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and a bag-truss, are proper. The varicous veins have been tied with success in very obstinate cases.

Hernia humoralis is an inflamed state of the testicle, in which that gland is much enlarged, and very painful. The scrotum is distended and red, and the pain shoots into the loins Irritation of the urethra is the most frequent cause, and particularly that which takes place in gonorrhea. The unpleasant symptoms of the latter complaint cease when the testicle swells, and often recur when the hernia humoralis abates. A recumbent posture, frequent application of leeches, saline purgatives, cold saturnine, or discutient washes, or in some cases poultices, and in all instances a suspensory bandage, are the means of relief. Camphorated mercurial ointment should be rubbed on the epididymis, when a hardness of that part remains.

Cancer scroti, or chimney-sweeper's cancer, commences in the scrotum with an ulcerated wart, or rugged ill-looking sore, with hard and elevated margin. It penetrates the scrotum, affects the testis, ascends along the chord, contaminates the inguinal glands, and terminates the patient's existence in a most deplorable way. Extirpation in the early state is the only effectual mode of treatment.

Gonorrhea is the discharge of a mucous or purulent fluid from the urethra, occasioned by the application of infectious matter from another subject labouring under the disorder, and generally communicated by coition. The urethra may be irritated so as to furnish a preternatural quantity of secretion by other causes; as strictures, use of bougies, &c. It general ly comes on from six to twelve days after the infection; and commences with an itching and fulness of the mouth of the urethra. A discharge follows, first of a watery and transparent kind, and then becoming thicker and white, yellow or greenish. The glands swell, and the membrane at the mouth of the urethra becomes smooth, red, and swollen. An acute scalding pain is experienced in making water, which is voided frequently, and in a diminished stream. Troublesome erections are experienced at night. Various sympathetic affections often attend; as pain and soreness over the whole pelvis, in the scrotum, testicles, anus, &c.; enlargement of the inguinal glands, forming sympathetic bubo, and irritability of the bladder. It has been much disputed, whether the matter of gonorrhea and chancre be the same, and consequently

whether the constitution can be affected from a gonorrhea. But at present most surgeons are inclined to support the negative side of the question; and all act in the treatment of the complaint on this supposition.

In ordinary cases the affection does not seem to extend more than about two inches along the urethra. The complaint increases in violence for about three weeks, and then gradually declines; a discharge often remaining when the other symptoms have entirely subsided, and being then termed a gleet. There is little power of stopping the course of the complaint, at least without great risk of inducing hernia humoralis; so that the safest plan is to palliate. Occasional saline purges, abstemious regimen, and copious draughts of diluting and mucilaginous liquors, are proper with this view. Suspension of the testicles is useful as a precaution against hernia humoralis. Cold applications to the penis. After a few days, astringent injections may be employed, often with the effect of lessening the duration of the discharge considerably. Zinc. vitriol. gr. ijss. in two ounces of water; or hydr. muriat. gr. j. in eight ounces of water, will do for the beginning; but their strength may be increased. Opium and antimony, where the symptoms of irritation are very considerable; balsam copaiva is also very useful.

The gleet which remains after a gonorrhoa is not infectious, although very troublesome. Astringent injections may be tried for it; as hydr. mur. gr. ij. in aq. distillat. 3 viii or zincum vitriol or cupr. vitriol. in larger proportions. Balsam copaivæ or tinct. cantharid. may be taken internally.

Chordee is an inflammation, attended with extravasation of coagulating lymph into the corpus spongiosum urethra, or corpora cavernosa penis, which renders the penis curved in its erect state. Bleeding by leeches, fomentations and poultices, with the antiphlogistic regimen generally; and afterwards camphorated mercurial ointment.

Sympathetic bubo should be treated as a case of common inflammation. Affection of the bladder may be combated by the warm bath, venesection, leeches, and fomentations to the perineum and bladder, and opiate clysters

Phymosis and Paraphymosis. In the former the prepuce is so contracted, that it cannot be withdrawn over the glans; while in the latter it cannot be drawn forward from behind the glans. The irrita

tion of chancres, gonorrhea, &c. is the common cause of these affections; but some persons are born with a phymosis. Frequent injections under the prepuce are necessary in phymosis, which need not prevent the use of mercury if it is required. If the contraction be so great as to confine the matter, and absolutely prevent its discharge, the prepuce may be slit open, but not otherwise, in the inflamed state. When the complaint has subsided, and the contraction still remains, the following operation may be performed. The surgeon grasps the prepuce with a pair of harelip forceps, leaving out as much of the outer fold as he wishes to remove, and cutting this away at one stroke of the knife. He then slits up the inner fold with a crooked bistoury passed in a director.

In paraphymosis the glans can generally be returned by pressing the blood out of it, after immersion in cold water, and drawing forwards the prepuce. Leeches may be applied to the glans to diminish its bulk. If these means do not succeed, the stricture must be cut through.

Amputation of the penis is necessary in cancer of that organ; but it should be done before the glans are affected. One stroke of the knife is sufficient for the purpose, after which the bleeding vessels must be secured.

Strictures in the urethra are contractions of the canal; which may be either temporary, when they are called spasmodic; or permanent, in which case there is a projecting ridge of the membrane, or a continued contraction, occupying some length of the canal. The latter are also subject to attacks of spasm from inflammation, &c.; and vary in their state under different circumstances. If there be only a single stricture, it will be generally found at the bulb of the urethra; that is, about six and a half or seven inches from the mouth of the urethra; and where strictures are situated nearer to the end of the penis, there is almost always one in the former part. The symptoms of the complaint are, diminished stream of urine, which is voided more frequently than is natural, and with difficulty; gleet, nocturnal emissions, impeded ejection of the seminal fluid in coition; irritability of the bladder, which secretes a mucous fluid. Sometimes there is a complete paroxysm of fever; and occasionally swelling of the testicle. Strangury and total retention of urine are sometimes the consequence of a stricture, which becomes affected with spasm from some occasional cause.

Our first object in treating strictures is to ascertain the number and situation of the contractions. The bougie should be curved to the requisite degree (which is necessary in all cases where these instruments are introduced) and oiled before its introduction. The surgeon holds the glans penis lightly with the fore-finger and thumb of the left hand, just under the corona glandis, and introduces the bougie with the right hand, carrying it forwards gently, and drawing the penis upwards, so as to make the urethra tense. When he meets with an obstruction, he waits a little, and tries again. He should make a mark with the nail on the bougie, opposite to the end of the urethra, if he cannot pass a stricture; and then try a smaller instrument The same plan must be pursued, until all the contractions are ascertained. If he makes this examination with a soft white bougie, he may get an impression of the stricture by pressing gen. tly, which will be of service in the subsequent treatment. For the cure of the complaint common bougies may be used; or they may be armed with caustic.

The common bougie acts mechanically by dilating the contracted portion. The largest instrument that the urethra will admit should be passed into the bladder daily, and left there for ten minutes at first, gradually lengthening the time. It should be secured by tying it to the end of the penis. The size of the bougie should be increased, as the strictures dilate.

Where caustic is used, a small piece of argentum nitratum is inserted in the end of a bougie, and surrounded laterally by its substance. This is termed an armed bougie. In using this method, we ascertain first how large a common bougie will pass to the stricture, and mark accurately the distance of the contraction; then take a caustic bougie of the same size, and mark the distance on this also. We then carry it pretty quickly down to the stricture, against which we hold it steadily, at first for a short time (less than a minute) but afterwards longer. This is to be repeated every other day, and to be practised successively with the different strictures that are met with. Mr. Whately has recommended a peculiar mode of employing caustic. He breaks a piece of kali purum, with a hammer, into bits, of which the largest should not exceed a pin's head, and keeps these in a phial with a ground stopper. He passes a bougie through the stricture, and marks the situation of the contraction. In the end

of this he makes a small hole with a pin, inserts a bit of the kali, smaller than a pin's head, and covers it with lard. He passes his bougie, properly curved, down to the stricture, and lets it rest for a few seconds, that the kali may dissolve; he then urges it about one-eight of an inch forwards, allows it to rest, and then passes it on about as much further. He now withdraws it to the beginning of the stricture, and passes it through again once or twice. This is to be repeated every seven days, the size of the bougie being increased as much as the stricture will admit. Mr. Whately adopts this plan, from supposing that the membrane of the urethra is diseased for some extent.

A new passage is sometimes formed by the use of bougies. Here all instruments should be laid aside, if the circumstances admit, to give an opportunity for the parts to recover.

Fistula in perineo. When the urethra is very much obstructed, nature often endeavours to procure relief by ulceration on the inside of that part of the urethra, which is between the stricture and the bladder. Hence the urine insinuates itself into the cellular substance of the perineum, scrotum, &c. causing suppuration and mortification. If the patient survive, the sloughs are detached, leaving a free communication between the urethra and the external surface: and the openings thus produced, by which urine is evacuate, are called fistula in perineo. The treatment consists in removing the stric. ture, which is the cause of the complaint; and this must be attempted both by the caustic and common bougie. If the fistula does not heal, when the urethra is perfectly restored to its natural dimensions, it should be laid open like any other sinus which does not seem disposed to heal. A catheter, or staff, having been passed into the bladder, a director is introduced along the sinus, until it meet the former instrument; then it will be easy to divide the sinuses with the crooked knife. An elastic catheter should be worn until the wound is healed, which should be dressed from the bottom. The treatment of the complaint, which terminates in a fistula in perineo, will be considered under the next head.

Retention of urine. When the evacuation of urine is prevented by any particular cause, the bladder becomes remarkably distended. Its fundus ascends towards the navel, and forms a hard circumscribed swelling above the pubes, while the lower portion of the viscus bulges towards

the rectum. Violent pain and straining, tension of the abdomen, cold sweats, anxiety, &c. are attendant symptoms. When the cause of the retention does not close the urethra, and it has proceeded to a considerable extent, the urine comes away by drops through the natural passage, leaving the bladder still distended. If the canal, through which the urine ought to flow, be obstructed, inflammation and ulceration or sloughing ensue. When this happens in the urethra, fistula in perineo are the consequence. But the bladder itself may slough and burst. Reten. tion of urine arises from the following causes. Weakness, or paralysis of the bladder, inflammation of this viscus or of the adjacent parts, a spasmodic affection of the urethra, or some actual contraction of the passage.

The paralytic retention of urine may be caused by an injury to some part of the spinal marrow; by an over distention of the bladder, arising from retaining the water too long after an inclination is felt to void it, &c. Two objects are to be accomplished in the treatment; to draw off the fluid distending the bladder, and to restore the natural contractile power of the viscus. The use of the catheter at certain stated periods accomplishes the first of these; the internal use of cantharides, blisters to the sacrum, pubes, or perineum, cold water thrown on the hypogastrium, cold bath, &c. promote the second indication. The catheter must be used regularly and frequently, until the cure is completed.

The retention arising from enlargement of the prostate belongs to this division. A neglect of the patient to obey the natural calls to void his urine is the first cause; and the regular use of the catheter is the most efficacious means of cure.

Use of the catheter. This instrument is either inflexible, and made of silver, or flexible and elastic, which is composed of the elastic gum. There are also flexible catheters made a of fusible metal, and others composed of the bougie plaster; but the former are employed the most frequently. The elastic catheter is less irritating to the urethra than a silver tube, and it can be introduced in cases where a metallic inflexible instrument will not pass. The most favourable posture for the introduction of the catheter, is that in which the patient lies down, with his pelvis at the edge of the bed, and the legs hanging to the ground. The corona glandis should be held between the thumb and

fore-finger of the left hand, so as to avoid compressing the corona glandis. The catheter, well oiled, should be introduced, with the concavity towards the abdomen, until its point has nearly reached the bulb. The handle should now be brought slowly forwards, between the patient's thighs; and the point will consequently describe that portion of a circle which is necessary for its entering the bladder. In the latter stage of the operation, the penis, which before had been drawn upwards, should be allowed to sink down. If an impediment is met with in any direction, let the point be withdrawn a little and then pushed gently onwards, according to the course of the urethra; but force should be avoided by all means. The fore-finger of the left hand, introduced into the rectum, will sometimes facilitate the operation. When the prostate gland is enlarged, the urethra turns upwards very suddenly, just behind the pubes; hence the end of the catheter should be more bent upwards. It has also been found that, by withdraw. ing the stilet of an elastic gum catheter for a small distance, the instrument itself becomes more curved; and by this means the point of the instrument may be ele. vated in the urethra in the due direction. Many surgeons introduce the catheter as far as the perineum, with its convexity towards the abdomen; then keeping the point stationary, they make the handle describe a semicircular movement upwards, so as to bring the concavity of the instrument towards the pubes; after which the operation is finished as in the former method.

When the retention of urine arises from an inflammatory cause, the nature of the disorder is entirely altered. Strictures in the urethra, when very bad, and irritated so as to fall into spasmodic contraction, are the most frequent source of this kind of retention. However, virulent gonorrhea, bad piles, injuries of the perineum, fistula in ano, and the absorption of cantharides from blisters, may have the same effect. The treatment of such cases must be of the antiphlogistic kind; venesection, leeches to the perineum, warm baths, fomentations to the perineum and hypogastric region; opium by the mouth, and in clysters, are consequently to be employed. The use of the tinctura ferri muriati internally is also a very powerful assistant in such affections. The patient may take fifteen drops every ten minutes until it acts. A common clyster will of ten suffice in slight cases.

If none of these methods succeed, and the catheter or bougie cannot be introduced, it becomes necessary to puncture the bladder; which operation is neither dangerous nor painful, and fails in success, probably, because it is employed generally too late. It may be done from the pe. rineum, pubes, or rectum. The two latter places are so much preferable to the former, that we shall describe those operations only. When the prostate gland is enlarged, (and such a case often requires the paracentesis vesica) the operation must be done above the pubes; if the patient should be fat, it would be preferable to puncture from the rectum. When all circumstances are equal, experience has not hitherto discovered any very decisive advantage in either of these methods over the other.

When the distention of the bladder can be clearly felt above the pubes, the surgeon may plunge a curved trochar directly into its cavity, about an inch above the bone, as in the paracentesis abdominis. He should remember to direct the point of the instrument in the axis of the bladder; and not to urge it forwards when the resistance to the point ceases. Then the stilet should be withdrawn, and the canula pushed onwards. The latter part must be confined in its situation, and should remain in the bladder until the natural passage is re-established: or, after a few days, an elastic catheter may be introduced through it, and the canula withdrawn. If the bladder cannot be felt so distinctly, the surgeon may dissect down to its surface before he penetrates it with the trochar.

In operating from the rectum, a long curved trochar should be employed. The two first fingers of the left hand serve as a direction to the instrument, which is firmly held in the right; and should be passed through the very middle of the projection caused by the distended bladder, care being taken to accommodate its direction as much as possible to the axis of the bladder. After forty-eight hours the canula may be withdrawn, and the artificial opening will serve until the natural passage is restored.

In women, the bladder should be tapped above the pubes, although it might be done from the vagina.

If the surgeon should not be called in until the urethra has ulcerated, and the urine becomes diffused, it will be his duty to make free incisions, particularly in the perineum, for the discharge of that fluid, and to use those general means which are

likely to allay the constitutional irritation. He must then wait until the operations of nature have separated the sloughs caused by the urine, endeavouring, however, to introduce an elastic catheter, where he should allow it to remain. Poultices, fomentations, and the warm bath, should be resorted to, if there are any appearances of inflammation; and abscesses, or accumulations of urine, should be opened early and freely.

Incontinence of urine. Sometimes this Auid dribbles away without any sensation of the patient. Here paralysis of the bladder is the cause, and may be induced in various ways, as from injuries of the spine, over distention of the organ, &c. In the latter case, the urine should be carefully drawn off at regular intervals; cold bathing, bark, blistering the sacrum or perineum, electricity, tincture of cantharides internally, &c. will be of service.

Sometimes the patient can hold his urine to a certain degree, when an irresistible propensity to evacuate it comes on. Here irritability of the bladder is the cause, and may be induced by bad piles, fistula in ano, &c. Opium, the warm bath, fomentations, diluting drinks, &c. may be resorted to, when no obvious cause appears.

Imperforate vagina. Sometimes the labia have their opposite surfaces grown together, leaving perhaps merely a small opening, through which the urine is imperfectly discharged, but marked with a line, showing the proper distinction. This may be congenital, or the effect of disease. Sometimes a thin membrane closes both the meatus urinarius and vagina in newly born children. In both these cases the use of the knife is necessary; and lint should be interposed between the divided surfaces. There is another form of the same mal-formation, in which the vagina alone is closed; and no symptoms appear until puberty, when the menstrual discharge does not flow. The uterus swells, and at last a kind of labour pains come on. Here the membrane must be divided to discharge the accumulated menses, and the edges of the cut kept asunder.

Imperforate anus. The part may either be closed by a membrane, or be too contracted to allow the feces to be evacuated. It may be rightly formed at its outer part, but terminate in a cul de sac; or there may be no vestige whatever of anus. In the first species, a division of the membrane is the remedy; and in the second, a dilatation of the contracted part by the VOL. XI.

crooked bistoury. If an obstruction should be discovered within the gut, it may be perforated with the trochar, introduced according to the course of the intestine. The latter species is attended with very little hope of saving life. The surgeon may cut in the situation of the anus, and follow his dissection along the sacrum, in order to find the end of the gut, which, when found, should be punc. tured.

Fistula in ano. Any formation of matter near the anus is very likely to terminate in this complaint; the suppuration extends in the fat and cellular substance round the rectum, and sinuses form, having small external apertures, and seldom healing without an operation. The commencement of the disorder may be a phlegmonous abscess, attended with considerable sympathetic fever; or it may have a more erysipelatous character, spreading more widely, being more superficial, and attended with depression of the powers of the constitution. The former is seen in young, strong, and healthy subjects; the latter in weakened, intemperate, and unhealthy constitutions. The parts in the neighbourhood of the disease are often affected; and hence retention of urine, strangury, prolapsus and tenesmus, piles, &c. are produced. The complaint sometimes begins in an induration of the skin near the anus without pain. This hardness gradually softens and suppurates. The matter may either point in the buttock, at a distance from the anus, or near this latter part, or in the perineum. It may escape from one opening, or from several. Sometimes there is not only an external aperture, but another internal one, communicating with the cavity of the intestine.

A soft poultice and fomentations are the best means of treating these abscesses; which, if they are phlegmonous, should not be opened until the skin has become thin; but, when they are of the erysipelatous kind, should be punctured immediately, to prevent any further extension of the malady. The general treatment must correspond with the nature of the constitutional disturbance. In all abscesses about the anus, the incision should comprehend all the skin covering the matter, as the cavity is then most likely to fill up from the bottom. The dressing should be small in quantity, light, and unirritating. If, however, the case passes into a fistula, it will be neces sary to make it an open wound, by cutting through the rectum from the end of the $ $

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