SURGERY. 673

by the pressure of the pad. Fig. 72, represents a truss for an in-guinal or femoral hernia of one side, fig. 73, a truss for the samedisease in both sides, and fig. 74, a truss for an umbilical hernia.The circumstances to be attended to in performing the operationfor hernia, in general, are these: A table of convenient size andheight being placed in a proper light, the patient must be so laidon "it as to relax the diseased parts as much as possible, andthen secured by proper assistants. To lessen the contents ofthe abdomen as much as possible, the bladder ought to beemptied previous to the operation. An incision is to be madewith a common round edged scalpel through the skin and partof tlie cellular substance, long enough to allow the stricture tobe fully exposed. The rest of the cellular substance is then to bedivided with the greatest attention. That part of the muscle form-ing the stricture or ring must next be laid distinctlyun view. Asmall portion of the protruding sac must also be exposed ; afterwhich the directory (tig. 75,) is to be passed between the ring andthe sac. A straight probe-pointed scalpel is now to he introducedinto the groove of the directory, and by it the ring is to be dilatedtill the point of the finger can be introduced. The finger is hereconsidered as the safest director; for it being insinuated into theaperture in the tendon immediately above the protruded parts, thepoint of the knife is easily introduced upon it; and by keeping theend of the finger always a little before the knife, the opening maybe enlarged to any necessary extent without risk of wounding any ofthe contiguous pai ls By the ease with which the finger is introducedthe operator will be enabled to judge when die ring is sufficientlydilated ; and if the strangulation was entirely in the ring, it willHow be evident that everv obstacle to the reduction must be re-moved, and oi consequence that the prolapsed parts may be re-turned with little difficulty. If the patient be young, or if thedisease has continued a considerable time, sucli a degree of in-flammation frequently ensues in the net k of the sac as to producethickening and straitness; so that, after the sac and its contentshave been entirely treed from the stricture of the ring, the intes-tines cannot be reduced. Wc judge tliis to be the case when, afterthe stricture of the ring lias been removed, the parts prolapsed doHot expand into their natural size, and farther, when they makeresistance when we attempt to return them. In this case, theHeck of the sac must be opened with the utmost caution, to avoidWounding the parts within it.

Of the Stone.

A variety of causes have been assigned for the formation ofcalculi in the bladder of urine; as, a decomposition of a super-abundant quantity of earthy matter from the blood, on account°f a sedentary life; certain articles of diet or drink, containing agreater quantity of earthy matter than others; a continued used ofsolid food without a sufficient quantity of drink ; the peculiarnotion of absorbent vessels; the particular structure of the kidney ;Bie nature of the different excretory vessels; the time the urinebiay remain in the kidney ; the habit of retaining the water in thebladder; particles of blood getting into the kidney or bladder,a bd attracting the stony mailer so as to form a nucleus. A certainoliang e of the vessels of the kidney forming the urine has by somebeen considered as a more probable cause than any of the former.

be formation of calculus sometimes begins in the kidneys, alether times in the bladder. After a calculus has begun to bejornied, it sometimes acquires a great size in a few months fromAfo first obvious symptoms; but sometimes it remains in the blad-< ei ' fin- many-years without arriving at any considerable size. Thes y>Hptoms commonly come on gradually, and bear some kind ofProportion to the size and inequalities of the stone. One of tlie‘■'st commonly taken notice of is an uneasy sensation at the pointbt the urethra, which for some time is perceptible only uponbaking water, or upon using violent or jolting exercise. ThisSensation gradually increases: and there is along with it a frequentesir e to m . lke lva(el) „.|,i c j, is commonly voided in small quan-l’es, anj sometimes only in drops. When running in a fullh'eam, it often suddenly'stops, though the patient is conscious“bt a considerable quantity still remains, and feels a strong incii-d. ii 011 lo avoid ‘h 11 the stone be large the patient has a constantI 11 pain about the neck of tlie bladder, and frequent desire offcb'ng to stool. The urine is generally of a limpid colour ; but itrequently thick, depositing a mucous sediment, and when thecase is violent it is often tinged with blood, All these com-Vol. iv.—no, 203.

plaints are generally increased by exercise, especially by ridingon horseback ; and from a long continuance of pain, the patient’shealth by degrees becomes much impaired, and unless effectualmeans are employed for removing the cause of the disorder, deathalone puts an end to his misery. We are certain of the existenceof calculus when small pieces of stone are parsed along with theurine. When this does not occur, we cannot be certain that thesymptoms do not arise from an ulcer or tumor in the body or neckof the bladder, or from the pressure of tumors in the neighbouringparts. In doubtful cases, however, we have one mark by whichwe can judge with certainty, and that is by sounding. This isperformed by introducing an instrument called a sound (fig. 76,)formed of steel finely polished, and having the natural curvatureof the urethra. The patient is to be laid upon a table or acrossa bed, with his shoulders raised upon a pillow, to bring the stoneto the neck of the bladder, and his thighs a little elevated andseparated from eacit oilier. A sound adapted to the size of tlieurethra is to be chosen ; and previous to the introduction it is tbbe laid in warm water till it be of tlie heat of tlie body, and thenwiped and rubbed over with tlie bland oil, butter, or axunge.The surgeon lays hold of the penis with his left hand, while withIlls right he introduces the sound with its concave side towards(lie abdomen. lie is now with his left'hand to draw the penisgently forward upon the instrument, which is to be graduallypushed into the bladder. It any difficulty occur about the neckof the bladder, this may he obviated by introducing tlie fingerinto the anus, and raising the point of the instrument; or the samepurpose is more readily answered by depressing tlie handle of thesound. If still it does not pass with ease, much force ought by nomeans to be used, lest the instrument perforate the membranouspart or the urethra. As soon as the instrument enters the bladder,ii it happen at once to touch the stone, a tremulous motion will becommuiucated to the fingers of the operator, and the business ofsounding is then accomplished, the nature of the disease being nowascertained. Great care, however, is here always necessary, as afew' particles of sand, or a hardened state of the bladder, have some-times communicated the same sensation. If the stone be not soondiscovered, the instrument is to be moved in all directions; andshould tlie operator be still unsuccessful, one of the fingers of theleft hand is to be introduced into tlie rectum, so as to raise thatpart of tlie bladder in which a stone may probably be concealed.If even this attempt prove ineffectual, the body of the patient isto be put into different positions, and perhaps one of the best isdepressing the shoulders and raising the pelvis. By these means astone may generally be felt, providing it is not contained in a cyst,which very rarely "happens. If, after all these different attempts,the surgeon should fail in discovering the stone, the instrument isto be withdrawn; and if symptoms of stone be strongly marked,and it appear that neither scirrhus nor inflammation, which mightgive rise to these symptoms, do exist, a second or even a third trialis to be made oil the following days. Various lithontriptics havebeen recommended for dissolving thS stone in the bladder; suchas lime-water, caustic alkali, soap, &c. but none of them can beconveyed in such a state into the bladder as to be much dependedupon, as they undergo the greatest change in the course of thecirculation. To obviate these changes, it has been recommendedto inject certain fluids of this class through tlie urethra into thebladder; but this has not been attended with any material advan-tages, and has generally been found to do injury to tlie bladder. Theonly effectual method"of removing stones from the bladder is bymeans ofachirurgical operation; the success of which depends muchupon the dexterity of the surgeon, as well as on the constitution of tliepatient. Severaf methods have been recommended for performingthis operation; hut there are only two which can be practised withany propriety. One is, where the operation is to be performed imme-diately above the pubes, in that part of tlie bladder which is notcovered with peritonaium ; the other, where it is done in tlie peri-tonaeum, by laying open the neck and lateral part of tlie bladder,so as to allow of tlie extraction of the stone. Friar Jacques, aFrench priest, was the inventor of tlie lateral operation. He firstappeared at Paris'in 1667, and afterwards operated in a great num-ber of eases. He introduced a sound through the urethra intothe bladder with a straight bistoury, cut upon the staff, and car-ried his incision along the staff into the bladder. He then intro-duced the fore-finger ot the lett hand into the bladder, searched forthe stone, which, having withdrawn the sound, he extracted by8 i means