfpond 
 fo exa£lly as it otherwife would do to the fize of the 
 other leg. 
 
 In addition to what I have faid upon the method of 
 amputating the leg immediately below the knee, I may 
 obferve, that, in operating above the ankle, it fhould 
 be done exaftly as I have advifed in defcribing the 
 amputation of the thigh : only in this fituation, inftead 
 of m.ufcles, we find a portion of both bones covered 
 merely wdth fkin and cellular fubftance ; but as the 
 cellar membrane is here commonly fufficiently lax, 
 
 
Se£t. VI. with a Flap; 497 
 
 and in greater quantity than in the upper part of the 
 leg, it is not only more eafily leparated from tTie peri- 
 ofteum, but ferves to give the bones a more complete 
 covering : by which, vi^hen the operation is properly 
 done, the cure for the moft part is accomplilhed in 
 lefs than three weeks, and the furface of the ftump is 
 equal, and every where covered with found Ikin. 
 
 SECTION VI. 
 
 Of Amputating with a Flap* 
 
 IN amputating in the ufual way, the cure was fo ex- 
 tremely tedious ; the health of the patient was 
 thereby fo much injured ; and the flumps, when heal- 
 ed, were fo pyramidal, and fo thinly covered with foft 
 parts, that another method of operating, as I have ob- 
 ferved above, was propofed upwards of a hundred 
 years ago ; in which an attempt was made to obviate 
 thefe difficulties, by preferving a flap of mufcles and 
 fldn for the purpofe of covering the flump. 
 
 This was firfl propofed by one Loudham, a Britifh 
 furgeon : it was afterwards praclifed in Holland, Ger- 
 many, Switzerland, and France ; and more lately by 
 fome individuals in Britain and Ireland : but it has 
 never been received into general ufe, nor is it proba- 
 ble that it will ever be frequently performed. 
 
 The chief objeftions to it were, the difficulty of re- 
 flraining hemorrhagies when they happened to recur 
 after the flap was applied and fixed in its fituation with 
 futures, for in order to difcover the bleeding arteries, 
 it was necelTary to undo the whole ; the flap not ad- 
 hering uniformly over the whole furface of the flump ; 
 and the pain, inflammation, and tenfion, that fuper- 
 vened to this operation, being much more fevere than 
 after the ufual method of operating. 
 
 Vol. III. I i 
 
498 Qf Amputating at Chap. XLIV. 
 
 To remove thefe difficulties, it was propofed, about 
 forty years ago, by Mr. O'Halloran, an ingenious fur- 
 geon of Limeric, to drefs the flump and flap as fepa- 
 rate fores for the firft twelve days ; when the rifk of 
 hemorrhagy being over, the fymptoms of pain, in- 
 flammation, and tenfion, fubfided, and fuppuration ef* 
 tablifhed, we are dire£led to turn the flap back upon 
 the furface of the flump, and by means of plafliers, 
 compreflion, and bandage, to fecure it in this fituation 
 till they unite. 
 
 By this improvement the operation was rendered 
 more fafe and certain ; and it is probable that it would 
 gradually have come into general pra6lice, if the im- 
 proved method of operating, that 1 have already de- 
 fcribed, had not in the mean time been introduced : 
 but although this will probably continue to be gener- 
 ally preferred, yet in particular fituations, the opera- 
 tion with the flap may with much propriety be employ- 
 ed. Wherever the divided parts cannot be properly 
 covered with {kin in any other manner, it ought cer- 
 tainly to be done with a flap : and this will always be 
 the cafe in amputating the arm at the flioulder, and 
 the thigh at the hip joint, as well as in removing any 
 of the fingers or toes : it may likewife by fome be pre- 
 ferred to the method of operating that I have defcrib- 
 ed, when it is refolved to amputate immediately below 
 the knee ; for the teguments being in this part ex- 
 tremely thin, the fl;ump cannot in any other manner 
 be fufficiently covered. But for the reafons that I 
 have given, it can never be neceflTary, either above the 
 knee ; immediately above the ankle ; nor in the arm 
 or fore-arm. Some, however, may continue to prefer 
 it, even in thefe parts ; fo that it will be proper to de- 
 fcribe the method of doing it in all of them ; which 
 I fliall therefore do in the following Sedions. 
 
Sea. VII. the Hip JoinU 499 
 
 SECTION VII. 
 
 Of Amputating at the Hip Joints 
 
 THE amputation of the thigh at the hip joint haa 
 always been cunfidered as one of the molt haz- 
 ardous operations : it has therefore been very feldom 
 performed. Indeed furgeons in general have fpoken 
 of it as one of thofe operations which authors might 
 defcribe, but which would never be pradifed ; and 
 when we confider the great fize of the blood vefTels 
 which fupply thefe parts : the difficulty of command- 
 ing the hemorrhagy during the operation ; and the 
 very extenfive wound which, in the ufual method of 
 operating muft necellarily have enfued here ; we will 
 not be furprifed at the averfion that has generally pre- 
 vailed againfl; it. 
 
 But if thefe difficulties can be removed ; if danger 
 from hemorrhagy can be prevented during the ope- 
 ration, as well as afterwards ; if the fore can be fo 
 completely covered with Ikin as to be healed in the 
 courfe of a few weeks ; and if cafes ever occur that 
 would otherwife end in the death of the patient ; we 
 furely would not hefitate to advife it. Now, I hope 
 to make it appear, that the operation may be done 
 with very little lofs of blood ; and that as much fkin 
 may be faved as will cover the fore entirely : and no 
 pradlitioner will doubt of difeafes taking place at the 
 top of the thigh, which cannot be removed but by 
 amputating the limb. 
 
 Having already treated fully of the caufes by which 
 amputation of limbs may become neceffary, I fhall 
 now refer to what was faid upon that part of the fub- 
 jedb ; and at prefent I fliall only obferve, that gunfhot 
 wounds, accompanied with frattures of this part of 
 the bone, fpina ventofa, or caries of the head of the 
 femur, will be the moll frequent caufes of amputa- 
 ting at the joint of the hip. When the operation is 
 
 I I 2 
 
500 Of Amptiiatmg at Chap. XLIV. 
 
 to be performed, it may be done in the following 
 manner. 
 
 The patient fhould be placed upon a table ; and it 
 will be found that the parts that are meant to be di- 
 vided will be brought moft clearly into view by lay- 
 ing him on the found fide. In this fituation he fliould 
 be fecured by two or three alliftants, while another 
 ailiflant takes the management of the limb. 
 
 Let a fmall pad or cufhion be now placed upon the 
 femoral artery, immediately after it paffes out from 
 beneath Poupart*s ligament into the thigh ; and, by 
 means of a tourniquet applied as near as poffible to 
 the top of the limb, let the circulation be completely 
 flopped. Let the (kin, membrana adipofa, and ten- 
 dinous facia of the thigh, be divided by a circular in- 
 cifion fix inches from the top of the thigh ; that is, 
 •at lead three inches beneath the circular band of the 
 tourniquet. Let the retraced fkin be pulled an inch 
 upwards ; and at the edge of it let the amputating 
 knife be applied, fo as with one perpendicular circu- 
 lar ftroke the mufcles may be cut down to the bone, 
 if the mufcles are freely divided, they will retraft fo 
 much as to admit of fufficient fpace for fecuring not 
 •only the femoral artery but all the mufcular branches. 
 This being done, take a ftrong round edged fcalpel, 
 larger than the common fize, and commencing at the 
 upper edge of the circular cut on the pofterior part of 
 the thigh, make a deep incifion down to the bone, 
 •and carry it up of the fame depth to a little above the 
 great trochanter into the joint. Let a fimilar cut be 
 made on the oppofite fide of the Hmb, at a fufficient 
 diftance from the femoral artery, and completely 
 down to the bone. Let the two portions of fleih be 
 now diffecled from the bone, and the flaps formed by 
 them be taken care of by affiftants, while any artery 
 that may be cut ihould be tied as foon as it is obferv- 
 ed. The joint being laid bare, fome dexterity is re- 
 quired to difengage the head of the femur from the 
 acetabulum j for it is rendered difficult by being tied 
 
Sea. VII. the Hip JoinU 501 
 
 down with the llgamentum rotundum : but by turn- 
 ing the bone in different diredions, and particularly 
 by prefllng it inwards, where it yields moft readily 
 from the brim of the acetabulum being lowed, the 
 head of it may be fo far turned out of the focket on 
 the oppofite fide as to admit of the ligament being 
 reached with the point of a fcalpel or a firm probe 
 pointed biftoury ; but to accomplifh this, the mufcles 
 muft all be previoufly detached from the bone. 
 
 The head of the bone being taken out, and the 
 limb removed, we may examine the ftate of the ace- 
 tabulum : for if it is found, our profpeft of a cure 
 will be more favourable than if any part of it were 
 carious. But in whatever ftate the bones may be, 
 our treatment of the fore muft be the fame : we muft 
 endeavour to cure it as nearly as poflible by the firft 
 intention : for which purpofe, after removing all the 
 coagulated blood from the furface of the wound ; 
 placing the muicles as nearly as poffible in their nat- 
 ural fituations : and drawing the two flaps together, 
 fo as to cover tlie fore as neatly as may be, they ftiould 
 be fecured in this fituation with three or four futures 
 introduced at the moft proper points ; by adhefive 
 plafters ; and by proper comprelfes retained with a 
 broad flannel roller pafl^ed different times round the 
 body, and fpirally over the ftump ; care being taken 
 to leave the ligatures upon the arteries of a fufiicient 
 length to admit of their being afterwards drawn out. 
 
 The patient fliould now be laid in bed, and treated 
 in other refpecls as I have advifed in general after the 
 operation of amputation : only it muft be remarked, 
 that more than ordinary attention is required to pre- 
 vent and remove fuch febrile fymptoms as ufually fuc- 
 ceed to amputation ; for where fuch a confiderable 
 part of the body is fuddenly taken away, almoft a 
 fourth part of the whole, we may rcafonably conclude 
 that the eftedt produced by it upon the fyftem muft 
 be confiderable. If the patient is plethoric, it will be 
 proper to diminiili the quantity of blood ; in the firft 
 
502 Of the Flap operation Chap. XLIV. 
 
 place by venefedlon, and afterwards by a low diet : 
 indeed moderate living fhould be perfevered in, if not 
 for life, at lead for a great length of time. 
 
 The drefiings may be removed at the ufual time, 
 and in the courfe of ten or twelve days the ligatures 
 may be all taken away ; at which time, any part of 
 the fore that remains open may be covered, by draw- 
 ing the fkin over it, and fecuring it with adhefive plaf- 
 ter. In fuch an extenfive foie, it is indeed probable 
 that matter may collecl in different parts beneath the 
 fkin ; for the preffure applied upon it, will not be fo 
 equal as in common cafes of amputation : but the in- 
 convenience arifmg from this will not be great ; for 
 if the matter cannot be difcharged by altering the 
 preffure, it will be eafily done with the point of a lan- 
 cet, by which this obftruclion to the cure will be re- 
 moved. 
 
 At all times this will neceffarily be confidered as a 
 very formidable operation ; but when performed in 
 the manner I have advifed, much of the hazard, and 
 many of the inconveniencies ufually fuppofed to at- 
 tend it, will be removed : nor fhould any praditioner 
 accuftomed to operate, hefitate in performing it, when 
 the life of a patient will otherwife be endangered. By 
 the tourniquet, we effeftually command the circula- 
 tion in the Hmb till all the large blood veffels divided 
 by the circular incifion are tied ; and by fecuring the 
 different arteries that are cut in making the longitudi- 
 nal incifions as foon as they appear, the lofs of blood 
 will be inconfiderable : nor will there be any rilk of 
 hurting the femoral artery in the courfe of feparating 
 the flap in which it is feated from the bone, if it is 
 done with caution. 
 
 It may be alleged, that by this method of operating, 
 more of the teguments and mufcles will be faved than 
 are neceffary for covering the fore ; but it muft be re- 
 membered, that the fore will here be very extenfive, 
 and that the divided mufcles will retrad confiderably. 
 And befides, the tourniquet could not be applied if 
 
Sed, VIII. above the Knee. 503 
 
 the firfl cut was much higher than I have direfted ; 
 by which the operation would neceflarily be rendered 
 much more dangerous : nor can any riik enfue from 
 the teguments and mufcles being left fomewhat lon- 
 ger than might juft be neceflary, while much incon- 
 venience would arife from their being deficient. 
 
 In the fixth volume of the Medical Commentaries 
 of Edinburgh, a cafe is recorded, in which the thigh 
 was amputated at this joint by Mr. Kerr, furgeon in 
 Northampton, In this cafe, the divifion of the femo- 
 ral artery was referved to the lafl ; nor was the tour- 
 niquet employed. No hemorrhagy indeed occurred ; 
 but there was furely more rifk of this than if the op- 
 eration had been done in the manner I have advifed : 
 nor could the operator ufe fuch freedom with the bone, 
 in rerrioving the head of it from the focket, as long as 
 the blood veflels remained undivided. I may remark, 
 however, that this cafe affords an inftance of this op- 
 eration being pra£lifed with fafety : for although the 
 patient died, yet fhe lived eighteen days after the op- 
 eration, and at lafl died from a different caufe, when 
 all rifk of hemorrhagy was over, and when the fore 
 had even a favourable appearance. 
 
 SECTION VIII, 
 Of the Flap Operation immediately above the Knee. 
 
 WHEN this operation is to be performed above 
 the knee, it may be done either with one or 
 two flaps, but it will commonly fucceed befl with one. 
 The flap anfwers befl on the forepart of the thigh ; 
 for here there is a fufliciency of foft parts for cover- 
 ing the bone, and the matter paffes more freely off than 
 when the flap is formed behind. 
 
 The patient being placed upon a table, the tourni- 
 quet being applied in the ufual way at the top of the 
 
504 Of the flap Operation Chap. XLIV. 
 
 thigh, and the teguments drawn firmly up and retain- 
 ied by an affiftant, the extent of the intended flap fhould 
 be marked with ink. A perfon much accuflomed to 
 this operation may not require this aliiftance ; but it 
 will be done with more neatnefs and accuracy if the 
 form and extent of the flap are previoufly marked. 
 
 The extreme point of the flap fliould reach to the 
 end of the limb, unlefs the teguments are in any part 
 difeafed ; in which cafe, it muft terminate where the 
 difeafe begins, and its bafe fhould be where the bone 
 is to be fawn. This; will determine the length of the 
 flap ; and we fhould be direded with refped to the 
 breadth of it by the circumference of the limb : for, 
 the diameter of a circle being fomewhat more than a 
 third of its circumference, although a limb may not 
 be exactly circular, yet by attention to this, we may 
 afcertain with fufficient exaftnefs the fize of a flap for 
 covering a flump. Thus, a flap of four inches and a 
 quarter in length will reach completely acrofs a fturap 
 whofe circumference is twelve inches ; but as fome 
 allowance muft be made for the quantity of flvin and 
 mufcles that may be faved on the oppofite fide of the 
 limb, by cutting them in the manner I have directed, 
 and drawing them up before fawing the bone ; and 
 as it is a point of importance to leave the limb as long 
 as poffible, inftead of four inches and a quarter, a 
 limb of this fize, where the firft incifion is managed 
 in this manner, will not require a flap longer than 
 three inches and a quarter, and fo in proportion ac- 
 cording to the fize of the limb. The flap at its bafe 
 ■fhould be as broad as the breadth of the limb will per- 
 mit, and fhould be continued nearly, although not al- 
 together, of the fame breadth to within a little of its 
 termination, where it fnould be rounded off" fo as to 
 correfpond as exactly as may be with the figure of the 
 fore on the back part of the limb. This being mark- 
 ed out, the furgeon ftanding on the outfide of the 
 limb fhould pafli a ftraight double edged knife with a 
 Iharp point to the depth of the bone, by entering the 
 
Scd:. VIII. abo-ve the Knee. 505 
 
 point of it at the outfide of the bafe of the intended 
 flap ; and carrying the point clofe to the bone, it muft 
 here be pufhed through the teguments at the mark on 
 the oppofitc fide. The edge of the knife muft now 
 be carried downwards, in fuch a diieflion as to form 
 the flap according to the figure marked out ; and as 
 it draws towards the end, the edge of it fliould be 
 fomewhat raifed from the bone, fo as to make the ex- 
 tremity of the flap thinner than the bafe ; by which 
 it will apply with more neatnefs to the furface of the 
 fore. The flap being fupported by an afllllant, the 
 teguments and mufcles of the other parts of the limb 
 fliould, by one Itroke of the knife, be cut down to the 
 bone about an inch beneath where the bone is to be 
 fawn ; and the mufcles being feparated to this height 
 from the bone with the point of the knife, the foft 
 parts mud all be fupported with the leather retraftors, 
 Plate XCVII. hg. 4. till the bone is fawn, and any 
 fplinters that may be left, are cut off. All the arteries 
 that discharge much blood muft now be fccured in 
 the ufual way with the tenaculum, the ligatures being 
 left of a fufiicient length for hanging out at the tAg& 
 of the flap. 
 
 The fl<in and mufcles fliould now be drawn down 
 and fecurcd with a flannel or cotton roller, in the man- 
 ner I have advifed when a leg is amputated with a cir- 
 cular incifion ; and the flap may now be laid down 
 over the furface of the fore, fo as to eft'edl a cure a3 
 much as poflible by the firft intention ; or it may be 
 dreflTed as a feparate fore, agreeably to the pradice of 
 Mr. O'Halloran, according to the judgment of the op- 
 erator. If the flap is to be applied immediately, the 
 coagulated blood fliould be carefully fponged out, and 
 it fliould be fecured to the mufcles and teguments fur- 
 rounding the reft of the ftump by three or four futures 
 paflfed at leaft three quarters of an inch into the niuf- 
 cular part of it : but care fliould be taken not to draw 
 the ligatures fo tight as to create much irritation or 
 pain. The under part of the ftump fliould now be 
 
5o6 Of the Flap Operation Chap. XLIV. 
 
 covered with a large pledget of common cerate ; and 
 a culhion of foft tow being laid over it, the whole 
 ihould be fecured in the manner I have formerly ad- 
 vifed, with crofs flraps of linen and a few turns of a 
 circular roller. 
 
 In three or four days, the dreflings may be renew- 
 ed ; and as foon as the ligatures are all removed, and 
 the tenfion and inflammation induced by the operation 
 abated, any part of the fore that was not covered at 
 firfl may now have the fkin drawn over it, and fecur- 
 ed with adhefive plaflers. 
 
 But if Mr. O'Halloran's method is to be adopted, 
 the eafielt mode of proceeding is this. The mufcles 
 and teguments being drawn down and fecured with 
 the roller, let the whole furface of the ftjump be cov- 
 ered with a pledget of foft lint fpread on both fides 
 with any foft emollient ointment ; let the flap be laid 
 down upon this ; and another pledget of the fame 
 kind being laid over the whole Vv^ith a cufliion of tow 
 and a comprefs of foft linen, the crofs fl:raps and cir- 
 cular roller fliould be employed to fupport them, but 
 with gentle preflfure. At the end of three or four days, 
 the dreflings may be renewed in the fame manner ; and 
 about the twelfth or fourteenth day, or whenever the 
 tenfion induced by the operation is removed, the lig- 
 atures being all taken out, and a proper luppuration 
 efl:abHflied, the flap may be brought into contad with 
 the fore beneath with a view to make them unite. For 
 this purpofe, any matter that may be obferved upon 
 the furface of either of them fliould be gently remov- 
 ed with a foft fponge ; and the flap being laid down 
 with as much exactnefs as poflible, it may either be 
 fecured with adhefive plafl:ers fupported by the band- 
 age above mentioned, or two or three futures may be 
 employed for it. This lafl; method will give more 
 pain than the other ; but this will be amply compen- 
 lated by the flap being retained with more accuracy in 
 its fituation. 
 
 Farther experience mufl evince which of thef^ me- 
 
SeOi. VIII. above ihc Knee, 507 
 
 thods fhould be preferred, for as yet it is not deter- 
 mined. It is my own opinion, that the fecondary 
 union recommended by Mr. O'Halloran is the beft : 
 for the pain, tendon, and inflammation that enfue from 
 the other, run often fo high as to render it neceflary 
 to remove the drefTmgs and even the ligatures ; by 
 which much additional trouble is given to the pradi- 
 tioner, and much diftrefs to the patient : whereas, 
 when the tenfion and inflammation are gone before 
 the flap is laid down, little or no pain is induced by 
 it ; nor is the cure eft'e6led in this manner more tedi- 
 ous : on the contrary, it would appear to be in gener- 
 al accompliflied more quickly in this way than in the 
 other. Even where the flap has not been applied to 
 the fore till the fourteenth day, the cure has been com- 
 pleted before the fourth week : whereas, few, if any, 
 cures, have been eft'eftcd fo early where the flap was 
 applied immediately after the operation. 
 
 In operating with two flaps, the following is perhaps 
 the eafiefl: method : the patient being placed upon a 
 table, and the tourniquet applied, let the fkin be drawn 
 up by an afliflant, and a circular incifion made through 
 the teguments and mufclcs down to the bone at the 
 inferior part of the limb, with the edge of the knife 
 turned obliquely upwards : let the fharp pointed knife, 
 mentioned above, be now puflied through the flvin and 
 mufcles on one fide of the limb down to the bone, at 
 that part where it is to be fawn ; and the under edge 
 of the knife being turned obliquely outwards, let the 
 mufcles be divided down to the circular incifion. The 
 teguments and nmfcles on the oppofite fide of the 
 limb mufl: now be divided by a fimilar incifion, when 
 any of the intermediate foft parts that may have been 
 left mufl; likewife be cut ; and the bone being fawn, 
 and the vefl^els fecured with ligatures, the cure may 
 either be attempted by laying the flaps together imme- 
 diately, or they may be kept feparate twelve or four- 
 teen days, and treated afterwards in the manner I have 
 advifed above. 
 
5o» Of the Flap Operation, Isfc. Chap. XLIV. 
 
 SECTION IX. 
 
 Of the Flap Operation below the Knee* 
 
 IN fpeaking of this operation below the knee, it is 
 not neceflary to defcribe all the fteps of it. The 
 views of the operator are the fame here as in operating 
 above the knee, and the method of effe^Ling them is 
 nearly fimilar. After the previous fleps of the opera- 
 tion are taken, the fize and form of a flap fufHcient to 
 cover a conllderable part of the fore muft be marked 
 out with ink, and this muft be feparated from the parts 
 beneath in the manner 1 have already advifed : the 
 reft of the foft parts muft now be divided, taking, care 
 to fave as much of the teguments on the fide of the 
 limb oppofite to the flap as with the flap itfelf will near* 
 ly or entirely cover the fore ; and the cure muft after- 
 wards be conduced, either by applying the flap im- 
 mediately, or after the fymptoms of pain, tenfion and 
 inflammation induced by the operation are gone, and 
 treated in the manner advifed in the laft fe6lion. 
 
 It muft be obferved, however, in operating beneath 
 the knee, that the flap cannot be formed on the fore- 
 part of the hmb as is done in the thigh ; for op this 
 part of the leg there is no mufcular fubftance ; and 
 for this reafon, we are advifed by authors to form the 
 6ap on the back part of the leg. But this is liable to 
 one very important objedion, the difficulty of prevent- 
 ing matter from lodging between the flap and the fore 
 after they are brought in contad ; for it muft be re- 
 marked, that it is moderate preifure only that we dare 
 venture to apply to the flap ; fo that it is fcarcely pof- 
 fible to prevent the matter from collecting where it 
 does not find a free vent below. 
 
 Inftead of forming the flap from the mufclcs of the 
 back part of the leg, it may be done with more pro- 
 priety upon the outfide of the limb, where there is a 
 
Sed. X. Of Amputating the Foot, tffc. 509 
 
 fufficient quantity of mufcular fubftance for this pur- 
 pofe. The point of the knife fliould be entered on 
 the outfide of the ridge of the tibia at the part where 
 the bone is to be fawn ; and being carried backwards 
 in a dired Hne, and at a proper depth to the oppofite 
 fide of the bafe of the flap, the edge of it muft after- 
 wards be carried down the line previoufly marked w ith 
 ink as a direction for the form and length of it. In 
 this manner the bones may be covered with a flap fuf- 
 ficiently thick, while the matter that forms in the pro- 
 grefs of the cure, finding a ready outlet by the inferi- 
 or edge of the flap, will not readily lodge. 
 
 In operating immediately above the ankle, we are 
 under the necefiity of leaving the flap behind, for there 
 is not a fufficicncy of foft parts to admit of it in any 
 other part. But I have elfewhere obferved, that the 
 leg fhould never be taken off fo immediately above 
 the ankle, as it leaves the ftump too long for a ma- 
 chine to be rightly fitted to it for walking : but at 
 nine inches from the condyles of the femur, which in 
 an adult is the mofl proper length for this purpofe, 
 the flap may with propriety be formed, in the manner 
 I have mentioned, on the outfide of the leg. 
 
 SECTION X. 
 
 Of Amputating the Fcoty Tecs, and Fingers^ 
 
 WHEN the whole foot is difeafed, it becomes 
 neceflfary to take oil the limb at the part I 
 have mentioned above the ankle; nay, this fliould be 
 done even where the parts about the joint are found, 
 if all the refl: of the foot is difeafed : for although fome 
 have advifed the foot to be amputated at the joint of. 
 tlic ankle, yet the praflice fliould not be adopted, as 
 the fore cannot be properly covered, nor is the ftump 
 ^'hcn of this length fo ufcful : but wlicn a confidera- 
 
5IO Of Amputating the Chap. XLIV* 
 
 ble part of the foot remains found, it ought undotibt* 
 edly to be faved, and the difeafed part of it only re- 
 moved. I have feen a whole foot taken off, where 
 two of the metatarfal bones only were difeafed : while, 
 on the contrary, it (hould be held as a fixed rule, to 
 remove the difeafed parts alone, even where two of 
 thefe bones only remain found ; for with the afTiftance 
 of a flioe properly fluffed, and a firm unyielding fole, 
 even a very fmall part of the foot proves ufeful in 
 walking ; efpecially when the bones on the infide of 
 the foot, or thofe correfponding to the great toe, and 
 thofe next to it, are left. 
 
 When the middle part only of the foot is difeafed, 
 the metatarfal bones on each fide remaining found, 
 thefe fliould be left, and the difeafed part only taken 
 out. In this cafe, the bones fhould be taken out at 
 the joint, whether they are difeafed through their 
 whole length or not ; for although inftruments might 
 be invented for cutting even a fingle bone acrofs in 
 the centre of the foot, the operation would neceffarily 
 be much more tedious, and more painful, than the 
 removal of the bone at the joint, at the fame time that 
 little or no advantage would be derived from faving a 
 fmall portion at the end of it. But where one, two 
 or three of the bones on either fide of the foot are on- 
 ly partially difeafed, as in this cafe it becomes an ob- 
 ject to fave as much of the foot as pofTible, the opera- 
 tion fliould be fo conducted that the bones may be 
 fawn acrofs nearly at the termination of the difeafed 
 parts. 
 
 In every cafe of amputation, it is an obje£l of im- 
 portance to fave as much fkin as will cover the fore ; 
 efpecially in amputating any part of the foot where 
 the effect of friction is much to be dreaded in walk- 
 ing. In making the incifion, therefore, at that part 
 of the bone where the faw is to be applied, it fhould 
 be done in fuch a manner, that a flap may be faved 
 of a fufficient fize for covering the fore. With pro- 
 per attention this may always be done, nor is it often 
 
Se£t. X. Foot, Toes, a?id Fingers, 5 1 1 
 
 difficult : for the flap may be formed either above or 
 below, or on one fide of the toe, according as the teg- 
 uments are found or otherwife. But it is proper to 
 remark, that where the ikin is found, it aniwers beft 
 to fave it below, for in this fituation it is firmer, and 
 therefore more able to rcfifl the etle^is of prefTure. 
 
 This operation is mofl eafily performed when the 
 patient is placed upon a table. The tourniquet fliould 
 be applied above the knee, with a comprefs placed 
 upon the artery in the ham : the linib fliould be firm- 
 ly fecured by afliflants ; and on fawing the bone, a 
 piece of pafteboard, or thin fplint of timber, fhould 
 be inferted between it and the contiguous found bone, 
 to protect the latter from the teeth of the inftrument. 
 
 The difeafed parts being removed, and the divided 
 arteries fecured, the flap fhould be applied as exadlly 
 as pofllble to the fore, and retained with flips of adhe- 
 five plafter and gentle prefTure with a flannel roller. 
 If futures are employed, they fhould be inferted in 
 fuch a manner as to avoid the flexor and extenfor ten- 
 dons of the toes and foot. 
 
 In amputating the toes and fingers, the operation 
 was formerly done by one flroke with a chifel and 
 mallet ; but this is liable to many objedions, and has 
 been long in difufe. In general, fingers and toes are 
 amputated in the fame manner with the larger extre- 
 mities, either by preferving a flap fufHcicnt for cover- 
 ing the fore, and afterwards dividing the bone with a 
 fmall fpring faw, rcprcfented in Plate XCVII. fig. i. 
 or by the double incifion, performed in the manner I 
 have advifed in SeQion IV. of this Chapter. But in- 
 ftead of this, it has for feveral years been the praftice 
 of fome individuals, to amputate fingers and toes at 
 the joints ; and whoever will give it a fair trial, will 
 readily prefer it. The patient being placed upon a 
 table, and the limb properly fecured, a flap fhould be 
 marked with ink of a fuflicient fize for covering the 
 fore. This being diflefted from the bone with a fcal- 
 pel, and fupported by an afhftant, a circular incifion 
 
512 Of Amputallng the Chap. XLIV. 
 
 Is then made through the reft of the foft parts a little 
 below the joint, and on a line with the bafe of the 
 flap. The lateral ligament is now to be cut ; and in 
 order to determine the point at which this fhould be 
 done, an afliftant (hould be directed to move the fin- 
 ger. This ligament being divided, the bones are eafily 
 diflocated, when the remainder of the operation may- 
 be quickly iinifhed. If an artery is to be tied, it fhould 
 be done with the tenaculum. The flap muft be ap- 
 plied to the fore, and fecured as neatly as poflible with 
 adhefive plafters, and moderate preflure with a flannel 
 roller. 
 
 The only chjedicn that has been made to this prac- 
 tice is, the fuppofed uncertain union of the contiguous 
 foft parts with cartilage. But we now know, that 
 there is no caufe for this apprehenfion, and that a flap 
 will unite as readily with cartilage as with bone, at 
 leaft I have uniformly obferved this to be the cafe ; 
 and we find from Mr. Alanfon's publication, that the 
 praftice has proved very fuccefsful in the courfe of 
 his experience. 
 
 SECTION XI. 
 
 Of Amputating the Ann at the fo'tnt of the Shoulder, 
 
 THIS operation having always been confidered as 
 hazardous and difficult to perform, it has not 
 frequently been attempted : but although it fhould 
 never be advifed when our purpofe can be accomplifh- 
 ed by amputating lower, yet no praditioner of mod- 
 ern times will decline it, when the life of a patient 
 cannot in any other manner be faved. AbfceflTes in 
 the joint, caries of the humerus reaching to the joint, 
 compound fraftures extending to the head of the 
 bone, gunfliot wounds and mortification, may render 
 amputation of the arm at the fhoulder neceffary. 
 
Sed. XI. Arm at the Shoulder. 513 
 
 The operation may be performed with fafety by any 
 furgeon of fteadinefs and experience, and who is pof- 
 felfed of an accurate knowledge of the anatomy of the 
 Joint and contiguous parts. 
 
 It may be done in different ways ; but the follow- 
 ing I believe to be the beft. 
 
 The patient (hould be placed upon a table of a con- 
 venient height, covered with a mattrefs and blanket ; 
 and he fliould be laid upon his back, and properly fe- 
 cured by afliflants, as near as poffible to one fide of 
 the table. 
 
 The next obje*^ is to guard againfl hemorrhagy : 
 for this purpofe the tourniquet might be placed upon 
 the upper part of the limb, in a manner fimilar to 
 what I have propofed in amputating at the hip joint. 
 But here it is unnecefl'ary, as the blood may be com- 
 pletely flopped in its flow to the arm, by comprefling 
 the fubclavian artery as it paffes over the firft rib : for 
 this purpofe, an alliflant fhould be properly placed 
 with a firm cufhion or comprefs applied upon the 
 courfe of this artery diredly above the clavicle, who 
 with his finger fhould make fuch a degree of preffure 
 as may be required : it will readily be known whether 
 it anfwers or not, by its influence on the pulfe at the 
 wrifl. 
 
 The circulation being flopped, the difeafed fhoul- 
 der fhould be made to project fomewhat over the fide 
 of the table ; and the arm being ftretched out and 
 fupported by an affiflant at nearly a right angle with 
 the body, a circular cut fhould be made through the 
 fkin and cellular fubflance jufl at the infertion of the 
 deltoid mufcle into the humerus. The teguments may 
 be allowed to retraft about half an inch ; and at the 
 edge of the retradled fkin, the knife may be applied fo 
 as to divide the mufcles with a perpendicular circular 
 cut down to the bone. Thus far we proceed with the 
 common amputating knife ; but the remainder of the 
 operation fhould be finifhed with a fcalpel. With a 
 
 Vol. III. K k 
 
514 Of Amputattng the Chap. XLIV, 
 
 firm round edged fcalpel a perpendicular inclfion 
 (hould now be made down to the bone, commencing 
 at the acromion, about half way between the centre 
 of the deltoid mufcle and the inner edge of it, and ter- 
 minating in the circular incifion about an inch above 
 or rather on the outfide of the brachial artery. This 
 being done, a fimilar cut muft be made on the back 
 part of the arm, commencing at the fame height with 
 the other, and ending in the circular incifion. This 
 fhould be at fuch a diftance from the firft, that the 
 two flaps formed by them both may be nearly of an 
 equal breadth. The brachial artery fhould be tied as 
 foon as it is cut by the circular incifion through the 
 mufcles ; and any anaftomofing mufcular branches of 
 arteries jthat may be cut on the upper and back part 
 of the joint, fhould be tied immediately on being ob- 
 ferved. The two flaps fliould now be feparated from 
 the bonCj care being taken to avoid the large artery in 
 diflTedling off that part of the flap with which it is con- 
 nected. An afl^iflant mufi: fupport the flaps fo as to 
 bring the capfular ligament of the joint into view ; 
 when an opening being made into it, the head of the 
 bone will be eafily diflocated by drawing the arm back- 
 ward ; and this being done, the operation will be ea- 
 fily finifhed, by dividing the remaining part of the lig- 
 ament. 
 
 Any arteries that may have been cut about the joint 
 being tied, the ligatures hanging out at the moll de- 
 pending part of the wound, and the parts cleared of 
 coagulated blood, the two flaps fhould be laid togeth- 
 er fo as to cover the joint as neatly as poflible, and re- 
 tained in their fituation with two or more futures. A 
 pledget of lint fpread with any emollient ointment 
 fliould now be laid over the joint ; and a foft cufhion 
 of tow or lint, with a comprefs of old linen, being ap- 
 plied over the whole, a flannel roller fliould be em- 
 ployed to make moderate prefl'ure upon the joint ; by 
 which the flaps will be kept in contact witli the parts 
 beneath, which will not only facilitate their union, but 
 
Seft. XI. Ar7n at the Shoulder. 515 
 
 will be the mofl: efFedual method of preventing the 
 lodgment of matter. 
 
 In other refpecls, the patient fliould be treated as I 
 have advifed in the preceding fections when fpeaking 
 of amputation in the lower extremities. With a view 
 to prevent any rifk from hemorrhagy after the opera- 
 tion^ an affiftant of experience fliould fit with the pa- 
 tient for the firfl two or three days, with diredions to 
 apply preffure above the clavicle in the event of any 
 confiderable quantity of blood being difcharged, till 
 the bleeding veflTel can be fecured with a ligature. In 
 the courfe of eight or ten days, the ligatures upon the 
 arteries will come eafily away. If matter colleds be- 
 neath any part of the fkin, it mud be difcharged ; and 
 if the patient is healthy, and no untoward circumftance 
 happens, a cure may foon be expelled. 
 
 Till of late, it was the practice in this operation to 
 tie the brachial artery and veins with a Hgature before 
 proceeding farther. This gave much unneceflary 
 pain, at the fame time that it did not render the pa- 
 tient more fecure. In the way I have mentioned, the 
 operation may be performed with no rifk from the he- 
 morrhagy ; and by tying the artery at the extremity 
 of the flap, feveral mufcular branches will be faved 
 that would be deflroyed by tying it near the axilla. 
 
 Mr. Bromfield, in the firfl volume of his Obferva- 
 tions and Cafes, has given the beft account yet publifh- 
 ed of this operation. The principal difference between 
 his method of doing it and the one that I have de- 
 fcribed, confifts in the latter being more fimple, and 
 therefore more eafily performed. By dividing the 
 mufcles down to the bone with a circular incifion, the 
 operation is more fpeedily done than by cutting firfl 
 one mufcle and then another, in the manner mention- 
 ed by Mr. Bromfield. And as the attachments of 
 the latiflimus dorfi, the deltoid and pedoral mufcles, 
 are removed by the arm being taken away, there is no 
 neceflity for proceeding with flownefs and caution in 
 K K 2 
 
5i6 Of Amputating the Amu Chap. XLIV. 
 
 dividing them ; nor is it neceffai-y to employ two lig- 
 atures upon the brachial artery, one confiderably high- 
 er than the other, as is advifed by that author ; one 
 ligature applied in the ufual way with the tenaculum 
 is quite fufficient, if it is done with care and attention. 
 And Mr. Alanfcn very properly obferves, in fpeaking 
 of this operation, that there is no necellity for fcrap- 
 ing oif the cartilage from the acetabulum of the joint, 
 as is recommended by Mr. Bromfield ; for it is found, 
 by experience, as I have obferved in the laft Sedion, 
 that the teguments adhere to cartilages as readily as 
 to bone. 
 
 SECTION XII. 
 
 Of A?7iputating the Ann. 
 
 THE general obfervations I have made upon the 
 method of amputating the thigh and leg, apply 
 equally to the amputation of the arm and fore-arm. 
 At prefent, therefore, I Ihall only obferve, that in am- 
 putating the arm, no more of it fhould be removed 
 than is difeafed ; for the longer the ftump is, the more 
 ufeful it proves j and the fame attention fhould be giv- 
 en to the faving of teguments for covering the fore 
 that I have advifed in amputating the leg. But it is 
 proper to remark, that this may always be done both 
 in the arm and fore-arm without the affiftance of a 
 flap : for there is in every part of both a fufficiency of 
 mufcles and cellular fubftance, for admitting of the 
 fore being completely covered by amputating with the 
 double incifion, in the manner I have pointed out for 
 this operation upon the thigh ; and wherever this can 
 be done, it fhould be preferred to the method of op- 
 crating with a flap. 
 
Chap. XL V. Of removing Ends of Bones* 517 
 
 CHAPTER XLV. 
 
 OF REMOVING THE ENDS OF BONKS IN DISEASES OF 
 THE JOINTS. 
 
 THE amputation of limbs Is more frequently ad- 
 vifed for difeafes of the joints than for any oth- 
 er caufe ; and as this often happens where the reft of 
 the Hmb is found, it were to be wifhed, that with fafe- 
 ty and propriety we could remove fuch parts as are 
 difeafed, and leave thofe that are found. In compound 
 fractures and diflocations, the ends of large bones have 
 frequently been fawn off, when fuch parts of them 
 have protruded as could not be replaced. The defi- 
 ciency thus produced, has in moft inftances been fup- 
 plied by nature ; and thus the limbs have remained 
 almoft equally ufeful as before. In a few cafes, too, 
 of difeafed joints, a cure has been obtained by the head 
 of a bone being fawn off. Among other inftances of 
 this to be met with in books, a remarkable one is re- 
 corded by a very ingenious and expert furgeon, Mr. 
 White of Manchefter, who preferved an arm by faw- 
 ing off the head of a difeafed humerus.* But Mr, 
 Park of Liverpool, was the firft who ventured to pro- 
 pofe it as a general remedy in aft'edtions of the joints.f 
 Whether or not it will ftand the teft of experience, 
 farther trials muft determine ; but in the mean time, 
 the public are much indebted to Mr. Park for the 
 pains he has taken to introduce a lefs formidable rem- 
 edy in place of amputation. 
 
 • Vide Cafes in Surgery with Remarks, Part I. by Charlci White, 
 F. R. S. &c. 
 
 t Vide An account of a new method of treating difeafes of the joints of 
 the knee and elbow, by H. Park. 
 
51 S Of removing Ends of Chap. XL V. 
 
 What Mr. Park propofes is, that inftead of ampu- 
 tating a limb for any external violence done to a joint, 
 for a white fwelling, a caries, or any other affection, 
 that the difeafed ends of the bones fhould be fawn oft' ; 
 when nature, he thinks, will commonly fupply the de- 
 ficiency of bone ; by which the limb will be preferv- 
 ed, and will prove more ufeful than any machine that 
 artifts can invent. 
 
 Mr. Park fuppofes that this operation will be chief- 
 ly applicable to affedions of the knee and elbow, and 
 more particularly to thofe of the latter ; and he relates 
 a cafe of white fwelling of the knee in which it was 
 pradifed with fuccefs : the under extremity of the 
 femur and the upper end of the tibia were fawn off"; 
 no artery of importance was injured j and the vacan- 
 cy produced by the removal of the ends of the bones 
 was fupplied with callus : in the courfe of ten weeks, 
 a cure of the fore was obtained ; the hmb became fo 
 firm that the man has fmce been able to go to fea as 
 a failor, and he does not even ufe a crutch. 
 
 This, however, is the moft favourable view of the 
 propofal ; and it is proper to remark, that in the courfe 
 of the cure, much perplexity occurred from various 
 circumftances ; particularly from the difficulty of pre- 
 ferving the limb in a fteady fixed fituation ; from the 
 great depth of the wound ; from the lodgment of mat- 
 ter ; and from the formation of finufes. By much at- 
 tention on the part of Mr. Park, all thefe difficulties 
 were fur mounted ; but although the merits of the op- 
 eration muft be determined by farther trials, yet the 
 rifk attending it appears to be fo great, that there is 
 much reafon to think that it \viU never be generally 
 practifed. 
 
 For a more particular detail of the method of do- 
 ing it, and of the after treatment of the fore, the pub- 
 lication itfelf muft be confulted j but for the advan*- 
 tage of thofe who may not eafily meet with it, the fol- 
 lowing fhort account of the operation is inferted in 
 Mr, Park's own words. 
 
Chap. XLV. Bones ai the Joints, 519 
 
 " An incifion was made, beginning about two in- 
 ches above the upper end of the patella, and continu- 
 ed about as far below its under extremity : another, 
 croffing this at right angles, immediately above the 
 patella, the leg being in an extended ftate, was made 
 through the tendons of the extenfor mufcles down to 
 the bone, and nearly half round the limb ; and the 
 lower angles formed by thefe incifions were raifed fo 
 as to lay bare the capfular ligament : the patella was 
 then taken out, and the upper angles were raifed, fo 
 as fairly to denude the head of the femur, and to en- 
 able me to pafs a fmall catling acrofs the pofterior flat 
 part of the bone immediately above the condyles, tak- 
 ing care to keep one of the flat fides of the point of 
 the inftrument quite clofe to the bone all the way. 
 The catling being withdrawn, an elaftic fpatula was 
 introduced in its place, to guard the foft parts while 
 the femur was fawing through : which done, the head 
 of the bone thus feparated was carefully diifeded out : 
 the head of the tibia was then with eafe turned out 
 and fawn off, and as much as pofTible of the capfular 
 ligament diffefted away, leaving only the pollerior 
 part covering the veffels ; which, on examining, I had 
 the fatisfadion to find had not only efcaped unhurt, 
 but that it was not a very narrow efcape : they had 
 flill a pretty good covering, and had been, through 
 the whole operation, far enough out of the courfe of 
 the knife. It nmfl be confefled, that the appearance 
 of the wound was fomewhat formidable, exhibiting a 
 very large cavern with very thin parietes ; and in 
 fhort, there feemed Httle wanting to complete the am- 
 putation : yet as the limb below would not be depriv- 
 ed of any part of its nourifhment, and as every heal- 
 thy incifed furface, as well of bone as of foft parts, 
 has a natural tendency to granulate, I could not fee 
 any room to doubt, that nature would be able to re- 
 pair the breach." 
 
 Mr. Park afterwards informs us, that he attempted 
 to perform the operation without making the tranf- 
 
520 Of removing Ends of Chap, XLV, 
 
 verfe incifion : but he found it could not be done ; 
 and after fpending fome time in the attempt, it \vas 
 thought advifable to dcfifl: from it. More than two 
 inches of the femur, and rather more than one inch 
 of the tibia, were removed ; which were but juft 
 enough to admit of the leg being brought into a right 
 line with the thigh, the previous contradion of the 
 flexor mufclcs being fuch as to keep the two fawn 
 ends of bone in clofe contaQ: : this produced a con- 
 fiderable redundance of the teguments. To fupport 
 this, that it might not fall inward, and to keep the 
 edges of the incifion in appofition till they fliould ac- 
 quire fome degree of firmnefs, a few ftitches were 
 pafled through the fkin ; not merely along the courfe 
 of the tranfverfe incifion, but upon that of the longi- 
 tudinal cut that extended up the thigh. The lighteft 
 fuperficial dreflings only were applied, and the limb 
 placed in a cafe of tin from the ankle to the infertion 
 of the glutaeus mufcle. 
 
 Mr. Park very candidly enumerates feveral objecr 
 tions that may be made to this operation ; but, at the 
 fame time, he thinks that all of them may be obvia- 
 ted. There are two however, which in my opinion, 
 will always appear with force againfl: it : the firil is, 
 that where the bones of large joints are fo much dif- 
 eafed as to render it necelfary to remove them, the; 
 furrounding foft parts are commonly fo much thick- 
 ened, inflamed or ulcerated, as to render any attempt 
 to fave them very uncertain, and much more hazard- 
 ous than the amputation of the limb : and the fecond 
 is, the high degree of inflammation that commonly 
 fucceeds to wounds of the larger joints. 
 
 With refpe£t to the firfl of thefe, Mr. Park himfelf 
 wiflies it to be underftood, that it is chiefly in afi'ec-r 
 tions of the joints produced by external violence, that 
 he thinks this operation will be peculiarly ufeful ; and 
 with refpecl to the laft, he obferves, that the heads of 
 large bones have been frequently fawn off, without 
 smy violent fymptom taking place : and as he fup- 
 
Chap. XLV. Bones at the yoints. 521 
 
 pofes this to be owing to the very free divifion of the 
 capfular ligaments, which in fuch cafes mud always 
 happen, he thinks that the total removal of this liga- 
 ment, which he advifes in this operation, will in a 
 great meafure prevent it. I have obferved above, that 
 experience alone can determine upon the merits of 
 this operation ; but I cannot avoid remarking, that 
 no neceflity appears for the removal of any part of 
 the capfular ligament. It may be highly proper to 
 make the opening into it free and large ; but to re- 
 move it, by diflecling it off from the contiguous parts, 
 mud probably add to the rilk of the operation, by 
 rendering the inflammation more fevere than it other- 
 wife might be ; at the fame time that it mufl necelfa- 
 rily render it much more painful as well as more te- 
 dious. Farther experience may perhaps, fet this in a 
 different point of view : but at prefent I fee no more 
 reafon for removing any part of the capfular ligament 
 in this operation, than for the removal of the tunica 
 vaginalis teftis in the operation for the hydrocele ; a 
 pradice now altogether laid afide, even where the 
 cyft is much thickened. 
 
522 Of If lies. Chap. XLVL 
 
 CHAPTER XLVL 
 
 OF ISSUES. 
 
 ISSUES are fmall artificial ulcers that we form in 
 different parts of the body, for the purpofe of pro- 
 curing a difcharge of purulent matter. 
 
 As I have elfevvhere treated fully of the advantages 
 that may be derived from iffues, and of the manner in 
 which they feem to a6b in the cure of difeafes, it is.not 
 at prefent neceffary to enter minutely upon this part 
 of the fubjeft : I fhall, therefore, only obferve, in gen- 
 eral, that I am daily more and more convinced of the 
 utihty of iffues in the cure of long continued fores, of 
 whatever kind they may be ; and that I am ftill of 
 the opinion that they ad folely by difcharging a cer- 
 tain quantity of the ferous parts of the blood j and 
 not that they ferve merely as drains for noxious hu- 
 mours, which, till of late, has been the prevailing 
 opinion of practitioners.* 
 
 Among other errors in practice to which this opin- 
 ion gave rife, the choice of fituation for iffues was 
 none of the leaft remarkable. As it was imagined that 
 ulcers as well as other local difeafes were produced by 
 a determination of morbific humour to a particular 
 fpot, when iffues were advifed, it was confidered as 
 neceffary to place them as contiguous to the affefted 
 part as pollible, and always on the fuperior part of the 
 limb when the difeafe was feated on any of the ex- 
 tremities, in order to prevent the morbid matter from 
 falling down to it. But as we now conclude that if- 
 fues prove ufeful or other wife merely by the quantity 
 
 • Sec Chapter TV. on the Theory and Management of Ulcers, where 
 ihii fubject is fully confiderctL 
 
Chap. XL VI. Of JJfues. 523 
 
 of matter which they afford, it appears to be of little 
 importance where they are placed ; and accordingly 
 they may be inferted wherever the patient thinks they 
 will occafion the lead inconvenience. 
 
 Some general rules, however, fhould be obferved in 
 the introduftion of iffues : they fhould never be plac- 
 ed immediately above a bone thinly covered ; nor di- 
 rectly above a tendon ; nor very contiguous to a large 
 blood veflel or nerve ; nor upon the belly of a muf- 
 cle. The befl: fituation for iffues is that fpace which 
 lies between the tendons on th^ back part of the neck, 
 where there is a confiderable depth of cellular fub- 
 ftance ; the middle of the humerus, near to the in- 
 fertion of the deltoid mufcle ; and a confiderable hol- 
 low above the flexor tendon on the infide of each 
 knee. They may likewife be inferted between two of 
 the ribs, and on each fide of the vertebras of the back ; 
 or, in fhort, wherever there is a fufficient quantity of 
 cellular fubflance for the prote£tion of the parts be- 
 neath. It is proper, however, to remark, that the fpot 
 ufually fixed upon for iffues is perhaps the moft im- 
 proper of any, I mean diredly below the knee ; where 
 there is never much cellular fubftance ; where the 
 veins of the leg can fcarcely be avoided ; and where 
 the peas are apt to hurt the contiguous tendons. 
 
 Iffues may be formed in various ways : by corrod- 
 ing or removing the fl^in with epifpaftic applications ; 
 by making an incifion with a fcalpel or lancet ; by the 
 application of cauftic ; and the introduction of a cord. 
 
 When an iffue is to be opened by removing a por- 
 tion of fkin, a blifter muff be applied upon the fpot, 
 exa£tly of the fize of the intended fore ; and on the 
 blifter being removed, a difcharge of matter may be 
 kept up, by dreffing the part daily with any common 
 ointment in which there is mixed a fmall proportion 
 of cantharides in fine powder : or, it fometimes proves 
 fufficient to ufe this irritating application, and a mild 
 ointment of wajc and oil alternately. 
 
524 Of Jfue.^, Chap. XL VI. 
 
 In forming an IlTue by incifion, or with caufUc, an 
 opening mufl be made of fuch a fize as is fufficient 
 for affording a proper quantity of matter ; and the 
 aperture mufl be preferred by inferting daily into it 
 fome extraneous body covered with any mild digeftive 
 ointment, fuch as bafilicon or linimentum arcasi, while 
 the whole mufl be fecured with a proper bandage. 
 Peas are commonly employed for this purpofe. Kid- 
 ney beans anfwer very well ; and fome make ufe of 
 gentian root, and of aurantia curaflaventia, ufually 
 termed orange peas, turned into a proper form. When 
 the opening is made by an incifion, the fkin fhould be 
 fupported on one fide by an afliilant, and on the oth- 
 er by the left hand of the furgeon ; who fhould now, 
 wdth a fcalpel in the other, make a cut of a fufficient 
 length and depth for receiving the number of peas in- 
 tended to be put into it, and thus the operation is fin- 
 ifned : but when done with cauflic, more attention i$ 
 requifite. Many compofitions of cauflic pafle have 
 been recommended ; but I have met with none that for 
 this purpofe anfwers fo well as the lapis infernahs or 
 cauflicum commune of different Difpenfatories. It 
 fhould be firfl reduced to powder, and made into a 
 pafle with water, or with foft foap, when as much of 
 it fhould be applied upon the fpot where the iffue is 
 wanted as will make an opening of a proper fize ; but 
 as it is apt to fpread to the contiguous parts, fome care 
 i^ required to prevent it. For this purpofe, a piece of 
 leather fpread with Burgundy pitch, or any adhefive 
 plafler, with a fmall hole cut in the centre, fhould be 
 placed upon the part, with the hole direclly on the 
 fpot where the cauftic is meant to be applied. The 
 fmall fpot thus left uncovered, mull now be fpread 
 with the cauflic pafle ; and over the whole there 
 Ihould be laid another piece of leather fpi-ead with the 
 fame adhefive plafler, fo that no part of the cauflic 
 may efcape. In the courfe of ten or twelve hours, the 
 whole may be removed ; for before this if the cauflic 
 
Chap. XL VI. Of TJues, s^S 
 
 is good, it will have produced an efchar of a fufficient 
 depth. In the fpace of three or four days, the efchar 
 will feparate from the contiguous found parts, when 
 the opening formed by it muft be filled with peas or 
 fome other of the fubf lances I have mentioned. 
 
 When it is neceffary to difcharge a large quantity 
 of matter by an iflue, and efpecially when we wilh to 
 have it from deep feated parts, we do it by the intro- 
 duflion of a cord of cotton or filk, forming what is 
 commonly termed a feton. This we often employ 
 with advantage in deep feated pains, particularly in 
 pains of the bread and fides in phthifis pulmonalis. 
 In fuch cafes it is commonly inferted between two of 
 the ribs ; and it anfwers better in the diredion of the 
 ribs than when placed acrofs them, as is fometimes 
 done. A cord is alfo a frequent remedy in difeafes 
 of the head, particularly in ophthalmia and other af- 
 fedions of the eyes ; and in fuch cafes it is ufually 
 placed in the back part of the neck. 
 
 In the introduction of a cord, the parts at which it 
 is to enter and pafs out, fliould be previoufly marked 
 with ink ; and the cotton or filk being put into the 
 eye of the flat needle, Plate LIV. fig. 5. and the parts 
 fupported by an alTiftant, the needle fhould now be 
 pulhed in at one of the fpots and carried out at the 
 other, along with two or three inches of the cord, 
 which fhould be left hanging out. The irritation 
 which the cord excites is foon followed by a plentiful 
 difcharge of matter, which may be increafed or dimin- 
 iflied at pleafure, by covering the cord daily, before 
 it is dra^n, with a mild or an irritating ointment. 
 
 In former tiuies, it was a frequent practice to form 
 iflues hf burning the parts into which they were to 
 be introduced with the adual cautery ; and in fome 
 parts or Europe it is flill continued : but as it is much 
 more terrifying than any of thofe that I have mention- 
 ed, andas it does not appear to be attended with any 
 particulir advantage, it is now in general laid afidc* 
 
526 Of IJues. Chap. XLVL 
 
 In China, Japan, and fome other eaftern countries^ 
 it is ftill a prevailing pradtice, in deep feated pains, to 
 burn the parts affe£led down to the bone with moxa. 
 Moxa is a Hght, foft combuftible down, of a particu- 
 lar plant. A fmall cone of it being wrapped up, the 
 bafe of the cone is fixed upon the part with glue or 
 mucilage ; and fire being put to the oppofite end of 
 it, it is allowed to remain till the whole is confumed ; 
 and if one appUcation does not prove fufficient, it is 
 repeated once and again as long as it is neceflary. The 
 operation may be done equally well with fine flax ; 
 but although it has been fometimes done in different 
 parts of Europe, it will not probably be ever general- 
 ly praftifed. I have known it, however, remove the 
 mod obftinate fciatic pains, where every other reme- 
 dy had failed. 
 
Chap. XL VII. Of the Inoculation^ Esfr. 527 
 
 CHAPTER XLVII. 
 
 OF THE INOCULATION OF THE SMALLPOX. 
 
 THERE is caiife to imagine, that ahnofl: all erup- 
 tive difeafes, as well as fome others, may be 
 communicated by inoculation : the practice, however, 
 is confined to fuch as are not apt to return ; for no 
 advantage would arife from inducing difeafes to which 
 the fyftem might afterwards be liable. The plague 
 has been communicated by inoculation ; but in this 
 country the fmallpox, and of late the cow pox, are 
 the only difeafes that we are accuftomed to inoculate. 
 Some trials have indeed been made for inoculating 
 the meafles ; but as yet they have not fucceeded. 
 
 From the refult of fome experiments, there is rea- 
 fon to think, that no difeafe can be communicated 
 by inoculating with the blood of an infeded perfon. 
 This, however, is not as yet precifely determined ; fo 
 that farther trials will be necefl'ary to afcertain it. In 
 inoculating the fmallpox and cow pox, we employ 
 the matter contained in the puftules. 
 
 The proper period for inoculating, the preparation 
 of the patient, and the fubfequent treatment of the 
 difeafe, are points that more particularly fall to the 
 confideration of the phyfician. The mode of com- 
 municating the infection is our only objed at prefent. 
 
 In the more early pradice of inoculation, it was 
 cuftomary to tie an inieded thread round the arm or 
 leg ; to rub a little variolous matter upon any part of 
 the body ; or to infert a piece of thread foaked in 
 matter beneath the cuticle, with a fmall needle, and 
 to allow it to remain till there was reafon to think 
 that the infedion had taken place. In any of thefe 
 
525 Of the Inoculation Chap. XLVlt. 
 
 ways the difeafe may be communicated : but as by 
 fome of them there is caufe to fufped that a variolous 
 atmofphere may be produced, and that the difeafe 
 may be thus induced in the fame way as in the cafe of 
 a common contagion, and confequently that fome of 
 the advantages of inoculation may not be obtained 
 from them, thefe modes of giving the fmallpox ought 
 therefore to be laid afide. 
 
 Till of late, inoculation was commonly performed 
 by making an incifion of about half an inch in length 
 through the fkin to the depth of the cellular fubftance : 
 a bit of thread impregnated with variolous matter was 
 then inferted, and retained for two or three days with 
 a comprefs and bandage. To this praftice, however, 
 the great unneceflary pain attending it, and the apt- 
 nefs of the wound to deeenerate into a dil'aoreeable 
 ulcer, are ftrong objedions. 
 
 The prefent mode of inferting the matter appears 
 to be in every refpedl more eligible. The point of a 
 lancet, previoufly covered with variolous or vaccine 
 matter, is infmuated through the cuticle fo as to fcratch 
 or nightly injure the cutis vera. It might frequently 
 indeed be fufficient to pafs it through the cuticle on- 
 ly ; but we do not fo readily fail when a fmall parti- 
 cle of blood follows the lancet. When the matter is 
 recently taken in an early period of the difeafe, the 
 lancet may be introduced without being moiftened ; 
 but whenever the matter has become firm and hard, 
 it fhould be rendered foft with a drop of warm water, 
 or by holding it in warm fteam. 
 
 The operation may be done in any part of the bo- 
 dv ; but the arm is generally preferred. One fcratch 
 would for the mofl part prove fufficient ; but with a 
 view to enfure fuccefs, two or even three are com- 
 monly made at the dillance of an inch from. each oth- 
 er. It is to be obferved, however, that when the mat- 
 ter takes effe6t in all the fcratches, the inflammation 
 that enfues being communicated from one to the oth- 
 
Chap. XLVII. vfthe Smallpox. 529 
 
 er, is often confiderable, and gives much pain and un- 
 eafinefs. This is eafily prevented by making only 
 one fcratch in each arm, which for fcveral years paft 
 I have uniformly done. 
 
 In this method of inoculating, we never employ 
 either bandage or comprefs ; for the wound is fo tri- 
 fling that no kind of dreffing is neceflary : fo that we 
 readily fee, at the end of a few days, whether the in- 
 fe£lion will take place or not ; for in general, by the 
 third or fourth day, if the operation is to fucceed, the 
 fcratches made with the lancet become red, fwelled, 
 and fomewhat painful. 
 
 Vol. III. L 1 
 
530 Of dimlniJJjing Pain Chap. XLVIII. 
 
 CHAPTER XLVIII. 
 
 OF PREVENTING OR DIMINISHING PAIN IN CHIRUR- 
 GICAL. OPERATIONS. 
 
 TO be able to alleviate the mifery of thofe who 
 are obliged to fubmit to dangerous operations, 
 muft afford the higheft gratification to every practi- 
 tioner : and as pain is the mod dreadful part of every 
 operation, it necelfarily demands our mod ferious at- 
 tention. 
 
 The pain induced by operations may be leffened in 
 different ways : by diminifliing the fenfibility of the 
 fyftem ; and by comprefling the nerves that fupply the 
 parts upon which the operation is to be performed. 
 
 Narcotics of every kind might be employed for the 
 purpofe of leffening general fenfibility ; but nothing 
 anfwers this with fuch certainty and effe£t as opium* 
 
 But as opiates, when given in dofes large enough 
 for this purpofe, are apt to induce ficknefs and vom- 
 iting, I feldom venture on giving them before an op- 
 eration, unlefs the patient has previoufly been in the 
 habit of ufmg them. In general they prove moft ufe- 
 ful when given immediately after, when they very 
 commonly alleviate that pungent forenefs of which pa- 
 tients at this time ufually complain ; and by continu- 
 ing to give them in adequate dofes from time to time, 
 we are often enabled to keep the patient eafy, till re- 
 lief is obtained by the formation of matter, or by the 
 removal of that inflammatory tenfion that ufually takes 
 place after every capital operation : and as this proves 
 
Chap. XLVIII. 171 Chirurgical Operations. 531 
 
 not only highly comfortable to the patient, but tends 
 in the moll etlVdual manner to moderate the febrile 
 fymptoms that commonly occur, it (liould never be 
 omitted. 
 
 It has long been known, that the fenfibility of any 
 part may not only be leffened, but even altogether fuf- 
 pended, by comprefling the nerves that fupply it : and 
 accordingly, in amputating limbs, patients frequent- 
 ly defire the tourniquet to be firmly fcrewed, from find* 
 ing that it tends to diminilh the pain of the operation. 
 
 The eifed: of this, however, being inconfiderable, 
 it has lately been propofed by Mr. James Moore, of 
 London, to comprefs the principal nerves fo com- 
 pletely as to render the parts beneath altogether in- 
 feiifible. In Plate XCIX. an inftrument is delineat- 
 ed, by which this may be very effedually done. 
 
 'Whether or not it will anfwer with eafe and cer- 
 tainty, experience alone muft determine : but, in the 
 mean time, we are much indebted to the ingenious 
 author, for affording a hint that eventually may tend 
 to mitigate the fufierings of thofe whom neceflity 
 obliges to fubmit to chirurgical operations. All that 
 this inftrument feems to require in order to render it 
 perfed, is the power of comprefTmg the nerves of a 
 limb without affeding the veins ; for as it is found 
 that the nerves muft be compreffed for a confiderable 
 time, at leaft an hour, before the parts beneath are 
 rendered altogether infenfible, the veins could not be 
 compreffed for fuch a length of time but with the rifk 
 of burfling. With a view to prevent fuch a difagree- 
 able occurrence, Mr. Moore propofes that one of the 
 veins in the limb fhould be opened. But as this might 
 prove hurtful to weakly patients, in whom it is often 
 of importance to guard againft the lofs of blood, it 
 would be better to avoid it, by having the inftrument 
 formed in fuch a manner, that it might comprefs the 
 principal nerves only, without materially affe6ting the 
 L h 2 
 
$^2 Ofdimimjhing Pain, isfc. Chap. XL VIII. 
 
 veins. This will not indeed be eafily done, as the 
 nerves ufually run at no great diflance from the veins : 
 but the fame purpofe may perhaps be anfwered by 
 comprefling the arteries of the Hmb for a minute or 
 two before any preifure is appHed to the veins j by 
 which the latter may be previoufly emptied. 
 
 I 
 
Sea. I. Of MJdwifery. 533 
 
 CHAPTER XLIX. 
 
 OF MIDWIFERY. 
 
 SECTION I. 
 
 General Ohfervations on Midwifery, 
 
 MIDWIFERY being now confidered as a diftind 
 branch of chirurgical pra«5lice, a minute ac- 
 count of it will not be expected in a Syftem of Sur- 
 gery. For more particular information, thofe authors 
 who have written upon it may be confulted : but I 
 have judged it proper to delineate the inftruments ufu- 
 ally employed in midwifery ; and to defcribe two op- 
 erations, which, although immediately conneded with 
 this branch, are yet more frequently performed by the 
 furgeon than the accoucheur ; namely, the Casfarean 
 operation, and the divifion of the fymphyfis pubis. 
 
 A great variety of inftruments have been invented 
 by practitioners in midwifery ; almoft eveiy publica- 
 tion, indeed, upon this fubjed, announces fome new 
 invention. It is only thofe inftruments, however, 
 which experience has fhown to .be ufeful, that I mean 
 to defcribe : they are not numerous ; and are all de- 
 lineated in Plates CII. CIII. CIV. CV. and CVI. 
 
 With the forceps in Plate CII. fig. 2. we lay hold 
 of the head of the child when the mother is much en- 
 feebled and th^ contradlion of the uterus not fufficient 
 to expel the child in the ufual way : and when deliv- 
 ery cannot be effedled even in this manner, or by turli- 
 ing the child, and bringing it away by the feet, as 
 fometimes happens from the pelvis being much dif- 
 torted, we employ the crotchet reprefented in Plate 
 
534. Of Mld'wlfery. Chap. XLIX, 
 
 cm. fig. 3. for bringing the child away piecemeal, af- 
 ter leffening the fize of the head by an opening made 
 in the fkull for difcharging the brain with the fciifars 
 reprefented in fig. i . of the fame Plate. 
 
 The neceffity, however, of iifing any of thefe in- 
 ftruments I believe to be exceeding rare : they are in- 
 deed frequently employed ; but this proceeds in a 
 great meafure from impatience on the part of prafti- 
 tioners, who often force the delivery of the child, when 
 nature, if left to herfelf, would eft'eft it in a much more 
 eafy manner. This fad is fo certainly well founded, 
 and is of fuch general importance, that practitioners 
 of every defcription, and more efpecially thofe who are 
 newly entering on bufmefs, fhould never lofe fight of 
 it. By not meeting with that attention which it me- 
 rits, both the forceps and crotchet are daily employed 
 with too much freedom, to the difgrace of the art, and 
 often with irreparable injury both to the mother and 
 child. 
 
 In fome cafes it happens, that delivery cannot be 
 accomplifhed even with the afliftance of thefe inftru- 
 ments, owing to the brim of the pelvis being fo nar- 
 row that it will not allow any part of the child to pafs. 
 In fuch circumftances, the Caefarean fedlion, as it is 
 termed, ufed formerly to be pra(3:ifed ; but the dan- 
 ger attending that operation being fo great that the 
 mother was feldom faved by it, Mr. Sigault of Paris, 
 about four and twenty years ago, propofed the divi- 
 fion of the fymphyfis pubis, for the purpofe of increaf- 
 ing the diameter of the pelvis, and for extracting the 
 child in the ufual way, by the vagina. 
 
Se£l. II. Of the Cxfarean Operation, 535 
 
 SECTION II. 
 
 Of the Cafarean Operation. 
 
 THIS operation may become neceflary, as we have 
 feen in the lafl fe6lion, by the brim of the pelvis 
 being fo narrow that it will not allow the child to pafs j 
 and it may alfo become proper where the child has 
 been forced into the cavity of the abdomen by a rup- 
 ture in the uterus, as fometimes happens from the ute- 
 rus contrading with too much force before the os tin* 
 cse is fufficiently dilated. 
 
 The Cccfarean feftion may be performed, either with 
 a view to fave both the mother and child, when the 
 child cannot be extraAed in any other manner ; to fave 
 the mother only when we know that the child is dead ; 
 or to fave the child immediately after the death of the 
 mother. 
 
 As there are few inftanees of the mother being fav- 
 ed by this operation, feme have advifed that it {hould 
 never be performed till after the death of the mother, 
 I am clearly of opinion, that an operation attended 
 with fo much hazard, fliould never be advifed as long 
 as there is the leafl reafon to hope that delivery may 
 be effedled in any other manner : but I alfo think, that 
 it is the duty of every practitioner to propofe it when 
 this cannot be accomplilhed ; for it is furely better to 
 afford the fmall chance to the mother that accrues 
 from it, than to leave her with the certain profpeft of 
 death ; while by the fame means we may be enabled 
 to fave the child, which otherwife would be deftroy- 
 ed. None will hcfitate in advifmg it after the death 
 of the mother, when the child is found to be living. 
 The following is the method of performing it. 
 
 The patient fhould be placed upon a table of the 
 ufual height, and laid upon her back j her ha^ds and 
 
53^ Of the Cafarean Opcraticn. Chap. XLIX. 
 
 legs being properly fecured by affiftants ; her head 
 fhould be moderately elevated with pillows, and her 
 thighs fomewhat railed, in order to relax the abdomi- 
 nal mufcles. The operator (landing on one fide of 
 the table, is, with a common round edged fcalpel, to 
 make an incifion, fix inches in length, through the 
 fkin and cellular fiibftance, on one fide of the abdo- 
 men : the cut fhould commence two inches above the 
 umbilicus on the outer edge of the rectus mufcle, and 
 from thence fliould be carried in a peipendicular dl- 
 redlon fix inches downwards. The uterus is now to 
 be laid bare, by carrying the incifion through the ten- 
 dinous parts of the abdominal mufcles, and peritonae- 
 um J and this being done, an opening of the fame 
 length mufl be made in the uterus itfelf. The eafieft 
 method of effecting this, is, to make a fmall opening 
 with the fcalpel, fufficient to admit the finger, to ferve 
 as a conductor to a probe pointed bifloury, w'ith which 
 the remaining part of the incifion Ihould be finifhed. 
 I may alfo remark, that the bifloury inferted upon the 
 finger, at an opening made for the purpofe, affords 
 the eafiefl method of dividing the peritonseum and 
 tendinous aponeurofis of the abdominal mufcles. 
 
 If any large blood veffel is cut either in making the 
 outward incifion or in dividing the uterus, it fhould 
 be immediately tied with, a ligature of a fuflicient 
 length to hang out at the wound. The child mufl 
 now be taken out ; the placenta, and any effufed blood 
 ^hat may have efcaped during the operation, being al- 
 fo removed, and the inteflines, if they have protrud- 
 ed, being replaced, the external opening fliould be 
 fecured with three or four futures, in the manner I 
 have advifed in Chapter III, Sed. XII. § 3, 
 
 The wound being covered with a pledget of any 
 emollient ointment, the abdomen fliould be fupported 
 with feveral turns of a broad flannel roller ; when the 
 patient fhould be carried to bed, and flriclly enjoined 
 to avoid fpeaking and every kind of exertion. 
 
Sed. II. Of the Cafarian Operation. 537 
 
 Various caufes concur to render this a very danger- 
 ous operation : of thefe, the extenfive expofure of the 
 abdominal vifcera, and hemorrhagies from the uterus, 
 are the mod material. Any protrufion, therefore, 
 which occurs of the bowels, fhould be immediately 
 replaced, and no veiTel of any importance that may be 
 cut in the divifion of the uterus fliould be left untied : 
 this is not adviied by writers upon this fubjeft, but I 
 fee no harm that can enfue from it. If the ligatures 
 are applied with the tenaculum, they will foon fepa- 
 rate ; and by hanging out at the external wound, they 
 may at any time be pulled away. It may be remark- 
 ed, that it is internal hemorrhagies only that we have 
 to dread, I mean fuch as occur from the veffels of the 
 uterus : for, by carrying the incifion on the outer 
 edge of the retflus mufcle, we avoid the epigaftric ar- 
 tery, the only veffel of importance that runs any rilk 
 of being hurt in the divifion of the teguments and 
 mufcles. 
 
 In order to avoid the rifk of hemorrhagies from the 
 uterus, fome have advifed the incifion never to be 
 made at that part where the placenta adheres ; while, 
 by others, we arc directed to make the opening into 
 the uterus exadly in a longitudinal direftion, by 
 which we are told that the principal veffels with which 
 it is fupplied will mod readily be avoided. No ad- 
 vantage, however, is derived from this : for the inci- 
 fion in the uterus mufl correfpond exactly with the 
 external incifion ; which cannot with propriety be 
 made in any other diredion than the one I have men- 
 tioned. Befides, it would often be impofTible to dif- 
 tinguifli the part at which the placenta adheres ; nor 
 is there much ground to fuppofe that the hemorrhagy 
 from the uterus depends fo much upon the diredion 
 as on the extent of the incifion ; and it ought not to 
 be lefs than fix inches in length, as the child could 
 not be extracted with freedom at a fir.alier opening. 
 It is fcarcely ncceiVary to remark, that the child and 
 placenta fhould be removed as foon after the incifion 
 
538 Of the Divifton of Chap. XLIX. 
 
 is made in the uterus as poflible. It is thus allowed 
 to contraft, which it does inftantaneoufly with great 
 force ; by which the hemorrhagy is more readily 
 flopped than by any means that we could employ 
 for it. 
 
 By others, we are advifed to leave a large opening 
 at the under part of the external incifion, in order to 
 give vent to any effufion of blopd that may happen. 
 No advantage, however, is gained by this, as the in- 
 cifion in the uterus, although oppofite to the external 
 opening at firft, very foon falls beneath it when it con- 
 tra£ls ; by which any blood that is difcharged falls 
 into the bottom of the abdomen where it coagulates, 
 and thus cannot be difcharged at the wound. And 
 as it is of importance to prevent the air as much as 
 pollible from finding accefs to the abdomen, the ex- 
 ternal cut fhould be quickly and entirely fliut, by as 
 many futures as the length of it requires. The moft 
 effeftual method with which I am acquainted of pre- 
 venting hemorrhagies is, the tying of any large veflels 
 in the manner I have mentioned ; keeping the patient 
 cool and free from pain, by regulating the air of the 
 apartment to a proper temperature, and adminiftering 
 opiates ; and by preventing, as I have obferved above, 
 every kind of bodily exertion. • 
 
 SECTION III. 
 
 Of the Div'ifi,n of the Symphyfis Pubis. 
 
 IT has been long known, that the bones of the fe- 
 male pelvis are connedled in fuch a manner, that 
 during the latter months of pregnancy, and efpecially 
 during labour, they are feparated in fome degree from 
 each other ; by which the pall^^ge of the .child is ren- 
 dered' much eafier than it otherwife would be. It 
 was a knowledge of this fa6t, and the great danger 
 
Sect. III. the Symphyfu Pubis. 539 
 
 attending the Ca^farean operation, that firft fuggefted 
 the idea of dividing the bones of the pubis at their 
 junction with each other in cafes of narrow pelvis. It 
 was propofed upwards of two hundred years ago, by 
 a French furgeon of the name of Pineau ; but Mr. 
 Sigault of Paris was the firfl who had the merit of 
 putting it in practice, in the year 1777. 
 
 The operation is eafily performed. The patient 
 piufl be laid upon her back on a table of a conveni- 
 ent height ; the pelvis fhould be elevated with two or 
 three pillows put beneath it, and the legs and arms 
 Secured by afliftants. When in this fituation, the blad- 
 der muft be emptied by the introduction of a cathe- 
 ter, which fliould be retained in the urethra by one 
 of the afliftants till the divifion of the bones is com- 
 pleted. 
 
 After (having the pubis, the operator, ftanding on 
 one fide of the patient, fliould, with a longitudinal 
 incifion, divide the fkin and cellular fubftance cover- 
 ing the pubes at their fymphyfis : the cut ought to 
 commence at the upper edge of thefe bones, and be 
 continued nearly, but not entirely, along their whole 
 breadth : on the bones being laid bare, the cartilage 
 by which they are joined muft be flowly and cautiouf- 
 ly divided ; and as it is by no means hard, it is eafily 
 done. Both the teguments and cartilage, may be di- 
 vided with a firm round edged fcalpel of the com- 
 mon form, which is the only inftrument except the 
 catheter that is neceifary in this operation. The in- 
 tention of the catheter is, to point out the courfe of 
 the urethra to the operator ; for it lies fo contiguous 
 to the pubes at their fymphyfis, as to be in great dan- 
 ger of being cut, if this precaution is negleflted : even 
 the bladder itfelf might be injured, were the divifion 
 of the cartilage not conducted with caution : but with 
 due attention to thefe points, and avoiding the total 
 divifion of the foft parts at the under edge of the 
 bones, all rifl^ of hurting either the bladder or urcr 
 Vbra may be prevented. 
 
540 Of the Dhi/ton of Chap. XLIX. 
 
 On the dlvifion of the cartilage being completed, 
 the bones recede confiderably from each other. To 
 prevent any confequences that might enfue from their 
 Separating forcibly and fuddenly,the affiftants who have 
 the charge of the thighs fhould be defired to fupport 
 them, particularly towards the end of the operation ; 
 and if a fufficient opening is not gained in this man- 
 ner, the thighs may afterwards be flowly and gradual- 
 ly feparated. 
 
 The child is now to be delivered in the ufual way 
 by the vagina ; and this being effected, and the pla- 
 centa removed, the bones fhould be immediately put 
 together, and retained as exactly as poflible in their 
 fituation, by the proper application of a flannel or cot- 
 ton roller round the pelvis and thighs ; at the fame 
 time that the patient fhould be defired to remain as 
 much as pofTible in one poflure. The fore does not 
 require any particular attention : in general, it heals 
 eaiily with light mild dreflings ; and for the mofl part 
 the union of the bones is completed in the courfe of 
 the fifth or fixth week. The patient, however, fhould 
 not be allowed to walk, or to put the body into any 
 poflure that might alter the fituation of the bones, till 
 nine or ten weeks have elapfed. 
 
 The chief objeftion that occurs to this operation is, 
 the fmall fpace that is gained by it in that pait of the 
 pelvis where fpace is mofl required. By feparating 
 the offa pubis at their fymphyfis, thefe bones do in- 
 deed recede to a confiderable diflance from each oth- 
 er : for the mofl part the feparation that takes place 
 will be at leafl two inches in length ; but this does 
 not increafe the narrow diameter of the pelvis, that is, 
 the bones of the pubis will fliil remain at nearly the 
 fame diRnnce from the os facrum as before the opera- 
 tion ; and in almoft every inflance of difficult labour 
 from malconformation of the pelvis, we find that it 
 proceeds entirely from the offa pubis and os facrum 
 being too near each other. It may often happen, 
 however, that th.e head of the child may be fo fitua- 
 
Se6t. III. tbi* Symphyfis Pubis. 541 
 
 ted, that even this reparation of the ofia pubis alone 
 may allow it to pafs, when otherwife it would have 
 remained entirely above the brim of the pelvis ; and 
 as we do not find that the operation is produ6live of 
 much danger, for in diiicrent inflances in has been 
 done more than once on the fame perfon, it fliould al- 
 ways be advifed, when we are convinced that the pel- 
 vis is fo narrow that the child cannot polTibly pafs 
 through it. It fliould always be advifed in preference 
 to the Ca^farean operation. 
 
 If farther experience (liall fliow, that in all cafes of 
 narrow pelvis, the child may be delivered in this man- 
 ner, it fhould even be preferred to the mode of deliv- 
 ering with the crotchet, which is undoubtedly one of 
 the moft barbarous operations in furgery ; for while 
 the very intention of the operation is to deftroy the 
 child, it often tears and mangles the mother fo much 
 that {he never recovers from the eii'edls of it. 
 
54- Of Opening Ghap.- L.- 
 
 CHATPER L. 
 
 OF OPENING DEAD BODIES. 
 
 WITH a view to difcover the feat and caufes of 
 difeafes, and at the inftance of the civil mag- 
 iftrat^ in cafes of violent tleath, furgeons are employ- 
 ed to open dead bodies ; and to do this with accura- 
 cy, every preternatural appearance fliould be commit- 
 ted to paper. After noting any external marks of dif- 
 eafe, we proceed to examine the Hate of the different 
 cavities and of their contents. ^Vhen the difeafe has 
 been evidently fcatcd in one cavity, we do not open, 
 the others ; but when they are all to be examined, it 
 is proper to begin with the head. 
 
 The body being placed upon a table of a conve* 
 nient height, and the head firmly fixed by an affiflant, 
 an incifion fiiould be made from ear to ear acrofs the 
 parietal bones. The fcalp is now to be dilTecled from 
 the parts beneath ; and one half being turned back- 
 ward and the other over the face, a common amputa- 
 ting faw is ufed for dividing the cranium : the uivifion 
 may be begun on the os frontis immediately above the 
 frontal fniufes, and fhouid afterwards be continued 
 backward through the parietal bones and os occipitis. 
 The upper part of the fkuU is now to be raifed with a 
 levator ; by which the dura mater may be freely ex- 
 amined ; and if we wifli to go to the depth of the ven- 
 tricles only, this may be done without removing the 
 brain. But when our objecl is to examine the ftate 
 of the brain and cerebellum, they muft both be remov- 
 ed and examined at leifure. This being done, and all 
 the extravafated blood taken off with a fponge, the 
 brain and cerebellum, mull be replaced with the fkuU 
 cap above them. The two portions of fcalp are now 
 
Chap. L. Dead Bodies. 543 
 
 to be drawn over the whole, and fecured in their fit- 
 uation by fewing the edges of the cut together from 
 one end to the other, either with the glover's flitch, 
 or in any other way which the operator may prefer. 
 For this purpofe narrow tape is ufually employed, and 
 a large curved needle with a triangular point. 
 
 The cavities of the thorax and abdomen are mod 
 effedually expofed in the following manner : let an 
 incifion be made through the common teguments from 
 the top of the fternum to the umbilicus, and let it be 
 continued on each fide through the abdominal muf- 
 cles, from the umbilicus in an oblique diredion down 
 to the top of the os ileum : the teguments and muf- 
 cles muit now be difl'eded from the thorax, till all 
 the cartilages which conned the fternum and ribs are 
 freely laid bare ; and being drawn backward, the car- 
 tilages mufl be divided v/ith a ftrong knife as near as 
 poltible to the ribs ; when the diaphragm being fcpa- 
 rated beneath, the under part of the fternum and car- 
 tilages conneded with it, being raifed and turned up- 
 ward, the fternum muft either be feparated from the 
 clavicles, or cut acrofs near to the upper end of it. In 
 this manner the contents of the thorax and abdomen 
 are brought into view, when moft of them may be ex- 
 amined without being removed ; but when more ac- 
 curacy is required than this admits of, the whole 
 (liould be taken out : or, when a partial examination 
 is only required, that portion of them only may be 
 removed vvhich we mean to infped. 
 
 To prevent the inconvenience refulting from the 
 infufion of much blood and excrement, two ftronsf 
 ligatures ftiould be paiicd at the diftance of an inch 
 from each other round the under part of the aliamen- 
 tary canal and large contiguous blood vefiels, and 
 round the trachea, oefophagus, and large blood vcilels 
 of the neck. The parts between the two ligatures both 
 above and below bcinsx divided, the vvhole viicera of 
 both the cavities may then be eafily removed by dif- 
 
544 Q/* Opoibig Dead Bodies. Chap. L. 
 
 feding them from the contiguous parts, and raifmg 
 them up as we go along. 
 
 The neceifary examination being finiflied, the ef- 
 fufed blood all wafhed off with a fponge, and the vif- 
 cera replaced, the teguments mull be drawn over 
 them, and flitched together with as much ne^itnefs as 
 poffible. 
 
 In opening bodies that have died of any difeafe, 
 the operator fliould be as cautious as poffible in avoid- 
 ing cuts or fcratches of his fingers and hands : vari- 
 ous inllances have occurred of much diftrefs being 
 induced ; and in fome cafes even death has enfued, 
 from inattention to this circumflance. 
 
Chap. LI. Of Embalming, 545 
 
 CHAPTER LL 
 
 OF EMBALMING. 
 
 IN former times, embalming was pra£lifed with more 
 care and attention than it is now. This was a ne- 
 ceHTary confequence of the defire which then prevail- 
 ed, of preferving dead bodies for ages. At prefent it 
 is feldom employed, except for the purpofe of pre- 
 venting bodies from putrefying, during the fhort fpace 
 which elapfes between the death and burial of the per- 
 fon ; and not even with this view, if the corpfe be not 
 to be kept longer than is ufually done in private life. 
 The following is the prefent method of embalming. 
 The brain, and all the vifcera of the thorax and abdo- 
 men, being removed in the manner I mentioned in the 
 laft Chapter, they are all, excepting the heart, put in- 
 to a leaden box with a confiderable quantity of an ar- 
 omatic antifeptic powder, prepared with myrrh, frank- 
 incenfe, cloves, the leaves of lavender, rofemary, mint, 
 fage, and other fimilar articles ; and to thefe are add- 
 ed a proportion of any odoriferous oils. The blood 
 being removed from the different cavities, and the 
 heart replaced, they are all filled with the fame kind 
 of powder, with a due proportion of odoriferous oils 
 or fpirits, and the parts afterwards fewed up in the 
 manner I have already advifed. By fome, too, the 
 mouth and noftrils are fluffed with thefe powders and 
 oils ; and incifions ai-e made into all the fiefhy parts 
 of the body, which are alfo fluffed with them, and af- 
 terwards fewed up : but there is no neceffity for this, 
 unlefs the body is to be kept for a great length of time, 
 or to be carried to a confiderable diftancc. In which 
 cafe, it is ufual, after fluffing the incifions in the man- 
 VoL. III. M m 
 
54^ Of Embalming. Chap. LI. 
 
 ner I have mentioned, to roll all the extremities, as tt 
 
 well as the trunk of the body, firmly and feparately |j 
 
 up with bandages, and to cover the whole with var- J 
 
 nifh. I 
 
 The body is now to be laid upon a cerecloth of a ■* 
 
 fufficient fize, which mull be applied with as much i 
 
 neatnefs as poffible to the head and every part of the \ 
 
 body, and either firmly fecured by fewing, or with 1 
 
 tapes tied at proper diftances. The cerecloth is made j 
 
 of linen dipped in a compofition of wax, oil, and re- 1 
 
 fin ; which fliould be of fuch a confiftence as to be fuf- ij 
 
 ficiently pliable, without being fo foft as to ftick to J 
 
 the fingers of thofe who apply it : it may be coloured j 
 
 with verdegris, red lead, or any other article, accord- 
 ing to the fancy of the operator. When two cere- 
 cloths are applied, one above another, they are ufual- j 
 ly made of difTerent colours. j 
 
 The cerecloth being put on, It was formerly the cuf- 
 tom to employ a painter to colour the face ; but this 
 is now very commonly omitted : the drefs intended 
 for the corpfe is immediately put on ; and the body is 
 either laid in the coffin, or allowed to be expofed, ac- 
 cording to circumftances. 
 
Chap. LII, . Of Bandages, 547 
 
 CHAPTER LII. 
 
 OF BANDAGES. 
 
 BANDAGES are employed for various purpofes 
 in furgery ; for the retention of dreflings ; for 
 (lopping hemorrhagies ; for removing deformities ; 
 and for effeding the union of divided parts. 
 
 As a proper application of bandages is an obje£l of 
 much importance, it is a branch of the art which au- 
 thors have not negleded : many treatifes have been 
 publifhed upon it ; but unfortunately it cannot be 
 taught by defcription : experience alone can give an 
 adequate idea of it ; nor is it poflible to acquire it but 
 by much manual praftice. Hence, in the ftudy of 
 this part of furgery, more advantage is to be gained 
 by praftifmg upon a block, than by reading the mofl 
 elaborate diflertations. My only intention, therefore, 
 at prefent is, to offer a few general obfervations upon 
 bandages. 
 
 I . Bandages fhould be formed of fuch materials as 
 are fufficiently firm for effeding the purpofe for which 
 they are intended, at the fame time that they may fit 
 with eafe upon the parts to which they are applied. 
 
 In fome cafes a degree of firmnefs is required, which 
 cannot be obtained from materials of a foft texture : 
 of this we have examples in the mofl part of trulfes 
 for hernia;, as well as in every bandage requiring much 
 elaflicity : but for the mofl part bandages are made of 
 linen, cotton, or flannel. Till of late, linen was uni- 
 verfally ufed for this purpofe ; but later experience has 
 fhown, that cotton and flannel are preferable. They 
 abforb moifture more readily, whether it be produced 
 by fweat, or as the ordinary difcharge of wounds or 
 
54S Of Bandages, , Chap. LII. 
 
 fores, at the fame time that they are better calculated 
 by their elafticity for yielding to the fwelling which 
 often takes place in luxations, fraftures, and other in- 
 juries for which bandages are employed. Flannel was 
 firfl ufed for this purpofe in the Royal Infirmary here, 
 about forty years ago, by Mr. James Rae of this place ; 
 and fmce that period the pradice has been generally 
 adopted. The objection made to the ufe of flannel 
 for bandages, by fome practitioners, of its not being 
 fo cleanly as linen, is frivolous : neither of them will 
 be cleanly if not frequently changed, while either of 
 them will be fufficiently fo, if this point is attended to, 
 
 2. Bandages fhould be applied of a degree of tight- 
 nefs fufficient for anfwering the purpofe for which they 
 are intended, without incurring any rifk of impeding 
 the circulation, or doing harm in any other manner. 
 No advantage will accrue from them, if the^ be not 
 fufficiently tight to fupport the parts aflected ; while 
 fwelling, inflammation, and even gangrene, will occur 
 if they are too tightly applied. 
 
 3. Every bandage fliould be applied infuch a man- 
 ner, that it may be as eafily loofened, and the parts 
 examined with as much accuracy as poffible. Thus 
 in fractures of the thigh and leg, where the limb can- 
 not with propriety be frequently raifed, we now pre- 
 fer univerfally the bandage with twelve or eighteen 
 tails to the common roller. The former can be un- 
 done and fixed at pleafure without moving the limb, 
 "while a roller can neither be applied nor removed 
 without raifing every part of the limb to a confidera- 
 ble height. 
 
 4. Bandages fhould always be laid afide as foon as 
 the purpofe for which they are intended is accomplifli- 
 ed. This being obtained, no advantage can accrue 
 from them, and they often do harm by impeding the 
 growth of the parts, upon which they are applied. 
 
 5. I have found it neceflary in the courfe of this 
 work to mention bandages for many parts of the body. 
 In fpeaking farther of bandages for particular parts I 
 
Chap. LII. Of Bandages, 549 
 
 fhall begin with the head, and proceed downwards to 
 the trunk of the body and extremities. 
 
 One of the beft bandages for all the upper and back 
 parts of the head, for the forehead, ears, and temples, 
 is a night cap, with one band to tie it before, and 
 another beneath the chin, as is reprefented in Plate 
 CVII. fig. I. The couvre-chef of the French, repre- 
 fented in fig. 2. is moft frequently ufed for thefe parts ; 
 but it can neither be applied with fuch firmncfs or 
 neatnefs as the night cap. 
 
 For the purpofe of making compreffion on any par- 
 ticular part of the head, the radiated bandage, as it is 
 termed, may be employed, as is reprefented in the 
 fame Plate, fig. 3. It may alfo be ufed for comprelT- 
 ing the temporal artery : but for this purpofe, the 
 fpring bandage reprefented in Plate LXIV. fig. 3. an- 
 fwers better. 
 
 In longitudinal culs of the head, the uniting band- 
 age, as it is termed, is ufed with advantage. "It is 
 formed of a long roller with two heads, with a flit 
 or opening in the middle, as is reprefented in Plate 
 CVIII. fig. 3. The fides of the cut being drawn neat- 
 ly together, and covered with a pledget of any fimple 
 ointment, the cure is to be effefted by means of this 
 bandage, applied in the manner reprefented in fig. 6. 
 of the fame Plate. In cuts of this defcription, their 
 edges may fometimes be retained together with fuffi- 
 cient exadnefs by this bandage ; and, when this caii 
 be done, it (hould always be preferred to the mod^f 
 doing it with futures. ^• 
 
 When it is necelfary to retain dreflings upon the 
 eyes, it has ufually been done by placing a comprefs 
 over them and retaining it by feveral turns of a long 
 roller, fuch as is reprefented in Plate CVIII. figure i. 
 This bandage, when employed for one eye, is the 
 monoculus of authors, and it is termed binoculus 
 when applied to both eyes. But as a roller palTed 
 round the head is apt to flip, even when applied in the 
 moft exa6t manner, the couvre-chef in Plate CVII, 
 
55^ Of ^ajidagfs. Chap. LIT. 
 
 figure 2. or the night-cap in the fame Plate, figure i. 
 Ihould be preferred. 
 
 In fradures and cuts of the nofe, the dreflings are 
 bell retained by a proper application of the uniting 
 bandage in Plate CVIII. fig. 3. and a proper applica- 
 tion of the fame bandage anfwers beft in longitudinal 
 cuts of either of the lips. 
 
 In fraftures of the lower jaw, we employ a four 
 headed roller, fuch as is reprefented in Plate CVIII. 
 fig. 4. The fpace left entire between the four heads 
 is applied to the chin, the hole in the centre being 
 meant to receive the apex of the chin. The two fu- 
 perior heads are then carried backwards ; and being- 
 made to pafs each other at the occiput, they are after- 
 wards brought forward over the os fronfis : they may 
 either be fixed there, or again reflefted back, and fix- 
 ed with pins on the fides or back parts of the head. 
 The two under heads of the roller being reflefted 
 over the chin, are then to be turned upwards, and 
 either tied or pinned on the top of the head ; or be- 
 fore fixing them, they may be made to pafs each oth- 
 er two or three times. Various other bandages are 
 defcribed by authors for the head ; but thofe I have 
 mentioned, with a proper application of the common 
 roller, Plate CVIII. fig. i. for particular purpofes, are 
 all that can be ever required. 
 
 6. In Plate XCII. fig. i. an inftrument is deline- 
 ated for one of the moll: material operations upon the 
 nepk, bronchotomy ; and in Plate LIV. fig. i . another 
 is* reprefented for the wry neck : a common roller 
 may be made to anf\^'er every other purpofe that can 
 be required of a bandage in any part of the neck. 
 
 7. A variety of bandages are ufed for the fhoulders 
 and contiguous parts, particularly for fraftures of the 
 fcapula, and fradures and luxations of the clavicle. 
 In fraftures of the fcapula, a proper application of a 
 long roller may, in mod inftances, prove ufeful ; but 
 in Chapter XXXIX. Section V. I have fhown, that no 
 utility is derived from bandages in fractures of the 
 
Chap. LII. Of Bandages. 551 
 
 clavicles : they cannot be applied with fuch tightnefs 
 as to comprefs the tVaclured bone without impeding 
 refplratlon ; and befides, we do not find that they are 
 necefTary, when the arm of the affected fide is proper- 
 ly fupported by the fling, Plate XCVI. fig. 2. 
 
 The mofl uieful of all bandages for the thorax and 
 abdomen, at lead: for the retention of dreflings on any 
 of thefc parts, Is that which we ufually term the nap- 
 kin and fcapulary, reprefented in Plate CIX. figure i. 
 That part of it which goes round the body A, is 
 termed the napkin. When applied for making pref- 
 fure upon a fradured rib, it fliould be in the form of 
 a roller, and fliould pafs two or three times round the 
 body : when only ufed for retaining drefllings. It fliould 
 not go more than once round : It fliould be fix or 
 feven inches broad for an adult ; and fecured by piec- 
 es of tape, tying it at each end, infl:ead of pins. The 
 fcapulary B C, confiflis of a flip of linen, cotton, or 
 flannel, about three inches broad, and of a length fuf- 
 ficient to reach from the upper part of the napkin be- 
 hind, to pafs over the flioulders and be pinned to it 
 before : it is fometimes made with a hole In the cen- 
 tre for pafling over the head ; but it anfwers better to 
 divide the anterior end of it by a longitudinal flit in- 
 to two, and In applying It, to make one of thefe flips 
 pafs on each fide of the neck. 
 
 This bandage anfwers the purpofe better than any 
 other, for making preflure on the parts at which the 
 vifcera protrude, in umbilical and ventral hernlse. As 
 in fuch cafes it is a point of much importance to have 
 the bandage firmly fixed, we not only employ the 
 fcapulary for preventing it from flipping down, but a 
 fl:rap connected with It behind is p:^fled between the 
 thighs, and pinned to it before, to prevent it from 
 flipping up. 
 
 In Plate XCI. fig. 1. a bandage is reprcilnted for 
 comprefling the abdomen in the operation of tapping ; 
 and in Plate LXV. different bandages arc delineated. 
 
552 Of Bandages. Chap. LII. 
 
 or trufles, as they are termed, for the retention of the 
 protruded vifcera in cafes of hernia. 
 
 9. As it is of much importance in various difeafes, 
 as well as in feveral operations, to have the fcrotuni 
 properly fupported, I have delineated fome bandages 
 for this purpofe in Plate CX. The bed bandage for 
 the penis is a pouch, or bag of linen or cotton, to be 
 fixed by a roller, or two pieces of tape paffed round 
 the body. 
 
 The T bandage, as it is commonly termed, Plate 
 CIX. figures 3. and 4. is ufually employed for the re- 
 tention of dreffings about the anus and perineum, as 
 well as for fome diforders of the fcrotum ; but in the 
 laft, one or other of the fufpenfory bandages, repre- 
 fented in Plate CX. will for the mod part be found 
 preferable. 
 
 10. In compound fradures of the arm, fore-arm, 
 or hand, where motion of the limb would prove hurt- 
 ful, the twelve or eighteen tailed bandage is equally 
 proper as in fimilar affections of the lower extremities ; 
 but in fimple fradures, as well as in almoft every oth- 
 er affeftion of thefe parts, we prefer a proper applica- 
 tion of the roller. 
 
 1 1 . I advifed the uniting bandage for longitudinal 
 cuts in the head ; it anfwers equally well in wounds 
 of a fimilar nature in every part of the extremities, a« 
 is reprefented in Plate CVIII. fig. 6. 
 
 END OF VOLUME THI.H.D. 
 
>5i 
 
m 
 s 
 
 /" 
 
 
 
 
 
 t k 
 
 Date Due 
 
 
 
 
 
 
 
 
 
 
 
 
 ' 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 L. B. Cat. No. 1137 
 
 ^W 
 
^ 
 
 Bell 
 A Syj 
 
 B'tc^o 43516 
 
 stem of Surgey 
 
 °^"^= DUt ISSUED TO 
 
 
 
 
 
 1 
 
 
 617 B433 
 
 43516