A TREATISE OF Lithotomy: OR, Of the Extraction of the Stone out of the Bladder. Written in French by Mr. Tolet, Lithotomist in the Hospital of the Charity at Paris. Translated into English by A. Lovel. LONDON: Printed by H. H. for William Cademan, at the Pope's Head, in the Lower-walk of the New-Exchange, in the Strand. M.DC.LXXXIII. To the Ingenious and Expert Chirurgeon, Mr. Tho. Hobbs, Lithotomist in the Hospital of St. Bartholomew in London. SIR, I Confess it is but a weak Apology for my Confidence in prefixing your Name to this Book, to tell you that I can more easily satisfy the World, than yourself in making this Dedication; though indeed it be all that I have to say for myself, for this Trouble I give you. The truth is, Sir, since most Books now adays do court, what but a few deserve, I mean, Protection; as I would not be singular in Publishing this Translation without a Patron, so I durst not be so unjust to the intrinsic value of the Treatise, as to send it into the English World no other ways provided than with the Credentials of a specious recommendation to the train of some great Man, who, perhaps after all, would not admit it into his Family without your Approbation. It was therefore in imitation of the Ingenious Author of this Book, who gave me a Precedent for Dedication, that following the guidance of Universal, and therefore least erring Fame, I was led to your Door, there to leave this Foreign Child, which I have taught to speak (I hope) intelligible English, to be by you disposed of in the World, according as you shall think it deserves, & as you are pleased to give it a Character. If it may be able to serve those that serve you in that Famous Hospital, where you successfully Operate, or prove Useful to any that profess Lithotomy, that laudable, but difficult and dangerous part of Chirurgery; you are in the judgement of most men the fittest Judge; so that the Public (I make no doubt) will justify my Conduct in submitting it to your Censure. But, Sir, how you yourself will Interpret this attempt of mine, I dare not affirm; seeing Fortune hath not encouraged me to it by intitling me to those freedoms that mutual Conversation & long Friendship do allow: However, Sir, I will not despair but that the kind Acceptance my endeavours shall meet with in the World, will so far interceded for me, that what is intended, and really found to conduce to Public Good, will not be thought by you to want any private Motives to commend it to your Patronage. I shall say no more, lest by seeming to know you better than indeed I do, I should spoil my own Plea, and appear to be an Intimate Friend, when in reality I am, Sir, Your Humble Servant, A. Lovel. London, Sept. 23. 1682. A TREATISE OF Lithotomy: OR, Of the Extraction of the Stone out of the Bladder. CHAP. I. What is meant by Lithotomy. LIthotomy, according to the Etymology of the word, signifies Cutting of the Stone. It had been a more proper way of speaking, to have used a term that might have expressed the part which is opened by the edge of the Instrument, because the division or cutting of the Stone happens contrary to the intention of the Artist; however I shall make use of the word Lithotomy, which is in vogue, and understood by all that are skilful in the Profession. That we may dive into the meaning, and give the definition of the thing; it is an Operation in Chirurgery, practised for the Extracting of Preternatural hard Bodies which are retained in the Bladder. By Preternatural Bodies is to be understood, all things that are retained within the Body of Man contrary to the ordinary course of Nature: And seeing sometimes there are several things in the Bladder which require the opening of it, we have put in the definition Preternatural Bodies, rather than the Stone; and for clearer distinctions sake, we have subjoined that Lithotomy is only practised for such as are hard, and retained in the Bladder. CHAP. II. Observations upon the Parts of the Body of Man. THE Vessels and Pores of the Glandules are the usual Conduits through which the Corpuscules or little Bodies pass and are filtrated, when their bigness and figure makes them fit to be received there; but if there be no proportion betwixt the Conduit-pipes and the Liquors which should pass through them, they stop: On the contrary, if the Humours have a very rapid motion, they distend the passages, and many times break them. Whatever the impulse of the Humours may be, their motion abates the more that they communicate it; they make no sensible attempt to get out when they are moved on every side in a place that can stretch and be enlarged to a certain bigness, as the Bladder and the Basins of the Kidneys: But when the place wherein they are contained is full, if they be not evacuated, they are the causes of several Diseases; for the Humours consisting of parts of different figure or bigness, it follows that sometimes they cannot glide through one and the same passage. It is true that Bodies of the like or different extent may pass through one and the same Channel; the contrary is not impossible, and may give a beginning to those Tumours, which swelling outwardly higher than the surface of the Body, go by the Name of Abscesses, after the same manner as the internal collections have other appellations: And if the same Humours be composed of unequal parts, and meet together in a narrow place that is full of wind, some of them join together, and by their conjunction form a Body that in respect of the rest is solid. This Body by its continuance there, and the apposition of other Corpuscules, becomes more sensible to us; it hardens according as the rough parts closely embrace one another, and the other separate and continue their motion. After the same manner as it is in Brooks and Rivulets, where the small stones separate and retain the Mud; so is it in the Glandules through which the Humours are filtrated: And in the Pipes where Water runs in great quantity, though they be straight, Earth and other Sandy substances mingled with the Water cleave close and stick together, and there form a stony Crust, which in time hinders the passage of the Waters. CHAP. III. Of the Causes of the Stone. OUR Food liquified is not destroyed, and the diversity of Aliments makes it apparent, that they have parts different in Bigness, Figure, and Number; the most Nourishing, as Jellies and strong Broths have all these qualities, seeing the Juices of Animals which are the basis of them are taken from the soft and hard parts of the Bodies with which they were assimilated, or being still within the Vessels and amongst the Glandules, tended to that assimilation; or from those Bodies that were to be retained or voided, by Physicians called Retenta or Excreta. Other kinds of Food contain also parts of a different Nature because Elementary Bodies are mixed, so that a simple unmixed Body is not to be found. The Air wherein we live, and which we breath, is full of little Bodies separated from different Substances, and contributes to our Health and Sickness. If then, one breath a thick and gross Air, if he drink thick and rough Wines that are not fine, muddy Waters of Lakes into which several Brooks empty themselves, or such as petrify other Bodies, or Snow-water, which contain matters that being frequently drank may lessen the motion of the Humours; if he eat a great deal of unleavened Bread Waterfowl, Curds, Pap, Old Cheese, hard Eggs, stony Fruits that are tart and not fully Ripe; as Quinces, Medlars, Pears; if he feed on Beer, Pork, or the Legs and Feet of Animals, Eels, Salt and Spiced Meats; or if he frequently make use of Medicines which cause the more subtle parts to transpire, as Sudorificks and Diuretics: If he bestir himself too violently at any time, and especially after eating. The long use, or the excess of these things, will be the cause of the Stone; as likewise too much idleness, and sleeping too long upon the back, because the Earthy parts of gross Food may meet together in several places, and disturbing one another, stop the passage. If those who take the greatest care of their Health, are not exempted from Living on Food which contains slimy parts, as strong Broths, what may we think must befall them who to excess eat and drink indifferently of all things, or indeed but to Moderation, since our Victuals participate of a Terrestrial Matter mingled with a kind of Salt; and Chemistry teaches us, that in the Body of Man there are some Juices which dissolve and liquifie our Food, and others again that thicken it; whence it may be concluded, that if the one of these Liquors by mingling with our Food, renders it fluid; but then being confusedly hurried away, and conveyed by straighter passages, it may be that the same Liquor does escape, and more easily glide away than the Nourishment that is retained in, and does Nourish the part, or even destroy it, according to the proportion or disproportion of the Humours which in general may be called Alimentary. It is much the same if a Terrestrial Juice remain with the Food after Chylification; for being circulated through all the parts of the Body, if it transpire not, it will clog and obstruct, and many parts of the same Nature joining together, will there produce a Stone. CHAP. IU. Of the Consequences that are drawn from the foregoing Chapter, and how the Stone is defined. THE Blood is carried to all the parts of the Body; but if its motion be more rapid than is usual, it may distend the Capsules and Ureters, and make some drops of Blood fall into the Bladder, or other gross Particles mingled with the Urine, which will then be red, bricky, and gravelly. People do not always make water so soon as the Serosity is separated from the mass of Blood: If there be a small Stone in the Kidney it may ulcerate it: It descends towards the head of the Ureter, and when it is rough or of an excessive bigness in respect of the narrowness of the passage, it stops it, or by the impulse and force of the Urine that follows, making a great dilatation, it opens a passage for itself unto the very Bladder, the patiented in the mean time, suffering most violent Nephritick Colicks, which sometimes are the cause of his Death. On the contrary every soft part having a peculiar sense of feeling, if the Kidneys have no exquisite feeling, and the Urine or small Stones have by little and little dilated their passages, the Glandules will separate and retain but a very small matter, all that was contained with the Blood will pass through; and as through a Seive, several sorts of grain may pass after that the holes are enlarged, so Gravel and little Stones may be conveyed into the Bladder, with the Urine, and the Patient hardly feel any pain or trouble. It is to no purpose to allege that the dryness, or close Union of the parts that compose the Kidneys does contribute to the forming of the Stone; because in the Dead Bodies of those that have been troubled with the Stone, it is to be observed that the Kidneys are moist and soft; and it is certain that in living Bodies they are continually moistened with some Liquor: And besides it cannot be said that their Bladder is narrow and dry, although Stones are more frequently form there, than in any other part of the Body. It is unjust to accuse our Parents, to make us bear more patiently the pains we suffer, because in every body the causes of the Stone may be sufficiently evinced, without imputing them to those to whom we own our life, and without blaming of them, reason may be given, why we see Children subject to the Stone, whose Fathers and Mothers enjoy perfect health. We are to conclude that Age and Excesses render the parts weak, whose Fibres being relaxated give occasion to obstructions in Old People, as well as in Children; because the abundance of humidity slackens the motion, and the earthy, slimy, and superfluous matters, that are not evacuated, occasion several diseases, as well as the Stone. Many distempers are bred according to the diversity of the food that one takes. Thus a man shall be afflicted with the Stone, if he feed on course food, and which may easily coagulate in the Body. There are not wanting sad instances of this; persons of different Ages, Sexes and conditions, are subject to it, and most of those who are troubled with the Stone, and who are to be seen in the Hospitals of Paris, come from the Country, where most part of their food is terrestrial and course; and many little Children who live in that manner are cut there. Stones are form in all the parts of the Body, and according to their dimensions that which stops the passage takes the name of Sand, Gravel, or Stone: experience confirms this; for Stones are found in the Lungs, the Liver, the Gall, the Spleen, the Kidneys, etc. Paraeus lib. 25. Chap. 15. reports that he took one out of a man's Knee. Some are found in the Heart: those which are found in the Nerves are by Paulus Aegynaeta named nodosae nervorum concretiones, knotty concretions of the Nerves. It is likewise observed that Stony crusts are form about the Teeth. I know a man that above twenty years ago voided one by the Navel: it was of the bigness of an Olive Stone; and the man is still alive. Stones are bred most frequently in the Kidneys and Bladder, because these parts are appointed for separating and containing the serosity which always carries along with it an earthy Sediment that accompanies the Urine; and the Stones of the Kidneys and Bladder give greater pains to the Patient, because they stop the emission of Urine; or irritate the parts whose use is frequent, and the sense more exquisite than that of many others. In a word, we may conclude, that the Stone is a preternatural hard body, begotten of the terrestrial and slimy parts of our Food. We have put in the definition the word slimy, to distinguish it from Viscous, because Viscous things do not harden in a place where there is moderate heat and humidity: but such as are slimy, like the White of an Egg, by little and little grow hard, and incorporate with the earthy parts they contain, when they have long continued in lukewarm Liquors. This proposition may be confirmed by the experience of those who render an Oily and Fat Urine, and who are not troubled with the Stone; and because unctuous and viscous Medicines, such as Turpentine, give ease to those that are afflicted with Gravel: Moreover, clear and slimy Urine is reckoned among the signs of the Stone in the Bladder. Authors are divided about the deciding of the question whether or not the Stone be a disease if all their reasons be considered, it may take the name of a disease, as well as that of a cause. CHAP. V How Stones are form and grow in the Bladder. THere needs no more but a grain of Sand, or any hard Body to serve for a Centre or Foundation for monstrous Stones, which cause terror in those that behold them, and most frequently death to those from whom they are taken. The Sand, and other things that are mingled with the Urine, sometimes are not wholly voided out, their continuance within gives time to what remains to gather together in some place; and after that one hath made Water, if there be still in the Bladder a little sand and slimy substance like the white of an Egg, preternatural heat and the separation and evacuation of the humidity make them join together in the same manner as the Saline and Tartarous parts of Wine; and the Urine of those that are troubled with Gravel which distils into the Bladder, being mingled with other Terrestrial parts, furnishes matter that joining with that which remained there before, forms and augments the Stone: Experience informs us that Stones are sometimes found which are in a manner like a mixture of Sand with the Whites of Eggs, having so little Solidity, that one cannot avoid the breaking of them betwixt the Teeth of the Forceps. If a little Sand may be the Centre or Kernel of the biggest Stones, a hard body got into the Bladder and remaining there, may likewise be as we have seen in an Italian Soldier; who to ease himself of a pain that he felt, thrust into his Yard the Tag of a Point about Two Inches long, which slipped into his Bladder, and there continued Eight Months. In the Spring of the year 1677, he came to the Hospital of the Charity at Paris, where without much minding the relation he gave of his condition, I was assured by the catheter that he had a Stone in the Bladder, he was cut, and the Iron Tag taken out; about which a Stone was form, that hindered not but that it might be seen in several parts. Parêus, lib. 25. chap. 15. Reports a like case. Fabritius Hildanus L. de Lith. c. 3. col. 2. writes that one of Geneva having for the space of Twenty Eight years complained of the Stone, at length died, and that he was found to have a Stone, the Kernel of which was a Leaden Bullet petrified, which he had received by a Musket-shot, and retained all that while. Joseph Covillart, Obs. VII. of his operations, assures us that he had seen a Stone, the Centre whereof was a Musket Bullet which a Gentleman had received in the Bladder, Five years before he was cut of it. I had in cure a young man, who had been cut at the Age of Four years Old, and who was troubled with a Fistula: since that time he had discharged Urine unto the Scrotum, where by degrees a Stone was form about the bigness of a little Pullet's Egg, ending in a point like the Stalk of a Pear. It cannot be determined how long time the Stone is in forming and growing; that depends upon the conjunction of the parts of the Sand, and the sudden and quick secretion that is made of it in the Bladder: besides, it may be, the Stone continues at a certain Size, because new Corpuscles do not always cleave and stick to it. I know one that hath had one for several years, seated in the beginning of the Perineum, near the Scrotum, without any sign of dilatation or sense of Pain. The growth of Stones in the Bladder happens not without alteration of that part; which becomes weaker according as the Stone increases. This remark affords us a reason why the Bladder of those that are troubled with the Stone is thicker than naturally it should be, which is only caused by the debility of the part; because not being able to send back the superfluous part of the Blood, it swells therewith as the womb in Women when they are with Child, and the parts where there hath been a Fracture, a great Contusion or a Wound; and in the same manner as by Suppuration, or the Transpiration of Wounds, Fractures and Contusions, or the Evacuations that happen after a Woman is brought to bed, the parts return to their natural thickness, so the Bladder being discharged of the burden that incommoded it, and besides assisted by Medicines and a regular Diet, is restored again to its former state. Bev. c. 4. de Cal. Ren. & Vesic. CHAP. VI Of the differences of Stones. THE most considerable difference in Stones, is in respect of their magnitude. The least Stones of Children of Three, Four, or Five Years Old, are like great Pease; or of the bigness of Cherries. Those of Seven, Nine, Twelve to Fifteen Years Old, have them a little bigger. In men grown up, who are of Middle age; and in Old men to the last period of life, Stones are found of the bigness of a Hens Egg. I pretend not to determine the exact Size of the Stones of every Age, there is no rule for it; and it is sufficient to remark what is commonly observed; for sometimes smaller Stones are cut from Children and Men, and at other times some of such a bigness that with relation to the subject, they are called Monstrous. The thing contained gives sometimes the Figure to that which environs it, but Stones rather take than give it. The Bladder, the Urine, or the Pressure and Justling of other Bodies, are the causes of many differences; do not we see that water hollows Rocks, though it fall drop by drop? It may be observed when the Stone is form by minute Bodies that have Angles, the Urine or the Salt of it blunts the points of them, and the wet Sand not having firmness enough, lies slat by the sides of the Bladder when there is little Urine in it, and forms a flat and smooth Stone, approaching to the Oval Figure of the Cavity of the place, but if the minute Bodies of the Stones are Round, they Roll in the Bladder from one side to the other; and when they join together and are dry, they make rough Stones of a Spherical Circumference, with very great Pores; as is represented by the Figures, the Superficies whereof are unequal like to Strawberries or Mulberries: On the contrary if they be composed of minute Bodies that draw near to a Triangular Figure, the contrary will be found, and they will have smother and less unequal Surfaces. A, B, Gravelly Stones which are the Roundest. C, D, E, F, G, Stones that have no other name than that of the things they resemble; as an Almond, a Hen's Egg, etc. It is also to be observed that there are many more flat Stones smooth and polished in the Surface, than round and rough: And this makes it probable that most of them are form of minute Particles, the points whereof are blunted. depiction of assorted kidney stones page 20 A B C D E F G The Corpuscles of Stones being small, the Stone will have a fine grain and be more polished and smooth, the Corpuscles that are big and Globular, make the grain course, and the Stones lighter; because their Pores are full of Urine, or of some other very subtle matter much lighter than the parts of the Stone; hence it is, that of two Stones of the same bigness the rougher or less polished shall be the lighter, and a dissolving Menstruum will Act much sooner upon those which are Globular and unequal, than upon those which are Smother and more polished in their Surfaces. When the Stone gins to be form by Globular Corpuscles, they are in such sort disposed, that they contain humidity in their Pores; the Stone in a short time growing in bigness, that Water or Humidity is by heat rendered more subtle according as the Stone grows harder, and then it acquires a motion that may drive the parts from the Centre, and making to itself a passage big enough to transpire through, but too little to allow an entry to other Terrestrial Corpuscles, that Stone will he hollow at the Centre. Corpuscles that come nearest a Triangle, cement and link the other Particles together; because Triangular and Square Figures, are more capable to hinder motion than Spherical. The Stones whose Pores are full of Humidity, are the softer, and that softness will be more or less, according to the quantity of Aquosity contained betwixt the Centre and the Surface; and therefore they are called soft Stones if there be much Humidity; and hard, if there be none, and that the parts of the Stone be closely compacted. It is certain, the hard are heavier than the soft. Sometimes Stones are taken out whose Centre is Globular, and the Surface smooth; the reason is because betwixt the Pores of the parts of the Kernel, other smaller, and less round Corpuscles are placed, and form a stony crust which has a finer Grain. On the contrary the minute Bodies having form an equal thickness from the Kernal, if many Globular Corpuscles join with them before the Stone be hardened, it will be unequal and rough in the Surface. If the Stone be form in the Kidney, and take its growth there, it will be Sized according to the shape of the Cavities wherein its Branches do extend themselves. Hence it follows that a Stone form and augmented in the Neck of the Bladder, will have a Figure Oblong, Cilindrical, or like a Pear, having one end smaller than the other; but if the Particles begin to join higher towards the bottom of the Bladder, it is not repugnant but that at the same time the Corpuscles may be separated without touching one another amongst the Wrinkles and Rugosities of the Bladder, and there form Stones which change their place, and which by mutual collision become smooth; as with two Stones of a moderate hardness and a little Water we may make the experiment, and they will have one or more sides flat, as is represented in the figures contained in the little space of the former cut. This may serve for instruction to those who have not seen the operation often performed; because considering the stones, they will be able to judge if there be many, which are sometimes uniform, sometimes unequal in thickness. It is rare to find Stones covered with a coat, or slimy humour; there are some that are sticking like those which have Prickles and Asperities, which are called Gravelly Stones, to distinguish them from those which are Smooth, Round, or Oval. Some are harder and more ponderous; others are gravelly only in the Centre, or in the Circumference, some are found to be hollow within, and others again solid, as in their Superficies differences are likewise taken from the Situation, because there may be Stones in the Vrethra, the Perineum, the neck of the Bladder, the bottom of it, betwixt its Tunicles, in the ureters, the Kidneys, and other parts of the Body. In the gallbladder some are found of a grayish colour; those of the Joints and Phlegmatic Abscesses are Whitish and those of the Kidneys and the Bladder are Reddish, Grayish, Whitish or of a colournear to these. We must not forget the number seeing it is sometimes excessive, and that sometimes there have been found in People subject to the Stone to the number of Twenty, Forty or Sixty stones; but the number is not to be limited no more than the bigness, because many Stones may be form at the same time, or successively, and the fragments that break off from them by grating, produce other Stones; and that is the reason that some are bigger than others. If a Stone have several flat sides, there will be commonly three Stones; there may be also more, or only but two. Stones that are cut out of Man's body are not so smooth nor so hard as the Pebbles of the Earth; And there are not so many adherent Stones as is believed, if you except those that have a coat, or prickles. The smoothest are not extracted without pain if they be large and the passage be not sufficiently dilated, or if they be not rightly laid hold off by the Forceps, or if the Membranous parts be doubled through which they are pulled out. It is very hard to judge whether the Stone adheres before the operation. CHAP. VII. Of the Diagnostic and Prognostic signs of the Stone. IF we reflect on the causes of Stones and their differences, we may observe the diversity of their signs, of which the First discover that there is a Stone, the Second if there be many, and the Third if the effects and consequences of them will be dangerous. The signs that discover to us the Stone or the number, are called Diagnosticks, and those which make us judge of the consequences, are named Prognostics. For facilitating the means to know if the Stone is in the Kidneys and that it descends into the Bladder, we cannot cite a better Master than Galen, book vi. of Places affec. chap. 2. who describes the signs of the Stone different from those of other Colicks. A straining to vomit, and great and frequent vomitings are much more troublesome to those that have the Colic; and then they vomit more Pituitous and Corrupt Matter than those that have the Stone. They are more bound and break no wind neither upwards nor downwards; The Colic seems often to move and take up more place, and sometimes it increases in divers parts; but the Stone Colic torments in the same place without intermission. And though pain that afflicts a place higher than the situation of the Kidneys be always produced by the Colic, yet it does not follow that that which is fixed in the region of the Kidneys, is an evident sign of the Stone; that situation signifies nothing at all to distinguish it, because with these marks the Urine must also be examined. Those that are subject to the Stone in the beginning render a clear and pure Urine, and in the following days something troubled is to be observed which subsides to the bottom, and at length it becomes all Sandy and Gravelly; which happens not to those who being free from the Stone, are tormented with the Colic, because if they render any gross excrements, one would say that there were Flatuosity in them, and many times they swim on the top of the water, being of a Consistency like to the Urine of an Ox. Moreover these great pains of the Colic are much sooner eased by laxative Glisters, than if they proceeded from the Stone. It happens sometimes that the Colic ceases by the voiding of some cold humour, and then it is a remedy that not only eases but cures and discovers the disease: In a word, as the one is cured by voiding of cold Humours, so the other is delivered from their distemper by voiding the Stone with the Urine, and at the same time we may know what part suffers. We have said that the Matter of Stones are all kinds of Slimy and Terrestrial Substances linked together according to the Proportion of more or less that forms a hard Body. That Stones forced against the side of the Bladder, cause pain, Inflammation, Ulcers, and make one void Purulent matter in the same Manner as the Acrimony of Humours, of Urine and Abscesses. Little Stones may come out with the Urine: Sometimes they stop in the Sphincter or Vrethra; they hurt the nerves of the neck of the Bladder which terminate in the circle or crown that is the beginning of the Glans; they may in like manner if they be big lay upon and press the Intestinum rectum and cause an extraordinary weight, because these parts are only appointed by nature to bear the burden of liquid things which are less ponderous than the Stone. When they have Asperities, or are covered with a coat, they are detained in the wrinkles of the Bladder: Now if they be very light, and without adherence, they float a long time in the water; but because of that weight they have they descend towards the Vrethra, and the smaller they are in bigness or the less unequal in their Surface, the more they close the passage, because the small Stones slide easily into the Vrethra, and the Urine may run down between the Asperities of the Stone. That Obstruction hinders the passage of the Urine and obliges the Patients to lie upon their backs; they hastily and with violence turn themselves, to make the Stone change its situation, that so they may facilitate the excretion of the Urine; and because pain makes the Spirits move towards the neighbouring parts, these are so distended that Men and young Boys are fain to draw out the Yard and Prepuce to appease the pain, and therefore they cross their Legs, and press their Thighs together: Moreover if the Stone change its place a little clear Urine, or mingled with slime comes out: According to the same principles it may stop the passage, which obliges those that are subject to the Stone to have often a desire to make water. They are commonly dry, because the Spirits and Humours are dissipated and spent by labour, pain and watching. By these observations we may judge that there are several Diagnostic signs which are equivocal, as the Yard and Prepuce drawn out by the hands of the Patient tormented with Inslammation, pain, and voiding of Purulent matter, by sharpness of Urine and gravel; because Sandy matter or little Stones having caused their symptoms, may be evacuated with the Urine; nevertheless when that hath a sediment mingled with Sand and thick Slime, when there is any shell of a Stone within, or squeezed out of the Yard, it is a pregnant presumption, which commonly serves for a certain sign. The univocal Diagnostic signs may be drawn from the same observations; as a sudden and fixed pain in the loins towards the one or the other side, and sometime towards both in the region of the Kidneys; after which the Urine looks reddish and Sandy, or sometimes Crude, Clear and Watery, a numbness of the Thigh on that side where the pain is when the Stone is big: There is a Flitting and restless Itching towards the Pubis and in the end of the Yard, accompanied with a frequent and sudden suppression of Urine, a pain and heaviness in the Perinenm with a continual heat of Urine, and immediately after the making of water a fresh desire to do it again. It may be observed why there are such violent strainings for a stool, and why the Urine stops all of a sudden when one is standing, which happens not in another posture. One of the surest of all the Diagnostic signs is the thrusting of the finger into the Rectum of Men. The Chirurgeon will feel a hard body betwixt his finger and the Pubis, or a little higher. If the finger be not long enough, they make use of a hollow Probe called a Catheter, which is introduced through the Vrethra into the Bladder; And then is felt something that is hard making a dry sound and noise as if one touched a Stone; this is the most certain of all Diagnostic signs. It is very necessary to make an Experiment of this in dead Bodies, by opening the Bladder, and putting Stones therein; and then having stitched up the Parts, to introduce the Catheter by the Yard. The Catheters that are made use of, to know if Women have the Stone, are of another Figure; they shall be represented with those of the other Instruments, When the Stone is skinned over by a peculiar Membrane, or when it is form betwixt the Membranes of the Bladder, or that there be an old excrescency of flesh, called a Sarcoma, (which are rare Distempers) or if there be a fungous' Body, it is not easy to discern it, because the Symptoms of these Diseases in those Parts are much alike; but the Stone is much more frequent there, and one is not often mistaken, provided he be attentive in sounding or searching. What we have said of the external Causes of the Shapes and Figures, serves us for Signs to foretell the plurality of Stones on which we see the marks of Collision, when during the time of the Cure, a Stone is taken out which was not left in the Bladder, it is said that Patient hath a Quarry of Stones. The figure and bigness of the Stone being considered after the Operation, one may judge whither or no the consequences will be dangerous, for if it be monstrous, the parts have been much dilated and coutused, and if it be craggy and pointed, there hath been dilaceration or adherence, and some times complication, the Stones that have many asperities are never so big as those that are even and smooth in their surface, and that for two reasons; the first is, because the minute Bodies that compose those rough Stones, are not so closely comparted, and some of them may break off and be voided with the Urine; the second, because those asperities cause a more sudden and pungent pain than other Figures, and force the Patient to betake himself more speedily to the Chirurgeon for ease, who performs the operation, before that it hath had time to increase to a greater bigness. CHAP. VIII. What is to be observed by the Chirurgeon before the Operation. HYpocrates having taken an Oath never to undertake the cutting of the Stone; hath instructed us how necessary it is to observe all circumspection in performing it. Wherefore when a Chirurgeon pretends to the cutting of the Stone, he ought to frame to himself a Notion or Idea of opening to himself a passage to the Bladder through a convenient place for extracting of the Stone; by his Rules and Precepts he will know if he can Operate, and then he is to resolve upon it. He that is troubled with the Stone, is his Subject matter, and it is the duty of a skilful Chirurgeon to foresee the consequences, to the end he may guard himself with necessary remedies against the accidents of the matter, and of the Operation. A Chirurgeon that is called to search or cut a Patient, aught to make himself be distinguished from Quacks; this will be easy for him to do, if he observe what is taught in the Principles of Chirurgie, where they treat of the Qualities of the Chirurgeon and of the Servants. It is one of his chiefest qualities to have great skill in Anatomy, that he may know the formation and fcituation of the Parts, that so he may Operate with necessary circumspection, being bold but yet not rash: he ought to make his prudence appear by making his prognostic, and distinguishing between those things that are ineffectual and perilous, and those things, wherein according to the Rules of his Art he may succeed, without exaggerating the least circumstances and events that depend not upon him, by an unnecessary stood of words. He is to consider the State, Strength and Age of the Patient; for knowing that a Man is upon the brink of death, before that he search or probe him, he is to acquaint those that are by, that it is no disgrace to him if he cannot search him, or if though the Catheter be even introduced into his Bladder if he make but little or no Water, by reason of his weakness; because a Patient falls sometimes into an apparent suppression when he hath no Urine to render: this happened to me about 3 Years ago. I was sent for to search Mr. Sartorin an advocate, he was very Ancient, Hydropical, and at the very point of Death, and had not made Water for three days: I did not search him, and he died within an hour after I saw him: when he was opened there was not one drop of Water found in his Bladder; his Ureters were so closed up that the Urine would not pass. The Chirurgeon ought to be Informed from the Patients own mouth, and by those that wait on him, of the secret matters and distempers to which he is subject; of the excesses that may have contributed to his Indisposition, nothing is to be concealed from him because of the Remedies and Instruments which he is to choose. Hypocrates in the sixth Aphorism of his sixth Book affirms that old Men are hardly cured of the Diseases of the Kidneys and Bladder; and elsewhere he assures us that he never saw any past fifty years of Age Cured; because according to Caelius Aurelianus, their Bladder is Nervous, and they have but little natural heat; besides it is seated too high, so that Medicines cannot be conveyed to it. They are weak, and many Excrements fall continually that way. Nevertheless several have been cut and cured of the Stone at a greater Age. It is a good presage for the Cure, after the operation is performed, if the Patiented sleep, if his respiration is equal, his tongue moist, and if he be not dry nor do vomit; the lower region of the belly little or not at all swelled, with moderate pain and a slight Fever; because in that disposition, (according to Celsus) the inflammation ceases most commonly about the fifth or seventh day. He ought to know that the Patient oftener dies by the accidents that accompany or follow the Operation, than by the Stones whilst they are in the Bladder. If the Patient be too weak, he ought to have time to gather strength, otherways the Operation would reduce him to evident danger, and the Chirurgeon ought to give notice of it, that he may avoid the blame: before the Operation some time is to be allowed for the digestion of the food that the Patient hath taken, that so his Body may be in better plight to endure it. Celsus observes that most of learned men have a weak stomach, and that they are not strong by reason of Watch and over Studying. The Medicines of Pharmarie cannot cure the Stone; they only bring relief when the Stones are very small in the Kidneys or Bladder, and when they are as yet but a kind of matter easy to be resolved into Powder, and to be evacuated with the Urine. The Chirurgeon ought to make his prognostic, examining, if he can, the bigness of the Stone, with his finger thrust into the Fundament; informing himself, how long the Patient has complained of it, observing the season, place, and other circumstances directed by the Principles of chirurgery. Those that have the Jaundice, or Dropsy, are not strong enough to endure the Operation. When one hath discovered the signs of the Stone or Gravel, if the Urine after it hath been bloody, or becomes full of purulent matter, it is a sign that there is an Ulcer in the Kidneys or Bladder, caused by the roughness and asperities of the Stone, and that there is no hopes of curing an Ulcer in the Kidneys, because hot and penetrating Medicines are required for expulsion of the Stones, and the contrary for Ulcers: nature sometimes stirred up or assisted by diverting Medicines, discharges itself of that load, and gives opportunity of easing the Patients of their tormenting pains. The Chirurgeon ought not to expect a Cure, if after the Patient has been cut, the Nephritick Colic continue long, with pains that are sometimes heavy and dull, and sometimes acute and sharp; because that is a Sign that there is a big Stone, or many little ones, which still remain and take growth in the Kidneys. A Patient labouring under a suppression of Urine, cannot be cured after the third day, if he be taken with a drowsy fit, and if he can hardly fetch breath. The Hicket is a mortal symptom. The Gout happening to those who are troubled with the Stone, may sometimes cure them; the contrary also, through the abundance of humours does also happen. When the Stone is Adherent, or covered with a Coat, or if we meet with a fungous or sarcomatick Body, the separation of them is gradually to be attempted by injection and moderately detersive Medicines. Children are sooner and more easily cured by this Operation, because they have a more sedate Mind, and less troubled with Passions, being nearer the source of Life, than those that are strucken in Age. Whilst all things are preparing, it is the Surgeon's part to comfort the Patient, ordering likewise that he have Spiritual and Ghostly helps Administered unto him. CHAP. IX. Of the Method of Searching. WOmen are least troubled with the Stone, because their Vrethra is shorter, wider, and more direct; and therefore is not so obnoxious to Diseases as that of a Man: but seeing all sorts of Persons are subject to the Stone: having first inquired into the Signs, the Patient is to be put in a convenient posture to be searched, that so the causes of their Pains may be discovered. If it be a Woman, she is to be laid upon her Back, her Buttocks a little raised, and having chosen a Catheter, bending only at the end, and anointed with Salade-Oyl, or some other sweet Oil, she is to be made to open her Thighs a little. Then the Operator is to open and separate the Nymphae, with two Fingers of the same Hand, that the Orifice of the Vrethra may appear beneath the Clitoris; afterward the Catheter is to be thrust in gently with the other Hand, and so a search to be made whether there be any Stone or not. It is no great matter whether the bended part of the Catheter be turned towards the Pubis, or the Vagina, because of the conformation of the Vrethra, and it is convenient not to be just opposite to the hollow of the Catheter; for fear of the Eruption of Urine. For the more easy searching of Men, they ought to lean a little back, or to be laid upon their Backs; and the Chirurgeon having made them open their Thighs, he is to raise the Yard, and hold it straight betwixt the Thumb, and the fore and middle Fingers of the same Hand, Skinning and taking the Prepuce off of the Glans, afterward with the other Hand he shall gently thrust an oiled Catheter to the very bottom of the Vrethra, holding it by the end where the rings are, like a Pen betwixt his Fingers, with this difference, that the rings of the Catheter are be hid with the same Fingers, his Hand being half open, turned toward the Pubis, and the bending or bill of the Catheter towards the Anus; then must the Catheter and Yard be moved towards the Groin that is remotest from him that searches, and in the mean time he is to turn betwixt his Fingers the Catheter, and the bill of it towards the Pubis. Observe that the fore and middle Fingers touch the Catheter on the one side, and the Thumb on the other, answering exactly to the space betwixt the Fingers; at the same time the Chirurgeon is to press a little more with the fore Finger, which is higher than the middle Finger, so that the Centre of the motion be upon the Thumb; by that means the handle of the Catheter is covered, and the bill or bending of the Catheter raised, that it may press the Sphincter, and enter into the Bladder; this is the Figure of it. depiction of stone removal procedure page 44 Sometimes, when the Catheter is introduced to the very bottom of the Vrethra, and when the bill of it is turned towards the Pubis, the Chirurgeon is obliged to let go the Yard, and to put a Finger into the Anus, and by a light compression of the Vectum, and the Vrethra, the Catheter is conducted into the Bladder; which being done, he is to draw out his Finger, and hold the Yard no longer. The Wire or Stilet is taken out of the Catheter before it be introduced, and when it is in the Bladder, it is held by the rings betwixt the fore and middle Fingers, having the Thumb upon the hollow of the Catheter, and the back of the Hand turned towards the Patient's Belly: then the Chirurgeon is to give some easy Jogs, moving the bill a little to the right and left, without turning the Catheter fully round. The rings are lowered, that the bending may mount towards the bottom of the Bladder, and sometimes they are inclined near the Belly, without forcing the Catheter out of the Sphincter, and by these kinds of motion, if one be very attentive, when it is a Stone, one shall hear a little sound as of two small Stones that touch one another, or at lest something is to be felt that makes a collision with the Catheter, as if it were rubbed with a Stone, if it float, it may be felt when there is Urine in the Bladder; And that requires that the Operator should stop the hollow of the Catheter with his Thumb; but if nothing be felt, the Urine is to be let out by the Catheter, and then diligent search to be made. There is another way of searching Men; the Yard is to be raised and moderately pulled up, laid upon the Groin, and the rings of the Catheter inclined towards the Belly; so that the bill be turned towards the Anus. There are Ungosities in the Bladder that sometimes deceives him that searches; but they may be discerned, because then, one finds only something that is soft or but moderately hard, which makes no noise by the touch of the Catheter, the Bladders of Children have no Ungosities like to those of Men. In the Hospital of the Charity at Paris, about the beginning of a cutting in the year, 1681. Two Children were presented to be cut; but the Stone not being felt, they were put to Bed again; notwithstanding, after many others had been cut, they were examined the second time, the Stones discovered, and immediately cut out, because they were prepared. This makes it appear that one should not be too hasty to give his Opinion, if sometimes the Stones are not felt though the Signs seem evident, because they may be small or change their place. At the same time a Man was searched with a Catheter, used to make Patients void Urine. After that the bill had been inclined to the right side, and several times thrust towards the bottom of the Bladder, the rings were pressed down towards the Belly, as if there had been a design to bring out the Catheter; but when the bill of it was judged to be near the Sphincter of the Bladder, it was turned to the left side, which could not have been done sooner, because of the length of the bending of that Catheter, and the smallness of the Bladder; the Operator continued to search the Stone, which not being felt, was found with another Catheter, whose bill from the beginning of the bending, was not so long, and therefore that Catheter turned easily in the Bladder. This observation instructs us what Catheters are to be chosen for voiding of Urine, whose bill ought not to be so long as those that serve for making of the incision, and which are Channelled or Furrowed. There are some Men who have very narrow Vrethra's, which require small Catheter like those for Children, and of a sufficient length. Catheters that do not easily bend or bow, are likewise to be chosen; and that depends on the Work of the Artist that makes them. When the Stone is in the Neck of the Bladder, it is not necessary that the Catheter should be introduced so far as the bottom of it, because the Stone may be felt, provided the Catheter be only introduced as far as the bottom of the Vrethra. When there is a Carnosity, which hinders the Catheter to slide into the Bladder, the Operator must put a finger into the rectum, and if there be a Stone he will find a hard and ponderous Body towards the Pubis, if there be a great inflammation, it is the opinion of Fernelius, that no search should be made; in that case one should observe to search gently and seldom, because otherways it may be the cause of pain, inflammation, excoriation, a gangrenous Ulcer in the Sphincter, nay and even a Supression of Urine, or a piercing of the Vrethra. Besides these Diseases, one cannot sometimes search because of a Phymosis, and of a Stone in the Vrethra; something must be said as to that, as much as is necessary to be known upon the account of Lithotomy. CHAP. X. Of a Phymosis, and of the Stone in the Urethra. MAny Children have a Phymosis; to search them, we must hold the Yard betwixt the little finger and the ring finger, the back of the hand being towards the Belly, and with the other fingers pull back the Prepuce, as if one intended to skin the Glans, the thumb on one side, and the forefinger and middle-finger on the other, gently pressing with these three fingers towards that part of the Nut or Balanus, where one Judges the end of the Glans to be seated, that by that means the Orifice of the Vrethra may be the more dilated; then the Catheter is to be entroduced gently, searching for the perforation of the Glans; one may know that he is in the Vrethra, if the Catheter enter easily, and by feeling with the fingers of the other hand along the Vrethra on the under side of the Yard. If the Prepuce be so straight that the Catheter cannot be introduced, or if one cannot hit upon the Orifice of the Vrethra, there is no danger, to dilate a little the Prepuce sideways, with the point of a common Bistori or a pair of sharp Cissars. Observe that before the introducing of the Catheter, it will be fit to squeeze the yard with the fingers along the Vrethra, and so to try if one do not feel some hard Body which stops the passage, as Carnosities or Stones. When it is a Stone the Catheter is to be drawn out; and if before searching it was known to be a Stone, and that it stuck in the middle of the Yard between the Glans and the Testicles, there is no searching, but having only pressed the Yard with the fingers from the Pubis to the Stone, the Operator shall take a Curette or Extractor oiled, and having introduced it by little and little, and passed it beyond the Stone, he may therewith draw it out of the Vrethra. The Curette or Extractor is like an ear-picker, made of Steel, because it is less apt to bend than if it were made of another Metal, the Operator must have of them of several sizes in bigness, four or five inches long; the figure of it you may see in the lower end of the second plate of Instrments. The extremitiy of the Vrethra may be dilated in the upper part of the Glans, when stones are extracted with the Curette, and when being brought as far as the Orifice, they cannot pass without pain. The Urine serves for a Remedy; and if there hath been a Contusion and Pain, it is enough to foment the Yard with the oil of Roses, and cover the Nut or Balanus with a little pledget dipped in the lineament of Arceus, dissolved with a little mel rasatum moderately expressed out with the Nucial or Cross bandage open in the middle, and the band with three heads to wrap it up in, and it is not to be forgot, if there be need for it, to put a girdle about the Child, to which the band may be tied, nay and a Collar hanging about the neck like a Chairmans' Strap, the lower part of which is to be fastened to the girdles that it may not sink lower than one would have it. That Bandage serves for other Distempers of the Yard, begininng to apply it upon the Glans, and then bringing it nearer to the Belly, with slight couling and circumvolutions to keep the Medicine fast to the part, and near to the Pubis an indifferent hard knot is to be cast, than the two heads at the other extremity of the Band or Truss are to be ●ied to the girdle. The precise length and breadth of all the parts of that bandage cannot be determined, because it depends upon the Judgement of the Chirurgeon to make them so long and so narrow as that they be not Cumbersome. There is still another way of extracting the Stone out of the Yard, when it is at a distance from the Sphincter of the Bladder. And that is this; having drawn back the skin of the Praepuce as much as one can towards the Nut of the Yard, Ligature is made betwixt the Stone and the Pubis; or otherways one may with the fingers compress the Yard and the ●kin be fore and behind the place where the Stone is observed to stick, and afterward make Incision upon the Stone a little side-ways in the Vrethra, that so the Stone may be taken out by means of the Curette or Extractor, introduced into the Orifice of the Incision, the Ligature being removed and the Skin losened, the Incision stops and is cured by the Balsam of the Urine; without other Medicine. If one be unwilling to make Incision in the Vrethra, or if the Stone cannot be got out with the Extractor, it will be fit to give Diuretic Medicines to force it forwards to the Glans thereby to facilitate its Extraction. CHAP. XI. Of the time of Searching and Cutting; of the Instruments; of the patient's Diet; and of the first Preparation. A Patient may at any time be searched or probed to make him render his Water, and to discover the Disease; if one find himself extremely troubled with the Stone, cutting is not to be delayed without danger; but since some diseases requires a speedy Operation, we shall not speak of the time which is called the time of necessity; but only of that of Election, which is laid hold of, when the distemper is in such a Condition as to give opportunity to do things in order and without precipitation. The Spring is the most temperate season of the Year; wherein Vitriol the father of all Productions, gives verdure to Plants, and contributes to the vigour and strength which men find renewing in themselves at that time, then do men undertake what was interrupted by the excessive cold or heat of other seasons, that in the Atumne they may enjoy the fruit of their past labours. With great reason then men choose the Spring time for many Operations, and amongst others for Lithotomy. In this Conutry we must expect till the impression of the Winter cold, and the frequent Rains be over. Though the Spring gins on the eleaventh of March, nevertheless according to the temper of the Air, the Operation of the Stone is accelerated or retarded; but commonly it is performed in the Month of May, Next to the Spring, the Autumn is to be preferred before the other seasons. Though Liquors and Menstruums for dissolving of Stones were in use, yet must we of necessity speak of the Remedies of Chirurgery, which are Instruments of Iron or other Metals proper for Lithotomy. Take here their figures and the names of their parts. 1. A Razor to shave off the hair from the privy parts. 2. Common Scissors for ordinary Incisions. 3. A Hollow sound or probe, called a Catheter, for searching of men, and making them render their Water, and its Stilet or Wire to cleanse it. 4. A Catheter or Staff for making Incision in men, furrowed in the back from A. which is the bill or bec, to the place marked B. without any cavity in its length. depiction of surgical instruments page 56 conductor forceps male dilator female dilator dilator hook scoop cannula languette wound dressing curette depiction of surgical instruments page. 56 razor 1 scissors 2 catheter 3 catheter 4 hollow catheter 5 straight catheter 6 bistoury 7 languette 8 bistoury 9 probes 10 conductor 11 6. A Straight Catheter or Staff and hollowed or furrowed from the bill to the place marked C. which is sometimes made use of for making Incision at the Orifice of the Vretha of Women. It is requisite to have always in the Catheter case a part, a little piece of a Sponge moderately moistened with Salad-Oyle, because sometimes it may be wanting when there is need of it to anoint the Catheters. 7. A Bistori that opens like a Lancet with a point and edge like the same only the point blunter, at the head whereof there is a flat tail to keep it firm against the handle when it is opened, 8. A Languette or roller to mount the Bistori, it is slit at the end, a finger broad, and a foot and half long. 9 A Bistori mounted, that is to say, armed with the Languette or Roller. 10. Conductors or Probes, whereof a pair serves for the Operation, that which is next to the Bistori mounted is forked, and the other has a line in the length of its cavity, for guiding and conducting the former. Nevertheless that alone which is remotest from the Bistori may be used for conducting the forceps or tenette. 11. Another kind of Conductor composed of the two above described; it turns with an elbow about the middle, and has a Spring betwixt the branches near the rings; it was invented by Joseph Covellart. 1. Another kind of Conductor called in French a Gorgeret more commodious and more in use. It is hollow tapers and grows narrower at the end, where there is a bill that is introduced into the furrowing of the Catheter, whilst it is held by the other end shaped like a T. There are some who do not approve of this Conductor, saying that it dilates the parts too much, and that it occasions Fistula's, but without ground, for it is narrower than the forceps which is drawn out with the Stone and possesses more room, and the Fistula is only occasioned by the consequences of the Operation, as shall be explained in its proper Place. 2. Sreight and crooked Forcipes or Tenettes. A. their Teeth, B. their Branches, C. their Rings. 3. A Dilatatory for Men. It is named a Compound or great Dilatatory. D. the bill or bec of the Dilatatory. E. the handle. 4. A simple Dilatatory for Women. The extremities of it are blunt, and very small, the Branches are joined in such a manner that closing the one end, the other opens. It represents the letter X. 5. Another Dilatatory that may serve for Women and little Boys. It hath a spring near the handle, and can dilate but moderately. It may be used when one fears that some Fibres have been left in time of the Incision. 6. A Hook or Crotchet to pull out the Stones that are in the Passage, either in the lesser Operation or otherways, some cause them to be made with little Teeth in the cavity of its bending; but there is no necessity for it. 7. A Button, a Scoop. About ten Inches long, and as big as a quill. F. the part properly called the Button. G. the body of the Button, H. the other end which is hollow, called the Curette or Scoop of the Button. I. a slight line to conduct the Forceps. 8. A hollow Tent, Pipe or Canula, having rings at one end called the Head, the other end is called the Point, where there are two holes called the eyes of the Tent. 9 A Languette or Fillet for mounting the hollow Tent, introducing it into the Slit, and putting the two ends of the Fillet through the rings of the Tent, than it is called a Tent mounted. That Fillet or Languette is to be two foot long, and a finger broad. page 62 depiction of medical and surgical supplies tourniquet 1 bolster 2 plaster 3 compress 4 bandage 5 truss 6 pledget 7 plaster 8 plaster 9 bolster 10 compress 11 tourniquet 12 bed 13 11. An Extractor or Curette for extracting Stones out of the Yard. 1. A Chair used in the Hospital of the Charity at Paris, on which the Patient is set, for the more commodious performing of the Operation. There are behind two bars or rods of Iron in form of Butteresses; they are hooked, that so they may enter into the rings of the Chair, and sharp at the end to stick firmer in the Floor, because the Patient struggles and uses violence in the time of the Operation. The Chair should be placed a little obliquely for the light to come upon the right hand of the Chirurgeon, that he may see the better when he is about his Operation. Instead of that Chair, the Patient may be seated upon the side of a Bed, or on a Table, with a Mattress or Quilt, whereof one part covers the back of a common Chair reversed, about half a foot distant from the edge of a Table, in a sloaping manner. That Chair is to be made fast with many strong cords, if there be no Matteress or Quilt, it will be sufficient to lay a Pillow or any other thing to make the place soft, and a folded Sheet over it. 2. A Sheet folded length-ways with many folds, to cover the Chair that hath been described, or the Matteress in the time of Operation: one part of it is before, and the rest hangs behind. 3. A Budget to put in separately the straight Forcipes in the one side, and the crooked, with the hook in the other, in the bottom the Dilatatory, the Button and the Conductor are hid. It may be shut, lifting up the sides of it where there are Button-holes, into which are put the Buttons that are fastened to the places marked C. D. near the strings. A Table whereon the Porringer with Oil is set, and the mounted Bistoris laid, under which a piece of linen-cloth folded with many plaits, is put cross-ways, that their points may not touch any thing. It is fit that several Bistories should be mounted, though there be but one Operation to be made, because the edge or the point are sometimes blunted, and it is necessary to have some rags of linen-cloth and napkins in readiness. All the Instruments may be made of Steel or Iron, nevertheless the Catheters, Conductors, Button and Tents, are neater when they are of Silver, and less subject to rust. Of each kind there ought to be several sizes, and those well polished. It is not enough to have spoken of the Instruments of Chirurgie, we must likewise, according to the Rules of good method, take into consideration, what things are necessary before, in the time, and after the Operation. Before the Operation the Patient ought to be prepared for some days by a Diet, Blood-letting, Glisters, Purges, reiterated more or less, according to the advice of a skilful Physician; and the night before the Operation, the Patient must take a laxative, or else an astringent clyster, according as need shall require. He must have a days time at least to rest in after he hath taken Physic: and spiritual Remidies are not to be omitted. At the time of cutting, the Operator must choose four faithful servants at least, a Chamber indifferently warm, and in a good Air where the light of day may suffice. He must have an Apron and Sleeves, and under the Table a tub of warm water to wash the Instruments; upon the Table there must be Salad-oyl or oil of Roses, and there he is to lay his Instruments in order for the Operation: all these things are called the preparatives. (Apparel) for the Operation: the Bandage and Medicines that are made use of to dress the Patient that is cut, are called the preparatives for the dressing, which ought to be in readiness, because they are used immediately after the Operation. The Medicines, both Powders and Ointments ought to be astringent, warm, Oxycrat and Oxyrodinum. The Bandages as well for Men as Women. are 1. The Ligature, or Colier, which is a great band for Blood-letting, when the two ends of it are tied together, it is of an oval Figure, which is put over the Head, and comes down as far as the Navel. This band may be put about the Patient before the Operation. 2. A Bolster or compress of a moderate thickness, three or four fingers broad, to put upon the wound when the Operation is done, and when the Patient is to be carried to bed; it ought to be laid upon the Table, with the Bistories and the Catheters. 3. An astringent Plaster of a sufficient bigness to cover the Belly. 4. A Ventriere or Belly-clout, which is a great Bolster or Compress to cover the Belly, it is to be dipped in warm, Oxycrat. 5. The Froude or Bandage or Truss with four Heads, A. the Heads which may be called Twins, because they begin in the same place, and are destined for one and the same use. 6. The Truss or double T. or second Truss, B. B. the girdle of the Truss, C. C. the Tails or Straps of the Truss. 7. A Pledget Plumacean covered with Astringent. 8. Astringent-Plasters of several sizes. 9 A Plaster longer than broad, to be put some days after the Operation upon the Pledget instead of the former Plasters, this Plaster ought to be somewhat longer than the Wound. 10. A small square Bolster or Compress indifferently thick, and somewhat larger than the Plaster above described. 11. Another double compress an Inch broad and a Foot long for Males, called a Truss. These two Bolsters are to be moistened in war m Oxycrat. 12. A Ligature or Farettiere, which is a long band to be Swathed about the Thighs, that the Patient may keep them within a moderate nearness to one another. 13. A Bed covered with a Rowling-Sheet, or a Sheet doubled into many folds, and laid cross the Bed, in the place where the Kidneys and Thighs of him that is cut do Rest. There is need of several Sheets or Alaises to shift and make it dry when it is wet, it is to be warmed with a Warming-Pan; if it be needful, it is requisite also to have a good many Napkins in Readiness to put under the Patient, when he hath a Looseness that he may be the sooner laid dry, and sometimes besides that Sheet a Serecloath or thin Blanket is put betwxit the Sheets & the Quilt to preserve it from spoiling and rotting by the Urines; but a Serecloath makes the Bed too hard, and is not good but when there is a want of Sheets or a Quilt to shift the Patient. It is not to be forgot that a cord must be fastened to the top of the Bed or some other place to help the Patient to raise himself. There are some Operators that hid their Instruments in their pockets, or put the Catheters in their Button-Holes before they anoint them with Oil; others lay them in a Dish, nevertheless seeing it makes a noise when the Operator takes them up to Operate with, it seems more commodious to have them in a Pouch or Budget. CHAP. XII. Of the Posture and Situation into which Children are to be put; when they are to be Cut. ALL things being prepared, the Catheters put into Oil, the Bistoris and Tents mounted, and laid upon the Table, the Tub with warm water underneath it, the straight and crooked Forcipes with the hook placed in order in the fore part of the Budget, a Conductor, the Button and Scoop, and a Dilatatory, if it be thought necessary in the bottom of the Pouch or Budget: the Patient is sent for, brought to the place of Operation, and set upon the Chair standing a little obliquely, that the light from the Windows may dart upon the right side of the Operator, who is to keep his Instruments from the sight of the Patient. If it be a Child of four, five, seven, ten or twelve years of Age, two Servants may hold him by the Hand and Feet on each side, whilst another getting up upon something behind the Chair, and looking forwards, may commodiously lean upon the Patient's shoulders, placing the Thumb of both Hands towards his Back, and the other Fingers upon the Clavicles, for the surer hold, the Servant who is on the right side of the Patient, aught to put his left Hand betwixt the Patient's Thighs, and take fast hold on his right Hand wrist, and that the Child be not hurt, the sleeve of his Shirt may be pulled down to cover his Hand; after that the same servant with his Right-Hand shall lay hold of the Leg on the same side by the Foot and Ankle. The Servant on the Patient's Lefthand shall do the same, taking hold of the Left-Arme with the Right-Hand, and with the Lefthand of the Left-Leg near to the Foot. In this posture the Child's Hands must almost touch his Heels, and if he but any way hold fast, his Thighs spread, the Lithotomist has Room to Operate, and because Children do extremely Struggle and Strive, two other servants may likewise keep their knees a sunder; but it is chiefly to be observed in this posture, that the Patiented lean half backwards according to the shape of the Chair, or for want of that, near the Bed's side, or the Table, covered with a Quilt or Matteress, so that his Fundament may be seen, and that his Feet do not rest upon any thing, so that he have less force to stir or move himself. Hear is the Figure of it. There are some Operators who choose a strong Man, and make him sit upon a pretty high common Chair, or upon the end of a Bench, who having a Cushion against his Belly, and a Sheet over it, takes the Child, who is to be cut, upon his Knees joined together, the Man having his Knees close, puts his Hands betwixt the Child's Legs, and so takes hold of his two Wrists; by this means the Child is put into a convenient posture to be cut, take here the Figure of it. Besides the Man that holds, it is requisite that some other persons lean upon the Child's Shoulders, open his Knees, and keep his Feet steady. depiction of stone removal procedure page 70 depiction of stone removal procedure page 70 Nevertheless, seeing the Operation is sometimes laborious, and that the Man who holds may be weary, it is better to make use of the first way. CHAP. XIII. Of the different ways of Extracting the Stone, according to the Custom of the Egyptians. The Practice of the high Operation SOmetimes the Chirurgeon cannot introduce the furrowed Catheter, because of pain or inflammation, occasioned by too frequent searching before, or because there may be fear of putting the Patient to too much pain, or that there may be a carnosity or callosity in the Part, or because the Stone is in the Perineum, or in the Neek of the Bladder. These different dispositions oblige the Operator to consider how and in what manner the Operation is to be performed. The first which is not in use, is called the high Operation. The second and third are daily practised, and are called the lesser, and the great Operation. We pretend not to comprehend the two Methods, mentionded by Prosper Alpinus, in the fourteenth Chapter, of his 3d. Book of the Medicine of the Egyptians, where he relates their Practice of extracting the Stone of the Bladder, without making Incision, but only by Dilatation of the Vrethra by blowing into the Yard. When I lived in Egypt, says he, a certain Arabian named Haly, in great Reputation for Extracting Stones without Incision, took out several in my presence from Horam Bey, a Turkish Commander, in this manner he set about it; he made use of a wooden Pipe eight fingers long, and about the thickness of ones Thumb; having applied this to the passage of the Yard, he blew into it with great force; at the same time with the other hand he pressed the extremity of the Privy Part towards the Perineum, to hinder the Wind from entering into the Bladder; then he stopped the mouth of the Pipe, to make the Vrethra swell and stretch. This being done, a Servant put his Finger into the Anus, and brought the Stone by little and little towards the neck of the Bladder, and the beginning of the Vrethra: and then the Operator perceiving that the Stone was near the Perineum, he suddenly and with force drew back the Pipe from the passage of the Yard, and so dextrously Extracted the Stone, which was about the bigness of an Olive-Stone. I was present at this Operation which he performed upon that Turkish Commander; and afterwards I saw him Practise it upon two Jews, one of which was a little Boy, from whom he took 8 small Stones, and the other was grown up, from whom he took one as big as an Olive. This Arabian made use of the same Method to draw Stones out of the Bladder. In the same Chapter he speaks of a Letter written to him by Octavius Poveretus, a most learned Physician in Egypt, for the Commonwealth of Venice. Some Months ago, says he, an Arabian of Sidon, a Christian, Extracted a Stone without Incision from another Christian named Cophtus, and it was done in this manner. The Arabian had many Pipes of different sizes, much of the shape of Flutes, or Pipes which are musical Instruments. They were made of a Cartiliginous matter, which would easily stretch: he introduced the smallest into the Vrethra, and thrust it forward as far as the Bladder: immediately thereupon, he blew in it with all his strength to make it swell; then he pulled out that Pipe, and put in a bigger, blowing in it after the same manner, and so continued charging the Pipes until he put in the fourth, which was the biggest; and when he thought by this means that he had dilated the passage sufficiently to make way for the Stone; he placed the Patient in a convenient posture, and put one Finger into the Anus, to bring it towards the neck of the Bladder where the end of that great Pipe was, into which he endeavoured to make the Stone enter. This being done, he put his mouth to the other end of the Pipe, and sucking with all his strength, he did what he could to draw the Stone towards him, which broke often when it was too big, as it happened to this Man named Cophtus; for he fetched from him but a part of it, and the rest being a big and large fragment could not be got out. This way, saith Kovoretus, is easy to be learned, and perhaps a skilful Chirurgeon might have better Success in the Practice of it, which is a thing to be desired by those who are troubled with the Stone. Beverovicius makes mention of those two ways taken from Prosper Alpinus. But it is more pertinent in this place, without examining the circumstances of those two ways, to give the descriptions of those which are called the high, the great, and lesser Operation. De Franco was the first that practised the high Operation, which is so called, because it is performed in the Hypogastre, and though he does not advise the doing of it, yet if there were a necessity for it, it does not seem impracticable in this manner. Let the Patient be laid and held fast upon a Matteress or Quilt, then let a Servant thrust his forefinger and middle finger one after another into the Rectum, to make the Stone rise as high as one can; at the same time the Operator is to make Incision gently above the Groin and on the side of the Linea-alba (the white line.) The Bottom of the Bladder may without doubt be opened withoutuhrting the Parts of the lower Belly, because it is situated between the Duplicature of the Peritoneum, and the fuller that it is of Urine, the more Apparent it will be: by means of the Urine the simple Dilatatory may be conducted, and then the button, which after the Dilatory is taken out, may serve for a Conductor to the Forceps. Mr. Jonnot told me, that Mr. Bonnet a Chirurgeon who heretofore Practised Lithotomie in the Hotel Dieu of Paris assured him, that he had cut in that manner. Mr. Petit a Master Chirurgeon of that Hospital told me that he had seen Mr. Bonnet Practise it upon a young Girl. The Cure is to be performed as of simple Wounds in the lowor Belly, or otherways the Method may be changed according as Symptoms happen to follow. Experience teaches us that the Wounds of the Bladder are not always Mortal. If any one would Practise the High Operation, it would be necessary to try many Experiments on dead Bodies, after the Water is taken out of the Bladder De Franco in the same place, Chap. XXXIII. Proposes another way of cutting, which is immediately after the Incision to put in a Tent, unless the Stone present itself at first, and some days after when the pain is ceased to pull out the Stone. But this way is only Practised when the Operation is Laborious; and instead of a Tent, a Pipe is made use of. CHAP. XIV. The Practice of the lesser Operation for Men. THE lesser Operation hath been so called because the Practice thereof requires but a few Instuments; it was invented by Celsus, and described in the seventh Book, twenty sixth Chapter, as it was heretofore Practised; but if the Stone be not towards the neck of the Bladder, and that it be felt in the Perineum near to and under the Scrotum, the manner of extracting it is different. That I may give a clear Notion of the thing, I shall here Observe what happened in many Lithotomies in the Year one thousand six hundred and eighty, in the Hospital of the Charity of Paris. Though I had my share in those Operations that were Laborious, yet I shall only mention one that happened to Monsieur Jonnot, the Circumstances whereof agreed exactly with other Operations which I performed in his presence: this Relation will give ground for making two kinds of lesser Operation for men. There was brought to him a Boy of seven Years of Age that had been cut the Year before. He needed not make use of the Catheter to assure him of the destemper, for with two fingers one might feel the Stone towards the middle of the Perineum above the former Cicatrice. To hold it fast, it was needless to put the fingers into the Anus, because the Stone being too high it could not be compressed, as is usually done, when it is in the neck of the Bladder; but having caused the Scrotum to be lifted up, and the Skin held straight, Monsieur Jonnot turning the inside of the left hand towards the Cod, he pressed the Tumour with his Thumb and forefinger on both sides of the Suture where he had observed the Stone; at the same time he made the Incision on the side of the Suture upon the Tumour, and having opened a passage, with a middle sized Hook, he extracted the Stone; afterwards feeling with one finger that there were others still remaining, he was obliged to keep the place dilated with the same finger that introduced the Hook, and that the Stone might not shift its place, he held it fast with the forefinger of the Lefthand put upon the upper part of the Wound, and with the Thumb on the lower part. By that means he happily finished that Operation, that he might cut the same Patent by the great Operation; for having pulled out all the small Stones and Fragments that were in the Perineum, he introduced by the Yard a furrowed Catheter wherewith he found another Stone in the Bladder, and upon that Catheter he continued the Incision with the other Circumstances whereof we shall speak in the great Operation. I was necessitated to do the same to a young Man of twenty two Years of Age. I remember that before Monsieur Jonnot made use of the Catheter to cut him by the great Operation, be introduced into the Yard a great straight Wire or Stilet to force down some Fragments that stuck a little higher than the Incision, whilst he compressed the Vrethra underneath, and then putting his Thumb below the Wound, he drew them out with a small Scoop without any trouble. depiction of stone removal procedure page 81 depiction of stone removal procedure page 81 It is not needful to make the Patient jump before he be cut by the lesser Operation; if he be a little Boy, and the Stone in the Neck of the Bladder, it is enough, after that he is put into a posture, and held fast by the Servants, that the Chirurgeon dip his forefinger and middle-finger into Oil, the nails being pared; and if one Finger be not suffiicient, that he thrust them one after another into the Fundament, as far as possibly he can, that they may reach beyond the Stone, and press it down to the Neck of the Bladder, betwixt the Rectum and the Os Pubis, a Servant in the mean time lifting up the Scrotum with one hand, and with the other armed with a Compress leaning upon the Belly, to make the Stone come down; then the Chirurgeon is to dry the Perineum, and stretch the Skin very straight with his other Fingers, as it is represented in this Figure. The Tumour that the Stone covered with Teguments makes, renders the Incision 〈◊〉 on the side of the Suture, which may be made long enough for extracting of the Stone; care nevertheless must be had, to avoid the Rectum, the Hemmorhoid Veins and the Cod. One must not fear the spoiling of the edge or point of the Bistori, for every time that it is to be used of new, it must be set again. So soon as the Incision is made, the Stone appears, and then the Operator lays aside the Bistori, and takes the Hook or Crotchet; he is to hid it in his Hand as much as he can, the end of its Handle being towards the little Finger, and the forefinger covering the length of its Body: without drawing the Fingers out of the Rectum, the Hook is to be slipped in betwixt the Pubis, and the Stone in this manner. When the Hook is behind the Stone, and that the Operator intends to pluck it out, the Handle of it ought to be in the Hand with the end resting upon the Thumb, that it may be used with greater depiction of stone removal procedure page 82 depiction of stone removal procedure page 83 The Fingers are not to be taken out of the Anus before the extraction, nevertheless when the Stone breaks because of its softness or shape which is sometimes crooked like a Crescent, if the rest cannot be extracted with the Hook or a little Forceps, the next course is, to remove the Fingers out of the Anus, and introduce the Button into the wound for searching of the Stone, and having felt it, conduct a Forceps upon the Button to lay hold of it, and gently draw it out. By what Operation soever an Operator may cut, when the Stone breaks, though many Stones have been taken out, it is still necessary to introduce the Button to search and examine if there be no more fragments remaining. When those that are of Age and grown up, are cut by the lesser Operation, it is not necessary to make the Incision so high as in the great Operation, because one cuts exactly upon the Stone, and it is also easier to avoid hurting of the Rectum. If a Patient hath been already cut; the Incision is to be made upon the Cicatrice or the Fistula. CHAP. XV. The manner of both the lesser and greater Operation for Women. WOmen and Maids are cut by the lesser Operation, introducing the forefinger and middle-finger into the Vagina Vteri, if it can be done without Violence, or into the Rectum, for feeling of the Stone, and holding it firm, whilst with the other hand the Operator presses the lower Belly to make the Stone come down. Then he is to make use of the hollow straight Catheter, which being introduced into the Vrethra, is to be held by a Servant, and the Orifice of the Vrethra is to be dilated by a simple Dilatatory, conducted in the cavity of the Catheter: it is not to be dilated too far forward, because the passage is short, and that the dilaacerted Fibres may not hinder the unvoluntary emission of the Urine, the dilatation being made, the Catheter is taken out with the Dilatatory, and the Fingers being still in the same place into which they were introduced, the Stone is pulled out with the Hook or a Forceps, in the same manner as from little Boys. Women and Girls may be excused from the violence which they sussex by the lesser Operation, because the great Operation is more convenient for the better succeeding in it, the Patient is to be placed upon the Chair, or upon the end of a Matteress, and that Conductor which is shaped like a Sword, and hath a bill, is to be introduced into the Vrethra, than a small simple Dilatatory; and having made a moderate dilatation, whilst the Dilatatory is still open, the Chirurgeon according to his own discretion and the bigness of the Stone, may cut a little sideways to the right and left, the external Orifice of the Passage, then draw out the Dilatatory, and introduce the Forceps along the Conducttor, to take hold of the Stone, and to extract it in the usual manner, its scarce credible how much the Vrethra may be dilated both in Men and Women. There are some Operators who having introduced the straight hollow Catheter, th●● thrust in one of the Conductors, shaped like a Sword that hath a bill; and the Catheter being drawn out, they slip easily in the other Conductor, which is sorked, because the first has a line that directs the second. Between those two Conductors which they press betwixt the Forefinger and Middle-finger of the left Hand; they thrust in a Forceps to continue the Operation. Others successfully make use of a narrow Gorgeret which serves for a Conductor to the Forceps. Mr. Jonnot makes only use of a hollow straight Catheter, or of a large Probe or Stilet for conducting the Forceps. CHAP. XVI. Of the Practice of the great Operation for Men, and of circumstances during the time of the Operation. JOannes de Romans a Physician of Cremona, in the year 1520. Invented and Practised at Rome, the great Operation, so called, because it requires more Instruments than other Methodes do. Men who are cut by the great Operation occasion more trouble, not only in respect of the Operation, but likewise in respect of the Cure; because their Vrethra is crooked, long and narrow, and their way of living renders that Part many times subject to more Diseases than those Parts in Women. depiction of stone removal procedure page 89 This posture is somewhat terrible to the Patient, and therefore since there are some Men of a strong Resolution and invincible Courage, if they be unwilling to suffer these Ligatures; it will be sufficient to bind their Thighs and Legs in the manner described, and cause their Arms to be held by two Men; or perhaps they may like it better to have their hands tied a part by themselves, making them lay their wrists one upon another which being tied together by the middle of a Bandage wrapped two or three times about them and two indifferent hard Knots, the two ends are to be brought about the the neck and tied, together with a running knot, so that the hands rest about the pit of the Stomach or the Cartilago Ensiformis. I saw a Gentleman who had had his Leg cut off, cut at Mr. Jonnots. his Arm was tied on the same side with his Thighs and the want of his Leg was supplied by the number of Servants who held him fast if one or both his 〈◊〉 had been cut off, he 〈◊〉 have 〈◊〉 mastered by the number of Men who could have held him by the Arms and Stump, whilst others leaned upon his Shoulders, without any use of Ligarures. Women ought to be Situated in the same posture. Whilst the Scarves are applying, it is fit that the Chrurgion should speak to the Patient, but in few words, that he look upon him and encourage him with discourse, shuning every thing that is undecent, because one must be very reserved, to oblige those that are present to be silent and with respect to be attentive, which wonderfully comforts a Patient; calling to mind, that to laugh at the disease, the infirmity, or expressions of a Patient, is to insult over a man in affluction. Neminem riseris ne miserum ririseris. It were better to have but a few spectators, because a great many may incommode the Operator, frighten the Patient, and put a bad construction on the accidents that sometimes accompany the Operation: it is fit, as much as conveniently may be, that a Churchman should be present to talk now and then to the Patient, that may help to divert his pain, and increase his Patience dureing the Operation. When the Patient is seated, the Chirurgeon, is to place his People to support him and make him spread open his knees, lean upon his shoulders, and to lift up the Scrotum or hold the Catheter, if a Servant present a Bistori, he is to be on the right side of the Operator, who is to cut with the right hand; and he shall hold it in this fashion. With the Right-hand in which he hides the Blade of the Bistori. The Operator when he takes it, is to put his hand upon the handle, the other Servants are placed in the same manner for the lesser, as for the great Operation; but they hold the Patient in a different manner, as it hath been represented by the Figures. depiction of surgical instrument page 92 Before the Operation there is sometimes a Procidentia or falling of the Anus occasioned by the straining of the Patient: if the falling be considerable, the Operator may endeavour to thrust it up without violence, and then lay a Bolster upon the Anus, which a Servant is to press hard: but if the Servants hand hinder the Operator, there is nothing to be put upon the Rectum; for after the Operation is over it is reduced, and many times returns again of itself. if the Patient have been cut already, the Incision is to be made upon the cicatrice, or the fistula, as hath been said speaking of the lesser Operation one may cut on the Right side as well as on the Left, taking heed not to cut the suture, because it does not so easily cicatrice, and is also attended by many accidents. The Incision in Children is made at least two fingers breadth in length; in men 3 or four finger's breadth or thereabouts, according as the Stone is thought to be of bigness, and according to the Grossness of the Subject. Not that it ought to be made too large, for when the Stone is in the passage, if the Incision be too small, recourse may be had to a Cut with the Bistori, or with a pair of Scissors in a convenient place. The Incision of the Skin and Membrances is easily made, but many times the Vrethra is not sufficiently opened unless one press the Bistori hard in the furrow of the Staff; Incision is never made in the neck of the Bladder, but always in the Vrethra, and experience convinces that a great Incision in that Operation is as soon cicatriced as a small one. The Patient being set in a posture and bound with the Scarves, his Arms and Legs are held by two strong Men, and, if need be, two others take care to keep his knees asunder, a Servant gets up behind the Chair to press upon his shoulders, during the time of the Operation, which is performed, if it be possible, by the lesser Operation, or at least in the great (which is commonly made use for Men and little boys) by introducing a furrowed Catheter, wherewith the Operator searches, and is certain if there be a Stone or not. If nothing be felt with the furrowed Catheter, it is necessary to introduce a Catheter, whose bill is not so long, making the Patiented void his Urine; and if there be a Stone it will by that means be more easily found, because when it Floats, being little and smooth, it will follow the course of the Urine; and the Catheter will turn better in the Bladder. When the Stone is found the furrrowed Catheter is again to be introduced. If the Patient hath been cut, it is harder to introduce the Catheter, and therefore one is to be taken of a size that would suit with a younger Subject, and sufficiently long, according to the age of him that is to be searched. There are some Operators who hold the Catheter themselves when they make the Incision: others cause a Servant to hold it, who is placed at the side of the Chair, opposite to the Groin whereon the Operator is to make the Incision; for example, the Chirurgeon performing his Operation on the left side of the suture, the Servant shall be on the Patient's Right-hand, and having wiped and dried the Scrotum and Perineum, he shall lift up the Cod with the Lefthand, and shall rest his other hand upon the Rings and end of the the Catheter, inclining the furrowing a little towards the Patients left side, and he must take care not to make it come out of the Bladder, which he may avoid: if he bring not the Rings of the Catheter too near the Belly. The Chirurgeon ought to mind first bidding him hold fast and not waver, and causing others to lean upon the Patient's shoulders, because at that very time the Operator ought to pull the suture towards the right side, placing the Thumb of his Lefthand near the Anus, and his other fingers near the Scrotum having felt with the fore finger of the Right-hand, and observed the place where the back of the Catheter is in the same manner as one does to find the Vein before blood letting) pulling still the suture to the Right, with the Right-hand he is to take the Bistori mounted, which the Servant presion in the place designed, as you see represented by this Figure. In making incision he is to search for the furrowing of the Catheter, into which he is to thrust the point of the Bistory, he is to press hard, swathing above towards the Cod, and below sinking the Wrist, that the point of the Bistory may be always directed into the furrowing underneath the Catheter that the Urethra may be exactly cut, avoiding the Scrotum, the Rectum and the Hemorrhoide veins; then he shall return back the Bistory. And take the Gorgeret to introduce it into the furrowing; after that with the left hand he shall lay hold on the Catheter by the end which the Servant held. To prevent the Fingers of the Operators left hand from sliding during the time of the Incision, he may make use of a very narrow compress, to help him to press and pull the suture towards the patients right side. If in making Incision the Operator himself hold the Catheter, the Servant who extends the Perineum may upon the same account put very narrow Compersses betwixt his Fingers and the Skin, that so he may hold the two sides of the suture firmer towards the Thighs; by that means the Humidity will not hinder him to press upon them as much as is necessary. Monsieur Ruffin a sworn Chirurgeon of Paris, one of the ablest of his time, performed the Operation in this manner in the Hospital of the Charity. depiction of stone removal procedure page 99 The furrowing of the Catheter being discovered and the Bistory returned back, he took a Conductor with an elbow towards the middle which is composed of two in the form of a Sword, he thrust the Bill of it into the furrowing still holding the Catheter, and when it was introduced into the Bladder, he drew out the Catheter, and conveyed his Forceps betwixt the Branches of the Conductor to introduce it into the Bladder: the Conductor being taken out he continued the Operation. These two ways are very good, and have both their advantages, because when the Operator himself holds the Catheter he is sure what place it is in; but also after the Incision, sometimes it is hard to find the furrowing because of Fat, Membrans and Blood that hid it; it is true that after Incision the point of the Bistory may be left in the furrowing, and may be held by some body whilst the Chirurgeon slides the Bill of the Gorgeret along the Bistory, but when a Servant holds the Catheter, after that the Incision is made and that the Operator hath given back the Bistory, as we have Just now described, he may put the Nail of his left Thumb into the Wound, and having found the slit or furrowing, thrust therein the Gorgeret which ought to be hid in his right hand, so that the right forefinger cover the length of it, suffering nothing almost to appear but the Bill: So soon as the Bill is in the furrowing, he takes the Catheter by the rings in the left hand, as is here represented. depiction of stone removal procedure page 100 And now there is great care to be taken in introducing the Gorgeret into the Bladder, for if the Patiented push hard he may make the Catheter to come out, and then bad accidents happen; for if one thrust forwards the Gorgeret and then the Forceps, when they are not in the Bladder, a space is made betwixt the Urethra and the Rectum. To avoid mistakes the Operator ought to have an attentive mind, and not talk. And then having passed the Bill of the Conductor called the Gorgeret into the furrowing of the Catheter, he is to hold them fast, keeping the Bill always in; And as if one intended by guiding and making it slide along and under the furrowing, to thrust the Bill upwards; by this means one is sure to introduce it into the Bladder, and holding it with his right hand the Catheter must be disengaged from the Gorgeret by turning it with the left, and then softly and easily drawn out of the Yard. A certain sign that the Gorgeret is in the Bladder, is the emission of Urine along the Conductor; that is, if there be any in the Bladder. When the Gorgeret is in the Bladder, and the Catheter drawn out, it is taken hold of with the left hand, and a convenient Forceps with the right, which is to be thrust upon and along the same Gorgeret in this manner. depiction of stone removal procedure page 103 The Button being blunt hurts not the parts in passing, and when it is in the Bladder (which may be known, because than it may be easily turned every way) the Stone is softly to be searched for by gently jogging and moving the Instrument; which being felt, the Chirurgeon is to take the Button in the left hand, conducting with the right the Forceps close upon the Button into the Bladder, this is the Figure of it. If it be a crooked Forceps, whilst it is introducing, the Bill being turned towards the Yard, the rings are more to be raised, as may be observed in this last Figure, in a manner different from the former Figure, Page 92. which represents the straight Forceps conducted upon the Gorgeret with the right hand bending lower upon the left. The Crooked Forceps is made use of, when the Stone is thought to be very near to the Groin; but most commonly the straight Forcipes are sufficient, and both the one and the other aught to be laid upon the line of the Button, so that it touch on both sides. depiction of stone removal procedure page 104 It is to be observed that as often as one would change a Forceps, or introduce it, there is a necessity of making use of the Button, except immediately after the Incision is made, when the Conductor is introduced, on which the Forceps is thrust forwards. Remember that after the Incision is made, and the Conductor introduced into the furrowing, when one would disengage the Catheter, or that it is out of the Yard, the Patient sometimes struggles before the Conductor be in the Bladder; or other ways when the Urethra has not been cut enough towards the Bladder, or that the Bill of the Conductor be not dextrously thrust into the Slit or Furrowing, instead of entering into the Bladder, a space is made betwixt it and the Rectum. Then must the Conductor be drawn back; and if afterwards one cannot introduce the Button, it will be necessary to take the same furrowed Catheter, or one somewhat smaller and less Furrowed: For better passing it into the Bladder, making use of the Second way of searching Men, described in the Ninth Chap. by that means the Catheter is gently introduced into the Urethra, without turning of it any way, lest it should come out at the Incision, and when it is passed into the Bladder, the furrowing is to be searched by the Wound with the Bill of the Gorgeret, that so the Operation may be continued. depiction of stone removal procedure page 106 There is as little use of this made as can conveniently be, nevertheless if necessity require it is used; after which it is pulled out, and without parting from the Gorgeret, the Operator takes a close Forceps conducting it into the Bladder to search for the Stone, where it must be gently turned and jogged every way, as hath been said. It is to be minded also that it hath been said, that so soon as the Forceps is in the Bladder, it may be moderately opened with both hands to dilate the passage a little, and at the same time to bring the Rings almost together, and afterwards with one hand it may be thrust and moved gently to the right and left, up and down where the Sphincter of the Rectum is, to feel the Stone, sometimes turning the Forceps so that one of its Rings be higher than the other, thereby endeavouring to lay hold of the Stone, which may be flat, or lie hid at one side of the Bladder. When it is found, the Forceps is to be opened with both hands, to gripe what has been felt. The Operator is sometimes so fortunate as to take good hold of the Stone in a small time; which is to be known, because after that the Forceps hath been opened, the Rings cannot be made to meet again, and some hard matter is to be felt betwixt the Teeth: This is the surest sign, for very small Stones may be taken hold of about the middle of the Forcipes, where they are more bend than else where; which will not hinder but that the Rings may be brought to meet; but still some hardness is to be felt. This hath happened to me, and it was thought that there had been nothing; but I felt that hardness in the Forceps, and I have the Stone of that Operation still by me. When the Stone is laid hold of, one must not at first pull towards him, but it is requisite to turn gently the Forceps to the right and left, holding it with one or both hands according to the convenience of the Operator, that so he may know if the Stone lie right in the Teeth, and disentangle it from among the Plicatures, pulling to him afterwards without violence: the Rings of the Forceps are to be raised and low'rd alternatly, to make the Stone slide with greater ease. If one have made use of a crooked Forceps, the Bill of it must have been turned towards the Pubis just at the passage of bringing it out; and the Rings be very near the Yard: that one may not be mistaken, it would be necessary to put a mark upon one of the Rings of the Forceps. When the Stone is in the Forceps, special care is to be had not to turn it quite round, because if the Stone be big or uneven, it will much confuse the parts of the Bladder: If the Stone be soft, it breaks and moulders, and the Forceps easily shuts; but than one feels as it were a heap of sand, and then the Rings are not to be brought wholly together, because then a small matter of gravel would be drawn out, and the parts of the Bladder might be hurt; the Forceps with what is betwixt the Teeth of it is to be pulled out, and this is to be reiterated conducting it upon the Button, as often as shall be judged necessary: And then a Tent or Pipe is to be introduced, as shall be mentioned in the following Chapter. When the Operator judges the Stone to be flat and of the shape of an Almond, he may endeavour to make one of the Teeth of the Forcipes slide under, and the other above; though commonly the Stones are taken sideways, and when it is taken hold of, he is to turn the Forceps again, so that the thickness of the Stone may answer to the length of the Incision. Sometimes a Stone of the shape of a large Hens-Egg is caught hold of by its two ends: which may be guessed by the great distance that is observed betwixt the Rings of the Forceps, nay one may see it when the Stone is near the passage; to keep it fast, the Forceps is to be thrust back into the Bladder, the Teeth of it a little opened that the Stone may be lose, and it will turn without fail; by that means it is afterward taken hold of by its thickness sideways, and the passage thereby less dilated. If the Stone be adherent and stick very close, it were better to delay the extraction of it, because suppuration contributes to the separation thereof. And if the Operator cannot hold the Forceps fast enough, he may make use of a Napkin to wrap the Rings in, that his hands may not slip. When it is excessively big, it is better to let it alone than to expose the Patient to evident Death, especially if Age and other circumstances are contrary to the Operation. Pareus and Beverovicius advise to break it with Forcipes whose Teeth resemble the Teeth of a great Saw: And Tevenin, Chap. 121. Of his Operations, proposes the introducing of a pretty long Tent or Pipe, to hinder that the Stone fall not upon the Sphincter, that so the Patient may make his water; that Pipe should shut with a Screw, that it may be used as need requires. When all the Stones have been extracted in an Operation, it is not needful to introduce a Tent or Pipe: Nevertheless there are some Operators who always use them, to void, as they say, the clots of congealed Blood; but they liquifie and come out by the Yard, or by the wound without a Tent which hinders the reuniting of the divided parts that still are Bleeding. It is true that they who well understand the conduct of that Operation may succeed in it, without leaving a Tent or Pipe long in the place; but yet it is sometimes necessary to use it for some days when there is an Ulcer in the Bladder; that injections may be the more conveniently made into it. CHAP. XVII. What time the Patient may be kept under the Operation, and what is to be done, when it is hard and laborious. AN Operation is called hard and laborious, when by a skilful man it is not performed in a short time. In such a case the Patient is not to be held in pain until the Stone or all its parts be extracted. Sometimes it so stops the passage, that the Conductor or Forceps cannot but with great difficulty enter: and therefore an expert Chirurgeon will not scruple to take out his Instruments, and with his Finger or the Button thrust back the Stone into the Bladder; and will afterwards make use of the Bottom and Forceps to continue the Operation. It many times happens that after that the Stone hath been often laid hold of, it escapes and mounts up again, because the Forceps gives way, or the Teeth of it are not good, or otherways because the Stone is monstrous in respect of the passage, or that it breaks when it is held too straight, or because it is soft, and cannot easily be extracted when it adheres. These circumstances are to be observed very exactly, and the Chirurgeon ought not to be more careful in his Operation, than in considering the strength and Age of the Patient, with the time that he has been upon the Chair, keeping him under the Operation rather too short a time than too long, lest he be surprised by death, if he be made to endure too much: But if after the Operation hath been methodically carried on, nothing is extracted because there was no Stone in the Bladder, or that the Stone is small, or if fragments remained, he may take the Button with a scoop by the small or middle; and introduce the scoop or spoon into the wound, and so endeavour to extract somewhat, and this having been two or three times reiterated, he ought to make use of a Tent or Pipe proportionable to the subject, and mounted according to Art. For introducing it he may make use, if he pleases, and with more security of the Button, put into the Incision, and having dipped the end of the Tent in Oil, he may conduct it along the Button even to the Bladder, in this manner. depiction of stone removal procedure page 114 When the fragments are but moderately big, they may be extracted a Bed, and it is good to leave the Tent until one be certain that there is nothing more remaining within: which may be known, if one observe what came out during the Operation, or afterwards with the Medicines. Moreover, after the Tent is taken out, one may introduce a Catheter crooked at the end, or a big Wire through the cavity of the Tent, without taking it out; and by several little joggs or motions, search as far up as can be done without Pain. One may likewise make use of a Feather to clear the Tent of Blood, or of Slime and Purulent matters that are form in the Bladder. The injection of warm Barley Water is proper, and after the first day one may gently press the Belly with the hand in time of Dressing. CHAP. XVIII. Of the Symptoms of Lithotomy. THE Symptoms of Lithotomy are divided into those which accompany the Operation, and those that follow it, the first called Concomitant and the others Subsequent. Accidents which accompany the Operation are Hemorrhage or Bleeding, the length of time which makes it to be called Laborious, the Bruising and Breaking of the Stone, the difficulty of extracting it, or the impossibility, the number and fragments which cannot be extracted because of their bigness, numerousness, or weakness of the Patient: sometimes also nothing is found, though the Patient hath been searched and examined before. A contusion Superveens if the Forceps be thrust too rudely or too frequently when it is in the Bladder, Excoriation, or even a Rupture of the Bladder, or other parts as well by the bigness and asperties of the Stone, as by the Teeth of the Forcipes, if they be shut close when they are in the Bladder, because it is wrinkled, and the sides of its Body or Bottom may be laid hold on without the Stone or with it. The Symptoms that follow the Operation in the Cure by Lithotomy, are a painful tension of the Belly, the retention of Urine, Watch, Inflammation in the parts affected, Looseness, Diarrhaea, Worms, Ecchymoses, Fluxions, Abscesses, Excoriations, Itchings and Putrefaction, Ulcers in the Scrotum, and the Neighbouring parts, Ulcers and Putrefaction of the parts of the Bladder, to great, or too long Suppurations; voiding of Purulent matter by the wound, or with the Urine by the Yard, Fevers, universal or particular Consumptions or Marasmus', Hemorrhages as in the time of Operation, Syncope's Convulsions, Vomitings, Lightheadedness or Deliriums and Shivering. The painful tension of the Belly is caused by an inflammation that attracts a Fluxion, because the Ligaments which suspend the Bladder, and the other parts to which it adheres, have suffered violence: The Fever and Restlessness proceed from the Intemperies of the chief parts, agitated by the passions of the mind; And the Hemorrhage from the Incision, or Erosion of the Vessels: The retention of Urine is occasioned by coagulated Blood, or the inflammation of the parts during suppuration, or by some little Stone fallen down from the Kidneys, or a fragment remaining after the Operation: The inflammation comes from a circulat motion of the Humours; the Scour, looseness of the Belly, and Worms in Children through the abundance of Phlegm; the Ecchimasis is an effect of extravasated Blood; the Abscess is produced by a collection and continuance of Humours in the interstices of the parts: the too great and too long suppuration, by the quantity of the matter whereof the Abscess is form, or by the Ulcerated Kidneys, and by the liquefaction of the Humours of the whole Body, of which part do suppurate whilst the rest are dispersed by Transpiration or Looseness, which causes at the same time a Marasmus or extenuation of the whole Body: The Ulcer of the Bladder is caused by contusion and suppuration of its parts, which excites the running of Purulent matter by the Yard or Wound: Fungous carnosities by a superfluity of ill concocted and too serous Blood; the Itching and excoriation are the effects of the sharpness of Urine, or of too straight bandage; the Putrefaction of the Ulcer comes from the corruption of the Humours and of the Air, or from the too great humidity of Medicines, and the Virulence, from the Acrimony of the Humours and Medicaments: The Vomiting happens after the Operation, because many nervous Fibres of the sixth pair are distributed and inserted into the Ventricle. There are other accidents occasioned by the distribution of the Nerves, which pass through the holes of the Os sacrum common to the Sphincters of the Bladder and Anus, which have been bruised or lacerated by the Forcipes, or by the asperities of a great Stone, especially when the Operation hath been hard and laborious. The Fainting or Syncope, is occasioned by a great Flux of Blood, and the dissipation of the Spirits: The Convulsion happens by Vomitings, the Diarrhea & Hemorrhage, which hinder the Nerves from receiving a sufficient quantity of Spirits: The Delirium and Lightheadedness Superveens, when there has been so great a dissipation of the Animal Spirits, that the Brain retains not enough for itself, and for supplying the whole Body with a quantity sufficient for performing the functions of its several parts. In a word, Fate puts and end to all these accidents by destroying the Machine; that is to say, by abolishing of Motion at the instant when the Soul is separated from the Body. If any be surprised that we have spoken nothing of Pain, they ought to consider that that is a Symptom, or rather an essential property of all diseases of the parts that are capable of feeling, since it always happens, where there is an Intemperies with a solution of continuity of the soft parts and by consequence it is more sensible in Lithotomy, than all the other accidents that we have been speaking of. These Symptoms have their causes, their Diagnostic and Prognostic signs: some are the cause and the signs of others, and all the Symptoms in general, are caused by Pain, Fear, Hemorrhage, Contusion and Dilaceration of the parts. The Prognostics are taken from the time, the violence, and the state of the subject in which the accidents happen. The Symptoms that appear at first, are not so dangerous, and those which last long, or happen in a Cacochymick Body, are more to be feared. An Operator who is expert in performing the Operation will avoid many concomitant Symptoms. There are some nimbleblades who have the knack of feigning that they have extracted a Stone, and convey one, though they have found none. The Symptoms that follow the Operation, are either by themselves apart, or many together according to their Nature, corrected by various Medicines. The first care is to assuage Pain by Imbrocations and Fomentations: a Hemorrhageiss sometimes to be feared, and therefore astringent topics are to be employed for preserving the treasure of life. The loss of Blood ceases commonly through the weakness of the Patient, because the Medicines that are applied to this part are dissolved by the Urine; and besides no other bandage but the contentive can be used, when in other parts one may put his Finger upon the Orifice or opening of the Vessel, or cut it in two, apply to it a Button, a Ligature, pledget's and Compresses. It is commonly observed that the first dressing be kept on, for the space of Twenty four Hours at most: it is tenderly to be taken off, leaving a Pledget upon the place out of which the Blood does Issue, if it can be known; and if the Hemorrhage recur, recourse is had to astringents. CHAP. XIX. Of the Method of curing those that are Cut, and removing their Symptoms. WE come insensibly to the cure by Lithotomy, the method of which is either general or particular. Having spoken of the Causes, Kind's, Signs and Prognostics of the Symptoms, it is now proper to give you a notion of those things which ought to be observed from the time of the Operation until the perfect cure of the Patient. By that means we may treat in particular of the remedies against accident; since they happen whilst the Patient is in the Surgeons hands. By the general cure by Lithotomy we understand that wherein no Symptoms happen which are of the Nature of a cause. And by the particular cure, that which is attended by troublesome accidents, such as cause the methods to be changed: of each of these we shall speak apart. Supposing that the Chirurgeon hath successfully performed his Operation, he must dress the Wound, and endeavour by the help of Medicines to cure it. The first thing that is to be observed after the Operation, whilst he that is cut is still in posture, and that with all expedition he is a clearing of the Ligatures, if any have been used, is to put upon the Incision a square dry Compress about three or four Finger's breadth in bigness and indifferently thick, and holding it on with one hand, to take the Patient about the Body, and with assistance and help to carry him to Bed. We have already said that the Collar may be put on before the Operation, afterwards taking a Frond or Truss suitable to the Patient, it is to be laid upon his Back above the Buttocks, that so the two heads or straps called the twins, and which may be then called the superior, may serve for a Girdle, the Body or middle of the bandage, in the mean time, declining towards the place where the Incision hath been made, which hinders the stopping up of the Anus. Before the two superior straps of the Frond or Truss he tied together for making of a Girdle, Imbrocation is to be made upon the Belly and the Cod with the warm Oil of Roses and Camomile, to prevent the painful tension of the Body, and to cure it, and an Astringent Plaster is to be applied to the Belly, with the Ventriere or Belly piece soaked in warm Oxycrat; then must the two superior or upper straps of the Truss be tied together towards the Patients right side, the one of them passing under the Collar. Afterwards, the Compress which was put upon the Wound dry, and is since the Operation steeped in Blood, is to be taken off, and Medicines applied to the place. If there be a Hemorrhage Astringent, Powders and Pledgets are to be made use of; and when there is no Hemorrhage, an indifferent thick Pledget covered with Astringent is to be put upon the Wound with a Triangular Plaster covered with Astringent, and the Cod are to be kept up with a Truss whose ends pass along the two Groins, and afterward a small Square Compress dipped in warm Oxycrat, as the Truss aught to be, is to be put upon the Plaster holding all the dressing of the Wound with one hand (for one must be ambidexter) and with the other hand taking hold of the Bandage betwixt the Thighs, by the end which is near the Anus, it is to be brought over the little square Compress that is upon the Wound, and carried along the left Groin; declining betwixt the Thigh and the Hand that holdeth on the dressing, and that end is to be left upon the Girdle still holding the dressing fast: than one must take the other end which is more remote from the Anus, and giving it a turn outwards towards the Body of the bandage to make an equal compressure, it is likewise to pass over the Square Compress that is upon the Wound, and disengaging the Fingers wherewith it is held, it is to be carried along the rite Groin making but a very slight compression: then the hand that held on the dressing is to be removed, and with the help of both hands this last end is conveyed under the girdle before, and on the right side, and then tied with the knot, called the Mariner's knot; the same is done to the other end on the left side; or otherwise if both ends be long enough, after they have been brought under the Girdle, they are tied together by the Collar towards the left side, during the whole time that the bandage is used, a Ventriere or Belly peace is to be applied to the Patient, and care had that the ends of the bandage keeps on the dressing of the Wound, for the Body of the bandage must not descend lower than the left Buttock: afterwards the Thighs must be made fast and kept at a moderate distance from one another with the garter or thigh band tied together under the Knees, with the knot on the outside towards the Thighs. If it be a Woman that has been cut, the dressing is to be put upon the Belly as to Men, and the Pledget covered with Astringent upon the Orifice of the Vrethra with a Plaster, Compress and the Frond or double T, of which a Girdle is to be made as with the Truss, and the other ends which make the tails of the T, passing betwixt the thighs, and crossways upon the dressing, will hold it fast, and press it as little as one pleases. When the Patient has a mind to make water, the bandage is to be taken off; they are not subject to so many accidents, and they are sooner cured than Men. In Men the first dressing may be removed within twelve hours after the applicat on, renewing the Imbrocation, with the same Astringent and the same Belly piece, for four or five days at least or more, if the Belly be Swelled or Pained; one may likewise make use of Fomentations of the Belly with rough Wine and Red Roses, and sometimes they are to be reiterated four or five times a day. The Wound is to be dressed with the Lineament of Arceus half Melted, to make it Penetrate the more, with the Finger, or Feather of a Quill introduced to the very bottom of the Wound as gently as may be: then a little flat Pledget dipped in the same Lineament is to be applied upon the Lips of it, with a Triangular Plaster, soaked in warm Oil of Roses, using a Compress, and a Truss moistened with warm Oxycrat; and a clean dry Frond or bandage to be changed at every new dressing as at first: for the following days the Patients are to be dressed twice every four and twenty hours, duly changing the dress, except that of the Belly, which may serve for the first days, and ever now and then the Patients are to be made dry; which is observed to be done when they are a dressing, not forgetting to make them clean for avoiding a Gangrene. They are to be dressed with all speed and diligence, and the Wound kept open as little as may be, having a fire always in the Room to correct the badness of the Air. After five or six days there is no more use made of Oxycrat, nor Astringent, nor of the Triangular Plaster, but only of a dry Belly piece; and in the Incision three or four drops of the Lineament of Arceus with a Feather or the Finger, and a flat Pledget upon the Lips of the Wound. The Balsam of Peru, and of Capivei, which is called natural white Balsam, are Sovereign remedies for Agglutination; that of Capivei is excellently good from the beginning to the very end. Some take equal parts of the Lineament of Arceus and the Oil of Eggs, others make use of the Lineament of Arceus during the whole cure, others again of Capivei; some there are that make a Mixture of equal parts of Basilicum, of Venice Turpentine, and Oil of Eggs, or the Lineament of Arceus, and the success is alike, provided the Operation hath been fortunate, and no bad accidents superveen. Upon these Medicines a Pledget is put and a Plaster of Diacalciteos a little longer than the Wound, and of a breadth proportionable to the subject, a dry Truss to bear up the Cod, a Compress, and a bandage upon the Wound, as has been before described, pressing it a little harder than in the beginning: the Jarretiere or Thigh band is used till the cure be perfected. After the first days are over, it is proper to advertise the Patient to press with his hand a little upon the dressing, that he may more freely make water in his Urinal. Though the Wound of itself requires consolidation, yet care is to be had that the Lips and Teguments thereof turn not inwards; and after some days when the fluxion is over, or if none have happened, with the help of little and very narrow Compresses the Lips are to be kept equally raised, and a little distant, only at the Orifice of the Incision; for that purpose several Compresses are to be put near the Lip which is on the side of the left Thigh, to the end the bottom may consolidate, before the Cicatrice be made. When one is sure of the bottom, than he is to use desiccatives upon a little Pledget, and several Compresses unequal in thickness and indifferently narrow, one on each side, and a Plaster to cover them, and over that another little Compress transversly at the upper part of the Wound, and over these three, two others of unequal breadth, to keep the bandage, by that means, the faster. If there grow up any fungous' carnosities, they are to be consumed with calcined Alum, or with Lapis infernalis. There are some Patients that by reason of a good constitution of Body are cured in eight, fifteen, or twenty days; but the ordinary time of curing Lithotomy is thirty or forty days. It is prudence in a Chirurgeon to observe the alterations that happen to the Patient, that he may discover the bad Symptoms that we have mentioned, which change the method of the general cure, and which require to be prevented, or corrected by a particular method contrary to their Nature. This is performed by Diet, Chirurgery, and Medicines: the Diet, until the seventh or eighth day consists in abstaining from Wine, unless the Patient be very weak; he is to use a Tisanne made of the shave of Hartshorn, and Ivory, or with a little Lint Seed, and the Roots of Mallows and Marsh-mallows, or at least, in time of need, he is to drink of Chalybeat Water, or of the Tincture of Red Roses, yet not according to his Thirst, but a little less for fear of a Looseness; it is enough that in four and twenty hours he take five or six messes of Broth, and very few Eggs: Blood-letting, and cooling and Anodyn Glisters are good if he have a fever, and pain in the lower Belly, but all by the advice of a Physician. And after the first seven or eight days are over, and that the Symptoms have ceased, his food is to be made stronger, beginning with Porridge, or Panadoes, than a little Meat and Bread, after that he hath been Purged, which is commonly to be done about the fourteenth or fifteenth day after the Operation. Chirurgery is necessary, when Blood letting is to be reiterated, abscesses and their Sinus' opened, places where there is a disposition towards putrefaction scarified; sometimes Scissors are made use of, to clip off Membranes and other parts that are wholly corrupted; Medicines are changed to discuss tumours, and ripen Abscesses; the Ulcers of the Scrotum and Bladder are cleansed by Injections and other Medicines that resist mortification and putrefaction. Extraordinary Symptoms appear before one another, or many together which make a complication: we ought therefore to speak of the remedying of every one of them in particular. It hath been said that Pain is mitigated, by Oxyrrhodinum upon the Belly, the Groins, and the Cod; Hemorrhage by Astringents; a Fever by Blood-letting, especially if the Patient hath not lost much Blood in the time of the Operation, or after, and if he have strength: restlessness is conquered by cooling Apozems, Emulsions, and Soporificks after the first days; the inflammation of the parts after suppuration is extinguished by the Ceratum of Galen, or by Nutritum; fragments and small Stones are voided with the Urine, and by the injection of warm Barley water, or they are extracted with the hook, the Extractor, Forceps, or the Scoop of the Button. The too great retention of Urine is cured by passing the Woman's Catheter into the Wound, and then by a Tent or Pipe left in it for some days; Gripe and Looseness are stopped, by Anodyn and Carminative Glisters, and by Juleps of Red Poppy, the Oil of sweet Almonds, Plantain Water, and Hartshorn Jelly: Worms and Vermous matter the cause of their generation, are brought away by Medicines and Physic which help digestion, as those into whose composition enter, Rheubarb, Wormwood, Tamarinds, Aquila Alba in a small quantity, etc. The Ecchymoses, Fluxion and moderate Tumours are dissipated by resolutives and discussing Plasters, by comfortative Cataplasms and Anodynes, according to the degrees of the evil, and the rules of Art, observing to apply more comfortatives, than simple Emollients and discussives, because of the Humidity of the part: Abscesses are form commonly above the Incision and many times pressing the head of the Tumour with one Finger, and the sides with other two, the Purulent matter is Evacuated by the Wound; but if it be perceived that the skin is very thin, and the matter ready to burst forth in a torrent, they are to be opened to the very bottom of the Sinus, and the cure performed according to Art. Detersive injections are made use of to mundify and cleanse the Bladder; and Emulsions are given to the Patients, that the purulent matter may the more easily be evacuated. Excoriations and Itching are cured by Nutritum, Vnguentum album Rhasis, the Cerat of Galen; Pompholyx dissolved in the Oil of Roses, and other desiccative Anodynes, taking heed not to compress the bandage for some days; and if the Excoriations and Itching possess a great space, the Patient might for some time be dressed without applying the Frond or Truss, but only the Triangular Plaster covered with convenient Medicines, upon the Medicaments of the place where the Operation hath been made, making always use of the Thigh band to keep the Thighs at a convenient distance one from another. The same thing is to be practised when the Scrotum or Testacles are much swelled and in pain, and on that occasion Anodyn and emollient Cataplasms, etc. spread upon Linen Cloth cut in the shape of the Plaster called the Plaster for the Scrotum, are to be made use of, with a bandage or suspensory, which is applied as in other distempers of the Cod or Testicles. Patients that are cut are subject to other accidents when they have lain long upon their Backs; they are to be remedied according to their kinds and degrees, and when they abate, the common bandages are made use of, such as the Truss, Frond or double T. which is more proper in the end than in the beginning, because it compresses more easily, and it is more commonly made use of for Women than for Men: to use it a right, the Girdle is to be put about the Patient's Body, and one end of it being carried within the Collar, and both ends tied, one of the ends of the Tail of the T. is to be taken betwixt the Thighs, and making it pass obliquely upon the dressing, it is tied to the Girdle in the opposite side to that from whence it is taken; the same is to be done to the other end, fastening them together by a kind of a knot called the Mariner's knot, having a care not to stop up the passage of the Anus. Fainting, Convulsion, and Vomiting, go often hand in hand together; but the last appears more frequently than the others; it is remedied by Wine, and by cordial Potions made of Treacle; the Confection of Hyacinth, Alkermes, Coral, prepared Pearl, Powder of Vipers, Syrup of Pomegranates, in Balm Water and Scorzonera Water, Carduus benedictus, and Woodforell, etc. according to the various indications: these Medicines and the Dose of them are to be chosen and determined according to the advice of a Physician, giving them at first in a small quantity often renewed, because of the debility of the Stomach. When the Vomiting is stopped; the Convulsion ceases, and the fainting is cured by succulent nutriment, such as good Jellies, strong Broths, new laid Eggs which strengthen the Patient if they stay with him: the reason is evident, because inanition is the cause of these two Symptoms, and the Animal Spirits being but in a small quantity, prick the Nerves, which contract and draw towards their Origination. The Wound does sometimes foul, and by too great suppuration, according to Guy of Chauliac; it is observed to degenerate into a sordid Ulcer, and most commonly virulent, because of the Acrimony of the Urine, and irritated Humours that grow mordicant and biting. These kinds of Ulcers are never without Inflammation, Itching, and Excoriation of the part: for such accidents we are to make use of diverting, restraining and local Medicines, applied according to the Temperament of the part, and the counsel of the same Author, in the Chapter of Wounds with Hemorrhage: When many Symptoms appear together, the same Rule is to be observed, and to have regard to the order, the urgency and the cause, and especially to that which is most urgent, amongst other things carefully observing the effects of topical Medicines, wherein Chirurgery does most consist. For curing of Diliriums and Lightheadedness, strong broths are given, minced meat made with Veal, Pullet's, Partridges cut small and put into an earthen than Pot glazed, without water, well luted, and digested in Balneo Mariae; hearty food that is full of good Juice, and of easy Concoction, for speedy repairing of the inanition, and tempering the Animal Spirits, the truth is a Dilirium with cold in the Extremities are of such affinity, one with another, that they may be put into the same rank, and a Dilirium after Lithotomy is, as it were, the last degree of the Disease, the struggling of Nature, and the forerunner of Death. CHAP. XX. Of the Ischuria, or suppression of Urine. THE Bladder is a Membranous part, that may be distended and enlarged by the quantity of matter contained therein, and when it is full or stimulated, that which is within opens the Sphincter that it may make to itself a passage into the Vrethra. When all things are in a natural state, Man suffers no inconveniency because the things contained within are in due time evacuated; but congealed Blood, or coagulated Pus, condensed Seed, a Stone, a Fungous' Body, gross Humours, or Phlegm with Sand, one or more of the inferior Vertebraes Luxated, hardened Excrements, a Child dead in the Mother's Womb, a Carnosity or Callosity sometimes stop the Sphincter of the Bladder, or a place of the Vrethra, it is the same when a Viscous Humour causes a Numbness of the Bladder, or when a Patient is in a dull and drowsy fit; which is occasioned by a diversion of sensation, an ecstasy in the Brain, or a convulsion of the Nerve which goes from the Os sacrum to the Sphincter of the Bladder, and by Malignant Fevers. Besides those causes of suppression of Urine which we have reckoned up, we are to take notice of the shrinking or flagging of the Vrethra, to which Old Men are subject; the Compression of the Neck of the Bladder caused by the falling down, or inflammation of the Matrix, or the Prostates and Parastates, the internal Hemorrhoide Veins, or by a great quantity of Urine which distends the Fibres of the Bladder, as is related by Pareus, L. XVII. of a Young Man, who having kept his Urine too long, fell into a suppression though he had no Stone, and was cured by the Catheter. Fabrit. Hild. says, L. the Lith. Chap. 3. Col. I. that that excellent Mathematician Tychobrahe being in a great assembly at Prague, where being forced to keep his water very long, he fell into so violent a Suppression, that he could not be cured, but died of it. The retention of Urine, from what cause soever it proceed, produces a violent Pain, and insupportable inflammation in all the Neighbouring parts of the Bladder, from whence a suppression is occasioned, because the Urine is not voided, and that it is continually augmented in quantity. In that case Patients are all over in a heat, their eyes look red, their face burning, have an Oppression, Restlessness, Fever, a hard, painful and very large Swelling above the Pubis; bilious Vomitings, and all these troublesome Symptoms reduce them to such a state, that without speedy help, they expect nothing but death. The Chirurgeon will know that it is a clot of Blood that is the cause of the Suppression, if the Patient hath been lately Wounded in the Kidneys, or hath pissed Blood; if an Ulcer in the Kidneys has preceded, and the Patient hath made Purulent water, he may conjecture that a collection of thick and viscous Pus is the cause of it: if the signs of the Stone have appeared, he is to acquaint the bystanders with it, he may discern it from a Fungus by the Catheter, unless the Stone be wrapped in a Coat; he may know if it be a Carnosity or Callosity, by means of the Catheter or a searing Candle. I say nothing of the Patient's manner of living, whose excesses may have been the cause of sharp Humours, or a great inflammation: nor shall I neither speak of other causes which manifest themselves. Now if many causes of Suppression join together, the diversity of Symptoms will serve for a sign to make the Prognostic by. The Patient cannot for many days endure a Suppression, without being much weakened and in danger. When it is caused by a falling down of the Matrix, there is no more to be done, but to reduce that part; when the Hemorrhoides press the Neck of the Bladder, they must be opened with a Lancet or Leeches; the Numbness of the Bladder is remedied by a grain of Salt or Nitre put into the passage of the Urine, or with a composition of Mel Rosatum and the Powder of Hiera, or the Oil of Scorpions: when there is congealed Blood, Purulent Matter, or thick Phlegm in the Bladder, we may make use of an injection of Oxymel with the Oil of sweet Almonds; in the Flagging of the Vrethra, hollow Wax Candles are employed; if there happen any Carnosity or Callosity in it, they are incided and eaten off, and afterward a Leaden Pipe introduced into the place. When one hath kept his water too long, if he be afraid of being searched, bags of Pellitory of the Wall moistened with the Oil of Capers or of Turpentine are to be laid upon the Pubis; and if he do not find ease upon that, he is to be persuaded to suffer the intromission of the Catheter. The inflammation of the Rectum, the Matrix and Prostates is allayed by Blood-letting, and Glisters of Oxycrat, Pellitory Water, or the Decoction of it with Mel Rosatum, and a Bath of warm Water. For all suppressions of Urine, when there is no other apparent disease, it is of singular advantage to let Blood, give cooling Glisters and Bath; because commonly they are caused by mere inflammation, and the weakness to which the Patient is reduced, does often laxat the parts, and make way for the Emission of Urine, the retention whereof puts him in danger of Death. Galen 13. of the Meth. before Pareus L. 17. C. 37. advises not to give Diuretics, nor strong purgatives before Blood-letting; because they may accelerate the motion of Humours, or of Preternatural Bodies towards the Bladder, and fill it fuller, whilst the obstruction of the Sphincter hinders the evacuation of the Urine. But though all remedies have been used; yet sometimes the Patient is not eased; in that case if he cannot be searched, and the distemper be very urgent, it is better without delaying several days, to bring him to consent to be cut, if he be troubled with the Stone. And if it be only Urine retained through an inflammation of the Sphincter, or by a thick and viscuous matter, it will be necessary to Prick or Tap the Perineum. CHAP. XXI. Of the Puncture or Tapping of the Perineum. IT is to be supposed that the Patient hath found no ease from all the Medicines that have been administered unto him, and that the suppression continues with such Symptoms as give ground to a sad Prognostic, and call for speedy relief to the Patient. The great relation that there is betwixt Lithotomy, and the Pricking or Tapping of the Perineum, gives us ground to propose three ways of Practising it; and seeing they have no proper names we shall distinguish them by those of the various Methods of Lithotomy, to wit, the Hight, the Great, and the lesser Operation. Though it hath been said, that the High Operation is not in use, nevertheless it would seem that the great Tumour above the Pubis, caused by the suppression of Urine, especially in an extenuated Patient, might render the Operation easy, without any fear of hurting the parts of the lower Belly; and that for that purpose, having Pricked the Tumour with a Lance as deep as the Bladder without Tying the Patient, it will be sufficient to introduce a Wire or Stilet, that may serve for a conductor to a crooked and convenient Pipe, passing it into its cavity. The High Operation of Tapping the Perineum may likewise be practised by means of a Trocart with which the Punction may be made in the Tumour above the Pubis; it may be certainly known when the Bladder is open, & then a Wire is to be passed into it; and having pulled out the Trocart, the Wire will serve for a Conductor to the Pipe, just so as to the Parakentesis or Tapping of People in Dropsies. We shall give the description of this Trocart, and of the manner of using it, when we come to speak of the third way of Pricking and Tapping the Perineum. The second way that is in use: is the great Operation, as I have seen it practised by men of great skill and reputation, whose method I have followed. There needs no more but a Pipe or Canula mounted, a small Tent proportionated to the Cavity of the Pipe, two Plasters, and two Compresses the one a little bigger than the other. All things being in readiness, and the Patient seated in posture and held as for Lithotomy; to be more assured of the way that must be taken in making the Incision the furrowed Catheter is to be passed into the Vrethra as far up as it can go, without forcing any thing; if the inflammation be moderate, or if there be no carnosity, nor other obstacles, it is to be introduced into the Bladder: A Servant or the Chirurgeon himself may hold the Catheter, and he is to observe all circumstances as in cutting for the Stone, making the Incision lower than for Lithotomy, and shorter upon the slit or furrowing; into which he is to thrust the Bill of the Gorgeret, to introduce it the more easily into the Bladder. It is fit that the furrowing continue like a gutter, without any thing to stop it at the Bill or Extremity of the Catheter; the voiding of Urine is a certain sign that the Gorgeret is in the Bladder; and then the Catheter is to be disengaged and softly pulled out. The Chirurgeon is to hold the Gorgeret in one hand, and in the other, the Tent or Pipe mounted with the end dipped in Oil, and he is to conduct it into the Bladder, by means of the Gorgeret, or in defect of that, if it be come out of the Bladder, he may take the Button with a Scoop, and use it as hath been said already. If there be no Button, one may make use of a big Wire, which being introduced into the Bladder, will serve for a conductor to the Tent or Pipe. Though one could not pass the furrowed Catheter into the Bladder before the Operation yet it will easily enter after the Incision, because that little Blood that is spilt, will dissipate the Spirits which caused the inflammation and tension in the parts. Tavenin Chap. 121. of his Operations proposes, not to introduce the Catheter, but the Patient being put into a posture to make the Incisio with a Bistory betwixt the Anus and Scrotum, on the side of the Seam or Suture, in the same place that it is made in for Lithotomy; being come, (says he) near the Bladder, it is to be opened, thrusting the Bistory or Lancet boldly up, until that the Urine come out, than the Tent is introduced, and so the Operation is accomplished. It is not convenient to evacuate all the Urine, if it was excessive in quantity; because too great evacuations are always hurtful, according to Hippoc. Book 2. of his Aphorisms; but having voided as much as may consist with the strength of the Patient, with a little piece of Linen Cloth one may stop the Orifice of the Tent or Pipe, and having put a Compress upon it, some Body is to hold his hand thereon, assisting the Patient to Bed; then lay upon the Tent a thick Pledget covered with Astringent, a little Plaster; another moderate Compress, and over that the Triangular Plaster covered likewise with Astringent, and another Compress still upon the Plaster, a Truss to bear up the Cod, and the Frond or double T. with the Thigh-band, as hath been described. The bandage that is only contentive, hinders not but that a little Urine may come out; nevertheless when the Patient hath rested and taken refreshment, he is to make Water through the Tent without pulling of it out. In dressing the Patiented the Chirurgeon is to examine if it be a Fungus which caused the suppression; and he may know that, by the Finger or the straight Catheter, by inspection into the matter that is voided with the Urine, or by the injection of warm barley Water, Detersives and the other Medicaments that are used in dressing such a Patient. If a Stone be felt, it is to be extracted with the Scoop, the Hook or the Forceps. Fungus's are fetched off by injections; if it be an Ulcer, proper remedies for cleansing it are to be used. An inflammation is more easily cured than any other distemper, because many times it is kept in being by the retention of the Urine. When the cause of the suppression is removed, the intention of the Artist ought to be the reuniting of the parts: And therefore the Tent is drawn out, and the Patients are dressed like those that are cut of the Stone, according to the general cure, if no accidents appear, or the particular method, by remedying every Symptom. depiction of surgical instruments page 153 This Trocart may be made of various kinds of Metal, excepting the point, which ought to be of Steel; it is seven or eight Inches in length, that it may be the more commodious for use, and as big as an ordinary quill: in the shape of it several things are to be considered; for the end of it which is of Steel, is of a Pyramidal and Triangular Figure. This point is about a Finger's breadth in length; in one side of it there is a furrowing that reaches from the point, or very near it, to the other end of the Trocart, and because of that furrowing the Instrument in its length represents a straight Catheter for making Incision, because it is hollow on the one side and round on the other, which is the out side of it. The Pyramid of Steel tapers and grows smaller from the basis till ye come to the point, but from that basis to the other end of the Trocart it is alike in bigness. The Wire or Stilet is strait, indifferently small, of the same bigness all along, and supple and pliant, about eight Inches long, proportionable to the furrowing of the Trocart. The mounted Tent, that is used in this Operation, may be crooked for the high and strait for the lesser Operation in the Punction of the Bladder, long and small in proportion to the Grossness and Age of the Patient, that so the end may be thirst into the Bladder, without making too great a Solutio Continui it is to be observed that the end of the Tent, where its eyes are, aught to be proportioned to the middle part of the Pyramid of the Trocart, that it may easily enter into the Orifice of the Punction, and that the body of that Tent be of a Conic Figure, growing bigger and bigger by degrees, as it comes nearer the head where the Rings are, though the extremity of the Tent, were smaller, yet it might suffice for conveying of the Urine; but it would be useless, if some more thick and viscuous matter were contained in the Bladder. In using of these three Instruments; when the Patient is situated in the posture that hath been said, the Cod are lifted up,, and having marked the place where the Punction is to be made in the Perineum on the side of the Seam or Suture, the Trocart is thrust in, and sinking the end by which it is held, the slit or furrowing being upwards, the Pyramid is to be thrust on forwards towards the Body of the Bladder, which being much distended, is therefore easily opened. So soon as the Trocart is within, the Urine will come running out by the furrowing, and the Wire is to be taken, and conducted into the Bladder by the same furrowing; afterward the Trocart is drawn out, in place whereof, holding the Wire in one hand, the Tent mounted is to be taken, and passing the Wire into its Cavity, it is to be made to slide along the same. When the Tent is near to the Perineum, the Wire is to be taken by the end, and the Tent at the same time conducted into the Bladder, we may know that it is in, when the Urine comes out at its Cavity: And then the Wire is pulled out; and as much Urine suffered to be voided as may be thought convenient, other things being to be performed as in the other manner called the great Operation. This Trocart has one thing that is singular, which is, that so soon as the extremity of its slit is in the place where the Water is, the Urine is voided, without any danger of being thrust too far in. There are some who make use of another Trocart for the same Operation this has a solid and round point of Steel about a Finger's breadth in length; others cause it to be made Triangular, or a little slat and two-edged; but still proportioned to the Tent or Pipe, the instrument in its length is straight and hollow, and has two openings near the basis of its point; that Instrument is passed into the Tent, and in that posture the punction is made, the opening of which is always less than the Orifice of the Tent; and it cannot be introduced without great pain to the Patient; besides, this Trocart must be Thrust deeper in than the other, before the Urine can be perceived to come out. All men are free to examine and try those things, and to choose what pleases them best. These Trocarts may serve for other Operations, as in a kind of Hydrocele, where the Waters are gathered together, without being stilled into the very substance of the Membranes; in the Parakentesis; or even in making perforations through the Skin, and passing the Silk and Stones because about three or four finger's breadth from one end of the Trocart that was first described, a hole may be made like the eye of a great Needle through which the Silk may be passed. Every time that it hath been used, it must be new set, for the Urine blunts the edges very much. It is good to practise such kind of Operations upon dead Bodies: for that end, one must with a Syringe Squirt as much matter as possibly he can, into the Bladder, then tie a Ligature about the Yard, and make the Punction as hath been described, and then make a dissection of the Bladder, to observe what hath been done, that so he may take his measures for another time. We may avoid offending the Rectum by conducting the point of the Pyramid towards the Bladder, which then is much distended, and we need not fear to open it in the Body, because these Wounds are not absolutely Mortal. And though they are said to be harder to consolidate in the Membranous part thereof, nevertheless we should banish such apprehensions, because we see by experience that they are cured, and that the business is to save the life of a dying Man. They to whom Fistula's do remain after the Punction of the Perineum, make use of a Tent which they cause to be opened, and stopped now and then for the voiding of the Urine: they may be made to stop with a Screw for greater security. The ends of the Linen Cloth or Languet of the Tent; are tied the one before, and the other behind to a Girdle, held up by a Collar, like those which have been described when we spoke of the bandage of the Yard for a Phimosis Chap. X. If some Symptom of Lithotomy succeed the Punction of the Perineum, it is to be remedied according to its kind; and when none appear, or if they be cured, the Patient and Chirurgeon may have good hopes, and both doing their duties, with external assistances the Lithotomy and Punction of the Perineum are brought to a perfect cure. Nevertheless what care soever the Chirurgeon may have, and how obedient, confiding and quiet, so ever the Patient may prove, assisted as he ought to be by those who attend him, and the administration of proper Medicines, yet sometimes he hath the trouble to be incommoded by the other distempers contained in the following Chapter. CHAP. XXII. Of diseases that happen after cutting for the Stone, and of the way of curing them. GVY of Chauliack in his second Treatise says, that if there be no Metastasis of the Humours into Apostemes, they are terminated by Discussion, Suppuration, Obduration and putrefaction and afterward he speaks of the manner of treating and curing them. This shows that there is a difference betwixt their term, their curing and their cure, the end of one disease may be the beginning of another; the cure hath an uncertain end, though healing be that which is proposed according to Art; we see but too many instances of this in those that are troubled with the Stone; that evil is terminated by the extraction of the Stone; and that Stone taken out, or that the distemper ended by the Operation, produces a Wound, or other accidents, the cure of which is necessary; and which nevertheless do not always terminate in a cure, but sometimes in a new Stone, a Fistula in the Perineum, an involuntary spilling of the Water, a preternatural voiding of excrements, or in many diseases together; they have each of them their Causes, Differences, Signs, Prognostics and Ways of Curing. We shall say nothing as to the Stone which may be observed after that the Patient hath been under cure; we must only take notice that the cause of it may be this, that there is a Quarry in the Kidneys, which from time to time furnishes the Bladder with Stones, and then the Operation ought to be delayed, unless the Patient be fully recovered in strength, the season be favourable, or that the accidents be remedied; And above all the Patient had need of a very great stock of resolution to endure a second cutting. The Fistula in the Perineum whereof of we speak is a Sinuous Ulcer below the Scrotum, with a Callosity along the length of it, by which the Urine issues out. It is caused by the Surgeons fault, or by the Patients, by the supervening of accidents, or indeed by many things concurring, when the Chirurgeon and Patient do not do their duties, and that bad and violent Symptoms appear in the time, or a little after the Operation. By the fault of the Chirurgeon; when in the beginning he suffers the Lips of the Ulcer to be to soon joined together, before he be certain that the Bottom of it is detersed and agglutinated, or because no accidents appearing he hath dilated the Bottom of it to much, and that he hath not had care after the first eight or ten days at most were over, moderately to Compress the bandage, and to make use of small and very narrow Compresses laid upon the two sides of the Incision. On the part of the Patient, when his Urine being too sharp corrodes the Vrethra, and hinders the reunion, or that he lies not still as he ought, not observing Directions, and not suffering himself to be treated according to the rules of Art; to which must be added his being emaciated, the abundance of Urine, and if he moderate not his passions, or exceed in his food, the superfluities whereof causes a too long suppuration. The most remarkable accidents that contribute to the Fistula, are a Putrefaction, which causes great loss of substance in the Vrethra, and adjoining parts; an Ulcer in the Bladder, or Kidneys, the suppuration whereof requires that the parts be kept dilated. The differences of these Fistula's are drawn from hence, that some of them are even and strait from the Skin to the Vrethra, without any other profound or superficial sinuosity, and are apparent on the side of the seam; others have their Orifice in the Rectum; some are accompanied with great loss of substance, others have one or more sinuosities in the Vrethra, and in the neighbouring parts, or otherwise they happen in a bad subject; and these differences are discovered, if it be observed in time of dressing the Patient, that thirty or forty days after the Operation, the Ulcer cicatrises, except one or more little passages, or a small Lump or Tubercle, which is named, the Pullet's rump on the side of the seam, through which the Urine escapes; or if the Patient being much extenuated, the superveening accidents have caused a great loss of substance in the Vrethra, or that new Flesh cannot breed; the issuing of the Urine by the Anus makes it apparent that the Orifice of the Fistula is in the Rectum. All Fistula's in the Perineum are not alike hard to be cured; for the first kind may be taken into cure, provided there be no great loss of substance, and that the subject be good, the rest being commonly incurable; some of those who are troubled with Fistula's have this comfort that they do not always run. If the subject be good, not too lean, and the Ulcer filled with well conditioned Flesh, the cure of the Fistula may without interruption be undertaken: but if the Patient be extenuated, or if there be great loss of substance in the Vrethra with Callous Flesh, the cure is not to be attempted, until the strength be restored, that it may be tried if new Flesh can be procured. In that case he must be comforted, giving him hopes that at another time he may be cured. Those that have their Orifice in the Rectum are sometimes less troublesome and they are not to be tampered with. For curing of the Fistula, we shall not speak in this place of the universal regiment, we suppose that to have been observed, either whilst the Patient was under cure for the Stone, or since, but we shall only treat of the particular management of that cure. Authors speak of Potions and many Topical Medicines for the cure of Fistula's: but since my design is only to describe what I have observed to have been successful, I can affirm that many have been cured by the following means; which consists in introducing into the Bottom of the Fistula, a Catheretick Trochisque described in the last Chapter; next the falling off of the Escar is to be procured by Basilicum; and then the Patient is to be dressed like one that hath been cut of the Stone after the seventh or eighth day; some make use at the same time of a desiccative Wax Candle, which they thrust into the Yard up to the bottom of the Fistula: others cure them without the use of Wax Candles; when any accident appears, it is to be remedied, as hath been said Chap. XIX. If those that are fistulous are to be pitied, they who are troubled with an unvoluntary emission of their water by the Vrethra, ought also to be ranked amongst the Miserable, as those also, who piss not at all: But they from whom the gross Excrements drop against their will, surpass the rest in Misery. What may be said then, if one should suffer many of these Inconveniences at the same time? The spilling of the Water is caused by a Palsy in the Sphincter of the Bladder, by the Incision of its Fibres, or by a great Dilaceration, when a big and rough stone hath too much widened the Passage, and hath caused a Suppuration of long continuance. The Kind's and Differences are taken from the Greatness or Smallness of the Emission; the Signs of it are visible, or rather most sensible and uneasy to the Patients, because Shame and Vexation hinders them sometimes from seeking a Remedy; from whence the Prognostic may be made, That all of them are extremely hard to be cured, the most part incurable; and that the Cure most commonly is but palliative. Women are not subject to Fistula's, but only to this spilling of their Water, which is more uneasy to them, than to men, because of the Conformation of their Vrethra, and that their Sex which hath Modesty for its Property, obliging them to a greater reservedness, hinders them from seeking relief: and this makes them to have Clouts or Sponges about them to receive the Water, or to employ something else, that Necessity and Uneasiness suggest to them. When the Spilling of Urine remains with men, they may have recourse to a little Engine, such as I saw in the Possession of a Person, whose Character and Quality allows me not to name him; I have heard him say, that it was very useful and commodious for him. That Engine is made of Steel, Iron, or any other convenient Metal: It is composed of two parts, each about three Inches long, and a Finger's breadth wide; one of the two pieces bends a little in its Longitude, and the other is strait; these two pieces join together at one end with a turning joint like a Compass, and at the other end both are bend backward to fasten within one another, so that pressing with the Finger, they may be opened and shut. These two pieces are covered with Linen, as much, or as little as one pleases; afterward the Yard is put into that Instrument, observing to keep the crooked part uppermost; and when one hath made water, it is shut: the Compression may be made as slightly as one pleases, covering or facing the Engine more or less, that it may be suffered without Pain, & letting the Urine pass through, which in some manner supplies the action of the Sphincter of the Bladder. I have seen some who have made use of Boxes of White Latin, or other Vessels of Leather made in form of an Urinal, tied to a Girdle, and wherein the Nut always hung, which is not done without Pain and Trouble. There is another Instrument much like to a Truss, for ruptures; it is made like the Steel Trusses, having a Girdle of the same Fashion, and on the left side, in stead of a Bolster, the end of the Girdle bends Elbow-ways downwards, and terminates in the shape of a small Iron Plate, which is covered with Felt, Leather, or Cork, sufficiently waxed over, that it may be of a convex Figure like an Olive, and indifferently hard, that it may exactly answer to the Vrethra above and near to the place where the Incision hath been made. When the Bandage is applied, the little Eminence presses the Vrethra below the Cod, and to keep it firm, it is made fast by the other end, where there is a strap of Leather of the same fashion as in the Steel Trusses for Ruptures; and besides, if a man were troubled with a falling down of the Intestines, one of these Trusses might be made on purpose for him, where there might be a Bolster for the Rupture, and the little eminence for compressing the Vrethra, and hindering the shedding of the Water. Though this Bandage or Truss be in effect only for a palliative Cure of this Distemper, yet it may sometimes serve for a real Cure, because hereby the parts gather strength, and are corroborated. There is another kind of Bandage still, the Girdle whereof is made of Fustian, and that part which is to pass upon the Pubis of a piece of Wood of the length and bigness of the Patient's Finger, covered with Fustian and Wax, betwixt which and the Pubis, the Yard being compressed, lies along looking upwards; that Posture hinders the spilling of the Water: The same Bandage hath Points fastened to the fore part of it, that they may be carried betwixt the Thighs, and tied side-ways to the Girdle, that so the Bandage may not rise too high. Involuntary voiding of the Excrements is caused sometimes by the Surgeons Fault, if in time of Lithotomy he make the Incision too low, and if he cut the Rectum, especially in the lesser Operation, if he take not good heed; most frequently the violent Motions of the Patient contribute to it, but much more Putrefaction, Abscesses, or other Accidents that follow the Operation. Their Kind's, Signs, and Prognostics, are taken from the more or less Ejection of the Excrements by the remaining Fistula, which is far more uneasy than the spilling of the Water, or the Fistula alone. The Cure of this stercoral Excretion is impossible, when it is caused by Incision of the upper part of the Sphincter of the Rectum, or when there is great loss of Substance; if any pretend to take such Patients into Cure, they are to observe the Method of curing Fistula's in the Anus. We need not enlarge to prove, that these kinds of Distempers may have several Causes concurring at the same time; when many of these Indispositions happen together, we must have our recourse to the Method of curing complicated Distempers, as well for the Prognostic Part, as for the order of the Complications. CHAP. XXIII. Of Medicines to prevent the Stone, for avoiding of the Stone, and of Medicaments for dressing those that are cut. THough we promised to inquire into the Medicines that may prevent the Stone; we must, however, confess, that it is very difficult, and perhaps impossible to determine precisely wherein they do consist; because the most learned in natural Discoveries, speak only in general of the Figures of Bodies, and Microscopes have not been able to make known the particular Nature of every one, nor yet of all their Pores. Possibly we might succeed without observing all these Particularities; for though Inquiries into Nature were pursued to that very point, yet still there would be causes that did not depend on us, and which might form the Stone; the Bigness, Figure, Number, and Motion of the Particles of Bodies of which we are composed, and of those which serve us for Food, are no ways in our power; though these things be sufficient to produce in us the Maladies that we fear, if the Secretions and Excretions be not performed according to the Course of Nature. That we may reap Benefit from the Miseries of others, it is to be considered, that they who are most subject to the Gravel or Stone, live after such a manner, as may be avoided, or at least corrected by other means; and seeing we have spoken of fenny and marshy Places, gross and thick Air, calculous Food, muddy Waters, and of the Excesses that may much debilitate the Parts of the Body, they are carefully to be avoided, using moderately those things that are for our Nourishment, following Exercises suitably to our strength, without affecting too much Niceness and Delicacy: It were better to use a little too much, than not enough; because Life consists in Action, and men love themselves too well, not to repose and take their Rest; if we be not guilty of Excesses, the Parts of our Body continue in good Health, ready to resist all attacks. Though few things contribute more to the forming of the Stone in the Bladder, than continuing long without making of Water, yet we must not at first give Diuretics, but only gentle Purgatives to empty the Intestines and adjoining Parts: of that kind are Manna, Cassia, Catholicum duplex, Lenitive Electuary, Diaprunum simplex; a day or two after, Turpentine prepared in this fashion, may be given in drink: Take an Ounce, or Six Drachms of the best Turpentine unwashed, dissolve it in a Mortar with a little of the yelk of an Egg, then add to it two or three ounces of the Water of Winter-Cherries, Smallage, Pelletory of the Wall, or of some other Liquor, according to the Nature of the Disease, and the state of the Patient: Stir all together that it may be exactly mixed, and become of so white a Colour, that it looks like Cream or coagulated Milk. Bever. C. XI. of the Stone of the Kidneys and Bladder. The Bath gives ease to those that are troubled with the Stone, and contributes much to the bringing away of little stones that stop in the Kidneys and Bladder. The use of the following Ptisanne, or Barleywater, is very good against the same Distempers: It is made with an Ounce of Linseed, and the Roots of Mallows and Marshmallows, of each two Ounces, put into five quarts of water boiled away to four; into three Ounces of this Ptisanne may be dropped four or five Drops of the Spirit of Sulphur, and it may be made stronger by augmenting the Dose of the Ingredients in the same quantity of water: It is approved of for making one void Water, mitigating Pain, and bringing away Stones. The two following Receipts were given me by Monsieur Jonnot, the first of which, he told me, hath often (to his Experience) been successful in easing Nephritick Pains, and those who are subject to void small Stones; and that the second never failed him, provided the Stone be of a Bigness fit to come out of the Pelvis, or Basin of the Kidneys. The first Medicine is to be taken in the Spring and Fall, every Morning for three days together. Take six Ounces of the Water of Pelletory of the Wall, an Ounce of the Oil of sweet Almonds, and an Ounce and a Half of the Syrup of Lemons; in case of necessity, it is taken at any time. For the second Remedy, the Patient must be once or twice blooded, and twice purged with two or three Drachms of Sena infused overnight in the Decoction of Dogs-grass, Roots of Marsh-mallows, and a little bundle of Flax; to the Colature of which must be added an Ounce of cleaned Cassia for every Dose: The day after he is to make use of the following Limonade, and is to continue it three days successively in the waning of the Moon, fasting three or four Hours after. Take of Argentine, or Wild Tansey, Water Lentils and Cresses, of each one Handful, let them boil half a quarter of an hour in a quart of water, when it is taken off the Fire, add to it the Juice and Rind of three or four Lemons; let all infuse together for the Space of four Hours, then strain it, and add thereunto three Ounces of the Powder of Sugar-Candy, and twenty Grains of the Spirit of Salt: Keep it for the Use aforesaid. The Garden-flags, or blue Flower-de-luce that grows upon Walls, infused cold into what quantity one pleases of White-wine, and an Ounce of the Infusion, taken for the first time by Children of ten or twelve Years of Age, brings away the Stone: The Dose is to be increased or diminished, according to the Age of the Patient and its Operation, giving always too little, rather than too much, for fear of drawing the Stones in too great abundance towards the Sphincter of the Bladder, which would cause a suppression of Urine. One may renew it two or three days after, and Purge by the Advice of a Physician. The use of White-wine, Raddish-water, and Wine made of the Fruit of Eglantine, or Sweet Briar, taken now and then, is good. Paracelsus, in the end of the Preface to his second Treatise of his great Chirurgery, prescribes for remedying the suppression of Urine, the use of the stones that are found in the Heads of Crabs, beat into a subtle Powder, drank in the Juice or Water of Radishes, and if the Patients do not thereby make water, to make a little bag of Saffron, and lay it upon the Kidneys, or the Belly, towards the passage of the Ureters, and upon the Perinaeum: Or to make a Powder of dried Acorns, and give it to be drank in the Water or Juice of Radishes, in what quantity the Physician shall judge fit. The two following Medicines are approved of for bringing away of Sand and small Stones. In the wain of the Moon, the Patient being Purged, let him take in the Morning the bigness of a Nut of fresh Butter, and swallow it down like a Pill; then let him take a four Limon, and squeeze out the Juice of it into four Ounces of White-wine, let him drink that Potion a quarter of an hour after that he hath swallowed the Butter: This may be reiterated two or three days after, according to its effect, and then Purge again. For the same effect, take a little white Onion, cut it into small pieces, infuse them over Night upon hot Embers in four Ounces of White-wine, and strain it; having taken the same quantity of fresh Butter in the manner above directed, a quarter of an hour after drink of this Infusion; it is more violent than the former. The Butter is taken first, that the Stomach may not be stung, or too much pricked by the Wine, the Limon-juice, or the Onion: And it is to be observed, that if the Patient should but once take a greater quantity than these Doses prescribed, instead of giving ease, it would expose him to a suppression again, because these Medicines are very Diuretic, and carry rapidly along with them what they meet with in their way. They say that Jet hath so much Virtue, that it is enough to hang it about the Arm, or to carry it in one's Pocket, to obtain ease of Nephritick pains, and to bring away the Gravel and Stone. The cold infusion of Nephritick Wood is Excellent; put what quantity of that Wood you please into water, to which it will give a Tincture; take of it two Glasses in the Morning, and one at Night, or at any other hour of the day, if the Stomach be empty; this Medicine assuages the pain, and brings away Sand. Pareus, Book 17. Chap. 37. describes the following Broth, and says, that he hath by Experience found it to be of marvellous Essicacy for hindering the forming and confirming of the Stone. Take a Cock and a Knuckle of Veal, boil them in water with a handful of Barley, Parsley-Roots, Sorrel, Fennel, Sichory, Butchers-broom, of each an Ounce; the four cold Seeds bruised, of each half an Ounce; towards the end, add Sorrel leaves, Purslain, Lettuce, Mallowtops, and March Violets, of each half a handful; and then keep the Broth, of which the Patient for four Mornings together fasting, shall take about half a Pint with a little of the Juice of a Limon, making it boil one turn over the fire, every time before it be taken; you will quickly see, says he, a wonderful Operation, and it is a Medicamental Aliment. In the same place he gives the Receipt of a rare Powder against the Stone. ℞ Nucleorum mespil. Unc. 1. Pul. elect. Diatrag. frigidi, Dracn. 2. Quatuor seminum frig. majorum mundatorum, glycyrisae rasae ana drac. 1. Sem. Saxif. dr. 2. Seminum milii solis, genistae, pimpinellae, brusci & asparagi, ana Scrup. 1. Seminis Altheae, dr. 1. semis. Sacchari albissimi, Vnc. 6. fiat pulvis. This Powder is to be taken the first days of the New Moon and First Quarter, of the Full Moon and Last Quarter; and so for all the Months after, to the quantity of a Spoonful in the Morning three hours before eating. For the same Effect he prescribes the following Powder. ℞ Coriand. praep. scrup. 4. Anisi, Marathri, granor. Alkekengi, Milii solis, ana drach 2. Zinzib. Cinnamomi, ana scrup. 2. Turbith Elect. drach. 1. Carvi scrup. 2. Galang. Nucis moschatae, & lapid. Judaici, ana scrup. 1. Foliorum Senae mundatorum ad duplum omnium, Diagredii dr. 2. Semiss. misce & fiat pulvis. Dosis erit ad drach. 1. Cum vino albo. Capiat ager tribus horis ante prandium. Glisters for asswaging Nephritick pains, are to be made of the Decoction of Lettuce, Scariole Purslain, the Flowers of Violets and Nenuphur. Melilot, Camomile, Dill, the leaves of Mallows, Marsh-mallows, Bran, and Linseed; and in the Colature is to be dissolved cleaned Cassia, a little Sugar, yolks of Eggs, and Turpentine, which is a Sovereign Remedy. Beverovicius speaks of a great many Medicines; but seeing he may be consulted, we shall here wave the Description of them, and speak only of Medicines that are used after the Operation, and for Remedying the Symptoms. They have nothing that is particular, but that they ought to be more moistening and humectant than for the other parts. Every Chirurgeon makes his Astringent Powders, and other Medicines to resist Putrefaction, and breeding of new Flesh. Sometimes the Rumps of Pullet's are dried with a little Rock Allom Calcined, and scraped Lint; or else there is added to it the Powder of Lead malaxated with a very little Diapalma, or de minio: A very good Epulotick is made with an Ounce of Pompholix, half an Ounce of the Plaster de minio, two Drams of Rock Allom Calcined, all incorporate together. In like manner a very good Desiccative may be made of Bole Armoniac and the lethargy of Gold, of each an Ounce; the Salt of Saturn, and Crollius his Medicamental Stone, of each a Dram; all being reduced into a Powder, they are to be made into an Unguent with a sufficient quantity of the Oil of Roses. To remove the Callosity of Fistula's, one may make use of the Powder which is found at the bottom of Sphagedenick Water: You may take what quantity you please of that Powder, let it dry in the shade, and then grind it upon Porphyry-stone, or Marble; add thereto a little Water, in which Gum Arabic hath been dissolved, and make it up into long and small Trochisks of divers shapes. A more violent and efficacious Catheretick for the same purpose may be made of equal parts of Corrosive Sublimate, and Rock Allom Calcined, a little Opium and Saffron; all must be pounded together, and to give it a Body, add as much Gummed water as is necessary, and make it into Trochisks according to Art. We ought not to forget the Description of the Lineament of Arceus, which in Dressing serves for a Digestive: Thus it is doscribed. ℞ Gummi Elemni & terebinthinae abietinae ana Vnc. 1. Sem. saevi castrati antiqui & liquefacti, Vnc. 2. Pinguedinis Porcinae Vnc. 1. Misce & ad ignem Linimentum facito. Arceus, in his first Book of the good Method of Curing Diseases, says, that this Medicine is of so great Virtue, that with half an Ounce of it one may Cure the greatest Wounds, provided no Accident supervene; sometimes they add to it as much of the Oil of St. Johns-wort as is thought convenient, according to the intention that is had in using it. Pareus gives the Description of the Oil of Eggs, pag. 752. Take the Yolks of hard Eggs, rub them betwixt your Hands, and fry them in a Frying-pan over a gentle fire, stir them with a spoon until they become red or tawny, and the Oil come from them, than put them into a Hair-cloath, and press out the Oil, as that of Almonds, and keep it for Use. Here we may subjoin the Description of Hartshorn Jelly, which is Excellent against the Looseness that happens to those that are cut of the Stone; it is made of two Ounces of the shave of Hartshorn, and as much of Ivory, which are to be boiled in a quart of Water until the Juice of them be Extracted: Then the Decoction is to be strained through a Cloth, and the Colature clarified with the white of an Egg, adding thereto a little of the Juice of Limon, white Sugar, and Cinnamon; the Colature is to be set over the fire again, and when it gins to boil, a white scum will rise, than a little White-wine is to be put into it to settle the scum, and a little after, when the scum rises again, some more White-wine is to be put into it; the Humidity is to be let evaporate, until one perceive that the Liquor becomes Glewy, than it is to be taken off, and quickly strained through a clean Linen Cloth, and put into Vessels, to be kept for Occasion: A spoonful or two of it is now and then to be given to the Patient, to stop his Looseness. FINIS. Some Books Printed for William Cademan, at the Pope's Head in the Lower-walk of the New-Exchange, in the Strand. Folio. AN Institution of General History; or the History of the World. By William Howel, L. L. D. in Two Volumes. Historical Collections; or, an Exact Account of the Proceed of the Parliaments in Queen Elizabeth's Reign. A Journey into Greece, by George Wheeler, Esq in Company of Dr. Spon of Lions. In Six Books. Containing, 1. A Voyage from Venice to Constantinople. 2. An Account of Constantinople, and the Adjacent Places. 3. A Voyage through the Lesser Asia. 4. A Voyage from Zant through several Parts of Greece to Athens. 5. An Account of Athens. 6. Several Journeys from Athens, into Attica, Corinth, Boeotia, etc. With variety of Sculptures. Pharamont, Complete in English, an Excellent Romance. Clelia, a Romance, in English. Parthenissa, Complete in English. 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