'RT)'^Q HISTORICAL COaECTlON ^h2^ 
 
 176/ 
 C.I. 
 
 Columbia 23ntt)ers(ftj) 
 
 Collese of Ptips^tciansi anti burgeons; 
 iCibrarp 
 
so 
 //// 
 
TREATISE 
 
 O N T H E 
 
 JOperations ^ S u r g er y,^ 
 
 ^^^. W I T H A St^/A/^^X^ 
 
 ^Defcription and Reprefentation 
 
 O F T H E 
 
 INSTRUMENTS 
 
 Ufed in Performing them : 
 
 To which is Prefix'd an 
 
 INTRODUCTION 
 
 O N T H E 
 
 NATURE and TREATMENT 
 
 OF 
 
 Wounds, Abscesses, <3:;^J Ulcers. 
 
 -By SAMUEL SHARP, 
 
 Fellow of the Royal Society, and Member of the 
 Academy of Surgery at Paris, 
 
 The E I G H T H EDITION. 
 
 L N D O ^: ^^ly 
 Printed for J. and R. To^^-*^^ -"^ ^ 
 
 M DCC U 
 
 (.ii. 
 
 ■^^ 
 
HiSTORlCAL COUECTiON, 
 
 C . I 
 
T O 
 
 William Cheselden, £/^j 
 
 Surgeon to Chelfea-Hofpkal. 
 
 S I Ry 
 
 \S lam chiefly indebted 
 to the Advantagre of an 
 Education under You, 
 for whatever Knowledge I can 
 pretend to in Surgery, I could 
 not in the leaft hefitate to whom 
 I fhould dedicate this Treatife, 
 though was it my Misfortune 
 A a to 
 
DEDICATION, 
 to be a Stranger to your Perfon, 
 that Merit which has made the 
 World fo long efteem You the 
 Ornament of our Profeflion, 
 would alone have induced me 
 to ftiew You this Mark of my 
 Relpedij which I hope will not 
 be unacceptable from^ . 
 
 ^/i?; 
 
 Your moft obedient 
 
 humble Servant. 
 
 S. SharF", 
 

 PR E F A C 
 
 S tile Methods of operating iri 
 Surgery have of late Years 
 been exceedingly improved in 
 England^ and there is no Treatife of 
 Character on that Subjedl written in 
 our Language, I believe it is not necef- 
 fary to apologize for this Undertaking % 
 It is true we have a few Tranflations 
 from the Writings of Foreigners, but 
 befides that they are unacquainted with 
 thele Improvements, their manner of 
 defcribing an Operation is io very mi- 
 nute, and in general fo little pleafingj 
 that could nothing new be added, or 
 nothing falfe exploded, the PoiUbility 
 A ^ of 
 
PREFACE, 
 
 of only doing it more concifely and 
 agreeably would be a reafonable In- 
 ducement to the Attempt. 
 ' In the Defcription of Difeafes, I 
 have only mentioned their diftinguifh- 
 ing Appearances, and have not once 
 dared to guefs at that particular Dif- 
 order in the Animal Oeconomy, v^^hich 
 is the immediate Caufe of them , in- 
 deed, the Uncertainty there is in Con- 
 jedures of this intricate Nature, and 
 the little Service that can accrue to 
 Surgery from fuch fpeculative Enqui- 
 ries, have entirely deterred me from all 
 Pretence to this fort of Theory ; and 
 fmce the moft ingenious Men hitherto, 
 have not, by the help of Hypothefes^ 
 done any confiderable Service to the 
 Pradice of Surgery, nay, for the moft 
 part have mifled young Surgeons from 
 the Study of the Symptoms and Cure 
 of Difeafes, to an idle turn of Rea- 
 foning, and a certain Stile in Converfa- 
 
 tion, 
 
PREFACE. 
 
 tion, which has very much diicre- 
 dited the Art amongft Men of Sen fe ; 
 I hope I am right in my Silence on that 
 Head. 
 
 It has been very much my Endea- 
 vour to make this Treatife fhort, and 
 therefore I have given no Fliflories of 
 Cafes, but where the uncommonnefs 
 of the Dodtrine made it proper to il- 
 luflrate it with Fad:, and thefe i have 
 recited in the mofi; concife manner I was 
 able : On this account too, I think I 
 have not attempted to' explode any 
 Practice which is already in difreput-Cj 
 and if it appears otherwife to Men of 
 Skill here in London ^ I beg they will 
 refer to thofe Books of Surgery which 
 are now the beft efteemed in Europe^ 
 and to which I have almoil always had 
 an Eye in the Criticifms I have made 
 on the generality of Opinions. 
 
 It is ufual with moft Writers to de- 
 
 fcribe at leno;th the feveral Bandages 
 
 A 4 P^^P^^ 
 
PREFACE. 
 
 proper to be employed after each Ope- 
 ration ; but as the manner of applying 
 them can hardly be learnt from a 
 Defcription only, or if it could, there 
 is fo little to be faid on that Subjedt, 
 but what muft be copied from others, 
 that I have forbore to follow the Ex- 
 ample ; though to fay the Truth, the 
 Purpofe of Bandage being chiefly to 
 maintain the due Situation of a Dref- 
 fing, or to make a Comprefs on par- 
 ticular Parts, Surgeons always turn a 
 Roller with thofe Views, as their Dif- 
 cretion and Dexterity guide them, with- 
 out any Regard to the exad Rules laid 
 down in thefe Defcriptions, which are 
 almoft impoffible to be retained in the 
 Memory without a continual Practice 
 of them, and therefore we fee are not 
 much attended to. 
 
 In the firft Edition of this Treatife, 
 I aflerted (p. 99.) that the Haemor- 
 rhage, which fometimes enfues in the 
 
 Lateral 
 
PREFACE. 
 
 Lateral Operation, had been efteemed 
 an Objedlion of fo great Weight, as to 
 have occafioned its being fuppreffed in 
 the Hofpitals of France by a Royal 
 Edid : I have fince been informed I 
 was miftaken in that Particular, and 
 that it had only been forbid in the 
 Charite by Moniieur Marechal^ the 
 King's firft Surgeon, who had the In- 
 fpedtion of the Pradice of Surgery in 
 that Hofpital : what were his Motives 
 for not fufFering this Method to be 
 continued there, after having been per- 
 formed a whole Seafon, I will not take 
 upon me to determine. 
 
 CON- 
 
CONTENTS. 
 
 INTRODUCTION, 
 
 C H A P. I. 
 
 Of Wounds, Page I 
 
 CHAP. 11. 
 
 Of Inflammations and Ahfcejfes, vi\ 
 
 CHAR IIL 
 
 Of Ulcers. xxix 
 
 TREATISE. 
 
 CHAP. I.' 
 Of Sutures. r 
 
 C H A P. 11. 
 
 Of the Suture of th^ Tendons, 5 
 
 CHAP. 
 
CONTENTS, 
 
 CHAP. III. 
 Of the Gaftroraphy. page 8 
 
 CHAP. IV. 
 
 0/"/^^ Bubonocele. il 
 
 C H A P. V. 
 
 Of the Epiplocele. 27 
 
 CHAP. VI. 
 
 Of the Hernia Femoralis. 28 
 
 CHAP. VII. 
 
 Of the Exomphalos. 29 
 
 CHAP. VIII. 
 
 Of the Hernia Ventralis. 3 1 
 
 CHAP. IX. 
 
 Of the Hydrocele. 32 
 
 C H A P. 5f. 
 Of Caftration. 48 
 
 CHAP. 
 
CONTENTS. 
 
 CHAP. XL 
 
 Of the Phymofis. page 54. 
 
 CHAP. XII. 
 Of the Paraphymofis. ^6 
 
 CHAP. XIII. 
 
 Of the Paracentefis. 58 
 
 CHAP. XIV. 
 
 Of the Fiftula in Ano. 66 
 
 CHAP. XV. 
 
 Of the PuiuSlure of the Perinaeum. 73 
 
 CHAP. XVL 
 
 Of the Stone, 7^ 
 
 CHAP. XVII. 
 
 Of Searching. 82 
 
 C H A P* XVIII. 
 
 Of the Leffer Apparatus, or Cutting on 
 ^^^ Gripe, 85 
 
 CHAP. 
 
CONTENTS. 
 
 C H A P. XIX. 
 
 Of the Greater Apparatus, or the Old 
 Way. page 87 
 
 CHAP. XX. 
 
 Of the High Operation. go 
 
 CHAP. XXI. 
 
 Of the Lateral Operation. 94 
 
 CHAP. XXII. 
 
 Of the Stone in 2^^^ Urethra. 109 
 
 C H A P. XXIII. 
 
 Of the ExtraSiion of the Stone in JVo^ 
 men, no 
 
 CHAP. XXIV. . 
 
 Of the Empyema. u6 
 
 CHAP. XXV. 
 
 Of Y.Vic^^Qdi Tumours, 125 
 
 CHAP, 
 
CONTENTS. 
 
 CHAP. XXVI. 
 
 Of the Amputation of the Cancered and 
 Scirrhous Breaft. page 129 
 
 CHAP. XXVII. 
 
 Of the Operation of the Trepan. 133 
 
 CHAR XXVIII. 
 Of the Catarad. 155 
 
 C H A R XXIX. 
 Of Cutting the Iris. 166 
 
 CHAR XXX. 
 Of the Fiftula Lachrymalis. 172 
 
 CHAR XXXI. 
 
 Of Bronchotomy. 186 
 
 CHAR XXXII. 
 
 Of the Extirpation of the Tonfife* 189 
 
 CHAP. 
 
CONTENTS. 
 
 CHAP. XXXIII. 
 
 Of the Polypus. page I93 
 
 CHAP. XXXIV. 
 
 Of the Hare Lip. 197 
 
 CHAP. XXXV. 
 
 Of the Wry Neck. 2oi 
 
 CHAP. XXXVI. 
 
 Of the Operation for the Aneurifm. 203 
 
 CHAP. XXXVII. 
 
 Of Amputation. 210 
 
 CHAP. XXXVIII. 
 
 O/' Inoculation. 229 
 
 INTRO- 
 
(i) 
 
 T 
 
 CHAP. I. :;V.v_ 
 
 Qi w u N D sr^^ 
 
 \0 Conceive rightly of the Nature and 
 Treatment of Wounds, under the Va- 
 riety of Diforders they are fubjed: to, 
 it will be proper firfi: to learn, what are the 
 Appearances in the Progrefs of Healing a 
 large Wound, when it is made w'ith a lli-arp 
 Inftrument, and the Conftitution is pure. 
 
 In this Circumflance, the . Blood-VefTels, 
 immediately upon their Diviilon, bleed freelyj 
 and continue bleeding till they are either 
 ftopp'd by Art, or at length contrading and 
 withdrawing themfelves into the Wound, 
 their Extremities are fliut up by the coagu- 
 lated Blood. The Hsmorrhage being ftopp'd, 
 the next Occurrence, in about twenty-four 
 Hours, is a thin ferous Difcharge, and a 
 Day or two after, an Increafe of it, tho' fome- 
 •what thickened, and ftinking. In this State 
 it continues two or three Days without any 
 
 B great 
 
11 
 
 I N T R O D U C r I N. 
 
 great Alteration, from which time the Matter 
 o-rows thicker and lefs ofFenlive ; and when 
 the Bottom of the Wound fills up with little 
 Granulations of Flefh, it diminiflies In its 
 Qiiantity, and continues doing fo, till the 
 Wound is quite skinn'd over. 
 
 The firft Stage of Healing, or the Dif- 
 charge of Matter, is by Surgeons call'd Z)/- 
 geftioji ; the Second, or the filling-up with 
 Flefli, Incarnation; and the laft, or skinning 
 over. Cicatrization. Thefe are the Tech- 
 nical Terms chiefly in ufe, and are fully 
 fufficient to defcribe the State of Wounds, 
 without the farther Subdivifions ufually found 
 in Books. 
 
 It is worth obferving, that the Lofs of any 
 particular Part of the Body can only be re^ 
 paired by the Fluids of that diftind: Part, and 
 as in a broken Bone, the Callus is generated 
 from the Ends of the Fra6ture, fo, in a 
 Wound, is the Cicatrix from the Circum- 
 ference of the skin only : Hence arifes the 
 Neceffity of keeping the Surface even, either 
 by Prefllire or eating Medicines, that the 
 Eminence of the Fleili may not refifl the 
 Fibres of the Skin in their Tendency to 
 cover the Wound. This Eminence is com- 
 IXifed" of little Points or Granulations called 
 
 Fungus^ 
 
I ,N T R O D U C T I O .N. 
 
 ^mgus^y or proud Fled), and is frequently 
 efteemed an Evil, though in truth, this Spe- 
 •cies of k is the conftant Attendant on healing 
 Wounds I for when they are fmooth, and 
 have no Difpoiitioi-^ to fhoot out above their 
 Lips, there is a Slacknefs to heal, and a Cure 
 is very difficultly effeded : Since then a 
 'Fungus prevents healing only by its Luxu- 
 riancy, and all Wounds cicatrife from their 
 Circumference, there will be no occafion to 
 deflroy the whole Fungus every time it rifes, 
 but only the Edges of it near the Lips of the 
 Skin, which may be done by gentle Efcha^ 
 roticks, fuch as Lint dipt in a mild Solution 
 oi Vitriol^ or for the moil part only by dry 
 Lint, and a tight Bandage, which will te* 
 duce it fufficiently to a Level, if apply 'd 
 before the Fungus has acquired too much 
 Growth. In large Wounds, the Applica- 
 tion of corrofive Medicines to tlie whole 
 Surface, is of no ufe j becaufe the Fungus 
 will attain but to a certain Height when left 
 to itfelf, which it will be frequently rifing 
 up to, though it be often v/afted ; and as all 
 the Advantage to be gathered from it, is 
 only from the Evennefs of its Margin, the 
 Purpofe will be as fully anfwered by l^^ep- 
 ing that under only, and aa iu6nis:e deal ©f 
 B 2 Pain 
 
 in. 
 
iv INTRODUCTION. 
 
 Pain avoided from the continual Repctltloa 
 of Efcharaticks. 
 
 When I Ipeak of the necefTity of a Wound 
 being repaired by the fame Fluids of which 
 the Part was before compofed, I mean, upon 
 the Suppofition, that the Renewal be of the 
 fame Subftance with the Part injured ; as 
 Callus is of Bone, and a Cicatrix is of Skin ; 
 for a Vacuity is generally filled up with one 
 Species only of Flefli, though it poiTefs the 
 Space, in which were included before the 
 Wound was made, the diftindt feparate Sub- 
 ftances of Membrana Adipofa, Membrana 
 Mujculorum, and the Mufcle itfeJf i and even 
 if we fcratch or perforate a Bone, there are 
 certain wounded VeiTcls in it that pufh out 
 Flefh which becomes the Covering of it j and 
 after Fradures of the Skul), when the Sur- 
 face of the Brain is hurt, and part of the 
 Membranes and Bones removed, the whole 
 Cavity is filled up by nearly the fame uni- 
 form Subftance, till it arrives even with the 
 Skin, which fpreads over it to complef^jhe 
 Cure. _ ; -i ^ii< 
 
 On this account it is, that after the healing 
 of Wounds, from the Surface of the Bone, 
 the Cicatrix is adherent to it, and no abfolute 
 Diflindion of Parts preferved s though if a 
 
 Wound 
 
INTRODUCTION. 
 
 Wound be made of any certain Magnitude, 
 the Adherence, after healing, will not be (o 
 wide as the Wound itfelf was, but only of 
 the Extent of the Cicatrix, which is always 
 much fmaller than the Incifion ; becaufe 
 Healing does not confift only in the form- 
 ing of new Matter, but alfo in the Elonga- 
 tion of the Fibres of the circumjacent Skin 
 and Flefh towards the Center of the Wound ; 
 which will cover it in more or lefs time, and 
 in greater or lefs Quantity in proportion to 
 their Laxnefs ; for the Scar does not begin 
 to form, till they refifl: any farther Extenlion ; 
 hence arifes the Advantage in Amputations, 
 of faving a great deal of Skin. 
 
 From what has been faid of the Progrefs 
 of a Wound made by a fharp Inftrument, 
 where there is no Indifpofition of Body, we 
 fee the Cure is performed without any In- 
 terruption but from the Fungus ; fo that the 
 Bufinefs of Surgery will confift principally 
 in a proper Regard to that Point, and in Ap- 
 plications that will the leaft interfere with 
 the ordinary Courfe of Nature, which in 
 thefe Cafes, will be fuch as a6t the leaft upon 
 the Surface of the Wound ; and agreeably 
 to this we find, that dry Lint only is gene- 
 rally the beft Remedy through the whole 
 B 3 Courfe 
 
vi INTRdDUCriO?^. 
 
 Cdurfe of dreffing : at firfl, it ilops the Blood 
 with lefs Injury than any ftyptick PowdefS' 
 or Waters, and afterv/ards, by abfol"bing thef 
 Matter, which in the beginning of Suppura-^ 
 tion is thin and acrimonious, it beconaes ii$ 
 ef?e<5l a Digeftive : During Incarnation it is- 
 the foftefl: Medium that can be applied be- 
 tween the Roller and tender Granulations, 
 and at the fame time, is an eafy Gomprefs 
 upon the fprouting Fungiu, 
 
 Over the dry Lint, may be applied a Pled-* 
 git of fome foft Ointment fpread upon Tow, 
 which muil: be renewed every Day, and 
 preferved in its Situation by a gentle Band- 
 age 5 though in all large Wounds, the firfl 
 Dreffing after that of the Accident or Ope-- 
 ration, fhould not be applied in lefs than 
 three Days, when, the Matter being formed, 
 the Lint feparates more eaiily from the Part ^ 
 in the Removal of which, no Force fluould 
 be ufed, but only fo much be taken away as^ 
 is loofe, and comes off without Pain. 
 
 Perhaps it may appear furprifing that I do 
 not reconnnend either digeftive or incarna^ 
 tive Ointments, which have had fuch Repu-? 
 tation formerly for their Efficacy in all Spe- 
 cies of Wounds ; but as the Intent of Medi- 
 cines is to reduce the Wound to a natural 
 
 Stat^j, 
 
INTRODUCTION. vii 
 
 State, or a Propenfity to heal, which is what 
 1 have already fuppofed it to be in ; the End 
 of fuch Applications is not wanted, and in 
 Other refpeds dry Lint is more advanta- 
 geouis, as may be learnt from what I have 
 ^d of its Benefits. There are certainly 
 many Cafes in which different Applications 
 will have their feveral Ufes, but thefe are, 
 when Wounds are attended with a variety of 
 Circumftances not fuppofed in that I have 
 been ipeaking of ; though even when thefe, 
 by the Virtue of Medicines, are reduced to 
 as kind a State, the Method of treating them 
 afterwards fhould be the fame, as will be 
 better underftood by the next Chapter, in 
 which I fhall treat more particularly of the 
 Dreffing of Wounds. 
 
 CHAP. II. 
 
 Of Inflammations ^s^W Abfcefles. 
 
 AS almofl all AbfcefTes are the Confe- 
 quences of Inflammations, and thefe 
 produce a variety of Events, as they are dif- 
 ferently complicated with other Diforders, 
 it will be proper fir fl to make fome Inquiry 
 into their Difpolition. ^ Inflammations from 
 all Caufes have three ways of terminating j 
 B 4 either 
 
INTRODUCTION. 
 
 either by Difperfion, Suppuration, or Gan- 
 grene 3 a Schirrhcus Gland is always men- 
 tioned as a fourth, but I think with Impro- 
 priety, fince it feldom or never occurs, but 
 in venereal, fcrophulous, or cancerous Cafes, 
 when it is the Forerunner, and not the Con- 
 fequence of an Inflammation, the Tumour 
 generally appearing fome time before the 
 Difcolouration. 
 
 But though every kind of Inflammation 
 will fometimes terminate in different Shapes, 
 yet a probable Conjed:ure of the Event, may 
 be aUvays gathered from the State of the 
 Patient's Health. Thus Inflammations hap- 
 pening in a flight degree upon Colds, and 
 without any foregoing Indifpofltlon, will mofl: 
 likely be difperfed : Thofe which follow, 
 clofe upon a Fever, or happen to a very grofs 
 Habit of Body, will generally impofl:humate : 
 and thofe which fall upon very old People, 
 or Dropflcal Confl:itutions, will have a flrong 
 Tendency to gangrene. 
 
 If the State of an Inflammation be fuch^ as 
 to make the Difperfion of it fafely prai^icable, 
 that End will be beft brought about by Eva- 
 cuations, fuch as plentiful Bleeding and re- 
 peated Purges : the Part itfelf mufl: be treated 
 v/ith Fomentations twice a Day :. and if the--- 
 
 Skin 
 
INTRODUCTION. ix 
 
 Skin be very tenfe, it may be embrocated with 
 a Mixture of three Fourths of Oil of Rofes, 
 and one Fourth of common Vinegar, and af- 
 terwards be covered with Unguent. Flor. 
 Samb. or a foft Ointment made of white Wax 
 and fweet Oil, fpread upon a fine Rag, and 
 roll'd on gendy. I know almofl all Surgeons 
 are averfe to the Application of any thing 
 unduous to an inflamed Skin, upon the fup- 
 polition of its obilrudiing the Pores, and by 
 that means preventing the Tranfpiration of 
 the obftruded Fluids, v/hich is imagined to 
 be one of the ways that an Inflammation is 
 removed -, but whether this Reafoning is 
 founded on Pradice or Theory only, I am 
 not clear ; though I think it very certain, 
 that Inflammations left to themfeives, often 
 grow flifF and painful, and are to be eafed 
 by any Medicine that makes them more foft 
 and pliable ; which does not look as though 
 relaxing Medicines interrupted the Difpoii- 
 tion to a Cure : However, to prefer ve ibme 
 fort of Medium, in Inflammations of tlie 
 Face, where they are efteemed moil dan- 
 gerous, it may be made a Rule to ufe no- 
 thing more oily than warm Milk, v/ith v/hich 
 the Face may be embrocated five or fix times 
 a Day. If after four or five Days the In- 
 
 llammatiou 
 
^ rNTRODUCTION. 
 
 ilammatiGn begins to fubfide, the Purging- 
 Waters and Manna may take place of other 
 Purges, and the Embrocation of Oil and 
 ■ Vinegar be now omitted, or fooner, if it has 
 begun to excoriate. The Ointment of Wax 
 2nd Oil may be continued to the laft, or if 
 upon conclufion of the Cure the Itching pf 
 the Skin fliould be troublefome, it may be 
 better relieved by the Application of Nutri- 
 tum, which is an Ointment made of equal 
 Parts of Diachylon and fweet Oil, melted 
 foftly down, and afterwards flirred together 
 with a little Addition of Vinegar till they are 
 cold. During the Cure, a thin Diet is ab/o- 
 lutely neceiiary, and in the- Height of the 
 Inflammation, the drinking of thin Liquors 
 is of great fervice. 
 
 Here I have fuppofed that the Inflamma- 
 tion had fo great a Tendency to Difcuffion, as 
 by the help of proper Affiftance to terminate 
 in that manner; but when it happens that 
 the Difpofition of the Tumour refiils all dif- 
 cutient Means, we muft then defifl from, any 
 farther Evacuations, and, as much as we can, 
 affift Nature in the bringing on a Suppu- 
 ration. 
 
 That Matter will mod likely be formed, we 
 may judge from the Increafe of the- fympto- 
 
 niatick 
 
INTRODUCTION. 
 
 sSlatIck Fever, and Enlargement of the Tu- 
 mour, with more Pain and Pulfation ; dfld 
 if a fmall Rigor com^s on, it is hardly to be 
 doubted : Inflammations after a Fever, and 
 fhe Small-Pox, almoft always fuppurate, but 
 thefe prefently difcover their Tendency, or 
 at leafl fliould be at firfl gently treated, as 
 though we expeded an Impofthumation. It 
 js a maxim laid down in Surgery, that Eva- 
 cuations are pernicious in every Circumftance 
 of a Difeafe, that is at lafl to end in Sup- 
 puration : But as Phyficians do now acknow- 
 ledge, that Bleeding on certain Qccafions in 
 the Small- Pox, is not only no Impediment 
 to the Maturation, but even promotes it -, fo 
 in the Formation of AbfcelTes, when the 
 Veffels have been clogged, and the Suppu- 
 ration has not kindly advanced, Bleeding has 
 fometimes quickened it exceedingly ; but 
 however this Practice is to be followed with 
 Caution. Purges are, no doubt, improper at 
 this time ; yet if the Patient be coftive, he 
 muft be affifl:ed with gentle Clyfters every two 
 or three days. 
 
 Of all the Applications invented to promote 
 Suppuration, there are none fo eafy as Pul- 
 licesj but as there are particular Tumours 
 very flow of Suppuration, and almofl void of 
 
 Paia 
 
I N T fe O D U C T I O N. 
 
 Pain (fuch, for Inftance, are fome of the 
 fcrophulous Swellings) it will be lefs trou- 
 blefome in thefe Cafes to wear the Gum- 
 Plaifters, which may be renewed every four, 
 or five Davs only. Amongft the fuppurative 
 Pultices, perhaps there is none preferable to 
 tliat made of Bread and Milk foftened with 
 Oil ; at leaft, the Advantage of any other over 
 it, is not to be diftinguifhed in Pradice. The 
 Ufe of fuppurative Flaifters in hafcy AbfcelTes, 
 or Inflammations in a weak or dropfical 
 Habit of Body, is by no means advifeable, as 
 they are apt to fit iineafy on the Inflamma- 
 tion, are often painful to remove, when we 
 enquire into the State of the Tumour, and 
 by their Comprefs, in bad Confiitutions add 
 fomething to the Difpofition of the Part to 
 mortify. The Abfcefs may be covered with 
 the Pultice twice a-day, till it be come to that 
 Ripenefs as to require opening, which will 
 be known by the Thinnefs and Eminence of 
 the Skin in fome Part of it, a Fluctuation of 
 the Matter, and generally fpeaking an Abate- 
 ment of the Pain previous to thefe Appear- 
 ances. The Manner ot opening an Abfcefs 
 I iliall dcfcribe, after having fpoke of a Gan- 
 grene, which is the otlier Confequence of an 
 Inflammation. 
 
 The 
 
INTRODUCTION. xlii 
 
 The Signs of a Gangrene are thefe : the 
 Inflammation lofes its Rednefs, and becomes 
 duskiih and livid ; the Tenfenefs of the Skin 
 goes off, and feels to the Touch, flabb}/ or 
 emphyfematous ; Vefications filled with Ichor 
 of different Colours fpread all over it ; the 
 Tumour fubfides, and from a duskifh Com- 
 plexion, turns black j the Pulfe quickens and 
 links, and profufc Sweats coming on, at lall 
 grow cold, and the Patient dies. 
 
 To flop the Progrefs of a Mortification, the 
 Method of Treatment will be nearly the fame, 
 from whatever Caufe it proceeds, except in 
 tliat arifing from Cold 3 in which Cafe we 
 ought to be cautious not to apply Warmth 
 too fuddenly to the Part, if it be true, that in 
 the northern Countries they have daily Con- 
 vidion of Gangrenes produced by this means, 
 which might have been eafily prevented by 
 'avoiding Heat ; nay, they carry their Appre- 
 henfion of the Danger of fuddeii Warmth fo 
 far, as to cover the Part vv^ith Snow firfl, 
 which they fay feldom fails to obviate any 
 ill Confequence. 
 
 The PracStice of fcarifying Gangrenes, by 
 feveral Incifions, is almoil univerfal, and, I 
 think, with Reafon, fince it not only fets the 
 Parts free, and difcharges a pernicious Ichor; 
 
 but: 
 
aiv JIsrTRODUCTION. 
 
 ibut makes way hv whatever Efficacy ^there 
 may be in topical Applications. Thefe are 
 different with different Surgeons, but 1 be- 
 lieve the Digeflives foftened with Oil of Tutr 
 pentine are as good Dreffings as any for the 
 Scarifications ; and upon them, all over the 
 Part, may ,be laid the Theriaca Londinenfo^ 
 which fhould be always ufed in the Begin- 
 fiing -of a Gangrene, before the Neceffity of 
 fcarifying arifes ; or what is equally ^good,, 
 if not often preferable, a Cataplafm made 
 with Lixivium and Bran, and applied warm, 
 which will retain its Heat better than moiic 
 other Topicals. There are fome who infill 
 i^pon having had particular Succefs in the 
 ftopping of Gangrenes, from the Ufe of the 
 Grounds of ftrong Beer mixed with Bread 
 or Oatmeal ; :but there are hardly any ,Fa<^ 
 lefs proper to infer from, than the chafing of 
 a Mortification, fince we fee amongfi: the 
 Poor that are brought into the Hofpitals, how 
 often it .happens without any Affiftance ; 
 however, it is certain, Service may be done 
 by fpirituous Fomentations, and the Dref- 
 iings above-mentioned, which are to -be re- 
 peated twice a-day : Medicines alfo given. in- 
 . tern ally are beneficial, and thefe fhould con- 
 
 lift, of the Cgr dial kind j though at prefent the 
 
 Bark 
 
INTRODUCTION. yj. 
 
 Bark is ordered by a great many Surgeons as 
 the fovereign Remedy for this Diforder : Af- 
 ter the Separation of the Efchar, the Wound 
 becomes a common Ulcer, and muil be treated 
 as fuch. 
 
 There are two ways of opening an Abfcefs : 
 either by Incidon or Cauflick ; but Incillon is 
 preferable in moft Cafes. In fmall Abfceiles, 
 there is feldom a Neceffity for greater Dilata- 
 tion than a little Orifice made with the Point 
 of a Lancet 3 and in large ones, w'here there 
 is not a great Quantity of Skin difcoloured and 
 become thin, an Incifion to their utmoft Ex- 
 tent, will ufually anfwer the Purpofe 5 or if 
 there be much thin difcoloured Skin, a cirGoIar 
 or oval Piece of it muft be cut away 5 which 
 Operation, if done dexterouHy with a Knife, 
 is much lefs painful than by Cauffick, and 
 at once lays open a great Space of the Ab- 
 fcefs, which may be dreiled down to the Bot- 
 tom, and the Matter of it be freely difchar-^ 
 ged 5 whereas after a Cauftick, tho' we make 
 Incifions through the Efcher, as is the ufual 
 Practice, yet the Matter will be under feme 
 Confinement, and we cannot have the Advan- 
 tage of drefling properly, till the Separation of 
 the Slough, which often requires-a confiderable 
 time, fo that the Cure mud be ne^efiarily de- 
 layed ^ 
 
Uyed ;-b&Tides,-that the Pain of burning cdnti- 
 nuing two Or three Hours, which a Cauftick 
 ufually takes up in doing its Office, draws 
 fuch a Fluxion upon the Skin round the 
 Efchar, as fometimes to indifpofe it very 
 nruch for healing afterwards. In the Ufe 
 of Caufticks, it is but too much a Pradice, 
 to lay a fmall one on the moft prominent 
 Part of a large Tumour, which not giving 
 Sufficient Vent to the Matter, and perhaps 
 the Orifice foon ^fter growing narrow, leads 
 on to the neceffity of employing Tents j which 
 two Circumftances more frequently make Fi- 
 bulas after an Abfcefs, than any Malignity 
 in the Nature of the Abfcefs itfelf. The 
 Event would more certainly be the fame after 
 .a fmall Incilion 5 but I obferve, that Surgeons 
 not depending fo much on fmall Openings by 
 Incifion, as by Cauftick, do, when they ufe 
 the Knife, generally dilate fufficiently ; where- 
 as in the other way, a little Opening in the 
 moft depending Fart of the Tumour ufually 
 fatisfies them : but as the Method of making 
 fmall Orifices for great Difcharges, is for the 
 moft part tedious of Cure, very often requiring 
 Dilatation at laft, and now and then per^ 
 nicious in the Confequence above-mentioned, 
 arid even making the adjacent Bones carious, 
 
 I thoueht 
 
I N T R O D tJ C T I O N. xvii 
 
 I thought it might not be ufelcfs to caution 
 againft this Pra53:ice. 
 
 Here it may not be amifs to obferve, that 
 notwithflanding the depending Part of an 
 Abfcefs is eftcemed the moil eligible for an 
 Opening, yet it is always on the Suppofition 
 that the Teguments are as thin in that Place 
 as any other Fart of it; othervvife it will be 
 generally advifeable to make the Incifion 
 where Nature indicates, that is, where the 
 Tumour is inflamed and prominent, though 
 it (hould not be in a depending Part. 
 
 The indlfcriminate Application of Caufticks 
 to all AbfcelTes, often runs into the fame Mif-» 
 chief of Tedioulhefs in the Cure, from a 
 Caufe exadily the reverfe of that I have been 
 defcribing ; for as in great Swellings they 
 are feldom laid on large enough, and the 
 Matter continues draining for want of a fufn- 
 cient Opening ; fo in fmall ones, they make a 
 greater Opening than is neceffary, and there- 
 fore demand a greater length of Time to re- 
 pair the Wound. I confefs the Difpofition 
 of AbfcelTes to fill up, after the Difcharge of 
 Matter, is fo very different, that fome few 
 large ones do well after the mere Pundure pf 
 a Lancet, if the Orifice be made in a depend- 
 ing Part, and a proper Bandage can be ap- 
 C , pliei 
 
xviii I N T r.o:d U C T I O N. 
 
 plied i - tho'if fever; we-^truft to fuch an Open- 
 ing, -it iljould be ifti(Abfceires about the Face, 
 ^vhere^w^ Ihouki be^Vft-bre careful to avoid the 
 Deformky of a Scar than in any other Part, 
 afi-d'where aUb the Method will be more likely 
 fo fucceed, from their Situation j it being a 
 Maxim in Surgery, that.Abfceiles and Ulcers 
 will have a greater or lefs Tendency to heal, as 
 they are higher or lower in the Body ; how- 
 * ever, even in AbfcelTes of the Face^ if the Skin 
 be very thin, it will be always fafer to open the 
 length of it, than truft to a Pundure only. 
 
 From this Account of the Method of open- 
 ing AbfcelTes, it does not appear often necef- 
 fary to apply Cauilicks ; yet they have their Ad- 
 vantages in fome refpeds, and are feldom fo 
 terrible to Patients as the Knife, tho' in fad 
 they are frequently more painful to bear -, they 
 are of moft ufe in Cafes where the Skin is thin 
 •and inflamed, and we have reafon to think the 
 Malignity of the Abfcefs is of that nature as to 
 prevent a quicknefs of Incarning, in which Cir- 
 cumftance, if an Incilion only was made thro* 
 the Skin, little Sinufes would often form, and 
 burrow underneath, and the Lips of it lying 
 -loofcrand flabby, would become callous, and 
 -retard the Cure, though the Malignity of the 
 ^"Wound v/as correded : Of this kind, are Vene- 
 - - - ' real 
 
iNtRODUCTION. xl3^ 
 
 real Buboes, which notwithftandlng they often 
 do wellfey mere InGirior)/i,yet when the Skin is 
 in the State I havefupposd, the Cauftick is, al- 
 ways preferable, as I have had many OpportU'*^ 
 nidesof being convinced* .jit is to be obferved, 
 I confine this Method to Venereal Buboes j fqr 
 thofe which follow a Fever, or the Smallpox, 
 for the moil part are curable by Incifion only. 
 There are many fcrophulous Tumours, where 
 the Reafoning is the fame as in the Veneral -, 
 and even in great Swellings w^here I have re- 
 commended Incifion, if the Patient will not 
 fubmit to Cutting, and the Surgeon is appre^. 
 henfive of any Danger in wounding a large 
 Veffel, which is often done with the Knife, 
 (tho' it may readily be taken up with a Needle 
 and Ligature) yet as this Inconvenience is a-, 
 voided by Cauftick, it may on fuch an occafion 
 be made ufe of; but I think after the Efchar is 
 made, it (hould be cut almoft all away, which 
 will be no Pain to the Patient, and will give 
 a much freer Difcharge to the Matter than In- 
 cidons made thro' it : However in fcrophulous 
 Swellings of the Neck and Face, unlefs they 
 are ve^y large, Caullicks are not advifeable, 
 fince ill; that part of the Body, with length of 
 time, they heal after Incifion. Caufiiicks are 
 of great Service in defi:roying fliabborp f^ro- 
 C 2 phul.qus 
 
XX INTRODUCTION. 
 
 pbulous Indurations of the Glands, alfo vene- 
 real Indurations of the Glands of the Groin, 
 which will neither difeufs nor fuppurate ; like* 
 wife in expofing carious Bones, and making 
 large IlTues. The heft Cauftick in ufe is a 
 Parte made with Lime and Lixivium Capitate, 
 which is to be prevented from fpreading, by 
 cutting an Orifice in a Piece of ftieking Plai- 
 ner, nearly as big as you mean to make the 
 Efchar, which being applied to the Part, the 
 Cauftick muft be laid on the Orifice and pre- 
 ferved in its Situation, by a few Slips of Plai- 
 fter laid round its Edges, and a large Piece 
 over the whole. When liTues are iiiade,"6^ 
 Bones expos'd, the Efchar ftould be cut out 
 immediately, or the next Day 3 for if we wait 
 the Separation, ^we mifcarry in our Delign of 
 maj^ing a deep Opening j fince Sloughs are 
 fiung off by the fprouting new Flefh under- 
 neath, V\^hich fills up the Cavity at the fame 
 time that it difcharges the Efchar ; fo that we 
 are obliged afterwards to make the Opening a 
 fecond time with painful efcharotick Medi- 
 cines. To make an Ififue, or lay a Bone bare, 
 this Cauftick may lie on about four Hours j to 
 deftroy a large Gland, five or fix j and to open 
 Abfcefi'es, an Hour and a half, two Hours, or 
 three Hours according to the Thicknefs of the 
 
 Skin 3 
 
IN T R O D U C T I O N. xxi 
 
 Skm ; and wliat is very remarkable, notwith- 
 ftaiidlng its Strength and fudden Efficacy, it 
 frequently gives no Pain where the Skin k 
 not inflamed, as in making Ifl'ues, and open- 
 ing fome few Abfceires. 
 
 Hitherto I have fuppofed the Surgeon has 
 had the Opportunity of opening the Tumour 
 at the moft eligible Time, that is, when the 
 Skin Ts thin, and the Fludluation of the Matter 
 very fenfible ; which is always to be waited for, 
 notwithftanding it is very much taught, to 
 open critical AbfceiTes before they come to an 
 exadt Suppuration, in order to give Vent fooner 
 to the noxious Matter of the Difeafe ; but in 
 opening before this Period, they mifs the very 
 Defign they aim at 5 fince but little Matter is 
 depoiited in the Abfcefs before it arrives to- 
 wards its Ripenefs, and beiides, the Ulcer after- 
 wards grows foul, and is lefs difpos'd to heal. 
 
 When aii Abfcefs is already burft, we arc 
 to be guided by the Probe where to dilate, 
 obferving the fame Rules with regard to the 
 degree of Dilatation, as in the other Cafe ; the 
 ufual Method of opening farther, is with the 
 Probe-fciflars, and indeed, in all Abfceffes, the 
 generality of Surgeons ufe the Sciffars, after 
 having firft made a Pundure with a Lancet ; 
 but as the Knife operates much quicker, and 
 '■ ■ C 3 with 
 
xxii I N T R O D U C t fd N. 
 
 with lefs Violence to tne Parts, than Sciffars, 
 which fqueeze at the fame time that they 
 wound, 'twill be fparing the Patient a great 
 deal of Pain to ufe the Knife, wherever it is 
 pradicable, which is in almoft all Cafes, ex-? 
 Cept feme Fijiulas iJt Am, where the SciiTars 
 are more convenient. The manner of open-^ 
 ing with a Knife, is by ilidlng it on a Diredor, 
 the Groove of which prevents its being mif- 
 guided. If the Orifice of the Abfcefs be fo 
 fmall as not to admit the Director, or the Blade 
 ©f the SciiTars, it mull: be enlarged by a piece 
 6f Sponge-tent, which is made by dipping a 
 dry Bit of Sponge in melted Wax, and imme- 
 diately fqueezing as much out of it again as 
 poffible, between two pieces of Tile or Marble ; 
 the Effed of which is, that the lodfe Sponge 
 being compreiTed into a fmall Compafs, if any 
 of it is introduced into an Abfcefs, the Heat of 
 the Part melts dov/n the remaining Wax that 
 holds it together, and the Sponge fucking up 
 the Moifture of the Abfcefs, expands, and in 
 expanding, opens the Orifice wider, and h^ 
 licgrees fo ^s to give very little Pain. 
 
 The ufual Method of dreffing an Abfcefs, 
 the firfl time, is with dry Lint only, or if there 
 Ise no Flux of Blood, with foft Digeftives 
 fpread on Lint. If there be no Danger of the 
 
 wpper 
 
INTRODUCTION. 
 
 upper Part of the Wound reuniting toq foon, 
 the Doffils muH: be laid in loofe, but ^if the 
 Abfcefs be deep, and the Wound harrow, as 
 is the Cafe fometimes of AbfcefTes in Ano^ the 
 Lint muft be crammed in pretty tight, that we 
 may have afterwards the Advantage of dref- 
 fing down to the Bottom without the ufe of 
 Tents, which are almofi; univerfally decried in 
 thcfe Days, though they ftill continue to be 
 employed too much by the very People^, who 
 would feem to explode them moft j fo difficult 
 is it to be convinced of the true Efficacy of Na- 
 ture in the healing of Wounds. Formerly, the 
 Virtues of Tents have been much infifled on, 
 as it was then thought abfolutely neceffary to 
 keep Wounds open a confidefable time, to give 
 Vent to the imaginary Poifon of the Conflita- 
 tion; it was fuppofed too, that tiiey were bene- 
 ficial, in conveying the proper fuppurative or 
 farcotick Medicines down to the Bottom -of the 
 Abfcefs J and again, that by abforbing the 
 Matter, they preferved the Cleanlinefs of the 
 Wound, and difpofed it to heal. But this 
 Reafoning is not now efleemed of kny force ; 
 Surgeons at prefent know a Wound cannot 
 heal top fail, provided it heal firm from the 
 Bottom ; they are very v/ell fatished'alfo from 
 what'they fee in Wounds, ;where no Medicines 
 C 4 are 
 
INTRODUCTION. 
 
 are applied, that Nature of heffelf flioots forth 
 new Flefh, and is interrupted by any PreiTure 
 whatfoeyer; befidps, as to tb^ Conceit of Tenta 
 fucking ii_p the Matter, which is efleemed nox-? 
 JQiis to healing, they are fo far fronv being 
 bei^eficial in the Performance of it, tb,at they; 
 are of great Prejudice : .for if the Matter b<& 
 qffenfive in its Nature, tho' t|iey do abibrb it, 
 they bring it into Contact with every Part of 
 the Sinus j and if it be prejudicial by its Quan- 
 tity, they do Mifchief in locking it up in the 
 Abfcefs, and preventing the Difcharge it woul4 
 ^nd, if the Dreffings were pnly fupefiicial-:; 
 but in £2.6:, Matter when it is good, js of no. 
 pilTervice to Wounds with regard to its Qua--. 
 lity ; and Surgeons fliould therefore he lefs 
 curious in wiping them clean, when they are 
 tender aqd painfu]. That Tents are, impedi-r 
 ment.s.tp. Healing rather than Affiftants, we 
 rnay learn from con^defing the Effed. pf a.Pe^ 
 jn an IfTue, which by PrelTure keeps open the 
 Wound jufl: as Tents dor, and if there are In-?; 
 fiances of Wounds healing very vyeH npjtwith- 
 ftandin? the ufe of Tpnis, fo there are alfo .of 
 Ifiues healing up, in fpite of any Meafures y/e 
 cap take to keep a Pea in its Cavity. In fl-iort, 
 Tents in Wounds, by refifting the Growth of 
 |l^e little Granulations ofyiefh, in prpc.efs of , 
 
 time 
 
tltile^ harden therrv, "arrd-ln- that mdfflii^Ji^prK." 
 dticfe a'Fillula ; fd that?irTfl:ead; of beirfg"urecf 
 for' the Cure' of an i^bTcefsi tfiey^never ilioulcl 
 be ehiplbyed but where we m"ean tro icitard'the: 
 Healing of the external Wo tifi'd, '^except in 
 fome little narrow AbTcelTes,* where if they be 
 not cramn^ed in too large, they becohie Is Dof- 
 iils,- admitting of Incarnatiofi at thei' Bottom' j 
 but Gare fliould be taken, not to infinu ate them 
 mu-ch deeper than the Skin in; this Cafe, and 
 that they (liould be repeated twice'a-day, to 
 give Vent to the Matter they, confine. Some-^ 
 tim-es they are of fervice in l^rge ^.bice^iTes, par- 
 ticularly -of the Breaft, where the Matter can-.' 
 not^fehargeitfeif by the^Orifice already ma'de,^ 
 and yet does hot- point fufficiently tb any other^ 
 Part for an Opening, tho' it rnakes Signs^vvhr-^ 
 therk%ould tend, if it was a little'^dnfined, 
 lii fuch a^ Inftance, a Tent plugging up the * 
 Qilfiee, would make the •Matter recur to the*. 
 Faft;<li|pofed to- receive it, _and .niaYk the' 
 PkeCfbr a Counter-opening: Blit.yTents do^ 
 moft good in little deep Abfceiie's, whence' 
 any extraneous Body is to be evacuated, fuch 
 ^S' fmall Splinters of Bone, &c. 
 
 The Ufe of Vulnerary Inje(flionsi intd"' "Ab'-^ 
 fcefles has been thooght to bear io neaf'a Re- 
 femblan^e: to the yfe of Tents, that they' both 
 
 fell 
 
 
ixvi INTRODUCTION. 
 
 fell into Difrepiite almoft at the fame Time. 
 It has been faid in their Favour, that in deep 
 Abfeefles where no Ointment can be applied, 
 they digeft, cleanfe, and correct the Malignity 
 of the Piis ; but they do (o much Mifchief by 
 frequently diftending the Parts of the Abfcefs, 
 firft, when they are injed:ed, and afterwards, 
 by their Addition to the Matter generated in 
 the Abfcefs, that they are hardly proper in 
 any Cafe : though one of the great Mifchiefs 
 of Injedions and Tents both, has been a mif- 
 taken Faith amongfl: Practitioners, that where- 
 ever their Medicines were applied, the Part 
 would heal ; and upon that Prefumption, they 
 have neglected to dilate Abfceffes, which have 
 not only remained incurable after this Treat- 
 ment, but would often have done fo for want 
 of a Difcharge, if they had been drelled more 
 fuperficially. 
 
 In dreffing Wounds, it is common to apply 
 the Medicines warm, or hot, upon the Sup- 
 pofition that heated Ointments have a ftronger 
 Power of digefting, than cold 3 but as any Me- 
 dicine will foon arrive to the Fleat of the Part 
 it is laid on, whether it be applied hot or cold, 
 the Efficacy of the Heat can avail but little in 
 fo fmali a Time ; and as Doffils dipt in hot 
 Ointments arc not cleanly, and even groWitiif 
 
 and 
 
I' N T R O # e^ T I O N. xxvii 
 
 and painful, befides that the Patient is liable 
 to be burnt by laying thenn on too hot, I think 
 it rather preferable to apply them cold, or 
 perM^p^ in Winter a little warmed ' before the 
 Fire after they are fpfead ; obferving, if the 
 Ulcer be uneven, to make the Doffils fmali 
 in order to lie clofe. Over the DofTils of Lint 
 may be laid a large Pledgit of Tow fpread 
 with Balilicon, which will lie fofter than a de- 
 fenfative Plaifler ; for this, though invented to 
 defend the Circumference of Wounds a^ainfl 
 Inflammation or a Fluxion of Humours, is of- 
 ten the very Caufe of them ; fo that the Dref- 
 iings of large Wounds fhouid never be kept on 
 by thefe Plaifters, where there is Danger of 
 fucb Accidents ; and 'tis on the account of the 
 Unfitnefs of Plaifters of any kind fpr an Inflam- 
 mation, that I have omitted to mention any of 
 them as proper Difcutients in that Diforder. In 
 this manner, the Dreflings may be continued, 
 till the Cavity is incarned, and then it may be 
 cicatrifed with dry Lint, or fome of the cicatrir 
 iing Ointments, obferving to keep the Fungus 
 down, as dire<5led before ; If the Drying-oint- 
 ment be the Cerat. de Lapid. Calam. the Stone 
 rnufl be thoroughly levigated before it is put 
 into it, otherwife the Ointment will be cor- 
 
 In 
 
In the courfe df'Dremng it will be proper 
 to have regard to the Situation of the Abfcefs,. 
 and as much as poflible to make the Patient, 
 favour the Difcliarge by his ordinary Pofture ;, 
 and to this end alfo, as what is of greater Im- 
 portance than the Virtue of any Ointment, the 
 Difcharge muft be affiled by Comprefs and 
 Bandage j the Comprefs may be made of Rags 
 or Plaifter J tho' the latter is fometimes prefer- 
 able, as it remains immoveable on the Part it 
 is applied to. The Frequency of Dreffing will 
 depend on the Quantity of Difcharge ; once in 
 twenty-four Hours is ordinarily fufficient; but 
 fometimes twice, or perhaps three times, is ne- 
 ceffary. I have before mentioned, not to be too 
 icrupuloufly nice in cleaning- a Wound j but it 
 is worth remarking, that a Sore fliould never be' 
 wiped by drawing a Piece of Tow or Rag over 
 it, but only by dabbing it with fine Lint, which 
 is a much eafi^r Method for the Patient j the 
 Parts about it may be wiped clean in a rougher 
 manner,- without any Prejudice. I do not think 
 tha Air has that ill Effect: on Sores as is gene- 
 rally-conceived 5 nor would the large Abfcef- 
 fes on Beafls, which are often expofed to the 
 Airthe v^hole time of Cure, do well, if it was 
 '.•>-Wy:' .pernicious as is represented j but as it 
 tc-pds; ta the making a Scab, and in Winter is a 
 
 little 
 
I N T R O D VO T I O N. xxix 
 
 Httle painful to the new Flefh, it; will be. right 
 tofiniili theDreffing as quick asmay be with- 
 out hiirrying* Another Caution necelTary in 
 the' Treatment of AbfcefTesj is, That Surgeons 
 fliould not upon all Occafions fcarch into their 
 Cavities with the Finger or Probe, as it often 
 tears them open and indifpofes them for a 
 Cure, 
 
 C II A P. III. 
 
 - -Of ULCERS, 
 
 oi asfio'.: :>/:■:■:•■ -^ '• - ^^^ mba^qr:r 
 
 HEN a Wound or Abfcefs"" degenerates 
 into (q bad a State as to refift the Me- 
 tliQds of Cure I have hitherto laid down, and 
 lafe^,,^hat Complexion which belongs to a 
 healing Wound, it, j«;Called an Ulcer; and as 
 the Name is generally borrowed from the ill 
 Habit of the Sore, it is a Cuftom to apply it to 
 all Sores that have any degree of Malignity, 
 tho' they are immediately formed without any 
 preyipu,s, Abfcefs or Wound ; fuch are the Ve-. , 
 nereal Ulcers of the Toniils, ^^. 
 
 Ulcers are diftinguiflied by their particular 
 Diibrders,. tlio' it feldom happens that the Af- 
 fedions are not complicated 3 and when we lay 
 down Rules for the Management of one Spe- 
 cies of Ulcer, it is generally requilite to apply 
 
 them 
 
XXX T N T R O D VC T I N; 
 
 them to almofl all others. However the Cha* 
 raders of moft eminence, are, the callous Ulcer# 
 the iinuous Ulcer, and the Ulcer with Caries of 
 the 'qdjacent Bone 5 tho' there are abundance 
 more known to Surgeons, fuch as the Putrid, 
 the Corrofive, the Varicous, &c. but as they 
 have all acquired their Names from forae parti- 
 cular Aftedion, I fliall fpeak of the Treatment 
 of them under the general Head of Ulcers. 
 
 It will be often in vain to purfue the bell: 
 means of Cure by Topical Application, unlefs 
 we are affifted by internal Remedies 5 for as 
 many Ulcers are the EfFeds of a particular In- 
 difpofition of Body, it will be difficult to bring 
 them into order, while the Caufe of them re- 
 mains, with atiy Violence ; tho' they are fome* 
 times in a great degree the Difcharge of the 
 Indifpofition itfelf, as in the Plague, SmalU 
 pox, &c. But we fee it generally neceffary in 
 the Po3C» the Scurvy, Obftrudions of the Men* 
 fes, Dropfies, and many other Diflempers, to 
 give Internals of great Efficacy > and indeed, 
 there are hardly any ConiLitutions, where Ul- 
 cers are not aliiiled by fome phyfical Regimen. 
 Thofe that are cancerous and fcrophulous feem 
 to gain -the lead Advantage from Phyllck, for 
 if in their Beginnings they have , fometimes 
 been very much relieved, or cured by Saliva- 
 tion, 
 
i N T R O D U C T I O N: xxxi 
 
 tion, or any other Evacuation, they are alfo 
 often irritated, and made worfe by them ; (o 
 that there is nothing very certain in the Ef- 
 feds of violent Medicines in thefe Diftempers. 
 I have feen alfo great Qiiantities of Alteratives 
 tried on a variety of Subjeds ; but I cannot fay 
 with extraordinary Succefs : Upon the whole, 
 I think in both thefe Cafes, the Milk-diet and 
 gentle Purging with Manna, and the Waters, 
 feem to be mofl: efficacious ; tho' brisk Me- 
 thods may be ufed with more Safety in the 
 Evil than the Cancer; and fometimes, parti- 
 cularly in young Subjeds, the Decod;ion of 
 the Woods is extremely beneficial for fcro- 
 phulous Ulcers : But it has lately been attefted 
 by Men of great Skill and Veracity, that Sea- 
 water is more powerful than any other Re- 
 medy hitherto known, both for fcrophuioua 
 Ulcers, and fcrophulous Tumours. 
 
 When an Ulcer becomes foul, and difcharges 
 a nafly thin Ichor, the Edges of it, in procefs 
 of time, tuck in, and growing skinned and 
 hard, give it the;Name of a callous Ulcer, ' 
 which, fo long as the Edges continue in that 
 State, muft neceffarily be prevented from heal- 
 ing : But we are not immediately to deftroy 
 the Lips of it, in expedation of a fudden Cure 5 
 for while the Malignity of the Ulcer remains^ 
 
 which 
 
xxxli INI'RODUCTION, 
 
 which was the Occafion of the Callofitv, Cd 
 long will the new Lips be fubject to a Relapfd 
 of the fame kind, however often the external 
 Surface of them be deilroyed j fo that whcrt 
 we have to deal with this Circumflance, we 
 are to endeavour to bring the Body of the Ulcer 
 into a Difpoiition to recover by other Methods. 
 It fometimes happens to poor laborious People, 
 who have not been able to afford themfelves 
 Reft, that lying a-bed will in a fhort time give 
 a Diverlion to the Humours of the Part, and 
 the callous Edges foftening, will without any 
 great Affirtance ilioot out a Cicatrix, when the 
 Ulcer is grown clean and filled with good 
 Flefli. The Effedt of a Salivation is generally 
 the fame ^ and even an Iffue does fometimes 
 difpofe a neighbouring Ulcer to heal : But 
 though Callofities are frequently foftened by 
 thefe means, yet when the Surface of the Ul- 
 cer begins to yield thick Matter, and little Gra- 
 nulations of red Flelh flioot up, it will be 
 proper to quicken Nature by deftroying the 
 • Edges of it, if they remain hard. The 
 manner of doing this, is by touching them a 
 few Days with the Lunar Cauftick, or hapi^ 
 infernalis, and feme choofe to cut them off 
 with a Knife ; but this laft Method is very 
 painful; and not, as lean perceive, more effica- 
 cious 3 
 
INTRODUCTION^ xxxiii 
 
 CJous ; tho' when the Lips do not tuck down 
 dole to the Ulcer, but hang loofe over it, as 
 in fome Venereal Buboes where the Matter 
 lies a great way under the Edges of the Skin, 
 the eafieft Method is cutting them off with 
 the Sciffars. 
 
 To digefl the Ulcer, or to procure good 
 Matter from it when in a putrid State, there 
 are an Infinity of Ointments invented ; but the 
 BaJiUcGnfiaviim alone, or foftened down fome- 
 times with Turpentines, and fometimes mixt 
 up with different Proportions of red Precipi- 
 tate, feems to ferve the Purpofes of bringing 
 an Ulcer on to Cicatrifation, as well as any of 
 the others. When the Ulcer is incarned, the 
 Cure may be fini{hed as in other Wounds 5 or 
 if it does not cicatrife kindly, it may be wafh- 
 ed with A(i. Calcis, or Aq. Pbag. or dreffed 
 with a Pledgit dipt in TinS^, Myrrhce : And 
 if Excoriations are fpread round the Ulcer, 
 they may be anointed with Sperm, Cet. Oint- 
 ment, or Unguent, Nutritiim. 
 
 The Red Precipitate has of late Years ac- 
 quired the Credit it deferves for the Cure of 
 Ulcers, but by falling into general Ufe is often 
 very un&ilfuUy applied : When mixed up with 
 the BqfiUcon^ or v^hat is neater, a Cerate of Wax 
 a,nd-.pij,it.is moft certainly a Digeflive, fmce it 
 D hardly 
 
xxxiv INTRODUCTION. 
 
 hardy ever fails to make the Ulcer yield a 
 ^ thick Matter in twenty-four Hours, which dif- 
 charged a thin one before the Application of 
 it. As greater Proportions of it are added to 
 the Cerate, it approaches to an Efcharotick j 
 but while it is mixed with any Ointment, it 
 is much lefs painful and corrofive, than when 
 fprinkled on. a Sore in Powder; tho' in this 
 Form it is almofl univerfally employed, but 
 I think injudicioufly : For as it is a ftrong 
 Efcharotick, much of It can never be ufed 
 without making a Slough, and therefore 
 continually repeating it Day after Day, will be 
 making a fucceffion of Sloughs ; or if it be 
 fprinkled on a Slough already formed, in order 
 to quicken the Separation of it, fo much of the 
 Powder as lies on the dead Surface, will be of 
 no Force, and the reft that lies at the Bottom, 
 and about it, will produce other Sloughs there, 
 by keeping under and deftroying the little 
 Granulations of Flefli, which In their Growth, 
 would elevate and pufh off the firft Slough, 
 fo that It cannot be a proper Remedy in this 
 Cafe. If it be anfwered, that daily Pradice 
 fliould convince us that Precipitate has pot, 
 this ill Eifedl, fince we fee Sloughs continu- 
 ally feparating, notwithftanding the ufe of it; 
 the fame fort of Argument may be ufed in fa- 
 2 ' vour 
 
INTRODUCTION. xxx\f 
 
 vour of any bad Pradlce, Unce Nature often 
 Surmounts the greatefl Obftacles to a Cure : 
 But whoever will attend carefully, without 
 any Prejudice from this Reafoning, to the 
 two Methods of promoting the Separation of 
 an Efchar, will find it not only more eafily, 
 but alfo more readily effeded by foft Digef- 
 tives, or the Precipitate Medicine, than by a 
 great Quantity of the Powder. 
 
 If the Ulcer fhould be of fuch a Nature as 
 to produce a fpongy Flefh, fprouting very high 
 above the Surface, it will be necefTary to deftroy 
 it by fome of the Efcharoticks, or the Knife : 
 This Fungia differs very much from that be- 
 longing to healing Wounds, being more emi- 
 nent and lax, and generally in one Mafs^ where- 
 as the other, is in little diftindl Protuberances. 
 It approaches often towards a cancerous com- 
 plexion, and when it rifes upon fome Glands 
 does adually degenerate fometimes into a Can- 
 cer, as has happened in Buboes of the Groin, 
 When thefe Excrefcences have arifen in Vene- 
 real Ulcers, I have pared them with a Knife j 
 but the Flux of Blood is ordinarily fo great, 
 that I do not recommend the Method, and 
 rather prefer the Efcharoticks. Thofe in ufe, 
 are the Vitriol^ the Lunar Caujiick^ the Lapis 
 Infernalis^ and more generally the red Preci- 
 D 2 pitafe 
 
INTRODUCTION. 
 
 pifate Powder ; but even In this Cafe, I do not 
 think that Powder the beft Remedy ; for the' 
 I have faid it is always an Efcharotick, yet the 
 Puh. Angel, which is a Compolition of the 
 Precipitate Powder and burnt Alum, eats 
 deeper, and I think is preferable to the Pre- 
 cipitate alone. 
 
 It is but feldom, that thefe Inveterate Fim- 
 giifes appear on an Ulcer j but it is very ufual 
 for thofe of a milder kind to rife, which may 
 often be made to fubfide with Preffure, and the 
 ufe of mild Efcharoticks ; however if the 
 Afped of the Sore be white and fmooth, as hap- 
 pens in Ulcers accompanied with a Dropfy, 
 and often in young Women with Obftrudions, 
 'twill anfwer no purpofe to wafte the Excre- 
 fcencies, 'till the Coniiitution is repaired, when 
 moft probably they will fink without any Af- 
 fiftance. In Ulcers alfo, where the fubjacent 
 Bone is carious, great Quantities of lopfe flabby 
 Flefli will grow up above the Level of the 
 Skin ; but as the Caries is the Caufe of the 
 Diforder, 'twill be in vain to exped a Cure of 
 the Excrefcence, 'till the rotten Part of the 
 Bone is removed ; and every Attempt with Ef- 
 charoticks, will be only a Repitition of Pain 
 to the Patient without any Advantage. In 
 fcrophulous Ulcers of the Glands, and indeed 
 
 of 
 
INTRODUCTION. xxxvn 
 
 of almoft every Part, this Diforder is very 
 common ; but before Trial of the fevere Ef- 
 charoticks, I would recommend the ufe of the 
 ftrong Precipitate Medicine, with Comprefs 
 as tight as can be bore without Pain, which 
 I think generally keeps it under. 
 
 When the Excrefcence is cancerous, and 
 does not rife from a large Cancer, but only 
 from the Skin itfelf, it has been ufual to re- 
 commend the adaal Cautery ; though I have 
 found it more fecure, to cut away quite under- 
 neath, and drefs afterwards v/ith eafy Appli- 
 cations ', but the Cafes where either of thefe 
 Methods are practicable, occur very rarely. As 
 to the Treatment of incurable cancerous Ulce- 
 rations, after much Trial, Surgeons have at lafl 
 difcovered, that what gives the mofl: Eafe to 
 the Sore is the moft fuitable Application -, and 
 therefore the ufe of Efcharoticks, is not to be 
 admitted on any Pretence whatfoever j nor in 
 thofe Parts of a .Cancer that are corroded into 
 Cavities, muft the Precipitate be made ufe of 
 to procure Digeflion, or promote the Separa- 
 tion of the Sloughs. The befl way therefore, 
 is to be guided by the Patient what Medicine 
 to continue, after having tried three or four, 
 ifthefirft or fecond don't agree with him. 
 Thofe ufually prefcribed are Preparations from 
 D 3 Lead, 
 
INTRODUCTION. 
 
 Lead, but what I have found moft beneficial, 
 have been fometlmes dry Lint alone, when it 
 does not flick to the Cancer ; at other times. 
 Lint Doffils fpread with .Bafilicon or Cerat. de 
 Lapid. Calam, and oftener than either with a 
 Cerate made of Oil and Wax, or the Sperm* 
 Cet, Ointment 5 and over all, a Pledgit of Tow 
 fpread with the fame. Embrocating the neigh- 
 bouring Skin and Edges of it with Milk, is of 
 fervice ; but the chief Good is to be acquired 
 by Diet, which fhould be altogether of Milk, 
 and things made of Milk, tho' Herbage may 
 be admitted alfo. Iffues in the Shoulders or 
 Thighs do alfo alleviate the Symptoms, and 
 Manna with the Purging Waters, once, or 
 perhaps twice a Week, will ferve to keep the 
 Body cool. All Methods more violent, ge- 
 nerally exafperate Cancers, and are to be re- 
 jedled in favour of this, which is fometimes 
 amazing in its Effects, not only procuring Eafe, 
 but lengthening Life. 
 
 When Ulcers or AbfcelTes are accompanied 
 with Inflammation and Pain, they are to be af- 
 fifted with Fomentations made of fome of the 
 dry Herbs, fuch as Rojna?2 Wormwood, Bay- 
 leaves, and Rofemary 3 and when they are very 
 putrid and corrofive, which Circumflances give 
 them the Name of foul Phag^denick Ulcers, 
 
 fome 
 
INTRODUCTION. xxxk 
 
 fome Spirits of Wine fliould be added to the 
 Fomentation, and the Bandage be alio dipt in 
 Brandy or Spirits of Wine, obferving in thefe 
 Cafes where there is^'much Pain, always to 
 apply gentle Medicines 'till it is removed. 
 
 As to the frequency of dreffing and foment- 
 ing, I think it may be laid down for a Rule 
 in all Sores, that where the Difcharge is fa- 
 nlous, and corrofive, twice a~day is not too 
 much; if the Matter be not very putrid and 
 thin, once Vv^ill fuffice. When the Pain and 
 Inflammation are exceffive, Bleeding and other 
 Evacuations will often be fei-viceable ; and 
 above ail things, Red and a horizontal Pofition; 
 which laft Circumiliance, is of fo great Import- 
 ance to the Cure of Ulcers of the Legs, that 
 unlefs the Patient will conform to it fliridtly, 
 the Skill of the Surgeon will often avail no- 
 thing ; for as the Indifpoiition of thefe Sores, 
 is in fome meafure owing to the Gravitation of 
 the Humours downwards, it will be much, 
 more beneficial to lie along than fit upright, 
 tho' the Leg be laid on a Chair ; fince even 
 in this Pofture they will defcend with more 
 force, than if the Body was reclined. 
 
 In Ulcers of the Legs accompanied with 
 Varices or Dilatations of the Veins, the Me- 
 thod of Treatment will depend upon the other 
 D 4 Circum- 
 
xl INTRODUCTION. 
 
 Circumftances of the Sore ; for the Varix can 
 only be affifted by the AppHcation of Bandage, 
 which mufl be continued a confiderable time 
 after the Cure j the neatefl Bandage is the ftrait 
 Stocking, which is particularly ferviceablc in 
 this Cafe, though alfo if the Legs are cedema- 
 tous, or if after the healing of the Ulcers, they 
 fvvell when the Patient gets up, it may be 
 wore with fafety and advantage. There are In- 
 ftances of one Vein only being varicous, which 
 when it happens may be deftroyed by tying it 
 above and below the Dilatation, as in an Aneu- 
 rifm ; but this Operation fliould only be prac- 
 tifed where the Varix is large and painful. 
 
 Ulcers of many Years (landing are very dif- 
 ficult of cure, and in old People the Cure is 
 often dangerous, frequently exciting an Afth- 
 ma, a Diarrhoea, or a Fever, which deftroys 
 the Patient uniefs the Sore break out again, fo 
 that it is not altogether advifeable to attempt 
 the abfolute Cure in fuch Cafes, but only the 
 Reduction of them into better Order, and lefs 
 Compafs, which, if they be not malignant, 
 js generally done with Reft and proper Care. 
 The Cure of thofe in young People may be 
 undertaken with more Safety, but we often 
 find it neceflary to raife a Salivation to efteft it, 
 tbo' when compleated if dees not always lafl, 
 
 fo 
 
INTRODUCTION. 
 
 fo that the Profpedt of Cure in flubborn old 
 Ulcers, at any time of Life/ is but indifferent. 
 In all thefe Cafes, however, it is proper to 
 purge once or twicp a- week with Calomel y if 
 the Patient can bear it, and to make an Iffue 
 when the Sore is almoft healed, in order to 
 continue a Difcharge the Conftitution has 
 been fo long habituated to, and prevent its 
 falling upon the Cicatrix, and burfting out 
 again in that place. 
 
 When an Ulcer or Abfcefs has any Sinufes 
 or Channels opening and difcharging them- 
 felves into the Sore, they are called finuous 
 Ulcers; thefe Sinufes, if they continue to drain 
 a great while, grow hard in the Surface of 
 their Cavity, and then are termed Fiftulse, and 
 the Ulcer a fiftulous Ulcer ; alfo if Matter be 
 difcharged from any Cavity, as thofe of the 
 Joints, the Abdomen, &c. the Opening is 
 called a finuous Ulcer, or a Fiftula. 
 
 The Treatment of thefe Ulcers depends on 
 a variety of Circumftances : If the Matter of 
 the Sinus be thick -, ftrid Bandage and Com- 
 prefs will fometimes bring the oppofite Sides of 
 the Sinus to a Re-union ; if the Sinus grows tur- 
 gid in any Part, and the Skin thinner, fliewing 
 a Difpolidon to break, the Matter muft be made 
 to pufli more againfl that Part, by plugging it 
 up with a Tents and then a Counter-opening 
 
 muft 
 
INTRODUCTION. 
 
 muft be made, which proves often fufficlentfor 
 the whole Abfcefs, if it be not afterwards too 
 rnuch tented, which locks up the Matter and 
 prevents the Healing j or too little, which will 
 have the fame Effeft : for dreffing quite fuper- 
 ficialiy does fometimes prove as mifchievous as 
 Tents, and for nearly the fame Reafon j fince 
 fuffering the external Wound to contradl into a 
 narrow Orifice before the internal one is in- 
 earned, does almoft as efFedually lock up the 
 Matter as a Tent : To preferve then a Medium 
 in thefe Cafes, a hollow Tent of Lead or Silver 
 may be kept in the Orifice, Vv^hich at the fame 
 time that it keeps it open, gives Vent to the 
 Matter. The Abfceffes where the Counter- 
 openings are made moil frequently, are thofe 
 of compound Fradures, and the Breaft ; but 
 the latter do oftener well without Dilatation, 
 than the former, tho' it muft be performed in 
 both, if practicable, the whole Length of the 
 Abfcefs, when after fome Trial the Matter does 
 not lefTen in Quantity, and the Sides of it grow 
 thinner; and if the Sinufes be fiftulous, there 
 is no expedation of Cure v/ithout Dilatation : 
 There are alfo a great many fcrophulous 
 Abfceffes of the Neck, that fometimes com- 
 municate by Sinufes running under large In- 
 durations, in which Inftances, Counter-open- 
 ings are advifeable, and generally anfwer 
 
 without 
 
INTRODUCTION. xliii 
 
 without the Neceflity of dilating the whole 
 Length ; and indeed there are few Abfceffes 
 in this Diftemper, which ihould be opened 
 beyond the Thinnefs of the Skin : When 
 Abfceffes of the Joints difcharge themfelves, 
 there is no other Method of treating the Fif- 
 tala, but by keeping it open with the Cau- 
 tions already laid down, till the Cartilages of 
 the Extreniities of the Bones being corroded, 
 the two Bones (lioot into one another, and 
 form an Anchylolis of the Joint, which is 
 the moil ufual Cure of Ulcers in that Part. 
 
 Gun-fliot Wounds often become linuous U1-* ^ 
 cers, and then are to be coniidered in the fame 
 light as thofe already defcribedj tho' Surgeons 
 have been always inclined to conceive there is 
 fomething more myfterious in thefe Wounds 
 than any others j but their Terriblenefs is owing 
 to the violent Contulion and Laceration of the 
 Parts, and often to the Admiffion of extraneous 
 Bodies into them, as the Bullet, Splinters, 
 Clothes, (jc. and were any other Force to do 
 the fame thing, the Effed would be exadly the 
 fame as when done by Fire-arms. The Treat- 
 ment of thefe Wounds, confifls in removing 
 the extraneous Body as foon as polTible, to 
 which end the Patient mufl be put into the 
 fame Poilure as when he received the Wound : 
 
 if 
 
INTRODUCTION. 
 
 if it cannot be extraded by cutting upon it, 
 which (hould always be pradifed when the 
 Situation of the Blood-veifels, &c. does not 
 forbid 5 it muft be left to Nature to work out, 
 and the Wound dreifed fuperficially, for we 
 mufl not exped that if it be kept open with 
 Tents, the Bullet, &c. will return that way, 
 and there is hardly any Cafe where Tents are 
 more pernicious than here, becaafe of the vio- 
 lent Teniion and Difpofition to gangrene which 
 presently enfue. To guard againfl Mortifi- 
 cation in this, and all other violent contufed 
 Wounds, 'twill be proper to bleed the Patient 
 immediately, and foon after give a Clyfler ^ the 
 Part (liould be drelTed with foft Digeftives, and 
 the Comprefs and Roller applied very loofe, 
 being firft dipt in Brandy or Spirits of Wine : 
 The next time the Wound is opened, if it be 
 dangerous, the fpirituous Fomentation may be 
 employed, and after that, continued 'till the 
 Danger is over. If a Mortification comes on, 
 the Applications for that Diforder muft be 
 ufed : In gun-fhot Wounds, it feldom happens 
 that there is any Effufion of Blood unlefs a 
 large VelTel is tore, but the Bullet makes an 
 Efchar, which ufually feparates in a few 
 Days, and is followed with a plentiful Dif- 
 charge -, but when the Wound is come to this 
 
 Period, 
 
INTRODUCTION. xlv 
 
 Period, it is manageable by the Rules already 
 laid down: 
 
 When an Ulcer with loofe rotten Flefh dif- 
 charges more than the Size of it fhould yield, 
 and the Difcharge is oily and /linking ; in all 
 probability the Bone is carious ; which may 
 eafily be diflinguifhed by [running the Probe 
 thro' the Fleih, and if fo, it is called a carious 
 Ulcer : The Cure of thefe Ulcers depends prin- 
 cipally upon the Removal of the rotten part of 
 the Bone, without which it will be impoffible 
 to heal, as we fee fometimes even in little Sores 
 of the lower Jaw, which taking their Rife from 
 a rotten Tooth will not admit of Cure 'till the 
 Tooth is drawn. Thofe Caries which happen 
 from the Matter of AbfcefTes lying too long 
 upon the Bone, are mo(t likely to recover : Thofe 
 of the Pox very often do well, becaufe that 
 Diftemper fixes ordinarily upon the middle 
 and butfide of the denfeft Bones, which admit 
 of Exfoliation j but thofe produced by the 
 Evil, where the whole Extremities of fpongy 
 parts of the Bone are affeded, are exceedingly 
 dangerous, tho' all inlarged Bones are not 
 neceffarily carious, and there are Ulcers fomcx 
 times on the Skin that covers them, which do 
 not communicate with the Bone, and confe- 
 quently do well without Exfoliation : Nay, it 
 
 feme- 
 
^Ivi INTRODUCTION. 
 
 ibmetlmes happens, tho' the Cafe is rare, that 
 in young Subje(5ts particularly, the Bones will 
 be carious to fuch a degree, as to admit a 
 Probe almoft through the whole Subflance of 
 them, and yet afterwards admit of a Cure, 
 without any notable Exfoliation. 
 
 The Method of treating an Ulcer with a Ca- 
 ries is by applying a Cauftick of the Size of the 
 Scale of the Bone that is to be exfoliated, and 
 after having laid it bare, to wait 'till fuch time 
 as the carious Part can, v/ithout Violence, be 
 feparated, and then heal the \¥ound : I caution 
 againft Violence, becaufe the little jagged bits 
 of Bone that would be left, if we attempted 
 Exfoliation, before the Piece was quite loofe and 
 difengaged from the found Bone, v/ould form 
 little Ulcerations, and very much retard the 
 Cure. In order to quicken the Exfoliation, there 
 have been feveral Applications devifed, but that 
 which has been mod ufed in all Ages is the 
 actual Cautery, with which Surgeons burn the 
 naked Bone every Day, or every other Day, to 
 dry up, as they fay, the Moifture, and by that 
 means procure the Separation ; but as this 
 Pradtice is never of great Service, and always 
 cruel and painful, it is now pretty much ex- 
 ploded : Indeed from confidering the Appear- 
 ance of a Wound, when a Scale of Bone is taken 
 
 out 
 
INTRODUCTION. xlvii 
 
 out of it, there Is hardly any queftion to be 
 made, but that burning retards rather than 
 haftens the Separation ; for as every Scale of 
 a carious Bone is flung off by new Flefli 
 generated between it and the found Bone, 
 whatever would prevent the Growth of thefe 
 Granulations, would alfo in a degree prevent 
 the Exfoliation j which mufi: certainly be the 
 Effed: of a red-hot Iron, applied fo clofe to it; 
 tho' the Circumflances of carious Bones, and 
 their Difpofition to feparate, are fo different 
 one from another, that it is hardly to be ga- 
 thered from Experience, whether they will 
 fooner exfoliate with or without the Affii1;ance 
 of Fire : for fbmetimes, in both Methods, an 
 Exfoliation is not procured in a Twelvemonth, 
 and at other times it happens in three Weeks, 
 or a Month ; nay I have, upon cutting out the 
 Efchar made by the Cauflick, taken away at 
 the fame time a large Exfoliation : However, 
 if it be only uncertain whether the a6lual 
 Cautery is beneficial or not, the Cruelty that 
 attends the ufe of it, Oiould entirely banifh it 
 out of Pradice. It is often likewife in thefe 
 Cafes, employed to keep down the fungous 
 Lips that fpread upon the Bone, but it is much 
 more painful than the Efcharotick Medicines j 
 tho' there will be no need of either, if a regu- 
 lar 
 
xlviii INTRODUCTION. 
 
 i lar Comprefs be kept on the Dreffings .; or at 
 worft, if a flat Piece of the prepared Sponge, 
 of the Size of the Ulcer, be rolled on with a 
 tight Bandage, it will fwell on every fide, and 
 dilate the Ulcer without any Pain. 
 
 Some Caries of the Bones are fo very (hallow 
 that they crumble infenfibly away, and the 
 Wound fills up 5 but w^hen the Bone will nei- 
 ther exfoliate nor admit of Granulations, it will 
 be proper to fcrape it with a Rugine, or per- 
 forate it in many Points with a convenient 
 Inftrument down to the quick. In the Evil, the 
 Bones of the Carpus and Tarfus are often af- 
 feded, but their Sponginefs is the reafon they 
 are feldom cured ; fb that when thefe, or in- 
 deed the Extremities of any of the Bones are 
 carious thro' their Subflance, it is advifeable to 
 amputate ; though there are Inflances in the 
 Evil, but more efpecially in critical AbfcefTes, 
 where after long dreffing down, the ^Splinters, 
 and fometimes the whole Subflance of the fmall 
 Bones, have worked away, and a healthy Habit, 
 of Body coming on, the Ulcer has healed ; but, 
 thefe are fo rare, that no great Dependence, is, 
 to be laid on fuch an Event. The Dfefiings of 
 carious Bones, if they are ftinking, may, be 
 Dofliis dipt in the Tindlure of Myrrh, other- 
 wife thofe of dry Lint are .eafieil, and keep 
 
 c down 
 
INTRODUCTION; xlix 
 
 down the Edges of the Uker better than aiiy 
 other gentle Apphcations. 
 
 Burns are generally efleemed a diftind kind 
 of Ulcers, and have been treated with a greater 
 variety of Applications, than any other ipecies 
 of Sore, every Author having invented fome 
 new Medicine to fetch out the Fire, as they 
 imagine j and indeed the Conceit of a quantity 
 of Fire remaining in the Fart burnt, has occa- 
 fioned the trial of very whimfical and painful 
 Remedies : tho' People who talk thus ferioufly 
 of Fire in VV'ounds, do not think of any re- 
 maining in a Stick that is half burnt, and 
 ceafes to burn any farther j noiwithftanding 
 the Reafoning is the fame in Barns of the 
 Flefh, and Burns of a Piece of Wood. 
 
 When Burns are very fuperficial, not raifing 
 fuddenly any Vefication, Spirits of Wine arefaid 
 to be the quickeil Relief 5 but whether they 
 are more ferviccable than Embrocations with 
 Linfeed-oil, I am not certain, though they are 
 ufed very much by fome Ferfons whofe Trade 
 fubjedts them often to this Misfortune, If the 
 Burn excoriateSj I think it is eafiell; to roll the 
 Part up gently v/ith Bandages dipt in fweet 
 Oil, or a mixture of JJngiieiit. Flor. Samhu. 
 with the Oil : When the Excoriations are very 
 tender^ dropping warm Milk upon them every 
 E Drefling 
 
I N T R O D U C 1' I O N. 
 
 DreiTing is: very comfortable ; or if the; Patient 
 can beiU':'..|Q have Flannels wrung ; out of it, 
 applied hot, it may be ftill better : If the Bura 
 has formed Efchars,. they may be dreffed with 
 Bafdicon,, though generally Oil alone is eafier j 
 and in thefe Sores, whatever is the eafieft 
 Medicine, will be thebeft Digeftive. I have 
 fometimes found it neceffary. to apply different 
 Ointments to Burns, where the Afpeil has been 
 nearly the fame, and upon changing them the 
 Patient has complained of great Pain ; fo that 
 we are obliged fometirrjes to determine what is 
 proper, from Trial. The moft likely things to 
 fucceed at firft, are, Oil, Ungt. Flor. Samb. U?2gt* 
 Bafilieon^ and a Cerate of Wax and Oil, and 
 afterwards the Cerate dc Lapid. Calam. Ungt. 
 Rid\. Deficcdt. Ungt. Sperm. Cet. the Nutritum 
 with bvH, little Vinegar ill, , it, Dr perhaps when 
 th^ FmgiiS rifes, dry Lint. There is great 
 Care neceiiary to keep down the Fungus of 
 Barns, .and heal the V/ounds fmooth, to which 
 end, the Edges fliould be drelled with Lint 
 dipt in Aqu. Vitriol, and dried afterwards, or 
 they may be touched with the Vitriol-ftone, 
 aiid the Dreffings be repeated twice .a-day. • 
 There is alfo greater Danger of Contractions 
 from. Burns after the Cure,, than from other 
 Wounds V to obviate which, Embrocations of 
 
 Neats^ 
 
llsrTRODUCTlON. « 
 
 Neats-foot Oilj and Bandage with Pafte^boarcis, 
 to keep the Part extended, are abfolutely nc* 
 ceffary, v¥here they can be applied. 
 
 >t i'^ • i-i I , ■ 1. ■ . . '-^ ■* 
 
 The EXP|,ANATI0N. 
 
 " yf. A Diredior by which to guide the Knife 
 in the opening of Abfceffes that are burft of 
 themfelves, or firft pundlured with a Lancet* 
 This Inilrument fhould be made either of 
 ^teel, Silver, or Iron, but fo tempered, that it 
 tnay be bent and accommodated to the direc- 
 tion of the Cavity. It is ufually made quite 
 ftraight, but that Form prevents the Operator 
 from holding it firm, while he is cutting, upon 
 which account, I have given mine the Shape 
 here reprefented. The manner of ufing it is^i 
 by paffing the Thumb through the Ring, and 
 fupporting it with the Fore-fingefj while the 
 flraight-edged Knife is to Hide along the 
 Groove with its Edge upwards, towards the 
 Extremity of the Abfcefs. 
 
 B. The llraight-edged Knife^ proper fof 
 opening Abfceffes with the AfTiftance of a 
 Diredor 5 but which, in few other refpeds, 
 is preferable to the round-edged Knife. 
 
 C. A crooked Needle, with its convex and 
 concave Sides fharp: This is ufed only in the 
 
 E a Suture 
 
INTRODUCTION. 
 
 Suture of the Tendom, and is made thin, that 
 but few of the Fibres of fo flender a Body as 
 a Tendon, may be injured in the paffing of it. 
 This Needle is large enough for the ftitching 
 the Tendo AcbilHs. '-ryc-Tq 
 
 D. The largeft crooked Needle neceflary for 
 the tying of any Veflels, and fhould be ufed 
 with a Ligature of the Size of tliat I have 
 threaded it with in taking up the Spermatick 
 VeiTels in Caftration, or the Femoral and Hu- 
 meral Arteries in Amputation. This Needle 
 may alfo be ufed in fewing up deep Wounds. 
 
 E. A crooked Needle and Ligature of the 
 moft ufeful Size, being not much too little for 
 the largefl Veflels, nor a great deal too big for 
 the fmallefl s and therefore in the taking up 
 of the greateft Number of VelTels in an Am-. 
 putation, is the proper Needle to be employed. 
 This Needle alfo is of a convenient Size for 
 fewing up moft Wounds. 
 
 F. A fmall crooked Needle and Ligature 
 for taking up the lefTer Arteries, fuch as thofe 
 of the Scalp, and thofe of the Skin that are 
 wounded in opening AbfceiTes. 
 
 Great Care lliould be taken by the Makers 
 
 of thefe Needles, to give them a due Temper ; 
 
 for if they are too foft, the Force fometimes 
 
 exerted to carry them through the Flefli, will 
 
 ^ bend 
 
INTRODUCTION. lili 
 
 bend tbem , if they are too brittle, they fnap ; 
 both which Accidents may happen to be ter- 
 rible Inconveniencies, if the Surgeon is not 
 provided with a fufficient Number of them. 
 It is of great Importance alfo to ^ive them the 
 Form of part of a Circle, which makes them 
 pafs much more readily round any Veflel, 
 than if they were made partly of a Circle and 
 partly of a ftraight Line, and in taking up Vef- 
 iels at the Bottom of a- deep Wound is abfo- 
 lutely neceflary, it being impradVicable to turn 
 the Needle with a ftraight Handle, and bring 
 it round the Veflel -when in that Situation. 
 The convex Surface of the Needle is flat, and 
 its two Edges are (harp. Its concave Side is 
 corapofed of two Surfaces, rifing from the 
 Edges of the Needle, and meeting in a Ridge 
 orEminence, fo that the Needle has three 
 Sides. This Eminence of the Subftance of 
 the Needle on its Infide ftrengthens it very 
 much, but is not continued the whole length 
 of the.Needle, which is flat towards the Eye; 
 fome are made round in this Part, but they 
 cannot be held fceady between the Finger and 
 Thumb, and are therefore unfit for ufe. There 
 have been Needles made with the Eminence 
 on the convex Side, and a flat Surface on the 
 concave Side, but I do not fee any particular 
 E 3 Advan- 
 
liv INTRODUCTION. 
 
 Advantage in that Strudure. The beft Mate- 
 rials for making l^igatures, are the flaxen 
 Thread that Shoemakers ufe j which is iuffi- 
 ciently ftrong when four^ fix or eight of the 
 Threads are twilled together and waxed j and 
 is not fo apt to cut the VefTels, as Threads 
 that are finer fpun 5 though the Prevention of 
 this Accident will depend in a great meafure 
 on the Dexterity of the Operator, who is care-s- 
 fully to avoid the tying them with too ereat 
 ^ Force. fx f 
 
 G, A ftraight Needle, fuch as Glovers ufe, 
 with a three^edged Point, ufeful in the unin" 
 terrupted Suture, in the Suture of Tendons, 
 where the crooked one C\ is not preferred, and 
 in fewing up dead Bodies 5 and is rather more 
 handy fqr taking up th^ Veilels of the Scalp, 
 
 TREATISE 
 
T. R'E A T,I S E ■ 
 
 OF THE 
 
 Operations ^Surgery. 
 
 CH Ap/ te!;^^^^ 
 
 Of SUTURE ^. -— -^ 
 
 WH E N a Wound is recent, and the 
 Parts of it are divided by a fharp 
 Inftrument, without any farther 
 Violence, and in fuch a manner that they may 
 be made to approach each other, by being 
 returned with the Hands, they will, if held 
 in clofe Contad; for fome time, reunite by 
 Inofculation, and cement liiie one Branch of 
 a Tree ingrafted on another. To maintain 
 them in this Situation, feveral forts of Sutures 
 have been invented, and formerly pradifed, 
 but the Number of them has of late been very 
 much reduced. Thofe now chiefly defcribed, 
 are the interrupted, the Glover's, the quilled, 
 the twifted, and the dry Sutures 5 but the inter- 
 rupted and twifted, are almoll the only ufeful 
 ones ; for the quilled Suture is never prefer- 
 able to the interrupted ; the dry Suture is ridi- 
 E 4 culous 
 
cu1oiis.4Q. leFrns,- fincpjilt is only a piece of 
 Plairier applied- in many different ways.tOTCs 
 unite-t^e: Xvips of a Wound 3 and the Glover's, 
 or .uniDterrupted Stitch, which is advifed in 
 Aiperficial Wounds, to prevent the Deformity 
 of a Scar, does rather by the Frequency of the 
 Stitches. >occafion it, and is therefore to be 
 rejeded in favour of a Comprefs and fticking 
 PJaif^er j,;^the only Inftance where I would 
 recommend it, is in a Wound of the Inteftine i 
 thcmanner of making this Suture I fhall de- 
 fjribe. in the Chapter of Gaftroraphy. 
 
 Fr-om the Delcription I have given of the 
 State-jofa Wo^^d proper to be fewed up, it 
 .may be. readily conceived, that Wounds are not 
 fit Suhjetts tor" Suture, v^hen there is either a 
 Cpntuiian,_ Laceration, L'jfs of Subftance, great 
 Jnfiammation, Difficulty of bringing the Lips 
 jnto. ^-ppQiition, or fome extraneous Body in- 
 iiniiat^d mto them J though fometimes a lace- 
 rated. Wound may be affifted with one or two 
 Stitches, -It; has formerly been forbid to few 
 up Wounds of the Head ; but this Precaution 
 is, v.eryj Uttle regarded by the Moderns j iho* 
 th^. ilj. Effeds I have frequently feen; frofti 
 Matter pent up under the Scalp, and tht: great 
 .Coav'enience there is of ufmo; Eandaare on the 
 HjegcL^.liavQ, coi?.vincg4 t-P-^j that. m,uclv.lefs 
 
 Harm 
 
operations ^iy^-S'-u r-g e r y. 
 
 Hafm''w(aild''be-doheV if Sutures were ufed 
 in this Part with more Caution. 
 . If 'we> flitch up a Wound that has none of 
 fhefe OMades, we always employ the inter- 
 rupted Suture, paffing the Needle two, three, 
 «r four times, in proportion to the Length of 
 it, tho' there can feldom be more than three 
 'Stitches required. 
 
 - The Method of doing it is this: the Wound 
 being emptied of the grumous Blood, and your 
 Affiftant having brought the Lips of it toge- 
 ther, that they may lie quite even ; you care^ 
 fully carry your Needle from without, inwards 
 to the Bottom, and fo on from within, outwards; 
 uiing.'the Caution of making the Punfture far 
 lenowgh from the Edge of the Wound, which 
 wih notion *y facilitate the paffing the Liga- 
 ture, but will alio prevent it from eating thro' 
 the SkiU' and Fkfli^ this Diftance may be three 
 or. foiir ten hs of an Inch : as many more 
 Stitches as you fhall make, will be only repe- 
 titions of the fame Procefs. The Threads 
 being all paffed, you begin tying them in the 
 middle or the Wound, though if the Lips are 
 held carefully together all the while, as they 
 fhould be, it will be of no great Confequence 
 .which is done firft The mod ufeful kind of 
 «Knot in large Wounds, is a lingle one fiift, 
 
 over 
 
4 .Treatise of the :\ \ 
 
 over tbi5, silittle Linnen-comprefs, on which Is 
 to b& made another fingle Knot, and then a 
 Slip- knQt^_ which may be loofened upon any 
 Inflammation ; but in fmall Wounds, there is 
 no Danger from the Double-knot alone, with- 
 out any Comprefs to tie it upon j and this is 
 moft generally pradifed. If a violent Inflam- 
 mation iliould fucceed, loofening the Ligature 
 'only will not fuffice ; it muft be cut through 
 and drawn away, and the Wound be treated 
 afterwards without any future Suture. When 
 the V/ound is fmall, the lefs it is diflurbed. 
 by dreffing, the better j but in large ones, there 
 will fometimes be a Qonfiderable Difcharge, and 
 if the Threads are not cautioufly carried thro' 
 the Bottom of it, AbfcelTes will frequently 
 ^x\{mq from the Matter being pent up under- 
 'neath, and not finding iffue. If no Accident 
 happens, you muft, after the Lips are firmly 
 agglutinated, take away the Ligatures, and 
 drefs the. Orifices they leave. ./ '^' 
 
 it muft be remembered, that during tfie 
 Cure, the Suture muft be always aflifted by the 
 application of Bandage, if poflible, which is 
 frequently of the greatefl Importance j ancl 
 that fort of Bandage with two Heads, and a 
 flit in the middle, which is by much the beft, 
 will ill iriOil Cafes be found pradicable. 
 
 •^' " " The 
 
"aerations of Stj k g ery. 
 
 The twifted Suture being principally em- 
 ployed in the Hare-lip, I fhall referve its de« 
 fcription for the Chapter on that Head, 
 
 CHAP. IL 
 
 Of the Suture ^Tendons. 
 
 P U N D S of the Tendons are not only 
 known to heal again, but even to admit 
 of fewing up like thofe of the fleiliy Parts, 
 tho' they do not reunite altogether in fo fhort 
 a time. When a Tendon is partly divided, 
 it is generally attended vi^ith an exceffive Pain, 
 Inflammation, ^c. in confequence of the re- 
 maining Fibres being ftretched and forced by 
 the Action of the Mufcle, which necelTarily 
 will contrad more, when fome of its Reliflance 
 is taken away : To obviate this Mifchief, it has 
 been hitherto an indifputable Maxim in Sur- 
 gery, to cut the Tendon quite thro', and im- 
 mediately afterwards perform the Suture ; but 
 I do not think this Pradice advifeable -, for 
 tho' the Divilion of the Tendon affords prefent 
 Eafe, yet the mere Flexion of the Joint will 
 have the fame Effed, if, for example, it be a 
 Wound of a Flexor Tendon : Befides, in order 
 to few up the Extremities of the Tendon when 
 divided, we are obliged to put the Limb in 
 
 fuch 
 
6 T K E A T I ^ ^ of the 
 
 fuch fl Situation, that they may be brought Into 
 Contad;, and even to fuftain it in that Pofture 
 to the iinifhing of the Cure : If tli^ny ithe 
 Pofture will lay the Tendon in this Pofition, 
 we can likewile i^eep it fo without ufing the 
 Suture^ and are more fure of its not fjipping 
 away, which fometimes happens from any care- 
 lefs Motion of the Joint, when the Stitches have 
 almoft wore through the Lips of the Wound ; 
 on which account, I would by all means ad- 
 vife in this Cafe, to forbear the Suture, and only 
 to favour the Situation of the Extremities. pf.thf;. 
 Tendon, by placing the Limb properly, o 'i-'r; 
 If it (houid be fuggeiled, that, for want of a 
 farther Separation, there, will not be Inflamma-. 
 tion enough to produce an Adhefion of the fe- 
 deral parts of the Wound, which is particularly 
 mentioned as the Property of this fort of Cica- 
 trix, tho' it is likewife of all others : I fay, that 
 ihQ Infiammation will be in proportion to the 
 Wound, and a fmall Wound is certainly more 
 likely to recover than a large one. If it fliould 
 be objected, that keeping the Limb in one Po- 
 ilure the whole time of the Cure will bring on 
 a Contradion of the Joint, the Objedion is.as 
 ilrong againft the Suture ; and now I am upon 
 this Subjed, I would advife Surgeons to be. lefs 
 ^pprehenfive of Contfadions after Inflamma- 
 tions 
 
operations <?/* S u r g e g y. ^, 
 
 tlons of the Tendons, than Pradlice (hews they 
 are : F<^r perhaps there is hardly any one Rule 
 has done more Mifchief than that of guarding 
 againft this Confequencej and I would lay it' 
 down as a Method to be purfued at all times, 
 to favour the Joint in thcfe Diforders, and 
 keep it in that Poilure we find moft' eafy for 
 the Patient. The Rifque of an immoveable 
 Contra6tion in fix Weeks, is very little, but 
 the Endeavour to avoid it has been the Lofs 
 of many a Limb in half the Time. 
 
 But when the Tendon is quite feparated, and 
 the Ends are withdrawn from one another, 
 having brought them together with your Fjji- 
 gers, you may few them with a flraight trian-. 
 gular pointed Needle, paffing it from without 
 inwards, and from within outwards j in a fmall 
 Tendon', about three tenths of an Inch from 
 their Extremities, and in the Te7idG AchilUs 
 half an Inch : I have Ibnietimes employed two 
 Threads in fewing up the T^endo AchilUs^ and 
 I believe it is generally advifeable to dp io^ 
 rather than to trult to'a ilngie Suture. ,^.}/V; 
 
 Some Surgeons, for fear the Mufcle fliould 
 contract a little, notv/ithftanding all our Care, 
 advife not to bring the Ends of the Tendon into 
 an exadt Apportion, but to lay one a litde over 
 the other, which allowing for the Contradion 
 
 ■ ' ' that 
 
T R t A t I S E df th& 
 
 that always enfues in Ibme degree, the Tendon 
 will become a ftraight Line, and not be fhort- 
 ened in its Length. As the Wound of the Skin 
 will be nearly tranlverfe, I would not have it 
 raifed to expofe more of the Tendon, but ra-* 
 ther fewed up with it, which will conduce to 
 the ftrength of the Suture. The Knot of the 
 Ligature is to be made as in other Wounds, and 
 the Dreffings the fame : There is a fort of thiri 
 crooked Needle that cuts on its concave and 
 convex Sides, which is very handy in the Suture 
 of large Tendons, and to be preferred to the 
 ftraight one. During the Cure, the DrefUngs 
 mufl be fuperficial, and the Parts kept fleady 
 with Paileboard and Bandage: The fmall 
 Tendons reunite in three Weeks, but the T^endo 
 Achillis requires fix at leaft, and by violent 
 Exercife I have known it tore open at the end 
 of ten Weeks j though in the Inftance I allude 
 to, I brought the lacerated Tendons to a per« 
 fed Reunion, without a Suture. 
 
 CHAR IIL 
 
 Of the Gastroraphy. 
 
 ''T^ H E Account of this Operation, has en* 
 
 gaged the Attention of many furgical 
 
 Writers, and occafioned much Debate about 
 
 the 
 
operations:: of- S u r g e^r y . 
 
 the proper Rules for performing it ;: aftd- ryet 
 what makes the greateft part, of the Defcription, 
 can hardly ever happen in Pradiee, and the reft, 
 but very feldom. I have been told that Du 
 VerneyyYjho was the moft eminent Surgeon in 
 the French Army a great many Years^ during 
 the Wars, and Fafhion of Duelling, declai-ed he 
 never had once an Opportunity of pradifiing 
 the Gaftroraphy, as that Operation is generally 
 defcribed ; for tho' the Word, in ilridnefs of 
 Etymology, fignifies no more than fewing up 
 any -Wound of the Belly, yet in common 
 Acceptation, it implies that the Wou'nd?of the- 
 Belly is complicated with another of the In- 
 teftine. ' Now the Symptoms laid down for 
 diftinguifhing when the Inteftine is wounded, 
 do not with any certainty determine it to' be 
 wounded only in one Place, which wanlvef In- 
 formation, makes it; abfurd to opm thQiiikk'' 
 Mm in order to come at it j if fo, the Operation 
 of flitching the Bowels can only take place, 
 where they fall out of the Abdomen^ and we can 
 fee where the Wound is, or how many Wounds 
 there are : If it happens that .the Inteilines fall 
 out un^vounded, the Btiiinefs of the Sorg-eon is 
 to return them immediately, without waiting 
 for fpirituous or emollient Fomentations ; and 
 ij^ijcaie.they ppff up. fo, as to prevent their Re- 
 . -,'•■ ..'■■ duction 
 
10 T R E AT Is S E of the 
 
 du(5ti6n by thp fame Orifice, you may with a 
 Knife or PVobe-rciffars dilate it fufficient for 
 that Purpofe, or even prick them to let out the 
 Wind, laying it down for a Rule in this, and 
 all Operations where the Omentum protrudes, 
 to treat it in the Method I fhall defcribe, in 
 the'Chapter on the Bubonocele, 
 
 Upon the Suppofition of the Inteftine being 
 wounded in fuch a manner as to require the 
 Operation (for in fmall Pundures it is not ne- 
 ceiTary) the Method of doing it may be this : 
 Taking a ftraight Needle with a fmall Thread, 
 you lay hold of the Bowel with your left 
 Hand, and few up the Wound by the Glover's 
 Stitch, that is, by paffing the Needle thro' the 
 Lips of the Wound, from within outwards all 
 the way, fo as to leave a length of Thread, at 
 both Ends, which are to hang out of the Inci^ 
 fidn of the Abdomen ; then carefully making 
 the interrupted Suture of the external Wound, 
 you pull the Bowel by the fmall Threads into 
 Conta£t with the Peritoitatm, for the more 
 readily uniting afterwards by Adhefion with it;, 
 and tye them upon a imall Bolfter of Linen 5 
 tho' 1 think it would be more fecure to pafs 
 the Threads with the ftraight Needle through 
 the lower Edges of the Wound of the Abdomen, 
 which would more certainly hold the InteHiine 
 
 in 
 

 Of tramp's .^f S u r ci t n y. 
 
 in that Situation. In about fix Days, it is faid 
 the Ligature of the Inteftine will be loofe 
 enough to be cut and drawn away, which muft 
 be done without great Force j in the Interim, 
 the Wound is to be treated with fuperficial 
 Drcffings, and the Patient to be kept very ftill 
 and low* 
 
 CHAP. IV. 
 
 0/" /^^ B U B O N O C E L E. 
 HEN the Inteftine or Omentum falls 
 
 W 
 
 out of the Abdomen into any Part, the 
 Tumour in general is known by the Name of 
 Jiernia^ which is farther fpecified cither from 
 the Difference of Situation, or the Nature of its 
 Contents. When the Inteftinc or Ome?2tum falls 
 thro' the Navel, 'tis called a Heriiia Vmhilica'^ 
 Usy or Exomphalos j when thro' the Rings of 
 the Abdominal Mufcles into the Groin, Hernia 
 Inguinalis ; or if into the Scrotum, Scrotalis ; 
 Thefe two laft, tho* the firft only is properly 
 fo called, are known by the Name oi Bubono- 
 cele, When thty h\\ \jiT\dzv the Ligame^itujn 
 Fallopii^ t|iro' the fame PafTage that the IliaCK 
 Veffels creep into the Thigh, 'tis called Hernia 
 Fempralis.^ The Bubo?20ceIe is alio fometirnes 
 accompanied with a Defcent of the Bladder : 
 F How^ 
 
12 T'SiE AT I s z of the . 
 
 However, the Cafe is very rar^ ; but when it 
 occurs, it is known by the Patient's Inability 
 to urine, 'till the Hernia of the Bladder is re- 
 duced within the Pelvis, With regard to the 
 Contents charaderifing the Swelling, it is thus 
 diftinguiflied : If the Inteftine only is fallen, it 
 becomes an Enter ocele ; if the Omentum (Epi^ 
 ploon) Epip/ocele j ^nd if both, Entero-Epiplo- 
 cele. There is befides thefe, another kind of 
 Hernia mentioned and defcribed by the Mo- 
 derns, when the Inteftine or Omentum is inli- 
 nuated between the Interftices of the Mufcles, 
 in different Parts of the Belly : This Hernia has 
 derived its Name from the Place affeded, and 
 is called the Hernia Ventralis j and laftly, there 
 have been a few Inftances, where the Intellines 
 or Omentum have fallen thro' the great Fora^ 
 men of the Ifchium into the internal Part of the 
 Thigh, between and under the two ,^nj^er49|: 
 Heads of the Triceps Mulcle. ^... -,,,.^5- 
 
 All the Kinds of Her?iias of the Inteftines 
 and Omentum^ are owing to a preternatural Di- 
 latation of the particular Orifices thro' which 
 they pafs, and not to a Laceration of them^ 
 which lad Opinion (together with a fuppofed 
 Laceration of the Peritoijc^mfi) has however 
 prevailed fo much, as by way of eminence to 
 give Name to the Difordcr, which is known 
 
 more 
 
operation^ (j/^Surgery. 13 
 
 more by that of RupturCj than any of thofe I 
 have mentioned j on which account I ihall 
 beg leave to make ufe of it myfelf. 
 
 The Rupture of the Groin, or Scrotum^ is 
 the moft common Species of Hernia^ and in 
 young Children is very frequent, but it rarely 
 happens in Infancy, that any Mifchiefs arife 
 from it. For the moft part, the Inteftine 
 returns of itfelf into the Cavity of the Abdomen^ 
 whenever the Perfon lies down, at lead a fmall 
 Degree bf Gompreffion will make it. To 
 fecure the Inteftine when returned into its 
 proper Place, there are Steel-truffes now fo 
 artfully made, that by being accommodated 
 exadly to the Part, they perform the Office of 
 a Bolder, without galling, or even fitting uneafy 
 on the Patient. Thefe Inftruments are of fo 
 great Service, that were People who are fub- 
 J€(5l to Ruptures aUvays to wear them, I be- 
 lieve very few would die of this Diftemper ^ 
 fince it often appears, upon Enquiry, when 
 we perform the Operation for the Bubonocele^ 
 that the Neceffity of the Operation is owing 
 to the Neglect of wearing a Trufs. 
 
 In the Application of a Trufs to thefe kinds 
 
 of Swellings, a great deal of Judgment is fome- 
 
 fimes neceffary, and for want of it, we daily fee 
 
 TrufTes put even on Buboes, indurated Tefticles, 
 
 F 2 Hydro- 
 
14. , 1l K'lL hi: I ^ z of the 
 
 ,HyJr6ceIeSy &c. But for the Hernias I have de- 
 fcribed, I fliall endeavour to lay down twc^^or 
 three Rules, in order to guide more pofitively to 
 the Propriety of applying or forbearing them. 
 
 If there is a Rupture of the Inteftine only, it 
 is eafily, when returned into the Abdomeji^ fup- 
 ported by an Inftrument j but if of the Omen- 
 turn, notwithftanding it may be returned, yet I 
 have feldom found the Redudion to be of much 
 Relief, unlefs there is only a fmall Quantity of 
 it J for the Omentum will lie uneafy in a Lump 
 at the Bottom of the Belly, and upon removal 
 of the Inftrument, drop down again immedi- 
 ately ; upon which account, feeing the little 
 Danger and Pain there is in this kind of 
 Hernia^ I never recommend any thing but a 
 Bag- trufs, to fufpend the Scrotum^ and prevent 
 poffibly by that means, the increafe, of the 
 Tumour. The difference of thefe Tumour^ 
 will be diftinguifhcd by the Feel \ that of th(?_ 
 Omentiimy feeling flaccid and rumpled^ the 
 other more even, flatulent, and fpringy. 
 
 Sometimes^ in a Rupture of both the Inte- 
 , fllne and Omentum^ the Gut may be reduced, 
 but the Omeiitum will Hill remain in the Scror 
 turn J _3.nd when thus circumftanced, mofl: Sur- 
 geons advife a Bag-trufs only, upon a Suppofi- 
 tionthat the Preilure of a Steel one^ by ftop- 
 ■r ■ ping 
 
operations of Su r g e ry, 15 
 
 pirig the Circulation of the Blood in the Vcflels 
 of the Omentum^ would bring on a Mortifica- 
 tion : But I have learnt from a Multitude of 
 thofe Cafes, that if the Inftrument be nicely 
 fitted to the Part, it will be a Comprefs fuffi- 
 cient to fuftain the Bowel, and at the fame 
 time, not hard enough to injure the Omentum ; 
 lb that when a great Quantity of Intefline falls 
 down, tho' it be complicated with the Defcent 
 of the Omentum^ the Rupture will conveniently 
 and fafely admit of this Remedy. 
 
 There are fome Surgeons, who to prevent 
 the trouble of wearing a Trufs, when the In- 
 teftine is reduced, deftroy the Skin over the 
 Rings of the Abdominal Mufcles with a Cau- 
 ftic of the Size of a half Crown-piece, and 
 keep their Patients in Bed till the Cure of the 
 Wound is finidied ; propofing by the Stricture 
 of the Cicatrix to fupport it in the Abdemen for 
 the future : But by what I have feen, the Event, 
 tho' often fuccefsful, is not anfwerable to the 
 Pain and Confinement j for if after this Ope- 
 ration the Inteftine fhould again fall down, 
 which fometimes happens, there might pof- 
 libly be more Danger of a Strangulation, than 
 before the Scar was made. This Pradice 
 feems to be more advifeable on Women than 
 Men j becaufe in Men, the Danger of injur- 
 F 3 ing 
 
1 6 T R E A T I S E <?/* //5d? 
 
 ing the fpermatic Cord, fometimes intimidates 
 lis from u(ing a Cauftick of fufficient Stfe-ngth 
 to do the proper Ofliee. "' - 
 
 I have hitherto confidered the Rupture as 
 moveable j but it happens frequently, that the 
 Inteftlne, after it has paffed the Rings of th«' 
 Mufcles, is prefently inflamed, which enlarging 
 the Tumourj prevents the Return of it into 
 the Abdomen, and becoming every Moment 
 more and more ilrangled, it foon tends to a 
 Mortification, unlefs we dilate the Parages 
 thro' which it is fallen, with fome Infirument, 
 to make room for its return ; which Dilatation 
 is the Operation for the Bubonocele. 
 
 It rarely happens that Patients fobmit to this 
 Incifion before the Gut is mortified, and it is 
 too late to do Service j not but that there are 
 Inftances of People furviving fmall Gangrenes, 
 and even perfectly recovering afterwards. I 
 myfelf have been an Eye-witnefs of the Cure 
 of two Patients who fometime after the Ope- 
 ration, when the Efchar feparated, difcharged 
 their F^ces thro' the Wound, and continued 
 to do fo for a io.^ Weeks in fmall Quantities, 
 when at length the Inteftine adhered to th© 
 external Wound, and then was fairly healed. 
 
 In Mortifications of the Bowels, when fallen 
 aut of the Abdomen juto the Navel, it is not 
 
 very 
 
Operat7o?2s ^Surgery, ij 
 
 very uncommon for the whole gangrened Tn- 
 Ceftine to feparate from the found one, fo that 
 the Excrement muft neceffanly ever after be 
 difeharged at that Orifice: There are likt wife 
 a few Inftances, where the Rupture oi the 
 Scrotufn has mortified and become the Anus^ 
 the Patient doing well in every other refpeCt j 
 nay I have had one Inftance of this Nature 
 under my Care, in which the Excrements were 
 voided totally by the Scrotum for three Weeks 
 or a Month, yet by degrees, as the Wound 
 healed, they pafled off chiefly in their natural 
 Courfe, and at laft almoft wholly fo, Thefe 
 Cafes however, are only mentioned to furnifli 
 Surgeons with the Knowledge of the poffibi- 
 lity of fuch Events, and not to miflead.them 
 fo far as to make favourable Inferences with 
 regard to Gangrenes of the Bowels, which 
 generally are mortal. 
 
 Before the Performance of the Operation 
 for the Biibonoceh^ which is only to be done 
 in the Extremity of Danger, the milder Me- 
 thods are to be tried; thefe are, fueh as will 
 conduce to foothe the Inflammation 3 for as to 
 the other Intent of foftening the Excrements, 
 I believe it is much to be queftioned, whether 
 there can be any of that degree of Hardnefs as 
 to form the Obftrudion ; and in fa^j thofe 
 F 4 Opera- 
 
iS Treatise^ //5^ 
 
 Operators who have unluckily wounded the 
 Inteftine, have proved, by the thla Difchafgc 
 of Fasces which has followed upon the-'lfi- 
 cifion, that the Induration we feel, is '^hc 
 Tenfionofthe Parts, and net the hardened 
 Lumps of Excrement. 
 
 Perhaps, except the Pleurify, no Diforder is 
 rnore immediareiy relieved by plentiful Bleed- 
 ing than this ; Clyfters repeated one after ano- 
 ther, three or four times, if the firft or fecond 
 are either retained too long, or immediately 
 returned, prove very efficacious ; thefe are fer- 
 yiceable, not only as they empty the great In-r 
 teftines or their Excrements and Flatulencies, 
 which latt are very dangerous, but they like- 
 wife prove a comfortable Fomentation, by 
 paffing through the Colon all around thb Abf 
 domen. The »S'fro/z<;//2^nd Groin muft, during 
 the flay of the Clyfter, be bathed with warm 
 Stoops wrung out of a Fomentation ; and after 
 the Fart has been well fomented, you mufl; 
 attempt to reduce the Rupture : For this Pur- 
 pofe, let your Patient be laid on his Back, fo 
 that his Buttocks may be confiderably above 
 his Head J the Bowels will theq retire towards 
 the Diaphragm, and give way to thofe which 
 ^jre to be pufhed in. If after endeavouring 
 two Pr three Minutes, you do not find Succefsj 
 
 you 
 
Operatiomi. of S- u, % g; f"T^ y. i-g 
 
 ;ypu:^B;ay Jlill repeat the. Trial : I h^j^^,.rgme- 
 eti^pSji at the end of %,Qu^rtef .of ^T^,j%om-, 
 •L^UFned ;fuch as I thought dp;rperijt?:^iaAd 
 , whieh did not feem to, give way .:in. |he JeaO:, 
 i 'till thp Moment they went up; ..however tl^is 
 
 muft be pradifed with Caution, for;,tOj^ ixi,iieh 
 .rough "handling will be pernicious... -,,,,.j..,cr 
 ,b~. If, notwithftanding thefe Means, the Patiept 
 
 continues in very great Torture, tho' not (o 
 
 bad as to threaten an immediate Mortification, 
 . we muft apply fome fort of Pultice to the Scrp" 
 
 turn ::th2Lt which I ufe in this Cafe, is,- equal . 
 
 Parts of Oil and Vinegar made into a proper 
 . Goniiftence with Oatmeal: After fome few 
 
 Hours, the Fomentation is to be repeated, and 
 
 the other Directions put in Practice; and. if 
 
 thefe, do not fucceed, I am inclined to think 
 
 .it advifeablc.to prick the Inteftine in five or fix 
 
 . Places with a Needle, as recomrriended. by 
 
 . Feter Lowe^ an old Eiiglifi Writer, who fays, 
 
 •He has often experienced the good EiFe(3:s,of 
 
 this Method in the inguinal Hernia^ when all 
 
 :PtberMeans have failed, 
 .u. After all, fliould the Pain and Tenfenefs of 
 
 'the. Part continue, and Hiccoughs and Vonut- 
 V jogs of the Excrernents fucceed, the. Operation 
 
 muft take places for if you wait 'till a languid 
 ,j;^wlfe epli;! Sweats, fubfiding of the Tumour, 
 'r^ ■■: and . 
 
T R vE A T J S E of the 
 
 and cmpbyfematous Feel come on, it will be 
 moft likely too late, as they are pretty fiaire 
 Symptoms of a Mortification. 
 
 To conceive rightly of the Occurrences in 
 this Operation, it muft be remembered that in 
 every Species of Rupture, a Portion of the 
 Peritcnawm falls down with whatever makes 
 the Hernia ; which from the Circumftance of 
 containing immediately the Contents of the 
 Tumour, is called the iS^<:of the Hernia; Now 
 the Portion of the Peritonceum which ufually 
 yields to the Impulfion of the defcending Vif- 
 cerdy is that which correfponds with the inmofl 
 Opening of the Abdominal Mufcles, juft where 
 the Membrana Cellulaiis Peritonei begins to 
 form the T^unica Vaginalis of the Spermatic 
 Cord, fo that the Sac with the Vifcera infintr- 
 ate themfelves into the Tunica Vaginalis of the 
 Spermatic Cord, and lie upon the Ttmica Vagi^ 
 milis of the Tefticle j tho' upon Examination, 
 I have alfo frequently found the Contents of the 
 Hernia in contad with the Tefticle itfelf j that 
 is to fay, within the Tunica Vagi?2alis of the 
 Teilicle ; which I confefs has furprifed me, as 
 it could not have been effeded, but by burft- 
 ing thro' the Peritonceum-, an Accident which 
 the Moderns do not feera to have thought - 
 poilible. 
 
 From 
 
leratkns of S- u r g e r y. 
 
 From this Defcription of the Dcfcent of the 
 Vifcerai it appears that the Herniary Sac. is con- 
 tained within the Tunica Vaginalis ^ and ought 
 to give the Idea of one Bag inclofing another ; 
 but in the Operation, this Diftind:ion of Coats 
 does not always appear : For tiie Herniary Sac 
 fometimes adheres fo firmly to the Tunica Va^ 
 ginaJis, that together they make but one thick 
 Coat: This Adhefion may poffibly refult from 
 the prefent Inflammation of the Parts, which 
 has rendered the Operation neceffary ; but I 
 am inclined to believe, that the Herniary Sac 
 adheres in all Bubonoceles^ which are not very 
 recent, and that when we reftore the Hernia 
 into the Abdomen^ and fupport it by a Trufs, it 
 is only the Vifcera and not the Herniary Sac 
 which is reduced } at leafl: I have found this 
 to be the Cafe in feveral that I have dllTeded. 
 
 The befl: way of laying your Patient will be 
 Qti a Table about three Foot four Inches high, 
 letting his Legs hang down j then properly fe- 
 curing him, you begin your Incifion above the 
 Rings of the Mufcles, be3^ond the Extremity 
 of the Tumour, and bring it down about half 
 the length of the Scrotum j thro' the Membrana 
 adipofa, which will require very little Trouble 
 to feparate from the Tunica Vaginalis^ and 
 confecjuently, will expofe the Rupture for 
 '-. • ■ : the 
 
Treatise of the 
 
 the farther Procelfes of the Operation ; but I 
 cannot help once more recommending it as ^^^ 
 thing of great Confequence, to begin the"di!i' 
 ternal Incifion high enough above the Rings^ 
 fmce there is no Danger in that Part of the 
 Wound: and for want of the room this Inci- 
 fion allows, the moft expert Operators are 
 fometimes tedious in making the Dilatation. 
 If a large Vellel is opened by the Incifion, it 
 muft be taken up before you proceed further. 
 
 When the "Tunica Vaginalis is laid bare, you 
 muft cut carefully thro' it and the Perito?iaum, 
 in order to avoid pricking the Inteftines; tho' 
 to fay the Truth, there is not quite fo much 
 Danger of this Accident as is reprefented ^'^6t^ 
 fornetimes the Quantity of Water feparated irf 
 the Sac of the Feritonceim, raifes it from th^: 
 Iiiteftine, and prevents any fuch Mifchief. ^ 
 . it has lately been confidered by fome as an 
 Improvement in the Operation, where the Dif- 
 order is recent, to forbear wounding the Pm- 
 tonmimy and to return the Sac intire into the 
 Abdomen^ thinking by this Means to make a 
 firmer Cicatrix, and more furely to prevent a 
 Relapfe for the future j but befides that it is of- 
 ten impradicable by reafon of its Adhefion, the'' 
 feeming Neceffity there is of letting out the Wa- 
 ters that are frequently fxtid, of taking away 
 
 any 
 
 a^ 
 
 i\ 
 
Oper attorn of Sv kg e^y. 23 
 
 any Part of the Ome?ttum that may pbflibiy be 
 mortified, and which we cannot come at with- 
 out the Incirion, and laftly to leave an Opening 
 for the iflhe of the Excrements out of the 
 Wound, in cafe an Efchar fliould drop from the 
 Inteftlne: AH which Accidents happen fome- 
 times very early, and put out of Difpute, in my 
 Opinion, the Impropriety of this Method. 
 
 The Feritonceum being cut thro', we arrive 
 to its Contents, the Nature of which will de- 
 termine the next Procefs ; for if it is Inteftine 
 only, it muft dirediy be reduced ; but if there 
 is any mortified Omentum^ it muft be cut ofFj in 
 order to which it is advifed to make a Ligature 
 above the part wounded, to prevent an He- 
 morrhage j but it is quite needlefs, andinfome 
 meafure pernicious, as it puckers up the Inte- 
 fline, and difordersits Situation, if made clofe to 
 it : For my part, I am very jealous that Wounds 
 of tkiQ Omentum are dangerous, on which ac- 
 count I cannot pafs over this Procefs of the Ope- 
 ra|ipn, , without cautioning againft cutting any 
 of it away, uniefs it is certainly gangrened ; and 
 when that happens, I think it advifeable to cut 
 off the mortified Part with a Pair cf Sciffars, 
 near, to, the found Fart, leaving a fmall Portion 
 of it to feparate in the ^^^(;;?2f;2 3 which may 
 be done, with as much Safety, as to leave the 
 ia^e Quantity below a Ligature. 
 
 V/hcn 
 
T R E A .T i s E of the 
 
 When the Omentum is removed, we next 
 dilate the Wound j to do which with Safety, an 
 infinite Number of Inftruments have been rfe 
 vented v but in my Opinion, there is none \<^b 
 can ufe in this Cafe v^ith fo good Management 
 as a Knife ; and I have found my Finger in the 
 Operation a much better Defence againft prick- 
 ing the Bowels, than aDiredor which I intended 
 to employ : The Knife muft be a little crooked 
 and biunt at its Extremity, like the End of a 
 Probe. Some Surgeons perhaps may not be 
 fteady enough to cut dexterouily with a Knife, 
 and may therefore perform the Incifion with 
 Probe-fcilTars, carefully introducing one Blade 
 between the Inteftine and circumference of the 
 Rings, and dilating upwards, and a little oblique- 
 ly outwards. When the Finger and Knife only 
 are employed, the Manner of doing the Ope- 
 ration, will be by preffing the Gut down with 
 the Fore-finger, and carrying the Knife be- 
 tween it and the Mufcles, fo as to dilate up- 
 wards about an Inch, which v/ill be a Wound 
 generally large enough : But if upon Examina- 
 tion it fhail appear that the Inteftine is ftrangu* 
 lated within the Abdomen j which may poffiblj^' 
 happen from a Contraction of the Pm/(j;?(^//»^ 
 near the Entrance into the Sac \ in that Cafe, 
 the Incifion mnft be continued thro' the Length 
 of the contracted Channel, cr tlie Conf^quence 
 
 will 
 
yer attorn ^/'Surgery. 25 
 
 will be fatal, notwithftanding the Intefline be 
 reftored into the Scrotum : On this account the 
 Operator fhould pafs his Finger up the Sac 
 into i\iQ Abdomen y after the Reduction of the 
 Gut, in order to difcover whether it be {^.My 
 returned into its proper Place. 
 
 The Opening being made, the Intefline is 
 gradually to be pudied into the Abdomen^ and 
 the Wound to be flitched up i for this Purpofe, 
 fome advife the quilled, and others the inter- 
 rupted Suture, to be pafTed thro' the Skin and 
 Mufcles J but as there is not fo much Danger of 
 the Bowels failing out when a DrefTing and 
 Bandage are applied, and the Patient all the 
 while kept upoo his Back, but that it may be 
 |)revented by one or two flight Stitches thro' 
 the Skin only, I think it by all means advife- 
 able to follow this Method, fmce the Stridure 
 of a Ligature in thefe tendinous Parts may be 
 dangerous. 
 
 Hitherto in the Defcription of the Bubono- 
 cele I have fuppofed the Contents to be loofe, 
 or feparate in the S^Cy but it happens fome-. 
 times in an Operation, that we find not only an 
 Adhefion of the Outiide of the Feritonceum to 
 the "Timica Vaginalisy and fpermatic VefTels, but 
 likewife of fome Part of the Inteftines to its in- 
 ternal Surface; and in this Cafe there is io much 
 
 Con- 
 
26 T R E A T I S E i?/" /;5^ 
 
 Confufion that the Operator is often obliged tO 
 extirpate the Teflicle, in order to diffedt away 
 and difmtangle the Gut, tho' if it can be done 
 without Caftraiion it ought : I believe how- 
 ever, this Accident happens rarely, except iri 
 thofe Ruptures that have been a long time in 
 the Scrotum v/ithout returning ; in which Cafe 
 the Difficulty and Hazard of the Operation arc 
 fo oreat, that unlefs urged by the Symptoms 
 pf an inflamed Inteftine, I would not have it 
 undertaken. I have known two Inftances of 
 Perfons fo uneafy under the Circumftance of 
 fuch a Load in their Scrotum^ tho' not other- 
 wife in Pain, as to defire the Operation j but 
 the Event in both proved fatal j which I think 
 (hould make us cautious how we expofe a 
 Life for the fake of a Convenience only, and 
 teach our Patients to content themfelves with 
 a Bag-Trufs, when in this Condition. 
 
 The dreffing of the Wound fir ft of all may 
 be with dry Lint, and afterwards as direded 
 in the Introdudion. 
 
 The Operation of the Bubonocele in Women 
 fo nearly refembles that performed on Men, 
 that it. requires no particular Defcription, only 
 in them the Rupture is formed by the Inteftine 
 or Qmentmn falling down thro' the Paflage of 
 th« IJgqmentum Rotundim into the Groin,, or 
 . .^ one 
 
perations of S u R q ^. k -^^ 27 
 
 one, of the Lal;ia Pudeiidi y where caufmg the 
 fame Symptoms, as when obftrudted in the 
 Scrotunty it, is to be returned by the Dilatation 
 o£_.that PaiTage. 
 
 CHAR V/ 
 
 Of the E P I P L O C E L E* 
 
 ^Tp Here have been a few In (lances 
 where fo great a Quantity of the Omentum 
 has fallen into the Scrotum ^ that by drawing 
 the Stomach and Bowels downwards, it has 
 excited Vomitings, Inflammation, and the fame 
 train of Symptoms as happen in a Bubonocele^ 
 in which Cafe the Operation of opening the 
 Scrotum is necelTafy : The Incifion muil be 
 made in the manner of that for the Rupture of 
 the Inteftine, and the fame Rules obferved with 
 regard to the Omentum^ that are laid down in 
 the laft Chapter. It is necelTary alfo, the Rings 
 of the Mufcles fliould be dilated, or otherwife, 
 tho' you have taken away fome of the morti- 
 fied part of the Omentum^ the reft that is out 
 of its Place, and ilrangled in the Perforation, 
 will gangrene alfo. The Wound is to be treated 
 in the fame manner, as that after the Operation 
 of the Bubonocele. What I have here defcribed 
 as an Inducement to the Operation, (hould, by 
 
 O the 
 
2 8 T Ki^ Ai: I ?> E of the 
 
 the Experience I have had, be the only one. 
 There are a great many People, who are fo un^ 
 eafy with Ruptures, tho* they are not painful, 
 that a little Encouragement from Surgeons 
 of Charadter will make them fubmit to any 
 means of Cure j but as I have feen two or 
 three Patients, who were in every refped: hale 
 and fbrong, die a few Days after the Ope- 
 ration, the Event tho' very furprifing, fliould 
 be a Leflbn, never to recommend this method 
 of treating an Epiplocele, unlefs it is attended 
 with Inflammation, (^c, 
 
 CHAP. VI. 
 
 Of the Hernia Femoralis. 
 
 '"T^ HIS Species of Rupture is the fame in 
 both Sexes, and formed by the falling of 
 the Omentum or Inteftine, or both of them, into 
 the Infide of the Thigh, thro' the Arch made 
 by the Os Pubis, and Ligame72fum Fallopiiy 
 where the Iliac Veflels and Tendons of the 
 Pfoai and Iliacus internus Mufcles pafs from 
 the Ahdomm. It is very neceffary, Surgeons 
 iliould be aware of the Frequency of this Dif^ 
 order, which creates the fame Symptoms as 
 other Ruptures, and muft firft of all be treated 
 by the fame Methods : The manner of operat- 
 ing 
 
Opef-ations ^SurgErVi 29 
 
 itig in the Redudion, is here too fo exadly the 
 fame, with the difference of dilating the Li- 
 gament ihftead of the Rings of the Murcles> 
 that it wouid be a mere Repetition of the Ope- 
 ration for the Bubonocele to give any Defcrip- 
 tion of it ; only it may be obferved, that the 
 fpernnatic Cord as it enters into the Abdomen^ 
 lies nearly tranfverfe to the Incifion, and clofe 
 in contad: with the Ligament, fo that unlefs 
 you make the Dilatation obliquely outwards, 
 inftead of perpendicularly upwards, you will 
 probably divide thofe VelTels* 
 
 CHAP. 
 
 Of the E X O M P H A L o s» 
 
 ^npHiS Rupture is owing to a Protrufioti 
 of the Inteftine, or Omentum^ or both 
 of them, at the Navel, and rarely happens to 
 be the Subjed of an Operation 3 for tho' the 
 Cafe is common, yet mofi: of them are gra* 
 dually formed from very fmall Beginnings^ 
 and if they do not return into the Abdomen 
 upon lying down, in all probability they ad- 
 here without any great LiGonvenience to the 
 Patient, 'till fome time or other an Lnfiam* 
 mation falls upon the Inteftines, which foon 
 brings on a Mortification, and Deaths unlefs 
 
 by 
 
 VJ % 
 
3© T R "^ A T 1 S E of i/je 
 
 by great Chance, the mortified Part fcparatcs 
 from the found one, leaving its Extremity to 
 perform the Office of an A?ms : In this Emer- 
 gency however, I think it advifeable to attempt 
 the Reduction, if called in at the Beginnings 
 tho' the univerfal Adhefion of the Sac and its 
 Contents, are a great Obftacle to the Succefs : 
 The Inftance in which it is moft likely to 
 anfwer, is, when the Rupture is owing to any 
 Strain, or fudden Jerk, and is attended with 
 thof Diforders which follow upon the Stran- 
 gulation of a Gut. 
 
 In this Cafe, having tried all other means iii 
 vain, the Operation is abfolutely neceflary ; 
 which may be thus performed : Make the 
 Incifioh fomewhat above the Tumour, on the 
 left Side of the Navel, thro' the Membrana 
 Adipofa J and then emptying the Sac of its 
 Water, or mortified Omentum^ dilate the Ring 
 with the fame crooked Knife, conducted on 
 your Finger, as in the Operation for the jB//- 
 bomcele ; after this, return the Inteftines and 
 Omentum into the Abdomen^ and drefs the 
 Wound without making any Ligature, but of 
 the Skin only. 
 
 CHAP. 
 
operations of Su rge p. y. 31 
 
 CHAP. VIII. 
 
 Of the Hernia Ventralis. 
 
 npHE Hernia Ventralis which fometimes 
 appears between the ReBi Mufcles is 
 very large ; but that Tumour which requires 
 the Operation, is feldom bigger than a Wahiut,. 
 and' is a Difeafe not fo common as to have 
 been obferved by many ; but there are Cafes 
 enough known, to put a Surgeon upon enquiry 
 after it, when the Patient is fuddenly taken 
 with all the Symptoms of a Rupture, without 
 any appearance of one in the Navel, Scrotum, 
 or Thigh : I have before defined this Hernia 
 to be a Strangulation of the Gut, between fome 
 of the In^erftices of the Mufcles of the Abdo^ 
 men : The manner of dilating it will be the 
 fame as that above direded in the other Her- 
 nias: After the Operation in this, and all 
 Hernias where the Inteftines have been re- 
 duced, 'twill be convenient to wear a Trufs, 
 fince the Cicatrix is not always firm enough 
 in any of them, to prevent a Relapfe. 
 
 G 3 PLATE 
 
Treatise^' the 
 
 PLATE II. 
 
 7he Explanation. 
 
 A. The round-edged Knife, of a convenient 
 Size for almoO: all Operations where a Knife is 
 ufed : The Make of it will be better underftood 
 by the Figure than any other Defcription ; only 
 it may be remarked, that the Handle is made 
 of a light Wood, as indeed the Handles of all 
 Inflruments fhould be, that the Refiftance to 
 the Blades may be better felt by the Surgeon. 
 
 B. A pair of Probe- fcilTars, which require 
 nothing very particular in their Form, but that 
 the lower Blade {hould be made as fmall as 
 poffible, fo that it is ftrong, and has a good 
 Edge } becaufe being chiefly ufed in Fiflulas 
 in AnOy the Introdaition of a thick Blade into 
 the Sinus, which is generally narrow, would 
 \>t very painful to the Patient, 
 
 C. The crooked Knife with the Point blunt-? 
 edj ufe^ in the Operation pf the Bubomcek, 
 
 CHAP, IX. 
 Of the Hydrocele. 
 
 ^T^H E Hydrocele, called alfo Hernia Aquofa^ 
 
 ■^ Hydrops Scrotiy and Hydrops T^ejiis^ is 
 
 a watry Tqmour of the Scrotum -, which not-. 
 
 withftanding 
 
Operations <9/'SuRGERy. 33 
 
 withftanding the multiplicity of Diftlndions 
 ufed by Writers, is but of two kinds : The one, 
 when the Water is contained in the Timica Va- 
 ginalis ', and the other, when in the Mcmbrana 
 Cellularis *Scrc// : This laft, is almofl always 
 complicated with an Anafarca^ which Species 
 of Dropfy, is an Extravafation of Water lodged 
 in the Cells of the Membrana Adipofa j and 
 when thus circumftanced, will not be difficult 
 to be diftlngulfhed ; befides that It is fuffici- 
 ently charailerifed by the Shining and Softnefs 
 of the Skin, which gives way to the leaft Im- 
 preffion, and remains pitted for fome time. 
 li\\Q,Fenis is likewife fometlmes enormouily 
 enlarged, by the Infmuatlon of the Fluids into 
 the Membrana Cellularis^ all which Symptoms 
 are abfolutely wanting in the Dropfy of the 
 'Tunica Vaginalis. 
 
 In the Dropfy of the Membrana Cellularis 
 Scroti^ the Pundure with the Trocar, is re- 
 commended by fome, and little Orifices made 
 here and there with the Point of a Lancet, by 
 others 5 or a fmall Skane of Silk palled by a 
 Needle thro' the Skin, and out again at the 
 diflance of two or three Inches, to be kept in 
 the manner of a Seton, 'till the Waters are 
 quite drained : But the two firft Methods 
 avail very little, as they open but k^ Cells 3 
 G 4 and 
 
Treatise of the 
 
 and the ]aft, cannot be fo efficacious in that 
 refpe^t as Jnciiions, and will be much more 
 apt to become troublefome, and even to gan- 
 
 grene. 
 
 . Indeed it is not often proper to perform any 
 
 Operation at all upon this Part, fince theiif^w- 
 
 brana Cellularis Scroti.^ being a Continuation 
 
 .of the Membrana Adipofa, Scarifications made 
 
 thro* the Skin in the Small of the Legs, will 
 
 eftedtually empty the Scrotum^ as I have many 
 
 times experienced ; and this Place ought ra-^ 
 
 ther to be pitched upcjn than the other, as being 
 
 more likely to anfwer the Purpofe by reafon 
 
 of its Dependency : However it fometimesi 
 
 happens that the Waters fall in fo great quan^ 
 
 r:titJes into the Scrotum, as by diftending it, to 
 
 . joccalion; great Pain, and threaten a Mortifica-- 
 
 tion : ,The Prepuce of the Peiiis alfo becomes 
 
 very often exceffiveiy dilated, and (o twifted, 
 
 that-the Patient cannot void his Urine.'' In 
 
 thefe two Inilances, I would propofe an Inci* 
 
 fion. of three Inches long to be made on each 
 
 Side of the Scrotum, quite thro' the Skin into 
 
 theGeils containing the Water, and two or 
 
 three, -.of half an Inch long, in any part of the 
 
 Penis, with a Lancet or Knife -, all which may 
 
 be done with great Safety, and fometimes with 
 
 the Succefs of .carrying, oft the Difeafe of the 
 
 whole 
 
operation of S u k g e k y, 
 
 Vjhdie Body.' This I can pofitively fay, that 
 tho' I have done it upon Perfons in a very lan- 
 gU^id Condition, yet by making the Wound with 
 a fharp Inftrument, and treating it afterw^ards 
 with Fomentations and fofr Digeftives, I have 
 rarely feen any Inftance of a Gangrene, which 
 is generally fo much apprehended in this Cafe. 
 The Dropfy of the 'Timica Vaginalis^ is ow- 
 ing to a preternatural Difcharge of that Water 
 which is continually feparating in a fmall quan- 
 tity, on the internal Surface of the Tunick, for 
 the moiflening or lubricating the Tefticle, and 
 which, colleding too fafl, heaps up, and forms 
 in time, a Swelling of great magnitude : This 
 is what I take to be the other Species of Hy- 
 drocele, and the only one belides -, tho' from 
 the time of Celfus, down to our own Days, the 
 Writers on this Subjed: make two kinds j one 
 on the Inlide of the Tunica Vaginalisy and an- 
 other between the Scrotum and Outlide of it s 
 and among the Caufes affigned for this Dif- 
 temper, the principal one is the Derivation of 
 Water from the Jffcites^ which Opinion, tho* 
 tmiverfally received, is abfurd in Anatomy : For 
 befides that People afflided with a Hydrocele^ 
 are very feldom otherwife dropHcal j and on 
 the contrary, thofe with an Afcites, have no 
 Jl^drocek'^ th^ Tu?iica Faginajis is like a Purfe 
 
 totally 
 
Treatise of the 
 
 totally ihut up on the Outfide of the Abdomen^ 
 fo that no, Water from any Part can infinuate 
 into it 5. and with refpecl to the Notion of Wa- 
 ter fallii)g from tlie Abdomen into the 7imica 
 Vaginalis and Scrotum, it is equally impofTiblei 
 for tho' in the Hertiia Intcjlinalh^ the Gut falls 
 into this Part, yet in that Cafe the Peritonaum 
 (which would hinder the Egrcfs of the Water) 
 falls down too, which the Ancients did not 
 know, and the Moderns have omitted to refled: 
 on in relation to this Subjed : It is true that 
 v/here.the A/cites is complicated with a Hernia 
 Zntefiirmlii ; or where there has been a previous 
 Jlexnia oi^th^ Scrotum, and the Sac of the 
 .Peri.tonfeum remains within the Scrotum, the 
 Water of the Afcites, in that cafe, may fall into 
 the /S^rof.the Peritonesum, and in that manner 
 form a . -Tumour of the 5(rr<?/?^;;^ 5 but this is 
 Rot Dpperly a Dropfy of the Twiica Vaginalis, 
 It muft be here.underftood, that when I fay 
 there is no Communication between the Ca- 
 .irity of the Abdomen, and the Cavity of the 
 'tunica Va^i7ialis, I fpeak of Adults ; for in 
 che E^tus^ and even in an infant State, there 
 is a Communication. 
 
 The Hydrocele of tht Tunica Vaginalis, is 
 very cp illy to be diftinguidied from the Hydro- 
 cele of the Menfvrana Cellularis, by the preced- 
 
operations of Sv k g e ry, 
 
 ing Defcription of that Species of Dropfy : I 
 {hail now explain how it diiFers from the other 
 Tumours of the Scrotum, viz the Bubonocele^ 
 Epiplocelcy and enlarged Tefticle : In the firft 
 Pia^e, it is feldom or never attended with Pain 
 in the Beginning, and is very rarely to be im- 
 puted to any Accident, as the Htr?iias of the 
 Omentum and Inteftine are : From the time it 
 firft makes its Appearance, it very feldom is 
 known to diiappear or diminish, but generally 
 condnues to increafe, tho' in fome much faller 
 than in others ; in one Perfon growing to a 
 very painful Diftenlion in a few Months, whilft 
 in an^'ther, it (hall not be troublefome in many- 
 Years ; nay, fhall ceafe to fwell at a certain 
 Period, and ever after condnue in that State 
 without any notable DifadvantagCi tho' this laft 
 Cafe very rarely happens : In proportion as it 
 enlarges it becomes moretenfe, and then is faid 
 to be tranfparent j indeed the Tranfparency is 
 jpaade the chief Criterion of the Diffemper, it 
 being conftantly advifed to hold a Candle on 
 one Side of the Scrotum^, which it is faid will 
 fhine thro' to the other, if there be Water : 
 But this Experiment does not always anfwer, 
 becaufe fometimes the Tunica Vaginalis is very 
 much thickened, and fometimes the Water 
 itfelf is not tranfparent : fo that to judge po- 
 
 fitively 
 
Treatise of the 
 
 fitively if there be a Fluid, we mufi: be guided 
 by feeling a Fludtuation ; and. tho' we do not 
 perhaps evidently perceive it, yet we may be 
 perfuaded there is a Fluid of fome kind, if we 
 are once affured, that the Diftenfion of the 
 tunica Vaginalis makes the Tumour, which is 
 to be diftinguillied in the following manner. 
 
 If the Inteftine, or Omentum^ fcrm the 
 Swelling, they will be foft and pliable, (unlefs 
 inflamed) uneven in their Surface, particularly 
 the Omentum^ and both of them extend them- 
 felves up from the Scrotum quite into the very 
 Abdomen ; whereas in the Hydrocele^ the Tu- 
 mour is tenfe and fmooth, and ceafes before, 
 ©r at its Arrival to the Rings of the abdominal 
 Mufcles ; becaufe the upper Extremity of the 
 Tunica Vaginalis terminates at fome Diftance 
 from the Surface of the Belly. 
 
 When the Tefticle is increafed in its Size, 
 the Tumour is rounder, and, if not attended 
 with an Enlargement of the fpermatic VefTels, 
 the Cord may be eafily diftinguiflied between- 
 the Sv/elling and Abdomen j but without this 
 Rule of Diftindtion, either the Pain or the very ^ 
 great Hardnefs, will difcover it to be a Difea4 • 
 of the Tefticle. .;.>rM/ii»ri> 
 
 ■ As to the Cure of this Diftem.per by external 
 Applications, or internal Means : after having 
 
 tried 
 
orations ^Surgery. 
 
 tried upon a great variety of Subjeds, tnoft of 
 the Medicines invented to that end, I have 
 found but very little Satisfadion in the Event ; 
 for if by chance, any one has mended under a 
 phyfical Regimen, it muft be confellcd too, that 
 there are fome Inftances of People recovering, 
 who have fo abfolutely negleded themfelves 
 as not even to wear a Bag-trufs ; on which ac^ 
 count, I Ihould judge it advifeable to wait with 
 Patience 'till the Tumour becomes troubk- 
 fome, and then to tap it with a Lancet or 
 Trocar. In opening with a Lancer,' it may pof- 
 fibly happen, the Oriiice of the Skin (liali flip 
 away from that of the Tunick, and prevent the 
 Egrefs of the Watery to obviate which Inconve- 
 niencey you may introduce a Probe, and by that 
 means fecure the exad: Situation of the-Woond; 
 but if the Coats are very much thickened, it 
 will be advifeable to ufe the Trocar, rather 
 than the Lancet. It is fpoke of as an eai)? thins", 
 to hold the Tefticle with the left Hand, whilfe 
 we^ make the Pundure with the Right, but 
 when the T^unica Vaginalis is very tenfe, it 
 cannot well be diflinguiflied \ however, I think 
 thereis no Danger of wounding it^ if you make 
 the Pundure in the inferior Part of the Scro- 
 turn. During the Evacuation, the Scrotum muil 
 be regularly -preiTed ; arid after the OperatioR> 
 
 a lirue 
 
4^ T R E A r I s E of tie 
 
 a little Piece of dry Lint and Sticking-plaiftef 
 are fufficient. 
 
 This Method of Tapping, is called ThepaU 
 liative Cure ; not but that it does now and then 
 prove an abfolute one. To prevent the Relapfe 
 of this Difeafe, Surgeons prefcribe the making 
 a large Wound, either by Incifion or Cauftic, 
 that upon healing it afterv^^ards, the Firmnefs 
 and Contradion of the Cicatrix may bind up 
 the relaxed lymphatic VefTels, and obftru(9: 
 the further preternatural EfFuiion of theif 
 Contents : But by what 1 have feen of this Prac- 
 tice, it is generally attended with fo much 
 Trouble, that notwithftanding its Succefs in 
 the end, I believe whoever reads the following 
 Cafes will be apt to difcard the Method, and 
 abide rather by the Palliative Cure, 
 
 CASE I. 
 
 A. B. aged 44. a flrong Man, never In his 
 Life having been fubjedl to any other Infirmity, 
 put himfelf under my Care for the Relief of a 
 Hydrocele on the left Side of the Scrotum. 
 
 December 3, 1733, I difcharged the Water, 
 by making an Incifion thro' the Teguments 
 about four Inches long. Towards Night he 
 grew feveriih, got no Reft, the Scrotum and 
 Tefticie on that Side, beginning to inflame, and 
 
 the 
 
operations of S v r g ^'"k y. 41 
 
 the capillary Arteries (dilating) to bleed freely. 
 He was feized too, with a violent Pairt in his 
 Back, which was in a great meafure removed 
 by fufpending the Scrotum with a Bag-.trufs. 
 
 From the 3d to the 7th, continued, in:a moil 
 dangerous Condition, when the Feven tended 
 to a Crifis, by the Suppuration of both Wound 
 and Tefticle. - 
 
 From the 7th to the 24th, he daily acquired 
 Strength; but the Difcharge from the Tefficle 
 increafing, and the Sinus penetrating now very 
 deep towards the Septum Scroti, I opened the 
 Body of the TefticJe, ;the whole Length of 
 the Abfcefs. ■ ^^ ' 
 
 From the 24th, the Difcharge Ic&Pied. fur- 
 priiingiy, fo that in fix Days, the Surface of 
 the greatefl part of the Teflicle united witfi 
 the Scrotu??2j and thei-e remained only a fuper- 
 ficial \¥ound, w^hich was entirely cicatrifed en 
 yen. 10, 1733-4. ; -, 
 
 ■'■r March 31,- 1737, he continued in^perfe^ 
 Health. 
 
 ■ C A S E IJ. 
 
 = !;Jh the Year 1733, I made an Inciiion thro^ 
 the . Scrotum and Tunica Vagi?2rJis of a Bay 
 
 about eight Years of Age, who narrowly efcaped 
 -with; his Life 5 but the fymptomatie Fever ter- 
 . . minating 
 
42 T VLE Ar I sE of the 
 
 minating at laft in an Abfcefs of the Scrotum^ 
 it proved his Cure, tho* with fome Trouble* 
 in a itv/ Weeks. 
 
 CASE III. 
 
 A. C. aged 37, of a very hale Habit of Body, 
 had complained of a Tumour on one Side of 
 the Scrotum J which continuing to enlarge for 
 fix Years, he applied to a Surgeon, who laid 
 a fmall Cauftic on the upper Part of it, and 
 opening the Efchar, emptied near three Pints 
 of Water j but he relapfing foon after this, I 
 undertook the abfolute Cure. 
 
 December i5> 1736, I laid, on the anterior 
 and upper Part of the Scrotum, a Cauftic about 
 fix Inchee long, and one broad. 
 
 December 16, by a fmall Pundure thro' the 
 Efchar, I emptied above a Quart of Water* 
 
 From the i7th to the 24th, he continued 
 in a great deal of Pain, not only in the Partj 
 but in his Back and Loins, and had very little 
 Reft ; the Scrotum on that Side, became ex- 
 ceedingly inflamed and thickened, the fymp- 
 tomatic Fever running very high, without any 
 Signs of the Digeftion of the Wound. 
 
 On the 24th at Night he grew a little 
 eafier, and continued fo'till the 29th, when the 
 Slough feparated ; but the Wound retained ftill 
 a bad Afped:, no Granulations appearing on its 
 Surface. Fronm 
 
er at tons '^Surgery. 43- 
 
 MtQ>Vii Dccemb.-^2^^ iQ^Jm. 5, he Ji^emaincd ^ 
 
 From the 5th to the 13th, the Swelling and' 
 Fain rather increafed,'and that Night he was 
 feized fvith an Ague-fit^ which returned , every 
 other Day twice more. 
 
 From the 17th to the 26th, the Ague being 
 ftopt, he began to alter much for the better, 
 two Impofthumations on the Scrotum being in 
 this Interim opened. 
 
 By Feb. 2, the Pain was quite gone,^ the 
 Tumour very much. funk, and the Induration 
 foftened. , <,..,* 
 
 In a very few Days after, the Wound cica- 
 trifedj and on iv/^. 24, I left him, in perfed; 
 Health, and free from. any Complaint, . 
 
 Having in the preceding Cafes been feera- 
 ingly threatened with the Death of the Patients, 
 I tried the following Experiment, upon the 
 Reputation of its having been done with Sue- 
 cefs by others, 
 
 CASE IV. 
 
 A. T). aged Forty-tv/o, had for near four 
 Years been troubled with. a 'Hydrocele on one 
 Side, for which I had tapped him about twelve 
 times, taking away near a Pint of clear Wa« 
 ter^eacb Operation. 
 
 -i^cii I^ 'Jan. .'^ 
 
44 T R E A T I S E (J/* //5^ 
 
 'jan. 3, i73^'7> ^^^^5: having emptied the 
 'T'lmica Vaginalis^ I injcd:ed an Ounce of Spirit 
 of Wine j in the Inflant, he complained of 
 oreat Pain, which continued to increafe, and 
 the next Day, the Teguments were very much 
 augmented in their Bulk and Thicknefs. 
 
 jjH. 7, The Tenfion became violently pain- 
 ful, and perceiving a Fiuduation, I made a 
 Pundure, by which he voided about half a Pint 
 of Water, very deeply tinged with Blood, but 
 - without any Flavour of the Spirits to be diftin- 
 guiflied by the Smell : This gave him fome 
 Eafe, but the Inflammation and Thicknefs con- 
 tinued a whole Month, and then terminated in 
 two Abfcefies on the Fore-part of the Sa'otumj 
 which I opened the 7th of Febriiai-y following, 
 and on their Difcharge, the whole Tumour , 
 fubiided, leaving a firm Cicatrix and abfolute 
 Cure of that Difordcr. , 
 
 Something fimilar to the Circumftance of 
 A. D's bloody Water, is the Cafe of another 
 Perfoh who was under my Care : He had at 
 confiderable Intervals of time been often tap- 
 ped, difcharglng that fort of ferous Water the 
 T^unica Vaginalis for the moft part yields 5 at 
 laft, it became tinged vvith Blood, and every 
 time grev/ more bloody than the other : The 
 fourth Difcharge of this kind, was attended 
 
 with 
 
'derations ^/'Surgery. 45 
 
 with a remarkable Hemorrhage, and termi- 
 nated in an abfolute Cure 5 no Signs of a Re- 
 lapfe appearing fome Months after, as I had 
 an Opportunity to inform myfelf. 
 
 To the Cafes above recited, I could add ftill 
 more that have fallen within my Knov/ledge, 
 lince the time I made tliefe Obfervations ; par- 
 ticularly tvi^o, attended with Inflammation and 
 Abfcefs, from the mere Pundure of the Lan- 
 cet I both of which terminated in an abfolute 
 Cure. It may be remarked however of thefe 
 two, that one was attended with a thickened 
 Tunick, and the Water bloody 3 and in the 
 other, the Coat was thickened, and the Epi- 
 didymis enlarged and indurated from a former 
 Gonorrhoea. 
 
 I would not however be underftood from 
 this Catalogue of Misfortunes, that the Opera- 
 tion is never performed without much Trouble 3 
 fome Examples I have known in its favour, 
 but by no means enough to warrant the Re- 
 commendation of it, unlefs to fuch Patients 
 who are inconfolable under the Diftemper, 
 and are willing to fuftain any thing for a Cure. 
 
 It is v/orth obferving, that upon examination 
 
 of the feveral Hydroceles^ it appeared evidently/ 
 
 their Cure was wrought by an univerfal Ad- 
 
 helion of the Tefticle to the tunica Vaginalis, 
 
 H 2 and 
 
4^ T R E A T I S E ^ //3^ 
 
 and again of that Coat to the Parts enveloping 
 it ', from which Obfervation it wiJl not be 
 difficult to conceive how it happens, that Dif- 
 charges of bloody Water work a Cure ; fince 
 Inflammations of Membranes almoft perpetu- 
 ally produce Adhelions of the neighbouring 
 Parts, and thefe Difcharges are no other than 
 a Mixture of Blood with the Water from the 
 ruptured VefTelsof the inflamed Tunick. 
 
 It has been fuggefted, that probably the 
 expofing the Tunica Vaginalis to the Air, mighi 
 occaflon the abovementioned Diforders i but 
 befides that the Cafe of the injeded Sp. Vin, the 
 Cafe of the Caudic, and the two Pundures, are 
 fufficient Anfwers to that Opinion, the Inftances 
 I have fecn of the whole Scrotum feparating in 
 a Gangrene from the Tunica Vaginalis, and 
 leaving it naked a great many Days without 
 any ill Effect, put it out of Difpute, that 'tis 
 the mere Inflammation of the Tunick produces 
 the Danger. I have caftrated feveral Men, 
 whofe fcirrhous Tefticles were accompanied 
 with 2.T-Iydrcce!e^ but the whole Tunica Vagi- 
 nalis being carried oft by the Operation, they 
 all recovered without any bad Symptoms. I 
 have here propofed an Inciflon only thro' the 
 Tunica Va<;inalis, as the Means to effcd; a 
 radical Cure j but it has been faid, that to cut 
 
 oflf 
 
Operatic72s ^Surgery. 47 
 
 off a large Portion of it, is a more effeaual 
 and a lefs dangerous Operation j this Fad 1 have 
 lately taken under Confideration, but have not 
 yet had fufficient Experience to form a pofi- 
 tive Opinion on the Subjea:. 
 
 I fhall finfli this Chapter with a further 
 Remark on the fuppofed Variety of Hydroceles. 
 Befides the imaginary one already Specified 
 betu^een the Scrotum and inferior Membranes, 
 there is mention made of a Species of Drojrfy 
 between the Cremajler Mujcle and Timica Va- 
 ginalis : But I judge it more likely to be within- 
 fide the Timica Vaginalis of the Cord, which 
 adhering in different Places to the fpermatic 
 VefTels, may form a Cyft or two between the 
 Adhefions, of which an Inftance has fallen 
 under my own Examination. Indeed if we 
 reiiea: on the Caufe of a Dropfy of this Part, 
 we muft necelTarily confine it to the Infide of 
 the Membrane, where only is that Order of 
 Veffels which are the Subjed of the Difeafe. 
 The Dropfy of the Teftis itfelf, is the lafl 
 fuppofed Species, but it is what I have never 
 feen j and from the Analogy of the Tejiisy to 
 the Strudure of other Glands, that are not 
 pretended to become Dropfical, I am fufpici- 
 ous there is no fuch Diftemper. 
 
 113 , C H A P. 
 
4^ T R E A T I S E 2/^ //5^ 
 
 CHAP. X. 
 
 Of Castration. 
 
 ^Y^HIS is one of the moft melancholy Ope- 
 rations in the Pradice of Surgery, fince it 
 feldom takes place but in Diforders into which 
 the Patient is very apt to relapfe, 'viz, thiofe of 
 a Schirrous, or Cancer -, for under moil of the 
 Symptoms defcribed as rendering it neceffar}?-, 
 it is abfolutely improper j fuch as a Hydrocele^ 
 Abfcefs of the T^ejiisy an increafing Mortifica- 
 tion, or what is fometimes underftood by a Sar^ 
 cocele ', of which laft it may not be ami(s to fay 
 a Word. In the utmofl: Latitude of the Meaning 
 of this Term, 'tis received as a fleiliy Swelling 
 of the Tefticle itfelf, called likewife Hernia 
 Carnofa ; or in fome Enlargements, fuch as in 
 a Clap, more frequently Hernia Humor-alis ; but 
 generally Ipeaking, is coniidered as a flefhy 
 Excrefcence formed on the Body of the Tejiisy 
 which becominp- exceedins; hard and tumefied, 
 for the moft part is fuppofed to demand Ex- 
 tirpation, either by cutting or burning away 
 the Induration, or amputating the Tefticle : 
 But this Maxim too precipitately received, 
 has, I apprehend, very much [mifguided the 
 Practitioners of Surgery, 
 
 In 
 
operations (^/^Surgery. 49 
 
 In order to conceive better of the Diftindlon 
 I am going to make, it muf!: be remembered, 
 that what is called the Tefticlc, is really com- 
 pofed of two different Parts ; one Glandular, 
 which is the Body of the T^ejiis \x.{€ii'y and one 
 Vafcular or Membranous, known by the name 
 of Epididymis^ v/hich is the Beginning pf the 
 Vas Deferens^ or the CoUedion of the excre- 
 tory Dudts of the Ghmd. 
 
 Now it fometimes happens that this Part is 
 tumefied, independent of the Teflicle 3 and 
 feeling like a large adventitious Excrefcence, 
 anfwers very well to the Idea mod Surgeons 
 form of a Sarcocele j bat not being aware of 
 the different Nature and Texture of the Epi- 
 didymisj they have frequently confounded its 
 Diforders with thofe of the Teflicle itfelf, 
 and equally recommended Extirpation in the 
 Induration of one or the other. But without 
 tiring the Reader with particular- Hiftories of 
 Cafes relating to this Subjecft, I fhali only fay, 
 That from diligent Enquiry I have colle<3:edj 
 that all Indurations of the glandular Part of the 
 Tefticle not tending to Inflammation and 
 Abfcefs, generally, if not always, lead on toScir- 
 rhus and Cancer j v/hereas thcfe of the Epi- 
 didymis feldom or never do. It is true, in fpite 
 of internal or external Means, thefe lafl often 
 PI 4 retain 
 
£0 , T R E A T I S E i?/" //6^ 
 
 retain their Hardnefs, and fomefimes fuppu- 
 rate, but hov/ever without much Danger in 
 either Cafe. 
 
 It will not be hard to account for this 
 Difference of Confequences, from Tumours 
 of feemingly one and the fame Body, when 
 we refiedt how much it is the Nature of can- 
 cerous Poifons to fix upon Glands, and how 
 different the Epididymis is from a Gland, tho' 
 fo nearly in the Neighbourhood of one. 
 
 I would not have it fuppofed from what I 
 have faid, that the Epididymis never becomes 
 cancerous ; I confefs it may, fo may every Part 
 of the human Body : But I advance that it 
 rarely or never is fo, but from an Affe6lion of 
 the glandular Part of the Teftic!e firft, which 
 indeed feldom fails to taint, and by degrees 
 to confound it in fuch a manner, as to make 
 one Mafs of the two. 
 
 Before we caftrate, it is laid down as a Rule 
 to inquire whether the Patient has any Pain in 
 bis Back, and in that cafe to reject the Opera- 
 tion, upon the reafonable Prefumption of the 
 fpermatic VefTels being likewife difeafed ; but 
 we are not to be too hafty in this Determina- 
 tion ; for the mere weight of the Tumour 
 ftretchine the Cord, will fometimes create the 
 Complaint. To learn the Caufe then of this 
 
 Pain 
 
Operatkns ^Surgery. 151 
 
 Pain in the Back, when the fpermatic Cord is 
 not thickened, let your Patient be kept in iBed, 
 and fufpend his Scrotum in a Bag-trufs, which 
 will relieve him, if difordered by the Weight 
 only 3 but if the fpermatic Cord is thickened or 
 indurated, which Difeafe, when attended with 
 a Dilatation of the VeiTcls of the Scrotum^ is 
 known by the G7'eek Appellations Circocele and 
 Varicocele, the Cafe is defperate and not to be 
 undertaken. 
 
 But fuppofing no Obftacle in the way to the 
 Operation, the Method of doing it may be this : 
 Lay your Patient on a fquare Table of about 
 three Foot four Inches high, letting his Legs 
 hang down, which, as v/eil as the reft of his 
 Body, muft be held firm by the Affiftants. 
 Then with a Knife, begin your Wound above 
 the Rings of the Abdominal Mufcles, that you 
 may have Room afterwards to tie the VelTels, 
 lince for want of this Caution, Operators will 
 neceifarily be puzzled in making the Ligature : 
 then carrying it thro' the Membrana Adipofay 
 it muft be continued downward, the Length of 
 it to be in proportion to the Size of the Tefticle. 
 If it is very fmall, it may be diffeded away 
 without taking any part oi %S\^ Scrotum \ but 
 I am not very fond of this Method, becaufe 
 fo much loofe flabby Skin is apt to form Ab- 
 
 fceffos 
 
152 Treatise^ //5^ 
 
 fcefTes afterwards, and very frequently grow 
 callous. If the Tefticle, for Inflance, weighs 
 twenty Ounces j having made one Jncilion 
 about five Inches long, a little circularly, begin 
 a fecond in the fame Point as the firft, bringing 
 it with sn oppoiite Sweep, to meet the other in 
 the inferior Part, in fuch a manner as to cut 
 out the Shape of an Oval, whofe fmalleft Di- 
 ameter fhall be two Inches : After this, difled: 
 away the Body of the Tumour with the Piece 
 of Skin on it, from the Scrotum^ firft taking up 
 Ibme of the Blood-veffels, if the Haemorrhage 
 is dangerous. Then pafs a Ligature round the 
 Cord, pretty near the AbdomeUi and if you have 
 Space between the Ligature and Tefticle, a 
 fecond about half an Inch lower, to make the 
 Stoppage of Blood ftill more fecure. The 
 Ligatures may be tied with what is called the 
 Surgeofi's Knot^ where the Thread is pafTed 
 ' thro' the Ring twice. This done, cut off the 
 Teflicle a little underneath the feCond Liga- 
 ture, and pafs a Needle from the Skin at the 
 lower Part of the Wound thro' the Skin at the 
 upper Part, in fuch manner as to envelope in 
 fome degree the found Teflicle, which will 
 greatly facilitate and quicken the Cure 5 or if 
 one Stitch will not anfwer the Purpofc; you 
 
 may 
 
operations ^Surgery. 
 
 may repeat it in fuch Part of the Wound, 
 where the Skin on each Side lies mofl: loote. ■ 
 
 The Method I have here dcfcribed is what 
 I have mod frequendy pradiifed 3 but i think I 
 have of late years performed the Operation 
 with more Dexterity, where I have divided the 
 Tefiicle from the Cord, before I had differed 
 away the Skin from the Body of the Tefticle ; 
 for having had by this means an Opportunity of 
 laying hold of its upper Part, I could feparate 
 it from the Scrotum with much more Eafe, 
 than without that Advantage : 
 
 I once cailrated a Man whofe Tefiicle 
 vi^eighed above three Pounds, where fome of 
 the VefTels were fo exceedingly varicous and 
 dilated, as nearly to equal the lize of the Hume- 
 ral Artery; however, I took up two or three 
 of the moft confiderable, and purfued the 
 Operation, cutting away near three fourths of 
 the Skin, by which means I avoided a dan- 
 gerous Effufjcn, as by dividing the VefTels 
 before they were much ramefied, I had fewer 
 Ligatures to make : The Succefs anfwered the 
 Defign, and the Patient furvived the Operation 
 and healing of the Wound ; but the cancerous 
 Humour falling on his Liver fome time after, 
 deflroyed him. In large. Tumours, fuch as the 
 laft I have mentioned, it is very much to be 
 
 advifed 
 
54 T R E A T J S E ^ //5^ 
 
 advlfed to cut away great part of the Skin ; for 
 befides that the H^Emorrhage will be much lefs 
 inthisCale, and the Operation greatly fhorl 
 tened j the Skin by the great Diftenfion having 
 been rendered very thin, will great part of it, if 
 not taken away, fphacelate, and the reft be more 
 prone to degenerate into a cancerous Uicer. 
 ^ It may be obferved, I do not in order to 
 avoid wounding the Spermatic VefTels, recom- 
 mend pinching up the Skin before the Incifion, 
 and afterwards thrufting the Fingers between 
 the Membrana Cellularis and the Tefticle, to 
 tear the one from the other ; the iirft is 'not 
 dextrous 5 and the other is painful ; and both 
 of them, in my opinion, are calculated to 
 prevent what there is little or no danger of. 
 
 CHAP. XI. 
 
 Of the V YiY M o z 1%, 
 
 f^ HE Phymofts fignifies no more than fuch 
 a Straitnefs of the Prepuce, that the 
 Clans cannot be denuded 5 which if it be- 
 comes troublefome fo as to prevent the Egrefs 
 of the Urine, or conceal under it Chancres, or 
 foul Ulcers, quite out of the Reach of Applica- 
 tion, is to be cut open. It fometimes happens, 
 that Children are born imperforate, in which 
 
 Cafe, 
 
operations ^Surgery. 55 
 
 Cafe, a fmall Pundure, dreffed afterwards with 
 a Tent, effeds a Cure : But this Operation is 
 chiefly praftifed in venereal Cafes, in order to 
 expofe Chancres, either on the Glans or within- 
 fide the Prepuce itfelf : And hpre, if the Prepuce 
 is not very callous and thick, a mere Incifion 
 will anfwer 5 which may be made either with 
 the ScifTars, or by flipping -a Knife between the 
 Skin and Glans to the very Extremity, and 
 cutting it up : The lafl; Method is more eafy 
 than that of the Sciilars, but it is fafer to make 
 the Wound on one Side the Prepuce than upon 
 the upper Fart, for I have fometimes feen the 
 great VeflTels on the Dorfum Penis afl:ord a ter- 
 rible Haemorrhage, which may be avoided by 
 following this Rule j tho' the Prepuce remains 
 better fhaped after an Inciflon made in the 
 upper Part, and therefore is to be preferred by 
 thofe who underfl:and hov7 to take up the Vef- 
 fels. In Children it fometimes happens that 
 the Prepuce becomes very much contraded 5 
 and in that Cafe, it is accidentally fubjed: to 
 flight Inflammations., which bring on fome 
 Symptoms of the Stone 3 but the Diforder is 
 always removed by the Cure of the Vhymojis. 
 
 If the Prepuce is very large and indurated, 
 the Opening alone will not fuffice, and it is 
 more advifeable to take away the Calloflty by 
 
 Circum- 
 
r6 Treatise^ the 
 
 CIrcumciiion, which muft be performed vvltli 
 a Knile j and if the Artery bleeds much, it 
 mull be taken up with a fmall Needle and 
 Ligature : It may be worth remarking here, 
 that in fome Fhymofes^ the Prepuce becomes fo 
 thickened, and at the fame time io elongated, 
 -that it refembles the Body of the Vents, and 
 has led fome into, the Miftake of fuppofing 
 they had cut off a Portion of the Ferns itfelf, 
 when it was only a monifrous Phy?nofis. 
 
 CHAT. XII. 
 
 Of the P A R A P H Y M O S I S. 
 
 ^"T^ H E Paraphymofis is a Difeafe of the 
 Penis, where the Prepuce is fallen back 
 from the Glans, and cannot be brought for- 
 wards to cover it : There are a great many, 
 w^hofe Pern's is naturally thus formed, but 
 without any Inconvenience 3 fo that fince the 
 time of the Romans (fome of whom thought it 
 indecent to have the Glans bare) it has not been 
 ufaal, as I can find, to perform any Operation 
 upon that Account 3 but we read the feveral 
 ProceiTes of it defcribed very particularly by 
 Celfiis, who does not fpeak of it as an uncom- 
 mon thing. Moft of the Inftances of this Dif- 
 temper, are owing to a venereal Caufe 5 but 
 
 there 
 
Operati07is (jTSurgery. 57 
 
 there are fome, where the Prepuce is naturally 
 very tight, which take their rife from a fudden 
 Retradion of it, and immediate Inlargement of 
 the Glans preventing its Return. Sometimes it 
 happens the Surgeon fucceeds in theRedudion 
 immediately, by compreffing the Extremity of 
 the 'Penis, at the time he is endeavouring to 
 advance the Prepuce ; if he does not, let him 
 keep it fufpended, and attempt again, after 
 having fomented, and ufed fome emollient 
 Applications : But if from the Gontradtion 
 below the Corona Glandis, there is fo great a 
 Stridure as to threaten a Gangrene, or even, 
 if the Penis is much inlarged by Water in the 
 Membrana Reticularis, forming Tumours, 
 called CryJiallineSy three or four fmall Incilions 
 muft be made with the point of a Lancet, into 
 the Stridure and Cryfiallines, according to the 
 Diredion of the Penis itfelf^ which in the firfl 
 Cafe will fet free the Obftrudion, and in the 
 other evacuate the Water : The manner of 
 dreffing afterwards muft be with Fomenta- 
 tions, Digeftives, and the Theriaca Londinenfis 
 over the Pledgits. 
 
 CHAP. 
 
58 Treatise of -the 
 
 CHAP. XIII. 
 
 Of the Paracentesis. 
 
 ^~V^ HIS Operation is an Opening made 
 
 "^ into the Abdomen^ in order to empty any 
 Quantity of extravafated Water, colle<:"led in 
 that Species of Dropfy called the Ajcites \ but 
 as there is much more Difficulty in learning 
 when to perform than how to perform it, and 
 indeed in fome Inftances requires the niceft 
 Judgment 5 I Ihall endeavour to fpecify the 
 Diilindfions which render the Undertaking 
 more or lefs proper. 
 
 There are but two kinds of Dropfy ; the 
 Anafarca^ called 2\(o Leucopblegmacy, when the 
 extravafated Water fwims in the Cells of the 
 Memhrana Adipofa 3 and the A/cites, when the 
 Water pofleiTes the Cavity of the Abdomen : In 
 the firft kind, the Water is clear and limpid, 
 but in the fecond, a little groffer, very often 
 gelatinous and corrupted, and fomctimes even 
 mixed with flefliy Concretions. I do not 
 mention the T^ympcmy or flatulent Dropfy of the 
 Abdomen j nor have I in the Chapter oi Hernias 
 fpoke of the Hernia VeJitofa^ it being certain 
 that the Afcites and Bubonocele^ have generally 
 been miflaken for thofe Difeafes j tho' there 
 
 are 
 
)erations f?/' S u r g e r y. J59 
 
 are fome few Inftances where an enormous 
 Tumour of the Abdomen^ arifes from exceffive 
 Flatulencies, and Diftenfions of the Inteftines. 
 
 It is of no great Confequence in the Pradice 
 of Phyfick or Surgery, whether the Vv^ater is 
 difcharged by a Rupture of the Lymphaticks, 
 or a Tranfudation thro' the Pores of their re- 
 laxed Coats, lince the Fadt is eftabliihed, that 
 they have a Power fometimes of abforbing the 
 Fluid, lying thus loofe, and conveying it into 
 the Courfe of the Circulation j after which, it is 
 often totally carried oiF, by fome Emunilory of 
 the Body. The great Difpofition there is in Na- 
 ture, to fix upon the Kidneys and Gknds of the 
 Inteftines for this End, has put Phylicians upon 
 promoting it by Catharticks and Diureticks, 
 which fometimes entirely carry off the Diitem- 
 per. If any one (hould doubt of the poffibility 
 of a Cure when the Water is extravafated, let 
 him injed: through a fmall Opening into the 
 Thorax or Abdomen of a Dog, a Pint of warm 
 Water, and upon Difledion fome few Hours 
 after, he fhall not find one Drop left there ; . 
 which puts out of Difpute this power of Ab- 
 forption : But indeed, tho' we do not much 
 attend to it, 'tis by this very Adt, the Circulation 
 is carried on regularly, with refped: to fome, 
 if not all the Secretions, which would overload 
 
 I their 
 
66- Treatise of the 
 
 their Pveccpt-acles, if they were not thus taken 
 up again. The Example lerving for Illuflra- 
 tion, may be the Circulation of the aqueous 
 Humour of the Eye, which no one queflions, 
 is an extravafated Fluid. 
 
 The Operation of Tapping, is feldom the 
 Cure of the Dilliemper ; but Dropfies, which 
 are the Confequence of a mere Impoverifliment 
 of the Blood, arelefs likely to return than thofe 
 which are owing to any previous Diforder of 
 the Liver j and it is not uncommon for Drop- 
 fies that follow Agues, Haemorrhages and 
 Diarrhoeas, to do well ; whereas in fuch as 
 are complicated wrth a fcirrhous Liver, there 
 is hardly an Example of a Cure. 
 
 The Water floating in the Belly, is by Its 
 Fludfuation to determine, whether the Opera- 
 tion is advifeable -, for if by laying one Hand on 
 any Part of the Abdome?j, you cannot feel an 
 Undulation from firiking on an oppofite Part, 
 with the other, it is to be prefumed there will 
 be fome Obftacle to the Evacuation. It fome- 
 times happens, that a great Quantity, or almoffc 
 all the Water, is contained in little Bladders, 
 ariherinp- to the Liver and the Surface of the 
 Peritona-um, known by the Name of Hydatids^ 
 and the reft of it in different fized ones, from 
 ihe degree oisiHydatidj to the Size of a Globe 
 
 holding 
 
operations ^Surgery. 6x 
 
 holding half a Pint, or a Pint of Water. This 
 is called the Encyfted Dropfy, and from tha 
 Smallnefs of its Cyfls, makes the Operation 
 ufelefs^ but is not dithcult to be diftinguiflied, 
 becaufe there is not a Fluctuation of the Water, 
 unlefs it is complicated with an Extravafation. 
 
 When the Fluctuation is hardly perceptible, 
 (except the Teguments of the Abdomen are very 
 much thickened by an Anajarca) in all pro- 
 bability, the Fluid is gelatinous : 1 have had 
 Inftances, v/here it was too-vifcid to pafs thro' 
 a common Trocar ; on which account it is 
 proper to be furnilhed with a couple, of the 
 Size defcribed in the Copper-plate. I once 
 tapped a Perfon when the Fluid would not 
 pafs even thro' the large one 3 fo to eafe him 
 from the Difteniion he laboured under, I dilated 
 the Orifice with a large Sponge-tent, and after- 
 terwards extra<fted a prodigious Quantity of 
 diftindl concreted J?)'^<:2//^J, differing in nothing, 
 as I could difcover, from the nature of a Foly^ 
 ^z^^ formed in the Nofe. 
 
 There is another kind of Dropfy, which 
 for the mofl part forbids the Operation, and is 
 peculiar to Women, being feated in the Body 
 of one or both Ovaries. There is, 1 believe, 
 no Example of this Species but what may be 
 known by the Hardnefs and Irregularity of the 
 I 2 Tu- 
 
62 Treatise*?/' the 
 
 Tumour of the Ahdomen^ which is nearly 
 uniform in the other Cafes. 
 
 When the Ovary is Dropfical, the Water is 
 generally depofited in a great number of Cells 
 formed in the Body of it, which Circumftance 
 makes the Fluctuation infenfibie, and the Per- 
 foration ufelefs J tho' fometimes there are only 
 one or two Cells, in which cafe, if the Ovary 
 is greatly magnified, the Undulation will be 
 readily felt, and the Operation be advifeable. 
 I once tapped a Gentlewoman in this Circum- 
 ftance, whole Ovary upon the Pundlure yielded 
 but half a Pint of Water, but being ftill per- 
 fuaded by the Feel, there was a large Cyfl, I 
 tapped her in another Part, and drew away 
 near a Gallon : I had an Opportunity after her 
 Death, to be convinced of this Faft, by ex* 
 amining the Body. 
 
 When the jifcifes and Aiiajarca are com- 
 plicated, it is feldom proper to perform the 
 Operation, fince the Water may be much 
 more efFedually evacuated by Scarifications 
 in the Legs, than by Tapping. 
 
 Upon the Suppofition nothing forbids the 
 F.xtradion of the Water, the Manner of Ope- 
 rating is this : Having placed the Patient in a 
 Chair of a convenient Height, let him join his 
 Hands fo as to prefs upon his Stomach ; then 
 
 dipping 
 
operations (jf S u R g e r y. 63 
 
 dipping the Trocar in Oil, you ftabit fuddenly 
 through the Teguments, and withdrawing the 
 Perforator, leave the Waters to empty by the 
 Canula : the Abdomen being, when filled, in the 
 circumftance of a Bladder diftended with a 
 Fluid, would make it indifferent where to 
 wound ; but the Apprehenlion of hurting the 
 Liver, if it happens to be much enlarged, has 
 induced Operators rather to choofe the left fide, 
 and generally in that Part, which is about three 
 Inches obliquely below the Navel : If the Navel 
 protuberates, you may make a fmall Pundure 
 with a Lancet, through the Skin, and the Waters 
 will be readily voided by that Orifice, without 
 any danger of a Hernia fucceeding, as is ap- 
 prehended by many Writers 5 though it fhould 
 be carefully attended to, whether the Protube- 
 rance is formed by the Water or an Exomphahs, 
 in which latter Cafe the Inteftine would be 
 wounded, and not without the greateft danger. 
 The Surgeon neither in opening with the Lan- 
 cet, nor perforating with the Trocar, need fear 
 injuring the Inteflines, unlefs there is but little 
 Water in the Abdomen^ fince they are too much 
 confined by the Mefentery, to come within 
 reach of Danger from thefe Inftruments ; but 
 it fometimes happens, that when the Water is 
 almofl all emptied, it is fuddenly flopped by 
 I 3 the 
 
64. T R E A r I s E of the 
 
 the Inteftine or Omentum preffing againfl the 
 end of the Canula j in which cafe you may 
 pu ill them away with a Probe: During tlie 
 Evacuation, your AHiftants mufl keep prefling 
 on each fide of the Abdomtm^ with a Force equal 
 to that of the Waters before contained there ; 
 for by negleding this Rule, the Patient will be 
 apt to fall^nto Faintings, from the Weight on 
 the great VefTels of the Abdomen being taken off, 
 and the linking of the Diaphragm fucceeding; 
 in confequence of which, more Blood flowing 
 into the inferior VeiTels than ufual, leaves the 
 fuperior ones of a fudden too empty, and thus 
 interrupts the regular Progrefs of the Circula- 
 tion. To obviate this Inconvenience, the Com- 
 preffion muft not only be made with the Hands 
 during the Operation, but be afterwards con- 
 tinued, by fwathing the Abdomen with a 'Roller 
 of Flannel, about eight Yards long, and five 
 Inches broad, beginning at the bottom of the 
 Belly, fo that the Inteftines may be bore up 
 againfl the Diaphragm : You may change the 
 PvoUer every Day, 'till the third or fourth Day, 
 by which time, the feveral Parts will have ac- 
 quired their due Tone. For the Dreffing, a piece 
 of dry Lint and Plaifcer fuffice ; but between 
 the Skin and Roller it may be proper to lay a 
 double Flannel a Foot fquare, dipt in Brandy 
 or Spirits oi ¥/ine, This 
 
Pa^.f^. 
 
 Fhti.i. 
 
 L. 
 
 
operations (j/' S u r g E R y. 65 
 
 This Operation, though it does not. often 
 ahfolutelycure, yet it fometimes preferves Life 
 a great many Years, and even a pleafant one, 
 eipecially if the Waters have been long colledl- 
 ing. I have known feveral Inftances of People, 
 being tapped once a Month, for many Years, 
 who felt no Diforder in the Intervals, 'till to- 
 wards the time of the Operationj when the Dif- 
 tenfion grew painful ; and there are Inftances, 
 where the Patient has not relapfed after it. Upon 
 the whole, there is fo little Pain or Danger in 
 the Operation, that in coniideration of the great 
 Benefits fometimes received from it, I cannot 
 but recommend it as exceedingly ufeful. 
 
 PLATE m. 
 
 I'he Explanation. 
 
 ji. A Trocar of the moft convenient fize for 
 emptying the Abdomen^ when the Water is 
 not gelatinous. It is here reprefented with the 
 Perforator in the Canula, jufl as it is placed 
 when we perform the Operation. 
 
 £.. The Canula of a large Trocar, which I 
 have recommended in Cafes where the Water 
 is gelatinous. 
 
 C. The Perforator of the large Trocar. 
 
 The Handle of the Trocar, is generally made 
 
 of Wood, the Canula of Silver, and the Per- 
 
 I 4 forator 
 
Treatise of the 
 
 forator of Steel j great care iliould be taken by 
 tlie M^j^p^r^j of this Inflrument, that the Perfgfy 
 rator rtipuld exadly fill up the Cavity of the Car^,, 
 nula J for iinlefs the Extremity of the Canula lies' 
 quite clofe and fmooth on the Peforator, the 
 I nti'od nation of it into the Abdomen^ will be 
 very painM "- To make it flip in more eafily, the 
 Edge of the Extremity of the Canula fliould be 
 thin and /harp 5 and I would recommend, that 
 the Canula be Steel, for the Silver one being of 
 too foft a Metal, bccomesjagged or bruifed at 
 its Extremity with very little ufe. After the 
 Operation, the Canula muft be wiped GleaEi^nd - 
 dry,, Ijy drawing a Slip or two of Flamie;]- tj^a 
 iti ptherv^^ife, when the Perforator is put; ifitp., 
 it,; tli^^ ^Will bodi grow rul'ty. 
 
 ■^'"■"'^;c H A.p.;, XIV. t^;^';^ 
 
 Of the Fistula in And. 
 
 ^r^ H E Fijlula in Ano^ without any regard 
 to the (lrid.1 Definition of the Word, is 
 generally underilood to be an Abfcefs, running 
 upon, or into the Intejiinum Return -j though 
 an Abfcefs in this Part, when once ruptured, 
 does generally, if negleded, grow callous in 
 its Cavity and Edges, and become at laii,' 
 what is properly called a Fifnila, 
 
 That 
 
operations <//' S u r g e r y. 67 
 
 ':irfVM tiie; Af« is To "often expofed ' to this 
 Malady, in any Crifis of the Conftltution, is 
 chiciBy-afcribed to the depending Situation of 
 the Part; but v/hat very much conduce to it 
 likevvife, * are the great quantities of Fat fur- 
 rounding the ReBian, and the PrefTure the 
 Hssmorrhoidal Veffels are liable to, which being 
 fuftained upon very loofe Membranes, will be 
 lefs able to refift any Effort, that Nature fliail 
 exert, to fling off a Surcharge ; and from one 
 Step to another, that is, from Inflammation to 
 Suppuration, lead on to the Diftemper we are 
 treating of. That the Fat is the proper Subjedt 
 of AbfcefTes, may be learned from an Inflam- 
 mation of the Skin affediog the Menibrana 
 Adipoja^ and producing Matter there 3 in which 
 Cafe, a Suppuration frequently runs from Cell 
 to Cell, and in a few days, lays bare a great 
 quantity of Flefh underneath, without affec- 
 ting the Flefh itfelf : Nay, I think it may be 
 doubted, whether in thofe AbfcefTes which arc' 
 efleemed Suppurations of the Mufcles, the In- 
 flammation and Matter are not abfolutely ■ firf^ ' 
 formed in this Membrane, where it is iniinu- 
 sted between the Interflices of their Fibres. 
 
 The Piles j which are little Tumours formed ' 
 about the Verge of the Anm^ immediately 
 within the Membrarm intenia of the ReBufn^ 
 
 do 
 
68 T R E A T I S E (t/ //5/? 
 
 do fomctimes fuppurate> and become die Fore- 
 runners of a large Abfcefsj alfo external Inju- 
 ries here, as in every other part of the Body, 
 may produce it ; but from whatever Caufe the 
 Abfcefs arifes, the manner of operating upon 
 it, will be according to the Nature and Direc- 
 tion of its Cavity. 
 
 If the Surgeon has the fir ft Management of 
 the Abfcefs, and there appears an external In- 
 flammation upon one fide of the Buttock only ; 
 after having waited for the proper Maturity, let 
 him with a Knife make an Incifion the whole 
 length of it, and in all probability, even though 
 the Bladder be affeftedj the Largenefs of the 
 Wound, and the proper Application of Doffils 
 lightly prelTed in, will prevent the Putrefaction 
 of the Inteftine, and make the Cavity^fiU^iip 
 like Impofthumations of other Parts. i- 
 
 If the Smiis is continued to the other But- 
 tock, almofl furrounding the Inteftine j the 
 whole Courfe of it muft be dilated in like man- 
 ner J iince in fuch fpongy Cavities, a Generation 
 of Flelh cannot be procured but by large Open- 
 ings ; whence alfo, if the Skin is very thin, 
 lying loofe and flabby over the Sifius, it is ab- 
 folutely necelfary to cut it quite away, or the 
 Patient will be apt to fink under the Difcharge, 
 wh'.ch in the Circumftance here d^fcribed, 
 
 is 
 
Op£ratw?t^ ^Surgery. '69 
 
 is foiiietimes cxcefTive. By this Methdd whkh 
 cannot be too much recommended, it is 
 amazing how happy the Event is hkely to be ; • ' 
 whereas from negleding it, and trufcing only 
 to a narrow Opening, if the Difcharge does 
 not deftroy the Patient, at leaft the Matter, by 
 being confined, corrupts the Gut, and infinu- 
 ating itfelf about it, forms many other Chan- 
 nels, which running in various Directions, often 
 baffle an Operator, and have been the caufe 
 of a Fiftula being fo generally efleemed very 
 difficult of Cure. 
 
 Here I have confidered the Impofthumation 
 as polTeffing a great part of the Buttock; but 
 it more frequently happens, that the Matter 
 points with a fmall extent of Inflammation on 
 the Skin, and the Direction of the Si?2us is even 
 with the Gut: In this cafe, having made a Punc- 
 ture, you may with a Probe learn if it has pene- 
 trated into the Inteftine, by paffing your Finger 
 up it, and feeling the Probe introduced through 
 the Wound into its Cavity; though for the mod 
 part, it may be known by a Difcharge of Matter 
 from the Anus. When this is the flate of the 
 Fiftula, there is no Helitation to be made, but 
 immediately putting one Blade of the Scifl^irs 
 up the Gut, and the other up the Wound, fnip 
 the whole length of it. This Prccefs is as ad- 
 vifeable, when the Inteftine is not perforated, if 
 
 the 
 
Treatise of the 
 
 the ^inus Is narrow, and runs upon or very near 
 it; for if the Abfcefs be tented, which is the 
 only way of dreffing it while the external Ori- 
 fice is fmall, as I have here fuppofed, it will 
 almoft certainly grow callous ; fo that the fureft 
 means of Cure, will be opening the Gut, that 
 proper Applications may be laid to the Bottom 
 of the Wound. However it fhould be well 
 attended to, that feme Sifuifes pretty near the 
 Inteftine, neither run into nor upon it, in which 
 cafe they mud be opened, according to the 
 courfe oftheir Penetration. Thereare abundance 
 of Inflances, where the Inteftine is fo much 
 ulcerated, as to give free ilTue to the Matter of the 
 Abfcefs by the A?ius ; but I believe there are 
 none where there is not by the Thinnefs and 
 Difcolouration of the Skin, or an Induration to 
 be perceived through the Skin, fome mark of 
 its Direction ; which, if difcovered, may be 
 opened into with a Lancet, and then it becomes 
 the fame Cafe as if the Matter had fairly pointed. 
 If the ^imijes into, and about the Gut, are 
 not complicated with an Induration, and you 
 can follow their Courfe; the mere opening with 
 Sciffars, or a Knife guided on a Dired:or, will 
 fometimes fuffice; but it is generally fafer to cut 
 the piece of Fle{l:i furrounded by thefe Incifions, 
 quite away, and when it is callous abfolutely 
 ■■ neceffary. 
 
operations of Surg e r y. 71 
 
 neceflary, or the Callofities muft be wafled 
 
 "' . ■ . - .... -l i'-..iV. 
 
 afterwards by Efcharotick Medicines, which 
 is a tedious and cruel Method of Cure. 
 
 When the Fiftula is of long ftanding, and 
 we have choice of Time for opening it, a Dofe 
 of Rhubarb the Day before the Operation will 
 be very convenient, as it not only will empty 
 the Bowels, but alfo prove an Aflringent for a 
 while, and prevent the Mifchief of removing 
 the Dreflings in order to go to flool. 
 , .it fometimes happens that the Orifices are 
 fo fmall, as not to admit the Entrance of the 
 Sciffars, in which cafe, Sponge-tents muft be 
 employed for their Dilatation. 
 
 In performing thefe Operations on th^Anus, 
 I do not think, in general, any Inftrument fo 
 handy as, the Knife and Sciffars ; almoft all the 
 others which have been invented to facilitate 
 the Work, are not only difficult to manage, but 
 more painful to the Patient : However, in thofe 
 Inftances where the Fiflula is very narrow, and 
 I opens into the Inteftlnes, juft within the Verge 
 of the AfUis, the Syringotomy may be ufed 
 with Advantage : But where the Openino- into 
 the Gut is high, it cannot be employed without 
 giving great Pain. I do not caution againft 
 cutting the whole Length of the Sphinder, 
 j^.xperience having (hewn it may be done with 
 
 little 
 
7.2 T R E A T 1 S E of t/je 
 
 little Danger of an Incontinence of Excre- 
 ment J and in fad the Mufcle is fo fliort, that 
 it muft generally be done in Dilatations of the 
 Inteftinc. ' f 
 
 The v/orft Species of Fiftula, is that coni- 
 municating with the Urethra, and fometimes 
 (thro' the Proftate Gland) with the Bladder 
 itfelf. This generally takes its rife from a for- 
 mer Gonorrhoea, and appears externally firft 
 in PcerincOy and afterv/ards increafing more 
 towards the Amis, and even fometimes into the 
 Groin, burfts out in various Orifices, thro' the 
 Skin ; which foon becomes callous and rotten ; 
 and the Urine paffing partly thro' thefe Ori- 
 fices, will often excite as much Pain, and of the 
 fame kind, as a Stone in the Bladder. 
 
 This Species of Fiftula taking its rife frotii 
 Stridures of the Urethra, is only manageable 
 hy the Bougie : for fo long as the Urethra is 
 obftrufted, the Cure of the Fifcula will be 
 imperfecfi- ; but if the Canal is opened by this 
 Application, it is amazing what obftinate In^- 
 darations and foul Siniijes sn\\\ in confequence 
 dlfappear ; tho' there are fome fo callous and 
 rotten, as to demand the Knife and skilful 
 Drcflings, notwithflanding the Urethra fliould 
 be dilated by the ufe of Bougies. 
 
 C H A P. 
 
operations <>/' S u r g e r y. y 3 
 
 CHAP. XV. 
 
 Of the Pundlure of the P ^e r i n e u m. 
 
 'np'HIS Operation Is performed, when the 
 Bladder is under fuch a Suppreffion of 
 Urine, as cannot be relieved by any gentler 
 Methods, nor by reafon of the Obftrudion in its 
 Neck, or the Urethra will admit of the Intro- 
 dudtion of a Catheter. The manner of doing 
 it, as defcribed by moft Writers, is by puiliing 
 a common Trocar from the Place where the 
 external Wound in the old way of cutting is 
 made, into the Cavity of the Bladder, and fo 
 procuring the liTue of the Water through the 
 Canula; but others, refining upon this Pradice, 
 have ordered an Inciiion to be carried on from 
 the fame Part into the Bladder, and then to 
 infinuate the Canula : But in my Opinion, both 
 the Methods are to be rejeded, in favour of 
 an Opening a little above the Os Pubis : For 
 befides, that it is not eafy to guide the Inftru- 
 ment thro' the proftate Gland into the Blad- 
 der, the Neceflity of continuing it, in a Part 
 already very much inflamed and thickened, 
 feldom fails to do Mifchief, and even to pro- 
 duce a Mortification. 
 
 Some time fince, a Gentlewoman complained 
 of a Difficulty of making Water, which flie 
 
 voided 
 
74 T RE AT 1 s E of the 
 
 voided by Drops with exceffive Pain, and foorS 
 after the urinary Paflage became totally ob- 
 liruded. Having in vain attempted to pafs th6 
 fmalleft Catheter 1 could get, I introduced my 
 Finger into the Vagina^ and felt a very hard 
 Tumour about the Neck of the Bladder : The 
 Patient had not voided any Water for five 
 Days, and being in the utmofl Agony, and as 
 we judged within a few Hours of dying, I put 
 in pradice the Inciiion above the Os Pubis, 
 making the Wound of the Skin about two 
 Inches long, and that of the Bladder about half 
 an inch : Having emptied by this Means, a 
 prodigious quantity of Water, I kept the Ori- 
 iice open with a hollow Tent, 'till fuch time 
 as the Tumour fubfided, which, with proper 
 Medicines, it did by degrees ; and in about fix 
 Weeks, all her Water came the right Way, 
 and fome time after, flie recovered perfed: 
 Health. I have lately pradifed a Method flill 
 more eafy both to the Patient and the Operator ; 
 which conlifts only in emptying the Bladder 
 with a common Trocar, and flopping the Ca- 
 nula with a little Cork, which is afterwards to 
 be taken out, as often as the Patient has occa- 
 lion to urine. The Canula is to be continuec^ 
 in the Bladder, till fuch time as the Perfon finds 
 he can void his Urine by the natural PafTagc. 
 
 In 
 
In tbis Operation the A^dojnen ougbt to be 
 perforated about two Inches above the Oi Fu-- 
 bis 'i and if the Patient be fat, the Trocar iliould 
 penetrate two Inches, otherwile, an Inch anc} 
 a half wjil be fufficient ; this Precaution is -of 
 great Importance, for I have ken an Example, 
 where the Trocar being introduced nearer to 
 the Os Pubis, the Extremity of it prelfed upon 
 the lower Portion of the Bladder, and in 51 few 
 Days made a Pailage into the Return-. 
 
 C H A R XVL 
 Of the STONE, 
 
 TONY Concretions are a Dirsafe, incident 
 to feveral Parts of the Body 5 but I feall 
 treat only of thofe formed in the Kidneys and 
 Bladder : Hitherto there has never been given 
 any fatisfadlory Account of the Caufes of thi? 
 concreting Difpofition in the Fluids 3 and tho' 
 there may be fome Propriety in confidering 
 the Sand of Urine, in the fame light as the 
 Tartar of Wine, from their Similitude in fe^ 
 veral Experiments, yet we cannot infer from 
 thence, what does immediately produce it : at 
 leaftj jtis not with any Certainty to be imputed 
 to a particular Diet or Climate, v>^hich however 
 are the Caufes commonly afftgred 5 fince we fee 
 K that 
 
76 T R E A Ti s E of the 
 
 that In all Countries, and amongft all Ranks of 
 People, as much among the Sober, as the Luxu- 
 rious, the Stone is a frequent Diflemper ; and 
 though the great Numbers cut at the Hofpitals 
 of Parisj where the Water of the Sein is fo 
 remarkable for its quantity of Stone, feems to 
 favour the Opinion of its being generated by 
 particular Fluids received into the Blood ; yet I 
 believe, upon enquiry, this famous Inftance will 
 not appear conclufive ; fince moft of thofe Pa- 
 tients come from the Provinces, or diftant Vil- 
 lages, where that Water is not drank ; and as 
 to the Inhabitants oi Paris itfelf, by what I was 
 able to learn of the Surgeons there, the number 
 of thofe afflided with, the Stone amongft them, 
 is pretty nearly in the fame proportion as. in 
 laondon : From which Confiderations, and the 
 circumftance of fo many more Children having 
 the Stone than Men, one would be inchned to 
 think, the Difpofition is much oftener born 
 with us, than acquired by any external means. 
 It is certain the Urine generally abounds 
 with Matter proper to compofe a Stone, ^nd 
 perhaps if it could grow cold in the. Bladder, it 
 would always depofite the Matter therCj as it 
 does on the Sides of the Chamber-pot,, tho'the 
 Coats of the Bladder being covered with a Mu- 
 cilacre, makes them more unfit than the Sides of 
 
 the 
 
operations (^Z S u r g fe r V* 
 
 the Pot, to attradt the ftony Particles j but we 
 fee, when once a hard Body is infmuated into 
 the Bladder, it feldom fails to become the Nu- 
 cleus of a Stone, whether it be a large Piece of 
 Gravel, a Needle, a Bullet, or any other firm 
 extraneous Subftance, even grumous Blood. 
 
 From the monftrous Increafe of fome Stones 
 in; a fmall time, and the CefTation of Grov^^th, 
 for many Years, of others, vve may be pef- 
 fuaded that the Conftitution varies exceedingly 
 at different times, with regard to thefe ftony 
 Separations ; and from the Appearances of moil: 
 Stones, when artfully fawed through, we may 
 gather, that this Variation of Conftitution does 
 not fliew itfelf only in the Quantity of Gravel^ 
 added to the Stone, but the Quality of it alio 5 
 fo that a red uniform Stone of an Inch diame- 
 ter, may perhaps at half that Size, have been a 
 fmooth white one ; at a quarter, a brown Mul- 
 berry one I and fo on, at different times^ altering 
 in its Species. , Hence, (from the Appofition of 
 different coloured Gravel,) arlfes for the mcfb 
 part, the laminated Appearance of a Stoae; 
 though fometimes the Lmnifice are very nearly 
 of the fame Colour and Campoiition ; and ih 
 this Cafe, their Formation feems to b^ t>wing to 
 the want of Accretion in the Stone for a certain 
 Time, during which, its Surface, by rubbing 
 K 2 aeaioi^ 
 
*yS T R E A T I s E <?/* the 
 
 again il the Coats of the Bladder, and its Attri- 
 tion from the Stream of Urine, becomes fmooth 
 and compadt ; fo that when more frefli loofe 
 Gravel adheres to it, its different Denfity in 
 •that Part, will neceffarily make the Streaks we 
 fee in a Sedion of the Stone, which are only 
 the external Surfaces of each Lamina. 
 
 That the ceafing to grow, gives them this 
 laminated Form, and not any particular Dif- 
 polition in Sand to fhoot into fuch a Shape, is 
 probable from the Examination of fome other 
 Stones, in which a great Quantity of Gravel 
 is firft colledled without any Nucleus, into a 
 fpongy uniform Mafs, and after that, is co- 
 vered with feyeral Lafnince. 
 
 It is no wonder that Stones fo generally form 
 in the Kidneys, lince the Diipoiition of the 
 Urine will naturally fhew itfelf as foon as it 
 is feparated into the Pelvis^ that is, the ftony 
 Particles having as flrong an Endeavour to 
 unite with one another in the Kidneys as the 
 Bladder, will confequently, from meeting firfl 
 there, generally produce Gravel and Stone in 
 that Part ; nay, I have found by opening the 
 Kidneys of calculous People, tliat Stone is 
 formed even earlier than I have here fuggefted, 
 for in them the T'libuli BelJiniani were full of 
 Gravel. 
 
 Small 
 
Operatio72s of S u r c e r y. 
 
 ■Small Stones and Gravel, are frequently ' 
 voided without Pain j but fometimes they, col- 
 led: and become very large in the Kidneys ; in 
 which cafe, a Fit of the Stone in that Part, is the 
 Cure, from the Inflammation and Pain occa-' 
 iioning convullive Twitches, which at laft expel 
 them : But in this Difeafe, the Patient is very 
 much relieved by feveral kinds of Remedies, 
 fuch as the mucilaginous, the faponaceous, &c. 
 fome of which lubricate, and others both lubri- 
 cate and flimulate. The Sand in paffing through 
 ^ho, Ureters, is very much forwarded -by the 
 Force of the Urine, which is fo conliderable, 
 that I have feen a Stone that was obilrudled in 
 the Ureter in its firft Formation, perforated 
 quite through its whole Length, and form a 
 large Channel for the Stream of Urine. The 
 Ureters being very narrow, as they run over the 
 PJoas Mufcle, and alfo at their Entrance into 
 the Bladder, make the Movement of the Stone 
 very painful and difficult in thofe Parts 3 but 
 there isfeldom fo much trouble after the firft 
 Fit ', for vi^hen once they have been dilated, 
 they generally continue fo : I have often (qqu. 
 them as big as a Man's Finger, but they have 
 been found mucfi, larger. 
 
 When once g Stone has acquired a mode- 
 rate Size in the Bladder, it ufually occalions the 
 K 3 follow- 
 
Treatise of the 
 
 following Complaints : Frequent Inclination to 
 make Water, exceffive Pain in voiding it Drop 
 by Drop, and fometinaes a fudden Stoppage of 
 it if difcharged in a Srreai;ii j after urining, great 
 Torture in the Ghim Penis^ which lafts one, 
 two, or three Minutes j and in moft Conftitu- 
 tions, the violent Straining makes the Redium 
 Contrad, and expel its Excrernents, or if it be 
 empty, occafions a Tt7/r//;7z^j, whiph is foftietimes 
 accompanied with a Prolapfus Ani : The Urine 
 is often tindtured vvith Blood from a Rupture 
 of the VelTels, and fometimes pure Blood itfelf 
 is difcharged; fometimes the Urine is very clear, 
 but frequently there are great Quantities of 
 {limy Sediment depofited at the Bottom of it, 
 which is no other than a preternatural Separa- 
 tion of the Mucilage of the Bladder, but has 
 been often miflaken for Pus ; whence has arofe 
 an Opinion, that Ulcers of the Bladder are com- 
 mon, tho' in facfl, the Diftemper is very rare. 
 
 Thefe are the Symptoms of the Stone in the 
 pladder ; yet by no means are they infallible ; 
 fmce a Stone in the Ureter or Kidneys, or an 
 Inflammation of the Bladder from any other 
 Caufe, vv^ill fometimes produce the fame Effeds: 
 but if the Patient c?innot urine, except in a cer- 
 tain Pofture, 'tis almoft a fure Sign the Orifice is 
 p'??llruded by a Stone 3 if he finds Eafeby pref- 
 
Operatkm <?/ S u r g e r"Y, 
 
 ^^x\% again ft the Perinaum with his Fingers or 
 fitting with that Part upon a hard Body, there is 
 little Doubt to be made that the Eafe is procured 
 by taking off the weight of the Stone ; or laftly, 
 if with moft of thefe Complaints, he thinks he 
 can feel it roll in his Bladder, it is hardly pof- 
 lible to be.miftaken ; however, the only fure 
 Judgment to be formed, is from fearching. 
 
 That we fhould not readily diftinguiih the 
 Complaints of the Stone, from many other Af- 
 fedions of the Bladder, is not very furprifing, 
 when we refled: that a Fit of the Stone is no- 
 thing but an Inflammation of its Coats, which 
 "tho* it be excited by the Stone, requires a Dif- 
 polition in the Blood to produce it j for if the 
 Complaints in a Fit, were owing to the imme- 
 diate Irritation of the Bladder, it fliould follow 
 that the Stone being always the fame, the Fit 
 would be continual j but belides that all Pa- 
 tients have confiderable Intervals of Eafe (often 
 of many Months) except in thofe Cafes where 
 the Stone is either very large or pointed, there 
 are Inftances of fomc few happy Conftitutions,. 
 where they have no Pain, even after having for 
 a certain time, fuffered very much. 
 
 To prevent the Violence, and frequent 
 
 Returns of the Fits of the Stone, Bleeding and 
 
 gentle purging with Manna, are beneficial -, 
 
 K. 4 ab^ 
 
82 T R E A T I S E <?/' //^^ 
 
 abflalnlng alfo from Malt-liquors, and Excefs 
 ot Eating and Drinking, is very ferviceable 5 
 but the Milk-Diet and Honey are the greatef^ 
 Preventives, not only of Inflammation, but per^ 
 ,haps fotnetimes too, of the farther Accretion 
 of the Stbne. 
 
 From confidering the Diforders of the Stone 
 in this light, and the frequent Intervals of Eafe 
 •which happen without the Affiftance of 
 Medicine, we cannot wonder that Co many 
 Patients have believed the Stone diflblved, 
 when they have been under any particular 
 Regimen, and that in all Ages there have been 
 many People deceived for a length of Time, 
 by a fuppofed Diiiolvent, tho' we have not 
 hitherto known any faie one, till lately that 
 Lime and Soap have been difcovered to have 
 fometimes that Effed. 
 
 CHAP. XVII. 
 
 Of Searching. 
 
 ^'T^HE Patient being laid on a horizontal 
 Table, with his Thighs elevated and- a 
 little extended, pafs the Sound with the concave 
 Part towards you, 'till it meets with fome re- 
 fiftance in Pe?'i?2ao, a little above the ^nus ; 
 then turning it without rptjch Force, pufh it 
 
 gently 
 
operations ^ S u r g e r v. 
 
 gently on into the Bladder, and if it meets 
 with an Obftrud:ion at the Neck, raife its Ex- 
 tremity upwards, by inclining the Handle of 
 it towards you j or if it don't then flip in, with- 
 draw it a quarter of an Inch, and introducing 
 your Forefinger into the ReSfumy lift it up, 
 and it will feldom fail to enter : There is fome 
 Art in turning the Sound in the proper Place 
 of the Urethra^ which Surgeons not verfed in 
 this Operation cannot fo w£ll execute j there- 
 fore they may pafs the Inflrument with the 
 concave Side always towards the^/^^i?;;/^';^ of 
 the Patient, obferving the fame Rule at the 
 Entrance into the Bladder, as in the other 
 Method . The Caufe of this Obftacle, . befides 
 the Rug(^ of the Ureihray and the Refinance 
 of the Vernmontaniim^ is fometimes a fmall 
 Projedion of the Orifice of the Bladder, in the 
 Urethra, like that of the Os T^incce in the Va- 
 gina, which occalions the End of the Sound 
 to flip a little beyond it. 
 
 It: is not to be fuppofed, that by fearching, 
 one can poflibly judge of the Size and Form 
 of a Stone J and indeed the Frequency of the 
 Fits, and Violence of the Symptoms, are a bet- 
 ter Rule to go by j though whoever fhall think 
 himfelf capable of diilinguilliing abfolutely the 
 difference of Stones, even , by thefe. Circum- 
 
 flancfcs. 
 
T.R E A T I S E of the 
 
 llances,- will fometimes be miftaken; fince the 
 Frequency and Violence of . the Pain, depend 
 Dot alsvays merely upon their Magnitude or 
 Shape; and there are fome Inftances, where 
 a Stone of fix Grains weight, has for feveral 
 Months given more Pain in one-Perfon, than 
 a much larger has in another, however, ceteris 
 paribus,, a large or a rough Stone is worfe than 
 a fmall or a fmooth one. 
 
 Though upon fearching, .w€ are aflured of 
 a Stone in the Bladder, we are not without 
 furthery Inquiry, to operate imn'^ediately j fince 
 there are fometimes Qbilacles which forbid 
 the Operation, either abfolutely, or only for a 
 certain time; among th^fe, that of greateft 
 Confequence, is the Gravel or Stone in the 
 Kidneys, which is known by the Painjn the 
 Loins, Vomitings, Contradions of the; Tefti- 
 cles, Numbnefs of the Tliighs, and often by 
 Matter which the Inflammation produces in 
 the Kidneys. . The ObjeOions of lefs Weight, 
 and which frequently are renioved; are a Fit 
 of the Stone, a Cough, a He<3:ick, ,and being 
 emaciated by long, Pain J exceflive hot or col el 
 Weather; afe like wife,.. Hindrances :,Biit in 
 extremity of Danger, thefe4aft .Confiderafions^. 
 inay be difregarded, tho' no doubt ,ye^y jhot 
 Y/eather is more inconvenieut and,.dan§fXoii3;, 
 
operations ij/'Surgery. 85 
 
 than cold, as lying-a-bed is then more trouble- 
 fame, and the Urine much falter. 
 
 Difference of Age makes an" extreme Dif- 
 ference in Danger, Infants and young People 
 almoft always recovering ; but ihll the Opera- 
 tion is advifable on thofe advanced in Years, 
 tho' it is not attended with near the fame Suc- 
 cefs. This Operation is performed four feveral 
 Ways, all- which I (hall defcribe with their par- 
 ticular Inconveniences, that we may the more 
 eafily pitch upon that, which has the leaft. 
 
 Before we perform any of them, 'twill be 
 proper to prepare the Patient with a gentle 
 Purge, the preceding Day, and a Clyfler early 
 in the Morning, which will be of great fer- 
 vice in cooling the Body, and making fome 
 of the Operations lefs dangerous where the 
 ReBum is liable to be wounded, when full, 
 
 CHAP. XVIII. 
 
 Of the Lesser Apparatus, or 
 Cutting on the Gripe. 
 
 ^*T^ H E mofl ancient way of cutting for 
 the Stone, is that defcribed by C^^i, and 
 known by the Name of Cutting o?j the Gripe, 
 though fince the Time of 'Johannes de Ro- 
 rnanis, it is alfo called, Cutting iioith the lejfer 
 Aff(iraiu^i to diftinguifh it from his new Me- 
 thod, 
 
86 . : T R E A T J s E of the 
 
 thod, which on account of the many Inftru- 
 ments employed in it, is called Cutting with the 
 Greater Apparatus. The Manner of doing the 
 Operation is this : You nnl introduce the Fore- 
 finger and Middle-finger of the left Hand, dipt 
 . in Oil, up the Anus, and preffing foftly with 
 ■your i ight Hand above the Os Pubis^ endeavour 
 to brinp- the Stone towards the Neck of the 
 Bladder -, then making an Inciiion, on the left 
 ^\aQoii\\c Per ilia: urn, above the c^/zz^i, diredly 
 upon the Stone, you turn it out through the 
 Wound, either with your Fingers or a Scoop. 
 
 This Way of Cutting was attended with 
 many Difficulties, for want of proper Inftru- 
 jiients to dircd; the Incifion, and extradl the 
 Stone, when it lay beyond the Reach of the 
 Fingers, v/hich in a large Bladder was frequent- 
 ly the Cafe 5 fo that 'tis ftrange Celfus confined 
 the Operation to the Age between Nine and 
 Fourteen, fince i't is much eaiier to be per- 
 formed in Infancy, than at thofe Years ; and it 
 plainly appears from his Account of it, that 
 many died from the Violence done to the 
 Bladder in endeavouring to bring the Stone 
 \ forwards, though the Operators failed in their 
 
 AttemptV and the Patients were not cut. 
 
 The Wound of the Bladder in this Opera- 
 tion is made in the fame Place as is now prac- 
 
 tifed 
 
operations ^Surgery. 87 
 
 tifed in the Lateral Method ; but it being Im- 
 pradicable on fome Subjcdls, and uncertain on 
 all otherSj has made it univerfally exploded ; fo 
 that no body now makes an Inciiion without the 
 Diredlion of a Staff, unlefs a Stone entirely pre- 
 vents the Introdudion of it, by prefiing againft, 
 and flopping up the Neck of the Bladder ; and 
 in this Cafe, when we cut diredly upon the 
 Stone, it is much fafer to pufh it back farther 
 into the Bladder, and lay hold of it with the 
 Forceps, than to endeavour with the Scoop or 
 Fingers to force it outwards, which Circum- 
 ftance alone makes it different homCeJfus^ Me- 
 thod. It muff bediftinguifhed however, when I 
 fpeak of pufhing the Stone back, that 1 fuppofe 
 it in the Neck of the Bladder : for it frequently 
 happens that it lies at the Extremity of the 
 Urethra, on the Gutfide of the Bladder; in which 
 Cafe the Wound of the Urethra may be made 
 large enough to turn it out with the Fingers, 
 or the End of fome ilender Inffrument. 
 
 ■ , ■ CHAR XIX, 
 
 Of the G R EATER A p p A R A T {] s , cr _ the 
 
 'ay. 
 
 Old W- 
 
 ^ H I S Method of Cuttinc^, invented by 
 
 Johannes de Romanis^ and pubhihed l>v 
 
 bis Scholar Mi^r/^/zz/ J in the Year i C2d, luis 
 
SS ^ RE AT IS E of ^/je 
 
 at different Times, and with different People, 
 varied confiderably in fome of its ProcefTes, and 
 particularly with regard to the U[e of certain 
 Inftruments. What I fliall defcribe, will be 
 the Manner, in which k is now pradtifed with 
 all its Improvements. 
 
 Having laid the Patient on a fquare horizon- 
 tal Table, three Foot four Inches high, with a 
 Pillow under his Head, let his Legs and Thighs 
 be bent, and his Heels made to approach his 
 Buttocks, by tying his Hands to the Bottom of 
 his Feet, with a Couple of flrong Ligatures, 
 about two Yards long ; and to fecure him more 
 eifedtually from flruggllng, pafs a double Liga- 
 ture under one of his Hams, and carry the four 
 Strings round his Neck to the other Ham ; then 
 palling the Loop underneath it, make a Knot 
 ' by threading one of the fingle Ends thro' the 
 Loop : After this, the Thighs being widened 
 from each other, and firmly fupported by pro- 
 per Perfons, you introduce the Staff, having 
 firft dipt it in Oil, which mufl be held by your 
 AlTiftant, a little leaning on the left Side of the 
 Seam in Perinao 5 and beginning the external 
 Wound juft below the Scrotum, (which muff he 
 held outoftheWay) you continue it downwards, 
 to within two Fingers Breadth of the Amis ; 
 then leaving that Diredion, you Hip the Knife 
 
 forwards 
 
Opef attorn vf: S b r- t^'k r y. 89 
 
 .f<?rwards'in" the Groove, pretty far into -the 
 bulbotiS' Partrof the Urefi^ra ; br, as^l^re is 
 ^. fonif Danger of wounding the R^£lum^^\n. the 
 v^ontinuation of the Iricifion, you may turn the 
 Knife' vyith the Back towards it, and make this 
 Part of the Incifion from within outwards. 
 Should a very large Veffel be cut, it wili be 
 advifeable to tie it before you proceed any 
 farther in the Operation. When the Wound 
 is made, Aide the Gorget along the Groove of 
 the Staff into the Bladder j and to do it with 
 more, Safety, when the Beak of it is received 
 m the Groove, 'twill be proper to take the Staff 
 yourfelf in, your left Hand ; for if the Afliftant 
 fliould, unwarily, either incline the Handle 
 of it too much towards you, or not refill: 
 enough to the Force of the Gorget, it is very apt 
 to ,j(lip out of the Groove, between tht Re^lum 
 and the Bladder, which Accident is not onlv 
 inconvenient to the Operator for the prefent, 
 but is attended for the moft part with vqvv bad 
 Confequences. The Gorget being palled, di- 
 late the Urethra and Neck of the Bladder v/ith 
 your Forefinger, and introduce the Forceps 
 into the Bladder, keeping them fliut 'till you 
 touch the Stone, when you mud grafp it with 
 a moderate Force, and extrad it by pulling 
 downwards towards the RcSlwn,-, Sliould you 
 
 find 
 
go Treatise of ii?e 
 
 find a Difficulty in laying hold of the Stone, 
 be careful to keep your Forceps in fuch a Pp- 
 lition, that they may open upwards and down- 
 wards, (not laterally) which will very much 
 facilitate the embracing of the Stone, in cafe 
 it fliould happen to be thin and flat. 
 
 CHAP. XX. 
 Of the High Operation. 
 
 ^T^ HIS Method of Cutting for the Stone 
 •^ was firft pabli{hed in the Year 1561^ 
 by Pierre Franco, who in his Treatife of Her- 
 nias fays he once performed it on a Child with 
 very good Succefs, but difcourages the farther 
 Pradlice of it. After him, Rojfetus recommended 
 it with great Zeal, in his Book intitled Partus 
 Cafareiis, printed in 1591 i but he never per- 
 formed the Operation himfelf. Monfieur To/ei 
 makes mention of its having been tried in the 
 Hotel Dieu 5 but without entering into the 
 particular Caufes of its Difcontinuance, fays 
 only that it was found inconvenient. About 
 the Year 17 19, it was firft done in England 
 % by Mr. Douglas^ and after him pradifed by 
 
 others. The Manner of performing it, with 
 the Improvements made fince Francos Ope- 
 ration, is this I 
 
 The 
 
Opetations ©/"Surgery. 91 
 
 The Patient being laid on a fqiiare Table, 
 with his Legs hanging off, and faftened to the 
 Sides of it by a Ligature paffed above the Knee, 
 his Head and Body lifted up a little by Pillows, 
 fo as to relax the abdommal Mufcles, and his 
 Hands held fteady by lome Affiftants 5 injed 
 through a Catheter into the Bladder as much 
 Barley-water as he can bear, which in a Man, 
 is often about eight Ounces, and fometimes, 
 twelve : For the more eafily doing this an Ox's 
 Ureter may be tied to the Extremity of the 
 Syringe, and Handle of the Catheter, which, 
 being pliable, will prevent any painful Mo- 
 tion of the Inflrument in the Bladder. 
 
 The Bladder being filled, an Affiftant, in 
 order to prevent the Reflux of the Water, mufl 
 grafp the Penis the Moment the Catheter is 
 withdrawn, holding it on one Side, in fuch a 
 manner, as not to ftretch the Skin of the Ab- 
 domen ; then with a round -edged Knife make 
 an Inciiion about four Inches long, between 
 the ReBi and Pyramidal Mufcles, through the 
 Membrana Adipofa, as deep as the Bladder, 
 bringing its Extremity almoil down to the 
 Tenis \ after this, taking a crooked Knife, con- 
 tinue the Inciiion into the Bladder, carrying it 
 a little under the Os Pubis, and immediately 
 vpon the Water's flowing out, introduce the 
 L Fors- 
 
92 T K E A T I S E of tie 
 
 Forefinger o( your left Hand, which will 
 direct the Forceps to the Stone. 
 
 This Method was at jfirft received with 
 great Applaufe in Londoii^ but after fonie Trial 
 was rejected for the following Inconvenien- 
 cies : 
 
 It fomctimes happens that the Bladder, not- 
 withftanding the Injedion, ftill continues fo 
 deep under the Os Pubis, that the Peritonaum 
 being neceiTarily wounded firft, the Inteftines 
 pudi out immediately at the Orifice, and the 
 Urine afterwards empties into the Abdomeriy 
 in which Cafe, hardly any recover. The In- 
 jedion itfelf is exceedingly painful, and how- 
 ever flow the Fluid be injeded, it diftends 
 the Bladder fo much more fuddenly than the 
 Urine from the Kidneys does, and fo much 
 fafter than it can well bear, that it not only 
 is feldom dilated enough to make the Opera- 
 tion abfolutely fecure, but is fometimes even 
 burfl, or at leafl: its Tone deflroyed by the hafty. 
 Dilatation. What adds to the Danger here, 
 is the Poffibility of meeting with a contraded 
 indurated Bladder, which is a Circumftance 
 fometimes attending on the Stone, and indeed 
 an exceedingly dangerous one in all the other 
 Methods, but would be frightful in this, by 
 reafon not only of the neceffity of wounding 
 
 the 
 
Operatio7is ^Surgery. 93 
 
 the Peritonaitm, but of the Difficulty of com- 
 ing at the Stone. If the Stone be very fmall, 
 it is hard to lay hold q^ it with the Forceps, 
 and in a fat Man, the Fingers are not long 
 enough for that Purpofe. It there are many 
 litde Stones, it will fcarce happen that more 
 than one at a time can be extraded ; and if 
 the Stone breaks, it not only is impradticable 
 to take it all away in the Operation, but alfo 
 from the fupine Pofture of tlie Patient, it will 
 generally remain in the Bladder j whereas in 
 the other Methods, for the moft part, it works 
 itfelf out with the Urine. But even fuppofing 
 that the Operation itfelf is profperous, the 
 Confequences generally are very troublefome, 
 for the Urine ifluing out at an Orifice where 
 there is no Defcent, fpreads itfelf upon the 
 Abdomen J and makes very painful Excoriations j 
 though, what is ftill worfe, it fometimes inii- 
 nuates itfelf into the Cells bet^ween the Bladder 
 and Abdoni'mal Mufcles, and together with 
 the Inflammation excited by the Operation, 
 brings on a Suppuration there, which is 
 always difficult to manage, and frequently 
 mortal. 
 
 L 2 C H A-.P^' 
 
 r^ 
 
94- T K E A r I s E of t/je 
 
 C H A P. XXL 
 
 Of the Lateral Operation. 
 
 ^T^ HIS Method was Invented by an Eccle- 
 fiaftic, who called \i\vi\i^i Frere 'Jaques : 
 He came to Faris in the Year 1697, bring- 
 ing with him abundance of Certificates of his 
 Dexterity in operating ; and making his Hiflory 
 known to the Court, and Magiftrates of the 
 City, he got an Order to cut at the Hotel Dieu^ 
 and the Charite, where he performed this 
 Operation on about fifty Perfons. His Succefs 
 did not anfwer the Promifes he had made, 
 and from that Time his Reputation feems to 
 have declined in the World, if we may give 
 Credit to Diofiis, who has furniflied us with 
 thefe Particulars. 
 
 He was treated by the Surgeons of thofe 
 Times as ignorant and barbarous 5 and though 
 upon enquiry into the Parts which fufi:er in this 
 Method, it vv^as once the Opinion of fome of the 
 moil eminent amongft them^ that it might be 
 made a moll: ufeful Operation, if a fewlmper- 
 fedions in the Execution of it Vv^ere removed j 
 yet after having given this Jijdgment, they 
 fuddenly dropt the Purfuit, for no other Reafon, 
 
 to 
 
operations (t/* S u r g e r y. 95 
 
 to all Appearance, but that they v/ould not be 
 obliged to any one but a regular Surgeon for a 
 Diicovery of fo great Confequence. The prin- 
 cipal DckO: in his Manner of cutting, was the 
 want of a Groove in his Staff, which made it 
 difficult to carry the Knife exadly into the 
 Bladder, nor did he take any Care of his Pa- 
 tients after the Operation, fo that for want of 
 proper Dreffings, fome of the Wounds proved 
 Fiftulous, and other ill Confequences enfued : 
 But I am inclined to think hefucceeded better, 
 and knew more at laft, than is generally ima- 
 gined ; for 1 remember to have feen, when I 
 was in France^ a fmall Pamphlet, publifhed by 
 him in the Year 1702, in which his Method 
 of Operation appeared fo much improved, that 
 it differed in nothing, or but very little, from 
 the prefent Pradice. He had by this time, learnt 
 the NecefTity of drefling the Wound after the 
 Operation, and had profited fo much from the 
 Criticifms of MefTieurs Mery^ Fagon^ Felix, 
 and Hunauld, that he then ufed a StafFwith a 
 Groove; and what is more extraordinary, had 
 cut thirty-eight Patients fucceflively at Ver- 
 failles, without lofing one, as appeared by a 
 Certificate annexed to the Piece. 
 
 Amongfl many that faw Frere Jaquei 
 
 operate, was the famous Profeflbr Ran, who, 
 
 L 3 carried 
 
 ^' 
 
g6 Treatise of the 
 
 carried his Method into HoUaiid, and pradlifed 
 it with amazing Succefs : He never publiflied 
 any Account of it himfelf, though he admitted 
 jfeveral to his Operations ; but fince his Death, 
 his SuGceiTor Albinus, Profeflbr of Anatomy 
 and Surgery at Leydcji, has given the World a 
 very circumftantial Detail of the feveral Pro- 
 celTes of it, and mentions as an Improvement 
 upon Frere Jaqties'^ Manner, that he made his 
 Incifion thro' the Bladder beyond the Proftate ; 
 but whoever will try the Experiment of making 
 a Wound in that Place, without touching the 
 Proflate, on a Staff, fuch as Albinm has de^ 
 lineated, which is of an ordinary Length, will 
 find it alnioft impracticable ^ for if by inclin- 
 ing the Staff a little towards the Abdomen and 
 right Groin, you endeavour to raife that part 
 of the Bladder towards the Wound, it flipis 
 out all but the very End of it into the Vre^ 
 tkra^ and leaves no Dire(5tion for the Knife, 
 Befides, that he cut the Proftate, may be ga-^ 
 thered from the Event of fome Cafes which 
 Mr. Cbfil}Iden publiilied, when he firft under-^ 
 took the Lateral Operation : He conlidered it 
 as almoil imppilible to make the Incilion in 
 this Place, unlefs the Bladder was diftended, 
 \o which purpofe, he injedled as much Barley^ 
 water as the Pgtient cpuld fufer, which made it 
 
 protut 
 
Operatmis of Su n ge ry, 
 
 protuberate forwards, and lie in the Way of 
 the external Wound, fo that leaving the Staff 
 in, he cut very eafily upon it. The Operations 
 were exceedingly dextrous j but the Wound of 
 the Bladder retiring back, when Jt was empty, 
 did not leave a ready Iffue for the Urine, v/hich 
 infinuating itfelf amongft the neighbouring 
 Mufcles and Cellular Membranes, deftroyed 
 Four of the Ten which he pradifed this 
 Method upon, and fome of the others nar- 
 rowly efcaped. 
 
 If therefore, this was the Confequence of a 
 Wound ot the Bladder beyond the Proftate, in 
 fo many Inftaiices, and we find by experience 
 that it is exceedingly difficult: in fome Men to 
 carry the Incilion even fo far as the Proflate, 
 fure it is poffible that Albinus may be miftaken 
 in his Defcription, or even that Rau himfelf, 
 if he was of that Opinion, might be deceived in 
 the Parts he wounded ; Unce we know it was 
 generally thought, till within thefe few Years, 
 that the Bladder itfelf was cut in the old Way. 
 
 After this unfuccefsful Trial, Mr. Chefelden 
 made ufe of the following Method, which m 
 now the Pradice of moft 'Englifi Operators. 
 
 The 'Patient being laid on a Table, vv'ith his 
 
 Hands and Feet tied, and the Staff pafled as in 
 
 the old Way, let your AiTiilant hold it a little 
 
 L 4 llaating 
 
Treatise of the 
 
 flanting on one Side, fo that the Diredlon of It- 
 may run exadly thro' the Middle of the left 
 EreSior Perns and Accelerator Uruice Mufcles j 
 then make your Incifion through the Skin and 
 Fat, very large, beginning on one Side of the 
 Seam in Fennao^ a little above the Place 
 wounded in the old Way, and finidiing a little 
 below the Am^s^ between it and the TuberoHty 
 of the J/chmm : This Wound muft be carried 
 on deeper between the Mi^fcles, 'thl the Proftate 
 can be felr, when learching for the Staff, and fix- 
 ing it properly if it has ilipr, you mufi: turn the 
 Edge of the Knife upv^^ards, and cut the whole 
 Length of that Gland from within outwards, at 
 the fame time pufliing down the Return with a 
 Finger or two of the left Hand, by which Pre- 
 cautions, the Gut Will always efcape wounding 5 
 after which, the Operation finifhes nearly in the 
 fame manner, as with the greater Apparatus. 
 
 If upon introducing the Forceps, you do not 
 perceive the Stone readily, you mufI: lift up, 
 their Handle, and feel almoft perpendicularly 
 for it, fmce for the moft part, when it is hard 
 to come at, it lies in one of the Sinufes fome-. 
 times formed on each Side of the Neck of the 
 Bladder, v/hich projed: forward in fuch a man- 
 ner, that if the Stone lie there, the Forceps 
 pafs beyond it tiie moment they are through 
 
 the 
 
per at 1 071 s ^Surgery. 99 
 
 the Wound, fo that it would be impoffible to 
 lay hold of It, or even to feel it, if not aware 
 of this Circumflance. 
 
 When the Stone breaks, it is much fafer to 
 take away the Fragments with the Forceps, 
 than to leave them to be difchargcd with the 
 Urine ; and if the Pieces are very fmall, like 
 Sand, a Scocp is the beft Inftrument ; though 
 fome prefer the injecting Barley-water into the 
 Bladder, which fuddenly returning, brings 
 away the broken Particles of the Stone. 
 
 As there are hardly any Inftances of more 
 Stones than one, when the Stone taken away 
 is rough; fo when it is fmooth and poliflied 
 in any part of it, 'tis almoft a certain lign of 
 others behind ; on which account, an Opera- 
 tor Ihould be careful in that Cafe, to examine 
 not only with his Fingers, but fome conve- 
 nient inftrument, for the remaining ones ; 
 tho* indeed, in all Cafes, it may be proper to 
 examine the Bladder after the Extradion of 
 a Stone; becaufe it is poffible there may be 
 a fecond Stone, notwithflanding the firft be 
 rough. 
 
 The great Inconvenience of the lateral Ope- 
 ration is the Hisemorrhage which fometimes 
 cnfuesin Men; for in Children the Danger of it 
 is not worth mentioning ; this however is the 
 
 principal 
 
lOO Treatise^?/' the 
 
 principal Objedion which has prevented it 
 being univerfally pradifed, but in all likelihood 
 it will be more general, when the Merits of 
 the Method are better known, and it is once 
 difcovered that the ill Coniequence of mofl of 
 thefe Hemorrhages is owing more to an 
 Error in operating, than to the nature of the 
 Operation j for I think I can poHtively fay, that 
 all thofe Branches of the Hypogaftrick Artery 
 which lie on this Side of the Proftate, may be 
 taken up with the Needle, if the Wound be 
 made large enough, to turn it about freely at 
 the Bottom ; yet this is a Circumflance, that 
 many Surgeons have been deficient in, and 
 inftead of making it three or four Inches long 
 in a Man, they have fometimes made it not 
 above an Inch ; in which cafe, it is not only 
 impoffible to tie the VefTels between the Skin 
 and Bladder, but it alfo prevents the proper 
 Application of Lint, or Stypticks to the Artery 
 creeping on the Proftate, fo that it is not 
 iurprifing the Operation lliould be difcountc- 
 Danced J when the Practice of it is attended 
 with this Difficulty. 
 
 I have here mentioned Lint or Stypticks, as 
 ;i proper Applicacion to ftop tjie Hemorrhage 
 jtrom the Artery of the Proftate \ but if they 
 tliould not prove efiedualj I would advife the 
 
 Intro- 
 
op era lions ^Surgery. I6i 
 
 Introdudtlon of a filver Canula through the 
 Wound into the Bladder, which fhould be three 
 or four Inches long, according to the Depth of 
 the Wound j and ahnoft as thick as a Man's 
 little Finger. It mufl be covered with Rajr 
 or Lint (that it may lie foft) and continue in 
 the Bladder two or three Days, before it is 
 taken away. 
 
 If in the Operation any very large VelTel of 
 the external Wound fliould be divided, it is 
 advifeable to tie it before the Extradlicn of 
 the Stone -, but the Neceffity of doing this, 
 does not occur once in twenty times : It rarely 
 happens that the Veflels of the Proftate burfl 
 open any coniiderable time after the Opera- 
 tion, if they did not bleed during the Per- 
 formance of it, but as it is the nature of the 
 Symptomatick Fever, to dilate the Veflels, and 
 quicken the Motion of the Blood, 'tis proper 
 to be upon our guard, efpecially in plethorick 
 People, and endeavour to obviate the Accident, 
 by taking away ten or twelve Ounces of Blood 
 from the Arm, and giving an Opiate imme- 
 diately. 
 
 There is but one Objedion more of any 
 (ponfequence, which is the danger of wounding 
 the ReBmn j and this I confefs is a very 
 Iroublefome Accident : Byt if the Operator 
 
 obferves 
 
102 T KE AT IS "E of the 
 
 obferves the Rule I have laid down with re- 
 gard to that Article, I fliould hope it might 
 always be avoided. 
 
 In this Defcription, I believe I have been fo 
 far from diiguiiing the Inconveniencies of the 
 Lateral Operation, that before I fpeak of its 
 Advantages I fiiould once again repeat, that 
 thefe Effufions of Blood are bat very rare, and 
 feldom or never mortal, when properly ma- 
 naged ', of which the World needs no better 
 Proof than the late extraordinary Succefs we 
 have cut with in our Hofpitals, which I be- 
 lieve has never been equalled in any Time, or 
 Country. 
 
 In this Method the remarkable Parts 
 wounded by the Knife are, the Miifculus 
 'Tranf-oer falls Feiiis, Levator Ani^ and Projiate 
 Gland : In the old Way, the Urethra only is 
 wounded, about two Inches on this fide the 
 Proftate, and the Inftruments are forced thro' 
 the reft of the PafTage, which is compofed of 
 the bulbous Part of the Urethra, the mem- 
 branous Part of the Urethra, the Neck of the 
 Bladder, and Projiate Ghind. This Channel 
 is fo very narrow, that 'till it be tore to pieces, 
 the Management of the Forceps is exceed- 
 ingly diiiicult, and it happens frequently, that 
 from the tender Texture of the membranous 
 
 Parts^ 
 
operations ^Surgery. 103 
 
 Parts, the Forceps are unwarily puflied thrb* 
 it between the Os Pubis and Bladder 3 be- 
 iides that in introducing the Gorget upon the 
 StafF, it is apt to flip downwards, between the 
 ReBum and Bladder, both which Inconve- 
 niencies are avoided in the Lateral Operation. 
 It is true, the Wound made in the Lateral 
 Method, will not admit of the Extradion of a 
 large Stone without Laceration, as well as in 
 the old Way ; but in the one Cafe, the Lacera- 
 tion is fmall, and made after a Preparation for 
 it by an Incifion, and in the other, all the Parts 
 I have mentioned are tore, without any pre- 
 vious Opening, and which are fo very tight 
 that the Pain of the Diilenlion, muft neceffarily 
 be exceffive. It is pity, the Operators do not 
 in the old Way always Aide the Knife along 
 the Groove of the Staff, 'till they have quite 
 wounded through the length of the Proftate, 
 fince they are convinced, that by the Extrac- 
 tion of the Stone, it is opened in a ruder and 
 more dangerous Manner than by Liciiion, 
 and without any Advantages from it 5 becaufe 
 this Opening is made by the iinifhing of the 
 Operation, whereas fbr u'ant of it berore the 
 Extradion, v.e can hardly widen the Forceps 
 enough to receive a large Stone, and when 
 We do, the Reiiliance is fo very great, as 
 
 often 
 
J 04 T R E A T I S E <?/* /^^ 
 
 often to break it, notwithftanding all our Care. 
 However, in both thefe Operations, the Sur- 
 geon muft not grafp the Stone with Violence, 
 and even in extracting, muft with both Hands 
 to the Branches of his j^orceps, refill their 
 Shutting fo tight, as the Compreliion from the 
 Lips of fuch a narrow Wound would other- 
 wife make them : Here I fpeak of the Diffi- 
 culty of laying hold of a Stone in any Part of 
 the Bladder 3 but if it happens to lie in one 
 of the Si?2ufes before-mentioned, the Forceps 
 are fo confined that it becomes ftiil harder. 
 The Extraction of very large Stones, is much 
 more impradicable with the greater Apparatus 
 than by this Method, becaufe of the fmalhiefs 
 of the Angle of the Bones in that Part where 
 the Wound is made; fo that indeed it is 
 neceflFary in ahnoft all Extractions to pull the 
 Stone downward towards the ReBiim^ which 
 cannot be done without great Violence to the 
 membranous Parts, and even the Separation 
 of one from another ; whence follow Ah- 
 fcefies and Sioughs about the Wound, which 
 is a Circumftance not known in the Lateral 
 Operation. Ecchyjncjes folloVk^ed by Suppu- 
 ration and Gangrene, fometimes fpread them- 
 felves upon the Scrotum, and in fhort, all the 
 Inconveniencies and ill Symptoms which 
 ' ■ attend 
 
operations ^Surgery; 105 
 
 attend upon the Lateral Operation, except the 
 Haemorrhage, are in a more violent Degree, 
 incident to the old Way. 
 
 An Incontinence of Urine, is not com- 
 mon after the Later^ Operation, and a Fiftula 
 feldoni or never the Confcquence of it j but 
 the Prevention of a Fiftula, feems to depend 
 very much upon the Skill of dreffing the 
 Wound afterwards, and perhaps it would not 
 fo often happen, if the Dreffing was rightly 
 managed in the old Way, though certainly 
 this Method is much more liable to them, as 
 the Wound is made among Membranes, is 
 more contufed, and in many, from an Incon- 
 tinence of Urine, is continually kept open. I 
 have feen feme Inftances indeed in the La- 
 teral Operation, where through Negled:, the 
 Bladder has remained fiftulous, but the Wound 
 being in a fisHiy Part, I have, without great 
 Difficulty, got little Granulations to ffioot up, 
 and healed it externally j fo that at prefent I 
 think a Fiftula can hardly be accounted one 
 of the Inconveniencies of cutting for the Stone 
 in the Lateral Way. ^ 
 
 The Manner of treating the Patient after 
 the Operation, is pretty nearly this : If it hap-* 
 pens, that the Veflels of the Proftate bleed, 
 dry Lint, or Lint dipped in fome ifypt;ck 
 
 Water, 
 
io6 Treatise^ th^ 
 
 Water, fuch as Aqua Vitriolic muft be applied 
 to the Part, and held there with a confiderable 
 degree of PreiTure for a few Hour?, or as I have 
 before mentioned, a iilver Caniila of three or 
 four Inches long, covered with fine Rag, may 
 be introduced into the Bladder and left there 
 two or three Days, which feldom fails to flop 
 the Hemorrhage. The Patient may alfo take an. 
 Opiate. If the Wound does not bleed, a little 
 dry Lint, or a Pledgit of Digeftive, laid gently 
 in it, is beft. The Place where the Patient lies 
 fhould be moderately cool, as Heat not only 
 difpofes the Veffels to bleed afrefh, but gene- 
 rally makes him low and faint. If foon after 
 the Operation, he complains of a Sicknefs at 
 the Stomach, or even a Pain in that Part of the 
 Abdo??icn near the Bladder, 'tis not always a fign 
 of a dangerous Inflammation, but frequently 
 goes off n\ half an Hour : To affid however in 
 its removal, a Fomentation put into an Hog's 
 Bladder, and applied pretty warm to the Part 
 in pain, will be of great fervice : If the Pain 
 increafes, after two or three Hours, the Confe-' 
 ■ quence is much to be feared, and in this Cafe, 
 Bleeding and emollient Clyfters by way of 
 Fomentation to the Bowels, are immediately 
 neceiTary. 
 
 The 
 
operations ^Surgery. loy 
 
 The firft good Symptom after the Opera- 
 tion, is the Urine coming freely away, as we 
 then know the Lips of the Bladder and proflate 
 Gland are not much inflamed ; for they often 
 grow turgid, and (hut up the Orifice in fuch a 
 manner, as not only to prevent the IfTue of the 
 Water, but even the Introduction of the Finger 
 or female Catheter, fo that fometimes we are 
 forced to pafs a Catheter by the Petiis, From 
 this Symptom too we learn, that the Kidneys 
 are not fo affeded by the Operation as to ceafe 
 doing their Office, which, tho' a very rare 
 Clrcumdance, may poflibly occur. If the 
 Patient fhould become languid, and continue 
 without any Appetite, Bliflers prove beneficial, 
 which may be applied with great Safety, and 
 little Pain -, as there is feldom or never any 
 Strangury. About the third or fourth Day a 
 Stool muft be procured by a Clyfler, for it 
 feldom comes naturally the firfl: time, and this 
 Method muil be continued as every Man's Dif- 
 cretion fhall guide him. As foon as the Patient 
 comes to an Appetite, he fliould be indulged in 
 eating light Food, with this Caution, that he 
 do not eat too much at a time : It fometimes 
 happens that a Fortnight or three Weeks after 
 the Operation, one or both Teflicles indurate 
 and Infj:ame j v/hich Diforder may generally be 
 M removed 
 
io8 Treatise of the S^ 
 
 removed by Fomentations and difcutient Ap« 
 plications 5 or if a Suppuration enfues, which 
 however is very feldom the Cafe, the Abfcefs 
 is not very difficult of Cure. 
 
 If during the Cure the Buttocks fliould be 
 excoriated by the Urine, let them be anointed 
 with Nutritum : The Dreffing from firft to 
 laft, is feldom any other than a foft Digeftive, 
 or dry Lint j for the whole Art of healing the 
 Wound, confifcs in the Force with which the 
 Doffil is applied j if it be crammed in hard, it 
 becomes a Tent, and prevents the Growth of 
 the little tender Shoots of Flefli, 'till in procefs 
 of time, from the continual Diftenfion, and 
 long Drain of the Urine, the whole Cavity 
 becomes callous, and forms itfelf into a Fiftula : 
 On the other hand, if the Wound be dreffed 
 quite fuperficially, the external Parts of it bq^^ 
 ing more prone to heal and contrad: than the 
 internal, the Confequence will be a degree of 
 Obftrudion to the Urine and Matter, which 
 lying about the. Wound of the Bladder, for 
 want of a Difcharge, will indurate that Part, 
 and likewife occafion a Fiftuia. This Method 
 of Dreffing, is not peculiar to Wounds after 
 cutting for the Stone, but is as applicable to 
 Fijltdas in Ano^ and almofi all Abfceffes what 
 foever i io that the Branch of Surgery, which 
 
 regards 
 
operations of Su rgery. log 
 
 regards the Treatment of hollow Wounds, 
 depends much more on the proper Obfervance 
 of this Rule, than the Application of particu- 
 lar Medicines. 
 
 C FI A P. XXII. 
 Of the Stone in the Urethra. 
 
 F a fmall Stone be lodged in the Urethra 
 near the Glans, it may often be pudied 
 out with the Fingers, or picked away with 
 fome Inftrument 3 but if it flops in any other 
 part of the Channel, it may be cut upon with- 
 out any Inconvenience : the befl way of doing 
 it, is to pull the Prepuce over the Glans, as 
 far as you can, and then making an Incifion 
 the Length of the Stone, through the Tegu- 
 ments, it may be turned out with a litde Hook 
 or the Point of a Probe : The Wound of the 
 Skin flipping back afterwards, to its proper 
 Situation, and from the Orifice of the Urethra, 
 prevents the ifTue of the Urine, and very often 
 beals in Twenty-four Hours. This is a much 
 lefs painful Method of extracting Stones from 
 the Urethra, than by any Inftruments that have 
 hitherto been devifed. 
 
 M z C H A F, 
 
1 10 Treatise of the -t 
 
 ' C H A P. XXIII. 
 
 Of the ExtraBion of the Stone in 
 
 Women. 
 
 'TpHE Extradion of the Stone in Wo- 
 ^ men, will eafily be underftood, fince 
 tlie whole Operation confills in placing them 
 in the fame Manner as Men, and without 
 making any Wound, introducing into the Blad- 
 der a ftraight Director, upon that, a Gorget, 
 and afterwards, the Forceps to take hold of 
 ■the Stone ; all which, may be done without 
 -Difficulty, by reafon of the Shortnefs of the 
 Urethra. If the Stone proves very large, and 
 in extracting draws the Bladder forwards, 'tis 
 advifeable to make an Inciiion through the 
 Neck of it, upon the Stone, which not only 
 v/ill facilitate the Extraction, but alfo be lefs 
 dangerous than a Laceration, which would 
 necelTarily follow. The Dreffings are Fo- 
 mentations and emollient Ointments, which 
 fhould be applied two or three times a-day, 
 and the Patient in other Refpeds be treated 
 like Men v;ho have undergone the Operation 
 for the Stone. '""'^ 
 
 PLATE 
 
P/afe.4. 
 
operations (J/^SurgeIy. hi 
 
 PLATE IV. 
 
 The Explanation. 
 
 A. A Sound ufed in fearching for the 
 Stone. 
 
 The Size reprefented here is but a little too 
 large for the youngeft Children, and may be 
 ufed upon Boys till they are thirteen or four- 
 teen Years of Age ; a larger Hiould be em- 
 ployed between that Age and Aduitnefsj when 
 one of about ten Inches, in a right Line from 
 the Handle to the Extremity, is proper. This 
 fhould be made of Steel, and its Extremity be 
 round and fmootb. 
 
 B. A Staff fit for the Operation on Boys 
 from eight to fourteen Years of Age. The 
 Staff for a Man muft be of the Size of the 
 Sound I have already defcribed. 
 
 C. A Staff fomething too big for the fmallefi: 
 Children, but may be ufed upon Boys from 
 about four Years of Age to eight. 
 
 The Staff has a Groove on its convex Side, 
 which firfl: ferves as a Diredion where to cut, 
 and afterwards receiving the Beak of the Gor- 
 get, guides it readily into the Bladder. Care 
 fhould be taken in making the Groove, that 
 the Edges of it be fmoothed down, fo that 
 M 3 ^ they 
 
12 Treatise^ //5^ 
 
 they cannot wound in paffing through the 
 Urethra, The Extremity fhould alfo be open, 
 otherwife it will be fometimes difficult to 
 withdraw the Staff, when the Gorget is intro- 
 duced, and preffes againll: the End of it. 
 
 Thefe Inflruments are ufually made with a 
 greater Bending than I have here reprefented j 
 but I think this Shape more like that of the 
 Urethra, and rather more advantageous for 
 xnaking the Incilion. 
 
 D. The Yoke, an Inflrument to be wore 
 by Men with an Incontinence of Urine : It is 
 made w^ith Iron, but for ufe muft be covered 
 with Velvet : It moves upon a Joint at one 
 End, and is faftened at the other by Catches 
 at different Diftances placed on a Spring, as 
 will be eafily underftcod by the annexed Print. 
 It muff be accommodated to the Size of the 
 Fenis, and be taken off whenever the Pa- 
 tient finds an Inclination to make Water. 
 This Inftrument is exceedingly ufeful, be- 
 caufe it always anfwers the Purpofe, and 
 feldom galls the Part, after a few Days 
 wearing. 
 
 PLATE 
 
erations ^Surgery, 113 
 
 P L A T E V. 
 
 Ihe Explanation. 
 
 A. A fmall Catheter made of Silver. This 
 Inftrument is hollow, and ferves to draw off 
 the Urine when under a Suppreffion : It is alfo 
 ufed in the high Operation to fill the Bladder 
 with Water ; Near its Extremity, are two 
 Orifices, through which the Water paiTes into 
 its Cavity. Care fliould be taken that the 
 Edges of thefe Orifices are quite fmooth. 
 
 B. The Knife ufed in cutting for the Stone : 
 It is the fame I have already defcribed ; but I 
 thought it might not be improper to repeat 
 the Figure with the Alteration of a Quantity 
 of Tow twifted round it, which makes it 
 eafier to be held, when we perform the La- 
 teral Operation, and turn the Edge upwards 
 to wound the proftate Gland. 
 
 C A Female Catheter, differing from the 
 Male Catheter, it being almoll ftraightj and 
 fomething larger. 
 
 D. A Silver- wire to pafs into either Cathe- 
 ter, for the removing any grumous Blood or 
 Matter that clogs them up. 
 
 M 4 PLATE 
 
il4 T R E A T I S E (j/" //6^ 
 
 P L A T E VI. 
 
 ^he Explanation. 
 
 A. The Gorget ufed upon Men in the 
 Lateral Oceration. 
 
 B. The Gorget ufed upon Children under 
 five Years of Age in the Lateral Operation. 
 
 A Gorget between the Sizes of thefe two, 
 v/ill be fit for Boys from five Years of Ag^ to 
 fiiteen or fixteen. 
 
 Thefe Inftruments are hollow for the Paf- 
 fage of the Forceps into the Bladder, and their 
 Handles He flanting, that they may the more 
 readily be carried through the V/ound of the 
 Proflate, which is made obliquely on the left 
 Side of it. The Beak at the Extremity of the 
 Gorget, muft be fmaller than the Groove of 
 the Staff which is cut upon, becaufe it is to be 
 received in the Groove. Care fhould be taken, 
 that the Edges of the Gorget near the Beak 
 are not lliarp,left inftead of dilating the Wound, 
 "' as it ought, it fliould only cut on each Side 
 
 \vhen introduced j in which Cafe, it would be 
 difficult to carry the Forceps into the Bladder. 
 
 Q. A Gorget, with its Handle exadfly in the 
 
 Middle ; this iliaped Inftrument is. ufed in the 
 
 old ¥/ay. All the Gorgets fliould be made of 
 
 Steel. 
 
 PLATE 
 
operations ^Surgery. 115 
 
 PLATE VII. 
 
 ^he Explanation. 
 
 A. The Forceps for extraQing the Stone. 
 Thefe are reprefented a little open, that the 
 Teeth may be better feen within-lide. 
 
 This Inilrument muft be of different Sizes 
 for different Ages and Stones, from the 
 Length of that in the Copper-plate, to one 
 of nea-r a foot long ; but the Forceps of about 
 eight Inches long will be found moft gene- 
 rally u fef ul. The number neceifary to be 
 furniflied with, will be four or five. 
 
 Great care fhould be taken by the Makers 
 of this Inflrument, that it move eafy upon the 
 Rivet, that the Extremity of the Chops do 
 not meet when they are fhut, and particularly 
 that the Teeth be not too large, left in enter- 
 ing deep into the Stone they fhould break it : 
 It is of confequence alfo that the Teeth do not 
 reach farther towards the Joint than I have 
 here reprefented, becaufe a fraall Stone, when 
 received into that Part, being held fafl there, 
 would dilate the Forceps exceflively, and make 
 the Extradion dilScult 1 on which account, 
 the Infide of the Blade§ near the Joint fliould 
 be fmooth, that the Stone may Hip towards the 
 Teeth. ^. 
 
Il6 T KE AT I s -£. of the 
 
 B. A Diredor made of Steel, ufcd for the 
 Dlreclion of the Gorget, in the Extradion of 
 the Stone from Women. 
 
 C A Scoop to take away the Stone when 
 it is broke into fmall Pieces like Sand. This 
 Inftrument is made of Steel. 
 
 CHAP. XXIV. 
 Of de EMPYEMA. 
 
 'T"^ H E Operation for the Empyema gene- 
 rally implies an artificial Opening made , 
 into the Cavity of the Thorax ^ by which we 
 evacuate any Fluid that lies there extravafated, 
 and" is become dangerous by its Weight and 
 Qiiantity. The Fluids defcribed as neceflary 
 to be avoided by this Operation, are Blood, 
 Matter, and Water. 
 
 When Blood is the Fluid, fuppofed to re- 
 quire Evacuation by this Method, 'tis always 
 extravafated through fome Wound of the Vef- 
 fels of the Lungs or Thorax^ and being dif- 
 charged in great Quantities on the Diaphragm, 
 is faid to opprefs Refpiration till let out by fome 
 convenient Perforation, made in the moft: 
 depending Part of that Cavity, which, is the 
 only kind of Perforation into the Thorax dif- 
 tinguifhed by the Name of the Operation for 
 
 the 
 
operations ^Surgery. 
 
 the Empyema : But though this Opening is 
 univerfally recommended in the Cafe here 
 ftated, yet we meet with few or no Examples 
 where it has been pradifed for a mere Extra- 
 vafation of Blood ; and I fliould think it can 
 hardly ever be advifeable on this Account : For 
 if we perform it immediately after the Accident, 
 and during the Hemorrhage, the Opening 
 made at the Bottom of the Thorax, might 
 probably make way for a dangerous EfFufion 
 of Blood, which perhaps would otherwife be 
 choked up and flopped for want of a ready If- 
 fue ; and if we wait till the Hemorrhage ceafes, 
 it becomes, needlefs, becaufe the Blood not 
 only for the mofl part, finds fome Vent by the 
 external Wound, if left open, but is conftantly 
 fpit up by the T^rachea^ fo that had we no 
 farther Proofs of this abforbent Power in the 
 Lungs, we might from hence be perfuaded of 
 the Probability of its being more fafely carried 
 off fo, than by any artificial Opening we can 
 poflibly contrive in the T^horax, 
 
 Or if it be thought that the extravafated 
 Blood, being coagulated in the Thorax^ cannot 
 be taken up by the VefTels of the Lungs, yet 
 even in that cafe, the Operation ufually prac- 
 tifed will not anfwer the Purpofe \ for beiides 
 the poffibility of the Lungs adhering to the 
 
 Pleura 
 
Treatise of the 
 
 Pleura in the place of Incifion, which would 
 abfolutely prevent any Advantage from it, the 
 Depth and Narrownefs of the Orifice, and its 
 Height above the Diaphragm, on which the 
 congealed Blood is fuppofed to lie, will make 
 the Succefs at bed but very precarious. 
 
 To empty the T^horax^ in a Rupture of any 
 Veffels which open into it, bleeding is very ne- 
 cefTary, which not only ftops the Haemorrhage, 
 by abating the Force of the Circulation ; but 
 iikewife, by unloading the Veffels of their 
 Contents, makes theni more fit to receive the 
 extravafated Fluid by Abforption : gentle Eva- 
 cuations and Pedoralsj are alfo very ferv'ice- 
 able^ and a low Diet is abfolutely neceffary. 
 
 The Rules laid down in fome Books for 
 diilinguifliing if a Wound penetrates, have led 
 Praditioners into miichievous Methods, by ad- 
 vifing them to examine thefe Wounds with the 
 Probe, or for more certainty the Finger ; whith 
 if rudely ufed, fometimes even tear into th€ 
 ^horax^ always force or prefs the Parts too 
 much, and often feparate the Lungs from the 
 Pleura, when they happen to adhere ; all 
 which Violences will produce AbfceiTes there, 
 efpecially if the Part be afterwards dreffed with 
 large Tents, or filled with any adlive Injedlion, 
 both which were formerly applied with a 
 
 View 
 
operations of Sv r g e ry. 
 
 View to deterge the Cavity of the Wound, 
 but now feem to be exploded in favour of 
 more fuperficial Dreflings -, the Advantages 
 of which Method, in my Opinion cannot be 
 too much inculcated. 
 
 But what I have here advanced concerning 
 the Excellence of fuperficial Applications, with- 
 out dilating the Wound, to make way for the 
 Iffae of the Blood or fucceeding Matter, mufl: 
 be confidered with regard to Pund:ures or Inci- 
 jfions by fliarp Inftruments, not followed with a 
 V great Difcharge : For where the Wound is made 
 by Fire-arms, the Method of Pradice muft be 
 fometimes altered 3 becaufe not only Sloughs, 
 and great Suppurations enfue, but very often 
 Pieces of the Shirt or Coat are carried in with 
 the Bullet, which will perhaps require an En- 
 largement of the Wound, in order to be freely 
 difcharged -, though even upon this Account, 
 there will be no Occaiion to make an Opening 
 at the Bottom of the Thorax, fince the mere 
 Dilatation of the Wound will more readily give 
 vent to the Pus and extraneous Bodies, than an 
 Orifice made lower ; becaufe the Lungs being 
 inflamed by the Wound, will generally adhere 
 to the Pleura, and break off the Communica- 
 tion between the Abfcefs and the Cavity below 
 it. In dreffing the dilated Wound, Care muft 
 
 be 
 
Treatise <9//f/5^ 
 
 be taken to apply the Doffils with fuch Pref- 
 fure only, as fliall be fufficient to keep open the 
 external Orifice j and not to crowd them into 
 the T^horaXy fo as to lock up that Matter, 
 whicli the very Defign of Dilatation, is to give 
 a Difcharge to. 
 
 The fecond Circumftance in which this 
 Operation takes place, is a Rupture of Matter 
 from the Pleura^ Mediajiinum or Lungs, into 
 the Cavity of the 'Thorax, where accumulating 
 it at length proves fatal for want of a Difcharge. 
 It is true that the Cafe occurs but very feldom, 
 where the Operation is necelTary j becaufe in 
 moil AbfceiTes of the Thorax^ the Matter is 
 ufually fpit up as faft as it is generated, and in 
 the Djffedtion of fuch, who have died of this 
 Species of Confumption, we rarely find much 
 extravafated Fus in the Cavity, though a great 
 Portion of the Lungs be deilroyed : However 
 as I have intimated, there are a few Examples 
 which require the Operation ; and thefe may 
 be diftinguifhed by the following Symptoms. 
 The Patient is obliged to lie upon the difeafed 
 Side, or in cafe there is Matter in both Cavi- 
 ties of the Thorax, on his Back 5 becaufe the 
 Mediajiinum can feldcm fupport the Weight of 
 the incumbent Fluid, without fuffering great 
 Pain s but this Rule is not certain, it fometimes 
 
 hap- 
 
operations of Sv r gery. I2I 
 
 happening that the Patient can lie with eafe on 
 that Side, where there is no Fluid. Another 
 Symptom of extravafated Matter, is an evident 
 Undulation of it, fo that in certain Motions, it 
 may be heard to quafh. For the moll: part too 
 upon careful Enquiry, an Oedema^ or at leaft a 
 thickening of fome Portion of the Intercoftal 
 Mufcles will be difcovered. And laftly, if there 
 be much Fluid, it will be attended with a pre- 
 ternatural Expaniion of that Side of the Chefl, 
 where it lies. When therefore thefe Signs 
 appear after a previous Pkuretic or Pulmonary 
 Diforder, and the Cafe has been attended Vv^ith 
 the Symptoms of a Suppuration, it is mofl: pro*- 
 bably owing to a Colledion of Matter -, though 
 the Patient -will alfo labour under a continual 
 low Fever, and a particular Anxiety from the 
 Load of Fluid. 
 
 I have here defcribed the Abfcefs as break- 
 ing ,into the Cavity of the Thorax j but generally 
 fpealiing, in any Inflammation of the Pleura 
 or Lungs, an Adhelion of both enfues 5 in Con- 
 fequence of which, Nature finds a Difcharge 
 outwardly, it being moft frequent for Ab- -J 
 
 fceffes of the Pleura and intercoftal Mufcles, 
 and not uncommon even for AbfceiTes of the 
 Lungs to break externally. In cafe of an Ad- 
 heiion, ao farther Operation is required than 
 
 open- 
 
122 T RE A-r 1 S E of tie 
 
 opening the Tumour when fuppurated, with 
 a Lancet -, and if the Difcharge is fo great as 
 to forbid the healing the external Ulcer, it 
 may be kept open with a hollow Tent ; by 
 which manner of Treatment many have lived 
 a long Time with a running Fiftula. 
 
 The laft Sort of Fluid faid to require Ililie 
 from this Operation, is Water, which however 
 very feldom colleds in fuch manner as to be- 
 come the proper Subjed of the Operation ; for 
 if the Dropfy of the Thorax is complicated 
 with an Anafarca^ or even AfciteSy it is certainly 
 improper, and indeed it can hardly ever take 
 place, but where the Diilemper is fmgle, and 
 takes its Rife from the fame fort of Diforder in 
 the Lymphaticks of the Pleura^ as the Hydro* 
 cele does from thofe of the Tunica Vaginalis. 
 The Symptoms of this Dropfy are, a fmall 
 Cough without Spitting, a little flow Fever from 
 the Difturbance of Refpiration ; fometimes too 
 the Water by a fudden Jirk, may be heard to 
 qualh, and generally fpeaking its Weight upon 
 the Diaphragm and Mediafiiniun are fo trouble- 
 fomc as to oblige the Patient to floop forward 
 when in an ered: Poflure, and to turn upon 
 the afFeded Side when he lies down j for the 
 fame Reafon, when there is Water in both 
 Cavities of the Thorax, he is forced to lie on 
 his Back. The 
 
operations of Surgery. 123 
 
 The Manner of operating, whether It be for 
 the Difcharge of Matter or Water, is to pitch 
 upon the mofl depending Part of the Thorax, 
 which fome have fuppofed to be between the 
 eighth and ninth Rib, and others, between 
 the ninth and tenth, at fuch a Diftance from 
 the VerteWce^ that the Depth of the Flelli may 
 not be an Impediment to the Perforation : 
 This Diftance is determined to be about a 
 Hand's Breadth ; and here, with a Knife, Scif- 
 fars, or Trocar, we are ordered to make the 
 Perforation ; but in doing it, there are a great 
 many Difficulties : In fat Perfons, 'tis not eafv 
 to count the Ribs, and the Wound will be very 
 deep, and troublefome to make % it is hardly 
 poffible to efcape wounding the intercoftal Ar- 
 tery, which runs in this Place between the Ribs; 
 or if you avoid it, by cutting clofe to one of the 
 Ribs, a Caries of the Bone will follow from the 
 Preffure of the Tent employed afterwards : 
 Again, the Iniiammation of the Wound may 
 pdflibly affed" the Diaphragm, v/hich is fap- 
 _pofed almoft contiguous to it, and this may 
 prove of very ill Confequence ; fo that upon 
 the whole, without any farther Recital of 
 Objections to the Kmpyema thus performed, it 
 cannot appear an advifeable Operation. But if 
 the only Advantage propofed by this Situation 
 ^ N of 
 
Treatise of the 
 
 of the Wound, is from ks Dependency ; the 
 Purpofe of difcharging the Fluid will be as well 
 anfweredj by an Opening between the fixth and 
 feventh Rib, half way from the Sternum towards 
 the Spine j which by laying ourfelves down, 
 becomes in effect as depending an Orifice, as 
 the other in fitting up 3 and by opening in this 
 manner, we avoid all the Inconveniences in the 
 other Method : For in this part of the Thorax ^ 
 there is very little Depth of Mufcles j the 
 Artery lies concealed under the Rib : and the 
 Diaphragm is at a great Diftance ; fo that none 
 of thofe Mifchiefs can enfue I have fuppofed 
 in the other Method ; which confequently will 
 give it the Preference. The Opening is beft 
 made with a Knife, and fhould be about an 
 Inch long thro' the Skin, and half an Inch, 
 through the fubjacent Mufcles : tho' to make 
 the Incilion with lefs Risk of wounding the 
 Lungs, it may be advifeable to dilate it with 
 the blunt-pointed Knife (as is pradifed in the 
 Operation for xkv^Bubonocele) after having made 
 a fmall Puncture with a common Knife. If it 
 fliould be objeded, that the Fluid cannot be 
 difcharged by this Orifice, while we are ered:, 
 w^hereas by making it in the lower Part of the 
 T'horaXy it will be continually draining ; I think 
 it may be anfweredj that after it is once cmp- 
 
 tied, 
 
Operatio7is ^Surgery. 
 
 tied, it will hardly in twelve Hours be generated 
 in greater Qnantity than what will lie upon the 
 Diaphragm below the Opening made even by 
 that Operation, and confequently cannot be 
 more readily difcharged by one Orifice, than 
 the other. The Treatment of the Wound will 
 be according to the Nature of the Difcharge ; 
 if after a few Days, there appears no Drain, 
 you may let the Orifice heal up, but if it con- 
 tinues, it may be kept open with a fhort filver 
 Camilaj 'till fuch time as an Alteration in that 
 Circumflance will give us leave to cicatrize 
 with Safetv. 
 
 CHAP. XXV. 
 
 Of Encyfted Tumours, 
 
 'T"^ H E S E Tumours borrow their Names 
 from a Cyft or Bag, in which they are 
 contained 3 and are farther diftinguiflied by 
 the Nature of their Contents : If the Matter 
 forming them refembles Milk-Curds, the Tu- 
 T^but' IS called Atheroma j if it be like Honey, 
 Meliceris ; and if compofed of Fat, or a fuety 
 Subilance, Steatoma. The two firft are not 
 readily diilinguifhed from one another, but their 
 Difference from the Steatoma is eafily learnt by 
 their Softnefs and Flud:uatIon. Thefe Tumours 
 appear in every Part of the Body, and in Places 
 N 2 where 
 
Treatise of the 
 
 where there are no Glands ; which, with the 
 Circumftances of their Compofition continuing 
 always the fame from their firfl Formation, 
 agrees but little with an Opinion fome of the 
 Moderns are fo fond of, that this kind of Swel- 
 ling is an obflruded Gland, whofe Membrane 
 forms the Cyft, and whofe Fluids, when they 
 burft out of their VeiTels after a long Obfbruc- 
 tion, make the Matter contained. 
 
 The Steatoma is never painful, 'till by its 
 Weight it grows troublefome, nor is it a Mark 
 of general Indifpofition of Body ; fo that the 
 Extirpation feldom fails of Succefs. The Size 
 of fom.e of them is very large, frequently weigh- 
 ing five or fix Pounds, and there have been 
 Inftances of their weighing above forty. 
 
 When the Steatoma is irregular in its Sur- 
 face, with Eminencics and Depreffions, it is 
 fuety s whereas the fat one is for the moif part 
 of a uniform fmooth Outiide. The Operation 
 for the Steatoma will be underftood by the 
 Defcription of that for the Scirrhus. 
 
 The Atheroma is much m.ore common than 
 the Meliceris^ at lead, if all encyfted Tumours 
 with Matter not curdled, may in compliance 
 with Cuftom, be called fo : Thefe are more 
 frequent, and grow larger than thofe where the 
 Matter is curdled, being often attendant on 
 
 fcro- 
 
operations of Surgery. 
 
 fcrophulous Indilpofitions, which makes them 
 more difficult of Cure. 
 
 The Cyfts of thefe Tumours, with the Skin 
 covering them, after a certain Period of Growth^ 
 refifling any furiher Enlargement, do fre- 
 quently inflame and break 3 but this Opening, 
 is not fo advantageous for the Cure, as Extir- 
 pation by the Knife, which Ihould be done 
 in the Infancy of the Swelling. When the 
 Tumours are no bigger than a fmall golden 
 Pippin, they may be differed away from un- 
 der the Skin, by making a ftraight Inciiion only 
 through it -, but if they exceed this Bulk, an 
 oval piece of Skin mufl be cut thro' firfl:, to 
 make room for the Management of the Knife 
 and taking away the Tumour -, m which cafe,- 
 it v/ill be advifeable to take off the upper Por- 
 tion of the Cyfl with the Skin, and then by 
 the Help of a Hook to diffed; away as much 
 of the Remainder of it as can be conveniently, 
 which is a lefs painful, and more fecure Me- - 
 thod than deflroying it afterwards with Ef- 
 charoticks : This Rule is to be obferved, when 
 the Cyft runs fo deep amongft the Interflices 
 of the Mufcles, as to make it impoffible to 
 remove the whole of it, where if vv^e cut off a 
 great Quantity, the reft ufualiy comes away 
 in Sloughs and Matter. I once opened a re- 
 N 3 mark- 
 
Treatise of the 
 
 markable Atheroma of this kind -, it was about 
 as big as the Crown of a Man's Hat, and lay 
 underneath the Pedoral Mufcle (as all I ever 
 met with on the Breaft have done) extending 
 itfelf towards the Armpit, amongft the great 
 Veflels, and preflnig againft the Clavicle : I 
 cut away a large circular Piece of the Skin, 
 Pedtoral Mufcle, and Gyft, but did not dare 
 to touch the lower Part of it, which I could 
 not remove without laying the Ribs bare ; 
 however, it feparated in the Digeftion of the 
 Wound, which for fome time difcharged 
 exceflively, and the whole Cavity filled up, 
 leaving him the Ufe of his Arm almoft per- 
 fect : After this, two or three fmall Splinters of 
 the Clavicle worked away through the Skin, 
 but without any great Inconvenience. 
 
 The Ganglion of the Tendon is an encyfied 
 Tumour of the Meliceris kind, but its Fluid 
 is generally hke the White of an Egg -, when 
 it is fmall, it fometimes difperfes of itfelf ; 
 PrelTure, and fudden Blows, do alfo remove it, 
 but for the moft part, it continues, unlefs it be 
 extirpated : It is no uncommon Cafe to meet 
 with this Species of Ganglion, running under 
 the Ligamenfum Carpale, and extending itfelf 
 both up the Wrill: and down to the Palm of 
 the Hand. The Cure of this Diforder cannot 
 
 be 
 
operations ^y^SuROERy. 129 
 
 be effedted but by an Incifion through its 
 whole Length and dividing the Ligame?2tum 
 Carpdie, which I have performed fuccefsfully 
 feveral times. 
 
 The DreiTing in thefe Cafes does not at all 
 differ from the general Methods of treating 
 Wounds. 
 
 CHAP. XXVI. 
 
 Of the Amputation of the Cancer d 
 and Scirrhous Breast. 
 
 ^np' H E Succefs of this Operation is exceed- 
 ingly precarious, from the great Dif- 
 podtion there is in the Conftitution after an 
 Amputation, to form a new Cancer in the 
 V/ound, or fome other Part of the Body. 
 When a Schirrus has admitted of a long De- 
 lay before the Operation, the Patient feems to 
 have a better Profpedt of Cure without dan- 
 ger -of a Relapfe, than when it has increafed 
 very fait, and with acute Pain. I cannot how- 
 ever be quite poiitive in this Judgment, but 
 upon looking round amongft thofe I know 
 who have recovered, find the Obfervation {o 
 far well-prounded. There are fome Surgeons, 
 fo difheartened by the Ill-faccefs of this Ope- 
 ration, that they decry it in every Cafe, and 
 N 4 even 
 
130 T K E A T I B "E of the 
 
 even recommend certain Death to their Pa- 
 tients, rather than a Trial, upon the Suppoii- 
 tion it never relieves j but the Inftances, where 
 Life and Health have been preferv^ed by it, 
 are fufficiently numerous, to warrant the Re- 
 commendation of it. 
 
 The Scirrhous may be diflinguiflied, by its 
 want of Inflammation in the Skin, its Smooth- 
 nefs and Sipperinefs deep in the Breafl, and ge- 
 nerally, by its pricking Pain, which as it is more 
 or lefs, increafes the Danger accordingly ; tho' 
 there are fome few with little or none in the 
 Beginning : As the Tumour degenerates into a 
 Cancer, which is the worll Degree of Scirrhus, 
 it becomes unequal and livid, and the VelTels 
 growing varicous, at lafl: ulcerates. 
 
 In extirpating the Scirrhus, if it be fmall, a 
 longitudinal Incifion will dilate fufficiently for 
 the Operation, but if too large to be diifedied 
 out in that manner, an oval Piece of Skin muft 
 be cut thro' firfi, the Size of which is to be 
 proportioned to that of the Tumour ; for exam- 
 ple, if the Swelling is five Inches long, and three 
 broad, the oval Piece of Skin cut away muft be 
 nearly of the fame Length, and about an Inch 
 ' and a half in Breadth. In takingoft the whole 
 Breafl, theSkin,may be very much preferved, by 
 1 making the Wound of it a great deal lefs than 
 
 the 
 
operations (^/'Surgery. 131 
 
 the Bafis of the Breaft, which muft be carefully 
 cleared away from the Pedoral Mufcle : This 
 is not difficult to do, becaufe all thefe Scirrhufes 
 being enlarged Glands, are encompailed with 
 their proper Membranes, which make them 
 quite diftind from the neighbouring Parts, and 
 eaiilv feparabie ; at leafl: this is the Cafe, when 
 the Tumour is moveable ; for fometimes it ad- 
 iieres to the fubjacent Mufcle, and that Mufcle 
 tQ the Pvibs 3 in which Circumftance, the Ope- 
 ration is irapradicable. When it is attended 
 with Knots in the Arm^pit, no Service can be 
 done by Amputation, unlefs the Knots be taken 
 away; for there is no fort of Dependance to 
 be laid on their fubiiding, by the Difcharge of 
 the V/ound of the Breaft : The Poffibility of 
 extirpating thefe Knots, without wounding 
 the great Veffels, is very much queftioned by 
 Surgeons 3 but I have often done it, when 
 they have been loofe, and diftindt. 
 
 The Bleeding of the large Arteries is to be 
 flopped by paffing the Needle twice through 
 the Flefli, almoft round every Veffel, and 
 tying upon it, which will necelTarily include 
 it in the Ligature. In order to difcover the • 
 Orifices of the VefiTels, the V/ound muft be 
 cleaned v^ath a Spunge wrung out of warm- 
 Water. 
 
 The 
 
132 Treatise of the 
 
 The fcirrhous Tumours which appear about 
 the lower Jaw, are generally fpeaking fcro- 
 phulous Diforders, that diftinguifh themfelves 
 almoft by the Circumfcance of fixing on the 
 Salivary Glands. Thefe are very ftubborn of 
 cure, but not fo bad as the Scirrhus, fince they 
 frequently fuppurate, and heal afterwards : If 
 they impoithamate again after healing, 'tis for 
 want of a good Bottom, which may fometimes 
 be procured by dellroying their bad Surface with 
 a Cauftick, and is a Method I have often prac- 
 tifed with extraordinary Succefs. Befides thefe, 
 > there is another Species of Scirrhus in the Neck, 
 that fucceeds better after Extirpation, than 
 either of the former kinds 3 this is an Enlarge- 
 ment of the Lympbatick Glands, which run 
 clofe up by the Jugular Vein, and is diftinguifh- 
 able from Cancers of this Part, by its Moveable- 
 nefs, want of Pain, the Laxnefs of the Skin co- 
 vering it, the fmall Degree of PrefTure it makes 
 on the OEfophagus and Trachea ; and laftly the 
 good Habit of Body, as it feidom aifeds the 
 Conftitution, which Cancers here do very early, 
 after their firfl Appearance. This Tumour, 
 from its Situation, requires great Exadnefs in 
 the cutting off: the laft I took away of this 
 kind, I feparated from the Jugular Vein near 
 the length of an Inch and a half : they fome- 
 times 
 
. operations ^Surgery. 133 
 
 times extend up to the Chin towards the 
 Mouth, and occafion a Divifion of the Sali- 
 vary Dud: in operating, which proves very 
 troublefome to heal, but when all other Me- 
 thods have failed, may be cured by a Perfora- 
 tion into the Mouth, through that Part of the 
 Cheek where it is wounded, which by a Tent 
 or fmall Seton may be made fiftulous ; then by 
 dreffing upon the Outlide, the Oozing of the 
 Saliva that Way v/ill be prevented, and the 
 external Orifice healed without Difficulty. 
 
 The Treatment of all thefe Wounds may 
 be with dry Lint firfl, and afterwards as in the 
 common incifed Wounds. 
 
 CHAR XXVII. 
 
 Of the Operation of the Trepan. 
 
 ''T^ H E Operation of the Hrepan^ is the 
 making one or more Orifices, through 
 the Scull, to admit an Inftrument for raifing 
 any Pieces of Bone, that by Violence are beat 
 inwards upon the Brain ; or to give iffue to 
 Blood or Matter, lodged in any part within 
 the Cranium* 
 
 Fractures of the Skull are at all times very 
 dangerops, not in confequence of the. Injury 
 
 done 
 
134 Treatise of the 
 
 done to the Cranlwn Itfelf, but as the Brain 
 becomes aiiefted either from the Preflure of 
 the fradured Bone, or that of the extravafated 
 Blood and Matter. If then the Symptoms ex- 
 cited by a Fra(5ture, do fometimes follow from 
 a mere Extravafation of Blood, as is the Cafe 
 when the Crminim is not beat inwards, it mud 
 likewife happen that a Rupture of the Veifels 
 of this Part, without a Fradure, will alfo 
 occaiion the fame Diforders : For this reafon, 
 the Operation may take place, where the Scull 
 is not much offended, but only the VelTels 
 of the Dzira Mater and Pia Mater. 
 
 -The Writers on this Operation, have de- 
 fcrlbed the different Diforders in which it is 
 ufeful, under a great Variety of Names ; but 
 thofe few general ones, which all Surgeons are 
 acquainted with, are quite fuflicient for the 
 underftandins: the Nature of every Cafe that 
 can happen. 
 
 When the Cranium is beat inward, without 
 any Fracture, it is called a Depreffion ; v/hen 
 very much broke, a Fradure ; or if broke and 
 beat in alfo, a Fradure with Depreffion 5 if it 
 is only cracked, without Depreihon, though 
 properly a Fradure, it is called a FilTure ; if 
 none of thefe Diforders appear, where there 
 is a Sufpicion of them, the Symptoms are 
 
 imputed 
 
operations (jTSurgery. 135 
 
 ' imputed to a Concuffion of the Brain. Thefe 
 are the four Diftincftions in ufe, and which 
 fully comprehend all the others. 
 
 The Depreffion of the Cram't/m without a 
 Fradure, can but feldom occur, and then it 
 liappens to Children whofe Bones are more 
 pliable and foft than thofe of Adults : I have 
 met with one Inflance of this myfelf in a Girl 
 of feven Years of Age : v/hen ilie firfi received 
 the Injury, (he had the Complaints of an op- 
 preffed Brain ^ but they foon went off j the Blovir 
 formed a large Tumour on the Parietal Bone, 
 for which /he was put under my Care fome 
 Days after the Accident 5 1 opened immedi- 
 ately into it, by cutting away a circular piece of 
 the Scalp, and took out a great Quantity of gru- 
 mous Blood lying underneath the Feriofteum ; 
 I then d relied the Depreffion with dry Lint, 
 and finding no Complaints come on, continued 
 the fame Method, 'till in about fix Weeks fhe 
 was perfedly cured. 
 
 In Blows of the Cranium^ requiring the ufe 
 of the Trepan, the Marks of a Fradture are 
 generally very evident, iince the Scalp is often 
 lacerated lo much, as to expofe it to our Sight : 
 But if the Wound of the Scalp be fo fmall, as 
 only to admit a Probe, we mufl: judge then by 
 the Feel of the Surface of the Bone, ufing the 
 
 Caution 
 
136 T ^E AT I s z of the 
 
 Caution of not miftaking a Suture for a Frac- 
 ture, which Hippocrates confefTes he himfelf 
 did ; tho' for his frank Confeflion of an Error, 
 to prevent others being milled, he is as much 
 recommended to Pofterity, as for any of his 
 other Qualities. 
 
 If there be no Wound of the Scalp, you muft 
 prefs about the Head with your Fingers, 'till 
 the Patient complains of fome particular Part, 
 which in all likelihood is the place affeded, and 
 if the Scalp there be feparated from the Cra- 
 , niii??2^ is almoft infallibly fo : The Symptoms 
 of a Fradure, are, a Bleeding at the Ears and 
 Nofe, a Lofs of Senfe, Vomitings, Drowfmefs, 
 Delirium, Incontinence of Urine and Excre- 
 ment J but what is moft to be depended upon, 
 is aDepreffion of the Bone, or a Roughnefs on 
 its Outfide ; for ail the other Complaints, not 
 only happen to Concuffions, which recover 
 without the Application of a Trepan, but like- 
 wife there are Fradures not attended with any 
 of them, or at leaft in a flight degree ; fo that 
 thefe Symptoms alone, without Examination 
 of the Part affeded, are but an uncertain Rule 
 to go by. 
 
 In Concuffions without a Fradure, that pro- 
 duce the Symptoms here laid down, and do well 
 afterwards, the VelTels of the Brain and Mem- 
 branes 
 
operations of S v r g e ky: ijy 
 
 branes are only inflamed and dilated; or if they 
 are ruptured, they abforb the extravafated 
 Blood again -, on which account, Nature fhould 
 be affifted by plentiful Bleedings, Clyfters, 
 and other Evacuations, and fo in all Fradures 
 where the Patient is not trepanned immedi- 
 ately j however, although People with Con- 
 cuflions in the violent Degree I have ftated, do 
 fometimes recover, it is fo very feldom, that 
 there can be no Pretence, when they happen, 
 for negledling the Trepan, but not being able 
 to learn in what Part the Concuffion is. The 
 Opportunities I have had of opening fome 
 People who have died under this Circumftance, 
 have fufficiently convinced me how little is to 
 be trufted to any other Method than an Open- 
 ing for the Difcharge of the Abfcefs, which 
 by Confinement of the Matter becomes very 
 large, fpreading over a great Quantity of the 
 Brain before it kills. 
 
 Writers difpute very much about the Pof- 
 fibility of the Contfa-Fijfurej or a FifTure oc- 
 cafioned on the Part of the Head oppofite to that 
 on which the Blow is given, or vi^here the inner 
 Table is fradured, while the outer one re- 
 mains intire j but there are Hiilories of Cafes, 
 which, if fairly ftated, make it unqueftionable j 
 and this is mofl certain, that if the Complaint 
 
 be 
 
138 T R E A T I S E ^ /& I 
 
 be at a Diffance from where the Blow w' " 
 received, there can be no Danger in Scaljiing, 
 and applying the Trepan to that Part'"Ovh^i^fe 
 the Pain is. 
 
 There are Surgeons, who fay that the 
 Veirels of the Diploe do fometimes by a Con- 
 cuflion break, and that the Matter making its 
 Way through the inner Table of the Scull 
 into the Brain, requires the Trepan i but I 
 believe there is no very good Authority* for 
 this Affertion. 
 
 When we are afiiired of a Fradture or De- 
 preffion, though the Symptoms in a great mea- 
 furc go offj and notwithftanding there are a 
 few Hiftories in Authors, where we read, that 
 Patients have furvived without the Operation, 
 it is in my Opinion always advifeable to trepan 
 as foon as pofiible, in order to prevent the 
 fpreading of the Abfcefs, which feldom fails to 
 follov/ upon the Rupture of the VefTels of the 
 Brain and Membranes, and for the mod part 
 in a few Days ; tho' there are a great many 
 Inftances of Fractures, no^ bringing on a fatal 
 Abfcefs, for a great length of Time afcer the 
 Accident. 
 
 1 once trepaned a young Woman about a 
 hundred Days after flie received the Blow^ ; the 
 lower Part of the Parietal; and upper Part of the 
 
 Temporal 
 
rf Operations of Surgery. 
 
 Temporal Bones, were fradured and deprefied; 
 fhe had bled at the Nofe and Ears when flie 
 firft received the Injury, and had at times 
 been droufy, and in fome little Pain, 'till to- 
 wards the ninetieth Day, when the Symptoms 
 of a compreffed Brain came on flronger, and a 
 Imall time after, flie put herfelf under my Carej 
 which, with the many Inftances of the fame 
 kind to be met with in Authors, (hew how 
 little fafe it is, to trufl to any Extravafation or 
 Depreffion on the Brain doing well, without 
 the Afliftance of the Trepan. 
 
 The Manner of treating a Fradlure of the 
 Cranium, will be according to the Nature of the 
 Fradure itfelf, and the Injury of the Scalp ^ if 
 the Wound of the Head be tore into Angles, 
 perhaps cutting off the lacerated Flaps will 
 make room for the Saw ; if the Bone be broke 
 into feveral Pieces, the Pieces may be taken 
 away with the Forceps 3 or if fome of the ScuU 
 be alfo depreifed, the removal of the Pieces will, 
 without perforating, make way for the Eleva- 
 tor to raife the depreffed part j but if the Fraq- 
 tcre be not complicated with a Wound of thp 
 Scalp, or tlie \¥ound is too fmall to admit of 
 the OperatioLL which feldom fails to be the 
 Cafe, then the Fradlure muft be laid bare, by 
 taking- away z kiige Piece of the Scalp. It is 
 '" ■ ' " O a fafhion 
 
1 4:0 Treat t s £ of the 
 
 a-fadiion with fome Surgeons, to make^ cru- 
 cial Incirion for this Purpole, which they prefer 
 to the other Merhody upon the Suppofition 
 that the Wound will more eafily heal again 
 after the Operation, by urning down the Flaps; 
 and in cafe we find no Fradure, which fome- 
 times happens after fcalping, that by making 
 this Species of Wound, an Exfoliation of the 
 Bone and tedioufnefs of Cure will be avoided. 
 But whoever has feen the Pradice of the cru- 
 cial Incifion, muft be fenfible of the falfe Rea- 
 foning ufed in its favour ; for it feldom happens 
 that vjiQ inquire for a Fradure of the Scull by 
 fcalping, but that the Scalp itfelf is contufed, 
 which Circumftance generally bringing on a 
 , pientifol Suppuration, and the Matter lodging 
 between the Cranium 2X\A Skin, not only prevent 
 their immediate healing, but generally occafion 
 -.a Cariesof the Bone, which is the Jlccident 
 : meant to be fliunned by it ; and frequently at 
 ' lafl-, the Lips of the Wound, growing callous, 
 require cutting off, to procure a Cicatrix. .If then 
 .the Objedioa be good, to the crucial 'Jncifion, 
 :when no Operation -is performed, it becomes 
 : of fo much more force when we arealTured 
 . of . ufmg tlie Trepan, that I think it is^ndif^ 
 . .putably right at all times, to take ofl'th'e Scalp 
 when we lay bare the Crmdtim- with a view to 
 
 the 
 
Oferatmts ;;^ S u e G fi^ k y. 
 
 •the Opei-ationi whicl^feldom, fails; to g-iiaBukte 
 ^ith plefli in afewDays, if dreffed lonly' wjtb 
 -dry^ Lintf and rarefy: giiows Giiiriausvaf J5iit '^'i- 
 'jfeded by a great Difcharige of Matter frorn; the 
 . Brarrij -and even in that'.Gafe but faperficially •, 
 or if after it is thusiexp^fed^ new FM> Hioiild 
 ■^.mk- generate tippn its; Surface, ibe-j Grbwth of 
 It may be quickened by boring little 'Qriijces 
 into the Subftance of the Bone, ot rafping'it 
 with the Rugine. The form of the piece taken 
 away may be nearly circular, and to be better 
 ^i;airared of the courfe of the Fradurc,: it will be 
 proper it fliould be of the whole length of it; 
 . I believe there are few wiii care.to expiOfe fo 
 much naked Scull, but whoever; knows the 
 -great Advantage and the little Danger of it, 
 .will not helitate. When the Scalp iis removed, 
 : 1^/Feriof.eiim mufl be; raifed, .and the Arteries 
 immediately tied, which will make^vt^ayii^ir the 
 Operation to be direclly performed;;); though 
 •;.the;EfFufion of Blood has been efteemedi (o 
 trdubiefome ix^i this Partj as to have made it 
 \aImoft an univerfal Pradice to poftpone the 
 ufeof the Trepan to the Day after ; but the 
 £,-) A|>prehenfion is without foundation ; for if 
 .■r:two.:or three of the larger Vcllels are tied, the 
 : r-OJthers may eafily be flopped with a little dry 
 :.• Li-nt, and the Operation take place without 
 ' ''? O 2 any 
 
142 T R E A T I S E ^ /^^ 
 
 any Inconvenience, which I have always done 
 myfelf, and. would recommend to others, 
 confidering how urgent the nature of the 
 Diftemper is, and that lefs than twenty-four 
 Hours is often the Difference between Life 
 and Death, when the Brain is much preffed. 
 by a fradured Bone. 
 
 Before the Application of the Trepan, it is 
 to be remembered there are certain Places on 
 the Scull, where it cannot be ufed with fo much 
 Safety as on others 5 the whole length of the 
 Sagittal Suture, down to the Nofe, is always* 
 mentioned as one where the Perforation is dan- 
 gerous, becaufe of the Spine of the Os Frontis^ 
 and the courfe of the fuperior longitudinal Sinus 
 under this Part, which it is fuppofed would be 
 necelTarily wounded by the Saw, and in con- 
 fequence deftroy the Patient by the Hemor- 
 rhage j but though a Perforation may, contrary 
 to the general Opinion, be made over the Sijius 
 without offending it, and even if it was wounded, 
 the Effufion of Blood would not in all pro- 
 bability be mortal, (as I have feen in two In- 
 ftances,) yet at beft it would be very trouble- 
 Ibme ; and fince we are not ftraitened in that 
 parr of the Cranium for room, I think it is ad- 
 vifeable to forbear operating in this Place. The 
 bony Siniijts of the Oi Front! s^ forbid the \^{^Qi 
 
 the 
 
Operauomof$VKGnm^^i^ 143 
 
 tlie Trepan near the Orbits of the Eyes j there- 
 fore if it (hould be deprefled near thofe Cavi- 
 ties, the Surgeon muft be careful to perforate 
 either above, or on one fide of the Fradturej 
 for fawing below it, will only lead into the 
 Si;2USj and anfwer rio Purpofe in the defign 
 either of giving a Difcharge to the Matter 
 from the Brain, or an opportunity to elevate 
 the Depreffion 5 nay perhaps leave an incu- 
 rable Fiftula, if the Patient efcapes with 
 Life. ^ 
 
 The Os Occipitis being very uneven, both 
 in its internal and external Surface, makes Tre- 
 panning there almoft impradicable ; belides, 
 the great 5/«z^i run about fo much of it, as 
 hardly to afford fpace to perforate without 
 danger of wounding them 5 but then it is fo 
 defended from Injuries by its Situation and 
 Strength, that Fradures do not happen to it fo 
 often as to the btheir Bones of the Cranium % 
 and when they do, for the mofl part, they 
 become fo foon mortal, by affeding the Q-'r^- 
 bellumvA\\<^ it fuftains, that the Operation is 
 feldem required in this cafe. Indeed the upper 
 Angle of this Bone lies above the Cerebellum^ 
 and when fradured or depreiTed, is not attended 
 with fa immediate Danger J but. when this ^ 
 happens, the courfe of the longitudinal Sinm 
 O 3 down 
 
144 T R E A T I s E of the 
 
 down through the middle of it, and the neigh-* 
 bourhood of the lateral Sihvfes beneath it, make 
 it advifeable to trepan at the lower part of the 
 Os Parieiaky or at leaA: upon or juft helow 
 the Lamdoidal Suture, fo that the Perforation 
 of the Os Occipitis can hardly ever be proper. 
 
 It may be obferved I have fpoke of Wounds 
 of the Cerebellum as proving inevitably mortal, 
 when affecfted by a Fiadture : How long a Pa- 
 tient may continue with Matter on its Surface, 
 I cannot take upon me to fay, but I believe 
 there is no Inftanceof a Cure after an Abfcefs j 
 and as for Wounds of it, they are generally 
 almoft inftantaneous Death -, whereas fome-i 
 times great Portions of the Cerebrum have been 
 carried off, or deftroyed, \vithout any notable 
 Inconvenience. From this -great Difference 
 of Danger, in x^ffedions of the Cerebrum and 
 Cerebdliuny has arifen the Opinion, that the 
 firfl, is the Organ of Animal Motion only, and 
 the other, of Vital, ' ■ ' 
 
 The Places then unfit to admit the Saw, are 
 the three I have defcrihed 5 that is, the Sagittal 
 Suture J that Part of the Oi Frontis near the 
 Orbits of the Eyes ; and the Os Occipitis. But 
 when a Fradure happens in any other part 
 above the Ear, there is no Objedtion to the 
 Operation. When there is only a fmall Fiffure 
 
 without 
 
Operatiom t?/ S u r g e r y. 145 
 
 without any Depreirion or Motion in the Bone, 
 the Trepan may be applied on the Fiflure itfeif, 
 which will more readily give vent to the Blood 
 or Matter underneath, than if made af adif- 
 tahce. If the FilTure be large, and the Bone 
 weakened or depreiled, the Trepan" mtrft be 
 applied on one lide of it, but fo as to make it a 
 Part of the Circumference of the fawed Piece ; 
 if the Fradure runs upwards, it will be eligible 
 always to perforate near its bottom, becaufe the 
 dependency of the Orifice will give better Iflhe 
 to the Matter, though the ill-grounded Appre- 
 henfion of the Brain i'aUing out there,"has made 
 many eminent Surgeons contradid: this Rule in 
 their Pradice. If by making one Orifice/you 
 cannot raife all the depreffed part, yoii muft 
 make a fecond and a third, and continue doino- 
 fo, '^till you have reduced the v^ho\Q Craiihim 
 even: there is frequently occafion to repeat it 
 twice or thrice, and it has been done twelve 
 times, nay oftener, with Succefs, which Imen-" 
 tion, to fhew the little danger there is, either in 
 fa wing the Scull, or expofing the Dura Mater 
 and Brain, when the Preilure is taken off. 
 Indeed the mifchief of laying the Brain bare, 
 is fo fmall, compared with a ConcuiTion of it, 
 or an Abfcefs from pent-up Matter, that thofe 
 Fradures of the Scull, wheK the Bone is broke 
 ■ O A '- ijvto 
 
146 T R E A r 1 s E of ^/je 
 
 into splinters the whole extent of it, and can 
 be taken away, much more readily do well, 
 than a iimple FiiTure only, where the Abfcefs 
 cannot difcharge itfelf freely j for which reafon, 
 though the deprefled Fracture may be raifed by 
 the means of one Orifice, yet if it is of a con- 
 iiderable length, it will be almoft abfolutely ne- 
 ceffary to make one or two more Openings, for 
 the convenience of Difcharge j fince for want 
 of this, we fee AbfcelTes increafe daily in their 
 quantity of Matter, and at the end of a few 
 Weeks, carry oit the Patient. Thofe that are 
 converfant in the Diifedion of Ferfons dying of 
 this Diforder, will be convinced of the force of 
 this Reafoning, fince they not only conftantly 
 jfind Pus lodged on the Brain, as far as. the 
 FJflure extends, but all round about it, fome- 
 times fpreading over a quarter of its Surface. 
 
 In Concuflions of the Brain without a Frac- 
 ture of the Cra7iium, if the Trepan be applied, 
 and vaft Difcbarges enfue, it will be alfoco|i'7 
 venicnt to make more Perforations into the 
 Abfcefs and the neighbourhood of the Abfcefs, 
 the Situation of which, will be eafily gueffed by 
 the direcftion of the ilream of Matter, . And 
 here it is to be obferved, that AbfcelTes which- 
 enfue from a ConcuiTion,. are generally wore 
 exteniive and dangerou?, than thofat which 
 
 atcompai>y 
 
operations of S urge r y. i 4.7 
 
 accompany a Fraflure with Depreffion ; for in a 
 Fradture^ the yielding of the Bone deftroys, in 
 a great degree, the Force ofthe flriking Body, 
 and prevents any violent Commotion of the 
 Brain ; fo that v^^h at the Brain fuiFers, refults 
 chiefly from the Freflure of the incumbent 
 Bone, and the Laceration of the Veffels, near 
 the Fradlure ; whereas when the Cranium 
 refifts the Shock, all, or great Part of the 
 Cerebrum fuftains the Concuffion, and is often 
 impoflumated or inflamed almofl: in its whole 
 Dimenfion, as we find upon opening thofe 
 who die of this Diforder. 
 
 The Manner of Trepanning is this : Having 
 flxed your Patient's Head fteady, either on 
 the Bolder of a Bed, or by placing him in a 
 low Ghair ; with the Pin of your SaWi uiark 
 the Center ofthe Piece of Bone to be taken out| 
 then with the Perforating Trepan, make an 
 Orifice deep enough to receive the Pin, which 
 being fixed in it, will prevent the Saw from 
 flipping J and thus you are to continue fawing, 
 'till the Impreflion made will preferve the 
 Steadinefs without the Pin, when it is to be 
 taken away, for fear of its wounding the Brain 
 before the Saw has entered through the Cra- 
 nitim-, which it would do at lafi, becaule of its 
 Projedion. In working through the Bone, the 
 
 Teeth 
 
1^.8, Treatise of the 
 
 Teeth of the Saw will begin to dog, by that 
 time you arrive to the Diploe^ wherefore a Brufli 
 niufl: be ready to clean it every now and then j 
 and with a pointed Probe you muft clear 
 away the Duft in the Circle of the trepanned 
 Bone, obferving if it be deeper on one Side than 
 the otlier, to lean afterwards on that Side where 
 the Impreffion is lead, that the whole thick- 
 nefs may be fawed thro' at the fame time. To 
 -do all this with lefs Interruption, it will be 
 proper to bave two Saws ofexadly the fame 
 Diamejter, that an, Afnftant may be brufhing 
 one while you operate with the other. We are 
 advifed to faw boldly^ 'till we come to the 
 jD//>/^^, which, it is faid, will always diftinguifli 
 itfelf by the Bloodinefs j but however this is 
 not a certain Mark to go by ; for tho' where 
 there is a Dipke^ \i will manifeft itlelf by its 
 Bloodinefs, yet fometimes.the Sculi is fo very 
 thin as not to admit of any ; in which cafe, if 
 ah Operator fhould p.ufli on his Inftrument in 
 expectation of meeting with this Subftance, 
 he would unwarily wound the Brain. This is 
 not very often the cafe, but however often 
 enough to put a Man on his guard, and make 
 him enquire whether the Bone be loofe after a 
 little fawing, which is the only Rule we go by 
 when we have pafled thro' the D-iphCf and 
 
 may 
 
operations ^Surgery. i 49:^ 
 
 may as well be attencled to, before coming at 
 it, without any confiderable lofs of Time. 
 When it is quite fawed through and lies Idofe, 
 it may be taken away with the Forceps, con- 
 trived for that life; and if the lower Edges^ 
 of the Orifice, next to the D/^rj M^/^r, are 
 iplintered, they may be fcraped fmooth With 
 a Lenticular. " . - . . ..^:i;i .;>: 
 
 Thefe are the chief Proceffes of this' Ope- 
 ration of the Trepan ; the only thing remaining 
 to be done, is ! with an Elevator introduced at 
 the Orriice to raife the Dcpreffion, or broken 
 Splinters, if they cannot otherwife be laid hold 
 of, and to draw out the grumbus Blood, or 
 any other extraneous Body. If tbe Dura Ma^ 
 Ur be not wounded or tore, an Incifion mufl 
 be made through it, to give way to the Blood 
 oi: Matter, which almoffc certainly lie tinder- 
 neath it, if the Symptoms have been bad, and 
 none has been difcharged from between the 
 Cranium and Tiiira Mater : Though it has been 
 lately; obferved that an Abfcefs will fometimes 
 be formed in the Subftance of the Brain ; and 
 therefore if the Pun(fture of the P/^r^ M^/^r; 
 does not procure an Evacuation of the Matter, 
 and the Symptoms of a Suppuration are ftill 
 urgent, it will be advifeable to make a fmall 
 Incjfion with a Lancet ijnto the Br^in itfelf. 
 
 I have 
 
I ^O T K Y. A 1 1 S "E of the 
 
 I have ufed the Word Trepan all along, for 
 the fake of being better underftood ; but the 
 Inflrument I recommend is a Trephine, the 
 Advantages of which, as alfo that of a cylindrical 
 Saw, or one nearly cylindrical, are defcribed 
 in the Explanation of the Copper-plate. 
 
 With regard to the Drcflings of thefe 
 Wounds, I think it is very certain, that as the 
 greateft part of the Evil, proceeds from the 
 Quantity and Prefliirc of the Matter, whatever 
 approaches towards the Nature of a Tent, and 
 increafes its Quantity and Prefliire, by locking 
 it up, mufl be pernicious : Therefore, I would 
 exclude the ufe of all Syndons whatever j the 
 hafty Application too of Spirits of Wine, which 
 is fo commonly advifed, cannot be proper 5 as 
 they are not only unfit for Inflammations in 
 general, but alfo crifp up the Yeflels of the Dura 
 Mater and Brain, and flopping the Suppura- 
 tion, foinetimes produce a Gangrene. Since 
 then a clofe Application is inconvenient, and 
 whatever good there may be in Topical Medi- 
 cines, it cannot for the moft part be commu- 
 nicated to the Abfcefs, by reafon of its extent 
 beyond the Orifice, the befl Remedy will be 
 dry Lint only, which mufl be laid on loofely to 
 give vent to the Matter, and be repeated twice 
 a-day *till the Difcharge is leffen*d, when once 
 
 in 
 
Pa^j^J- 
 
 F/ai 
 
operations ^Surgery. 151 
 
 in twenty-four Hours will be fufficient to the 
 finifhing of the Cure, which will be fomething 
 retarded by the Exfoliations that fometimes 
 follow this Operation. The Patient afterwards 
 may wear a Plate of Tin upon the Scar to de- 
 fend it from Blows or any accidental Injury. 
 
 PLATE VIII. 
 
 The Explanation. 
 
 A. The Perforator, commonly called the 
 Perforating Trepan. With this Inftrument, an 
 Orifice is ufually made for the Reception of 
 the Pin, on the Center of the Piece of Bone 
 that is to be taken away, in the Operation of 
 Trepanning ; though if the Pin be very (harp, 
 and projedt but little beyond the Teeth of the 
 Saw, as in that marked with the Letter JB, the 
 Perforator would be needlefs ; but as the Point 
 of the Pin prefently grows blunt with Ufe, and 
 in that cafe, it is difficult to fix the Saw, I 
 think it advifeable to have this Inftrument in 
 readinefs. It is alfo handy for boring into the 
 Subftance of the Bones, in order to promote a 
 Granulation of Flefli on their Surfaces : When 
 it is made ufe of, it muft be received and 
 fafiencd in the Handle C. 
 
jr^2 T RE A T ^;;S K^y(^ th) : 
 
 1, .iiE^.. -The Crown, or Saw of the Trepan, with 
 the Pin appearing juft beyond the Extre- 
 mities of the Teeth. It may be obferved, the 
 Shape of this Saw is cylindrical, differing from 
 thofe in ufe which are all Conical, and fome, 
 in as .very great Degree. Surgeons have gene- 
 rally conceived great Advantages to arife from 
 this Form : Firfl:, as a Circumftance of the 
 utmod Importance, they have imagined there 
 would be danger of injuring the Brain, by faw- 
 ing too fuddenly through the Crajuum^ if the 
 Enlargement of the Saw did not increafe the 
 Obftrudion, in proportion as they advanced to- 
 wards it, and make the working of the Inftru- 
 ment exceedingly flow. It has alfo been believed, 
 that ynlefs the Saw was fmaller near the Teeth, 
 than^owards its Bails, it would be impoffible 
 to incline it on any part where it had not made 
 fo deep an Impreffion as in others, in con fe- 
 quence of which, one fide of the Circle would 
 be fa wed through, and the Membranes or Brain 
 injured, v^^hile on the other, perhaps the Sii-W 
 would not have penetrated through the.- fif ft 
 Table of the Cranium :■- The laft : rernarkable 
 Argument in favour of the Conic Sawv.is,-that 
 it, more, readily admits, and afterwacd^^.i'etaiRS 
 • the fa\yed piece of Bone. injtS:CaMity,j?But I 
 think, all tlie Advantages attributed^tP ife Fi- 
 
Operatio?ts ^f S u r g e r v. 153 
 
 gure are almoft imaginarjr j and the gi^eat La- 
 bour of working (o flowly and diflicultly, is not 
 only very inconvenient to an Operator, but by 
 no means ferviceable to the Operation ; for not- 
 withftanding the fau^ be Cylindricai, and works 
 without any other Impediment than what lies 
 before the Teeth, yet even with this Advan- 
 tage, the Operation goes on fo gradually, that 
 from the Experience I have had, I do not iind 
 the leaft danger of fuddenly paffing throu<>h to 
 the Brain as is apprehended, if vv^e proceed with 
 the Caution of not leaning too hard oh the 
 Inftrument when the Bone is almoft fawed 
 through ; and with refped: to the Impracti- 
 cablenefs of inclining it on any particular part 
 of the Circle, when fawed uneven, which is 
 commonly alledged, whoever will try the Ex- 
 periment, will in a moment difcover the Falfe- 
 nefs of the Ailertioo ; befides, t\it very In- 
 fiance ftated overthrows this reafoning, for if 
 the Circle has been already made deeper in one 
 part than another, it muft imply that we 
 have leaned with more Force on one part than 
 another, and confequendy may at pkafure do 
 the fame thing again : As to ^nQ laft fuppofed 
 Advantage, of its receiving and retaining the 
 fawed piece of Bone in its Cavity, the Benefit 
 would be fo frivolous, if it had truly the Prefe- 
 rence 
 
I^/|. T R E A T I S E 2/* //5^ 
 
 ' rence of the Cylindrical one in that refped, tha€ 
 it would not be worth mentioning -, but in fadt, 
 the Cylindrical Saw receives the piece of Bone 
 very readily, and often retains it in its Cavity. 
 
 C. The Handle of the foregoing Inftrument, 
 called the Trephine, which is much preferable 
 to the Trepan, (an Inftrument like a Wimble 
 ufed by Joiners) becaufe of the great Conveni- 
 ence of holding it, and leaning on one lide or 
 other of the Saw, as we find it neceflary : The 
 Trepan however, though allowed to be un- 
 handy, is the Inftrument moft ufed by Surgeons 
 in other Parts oi Europe, upon the Suppolition 
 of its working quicker than the Trephine. 
 
 I have reprefented the Trephine of fuch a 
 Shape as to make it a convenient Elevator, for 
 which purpofe the Extremities of it are made 
 rough. 
 
 £). A Key to take out the Pin E, when the 
 Saw has made an Impreflion deep enough to 
 be worked without the help of it. 
 
 £. The Pin. 
 
 PLATE IX. 
 
 I'he Explanation. 
 
 A. A convenient Forceps to take out the cir- 
 cular piece of Bone, when it does not ftick to 
 
 the 
 
operations of S v r g e kYs t^^ 
 
 the Saw : the Contrivance by whlcJi'they rea- 
 dily lay hold of it, is to make the Extremities 
 that are to grafp it, with an Arch of the fame 
 Circl<i as the Saw is. Upon one of the Handles, 
 there is added a little Elevator, to lift up any 
 fmall Splinter of Bone, but it is not of much ufe. 
 B. A Lenticular : the forepart of its Blade is 
 fharp, in order to fcrape the lower Edge of the 
 Orifice of the Cranium, in cafe any Splinters 
 fliould remain after the Operation, and the 
 Button at its Extremity receives the Duft, that 
 it may not fall on the Brain ; but there is feU 
 dom any Occafion for this Inflrument, and I 
 have never myfelf been under the Neceffity of 
 ufing it. 
 
 - 'C. A Rugine, or Rafpatory, which I have 
 recommended for fcraping Bones, in order to 
 promote Granulations of Flefh. The Handles 
 of thefe two lafl: Inftruments are Wood, 
 -whereas eviery Part of the others fhould be 
 n>ade of Steel. 
 
 CHAP. XXVIIL 
 Of the Cataract. 
 
 npHE Cataradt, called by the Latlnes, 
 
 ^ Siiffiifio, is a Difeafe of the Cryftallihe 
 
 Humour, rendering the whole Body of it 
 
 P opakej 
 
T56 Treatise of the 
 
 opake, fo that the Rays of Light, which in the 
 natural State of its Tranrparency, were tranf- 
 mitted to the 'Timica Retma, become now to- 
 tally intercepted, and produce no Efted. This 
 is pretty nearly the Account delivered down to 
 us bv Hippocrates and the ancient Greeks, who 
 likewife knew it by the Name of Glaucoma, 
 Galen was perhaps the firft, who fpecified any 
 Difference, in defining the Catarad to be a Film 
 fituated behind the Iris; and iho, Glaucoma^ a 
 Diforder of the Cryftalline Humour y which 
 Opinion, with very little Alteration, has pre- 
 vailed from his Time, down to the latter End 
 of the feventeenth Century, when there arofe 
 a Difpute on this Diftindion of Galen s, fome 
 of the Moderns afiertiiig with Hippocrates, that 
 the Catarad: is always a Difeafe of the Cryftal- 
 line Humour, and indeed with fo much Reafon, 
 that there is now hardly any one v/ho doubts 
 it : However, during thefe laft forty Years, 
 this Subjed has produced many Arguments oa 
 both Sides. 
 
 The Mathematicians having obferved in 
 thofe who have been couched, that the Defed 
 of Sight remaining after the Operation, anfwers 
 nearly to what in Optics, the removing the 
 Cryftalline Humour would occafion, have en- 
 deavoured to prove, that the Operation mutl in 
 
 'cncfe- 
 
Operatio7js (2/*Surgery*, 157 
 
 confequence be, the depreffing that Humour, 
 and leaving the Eye to perform its Fundion 
 afterwards with the Aqueous and Vitreous only j 
 which wanting the Denlity of that Humour, 
 will not refrad: the Rays fufficiently to re- 
 unite them on the Ketina 3 whence Patients 
 after their Cure are obliged to ufe Convex 
 GlafTes, as Subditutes for the deprefled Cry- 
 ftalline Humour. 
 
 Y^t, Petit, a moft accurate Anatomift of 
 Paris, has from a critical Examination of the 
 Figure of the Eye, argued againfl: the Foffi- 
 biiity of a Film's Exiftence in the Pofterior 
 Chamber, by reafon of the Smallnefs of that 
 Chamber, or Proximity of the Cryftalline 
 Humour to the back of the Iris; and again, 
 from the Impracticability of dillodging fuch 
 a Film, without offending the found Cryftal- 
 line Humour. 
 
 Laftly, and what is more certain, Anato- 
 mifts have frequently diifeded the Eyes of 
 Perfons under this Diforder after their Death, 
 and have found it to be always an Opacity of 
 the Cryftalline Humour, agreeably to the De- 
 finition of a Glaucoma : fo that by confequence, 
 we muft underftand the Words CataraB and 
 Glaucoma, as fynonymous Terms, fince they 
 are in fad, but one and the fame Difeafe. 
 
 P 2 I think 
 
158 T V. E A T I s E of itie 
 
 I think 'It needlefs to flate the Reafons on 
 the other Side of the Queftion, as they are of 
 little weight, and indeed almofl univerfally 
 exploded. 
 
 In defcribing the Nature of a Cataradl, it 
 has hitherto been a pofitive Maxim laid down 
 by Oculifts of every Nation, that there is one 
 certain Stage of the Diftemper, in which only, 
 the Operation is proper, and this State of the 
 Difeafe, is faid to be the Maturity of the Cata- 
 rad: : They have compared it to the Ripenefs of 
 Fruits, and have fuppofed a regular Change in 
 the Confiftence of the Cryftalline Humour, 
 from the Moment it is affected. They fay, 
 the Difeafe upon Its firft Invafion, gradually 
 liquefies the Humour, and that after its Ar- 
 rival to the utmoft Period of Liquefadlion, it 
 then begins to acquire various Degrees of 
 Tenacity, 'till at lafi: it becomes perfedly hard, 
 or as they flile it, horny : That the Skill of 
 the Surgeon difcovers itfelf, by fixing on that 
 Time for the Operation, in which the Flui- 
 dity of the Cataract is no Obftacle to the 
 Depreffion of it, from its want of Refinance 
 to the Needle j nor its Hardnefs, from the 
 Elafticity of Its connefting Fibres, which im^ 
 mediately return it to its former Fofition. 
 
 This, 
 
operations ^Surgery. 159 
 
 This, in a few Words, is the general Doc- 
 trine J but I think the regular Alteration of the 
 Denfity of the Cryftalline Humour is very 
 much to be doubted, and for my part I cannot 
 help poiitively excepting to the Rule here laid 
 down ', having not only feen Cataradts of twenty 
 or thirty Years growth, often upon the Touch 
 of the Needle prove foft and milky, but alfo 
 many Inflances, in which a due Degree of 
 Coniiftence occurred after four or five Months j 
 I may venture to fay Days, when the Cataratl 
 was the Confequence of a Blovv^ or Pundure ; 
 both which Cafes, fo little correfpond v/ith 
 this fuppofed Change, that they feem not only 
 to overthrow it, but to imply, that the Cata- 
 rad", after it has acquired its total Degree of 
 Opacity, may frequently, if not generally, 
 continue in the fame ftate of Tenacity to the 
 Life's end : And tho' 1 will not take upon me 
 to affirm that Catarads come always very early 
 to their greateft Confidence, yet this we may 
 fafely deduce from thefe Obfervations 5 that 
 whenever they become intirely opake, v^e may 
 properly undertake the Operation j which has 
 been my method, of Practice hitherto, nor do 
 I find any Reafon to lay it afide. 
 
 I fliall however obferve in this Place, that 
 
 contrary to the received Opinionj I have upon 
 
 P Q Examina- 
 
3 6o T K E A 'V I S "E of tJje 
 
 Examination, found Catarads of a proper 
 Confluence to be couched, long before they 
 would have been opake ; but this only confirms 
 what J have already laid down, that there is 
 not fuch a regular Change in them as has 
 been fuggefted, and that we may always ven- 
 ture on the Operation when they are quite 
 opake 3 fince it might be fuccefsful as I have 
 here intimated, even before that time ; though 
 I fhould never advife it, nor do I believe that 
 Patients would fubmit to it, whilil they en- 
 joyed a certain degree of Sight. 
 
 Since then the Glaucoma is no other Difeafe 
 than the Catarad:, we muft at once difcard the 
 Diftindion of thefe two Diftempers as merely 
 imaginary ; and from what has been faid with 
 regard to the Confiftence of a Cataract, that 
 whatever it be, the Removal of the Humour is 
 the fole End of the Operation, the Diftindion 
 of a true and falfe Catarad will appear equally 
 frivolous 5 and confequently moil: of the Sub- 
 divifions comprifed under this laft ; fuch as the 
 Bag, the Milky, the Purulent, the Doubtful, 
 the Membranous, the Fibrous, the Shaking, 
 and many more, in the Books on this Difeafe ; 
 the greatefl: part of which, are Names that 
 puzzle the Memory, without informing the 
 Underflanding, and indeed, have not a fuffi- 
 
 cient 
 
Operatmis ^j/'Surgery. i6i 
 
 cient foundation in Nature, but owe their di- 
 verlity of Chara6ler more to the-Imagination of 
 Writers, than any real Variety in the Difeafe. 
 
 The general Criterion of the Fitnefs of Ca- 
 taracts for the Operation, is taken from their 
 Colour J the Pearl-coloured, and thofe of the 
 Colour of burniilied Iron, are efteemed proper 
 to endure the Needle ; the White are fuppofed 
 milky, the Green and Yellow horny and incu- 
 rable : The black Cataradl is defcribed by mofl 
 Authors, but I dare fay, has been miftaken for 
 a Gutta Sere?2a^ where no Difeafe appearing, 
 the Pupil feems black as in a natural ftate of the 
 Eye : And as to the Green one, I have not as 
 I remember, in a great number of Catarads, 
 met with a lingle Inftance of it, but poffiblv 
 it may be in Nature ; and one would indeed 
 imagine the Defcribers of it could not be mif- 
 taken, in what mufl have been fo evident. 
 
 The Depreffion of a Catarad: of any Colour 
 would be the Cure, if that alone was the Dif- 
 temper of the Eye ; but it generally happens, 
 that the Yellow Catarads adhere to the Iris fo 
 firm as to become immoveable 3 befides, when 
 they follow in Confequence of a Blow, which 
 is often the Cafe, either the Cells of the Vi- 
 treous Humour are fo much difturbed and 
 broken^, or the Kethta affeded, that a degree 
 P 4 of 
 
Treatise of the 
 
 oFBIindnefs will remain, though the Cataradl 
 be depreffed, and that one Caule removed. 
 
 To judge whether the Catarad adhereS;,;tG, 
 the im, if you cannot at once diftinguidi it by 
 your Sight, fliut the Patient's Eye, and rub 
 the Lids a little ; then fuddenly opening it, 
 you will perceive the Pupil contrad, if the 
 Cryftaliine Humour does not prevent the 
 Adion by its Adhefion : And when this is 
 the cafe in any kind of Catarad, the Operation 
 can hardly be advifed, though where the Ad- 
 hefion has been flight, I have now and then 
 performed it with Succefs. 
 
 Another Confideration of the greatefl mo- 
 ment, before undertaking the Cure, is to be 
 afTured of the right ftate of the Tunica Retina, 
 which is very readily learnt, where there is no 
 Adhefion of the Catarad, from the Light fall- 
 ing between the Iris and Cryftaliine Humour, 
 which if the Eye is not fenfible of, it is a 
 certain L^dication of another Malady, and ab- 
 folutely forbids the Operation. Generally, this 
 Catarad takes its rife from Head-achs, Con- 
 vuhions, and nervous Diforders. How the Eye 
 perceives in this cafe, vide the Copper-plate. 
 
 The Operation for the (oft Species of Cata- 
 rad, which may perhaps properly be ftiled 
 Milky, has been by forne Writers- falfly faid 
 
 never 
 
operations o/'Surgery. 163 
 
 never to fucceed. Of this there are two forts j 
 feme where we do not perceive any Mem- 
 brane, but which are almoft uniformly foft, 
 and admitting the Needle through them as 
 through Water, are confequently immoveable ; 
 and others where the Humour is liquefied, 
 and contained in its own Membrane, now 
 pretty much thickened by the Difeafe, which 
 laft frequently does well ; for upon breaking 
 the Membrane, the Fluid burfls out and pre- 
 cipitates, and the Membrane itfelf, if it is not 
 deprefled, in procefs of time fhrinks into a 
 fmall Compafs, or waftes quite away. 
 
 Whether the whole Cataradl after its fub- 
 liding continues to lie at the bottom of the 
 Eyej or- is quite wafted by being feparated from 
 its Vefi'els, I have never had an Opportunity of 
 knowing pofitively by dilTeding one that had 
 been couched ; but by Vv^hat we fee of thofe, 
 which have not been totally depreffed below 
 the Pupil, and continue in that ftate for ever 
 aftefi we may fuppofe that they only wafte a 
 little : I know one Inftance of a Woman whofe 
 Cataract after couching, became quite loofe in 
 the Eye, and in an ered: Pofture funk to the 
 bottom, but by ftooping the Head forward, 
 {he could bring it quite over the Pupil. On 
 the other hand, I pnce couched a Perfon, 
 
 when 
 
164 Treatise of the 
 
 when i^pon the firfl Attempt to deprefs the 
 Catarad: it fuddenly fprung up, and made its 
 Way thro' the Pupil into the Anterior Cham- 
 ber of the Eye, where I left it without en- 
 deavouring to difiodgs it again. In about fix 
 Weeks it began to dimiiilil:, and at the End 
 of XQXi Weeks was entirely wafted, and the 
 Patient faw extremely weii. 
 
 When none of the Objedions I have ftated, 
 forbid the Operation, it may be thus done : 
 •Having placed your Patient in a convenient 
 Light, and in a Chair fuitable to the Height of 
 that you yourfelf fit in, let a Pillow or two be 
 placed behind his Back, in fuch a manner, that 
 the Body bending forward, the Head may 
 approach near to you 3 then inclining the Head 
 a little backward upon the Breaft of your 
 Affiftant, and covering the other Eye fo as to 
 prevent its rolling, let the Alliftant lift up the 
 fuperior Eye-lid, and yourfelf deprefs a little 
 the inferior one : This done, ftrike the Needle 
 thro' the Tunica ConjunBiva^ fomething lefs 
 than one tenth of an Inch from the Cornea^ 
 even with the Middle of the Pupil, into the 
 pofterior Chamber, and gently endeavour to 
 deprefs the Cataradl with the flat Surface of 
 it. If after it is diflodged, it rifes again, though 
 not with much Elafticity, it muft again and 
 
 again 
 
operations of Sv k gury. 165 
 
 again be pufhed down. If it is membranous ; 
 after the Difcharge of the Fluid, the Pelli- 
 cule muft be more broke and deprefled : If it 
 is uniformly fluid, or exceedingly c'aftick; 
 we muft not continue to endanger a terrible 
 Inflammation, by a vain Attempt to ftfcceed. 
 If a Catarad of the right Eye is to be couched, 
 and the Siirgeon cannot ufe his left Hand fo 
 dextroufly as his right, he may place himfelf 
 behind the Patient, and ufe his right Hand. 
 
 I have not recommended the Speculum Oculi, 
 becaufe upon the Difcharge of the Aqueous 
 Humour through the Puncture, the Eye be- 
 ing fomewhat emptied, more readily admits 
 of the Depreffion of the Cryftalline Humopr, 
 than when prefled upon by the Inftrument, 
 
 As to the Method of treating the fucceed- 
 ing Inflammation, (when it happens, for fome- 
 times there is none) lean advife nothing parti- 
 cular, but to refrain from thofe Collyria, that 
 are charged with Powders -, for the thinner 
 Parts flying off, leave a gritty Subfl:ance in the 
 Eye, which muft be pernicious : Bleeding, and 
 other gentle Evacuations are found abfolutely 
 necefi'ary. The Ufe of cool Applications ex- 
 ternally, is moft eafy to the Eye ; but after 
 all, there vs^ill fometimes enfae a troublefome 
 Ophthalmy, which, with the Uncertainty there 
 
 always 
 
|66 1l ^E AT IS E of ths 
 
 dways is of Succefs after the Operation, have 
 deterred tnofi: Surgeons from undertaking it, 
 and 'till lately from ftudying the Nature of the 
 Difeafe 3 but I fancy the Operation will come 
 into greater Repute, when more generally 
 jpfadifed by Men of good Charader 3 for it is 
 iefs the Difiicultyj than the Abufe of it by Pre- 
 tenders, which has brought it into Difcredit. 
 
 Since the Publication of the fixth Edition of 
 iKis Treatife, a Method of removing the Ca- 
 tarafl by opening the Cornea^ and extracting 
 the Gryftalline itfelfj has been difcovered. 
 The Experience of a little more Time will 
 Evince whether it be preferable or not to the 
 &ld Operation. For the Manner of perform- 
 liig it, and the Succefs attending it, I muft 
 refer the Reader for the prefent to the Philo- 
 Jophical Tranfa6iio?2Sy and to the third Edition 
 of my Critical Enquiry ^ where I have faid all 
 I yet know on this Subjed* 
 
 CHAP. XXIX. 
 
 Of Cutting t/je I R 1 s, 
 
 ^^ HERE are two Cafes where this Ope- 
 ration may be of fome Service ; one, 
 ^hen the Gatarad is from its Adhefion im- 
 moveable J and the other, when the Pupil of 
 the Eye is totally clofed up by a Diforder of the 
 
 Mufcular 
 
operations (?/*Surgery, i6j? 
 
 Mufcular Fibres of the Iris, which gradually 
 contrading the Orifice, at laft leaves the MerQa 
 brane quite imperforate. This laft Diftempef 
 has hitherto been deemed incurable. Th© 
 Adhefion of the Cataracft I have ipoke of in th@ . 
 preceeding Chapter, and confidered it as a Spe= 
 cies of Blindnefs not to be relieved : But Mr? 
 Chefelden has invented a Method of making an 
 artificial Pupil, by flitting the /m, which may 
 relieve in both the Inftances here dated. 
 
 In doing this Operation, the Patient mud 
 be placed as for couching, and the Eye kepi 
 open and fixed by the Speculum Oculi, which 
 is abfolutely neceifary here, for the very Reafon 
 I would difcard it in the other j fince the Fhc^ 
 cidity of the Membrane from the IlTue pf tb@ 
 Aqueous Humour, would take away itp pror^ 
 per Refiftance to the Knife, and make \% 
 inftead of being cut through, tear from th§ 
 Ligament wn Ciliare : then introducing th@ 
 Knife in the fame Part of the Co?7Jun^iva ypii 
 wound in couchixng, infinuate it with its Bladi 
 held horizontally, and the Back of it towards 
 you, between the laigame^itum Ciliare an^ 
 Circumference of the /m, into the anterior 
 Chamber of the Eye, and after it is advaqcgd 
 to the farther Side of it, make your Incijtipii 
 quite thro' the Membrane ; and if the Opera..^ 
 
 • tiP3 
 
i68 T K ^ A r I s "E. of the 
 
 tion fucceeds, it wilJ, upon wounding, fly open, 
 and appear a large Orifice, though not fo 
 wide as it becomes afterwards. 
 
 The Place to be opened in the /m, will be 
 according to the Nature of the Difeafe : if the 
 Membrane itfelf be only affeded with a Con- 
 tradion, the middle Part of it, which is the 
 natural Situation of the Pupil, muftbecutj 
 but if there be a Catarad, the Inclfion muft be 
 made above or below the Catarad, though I 
 think it more eligible to do it above. 
 
 The contraded /m, from a paralytick Dif- 
 order^ is fo often complicated with an Affec- 
 tion of the Retina, that the Succefs is very pre- 
 carious in this Cafe. This Operation, by what 
 I have feen, has anfwered beft in Adhelions of 
 the Cryftalline Humour, though to fpeak truly, 
 but very feldom even there. As I would not 
 millead any one who fhall pradife an Opera- 
 tion not yet much known in the World, I do 
 confefs that either the Danger of the Iris 
 feparating from the Ligamentum Ciliare, or o£ 
 the Wound not enlarging fufficiently, do upon 
 the whole make the Event very doubtful. I 
 once performed it with tolerable Succefs, and 
 a few Months after the very Orifice I had 
 made, contraded, and brought on Blindnefs 
 again. Since it has been difcovered by the 
 
 Ex- 
 
operations of S v r g e r y: 169 
 
 Extradion of the Cryftalline, that a large 
 Wound may be made through the Cornea 
 without any bad Confequence. I fliould ima- 
 gine this Operation would be much improved 
 by introducing the Knife perpendicularly thro' 
 the Cornea and /m, and cutting both at the 
 fame time, fo that the Incifion of the Iris 
 fliould be exadly in the fame Part, and of the 
 fame Dimenfion as by the other Method. 
 
 In thefe two Chapters I have not once ufed 
 the Word Uvea, but have made mention of the 
 Ligamentiim Ciliare^ two or three times ; both 
 which Parts are but little underflood for want 
 of proper Explanation ; , but which mufl be 
 rightly conceived of, in order to underlland 
 what I have faid upon thefe Difeafes. 
 
 The generality of Anatomifls call that 
 Membrane which I have fpoke of under the 
 Name of Iris, the Uvea, and its anterior La-' 
 mina, the Iris 5 others again, call the Mem- 
 brane^ l/w^, and the Colour of it, Irisy but 
 both one and the other Diftindion confound 
 Learners exceedingly, and take their rife from 
 a want of proper Attention to the Hiftory of 
 Anatomy. The Ancients, who have given moil 
 of the Names we now employ in the Defcrip- 
 tion of the Eye, were verfed chiefly, if not 
 altogether, in the Diire(5tion of Brutes^ amongft 
 
 which 3 
 
I yO T R E A T I S E ^ /v5^ 
 
 which, thofeof the graminivorous kind, have 
 a party-coloured Choroides, one half of it being 
 dark, and the other of a light fhining Green ; 
 this laft, from its Refemblance to an unripe 
 Grape, was called the Uvea ; but the fucceed- 
 ing Writers amongft the Moderns, applying 
 themfelves to human Diffedions only, and not 
 duly confidering the Difference of the human 
 Choroides, which is nearly of an uniform Co- 
 lour, and of that above defcribed, have retained 
 the Appellation, though we have not the Thing. 
 Hence has arifen the great variety of Mifap- 
 plication of this Word, which ought no more 
 to be fpoke of in the Anatomy of the human 
 Eye, than the Tunica NiBitanSy which is pro- 
 per to certain Beafts and Birds. 
 
 The Ligamcfitum Ciliare is that circular 
 Line on the Globe of the Eye, where the 
 Sclerotis, Choroides, Retina, Cornea, Procejfus 
 Ciliares, and Iris, terminate ; forming a whitifh 
 Ring fomewhat denfer than any other Part 
 of the Coats ; but fince the Inltitution of this 
 Term, the Defcription of the Part it implies, 
 has been very much negledted, and the Term 
 itfelf confounded with the Procejfia Ciliares ; 
 wherefore it was neceiTary to define it, that the 
 Procefs of the Operation of the Iris might be 
 better comprehended, 
 
 PLATE 
 
R2f.qr. 
 
 P/ate. '0. 
 
 A 
 
leratimis of ^\j kge^y, tyt 
 
 P L A T E X. 
 
 Th Explanation. 
 
 ^. The Couchlng-Needle, the broad Part 
 of which towards the Point is flat on one Side ; 
 but on the other, is a little convex, to give it 
 more Subftance and Strength. 
 
 The Handle of this Inftrument is white 
 Ivory, inlaid with a Streak of Black in that Part 
 of it lying even with the convex Surface of the 
 Blade : The Meaning of which is, that by 
 holding the Handle with the Streak upwards, 
 v/Q may be guided to deprefs the Membrane of 
 a milky Catarad with the ilat SurfacCj tho' the 
 Subftance of the Catarad: fwimming in the Eye- 
 obfcures the Needle, and prevents its being 
 direded in a proper Polition by the Sight. 
 
 B. A Speculum OcuU, which is made to open 
 or {hut by an Iron Button Hiding along a Slit in 
 the Handle. This Inilrument is compofed of 
 one Piece of Steel, in fuch a manner that it would 
 fly open by its Eiafticity, if the two Branches of 
 the Handle were not confined by the Button. 
 The Circle of it iliould be covered with Vel- 
 vet, to make it lie fofter on the Eye-lids. 
 
 C. The Knife for cutting the /m, the Blad^ 
 of which has but one Edge. 
 
 Z). The Figure of the Eye* 
 
 Q^ The 
 
172 T K E A r I s ^ of the 
 
 The fmall Arch on the Forepart of the 
 Figure,- is the Cornea ; the two ftraight Lines 
 tending to each other are the Iris, and the 
 Opening between them is the Pupil -^ the Space 
 between the Cornea and the Iris, is the anterior 
 Chamber of the Eye ; the Spheroidal Body is 
 the Crjjlalline Humour j the Space between the 
 Jris and Cryftalline Humour, is the tcjierior 
 Chamber ; and the two fliort Lines which 
 arife from the meeting of the Cornea^ Iris^ &c, 
 and run upon the Cryftalline Humour, are the 
 Procejfus Ciliares. The Delign of this Repre- 
 fentation is to fliew the Smalhiefs of the pof- 
 terior Chamber, and how fome Light may 
 pafs obhquely between the Iris and Cryftalline 
 Humour, thro' the Interllices of the Ciliary 
 ProcelTes, and occafion that Degree -plf. §ig})t . 
 which People with Cataracts have. -,;r vt; -,. 
 
 C H A P. XXX. 
 
 , Of the F I S T U L A L A C H R Y M A^tl &, 
 
 •""T^ H E Fijlula Lachry?naUs is generally 
 underftood to be fuch a Diforder of the 
 Canal,? leading from the Eye to the Nofe, as 
 obftruds the natural Progrefs of the Tears, and 
 makes them trickle down the Cheek : But this 
 
 . : - ■' is 
 
operations of Su r g'e r y. 17! 
 
 IS only the firft and hiildeil Stage of the DIf- 
 eafe J ih the next, there is Matter difchjirged 
 with the Tears from the PimBd Lachryfrialia^ 
 and fometimes'from an Orifice broke thro' the 
 Skin between the Nofe and Angle of the Eye • 
 The laft and v/orft Degree of it is, when the 
 Matter of the Abfcefs, by its longContinuance^ 
 has not only corroded the neighbouring foft 
 Parts, but alfo afFeded the fubjacent Boiie. 
 
 For the better underflanding the Seat and 
 Nature of this Diflemper, I have here annexed 
 a Reprefentation of the Lachrymal Duds. 
 
 In treating 'of the Fiftula LachrymaJiSy mofl: 
 Writers mention the Inflammation and Ulce- 
 ration- of the ^accus, as being fometimes the im- 
 mediate Caufes of it 3 but then they all fuppofe^ 
 that the Tears becoming acrid and eorroiivej 
 excite the Inflammation and Abfcefs • thouf^h 
 many of them imagine that the Tears them- 
 felves not finding a way thro' the Nafal Dud:, 
 do, from flagnating in the Sacciis^ corrupt and 
 become the Matter difeharged by the FunSia 
 Lachrymali j but the latter Opinion is moffc 
 certainly ill-grounded 5 for belides that thfe 
 Tears are -not of a Gontpofition to become Pus, 
 it may- be obferved almoft at any time upon 
 prefTing the Abfcefs, that the two Fluids ap- 
 ^ pear unmi)ied ; and with regard to the general 
 Q_2 Dod- 
 
f 74 T R E A T I S E <?/' //3^ 
 
 Dodriiie of the Sharpnefs of the Tears pro- 
 ducing the Diforder, I think it is much to be 
 queftioned ; fmce the Cornea and 'Twiica Con- 
 
 jiinciiva being more fenfible Membranes than 
 the Sacciis, would more readily be offended 
 by them ; but as v/e fee they are not in the leail 
 injured, and every Part of an Animal Body is 
 fubjedl to Inflammation, &c. from internal 
 Caufes, I believe this external one may be 
 juftly doubted. 
 
 Whatever be the Caufe of the Inflammation, 
 whether the Small~pox, Lues Venerea, &c. the 
 Effect of it, is an Obilrudion of the DuBus 
 {id Nafiim, That a total Obftrudion fhould fol- 
 low upon an Inflammation in fo large a VefTel 
 as the Nafai Dud, I prefume is owing to its 
 Situation in the bony Groove of the Os Unguis ^ 
 which not allowing it to dilate in its Inflam- 
 mation and thickening, muft neceffarily make 
 it fill up the whole Channel, and caufe that 
 Rep-urgitation of Tears and Matter, vvhich is 
 the confiant Symptom of this Difeafe. 
 
 Some Years fmce, Mon(leur^;z7Z!?//a French 
 Surgeon, recommended in the recent Fiftula, 
 to pafs a fmall Probe thro' one of the PunSla 
 Lachryinalia into the Sacctis and Nofe, in order 
 
 "to break the Concretions which were fuppofed 
 to make the Obflrudion, and with a fmall 
 
 Pipe 
 
operations ^Surgery. 175 
 
 Pipe and Syringe to throw an Injedion tbro* 
 the other, in order to wafh them away. This 
 Method was at firft received with great Ap- 
 plaufe, and foil continues to be pradifed by 
 fome very eminent Surgeons ; yet by v/hat I 
 have been able to learn from the Experiments 
 of others, and the reafon of the Thing, I am 
 by no m.eans inclined to think favourably of 
 the Invention ; for as the very CharaderiHic 
 of this State of the Fiftala, is the Pveflux of 
 the Tears from- the Saccus, the Channels lead- 
 in?? to it from the FimSia Lachrymalia mufb 
 be fuppofed clear ; and as to the Obflrudion 
 in the Nafal Dud 3 an Injedion thrown with 
 fo Httle Force, can hardly be imagined fuffi- 
 cient to remove it -, and ilill lefs, if it be true 
 that the Obftrudion is not owing to any loofe 
 Subftance clogging up the Paffage, but to an 
 Inilammation of the Membranes. 
 
 If then the Injedion cannot affifl by the Force 
 of its Stream, the Advantage mufl arifefrom its 
 balfamick Qualities \ but no Surgeon at this 
 time dilates an Abfcefs of any kind by Injec- 
 tions when the Fus is good-conditioned, and he 
 can by Comprefs diminiih the Cavity of it, as 
 may be done in this very Cafe, and which iliould 
 be pradifed before any other Method is under- 
 taken : Indeed Annell and his Followers, after 
 
 hp 
 
17^ T R E AT I S E of the ■" 
 
 the Inje(flion,, applied a Comprefs and Bandage^ 
 to the good Effeds of which, rather than any 
 of the other Proceffes, I am inclined to think 
 tne ouccels was owing. *^ 
 
 When the Quantity of Matter returned by 
 the Pun&a increafes, notwithftanding the ufe 
 of Cornprefs, and the Tumour cftVc Saccus 
 grows larger ; it then becomes neceffary to 
 perform the Operation ; the Dei%n of which, 
 is to cure the Ulcer, and make way for the 
 Tears into the Nofe. 
 
 The general Notion that the Abfcefs of the 
 Bag always occafions a Caries of the Os Unguis^ 
 perhaps may have led Surgeons into the Me- 
 thod of deftroying both Saccus and Bone with 
 a perforating Inftrument, and afterwards more 
 efFetflualJy with an a(5tuai Cautery, in, order to 
 remove the difordered Bone, and at the fame 
 time to make an artificial Canal into the Nofe: 
 But as there are many Inftances of Cure by a 
 mere Incifion of the Saccus Lachrymalisy the 
 rougher Method of Perforation ought not to 
 be ufed, unlefs there is evidently a Caries in 
 the adjacent Bone, or that after the Ulcer of 
 the Saccus is healed, the Tears cannot be made 
 to pafs through the Dud: ; tho' even in that 
 cafe, the Application of Fire is not only gene- 
 !j-al]y ufeJefs, but often proves hurtful, and de- 
 feats 
 
operations of S urgery. 177 
 
 feats the very End it was intended to promote. 
 The Defign of the Cautery, is to prevent the 
 artificial Canal made by the Perforation from 
 clofing up ; but the Operators who recom- 
 mend it, confefs that in Perfons who have been 
 cauterifed, even at the beff, the Tears trickle 
 down ever after ; whereas that Accident does 
 not fo often attend on thofe where the In- 
 cilipn only is pradifed : The Reafon of this 
 Difference may perhaps be more clearly ex- 
 plained by a parallel Inftance : If we divide a, 
 Vein quite thro', and cauterife its Extremities, 
 'tis well known that the Sloughs formed by the 
 Fire, hardly ever feparate from the living Parts 
 of the Vein, until they are totally clofed up {o 
 as to prevent any Effuiion of the circulating 
 Bloods the Confequence of which is, the break- 
 ing off the Communication of the divided Parts 
 of the Vein ; whereas if there was only an 
 Opening'n)ade with a fearp Inflrument, or even 
 a Piece of the Vein carried away by it, the di- 
 vided Parts would foon re-unite, and the Cir- 
 culation be continued .thro' them : for the fame 
 Reafon, by the ufe of the Cautery, the Com- 
 munication between the PunBa Lachrymalia 
 and SaccuSj will often be intirely deilroyed j 
 and the Perforation into the Nofe, tho' it 
 remain open, will of confequence not anfwejc 
 the Purpofe for which it was intended. 
 
 0.4 I' 
 
J 7 8 T K^E AT I ^^ of the 
 
 It may perhaps be faid, that by introducing 
 the Cautery through a Canula^ the upper part 
 of the- Saccus, or opening of the Lachiynal 
 Channels, may be protected from thefe ill 
 Effeds. But I believe it will plainly appear, 
 by the Rudenefs of the Scar after the healing of 
 the Wound, how pov/erfully Fire will work 
 upon the neighbouring Parts, notwithftanding 
 this Precaution. 
 
 From what has been faid of the Nature of 
 this Difeafe, the ufe of Fire muft be difcarded 
 in all the Stages of it, and even Perforation for 
 the mod part be pradifed only when the fub- 
 jacent Bone is carious j but this Circurnilance 
 is very rare, and for my own part, iince I have 
 doubted its frequency, it has not been may for- 
 tune to meet with a fingle Inftance of it, tho' 
 I have had Fiflulas of many Years flanding 
 under my Care, in fome of which, the Fits has 
 found iffae thro' the Bag and Skin, and formed 
 an external Ulcer likewife. The Reafon why 
 the inferior part of the Saccus is not fo often 
 corroded as the fuperior (in which cafe the Bone 
 would neceffarily be affected) is, that here, as 
 in every other part of the Body, Abfceffes will 
 break where they are leaft under Confinement, 
 as in thofe Places they fooner give way to the 
 preternatural Influx of the Juices, and in confe- 
 
 quence 
 
operations <?/'Surgery. ij-q 
 
 quenc':' becoming weaker, will fooner be de-. 
 flroyed. Since therefore, neither the long con- 
 tinuance of the Difeafe, nor the great Difcharge 
 of Matter, are pofitive Symptoms of a Caries, 
 we ought to be well fatisfied of it by the Feel 
 of the Probe before we perforate ; but if upon 
 opening the Bag, or in the ccurfe of the Dref- 
 fing, it appears the Os Unguis is bare, we are 
 not to wait for an Exfoliation, thz Bone being 
 fo very thin, but to break thro with a fmall 
 Perforator, 
 
 Many Writers mention the Succefs of hav- 
 ing fometimes treated the Fijiula Lachrymalis 
 as a mere Abfcefs of the Saccus, though in 
 general they recommend the ufe of Fire ; but 
 when the Abfcefs is fo foul as not to cure by 
 Incifion, a piece of the Bag itfelf mufl be cut 
 away j and thus Celfus treated the Fiftula 
 Lachrymalis (tho' he alfo ufed the Cauterv) 
 without perforating. 
 
 The Manner of operating in thofe Cafes 
 where Perforation is not required, is this : 
 Suppofing the Abfcefs not broke, choofe a time 
 when it is moil turgid with Matter : and to 
 this end, you may fhut the Patient's Eye the 
 Day before, and lay little Slips of Plaifter upon 
 one another acrofs the Lids, from about the 
 PunBa Lachrymalia to the internal Angle ; 
 
 which 
 
T R E A T I S E of the 
 
 which compreffing their Channels, and pre- 
 venting the Flux of the Matter that way, wilj 
 heap it up in the Bag, and indicate more <;^j^f 
 tainly the Place to be cut- If the Abfcefs is 
 already open, the Orifice and Probe will, inform 
 you where to enlarge : Then placing the Pa- 
 tient in a Seat of convenient height for the Ma- 
 nagement of your Hand ; with a fmall Incifion- 
 knife dilate from the upper part of the Bag, 
 down to the Edge of the Orbit, without any 
 regard to the Tendon of the Orbicularis Mufcle, 
 or fear of wounding the Blood Veffels ; tho' .if 
 you fee the VelTels, 'tis proper to (liun tliem':: 
 The Length of this Incifion, will be near four 
 tenths of an Inch. It has been a-^vifed in open- 
 ing the Bag, to introdv.ce a fmail Probe thia 
 one of the PunBa into its Cavityj to prevent 
 wounding the pofterior Part of it 3 but 1 think 
 this excefs of care may be more trci-blefonie 
 than ufeful ; fince in fo large a Veflel, a :^efy 
 fmall fhare of Dexterity is fuflicient to avoid the 
 miftake : In making this Incifion, care-. mtift 
 be had, not to cut too near the joining of the 
 Eyelids, becaufe of the Deformity of the fuc- 
 ceeding Scar : tho* the blear Eye or uneven 
 Contraction of the Skin in that Part, after the 
 Operation, is generally owing to the ufe of the 
 Cautery, and not to the Wound of the Tendon 
 
 of 
 
Operatims' of Sv r g'e R y. 1 8 1 
 
 cf the Orbicularis Mufcle ; for thti^~l''^ft,48 ne- 
 celT^rily from its fituation always c; ; thrbugh, 
 but without any^ Inconvenience, becitufe oi* 
 the firm Cicatrix afterwards that fixes' ^t 
 flror'.gly to the Bone. 
 
 When the B-^g is open, it is to be filled with 
 dry Lintj which the next Day may be removed, 
 and exchanged for a Doffil dipt in a foft diges- 
 tive Medicine : This muft be repeated every 
 Day once or twice, according to the quantity 
 of the Difcharge -, now and then, when 
 the Matter is not good, ufi hg the Precipitate 
 Medicine, and from time to time, a Sponge- 
 Tent, to prevent the too fudden reunion of the 
 upper part of the Abfcefs. When the Difchargte 
 begins to leiTen, it will be proper to pafs' a fiiisSl 
 Probe, a fmall Bougie, or Silver Wire through 
 the Nafal Dud into the Nofe, every time it is 
 dreft, in order to dilate it a little, and maKb 
 way for the Tears and Matter which by their 
 Drain will continue to keep it open. This 
 Method muft be followed 'till the Difchai'^e 
 is nearly over 'fwhich will be in a feW 
 Wieeks) and then'dreffing fuperficially with 
 (Iry Lint, or any drying Application, the 
 Wound will- feldom fail of healing:. After 
 the Ciii^e,'m"ordei' to prevent a Relapfe, it 
 will be piioper,' for a few Weeks, to wear the 
 
 com- 
 
182 T R E A T -J S i oJF the 
 
 compreffing Inftrument reprefented in the 
 Copper-plate. 
 
 When the Bone is bare, and the Fiftula 
 requires Perforation, the Perforator is not to be 
 carried down the Dudius ad Najum, for fear of 
 boring into the 817211$ Maxillaris ; but more 
 internally towards the Nofe, which will bleed 
 freely, if properly wounded : The Wound af- 
 terwards fliould be dreffed with Doffils, in the 
 manner above defcribed, and the Probe or Silver 
 Wire be every Day palTed through the DiiBm 
 ad Nafeim^ left after the Cure of the Abfcefs, 
 it {hculd ftiU remain obilruded j and if upon 
 trial, the Du6l fliould be fo filled up as not to 
 admit the Wire, it will be right to keep open 
 the Perforation into the Nofe, with a fmall 
 Tent, 'til! the Difcharge is almoft quite ceafed. 
 I fhall finifh this Chapter with oblc ving, 
 that though a v>^eeping Eye will fometimes 
 remain after the Treatment of the Fijhda 
 Lachrymalis, yet the Inconvenience of it is fo 
 fmall, compared with a Difcharge of Matter, 
 that it would be happy if this was the worft 
 , Confequence of the Operation ; but it fome- 
 times happens, that the Ulcer when healed, 
 breaks out again, and fometimes too, that It 
 cannot be quite healed, by reafon of the inferior 
 part of the Saccus an'd Nafal Dud lying fo 
 
 deep 
 
_ 
 
 Pat/. I S3 
 
 F/atd //. 
 
operations ^Surgery* 183 
 
 deep below the edge of the Orbit, which makes 
 the proper application of Dreffings to the 
 bottom of the Ulcer more difficult : 'Tis this 
 fituation of the Saccus, that in a great mea- 
 fure prevents any good effccls from burning 
 and perforating, if the Perforation only be 
 drelTed, as is very much pradifed, fince the 
 Dreffing will be full four tenths of an Inch 
 above the loweft part of tne Ulcer. 
 
 With regard to the trickling of the Tears, 
 though generally fpeaking, it is prevented by - 
 the Method I have recommended j yet it does 
 not appear at all wonderful, it fhould fo fre- 
 quently be the confequence of the others, when 
 v/e conlider how much at beft the Saccus con- 
 trads after a great deal of it has been deflroyedj 
 and how poffible it is for the Wound to fill 
 UD with Granulations of Flefli, which cannot 
 fail to prove an Obftaele to their Paffage into 
 the Nofe. 
 
 PLATE XL 
 
 The Explanation. 
 
 A, The Eye, with the Skin of the Eye-lids, 
 denuded, in order to fhew the Orbicularis 
 Mufcle : The white flreak running from the in- 
 ner Angle of the Eye toward the Nofe Is called 
 
 the 
 
. .^P;]^ E^A T i s ^ of the \ 
 
 the Tendon of the Orbicularis Mufcle, thoagh 
 I think it; rather a fmall Ligament. At a little 
 diftance from the internal Angle, on the edge of 
 the EyerHds may be obferved two black SpotSj 
 whiGh^ce the Orifices of the Lachrymal chan- 
 nels, ,end called the FunSia Lachrymalia. 
 
 B. The'exad Dimenfion of the-Lachrymal 
 Channels and Bag ; the pricked Liiie reprefents 
 the edge of the Orbit. I have here taken care 
 to fhevv the oblique Diredion of the Bag as it 
 runs from the Nofe towards the Orbit. 
 
 From comparing this Figure, with the Situ-^ 
 ation of the Fun6fa Lachrymalia in the fore- 
 going one, it will appear that only the upper 
 part of the Bag lies under the Tendon of the 
 Orbicularis Mufcle, and confequently is the only 
 part wounded, and burnt through in the com- 
 mori Operation, when the Perforator is carried 
 hbrizontally from the Angle into the Nofe, as 
 is generally pradifed. And I believe the fize 
 of the Bag here reprefented, though not fo large 
 as when it is difeafed, will at once fhew the 
 Propriety of opening it firft by an Incilion 
 down to the Orbit, or even farther, and then 
 treating the Fiftula with the fame Dreffings 
 as we do other fiftulous Ulcers. 
 
 C. A fmall Incifion-knlfe, more handy thaft 
 a larger for opening the Bag. 
 
 D. The 
 
Operatiofis ^Surgery. 185 
 
 : Dy The Perforator to deftroy the Os Unguis^ 
 if ever it fhould happen to be neceflary.. 
 
 iS. An iron Inftrument made thin and pli- 
 able, to fet even on the Forehead, and for ufc 
 covered with Velvet ; the Holes at the three 
 Extremities receive two pieces of Ribband, by 
 which it is faftened on the Forehead : The 
 Button at the end of the Screw is to be placed 
 on the Sacciis Lachrymalis^ and the Screw to 
 be twifted 'till the Button makes a confider- 
 able PrcjTure on the Bag : The Button fhould 
 be covered with Velvet, and a little Comprefs of 
 Plaifter be laid on the Bag before it is applied, 
 to prevent the Skin from being galled by the 
 PrefTure. The little branch of Iron which 
 receives the Screw, muft be foft enough to 
 admit of bendiiig, other wife it w^ill be difficult 
 t(3; place the Button exadly on the Bag^ This 
 Inftrument is for the left Eye only ; it ihould 
 be wore Night and Day in the beginning of a 
 Fiftula, and after a Fiftula has been healed by 
 Incilion j but as the Succefs depends upon the 
 :exad Situation of the Button upon the Bag, it 
 fliould be carefully looked after. 
 
 CHAP. 
 
1 86 Tl K E A T I s -E of the 
 
 CHAP. XXXI. 
 
 Of B R O N C H O T o A/r y. 
 
 ^TpHE Operation oi Bronchotomy is an In- 
 cilion made into the Afpera Arterta^ to 
 make way for the Air into the Lungs, when 
 Refpiration is obftrudted by any Tumour com- 
 preffing the Larynx^ or fome other Diforder 
 of the Glottic and Afpera Arteria, without any 
 apparent Tumour, Thefe are the Cafes in which 
 it is fuppofed to be ufeful ^ but I am inclined to 
 think it hardly ever can be of fervice, but where 
 the Complaint is attended with fome Swelling, 
 fmce I cannot fisd any Infcance to my fatisfac- 
 tion of good done by this Operation in the other 
 Species of Angina -, nor has it appeared upon 
 the Examination of feveral who have died of it> 
 that the Air was obdruded by any Stridure 
 of the Glctiis, or Afpera Arteria : If then the 
 Paflage remains open, and Refpiration be dif- 
 turbed from other Caufes, the making a new 
 Orifice can be but of little advantage : I once 
 performed it under this circumflaiice, but it 
 gave no fort of Relief. 
 
 Upon the whole then, I imagine the prac- 
 tice of this Operation ufeful only in that Species 
 of Angina, where the Throat is exceedingly en- 
 larged 
 
lefations i^/'SuRGERYi 187 
 
 larged by the rwelliilg of the Thyroid Gland, 
 and Parts adjacent, called Brofichocde ; which 
 by their weight may prefs upon the Trached, 
 fo as to make it in fome degree narrower, and 
 prevent the free courfe of the Air to and from 
 the Lungs. But (hould any one judge it proper 
 in the Infcance I objed to, the Operation is fo 
 eafy to perform, and fo utterly void of any 
 Danger whatfoever, notwithftanding the fright- 
 ful Cautions laid down by Writers, that I would 
 not altogether difcourage the Trial, 'till I have 
 farther Proof of its Infignificance. 
 
 The manner of doing it, is by making a 
 longitudinal Incilion through the Skin, three 
 quarters of an Inch long, oppofite to the third 
 and fourth Ring of the Trachea^ if you have 
 the choice of the Place ; and when you cannot 
 make it fo high, the Rule will be to wound a 
 little below the Tumour: It is always advifed 
 to pinch up the Skin for this Procefs, which 
 however may be left to the Difcretion of the 
 Surgeon. When the Skin is cut through, you 
 muft m.ake a fmall tranfverfe Incifion into the 
 Wind-pipe, and immediately introduce a Silver 
 crooked Ca?nda near half an Inch long, with a 
 couple of little Rings at the top of itj through 
 which a Ribband may be paiTed round the 
 Neck, to keep it fixed in the Wounds 
 
 R Some 
 
I 88 ■ T R E A T I S E (t/* /& 
 
 Some have prefcribed making an Incifion 
 through the Skin and 'Trachea at once, with a 
 ^ Lancet or Knife, as tlie more eaiy and expedi- 
 tious Method 5 and I once faw it performed in 
 that manner, but it proved very inconvenient ; 
 for the Windpipe in Refpiration moving up and 
 down, flipped fronj the Orifice of the Skin, and 
 made it very difficult to introduce the Cai7ulay 
 and afterwards to maintain it in its Situation : 
 Wherefore I think it ablblutely necelTary, to 
 make the external Incilion longitudinal, and 
 even pretty large, as I have direded above. 
 
 The Caution laid down, of raifing the Ster- 
 nobyoidei and Sternothyroidei Mufcles, before 
 cutting the Windpipe, is not to be regarded ; 
 and as to the Divilion of the recurrent Nerves 
 and great Biood-VefTels, fo much apprehended 
 in this Operation, 'tis not in the leaft to be 
 feared j fioce they are quite out of the reach of 
 the Inftrument, as any one skilled in the Ana- 
 tomy of thofe Parts mufl very well know. 
 
 The Method of Dreffing will be eafily 
 underftood, fince after the Patient can breathe 
 by the natural Paffage, if you withdraw the 
 hollow Tent, the Wound will become a fimple 
 one, and notwlthftanding Its Penetration 
 through a Cartilage into a large Cavity, require 
 a fuperficiai Application only; 
 
 C H A P. 
 
operations t?/*SuRGiEkVj 189 
 
 CHAP. XXXIL 
 
 the Extirpation of the Tonsils. 
 
 'T^HESE Glands fometimes grow fo large 
 ^ and fcirrhous as to to become incurable, 
 and even to threaten Suffocation if not extir- 
 pated ; The manner of doing this Operation 
 formerly, was by cutting them off 5 but the 
 almofl: conftant Confequence of this Wound, 
 was a violent Bleeding, and fometimes too a • 
 mortal one; on v^hich account it is rejeQed iii 
 favour of the Ligature, which is not only void 
 of Danger, but alfo feldom fails of cure. 
 
 If the Bads of the Tonfil is fmaller than the 
 upper part, you may pafs the Ligature by tying 
 it to the end of a Probe, bent into the form of 
 an Arch and fet into a handle, which beinsf 
 carried beyond the Gland, and round it, is to be 
 brought back again , this done, you may ealily 
 tie it by the means of an Inftrument of Mn 
 Chefeldenh Contrivance, which holds one end of 
 the String on the iide of the Tonfil next the 
 Throat, while you make the Knot by pulling 
 the other v;ith the right Hand quite out of the 
 Mouth, as will be eafily underffood by the 
 Draught in the Copper-plate. Should it happen 
 that the Tonfils are Conical, fo that the Liga- 
 ture will neceffarily flip over its Extremity when 
 R 2 we 
 
190 T R E A r I s E of the 
 
 we attempt to tie. in this cafe, he has recom- 
 mended an Inftrument like a crooked Needle, 
 fet in a Handle, with an Eye near the Point, 
 threaded with a Ligature, which is to be thruft 
 through the bottom of the Gland, and being 
 laid hold of with a Hook, the Inftrument is to 
 be withdrawn; then pulling the double Ligature 
 forwards, it muft be divided, and one part be 
 tied above, and the other below the Tumour : 
 The Knots are to be always double, and the 
 Ligature to be cut ofFpretty near them : How- 
 ever, toconfefs the Truth, I have never in one 
 Inflance been obliged to ufe this Method ; for 
 where the Toniils have been Conical, I have 
 employed a very thin Thread, which has cut 
 into the Subftance of the Gland a little, and 
 making a fmall Groove, prevented its Hiding 
 over. If after four or five Days they flip, or 
 feem to have mortified the Tonfil only in part, 
 you muft repeat the whole Operation ; and if 
 it fails a fecond time, you muft even repeat it 
 again, as I have fometimes done, though it 
 frequently happens, that the Cure is efteded 
 by the firft Operation. 
 
 This kind of Extirpation is more pratflifed 
 in large Piles, that are efteemed incurable, 
 and if the Succefs of it was better known, the 
 Operation would be much more frequent. I 
 
 have 
 
operations o/* S u r o e r y. 191 
 
 have by this Method cured feveral People 
 that have dlfcharged Blood every Stool for 
 many Years, and fome that have been almoU 
 quite deflroyed by the repeated Loffes of it. 
 When the Piles are withiniide of the Intef- 
 tine, you muft place your Patient over a Fo- 
 mentation in a Ciofeftool, and have a crooked 
 Needle with a double Ligature ready to pais , 
 through them, when by ftraining they are 
 puflied out of the Amis (for fometimes the In- 
 'teftine will return fuddenly) and tie above and 
 below as in the Inftance of the Tonfil. Some- 
 times the Piles are of that fhape as to admit 
 a fingle Ligature to be tied round them with- 
 out the help of a Needle, which is lefs painful : 
 If there are feveral, you muft only tie one or 
 two at a time 5 for the Pain of the Ligature is 
 exceffive, and would be intolerable if many 
 were tied at once : However, every five or fix 
 Days, the Operation may be repeated 'till all 
 are extirpated, and the Parts muft be kept 
 fupple by fome emollient Ointments. 
 
 When the Piles are fmall, they may fafely 
 and with much lefs pain be cut ofFj but when 
 this Method has been taken with very large 
 ones, I have feen the Patient in the utmoR' 
 Danger, from a violent EfFufion of Blood. 
 
 R \ The 
 
ig2 T ^Y. AT I z ^ of the 
 
 The Vviila is fubjed to fo great a degree of 
 Relaxation fometimes, that it almoil: choaks 
 the Patient i the readied Cure is cutting off 
 all but half an Inch of it, which rnay be done 
 at one fnip with a pair of Sciffars (particularly 
 curved for that purpofe,) laying hold of it with 
 a Forceps, left it {liould flip away. I once 
 cut off a JJ'Viila that lay rolled upon the 
 Tongue about two Inches j the Patient re-f 
 covered immediately, and never felt any 
 Inconvenience afterwards. 
 
 PLATE XII. 
 '^he Explanation. 
 
 A. The bent Probe fixed in a Handle, with 
 the Ligature made of the fame Thread, as the 
 J^igatures for tying the Blood- VeiTels. 
 
 B. The Iron Inilrument for tying the 
 Tonfils. 
 
 I have here made a Knot upon a Pin, 
 which is to be fuppofed in the Situation of 
 one of the Tonfils, and may eafily be imagined 
 to have been tied by pufliing the Srring be^ 
 yond it, when held firm by one Hand againfl 
 the Inftrumentj and pulled by the other, on 
 t|ae outfide of the Meuth^ 
 
 This 
 
F/atd:i2 
 
Operatt072s (j/" Surgery. 193 
 
 This Inftrument is alfo of great Service in 
 extirpating by Ligature, a Species of Scirrhus 
 that fometimes grows from the Neck or Ca- 
 vity of the Uterus. 
 
 C. The Needle with the Eye towards the 
 Point, for pafling the Ligature through the 
 Tonfil, when the Bafis is larger than the 
 Extremity. 
 
 Z). A Caimla made of Silver to be ufed in 
 the Empyema. 
 
 E. A Canula to be ufed in Br orchotomy. 
 
 To keep the Canulas in their place, fmall 
 Ribbands may be pafTed through the Rings of 
 them, and carried round the Body and Neck ; 
 or they may be held by a Ligature run through, 
 and faftened to a Hole cut in a piece of flick- 
 ing Plaifter, which is to be laid on each fide 
 of them. 
 
 CHAP. XXXIII. 
 
 Of the Polypus. 
 
 ^T^ H E Polypus of the Nofe, is faid to be 
 an Excrefcence of Flefh, fpreading its 
 Branches amongft the Lamince of the Os Eth- 
 moidesj and through the whole Cavity of one 
 or both Noftrils. It happens very often to 
 both fides of the Nofe at once, and in that cafe 
 is very troublefome, almofi: fufFocating the 
 R 4 Patient, 
 
194 Treatise of the 
 
 Patient, at leafl: making Refpiratlon very dif- 
 ficult. The Intent of the Operation is the 
 Removal of this Obftacle, but as it is attended 
 with different Events from the variety of Na- 
 ture in the feveral forts of Polypus s^ I (hall 
 endeavour to diftinguiih their Species, fo as to 
 lead us into fome Judgment of the greater or 
 lefs Probability of Succefs; 
 , They all arife from the Membrane fpread 
 upon the Lamince Spongiojt^j pretty nearly in 
 the fame manner as the Hydatids of the 
 Abdomen^ in one kind of Dropfy, do from the 
 Surface of the Liver \ or as Ganglions from the 
 Tendons, borrowing their Coats from a Pro- 
 dudion of its Fibres and Veffels : If they appear 
 foft, and of the Colour of the Serum of the 
 Blood, in all likelihood they are formed of fuch 
 a fort of Water contained in Cyfts, which upon 
 breaking the Membrane, leaves fo little hold for 
 the Inflrument, that but a fmall part of it can 
 be extraded afterwards. This Polypus is to be 
 left to harden, before the Operation be under- 
 taken, which in procefs of time it generally 
 Vx^ill do. In the next degree of Confidence, 
 they retain, pretty near the fame Colour, and 
 are often partly watry, and partly of a vifcid 
 Texture, which though not tenacious enough 
 tQ ^(jmit of drawing thena out by the Roots, 
 
operations ^/'Surgery. 195 
 
 may at feveral Attempts be taken away by bits. 
 The next Degree of Coniiftence, is that which 
 is neither fo foft as to be fqueezed to Pieces, 
 nor fo hard and brittle as to crumble, or ad- 
 here to the Membrane with that Force as not 
 to admit of Separation : This is the moft fa- 
 vourable one. The laft, is hard and fcirrhous, 
 adhering fo tight as to tear rather than feparate 
 in the Extradion, and fometimes even tends 
 to degenerate into a Cancer ; This Polypus is 
 very difficult of Cure. 
 
 The Polypus fometimes dilates to that degree, 
 as not only to extend beyond the Os PaJatiy 
 and hang over the Oefophagus and Trachea ; 
 but alfo ipreading into the Sinus maxillaris^ fo 
 exadtly fills up every Interflice of the Nofe, as 
 to obftrudt the lower Orifice of the DuBus ad 
 Nafunij and prevent the Defcent of the Tears, 
 which necelTarily muft return through the 
 PunBa Lachrymalia: and fometimes they grow 
 fo enormoufly large, as even to alter the Shape 
 of the Bones of the Face. When the Polypus 
 appears in the Throat, it is always advifeable 
 to extrad it that Way; it being found by 
 Experience, more ready to loofen when pulled 
 in that Diredion, than by the Nofe. To this 
 end, it would be right, before undertaking 
 she Operation, to let your Patient lie fupine 
 
 tWQ 
 
t^6 ^ Treatise of the 
 
 rv^a or three Hours, which will bring It flil! 
 farther down ; for the Body of the Polypus does 
 j>et Dniver-fally'adhere, and will by its Weight 
 . ilrvttch olit the Fibres^ by which it is connected 
 foSheNofe; nay, there are Inftances, where 
 by a little Eitbrtj fuch as Hawking, they have 
 droDt quite off. 
 
 The Method of extrading it, is by a Pair 
 cf Forceps, with a Slit at their Extremities for 
 the better Hold, v/hich muft be introduced into 
 the Noftril about an Inch and a half, to make 
 jHore fure of it towards the Roots ; then twifl:- 
 sng them a little from one Side to the other, you 
 muft continue in that Adion, while you puU 
 very gradually the Body of the Polypus. If it 
 breaks, you muft repeat the Extradion as long 
 as any remains, unlefs it is attended with a vio- 
 lent Hemorrhage, which is an Accident that 
 fometimes follows upon the Operation, and 
 feldom fails when the Excrefcence is fcirrhous: 
 However, the Surgeon is not to be alarmed at' 
 the Appearance of an immoderate EfFufion the 
 Moment after the Separation, for generally 
 fpeaking, the VeiTels collapie very foon again ; 
 fjut if they do not, dry Lint, or Lint dipt in 
 fom€ Styptick, will readily ftop it. 
 
 After the Extirpation, it has been ufual 
 JEJ order ta prevent a Relapfe, to drefs with 
 
 Efcha- 
 
operations o/* S u r g e r y. 197 
 
 Efcharotlck Powders, and even to burn with 
 the adual Cautery ; but neither the one or the 
 other, can be of great fervice in this Cafe, and 
 both are painful and dangerous. If ever the 
 ufe of corroUve Medicines is advifeable, it fhould 
 be for deftroying the remainder of a PolypuSy 
 Vv'hich cannot all be taken away ; and thefi the 
 Efcharoticks may, in my Opinion, be better 
 conveyed to the part by a long Tent, than a 
 Seton palTed thro' the Nofe and Mouth, which 
 is difficult to do without hurting the Patient, 
 and very nafty to bear, tho' this is the Method 
 at prefent pradifed, and recommended by 
 fome eminent Surgeons. 
 
 CHAP. XXXIV. 
 
 Of the Hare Lip. 
 
 'T^ HIS Difeafe is a Fiflure in the Upper 
 Lip, with want of Subftance, and is a 
 natural Defecft, the Patient being always born 
 with it, at leaft that Species of Hare Lip which 
 requires the Operation I am going to defcribe. 
 The Cure 13 to be performed by the twifted 
 Suture, the Explanation of which, [ have 
 referved for this Chapter. There are many 
 J^ips, where the Lofs of Subftance is fo great, 
 
 that 
 
i 9^ Treatise of the 
 
 that the Edges oi the FifTure cannot be brought 
 together, or at bell where they can but juft 
 touch, in which cafe it need not be advifed to 
 forbear the Attempt : It is likewife forbid in 
 Infants, and with Reafon, if they fuck ; but 
 otberwife it may be undertaken with great 
 Saiety, and even with more probability of 
 Succefs, than in others that are older, as 1 have 
 myfelf experienced. 
 
 It is not uncommon for the Roof of the 
 Mouth to be fiffured likewife, but this is no 
 Objedion to the Operation, if the Skin of the 
 Lip is loofe enough to admit of Re-union : 
 and it may be remarked, that the FilTure of 
 the Palate, in length of Years, clofes furpri- 
 fingly in fome Cafes. 
 
 The Manner of doing it is this. You iirfl 
 with a Knife feparate the Lip from the Upper 
 Jaw, by dividing the Frcenulum between it and 
 the Gums ; and if the Denies Inciforii pro- 
 jeft, as is ufual in Infants, they muft be cut 
 out with the fame Knife 3 then with a thin pair 
 of flraight Sciffars take off the callous Edges of 
 the Fiffure the whole Length of it, obferving the 
 Rule of making the new Wound in ftraight 
 Lines, becaufe the Sides of it can never be 
 made to correfpond without this Caulion. 
 
 For 
 
operations ^Surgery. 199 
 
 ^ For inftance, if the Hare Lip had 
 y V this Shape, the Incifion of the Edges 
 ' mufl be continued in ftraight Lines 
 'till they meet in the manner here repre- 
 fented. The two Lips of the Wound 
 being brought exadly together, you 
 pafs a couple of Pins, one pretty near 
 the Top, and the other as near the Boitom, 
 thro' the Middle of both Edges of it, and fecure 
 them in that Situation by tvv^ifling a Piece of 
 waxed Thread crofs and round the Pins {(cvtn 
 or eight times ; you mull then cat oil* the 
 Points, and lay a fmall Bolfter of Piaifier un- 
 derneath them to prevent their fcratching : 
 Bat when the lower Part only of the Hare 
 Lip can be brought into Contad:, it wWl not 
 be proper to ufe more than one Pin. 
 
 , The Pins I employ are made three fourths 
 of their lengths of Silver, and the other Part 
 towards the Point, of Steel j the' Silver Pin is 
 not quite fo offenfive to a Wound as a Brafs or 
 Steel one j but a Steel Point is neceilary for their 
 cafier Penetration, which indeed makes them 
 pafs fo readily, that there is no need of any 
 Inftrument to affifl: in pu(hing them thro'. The 
 Pradice of bolftering the Cheeks forward does 
 little or no Service to the Wound, and is very 
 uneafy to the Patient ; wherefore I would not 
 
 advife 
 
200 Treatise of the 
 
 adviTe the Ufe of it. The Manner of drefllng 
 will be to remove the Applications which are 
 quite fuperficial, as often only as is necefiary 
 for Cleanlinefs. The Method I would re- 
 commend, is to defift the three firfl Days, and 
 afterwards to do it every Day, or every other 
 Day : 1 do not think it at all requifite to drefs 
 between the Jaw and Lip where the Frcenuhum 
 was wounded, there being no Danger that an 
 inconvenient Adheiion fliould enfue. In about 
 eight or nine Days, the Parts are ufually united, 
 and in Children much fooner, when you muft 
 gently cut the Threads, and draw out the Pins, 
 applying upon the Orifices a Piece of Plaifter 
 and dry Lint. It will be proper in order to 
 withdraw - the Pins more eafily, to dab the 
 Ligatures and Pins with warm Water, and alfo 
 moiften them with fweet Oil, two or three 
 Days before you remove them, which will 
 waih off the coagulated Blood, that would 
 otherwife faften them fo hard to the Ligature 
 as to make the Extradion painful. 
 
 The twifted Suture is of great Service in 
 Fiftulas of the TJrethra remaining after the 
 Operation for the Stone, in which cafe the 
 callous Edges may be cut off, and the Lips 
 of the Wound be held together by this 
 Method, 
 
 CHAP. 
 
er at ions of S\j r g e k y . "'20 1 
 
 C H A. P. ■ XXXV. 
 
 Of the \N R Y N E c K. 
 
 Hi^HE Operation of cutting the Wry Neck 
 ^ is very uncommon, and is never to b^ 
 pradifed but when the Diforder is owing to 
 a Contraction of the Maftotdem Mufcle' only ; 
 as it can anfwer no Purpofe to fet that Mufcie 
 free, by dh/iding it, (which is all that is to 
 be done,) if the others in the Neck are in iwc 
 fame State, and more eipecially, if it has beeji 
 of long landing from Infancy ; becaufe the 
 Growth of the Verfebrce^ will have been 
 determined in that Direction, and make it 
 impoffible to fet the Head upright. 
 
 When the Cafe is fair, thie Gperation is 
 this. Having laid your Patient on a Table, 
 make a tranfyerfe Incifion through the Skin 
 and Fat, fcmethihg broader than the aMufcle/ 
 and not above half an Inch from the Clavicle -, 
 then paffing the probed Razor with Care un- 
 derneath the Mufcle, draw it out and cut the 
 Mufcle. The great VelTels of the Neck Yiq 
 underneath, but 1 think, when we are aware 
 of their Situation, the Danger of wounding 
 them may be avoided. After the Incifion is 
 made, the Wound is to be crammed with dry 
 
 Lint, 
 
202 Treatise of the 
 
 Lint, and always drefled fo as to prevent the 
 Extremities of the Mufcle from re-uniting ; to 
 which end, they are to be feparated from each 
 other as much as poflible, by the Affidance 
 of a fupporting Bandage for the Head, during 
 the whole Time of the Cure, which will 
 generally be about a Month. 
 
 PLATE XIII. 
 
 ^he Explanation. 
 
 A. The Inftrument called the Probe-Razor 
 to cut the Majioideus Mufcle in the Wry Neck, 
 and is {harp only about half its length, at that 
 End where the Blade is broad. 
 
 B. The two Pins with the twifled Suture, 
 ufed in the Hare Lip. 
 
 C. The Polypus Forceps, with one of the 
 Rings open for the Reception of the Thumb, 
 which would be cramped in pulling the For- 
 ceps with much Force, if it was received in 
 the fanie fort of Ring as in the other Handle. 
 'Tis for this Reafon I have reprefented the 
 Stone Forceps with open Rings. 
 
 CHAP. 
 
eratlons of Surgery. id"^. 
 
 C H A P. XXXVI. 
 Of the Aneurism. 
 
 '^Tp HIS is a Difeafe of the Arteries, iri ^ 
 
 which, either by a preternatural V/eak- 
 liefs of any part of them, they become excef- 
 iively dilated ; or by a Wound through their 
 Coats, the Blood is extravafated amongft the 
 adjacent Cavities. The firfl: Species oi Aneu- 
 rifm, is incident to every part of the Body, but 
 does not often happen, except to the Curvature 
 of the Aorta, which is fubject to this Diforder 
 from the extraordinary Impulfe of the Blood 
 on that Part : from the Curvature, it runs 
 upwards along the Carotids of SubcIavianSj' 
 generally increaiing, 'till by its great Diften- 
 lion it is ruptured, and the Patient dies. 
 
 There have been great Disputes amongfl 
 Writers, concerning the Natufe of this Dila- 
 tation of the Artery ; fome even denying the 
 Fact, and fuppoiing it always a Rupture 5 fome, 
 that all the Coats are diflended 5 others, only 
 the external one \ and again others, whofe 
 Doffine has been the befl received, that the' 
 internal Goat Vs^as ruptured, and the external 
 dilated : Thefe laft have fupported their Hy- 
 potheiis with Arguments drawn from the Ana- 
 
 S iomj 
 
T R E A ^1 s E of the 
 
 tomy of the internal Coat, which is ligamentous 
 and incapable of much Diftenfion j fo that if 
 an Artery be inflated with a fuflicient force, 
 the Air will burft that Coat, and expand the 
 external one, that is, make an artificial Amu- 
 rifmy in the fame manner as Blood is fuppofed 
 to make a natural one : But this Argument is 
 of little force, when we confider, that there 
 are many parts of an animal Body, which Vio- 
 lence cannot flretch confiderably, but which, 
 by the gradual Influx of the Juices, become 
 fufceptible of monftrous Diftenfion, as is the 
 cafe of the Uterus, and upon Obfervation, h 
 evidently the cafe likewife, of all the Coats of 
 the Artery, as I have had an Opportunity to 
 examine in feveral Aneiiriim in the Colledion. 
 of the late Dr. Douglas'^ which he was fo kind 
 to lend me for that purpofe. 
 
 There are feveral Hiftories given' of Aneu- 
 rifms of the Curvature of the Aorta^ in fome 
 of which, the Veffel has been fo exceffively dila- 
 ted, as to poiTefs a great fpace of the upper part 
 of the I'horaXy and the moft curious circum- 
 ftance to be gathered from them is, that the 
 Spot of the VelTel which is weakeft, and where 
 the Difeafe begins, generally gives way in fuch 
 a manner to the force of the Blood continually 
 pufhing it outwards, as to form a large Pouch 
 
 or 
 
lefations ^Surgery. 205 
 
 Of Cyftj with Coats nearly as thick as thofe of 
 the Artery itfelf : However the Thicknefs of 
 the Coats of thefe Cyfls, will lajfl but to a cer- 
 tain Period ; for when the VefTels of the Coats 
 tan no longer conform to the Extenlion, the 
 Circulation grows languid, the Cyft becomes 
 thinner at its Apex, and foon after, burfts. 
 
 From this Defcription of the Cyft, it will be 
 tinderftood to refemble the Bladdef, having a 
 large Cavity, and a narrow Neck or Opening. 
 
 The Symptoms of this Aneurifm, are a 
 flrong Pulfation againft the Sternum and Ribs,' 
 every S)jiole of the lleart ; and when it extends 
 above the Sternum, a Tumour v/ith Punation: 
 Upon Difledion, the Ribs, Sternum^ and C!a- 
 ^icky are fometimes fotind cariods, from the 
 Obftrudion- of the Veffels of the 'Periojieimi^ 
 which are preiTed by the Tumour. What are 
 the Caufes of a particular Weaknefs in any of 
 the Coats of the Artery, I cannot take upon* 
 me to determine : but 'tis worth obferving, 
 that the dilated Aorta every where in the 
 neighbourhood of theCyft, is generally offified,;- 
 and indeed Offifications, or Indurations of the? 
 Artery, appear fo conftantly in the beginnings 
 of Aneurijm of the Aorta, that 'tis not eafy 
 to judge, whether they are the Gaufe o^ the 
 EiFedof them. 
 
 % z What 
 
Treatise of the 
 
 What I have fpoke of hitherto, has been 
 only the Aneurifm of the Thorax from an in- 
 ternal Diforder ; Aneurifms of the Extremities, 
 are for the moft part owing to Wounds, though 
 when they happen of themfelves, they differ 
 very Httle from the Defcription I have given of 
 that in the T^horax : The further Symptoms of 
 them are (belides Pulfation) the Tumour's 
 being without Difcolou ration in the Skin j its 
 fubiiding when preffed by the Hand, and 
 immediately returning when the Fland is 
 taken away j though if it be upon the point of 
 burfling, the Skin vv^ill grow inflamed, and the 
 coagulated Blood in the Cyil will fometim.es 
 make the Pulfation much lefs perceptible. 
 
 This Species of Aneurifm may fometimes 
 be fupported a great number of Years, if we re- 
 fift its Dilatation by proper Bandage 3- but if w^e 
 do not there is danger of its burfting^ and if it 
 be pretty large, of rotting the adjacent Bones. 
 
 A found Artery wounded through part of 
 its external Coat, would in all probability 
 produce nearly the fame Appearances as where 
 the whole Coat is weakened from an internal 
 Tndifpofition ; and this moft hkely is the cafe 
 after bleeding in the Arm, when it has not 
 been immediately perceived that the Artery 
 v/as pricked, and the Tumour has begun to 
 
 form 
 
per at WIS (^/^ S u r g e r y. 207 
 
 form fome Days after the Pundure 5 though 
 tjae common Appearance of an Aneiirifm from 
 the Wound of a Lancet, is a Difcharge of 
 Blood firft through the Orifice of the Skin, and, 
 upon being ftopt from bleeding outwaidlyi 
 an Infinuation of it ao-iong all the Mufcles 
 as far as it can fprcad, in the Shoulder and 
 Arm : here, the Arm grows livid from the 
 Eccbymofi, and the Blood coagulating to the 
 confiftence of Fleih, prevents any fenfibic 
 Pulfation. The Cyft which arifes near the 
 Orifice' of the Artery is formed by the Cel- 
 lular Gapfula enveloping the Vefiels of that 
 Part, and a portion of the Aponeurofis oi the< 
 Biceps Mufcle, which admitting of feme 
 extravafated Blood underneath it, become 
 exceflively thickened and expanded : Thefie 
 Membranes mufl: make the Cyft, otherwife we, 
 could not upon opening the Tumour in the 
 Operation, difcover fo readily the Pundure, 
 or if the Coats of the Artery made it, we could 
 not feparate it diftindly from the Veffel, which 
 ^^ouid be always dilated above and below thg. 
 'Qyft,: as we fee in other Aneurijim. 
 
 There are fome few Indances of fmali 
 
 Aneurifrjs and Pundures of the Artery froni. 
 
 Bleeding, doing well by Bandage j but they 
 
 ^l^jcft all require the Operation at lad, which 
 
 S 2 is 
 
Treatise of the 
 
 is to be performed nearly in the fame manner 
 in every part ; and fuppofmg it in the Bend 
 pf the Arm, is to be done after the following 
 Method. 
 
 Having applied the Tourniquet near the 
 Shoulder, and laid the Arm in a convenient 
 Situation, make an Inciiion on the Infide of 
 the Biceps, Mufclcj above and below the Elbow 
 ^ confiderable length, which being in the courfe 
 pf the Artery, will difcover it as foon as you 
 have taken away the coagulated Blood, which 
 mufi be all removed with tlie Fingers, the 
 Wound being dilated fufficlently for that 
 purpofe : If the Orifice does not readily ap^ 
 pear, let the Tourniquet be loofened, and the 
 EfFufion of Blood will direct you to it ; then 
 carefully carrying a crooked Needle With ^ 
 Ligature under it, tie the YelTel juft above the 
 Oriiice, and pafling the Needle again, make a 
 fecond Ligature below it, to prevent the Returi> 
 of the Blood, and leave the intermediate piece 
 of the Vefiel to Hough away without dividing 
 it. To avoid wounding or tying the Nerve 
 in making the Ligature, the Artery may be 
 cleared away from it firft, and held up with a 
 Hook 5 but fliould the Nerve be tied with the 
 Artery, no great Inconvenience would enfue 
 |i-om it. After the Operation; ttie Arm muft 
 
 be 
 
Operatio7is of Su rger'x* 20^ 
 
 be laid eafy, on a Pillow in Bed, and the 
 Wound be treated in the common Method, 
 keeping it in that Poflure a Fortnight or three 
 Weeks, efpecially if it Ihould fwell much, 
 and not digeft kindly. 
 
 |a doing this Operation, it will be proper 
 to have the amputating Inftruments ready, lejffc 
 it fliould be impradicable to tie the Artery 
 (though I have never met with fuch an In- 
 fiance ;) and even after having tied it, the Arm 
 muft be carefully vi^atched j that in cafe of a 
 Mortification it may be taken ofF^ which 
 though from Experience we learn is very fel-' 
 dom the Confequence, fliould to all appear- 
 ance be the perpetual one j for thefe Aneu^ 
 rifms, following always upon bleeding the 
 B^ftUc Vein, mufl necelTarily be Aneurifms 
 of the Humeral Artery, near an Inch above 
 its Divifion, which being obftru6ted by the 
 Ligature, one would think, fhould neceffarily 
 bring on a Mortification ; but we fee the 
 contrary, though for fome time after the Ope- 
 ration, we can hardly diftinguiili the leaft 
 degpeQ of Pulfe, and ever after, it continues 
 languid. \i xht Humeral Artery happens to 
 divide above the Elbow, which is not v^ry 
 uncommon, the Profped: of Cure is better, and 
 the I?;ulfq,wiil be ftronger after the Operation. 
 ; ^ ' S 4 C H A P. 
 
210 T R E A T 1 s E of the 
 
 CHAP. XXXVII. 
 
 Of Amputation. 
 
 A Spreading Mortification has been always 
 •* efleemed fo principal a Caufe for Am- 
 putation, that it is a fadiion with Writers, 
 to treat of the nature of a Gangrene, pre- 
 vious to the Defcriptibn of this Operation ^ 
 and I think they have all agreed, that what- 
 ever the Species of it be, if the Remedies they 
 prefcribe, do not prevent its Progrefs, the 
 Limb mufl be amputated : However, this 
 Operation is fpoken of as frequently unfuc- 
 cefsful, and in length of time, its want of 
 Succefs has been fo unqueflionably confirmed 
 by repeated Experiments-, that fome of the 
 mofl eminent Praditioners here in Englaftd, 
 make that very Circumftance an Exception to 
 the Operation, which fo few Years fince was 
 the great Inducement ; and the Maxim now 
 is, never to extirpate 'till the Mortification is 
 abfolutely flopped, and even advanced in its 
 Separation. 
 
 Gangrenes may be produced two ways ; 
 either by Indlfpofition of Body, or by Accident 
 in a healthful State ; for as the Life of a Part de- 
 pends upon the Circulation of its Fluids, Vt^hat- 
 
 ever 
 
operations <?/'Surgery. 2ii 
 
 ^ver fhall make the Circulation ceafe, will 
 inevitably occafion a Gangrene : Thus a mere 
 Comprefs preventing the Courfe of the Blood, 
 as effedually caufes a Mortification, as any 
 Indifpolition in the Fluids or VefTels. 
 
 It frequently happens in old Age, that the 
 Arteries of the lo¥/er Extremities offify, which 
 deflroying their Elafticity, muft in confequence 
 produce a Gangrene in the Toes firft, and af- 
 terwards in the Limb nearly as high as where 
 the OfTiiication terminates ; fo that in Mortifi- 
 cations ariling from this Caufe, we at once fee 
 why Amputation, during their Increafe, is of 
 fo little Service, unlefs performed above the 
 OiTification i but we have no way to judge where 
 the GfTification ends, but by the Inference we 
 make from the Gangrene's flopping : Hence 
 we may learn the Propriety of our modern 
 Practice in this Cafe. 
 
 If by any Accident the Limb has been 
 injured to that violent degree as to begin to 
 mortify, it will be no more fit to operate here 
 'till it fliops, than in the other Inftance ; becaufe 
 all Parts that are mordfied, have had the Dif- 
 pofition to become fo, before the EfFedt is pro- 
 duced : and cutting off a Limb, half an Inch 
 above the abfolute dead SkiL), is generally leav- 
 ing a Part behind, yiiih. tlie Seeds of a Mortifi- 
 cation 
 
212 T R E A T I S E (j/' //5^ 
 
 cation in it^ fo, unlefs we can be fure, the 
 Vdlels arenot afFeded in the Place of Ampu- 
 tation, which will be hard to know but from 
 the Confcqucnce, the Operation will be ufelefs. 
 Sometimes the Fluids of the Body are fo 
 vitiated, as to lofe their proper nutritious Qua- 
 lities, and the Limb becomes gangrened, not 
 from any Alteration in its Veffels, but chiefly 
 from its Situation, which being at a great Dif- 
 tance from the Heart, will be more prone to 
 feel the ill EfFeOs of a bad Blood than any other 
 Part, as the Circuladon is more languid in the 
 Extremities : and it feems not very improbable 
 that.ijifome Dirpolitions of the Blood, a Morti- 
 fication may alfo be a kind of critical Difcharge. 
 When therefore a Gangrene ariiing from ei- 
 ther of thefe Caufes, is running on, Amputation 
 above it, will for the mod part be ufelefs 3 fince 
 it is only removing one Degree of the Eifedls of 
 the bad Juices, and leaving them in the fame 
 State to produce the like Mifchief ii^ other 
 Parts: Thus we fee after Amputation^' on this 
 account, the Gangrene fometimes falls on the 
 Bowels, or the other Extremities j ffom which 
 Obfervation, I think we may conclude it not 
 fafe to amputate, 'till the Fluids are altered -, 
 and this Alteration will prefentl^ difcover itfelf 
 by the Stopping of the Mortification. 
 
 J havQ 
 
operations of Su rgi£.^y. 213 
 
 I have laid it down as a Rule, that the 
 Mortification fliould not only be ftopped, but 
 advanced in its Separation ; the Reafon of which 
 is, that tho' the Blood is fo much altered for 
 the better as to occafion a Stoppage of the Gan- 
 grene, yet at this point of Alteration, 'tis ftill in 
 a bad State, and fhould be left to mend, with 
 the utmoft Tranquility of Body, and Affiftance 
 of Cordial Medicines, 'till fuch time as Gra- 
 nulations of Flefh upon the living Part of the 
 Extremity, {hew the balfamick Difpofition of 
 the Blood ; In the mean while, to take off the 
 Stench of the Gangrene, it may be wrapt up in 
 fpirituous or odoriferous Applications. I have 
 feen fome Limbs takpn off immediately upon 
 the Mortification's ceafing, when afterwards 
 the Patients have funk from frequent Effufions 
 of Blood, not difcharged by the great Vellels, 
 but the whole Stump : Thefe Haemorrhages 
 I conceive were owing to the Thinnefs of the 
 Blood, which hardly gave a reddifh Tin(5ture 
 to the Cloths and Bandages ; on the other 
 hand, upon waiting a confiderable Time after 
 the ceafing of the Mortificadon, I have taken 
 off fome myfelf with as good Succefs, as for 
 any other Diforder. 
 
 Gunfhot Wounds, compound Fracftures, and 
 ^U fudden Accidents requiring Amputation, 
 
 are 
 
^ 1 4 Treatise of the 
 
 are attended wi^ih the bcft Siiccefs iffimmedi- 
 ately performed. Diforders of the Joints, Ulcers 
 of long ftanding^andall fcrophulous Tumours, 
 do fometranes return on other Parts after the 
 Operation. .When a Leg is to be amputated, 
 the Manner of dokig it is this. 
 
 ■ Lay your Patient on a Table two Foot fix^ 
 Inches high, which is much better than a low 
 Seat, both for fecuring him flieady, and giving 
 yourfelf the Advantage of operating without 
 ftooping, which is not only painful, but incon- 
 venient in the other Situation. While one of 
 the Affiftants holds the Leg, you muft roll a 
 Slip of fine Rag half an Inch broad, three or 
 four Times round it, about four or five Inches 
 below the inferior Extremity of the Fatella : 
 This being pinned on, is to ferve as a Guide for 
 the Knife, which without it, perhaps would not 
 be direded fo dexteroufly : The manner of 
 rolling has always been perpendicular to the 
 Length of the Leg, but having fometimes ob- 
 ferved, that tho' the Amputation atfirft be even, 
 yet afterwards the Gaftrocnemius Mufcle con- 
 tra(5ting, draws back the inferior Part of the 
 Stump more fcrongly than the other Mufcles 
 can do the refi: of it 5 I have lately, in order to 
 preferve the Regularity of the Cicatrix, allowed 
 for this E.xcefs of Contradion, and made the 
 
 circular 
 
)eratio?is <?/' S u r o e r y. 2 r^ 
 
 circular Incifion in fuch a manner that the Part 
 of the Wound which is on the Calf of the Leg 
 is a little farther from the Ham than that on 
 the Shin is from the Middle of the Patella. 
 
 In the, mean time, one of your Affiftants 
 muft carry a ftrong Ligature round the Thigh, 
 about three or four Inches above the Patella^ 
 which paffing thro' a couple of Slits in a 
 fquare Piece of Leather, he mufb twiil with » 
 Tourniquet, 'till the Artery is fufficiently com- 
 preffed, to prevent any great Effufion of Blood ; 
 and to do it more effedtually, he may lay a 
 Bolfler of Tow or Linen under the Ligature, 
 upon that Part where the Artery creeps. It 
 will alfo be a little more eafy to the Patient^ 
 to carry a Comprefs of Linen, three or four 
 times double, round the Thigh, on that Part 
 where the Ligature is applied, in order to 
 prevent it from cutting the Skin. 
 
 The Gourfe Oi^.the Blood being flopped, you 
 muft begin your Incifion juft below the Linen 
 Roller, on the under Part of the Limb, bring- 
 ing your Knife towards you, which at one 
 Sweep may cut more than the Semicircle ; then 
 beginning your fecond Wound on the upper 
 Part, it muft be continued from the one Extrc- 
 .mity to the other of the firft Wound, making 
 them but one Line. Thefe Incifions/muft bt 
 
 made 
 
2i6 I'reatise 0/ the 
 
 made quite thro* the Membrana Adipofa^ as 
 far as the Mufcles ; then taking off the Linen 
 Roller, and an Affiftant drawing back the Skin, 
 as far as it will go, you make your Wound from 
 the Edges of it when drawn back, thro' the 
 Flefh to the Bone, in the fame manner as you 
 did thro' the Skin. Before you faw the Bones, 
 you muft cut the Ligament between them, 
 with the Point of your Knife, and the Affift- 
 ant who holds the Leg while it is fawing, muft 
 obferve not to lift it upwards, which would 
 clog the Inftrumerit ; and at the fame time, 
 not to let it drop, left the Weight of the Limb 
 {hould fradure the Bone, before it is quite 
 fawed thro'. 
 
 In amputating below the Knee, it is of 
 Advantage to ftand on the Infide of the Leg 5 
 becaufe the T^ihia and Fibula lie in a Pofition 
 to be fawed at the fame Time, if the Inftru- 
 ment be applied externally : Whereas, if we 
 lay it on the Infide of the Leg, the T^ibta will 
 be divided firft, and the Fibula afterwards ; 
 which not only lengthens the Operation, but 
 is alfo apt to fplinter the Fibula when it is al- 
 moft fawed thro', unlefs the Affiftant be very 
 careful in fupporting it. 
 
 When the Leg is taken off, the ne±t Re- 
 gard is to be had to the ftopping the Blood, 
 
 whicb 
 
operations i?/' S u r g e r y. 217 
 
 which muft be efFedually done before the 
 Patient, is put to Bed, or there will be great 
 Danger of bleeding again, when the Fevef is 
 excited, and the Veffels of the Stump dilated, 
 both which happen a very little while after 
 the Operation. There is no Method for this 
 Purpofe fo fecure, as taking up the Extremi- 
 ties of the Veffels with a Needle and Ligature 
 in the following Manner. As foon as the 
 Amputation is performed, the Affiflant mud 
 loofen the Tourniquet for a Moment, upon 
 which the Orifices of the Arteries will appear 
 by the Iffue of the Blood. The Operator hav- 
 ing then fixed his Eye upon one of the largefl: 
 Veffels, paffes a crooked Needle thro' the Fiefli, 
 a little more than a quarter of an Inch above 
 the Orifice, and about the fame Depth, in fuch 
 a Diredion, as to make nearly one third of a 
 Circle round the Veffel : then withdrawins; the 
 Needle, he a fecond time paffes it into the Fledi 
 and out again, in the fame Manner and about 
 the fame Diftance below the Orifice of the 
 Veffel : By this means, the Thread will almoft 
 cncompafs the Veffel, and when it is tied (wh-icli 
 fliould be done by the Surgeon's Knot) will 
 neceffarily inclofe it within the Strid:ure. Ail 
 the conliderable Arteries are to be taken up in 
 the fame manner : that is, the Tourniquet 
 
 is 
 
iS T RE A T I s E of f/je 
 
 is to be loofened in order to difcover the VeP 
 fel, and then the Needle is to be paiTed round 
 it as I have here defcribed. This is a much 
 better Way than ufnig the Artery Forceps,- 
 where the Veflels are apt to flip away out of 
 the Ligature 5 and as to ftyptick Applications; 
 their want of Safety is fo well known now, 
 that the Ufe of them, in Hemorrhages from 
 large VefTels, is almofi: univerfally rejeded ; 
 though it is thought by feveral Surgeons 
 who have experienced the Virtue of Aga- 
 ric, that it will be found to be a more 
 powerful Aflringent than any hitherto dif- 
 covered. 
 
 It fometimes happens in a large Stump, 
 that ten or more VeiTels require tying, which 
 done, you muft apply loofe dry Lint to' 
 the Wound ; or in cafe the fmall Vefiels" 
 bleed plentifully, you may throw a handful 
 of Flour amoneft the Lint, which will 
 contribute to the more effedual flopping up 
 their Orifices : Before you lay on the Pled- 
 git, you mufl bind the Stump, and begin 
 to roll from the lower Part of the Thigh 
 down to the Extremity of the Stump. The 
 ufe of this Roller, is to keep the Skin for- 
 wards, which, notwithftanding the Steps al- 
 ready taken to prevent its falling back, would 
 
 in- 
 
operations ^Surgerv. 519 
 
 in fome meafure do fo, unlefs fuftained in this 
 manner. The Dreffing may be fecured by 
 the crofs Cloth and gende Bandage ; and the 
 Method of treating the Wound, may be learnt 
 from what has been faid, with refped: to re- 
 cent incifed Wounds. 
 
 Before the Invention of making the double 
 Incifion 1 have juil now defcribed, the Cure of 
 a Stump was always a Work of length of Time j 
 for by cutting down to the Bone at once, and 
 fawing it diredly, the confequence was, that 
 the Skin and Flefh withdrev/ themfelves, and 
 left it protruding out of the Wound two of 
 three Inches in fome Cafes, fo that it rarely 
 happened, that an Exfoliation did not folloWj 
 which beiides being tedious, alfo frequently 
 reduced the Wound to an habitual Ulcer, and at 
 beft, left a pointed Stump, with a Cicatrix ready 
 to fly open upon the leaft Accident 5 all which 
 Inconveniencies are avoided by this new Me- 
 thod ; and I know not of any Objedion to it, 
 unlefs that the Pain of making the \¥ound, is 
 fuppofed to be twice as much as in the other^ 
 becaufe of the double Inciiion j but when we 
 confider, that we only cut the Skin once, and 
 the Flefii once, though not in the fame mo- 
 ment, I fancy upon Reflexion, the difference 1 
 of Pain will be thought inconiiderable, i 
 T 1$ 
 
2 2 O T R E A T I S E <?/' /^^ 
 
 It mufl be confeiTed however, that notwitli- 
 ftanding we derive fuch Benefits from the 
 double Incilion, the contradile Difpofition of 
 the Mufcles, and perhaps of the Skin itfelf, is 
 fo great, that in fpite of any Bandage they will 
 retire from the Bone, efpeclally in the Thigh, 
 and fometimes render the Cure tedious. 
 
 To remove this Difficulty, I have lately in 
 Amputations of the Thigh made ufe of the 
 Crois-ftitch, which I would advife to be ap- 
 plied in the following manner. 
 
 Take a Seton Needle, and thread it with 
 about eight Threads of coarfe Silk, fo that 
 when they are doubled, the Ligature will confift 
 of fixteen Threads about twelve or fourteen 
 Inches long ; wax it pretty much, and range 
 the Threads fo that the Ligature may be flat, 
 refembling a Piece of Tape, after which, oil 
 both it, and the Edge of the Needle : The 
 Flatnefs of the Ligature will prevent its wear- 
 ins: through the Skin fo fail as it would do, if 
 it was round, and the Oil will facilitate its Paf- 
 fage : Then carry the Needle through the Skin, 
 at about an Inch from the Edge of the Stump, 
 and out again on the Infide of the Stump ; 
 after v^hich it raufl be pafTed through the cp- 
 pofite-fide of the Stump, from within outward, 
 "exadiy at the fame diftance from the Lips of 
 
 the 
 
Operatmts (^/'Surgery. 221 
 
 the Wound 5 this done, the Silk is to be tied 
 in a Bow-knot, With another Needle and 
 Skaln of Silk, the fame Procefs is to be repeated, 
 in fuch manner, that the Ligatures may cut 
 each other at right Angles. 1^ it is a large 
 Thigh, the Lips of the Wound may be made 
 to approach each other fo near, as that the Dia- 
 meter of the Wound may be abouttwo, Inches 
 3ong 5 but in this, and in all other Stumps, the 
 Approximation of the Lips will depend upon 
 the Laxneis of the Skin, and the Quantity 
 preferved by an artful double Inciiion ; for 
 the Skin muft not be drawn together fo tight 
 as to put it upon the Stretch, left it iliould 
 bring on an Inflammation and Pain. 
 
 The Manner of applying the Crofs-flitch 
 after the Amputation of a Leg has nothing par- 
 ticular in it, only that the Threads mufb be car- 
 ried between the Tibia and Fibula, rather than 
 diredly over the Ttbiay and before the Skin is 
 drawn over the End of the Stump, it will be 
 proper to lay a thick DolTil of Lint on the 
 Edges of the Tibiay in order to prevent them 
 from wounding the Skin. The Dreffings mufl 
 be fuperficial ; and to preferve the Wound 
 clean, an Injedion of Barley Water, or v/arm 
 Milk, may be thrown m^ with a fmall Syringe, 
 T 2 betweea 
 
2 2 2 Treatise of the 
 
 between the Stitches, which will prevent any 
 Matter from harbouring there. 
 
 I have advifed the Skains of Silk to be tied 
 with a Bow-knot, that in cafe of a Hamor^ 
 rhage, they might be undone in order to dis- 
 cover the VefTel more eafily, and alfo if any 
 Tenfion (liould enfue, that they might be 
 loofened for three or four Days, and then tied 
 again, when the Suppuration comes on, and 
 the Parts are more at liberty. 
 
 Perhaps it may be objed"ed that the double 
 Incifion is of itfelf fufficient for anfwering the 
 Ends propofed by this Meafure ; but whoever 
 is converfant in this branch of Practice, muft 
 know, that notwithftanding the lax State of the 
 Skin and Mufcles at the Time of the Opera- 
 tion, yet fome Days after, they fall conliderably 
 back from the Bone, and in the Thigh parti- 
 cularly fo much, that no Bandage will fuftain 
 them i the Confequence of which, is a pro- 
 portionable Largenefs of Wound, aTedioufnefs 
 of Cure, and fome degree of Pointednefs in the 
 Stump. It may be obferved too, that the Stridt- 
 nefs of Bandage employed for fupporting the 
 Skin and Mufcles of the Thigh, is not only 
 painful, but in all probability may obftrud the 
 Cure of the Wound by intercepting the Nutri- 
 tion j for it is certain, that by long Continu- 
 ance, 
 
operations ^Surgery. 22 j 
 
 ance, it often waftes the Stump, and I am 
 jealous it may alfo be acceflary to thofe Ab- 
 fcelTes, which fometimes form amongft the 
 Mufcles in different parts of the Thigh. 
 
 The Queftion then remaining is, whether 
 thefe Stitches will fupport the Skin and Mulcles 
 more effedually than Bandage, without pro- 
 ducing fome new Evil, a Point which can only 
 be decided by Experiment. It is true that this 
 very Method was followed by fome of our An- 
 ceftors, and the Objedlions to it have abfolutely 
 prevailed over the Arguments in favour of it ; _ 
 for few People now even know it ever was 
 pra<5lifed. Yet I cannot help imagining that 
 Caprice may have had more Share in utterly 
 difcarding this Method, than Reafon and Obfer- 
 vation ; for it is pofitively faid by fome of the 
 moft able and candid Praditioners, to have fuc- 
 ceeded marvelloufly i and as the Inflammation 
 and Symptomatick Fever, fuppofcd to be ex- 
 cited by it, were always relievable by cutting 
 or loofening the Stitches, there does not feem 
 to have been reafonable grounds for wholly 
 giving up fuch great Advantages. 
 
 But if the Objedions to it were of force, 
 when the lingle Inciflon was pradifed, they di- 
 minish exceedingly now that we perform the 
 Operation by the double Incilion 5 for though 
 T Q the 
 
Treatise of the 
 
 the double Incifion does not wholly prevent the 
 withdrawing of the Mufcles from the Bone, 
 yet it abates the Degree of it (o much, that they 
 can fuffer the Stitches, without incurring either 
 Inflammation or Pain, to which they were 
 much more liable after the fing^e Jncifion. Jt 
 muft be remarked hov/ever, that they draw 
 with that Strength as to make the Stitches wear 
 thro' the Skin and Flefli in twelve or fourteen 
 Days; but this is done fo gradually, that it 
 caufes very little Pain or Inflammation, and tho' 
 they confequently come off with the Drefiings, 
 yet by this Time the Skin and Muicles are 
 fixed ; and a flight Bandage will be fufficient 
 to maintain them in the fame Pofltion. 
 
 The two greateft Objedions I know of, to 
 this Method, are, the Deformitv of the Stumps, 
 and the additional Pain of the Operation : but 
 as a Stump is not expofed to View, after the 
 Cure, its want of Beauty is of no great Confe- 
 quence j and though it muft be granted that 
 the Stitches cannot be made without fome 
 Pain, perhaps it will not be found fo bad 
 as one is apt at flrfl: to fuggeft \ for the mere 
 pafiing of a large Needle through the Flefh 
 without making a StriBiirey is very bearable 
 in comparifon of a tight Ligature : but what- 
 ever be the Increaf? pf Pain for the prefent, 
 
 the 
 
operations ^Surgery. 
 
 the future Eafe in confeque^ice of it, is an 
 ample Compenfationj and, if i am not mif- 
 taken, there is flill another Conficleration of 
 much higher Importance than any Ihave men- 
 tioned, I mean a lefs hazard of Lift 
 
 For the Symptomatick Fever, and tVe great 
 danger of Life attendant upon an Amputation, 
 do not feem to proceed purely from the Vio- 
 lence done to Nature by the Pain of the Opera- 
 tion, and the removal of the Limb j but alfs) 
 from the Difficulties with which large Suppu- 
 rations are produced ; and this is evident, from 
 what we fee in very large Wounds that are fo 
 circumflanced as to admit of healing by Inof- 
 culation, or as Surgeons exprefs it, by the firfl: 
 Intention ; for in this Cafe, we perceive the 
 Cure to be effeded without any great Com- 
 motion, whereas the fame Wound, had it been 
 left to fuppurate, would have occalioned a 
 Symptomatick Fever, ^c, but in both In- 
 flances, the Violence done by the mere Ope- 
 ration is the fame, whether the Wound be 
 fewed up, or left to digeiL 
 
 Upon this Principle, we may account for the 
 diminution of Danger, by following the Me- 
 thod here propofed ; becaufe as the Stitches 
 have a power of holding up the Fielh and Skin 
 over the Extremity of the Stump, till they ad- 
 T 4 here^ 
 
 -,,«fj«' 
 
2l6 Tr e/t I s E of the 
 
 here to each ocher in that Situation ; they 
 aa:ually do hy this means leffen the Surface 
 of the Wound ; in confequence of that, the 
 Suppuratio;/; and in confequence of both, the 
 Danger r/ulting from the Suppuration. 
 
 In Amputating the Thigh, the firft Tncifion 
 is to \^ made a little more than two Inches 
 aboy^ the middle of the Patella 5 after the 
 Q.^^ration, a Roller fhould be carried rounci 
 tMe Body, and down the Thigh, to fupport the 
 /bkin and Fiefh j this is alfo the mofl proper 
 Bandage, as AbfcefTes will fometimes form in 
 the upper part of the Thigh, which cannot 
 difcharge themfelves {q conveniently with any 
 other, it being almoft impradlicable to roil above 
 the Abfcefs, unlefs we begin from the Body. 
 
 The Amputation of the Arm or Cubit dif. 
 fers fo little from the foregoing Operations, 
 ' that it will be but a Repetition to defcribe it. 
 However, it muft be laid down as a Rule, to 
 preferve as much of the Limb as poffible, and 
 in all Amputations of the upper Limbs, to 
 place your Patient in a Chair. 
 
 There are in the Armies a great many In- 
 llances of Gun-fhot Wounds of the Arm near 
 the Scapula, which require Amputation at the 
 Shoulder j but the Apprehenfion of lofing their 
 Patients on the Spot by the Haemorrhage, has 
 
 deterred 
 
 
operations ^/"Surgery. 
 
 deterred Surgeons from under-aking it. I have 
 known where it has been done rnore than once 
 with Succefs J but though it had n?.ver been per- 
 formed, we might learn it is pra6l"cable, from 
 the Cafe of a poor Millar, whofe Arm and Sea- 
 pula were both torn from his Body, b;; a Rope 
 which was accidentally twifted round hisWrift, 
 and fuddenly drawn up by the Mill. A\moft 
 every one in London knows the Story, and vhat 
 he recovered in a few Weeks : It is very ic- 
 markable in this Accident, that after Fainting^ 
 the Hasmorrhage flopped of itfelf, and never 
 bled afreih, though nothing but Lint and Tur- 
 pentine were laid on the great VelTels. In cafe 
 therefore of a Wound or Fracture near the 
 Joint, or incurable Fiftulas in the Joint, not 
 attended with much Caries, I think the Opera- 
 tion may be performed fafely in this manner. 
 
 The Patient being laid on his Back, with his 
 Shoulder over the Edge of the Table, make an 
 Incifion through the Memhrana Adipoja^ from 
 the Shoulder acrofs the Federal Mufcle, down 
 to the Armpit j and in order to fave as much 
 Skin as poffible, begin it about two Inches 
 below the Joint j then turning the Knife with 
 its Edge upwards, divide that Mufcle, and 
 part of the Deltoid, all which may be done 
 without danger of wounding the great Veflels, 
 
 which 
 
8 T K 11 It IS -E of the 
 
 which will becocie expofed by thefe Openings; 
 if they be not/ cut flill more of the Deltoid 
 Mufcle, and /^rry the Arm backward : Then 
 with a ftropg Ligature, having tied the Artery 
 and Vein/carefully divide thofe VelTels at a 
 confider/Die diflance below the Ligature, and 
 purlaethe circular Inciiion through the Joint, 
 cuttijfg firft into that Part of the Burfal Liga- 
 ment which is neareft to the Axilla : for if you 
 auempt to make way into the Joint, on the 
 /pper part of the Shoulder, the Projection of 
 the Procejfus Acromicn and Procejfiis Coracoides^ 
 I will very much embarafs, if not baffle the 
 / Operation. After the Amputation, the Crofs- 
 ftitch may be pradifed here with great Benefit. 
 The Amputation of the Fingers and Toes is 
 better performed in their Articulation, than by 
 any of the other Methods : For this purpofe, a 
 llraight Knife muft be ufed, and the Incifion 
 of the Skin be made not exadlly upon the Joint, 
 but a little towards the Extremity of the Fin- 
 gers, that more of it may be prefer ved for the 
 eafier healing afterwards ; it will alfo facilitate 
 the Separation in the Joint, when you cut the 
 Finger from the Metacarpal Bone, to make two 
 fmall lonjjitudinal Incilions on each fide of 
 it iirft. In thefe Amputations, there is gene- 
 rally a Veficl or two, that require tying, and 
 
 which 
 
Pa^. 22^ 
 
 F/<7tr 14. 
 
Operations ^Suhgery. 229 
 
 xvhich often prove troublefcme when the 
 Ligature is omitted. 
 
 It may happen that the Bones of the Toes, 
 and part only of the Metatarfal Bones are 
 carious, in which Cafe, the Leg need not be 
 cut off, but only fo much of the Foot as is dif- 
 ordered ; a fmall Spring-Saw is better to divide 
 with here, than a large one : When this Ope- 
 ration is performed, the Heel and Remainder 
 of the Foot, will be of great Service, and the 
 Wound heal up fafely, as I have found by 
 Experience. 
 
 PLATE XIV. 
 7he Explanation. 
 
 A. The Figure of the Amputating Knife. 
 The Length of the Blade and Handle (hould 
 be about thirteen Inches. 
 
 B. The Figure of the Saw ufed in ampu- 
 tating the Limbs. The Length of the Handle 
 and faw il:iould be about feventeen Inches. 
 
 CHAP. XXXVIIL 
 
 Of Inoculation. 
 
 T T is ufual to prepare the Patient for this 
 
 Operation, by Diet and Evacuations, which 
 
 according to the Habit of Body, are to be more 
 
 or 
 
230 T R E/A r 1 s u of t^e 
 
 or lefs fevere. /Some Physicians recommend 
 frequent Blee^ngs and Purgmgs, with a ftndt 
 Milk Diet, the preceding two Months j others 
 a Re'3;imen/cf mercurial Alteratives, with gentle 
 Purges ai/proper Intervals, for the fame length 
 of Tim^; but, I think, thoie ot the greateil 
 Eminence in Londoriy feldom prefcribe Bleed- 
 ing more than once, and irequently not at all, 
 trufting to an abflemious Courfe of Life, and 
 two or three gentle Purges, and fomctimes 
 to one ^nly, the Week before the Operation, 
 at lead, where the Subject is young 
 
 The proper Time for inoculation, is <:;ene- 
 rally fuppofed to be Infancy ; and fome think 
 the earlier, the better ; but as Children, the 
 firft two or three Years nf their Life, are 
 fubjed: to many terrible Diforders from the 
 Circumflance of brerd ng their Teeth, and 
 indeed feem more liable to fatal Convuifions 
 upon the Eruption of the 5malI-Pox, than 
 after that Time, I believe it is advifeable to 
 poftpone the Operadon 'till they are three or 
 four Years old, when probably, the longer it 
 is deferred, fo much the worie -, though the 
 Succefs of this Pradice has been furprifing, 
 even in the moft advanced Age. 
 
 Phyficians have not unanimoully determined 
 which is the preferable Fart for Inoculation, 
 
 the 
 
operations ^Surgery. 231 
 
 the Arms or Legs ; and Tome order the Ope- 
 ration to be performed in one of each : In 
 either Cafe, it is right to do it \^ two Places 5 
 though probably it will not be abfolutely necef- 
 fajy ', but as one of^ the Applications may by 
 Accident fall oiF, or flip on one Side from the 
 Orifice, the other will generally take effed, 
 and prevent a Difappointment. The Prad:ice 
 of Inoculating in the Legs is preferred to the 
 other Method by fome, from an Obfervation 
 that the Incilions in thefe Parts, are more 
 difpofed to ulcerate and yield a greater Dif- 
 charge, than thofe in the Arms, which Cir- 
 cumftance they imagine to be advantageous, 
 upon a Perfuafion it makes a powerful Re- 
 vulfion of the morbid Matter from the Face 
 and Throat : On the contrary, the Advocates 
 for Inoculating in the Arms, advife it for the 
 very Reafon, that the Orifices are lefs liable 
 to become fore and painful j alledging, that 
 the Difcharge from the Vv'ounds cannot be 
 favourable to the Eruption, iince it feldom 
 happens 'till the Puftules appear, and are 
 even ripe j or fliould it be judged necelTary 
 from the Nature of the D]fl:emper, or the 
 Patient's Conftitution, to continue the Dif- 
 charge, ftiil it may be done as efficacioufly in 
 the Arms, by converting one or both Inci- 
 
 fions 
 
\5 
 
 2^2 Tr E AT I S E 0/ t,.. 
 
 fions into an liTue. Thefe Confiderations have 
 induced the Generality of Phyikians to ap- 
 prove of this hft Method. 4 
 
 The Ope^tion is to be performed after this 
 manner, ^oa muft v/ith a Stocking Needle 
 prick five/br fix large Puftules on the Arm or 
 Leg of the Subjed you inoculate from, when 
 they are plumpeft, and the Diftemper is at its 
 Height -; then taking a few Threads of Lint, 
 roll them up fo as to make one Thread of the 
 Thicknefs of fine Worfted : draw this over the 
 Orifices made into the Puftules, 'till a fuffici- 
 ent Quantity of it is moiflened by the Matter 
 jfiTuing out of them. Cut this Thread into 
 Pieces of the Length of a Barley-Corn, and put 
 them immediately into a little Box or Bottle, 
 which fhould be lliut up clofe 5 and tho' per- 
 haps the Matter may retain its Efficacy for 
 many Hours or Days, yet it is advifeable to 
 ufe it as foon as poffible. It w^ould be of no 
 Importance, what Part of the Arms or Legs 
 were to receive the Infedion, but that a Drain 
 may be defireable after the Illnefs j and there- 
 fore the Incifions fhould be in thofe Places, 
 where Ifiues are generally ordered, that by 
 putting in a Pea, you may at pleafure procure 
 a Difcharge from them, as long as you fliall 
 think properj a Month, two Months, or more ; 
 
 The 
 
operations ^Surgery. 233 
 
 The Orifices fhould be cut with a Lancet, the 
 length of a Barley-corn, and fo fliallow, as 
 barely to fetch Blood ; the Pieces of Lint mud 
 be laid exadly on them, and fecured in their 
 Situation by a fticking Plaifter and, Bandage ; 
 this Application flioiild remain twenty-four or 
 thirty-fix Hours, and afterwards, the Orifices 
 may be treated every Day v/ith Digefcives or 
 other Medicines, according to their Degree 
 of Inflammation, Ulceration and Pain. After 
 the Operation, the Patient muft be confined, 
 and live low till the time of the Eruption, 
 which is ufually about the eighth or ninth 
 Day, when the Diftemper is to be managed 
 as in the ordinary Method. 
 
 It is imagined by fome, that the Matter 
 from an inoculated Subject, is lefs malignant 
 than from a Perfon Vv^ho has the Diftemper, 
 however mildly, in a natural Way -, but, I 
 think, there is not a fufficient Foundation for 
 this Opinion : it is without doubt proper to 
 take it from a kind fort of a healthy Subjed" ; 
 • and though it is not probable any other con- 
 ftitutionai Illnefs will be communicated w^ith 
 the Small-Pox by Inoculation, rather than by 
 the natural Way, which no body even fug- 
 gefls ; yet, as we may have choice of Patients 
 to borrov/ it from, we lliould not run any 
 
 riik. 
 
234- Treatise, &^c. 
 
 rifk, but fix on fuch if poffible, who are 
 under nine or ten Years of Age, and whofe 
 Parents have always been healthy as well as 
 themfelves. 
 
 It may not be amifs to obferve, that upon 
 the Introdudlion of the Pradice of Inocula- 
 tion into England, anion gft the many popular 
 Prejudices which prevailed againft it, there 
 was none of fuch feeming Weight, as the 
 Opinion that it did not abfolutely fecure the 
 Patient from contracting the Diftemper again 
 in the natural Way j but length of Years, and 
 a ftrid: Enquiry, have at lad intirely falfified 
 this Dodtrine, amongft Men of Learning and 
 Candour. 
 
 
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