SURGEON GENERAL'S OFFICE
    LIBRARY.
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• 
LECTURES
CLINICAL    SURGERY.
DELIVERED IN THE HOTEL-DIEU OF PARIS,
BARON  DUPUYTREN,
           *-* •


        SURGEOX  IN CHIEF.
COLLECTED AND PUBLISHED BY AN ASSOCIATION OF PHYSICIANS.
Translated from the French, for the Register and Library of Medical and Chirurgical Science.

112/t  G  O
                WASHINGTON:

STEREOTYPED AND PUBLISHED BY DUFF GREEN.
1835. 
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  One of the immense advantages of the Clinical Surgery of the Hotel-Dieu
of Paris, is the great number of curious  cases, either previously unknown,
scarcely thought of, or badly explained,  which presented themselves daily
for observation. But if this theatre of human misery is rich in  incidents of
all kinds, the  celebrated surgeon  who there exhibits the  resources of his
genius, is justly entitled to the best part of the celebrity acquired by this
establishment.   An  able, ingenious and inventive operator; a clear metho-
dical  and eloquent Professor:  such are the qualities which recommend the
instruction of M. Dupuytren to the physician and pupil.  We shall esteem
ourselves happy if we can give to these Lecons a part of the interest excited
by the words of the Professor. 
<<• 
          LECTURES

                  ON

CLINICAL  SURGERY.
                            CHAPTER I.

On the Permanent Contraction of the Fingers, in consequence of an Affection
                      of the Aponeurosis Palmaris.

  The cause of the contraction of the fingers, and especially of the ring finger,
was almost unknown until the present day.  When we reflect on  the multi-
tude of causes to which it has been attributed, the quantity of remedies sug-
gested, the numerous hypotheses advanced as to its origin, we should not  be
surprised that it was considered incurable. Those authors who have treated
of the contraction of the fingers have done it very  incompletely.  M. Boyer
in his Treatise on Surgery, designates it under the name  of Crispatura TeH-
dinum, but says merely a  few words concerning it.  It has been  attributed
successively to a rheumatic or gouty affection, to external violence, to  frac-
ture, to the metastasis of some morbific cause, as sometimes happens after an
inflammation of the sheaths of the flexor tendons, or to a  species of anchylo-
sis :  we shall soon see how unfounded are  all these pretended causes.
   The majority of individuals affected by this disease  have been  obliged to
use violently the palm of  the hand, and  to handle hard bodies.  Thus the
wine-dealer and coachman whose cases we shall relate, were accustomed, the
former to pierce barrels with a punch, or to stow away hogsheads ; the latter
to ply incessantly his whip on the backs of his miserable  hacks.   We might
also cite the case of a gentleman employed in an office, who took peculiar tare
in sealing his letters.  This is found among masons, who  take hold of stones
with the ends of the fingers; among gardeners, &c.  We see, therefore, that
this  disease is mostly found amongst those whose business obliges them to
make much use of the palm of the hand.
   Individuals, in whom there exists a tendency to this disease, find that they
can extend with less facility the  fingers of the diseased  hand; the annular
finger soon begins to contract, commencing in the first  phalanx, the others
follow in succession; in proportion as the disease advances this  finger con-
tracts more  and more; and now  the flexion  of  the two adjoining fingers
becomes very evident.  At this period of the affection, no hardness can be 
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LECTURES ON
 felt in front of, and around the cord presented by the palmar face of the annu-
 lar finger.  Its two  last phalanges are  straight and movable.  The first is
 flexed at an angle more or less approaching a right angle, and movable on the
 metacarpus.   In this situation, notwithstanding the greatest efforts, it cannot
 be extended.  A person laboring under this deformity, with the  desire of
 effecting a cure, suspended to his finger different weights, in all amounting to
 one hundred and fifty pounds, but in spite of this  great weight, he  could  not
 succeed in overcoming the contraction.
  When the ring finger is very much  flexed, the skin presents folds whose
 concavity looks towards the  finger, and whose  convexity towards  the radio-
 carpal articulation. These folds result from the natural adhesions of the skin
 to the altered parts.  At first sight we should be inclined to suppose that the
 skin was affected, but dissection proves this not  to be the case.  On touching
 the palmar surface of the annular finger, we can feel a very tense cord, whose
 summit is directed towards the  first phalanx; and it may be followed as  far
 as the superior extremity of the palm of the hand.  By  flexing the finger it
 may be made to disappear almost entirely.  On  extending the fingers,  the
 tendon of the palmaris longus is put in motion, which is communicated to the
 superior  part of the aponeurosis palmaris, the continuity of  these two  parts
 explains  their simultaneous action.  It will be seen that this remark will
 demand our further attention.
  To what, then, can we attribute the cause of the affection ?   The annular
 finger can no longer be extended, and the adjoining fingers but very partially.
 The patient can only take hold of bodies  of small volume ; on grasping tightly
 any object he experiences acute pain.  When the hand is at rest, the pain
 ceases, and is only felt on attempting to  extend the fingers too suddenly.
  M. Dupuytren, having in public and private practice, seen thirty or forty
 cases of  this nature,  cites many different opinions  as  to the cause of the
 disease.  Some have regarded it as a thickening  and  hardening of the skin,
 Got remembering that it was  drawn and  folded upon itself.   Because it fol-
 lowed the movement of the cause producing the malady; others have  made
 it depend on  a  spasmodic affection  of  the muscles, but this explanation is
 purely hypothetical, for with the exception of extension, all the other motions
 are  freely and easily performed.  The majority thought that  this contraction
 was connected with a disease  of the flexor tendons; such was for a long time
 the  opinion of  Dupuytren.  But it was necessary to determime the  nature of
 the  affection.  Was it an inflammation,  swelling,  or adhesion of the cellular
 tissue, or a chronic disease of these parts ?  Dissection has answered all these
 questions, by showing that none of these supposed alterations existed.  Some
surgeons have thought it proceeded from a disease of the tendinous sheaths;
 others, from a  peculiar arrangement of the articulating surfaces of the fingers
 and the lateral attaching ligaments.  On examining the articulation, it will
 be seen that the surfaces are very extended, and united in such a manner as
 to affect more especially flexion, whilst  the movements of extension are less
 easy.   The lateral ligaments placed on each side  of the articulation,  present
 a remarkable disposition, they are nearer to the anterior than to the posterior
 plane, whence it follows that the fingers have a greater tendency  to flexion
 than to  extension.   But admitting that this hypothesis was of value, it
 could not be applied to men  in the flower of life; moreover, it falls before 
CLINICAL SURGERY.
facts.  Lastly, some physicians think that this  contraction is  owing to a
disease of the articular surfaces which has caused dryness, destruction, and
anchylosis of the articulation.
  We will waste no more time on these  different theories; they have been
mentioned merely as being closely connected with the history of the disease.
The important point is, that some lesion exists, and it remains for us to dis-
cover its cause.
  Such was the state of knowledge relative to this disease when a man labor-
ing under this species of affection happened to die in the hospital. M. Dupuy-
tren, who had observed him for a long time, was informed of his decease, and
was fortunate enough to secure this  remarkable fact for the benefit of the
healing art.   Having obtained the arm, he had a correct drawing taken of it,
and then proceeded to dissect it. The skin having been removed from the whole
of the palm of the hand and the palmar surface of the fingers, the folds and
wrinkles which it before presented, entirely disappeared ; it was then evident
that the  disease was not situated in  the skin, but was communicated to it;
but whence and by what means ?   The dissection was continued, the profes-
sor displayed the aponeurosis palmaris, and saw with astonishment  that it
was tense, contracted, diminished in length, and from its lower edge there
proceeded two cord-like processes extending to the sides of the affected  fin-
ger. In extending the fingers* M. Dupuytren saw clearly that the aponeurosis
underwent a kind of tension, corrugation; this was new  light to him; thus
he conjectured that this aponeurosis was interested in the  disease. But still
the  diseased point was undiscovered; he divided the processes  sent to the
sides of the fingers;  immediately the contraction ceased, the fingers returned
to one-eighth of their flexion, and  the slightest  effort sufficed to bring the
phalanges into complete extension.  The tendons were untouched; their
sheaths had not been opened; what then had been changed ?  The removal
of the skin, and the  section of the extremities of the aponeurosis going to the
base of the phalanges.  In order to leave no  doubt, M. Dupuytren displayed
the tendons, they retained their ordinary size and mobility, their surfaces were
smooth ; he carried the examination farther;  the articulations were in a nor-
mal state, the  bones neither enlarged nor unequal; presenting no trace of
alteration either externally  or internally; no change in the induration of the
articular surfaces; no alteration or anchylosis in the external ligaments; the
synovial membranes, cartilages, and synovia were in a perfectly normal state.
It was therefore natural to conclude, that the disease originated in the abnor-
mal tension of the aponeurosis palmaris, and that this tension was owing to a
contusion of the aponeurosis, by the too long continued action of a hard body
in the palm of the hand.  There  now remained only an opportunity to apply
this theory to  new cases, which very soon presented themselves.  The  dif-
ferent opinions as to the causes of this affection have necessarily caused much
uncertainty as to its mode  of cure.  Many surgeons have thought it beyond
the resources of art.  Sir Astley Cooper informed Dr. Bermati, who consulted
him in the case of an Italian, named Ferrari, that he considered  the disease
incurable.  Others,  admitting the possibility of curing it, have suggested so
many modes, of which immense number have proved their inefficiency.   M.
Dupuytren having had many patients with a contraction of the annular finger,
has  successively employed  vapor baths, cataplasms day and night; leeches, 
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LECTURES ON
frictions with resolvent ointments, and especially mercurial pomatum, or with
calomel; he had also recourse to alkaline, simple, sulphurous, and saponaceous
cataclysm, of various temperatures, without any success.  He has also used
permanent extension by means of a machine made by Lacroix.  The use of
this machine produced no improvement; on the contrary, the acute pain  felt
in the hand when extension had been too long continued, caused it to be laid
aside.  Some surgeons had proposed the section of the flexor tendons.  This
operation has been twice performed.   In the first case the tendon was divided
in its middle; inflammation, with strangulation along the sheath ensued, the
life of  the  patient was endangered, and the finger remained  flexed.  In the
second case, the section was made lower down, nothing unpleasant occurred,
but the finger preserved its contraction.  Some  time  after these operations,
M. Dupuytren was consulted in a similar case by Dr. Mailly; the following is
the history of the case :

   Contraction of the Annular and Little Finger completely^ Removed by  a
               simple Division of the Aponeurosis Palmaris.
   In 1811, M. L., wholesale wine merchant, having received a large invoice
of wine from the South of France, insisted upon helping his workmen to stow
them away in his cellar.  In an  attempt to lift one of  the pipes, which  are
generally very heavy, by placing the left hand under the projecting extremity
of the staves, he  felt a slight cracking and pain in the inside of the palm of the
hand.  There remained for  some time slight uneasiness and stiffness in  the
hand, but the symptoms gradually disappearing, he paid little attention to it.
The accident was almost forgotten, when he perceived the ring  finger  begin-
ning to contract  and incline towards the palm.   As  no pain accompanied it,
he neglected this slight deformity.   Still it increased and every year became
more obvious.  At the beginning of 1831, the ring and  little finger were en-
tirely flexed upon  the palm of the hand; the second phalanx bent upon  the
first, and the end of the third applied to the middle of the ulnar edge of the
palmar surface.   The little finger much flexed, was fixedly inclined towards
the palm.  The skin of the part was wrinkled and drawn towards the base of
the two contracted fingers.
   M. L. seeing this deformity  increasing daily, and wishing to be relieved
from it,  consulted several physicians.  All thought that the disease  was
situated  in the flexor tendons of the affected fingers, and  that the only remedy
was the section of these parts.  Some wished to divide both tendons at once,
others  only one of them. M. Mailly being consulted was of the  same opinion,
but advised the  patient to rely entirely on the vast experience of M. Dupuy-
tren.  Scarcely had the latter seen the hand of  M. L., when he declared  that
the affection was not seated in the tendons but in the aponeurosis palmaris,
and that a few incisions in this aponeurosis would  restore to the fingers their
freedom of motion.   The operation was agreed upon, and fixed for the 12th
of June, when,  assisted by Drs.  Mailly and  Marx, M. Dupuytren performed
it in the following manner :
   The hand of  the patient being  firmly fixed,  he made a transverse incision
ten lines in length, opposite to the metacarpo-phalangial articulation of the
 ring finger; dividing the skin and aponeurosis palmaris with an audible crack-
 ling noise.  After this step of the operation, the ring finger rose, and could 
CLINICAL SURGERY.
9
be extended almost as much as in the natural state.   Wishing  to spare the
patient the pain  of a new incision, M. Dupuytren endeavored to prolong the
section of the aponeurosis,  by passing the  bistoury transversely and deeply
beneath the skin, towards the outer edge of the hand, in order to disengage the
little finger, but in vain.  He could only succeed in slightly dilating the inci-
sion in  the aponeurosis; he, therefore, determined  on making a transverse
incision opposite the articulation of the first and second phalanx of  the little
finger, and thus  renewed its extremity from  the palm of the hand; but the
rest of the finger remained flexed.   Then  a new incision divided the skin
and aponeurosis opposite the  corresponding metacarpo-phalangial  articula-
tion ;  it was followed  by some relief,  but  its success was still incomplete.
Lastly,  an incision was made transversely,  opposite to the middle of the first
phalanx itself, and  instantly the little finger was extended with the utmost
ease; this result showing clearly that the last division had reached the point
of insertion of the  aponeurotic digitation.  But little blood flowed  from the
incisions.   The  hand was  dressed with dry lint, the  fingers, were kept ex-
tended, by means of an appropriate machine fastened to the back of the hand.
  During  the day that the operation had been performed, and the following
night, there was  little or no pain, but some slight uneasiness caused by the
continual  extension ; the next morning, the hand was  the seat of some swell-
ing, resulting from the compression of the machine, which had been made by
an unskillful workman.  On the morning of the 14th,  a machine invented by
M. Lacroix was substituted,  consisting  of a demi-cylinder of pasteboard,
terminated by metallic plates, which could be lengthened or shortened at will,
and ending in  a kind of thimble, which embraced the extremity of the fingers.
The patient at first experienced some relief;  but during the evening the irri-
tation returned,  the pain was redoubled, and  the hand became much swelled.
Then, without removing the machine, M. Dupuytren  ordered the parts to be
kept constantly wet with a cold solution  of the sacch.  saturni; under this
treatment the  pain and tension diminished, and he became more comfortable.
The 15th, the lint was removed, suppuration  was scarcely established, the
hand  was yet engorged, and a sensation of tension  felt along the  diseased
fingers.   Extension was still kept up, as well as the cold applications.   16th,
Only a slight tension in the hand, stiffness of the fingers; suppuration was com-
pletely established.  17th, The severity of  the symptoms diminished, the.ex-
tension of the  fingers could be  increased without pain. Afterwards the swell-
ing and tension  disappeared, the wounds began to cicatrize but slowly on
account of the separation of their edges, effected by the position in which the
hand was purposely kept.  On the 2d of July, the wounds had entirely cica-
trized.  The  mode in which this took place should  be preserved, as they
observed a progression in  proportion to the degree  of  influence exercised
upon them by  the extending power.
  Thus there  was perceived to  close successively,  1st, that incision corres-
ponding to the  articulation of the first and second phalanges of the annular
finger;  2d, that  opposite to the middle of this first phalanx; 3d, that relating
to the metacarpo-phalangial articulation of  the little finger; 4th, and  lastly,
the one first made, corresponding to the metacarpo-phalangial articulation of
the annular finger.   The patient used the extending machine for more than a
month, in  order  to guard against the contact of the edges of the aponeurotic
                2 
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LECTURES ON
 sections and to  procure  cicatrization alone.  On taking away the machine,
 the patient can  easily flex  his  fingers,  and is only incommoded by the
 stiffness in which the 9tate of continual  extension  has  kept the articula-
 tions, but which will  be  removed, when he is allowed to use some motion.
 On the 2d of August, M. L. uses the machine only at night, and the joints of
 the hand are gradually recovering their mobility, which induces the supposi-
 tion that the flexor tendons are uninjured, and that soon the fingers will have
 recovered their natural state.
   The case we have just related leaves no doubt as to the cause of the disease,
 the opinion of M. Dupuytren, therefore, the only correct one, and that which
 truly accounts for the phenomena.
   But how can the aponeurosis palmaris determine similar effects ? this will
 be soon understood by a brief description of this fibrous envelope.  The super-
 ficial aponeurosis palmaris proceeds partly from the expansion of the tendon
 of the palmaris brevis, and the prolongation  of the anterior annular ligament
 of the carpus.  At its origin it is very thick,  as it advances it gradually grows
 thinner, so that near its inferior edge, it gives  rise to  four fibrous processes,
 which  are directed towards the inferior extremity of the four last metacarpal
 bones.   At this point  each of them bifurcates for the passage of the flexor
 tendons, and each of the branches of this bifurcation is inserted  into the sides
 of the  phalanx, and not in front, as many anatomists  have thought.   These
 prolongations, which are more tense than the aponeurosis, should be divided.
 On dissecting the skin from the aponeurosis, we experience some difficulty in.
 separating them, on account of the  cellular tissue and the fibrous prolonga-
 tions arising from the  aponeurosis.   These  adhesions explain the wrinkling
 and movements of the skin.   We might fear in  the division of the fibrous
 prolongations injuring the nerves and  blood-vessels, but when the aponeuro-
 sis is tense, it forms a bridge which protects them, so that we may cut without
 danger.  The use of the aponeurosis palmaris  is to keep the  tendons of the
 flexor muscles in  their  place, to preserve  the anterior  concavity of the hand,
 and protect its different parts; in animals which roost, it is very well marked,
 and possesses great elasticity.  Such are the ordinary functions of this apo-
 neurosis ; but it performs  others, by which it tends constantly  to restore the
 fingers to demiflexion,  which is their state of rest, and it  is the exaggeration
 of this function, produced by disease, which causes the contraction  of the
 fingers.
   This contraction, and especially that of the  ring finger, is, therefore, now
 a disease whose cause is known, and the mode of treatment founded on fixed
 rules;  hence we can easily imagine the success of the following operation,
 performed by M. Dupuytren, on Monday the 5th of December.
   The individual was a coachman of about  forty years of age.  Many years
 since he had observed his fingers inclining towards the palm of the hand ; the
annular finger was especially contracted.  When he came to the Hotel Dieu,
there existed only one inch and a half between the end  of the fingers and the
hand; the  skin of the palm was thrown into wrinkles, whose concavity  was
turned towards the fingers.  On extending the phalanges there could be per-
ceived a cord running from the finger  to the  palm of the hand.   The  disease
existed  in  both hands. . The diagnosis was  easy.  The patient being seated
on a chair,  M. Dupuytren  took hold of the  right hand, and desired  him to 
CLINICAL SURGERY.
11
move his fingers; the tension of the aponeurosis was thereby made manifest;
then with a curved bistoury he  made two semi-circular incisions,  one at the
base of the ring finger, in order to divide the two lateral and digital prolonga-
tions of the aponeurosis; the second, an inch and a quarter below the first,  in
the palm of the hand, in order to make a second section of this digital prolon-
gation, and to separate it at its base from the body of the aponeurosis palmaris.
After these incisions, the ring finger regained almost its normal position; but
little blood was lost.  The patient being very weak, M. Dupuytren deferred
until another day the operation on the left hand.  The dressing was the same
as in the preceding case.                          (
   The facts just enumerated prove incontestably that the contraction of the
fingers in these cases, is owing  to a contraction of the aponeurosis palmaris,
and  particularly of the processes it sends to the base of the fingers; and that
this  disease may be cured by the transverse section of these processes and of
that  part of the aponeurosis which furnishes them.   But, it must be  remem-
bered,  that all analogous cases do not resemble each other, that the same me-
thod is not applicable to all, that the  best may be depreciated and  dishonored
by misapplication; such for example would be those  in which we should apply
the  method to contractions of the fingers produced by  rheumatism, gout,
whitlow, &c.
                           CHAPTER  II.

                         Effects of a Pistol-shot.

  Destruction of the greater part of the body of the inferior maxillary bone,
the lip, and other soft parts as far  as the os hyoides, causing an enormous
hiatus, through which the saliva constantly flowed.   Projection on the right
side of a fragment of the inferior maxillary, which being lifted upwards, raised
the upper lip, and assumed the appearance of a tusk.  Removal of the bone as
far  as the mouth: formation of a lower lip, union of the edges of the wound
by the twisted suture.  (Case reported by M.  Saubert, in  the service of M.
Dupuytren.)
  Gun-shot wounds cannot, like fractures or luxations, be subjected to fixed
rules.  The course of projectiles, the injuries they produce, and  the accidents
they give rise to, demand on the part of the surgeon innumerable resources
and sound judgment. Wounds of the head, resulting from attempts at suicide,
demand especially peculiar attention.  We might here cite many very curious
cases, were we not  forbidden to stray beyond the  halls of the Hotel Dieu.
The case we are about to relate is  remarkable  amongst those appertaining to
the same subject.
  Mercier, (C. A.,)  about thirty-six years of age, a soldier, entered the hos-
pital on the  23d  of March,  1831,  in  order  to be treated  for  a horrible
deformity seated in the lower jaw.   This man, who had served  with  distinc-
tion for fifteen years in  the 6th dragoons, fell under the  displeasure of his
second captain, who, according to his account, neglected  no  opportunity of 
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LECTURES ON
manifesting his enmity towards him.  In August 1830, numerous promotions
were made in his regiment; he was designated for the post of quartermaster,
and would have received it, but  for the powerful  interference of the captain
who formally opposed his nomination.  Mercier, thus seeing himself deprived
suddenly and irremediably of the rank to which he had aspired for many long
years, and which he thought he deserved, could not bear  with such injustice,
and resolved to destroy himself.  With this intention, on the 31st of August,
he discharged a horse-pistol loaded with two balls under his chin. It appears
that the barrel of the  pistol was  directed obliquely forwards, for the lower
jaw alone and the soft parts covering it were injured but in a most dreadful
manner.  The inferior maxilla was broken  into fragments, extending from
the canine tooth of the right side, as far as the ramus of the left; the lower
lip, excepting about half an inch on the left, and  the soft parts  covering the
chin as  far as the os hyoides, disappeared in the explosion.  Such a severe
injury, however, gave rise to but few general phenomena;  at the end of two
months  the wounds were cicatrized, but the cicatrices were horrible to the
sight, as nothing had been done to diminish the deformity, and prevent the
flow of  the saliva.   The deformity was afterwards increased, by the contrac-
tion  of the masseter and  internal pterygoid  muscles,  which not being
counterbalanced by the antagonizing muscles, had insensibly raised the frag-
ment belonging to  the right branch of the lower maxilla, to a level with the
alae of the nose, where it projected like a tusk, lifting the upper lip.   In this
situation the patient came to the Hospital Dieu, determined to submit to any
thing which  might relieve the  deformity.  An enormous hiatus, of a tri-
angular shape, existed between the lower maxilla and the os hyoides; its up-
per edge was formed by the upper lip, and its lateral borders converged to their
point of meeting at the os hyoides; the left lateral border extending from the
commissure of  that side, was formed superiorly, and for the extent of about
half an inch, by a fragment of the free edge of the lower lip; the  right lateral
border  was formed entirely at the expense of the soft parts of the cheek and
neck;  the upper lip, at its point of junction with the right  lateral edge, was
raised up by the portion of the lower jaw of which we have spoken, and pushed
out by the canine tooth which projected like  a tusk; add to this  description, a
constant flow of saliva, and you  can form an idea of the horrible appearance
of the man.  What was to be done ?  Was it possible to preserve the portion
of the maxilla, and make it serve the purposes of mastication ?  In order to
this, it  must first be brought from its unnatural position, which could only be
done by dividing  the masseter  and internal pterygoid muscles; and when
they are divided, how is the jaw to be again elevated ?  This operation would
be of no advantage to the patient; we must, therefore, confine  ourselves to
endeavoring to correct the deformity by the  removal of the projecting portion
of the jaw; attempt  the  formation of a  lip; and unite the wound as  far as
possible.
   How is the removal to be performed ?  By making a transverse incision on
the right side of the cheek, displaying the bone, and using a chain-saw.
   The lip on that side could only be made at the expense of the cheek, and
 the wound united by the twisted suture,  after having pared away its edges.
   The operation was performed on the 16th of April, in the following manner :
 A transverse incision of an inch and a half  in length, divided the right cheek 
CLINICAL SURGERY.
13
at the junction of the upper edge of the hiatus with the right lateral edge.
The maxillary  bone was displayed  and  completely isolated.  The saw was
carried behind  the second great molar tooth, and the bone sawed off in a few
seconds.  The  lateral edges of the  hiatus were then pared with a bistoury:
the right along  its whole length; the  left as far as the point where there re-
mained a portion of the lower lip, of which it was intended to make use.  The
wound of the cheek was then brought together by two stitches of the twisted
suture; taking  care whilst making  this union, to  draw strongly inwards the
inferior fragment, which projected  an inch beyond  the superior, and thus
assisted in the formation of  a lower lip;  the lateral edges were then brought
together by five points of the suture.  The union of this longitudinal wound
was perfect, except at the junction  of its inferior three-fourths with the supe-
rior fourth, at which point the tissues having acquired a fibrous texture were
inextensible.  The suture was aided by the application of adhesive straps and
graduated compresses which brought the integuments powerfully forwards.
On the fifth day, the needles were withdrawn from  the wound  in the face
which was found perfectly united.   It was thought proper to leave those in
the neck a longer time; on the eighth day, upon withdrawing them the wound
was found to be united above and below,  and the lower lip formed; but at the
point corresponding to the  fibrous tissues, union  by the first intention had
failed, and the needle cut through the  lips of the wound.  However, there
was still hope for  union by second intention;  the edges of the wound  were
therefore brought together  by graduated compresses and adhesive plaister,
applied behind the ears crossing each other on  the median line. These means
continued for a month, and assisted  by cauterizing the wound, were entirely
successful, and two months after the operation, there remained only an almost
imperceptible orifice through which a little saliva percolated.  Will this fistula
be  cured ? We hope so. At all events, the patient would not be recognized;
he  has to regret the loss of the jaw alone, which no human skill could restore;
instead of that enormous hiatus, displaying the  whole of the mouth, there
exists a linear  cicatrix, and he possesses  a new lower lip.
   We have spoken in the course of this case of no constitutional phenomena,
because none  were developed.  The patient was nourished with milk by
means of a sucking-bottle.
                         CHAPTER  III.

                             ON CATARACT.

               Its different Species—Operations—Treatment.

  M. Dupuytren has lately operated at the Hotel Dieu on eleven patients
affected with cataract, according to the method he generally follows, that is,
by depression.   These patients gave him an opportunity of developing those
luminous principles  which he has for many years taught concerning  this
disease.  The improvements he has introduced into this interesting branch of 
14
LECTURES  ON
 surgery, and the practical consequences he has deduced from his vast expe-
 rience and numerous cases, are the motives which have induced us to present
 now to our readers all the doctrines  (or rather an analysis of them) of this
 celebrated surgeon, with regard to cataract, the method  of operating, and all
 the circumstances  relating to the operation and its consequences.  Such, in-
 deed, is the plan we intend following in our account of the Clinical Surgery
 of the Hotel  Dieu, as it seems most advantageous to the reader and student.
 In this manner, will constantly be presented to them, not only the remarks
 made by the  professor in a recent lecture on a surgical case  or analogous
 cases, but also the  whole of the most  important points of doctrine  which he
 may have professed at other  times, on the order or class of the disease to
 which these specific  cases belong.  By such means the reader will be pre-
 sented with a complete treatise on surgery as practised by M. Dupuytren.
  Cataract, like many other diseases, has been divided into  a certain number
 of species.  Simple cataract  consists in an opacity of the crystalline lens.
 Another species, almost as common as the preceding, results from the opacity
 of the crystalloid membrane; it is called membranous cataract.  The latter,
 according to the observation of Dupuytren, is to ordinary cataract in the pro-
portion as 1 to Ik.  It is especially frequent among children, where it is con-
genital, and where  Saunders has observed it in  twenty-one out of forty cases.
It is then most complete, very rarely incomplete.  In  adults  it commonly
follows blows, contusions, or punctures of the ball of the eye.  It is also met
with in persons of a scrofulous diathesis, and in those who have undergone the
operation  of  extraction, without the precaution  of displacing the capsule.
 Lastly, when incomplete, it appears under different forms.  The most com-
mon is that named  by Saunders, central, affecting the centre of the crystalloid
 capsule, which  is sometimes congenital, but generally does not happen until
after birth.  It is known by a salient, opaque,  and pearly point in the centre
 of the capsule. This point gradually decreases in opacity,  and is sometimes
divided into radiated filaments, as it approaches the circumference of the lens,
 so that this portion preserving in a degree  some of its  clearness, sight is not
entirely destroyed.  This variety of cataract is  always accompanied by a
 convulsive movement of the eyes, which revolve on their axis,  as if in  order
to present successively  to the light the transparent parts of the membrane.
 The eyelids,  and sometimes the whole head  itself, are affected by a similar
movement apparently with the same design.
  After this variety of cataract, the most frequent is that called milky, soft,
 or pullateous.  In  this case,  the lens is at times throughout  very  soft; at
 others, this softness is  only  partial; often, indeed, it is entirely converted
into a white,  lactescent, opaque liquid.  The crystalloid membrane, and the
lens itself, may be encrusted with a greater or less  quantity of calcarious
phosphate, and acquire an osseous consistency; which is  easily  known by the
 shock produced by the contact of an  instrument against this organ.  In this
 case, the cataract is said to take place, by ossif cation.  Again, according to
 some authors, cataract assumes the variety called black cataract.  It is per-
fectly distinct from amaurosis, and manifested by sensible symptoms;  some-
times reflecting many colors at once,  sometimes brown  or  greeni-h, or
radiated with white strips on a black ground, and always accompanied  by
 great mobility of the iris.  Many surgeons, and amongst them M.  Delpech, 
CLINICAL SURGERY.
15
have denied its existence.  M. Dupuytren in his  extensive practice,  never
having seen the disease, is also far from believing  it.   We have frequently
heard him relate the following anecdote: Pellatan and Giraud thought they
had  a patient laboring  under this  disease.   They desired Dupuytren to
examine him.   He thought it was amaurosis.   After some consultation, Pel-
letan and Giraud remained fixed in their opinion, and begged him  (in order
to be convinced) to perform the operation.  He extracted it, and brought it
out a lens perfectly healthy.   The operation was followed by no bad symp-
toms, but the patient remained blind;  the retina being paralyzed.
   Many facts observed in the Hotel Dieu, have induced M. Dupuytren to
admit a hereditary disposition to cataract.   We will only relate one, taken
from his public consultation which seems  to  establish this  opinion beyond
doubt.  The following is a very remarkable example:
   A lady came to the hospital, accompanied by a part of her family.  At the
age of sixty odd years the sight of this lady began to be impaired.   Eighteen
months after,  both lenses were entirely  opaque.  The depression of  one of
them by M. Dupuytren was successful, and restored her sight, which she has
since preserved, and at the age of eighty years saw very clearly.   No opera-
tion had been performed on the other eye.
   The daughter's sight  began to weaken  at  the  age  of twenty eight; she
could no  longer walkialone, but could distinguish day from night; the pupils
were movable, the  eyes healthy.  Two years after the commencement  of the
disease, M. Dupuytren performed the same operation on one eye as on the
mother, with  equal  success.  Ten years after, the sight of the other eye
remained unimproved.  Encouraged by success, the patient wished to be rid
of the remaining cataract.  The journals  of  the day  were filled with the
praises of an oculist, she went to him, and he performed the operation of ex-
traction.  But as it happens in the majority of cases, this  operation was not
so successful  as the former;  acute pain, intense inflammation defeated the
cure, the cornea became opaque, and the patient lost her eye; whilst the one
on which  Dupuytren had operated by depression  remained perfectly sound.
   The son of this lady, aged seventeen, had also two cataracts.   The  opera-
tion of depression was performed on him at the hospital with equal success.
   The grandmother brought with him, another of her grandsons in  whom the
lenses were beginning to be opaque; and  lastly, a granddaughter, who saw
objects as through a cloud, a precursory symptom of opacity of the crystalline.
Here were the grandmother, daughter, and three grandchildren, all affected
with cataract.  These cases  are remarkable, both, for the predisposition of
this family to  the affection, and the success of M. Dupuytren.
   The professor has frequently operated on congenital cataracts, and made on
the results of these operations some interesting remarks well worthy of peru-
sal.  But, said he, I must here observe, that I have never seen the prodigies
9poken of by many authors, nor heard persons to whom I had restored sight, make
upon the distance, form, and color of objects, those wonderful remarks whose
history has been the subject of so many  commentaries of metaphysicians and
others.   I have almost always, on the contrary, remarked, that persons blind
from cataract, whether congenital  or of long duration, accustomed to live
with but four  senses, were generally embarrassed by the new one restored to 
16
LECTURES  ON
them; with difficulty, this could associate its actions to the others, and even
have shown such slowness in using it, that I had been obliged to deprive them
temporarily of one or even two of  the senses, in order to force them to exer-
cise their sight.  Thus I have been obliged to close  the ears of a child, who
was guided by the sound or the impressions received by the hands which he
carried constantly before his body,  like tentacula.
  Such serious difficulties sometimes arise, that M. Dupuytren has failed  in
restoring sight, even after having  completely restored the organ of vision.
Might there be, in such cases, a disease of the optic nerves at their decussation,
or their origin, so that like paralyzed limbs, atrophied by long  inaction,  they
have not been able to recover with their nutrition, their normal  functions ?
  There are three principal ways of destroying  the  cataract by turning the
lens and its appendages from the axis of vision, in order to leave for the rays
of sigh* a free passage to the bottom of the eye; the extraction of the opaque
parts by an incision into the transparent cornea; depression or breaking up of
these parts by a puncture in the sclerotica; and lastly, keratonyxis, which is
the depression of these same parts, performed from before backwards by means
of a needle traversing the transparent cornea.
  The professor condemned the practice inculcated by some authors, to  con-
stantly depress the cataract, or by others, to  divide or break it up in all cases.
He maintains that either depression or division that requires such  conditions
that  we cannot  decide a priori which operation  is preferable.   Indeed, a
cataract of some density can only be displaced, not broken up, for the want
of a support; whilst a soft cataract cannot be wholly displaced, on account of
its want of consistency, and should  be broken up.  M. Dupuytren maintained
that we should be guided by circumstances, and perform depression or division
accordingly.
   But he prefers depression  to extraction; seldom perform  the latter, and
only in cases where it is manifestly indicated:  as for example, when the lens
or its membrane has undergone such an alteration in its nature, that its absorp-
tion is impossible.  Division is only a modification of depression; it  consists
in dividing the lens by plunging the needle into its centre, destroying its cap-
sule,  and scattering the fragments  in the aqueous humor.  According to M.
Dupuytren, one-third of  the cataracts  which are depressed may be divided.
We  cannot be too well  convinced how irrational it would be to employ the
same  method in  all cases.   In surgery, as  in  medicine, the same treatment
does not always tend to the same end;  thus, in cataract, the age of the patient,
certain conditions relative to the form and volume of the organ of sight and
its appendages, may cause the surgeon to have recourse alternately to one or
the other operation.   As regards age, if we reflect on the degree of energy of
the absorbent system, it will be seen that, in general, it is better to operate on
children by depression, on old persons  by extraction. In the former case, the
functions of life are in all their energy;  the movements of composition and
decomposition are executed with an astonishing rapidity; the absorption of
the lens is effected almost at the very moment when this organ losing its rela-
tions, loses its conditions of life; besides, in youth the lens is  never so con-
sistent as in more advanced age, and, therefore, less difficult to be absorbed.
In old age, on the contrary, the movements of composition and decomposition 
CLINICAL SURGERY.
17
are diminished, absorption especially seems to have lost part of its energy,
exhalation predominates, and often the lens is remarkably hard, and on that
account less easy to be absorbed.  M. Dupuytren has found the lens wholly
untouched, although displaced two years before, in old men who had perished
by some other disease.  But other considerations are in favor of depression in
all ages; children are  rarely docile; and not being able to distinguish between
what is hurtful or advantageous, they will not keep their  hands  from their
eyes, or remain perfectly tranquil during the operation.  Thence arise diffi-
culties for extraction, and  causes which may produce the expulsion of the
vitreous humor.  In old  age the eye  is  often  deeply sunk in the orbit; the
borders of the osseous cavity very projecting, or the ball of  the eye small; in
these cases extraction is exceedingly difficult.  We meet with individuals of
all ages in whom, on account of some  aberration in the movements, conforma-
tion, or relations of the organ, this operation becomes very difficult; others,
whose eyes are in continual  and almost convulsive  motion;  lastly, it is a
common observation,  that with the loss of sight we lose the habit of looking;
the movements of  the globe of the eye no longer obey the will, and this cir-
cumstance increases the difficulty of extraction.   Such are some of the rea-
sons  for which M. Dupuytren prefers depression; he has also made some
modifications in the mechanical part of the operation.   The needle he uses is
neither the old spear-shaped needle nor the hook of Scarpa, but partakes of
each, inasmuch as it presents a spear-shape like the former and the curvature
of the latter;  its blade is narrow and elongated, curved on one of its  face,
very sharply pointed, and sharply edged, the size of the stem exactly propor-
tioned to that of the blade;  qualities  which render it equally useful in punc-
turing, dividing, seizing, and  displacing, yielding to the hand, and moving
without much effort,  and without permitting the escape of the aqueous humor.
For fifteen or twenty years this instrument has been adopted by a majority of
practitioners,  and  is known by  the name of its author.  In cases requiring
extraction, M. Dupuytren uses the knife of Richter, which he prefers to that
of Lafaye, as  the former acts by sawing,  whilst the latter acts rather by
pressure.
   The operation of depression,  when the cataract is simple and free  from
any complication, is performed after the ordinary method, and  the  lens,
according to circumstances, is depressed in mass  or divided.   When the lens
is depressed, and the capsule torn by  the needle has been drawn out, M. Du-
puytren examines carefully if this capsule is perfectly black and free. Should
any fragments remain, they are  carried  into the  anterior chamber, where ab-
sorption is more active than in the posterior.  The same method  is followed
in the operation  by  division  (broiernentj.  If the cataract be membranous,
whether the opacity of the capsule be  complete or not, whether it be or be not
complicated with opacity of the  crystalline lens,  it is treated precisely as in
the preceding cases, and the operation by depression preferred.  Indeed, this
variety whose pathological history is so interesting, is of no importance as
regards the operation.   In milky cataract, partial or incomplete, depression
must be accompanied by division, and the fragments being too soft to be con-
veniently divided, are scattered  here and  there into the aqueous humor  by
means of the  instrument.   But when this softening, having reached its full
term, leaves in the interior of the capsule nothing but a fluid of greater or less
            3 
18
LECTURES ON
 consistency, it necessarily flows into the interior of the eye when the capsule
 is divided by the needle, and then the observation of this organ conceals
 entirely from the operator the movements  of his instrument.  Under similar
 circumstances M. Dupuytren suspends the operation, and waits until absorp-
 tion has restored the clearness  of  the eye, in order to recommence it.   We
 shall say nothing about the operation for cataract with ossification ; it is evi-
 dent that here extraction alone can be performed.  In order to perform it, the
 foreign body is seized by means of forceps, which dispose it in such a manner
 that one of its edges is  presented to the opening in the pupil, according to the
 authors who admit the black cataract.  The diagnosis in these cases is the
 most difficult point.  When the color of the lens is  only brown or spotted
 with many luminous reflecting points,  there can be no doubt; but if  it is
 entirely black, for example, we  cannot certainly decide as to the existence of
a cataract.  M. Dupuytren, however, always treats  such cases like those of
 amaurosis; and decides  on  the operation only when the means used  have
 proved  ineffectual.  It may be easily conceded, therefore, that should the
operation  not succeed, the  patient  loses nothing, as he would have  been
equally blind without it.
  About twenty-three years ago, M. Dupuytren was obliged by an unforeseen
occurrence, to  perform the operation for cataract in an unusual  manner.
Being unable to steady the eye  of a young girl affected with accidental catar-
act, and penetrate the  anterior and external part  of the sclerotica, for the
operation of depression;  he determined to puncture  the /transparent cornea,
the only part of the eye left  clear by the convulsive motions  of the mus-
cles, to  carry the needle  as far as the lens, making it traverse the pupil;   this
operation succeeded perfectly. But as he had penetrated into the eye through
the transparent cornea  from necessity and not from choice, he did not think
it a method that ought  to  be followed.  He knew not, however, that  it  had
been done before him in other countries, and above all, that it had  been  laid
down as a regular operation.  However, the favor it had acquired in Germany,
and the advantages attributed to it, caused him to reflect on it; and he deter-
mined to perform several operations by depression or division from  before
backward, after having punctured the transparent cornea with a needle, or as
it is called  by Keratonyxis.   After having subjected  the patient to  a prepa-
ratory treatment, of which we shall hereafter speak, as he also  does in all
operations; M. Dupuytren causes an  assistant to raise the upper eye-lid,
whilst he himself depresses the  lower with the middle finger of the left hand,
taking care -to keep  them well separated ; directing  then the point of the
needle forward, and the concavity of the curve upward, he plunges it into the
cornea, on a level with the lower edge nf the pupil which has been previously
dilated, and assists the passage of the needle by pushing it by its convexity
 with the index  finger of  the right hand, whilst  he moves upwards and down-
 wards, and from before backwards, with the other hand applied to the handle.
 Having traversed the cornea, the point of the needle is guided into the anterior
 chamber, in the pupil and as far as the lens.  On reaching this  point, if he
 wishes to depress the body in mass, he gives to the needle a rotatory motion
 on its axis, so as to direct the convexity of the curve upwards, and slipping
 its points between the upper part of the circle which bounds the pupil and the
 upper part of the lens,  he embraces the lens with the concavity of the instru- 
CLINICAL SURGERY.
19
raent;  then elevating the handle, he depresses the lens below the level of the
pupil and the axis of the visual rays.  Should he wish to divide the cataract,
he presents alternately the point, and the cutting edge of the needle  to the
capsule and the lens, which he breaks in small fragments and scatters as far
as possible from the axis of the visual rays.   The operation is terminated by
withdrawing the needle, having first given it the direction it had on entering
the eye.  The patient's eyes are covered with a bandage, the light carefully
excluded, strict diet, and absolute rest enjoined.   If unpleasant  symptoms
arise they are to be subdued by appropriate means.  Since 1819, the profes-
sor has been engaged in very numerous observations, in order to  determine
the advantages or disadvantages of this operation, when compared with others.
The following are  his conclusions :  1st, That keratonyxis is not, in general,
as easily performed as the operation through  the sclerotica;  2d, that the
facility with which it can be performed on both eyes with the same hand, is
but a slight advantage, especially, if the operator can  like himself,  use indis-
criminately either hand. However, M. Dupuytren thinks, that in this respect,
it has an advantage over the puncturing of the opaque cornea, and that this
circumstance should give it a preference over  the puncturing of the  sclerotica,
if it did not present other inconveniences; 3d, that the situation of the hand
and the needle, between the eye of  the surgeon and that of the  patient, does
not permit him to follow with ease, the movements  of  the instrument, nor
those communicated to the cataract, especially at the moment of depressing
it, when it is  necessary to raise the hand with the handle of the instrument;
4th, that the circle bounding  the pupil obstructs the motions of the needle,
and  prevents the easy displacement of the cataract, its being plunged into the
lower part of the vitreous body, and above all, the separation of the  fragments
of the  capsule of the lens, which adhere so often to the ciliary processes;
5th, that keratonyxis neither prevents the  nervous nor inflammatory acci-
dents  urged  against the operation by  depression,  performed through  the
sclerotica; an important  remark, since it is on account of the  pretended
safety  of this operation that some German practitioners  have given it a pre-
ference ; 6th, that, moreover, according to reason and experience, this opera-
tion predisposes more  to iritis than the ordinary method, since, indeed, the
iris is  much more  fatigued than in  the other  manner  of  operating; 7th, that
ketaronyxis is sometimes followed by an opaque cicatrix, constituting either
a deformity, or both a deformity and an obstacle to vision; 8th, lastly, that
the  results of the  operation for cataract performed by  this method,  do  not
sensibly differ from  those of the operation by puncturing the sclerotica.   Of
twenty-one operations  of this  nature performed by M. Dupuytren, on indivi-
duals of different sexes and constitutions, presenting cataracts  with various
complications, and such as are generally found  in patients taken at random
eleven were  immediately and permanently successful;  six were  successful
at the expiration of a month; two were followed by nervous accidents ; five
had slight  opthalmia; two  were followed by inflammation of the iris; one by
inflammation and atrophy of the ball of the eye ;  in  five the fragments of the
crystaline  membrane remained adherent to the circumference of (he pupil; on
four, a second and  even a third operation was performed; one lost his eye
from inflammation ; one lost his sight from the formation of an opaque cicatrix 
20
LECTURES ON
before the pupil;  two were  attacked with amaurosis, independent of the
operation and its consequences, and which thus prevented the cure.
  It is true, on the one hand, that the nervous symptoms yielded after some
days, to  the use of antispasmodics and derivatives; and on the other, the
opthalmia was cured in ten or twelve days, by the antiphlogistic treatment;
of the two cases of iritis, one yielded to these last means combined  with de-
rivatives and purgatives,  and to the use of the belladonna, whilst the other
was  cured by an operation to detach the membranous pellicle, which almost
always forms in similar cases behind the iris, and to which the edge of the
contracted pupil seems to adhere.
  In fine, of twenty cases, seventeen have recovered their sight, that is 17-21
of the whole.  This result does not essentially differ from that obtained by M.
Dupuytren, in the operation by puncture of the  sclerotica.  Nevertheless, he
does not thence infer that we should abandon the keratonyxis; but, on the con-
trary, that it should be considered as a new resource, preferable in certain
cases to  the ordinary method by depression.   It is true the number of these
cases is limited, and up to the present time, the only considerations worthy of
giving it a preference, are the projection of the orbit, the narrowness of the
opening of the eye-lids, the small size and depth of the eye-ball, its excessive
mobility, and the convulsive motions by which it is agitated in some patients,
especially in children affected with congenital cataract, and in those laboring
under  cataract of the centre  of the crystaline membrane.  Under these cir-
cumstances keratonyxis  should be preferred,  not only to depression by a
puncture of the sclerotica, but also for a still stronger reason to the operation
by retraction.
  It now remains for us to detail briefly, the general  principles  followed by
M. Dupuytren,  both before and after any operation he may perform.   Before
it, the professor attaches great importance to the careful study of the atmos-
pheric phenomena, the temperature, and prevalent medical  constitution.
Every one  knows that at  certain periods opthalmia is very prevalent, and at
such times the operation would most probably be followed by severe inflamma-
tion.   He  pays, moreover, strict attention to the  examination of the general
state of the patient,  and  the nature of any  affections  accompanying the
cataract.  The  affections, which often contra indicate or  delay the opera-
tion, are—an old or a recent rheumatism, a pulmonary catarrh, disease of the
stomach, intestines, &c, constipation, haemorrhoids, cutaneous eruptions; the
different central affections, may, directly or indirectly, aggravate the eye when
irritated by an operation.  If a rheumatic affection should exist, the opera-
tion  may determine  an attack of it to the  head; the  eye and its vicinity
become painful, and often  a severe opthalmia  follows.   Explain this  as you
will,  it matters but little, it is always most prudent not to operate in such
cases.  We should first subdue the rheumatism, and should we decide on the
operation during the existence of some vague pains, we should first apply a
blister on some  remote part of  the  head.  If a pulmonary catarrh exists,
besides the inconvenience of the afflux of blood to the head by the effects of
the cough, we should have to fear in the operation by depression, the ascension
of the cataract,  in consequence of the shock communicated to the head by the
effects of coughing.  Should  an affection of the  stomach be present, we should 
CLINICAL SURGERY.
21
have to dread not only the same mechanical accidents as in the cough, here
produced by vomiting, but also all the complications necessarily resulting from
the sympathy between  the stomach and eyes, as we know that many affections
of the latter depend immediately on disease of the primae viae.   Moreover,
if we operate during a disease of the stomach, although it be slight, we must
keep  the patient longer on diet, which is very difficult in the case of children
and old persons, and  in the  latter sometimes dangerous.  Diarrhea obliges
the patient to  rise frequently, thence  arise displacements of the cataract.
Constipation may occasion many of the inconveniences of  cough and  sym-
pathetic  effects resulting from  irritation.   The existence  of bleeding piles
contra indicates the operation, and although we  may operate when the bleed-
ing has  ceased, we must guard against the cerebral congestion, and  subdue
the slightest  symptoms of it by leeches to the anus.   In cutaneous diseases,
a metastasis of  irritation is to be feared, which might give rise to some trouble-
some affection of  the eye.  It is only after having overcome all the complica-
tions  of  the cataract,  which we have  by no  means enumerated, that M.
Dupuytren decides on the operation.  When no such circumstances obtain,
the patient before undergoing the operation, is subjected invariably to prepa-
ratory measures,  as important perhaps as  the skill of the surgeon.  They
consist in baths, emollient enemata, drinks of  the same nature,  general or
local  bleeding, according to circumstances  and  the  strength of  the patient;
from  time to time a dose of castor oil, and lastly, if the eye is very movable,
and excited easily by the approach of an instrument, it is accustomed to it
beforehand, by simulating the operation, and exposing frequently to its sight
the motions which it is afterwards to undergo.  More particularly, previous
to the operation of  keratonyxis, M.  Dupuytren drops between the eye-lids,
a little of the solution  of the extract of belladonna, or cherry-laurel water, in
order to secure a dilation of the pupil.
   After  these measures the operation is performed, and that of depression
generally preferred by the professor.  The  patient is laid in his bed, in the
horizontal position, the head elevated.; this position less favorable for retrac-
tion,  in depression has the advantage of keeping the eye and the, patient him-
self perfectly immovable ; besides there is less danger of the ascension of the
lens  from the restlessness of  the patient.   Contrary to the opinion of many
surgeons, M. Dupuytren prefers the horizontal position.
   Syncope is a  disagreable occurrence which may happen when the patient is
seated on a chair.   This event, during  so delicate an operation as that for
cataract, is very embarrassing to the surgeon.  Last year, (1830)  M. Thusson
desired M. Dupuytren to visit  a patient who had undergone this operation
some time since, and one of whose eyes was diseased.
   In  this case extraction had been performed on one  eye only.  The patient
was placed on a chair, and the surgeon scarcely completed  the section of the
cornea, when he fell into a syncope, and the operation was left unfinished.
The  lens remained in its place; the wound healed,  and some months after,
the operation was performed in the same manner upon the other eye.   He
was placed as before, on a chair, he again fainted, and only after much time
and difficulty the operation was terminated. This accident would probably
not have happened, or been of  shorter duration, had the patient been placed in
bed.   (Note by Doctor Paillard.) 
22
LECTURES ON
   After the operation, the patient's eyes were  covered with a  bandage, the
 Tight carefully excluded from his room, and he is confined  to strict  diet and
 rest.  The duration of dieting is  regulated by age, and other circumstances.
 If he be of a strong constitution, or evince any symptoms of cerebral conjes-
 tion, the professor orders him to be bled, which is to be repeated whenever he
 has pain in the head or eyes; at the same time he administers to him an anodyne
 draught, pediluvia, and enemata.   Should vomiting ensue, which is almost
 always the case in children, he prescribes  an anodyne potion, composed of
 lettuce water (lactura virose), orange flower water, and the syrup of poppy
 head  (diacodium); should the vomiting still continue, seltzer water, or the
 draught of Riverus.
   In case of restlessness and nervous symptoms, enemata, with  a few  drops
 of laudanum produce a happy effect.   In short, general venesection, leeches,
 principally to  the anus  or inferior extremities, pediluvia, antispasmodics,
 diluents, purgatives, internal revulsives, blisters, setons, to the  nape of the
 neck, are the principal remedies used by M. Dupuytren, and on which he re-
 lies more or less according to the nature of the symptoms.
   Contrary to the practice of many celebrated surgeons, when the patient is
 affected with cataract  in both  eyes, M. Dupuytren operates at first, only on
 one, and waits before  performing the operation on the other, until the fate of
 the first shall have been decided.  Experience  has pointed out to  him the
 advantage  of this method, which reason and a knowledge of the laws of physi-
 ology both justify.  Indeed two simultaneous operations are more severe for
 the patient than a single one, and the consequent inflammation, seated at once
 in two important organs, will produce  effects more serious and less easy to
 subdue.  But the circumstance particularly worthy of notice is, that this inflam-
 mation seldom occurs in both eyes with equal force; it generally happens, that it
 is violent in one of them, and produces, rapidly complete disorganization, whilst
 the other is but slightly attacked.   This is generally the case in inflammation
 of symmetrical  organs.
   Let us now turn our attention to the treatment of the different complications
 of cataract, which increase more or less the difficulties of the operation.   One
 of the principal and most common is the contraction of the pupil:  the pupillar
 aperture is sometimes  so small, as  not to  allow the  passage of the needle.
 This contraction depending on no organic cause, and which on that  account,
 might be termed inorganic, is often found in individuals of a scrofulous habit;
 it is owing to  an inflammation of the retina, known by the thickening and
 redness of the latter.  This disease attacked in time, yields  to antiphlogistics,
 and a few drops of  the aqueous solution of  the ext. of belladonna.  Another
 complication is the adhesion of the capsule to the posterior surface of the iris,
 of the lens  to its surrounding membrane, or of the iris to the ciliary circle,
 lastly, the displacement of the lens, &c.
   In general, says M. Dupuytren, almost all the diseases affecting the crystal-
 ine membrane,  the iris, pupil, ciliary circle or other parts of the eyes, im-
 plicated in cataract, are the result of inflammation of the iris, which is  very
 common, and often injurious to vision.   If we examine the adhesions between
 the capsule and the iris, we will see clearly that the vessels  developed ad in-
finitum proceed principally from the latter, and every one knows, that in the
 formation of adhesions by which two surfaces are united, the greater number 
CLINICAL SURGERY.                         23
of vessels  proceed from that which is more active, that is the more inflamed.
In  these cases, therefore,  very probably, the capsule has been secondarily
affected.  Again,  when we reflect that 3-10 of membranous  cataracts are
owing to contusions, or external violence to the ball of the eye, or  to a scro-
fulous affection displayed  in  this organ, this opinion appears more  correct.
Lastly, if we observe  attentively the  anatomical structure of the eye, and
especially the disposition of the vessels distributed on its  different parts; if
we observe that the plexus  of vessels is situated, not without, but within the
conjunctiva; that  the  anastomoses of  these little vessels are very  numerous,
and forming a kind of  belt at the junction of the sclerotica with  the trans-
parent  cornea, disappear  at  this point, as  they penetrate the sclerotica to
be spent upon the iris,  we will understand how an ophthalmia, even arising in
the conjunctiva, may be extended to the iris, and cause the effects of which
we have spoken.   What holds true as regards the  alterations of the  capsule,
is not less so in other morbid lesions of the eye.   A slight inflammation of the
iris may produce two remarkable  phenomena; the contraction of the pupil,
and the deposition of a small  quantity of lymph on its anterior part, filling
the space which separates it from the crystalloid membrane; this quantity may
increase so that the lymph effused, may traverse the pupil, and be  suspended
at the bottom of the anterior chamber.   If  nothing oppose the progress of the
disease, the same thing happens as in all similar cases of effusion,  that is, on
the one hand, a false membrane is formed, and on the other, it forms adhesions
between the  different tissues; or the pupil is, rarely, entirely obliterated; or
the iris adheres to the capsule of the lens.
   But we should understand what we mean when speaking of iritis, and of con-
traction of the pupil.   It often happens that a sympathetic  state depending on
inflammation of the retina  is taken for  an  idiopathic inflammation of the iris.
This inflammation is much more frequent than is generally supposed. Scarcely
a week passes without our seeing a case of it.  It is especially common in scro-
fulous  children.   When these  last are brought into the house, the nature of
the disease may be known, as far as they can be seen ; they walk  unsteadily,
with their hands to their eyes to protect them from the light, and on  stopping
before a window they suddenly turn round, move the  head  to the  opposite
6ide,  and cover their  eyes;  tell them to  remove them, they keep them still
more closely applied; they resist any attempt at removing them;  separate
the eyelids, they oppose it  with violence, and when you succeed in so doing
they  scream violently; keep the eye  turned convulsively upwards, and the
transparent cornea hidden under the upper eyelid ; they have a perfect horror
of light.  Now whence comes this hemeraphobia ?  Why does the least ray
of light produce  so painful  an impression ?  Most certainly we cannot seek
for the cause in a lesion of the tissues  of the eyes which  are completely de-
prived  of sensibility. Is it an inflammation of the iris ? But this inflammation
often  exists to a great degree without giving rise  to this phenomenon.  It
must, therefore, consist in  a phlegmasia of  the retina, that nervous expansion
endowed with an exquisite sensibility, and whose  office it is to receive  and
transmit the impressions of light.  The irritation of this organ reacts upon the
iris, and produces that contraction of the pupil so often taken for a character-
istic  si<m of iritis.  We  see, therefore, that the difference between the two
cases, is, that in one, the pupillar contraction is the  consecutive effect of an 
24
LECTURES ON
inflammation of the retina ; and in the other, the immediate efLct of an idio-
pathic affection of the iris.   Their distinguishing mark is the horror of light,
of which we have just spoken.
   Another complication of cataract, of which it remains to treat, and which
renders the operation completely abortive, is paralysis of  the retina.   It is
highly important to be assured of this, in order to prevent  an useless opera-
tion, and to save the patient from the accidents which may follow.  In the ab-
sence of all other signs (as the adhesion of the capsule to the posterior surface
of the iris) to which we can attribute the immobility of the pupil, this last is,
perhaps, the least  equivocal.  But  in  some individuals, certain peculiarities
exist, which establish, if not absolute certainty, at least a very strong presump-
tion of, the existence of this paralysis.  A young man, now in the Hotel Dieu,
labors under accidental membranous cataract, that is, one produced  by  acci-
dent, a blow on the eye.  The capsule of the lens is not  wholly changed;
many points in its surface and the lens are perfectly transparent; yet his sight
is  lost, he cannot distinguish  day from night.  An old woman, on whom M.
Dupuytren operated on  the  16th December ultimo, presented the  contrary
peculiarity.  Although the lens was perfectly opaque, her  sight  still existed
faintly,  she  could  discern light from darkness.  Whence arises this singular
difference ?  In the young man what prevents all perception of light ? Every
one would suppose it was a simple  cataract; yet  we have strong reasons for
believing that it is owing to paralysis of  the retina.   We can then  have but
little hope of restoring sight.  However, the patient insists upon the operation,
even though it should be unsuccessful; he wishes to be rid of the deformity.
I have often seen, said  the  professor, persons in similar circumstances, espe-
cially females, desiring an analogous operation, without any hope of the resto-
ration of sight, but in order to be freed from this blemish to the face.
   However skillfully the operation by depression may be  performed, it fre-
quently happens, and this is one of the greatest objections to this  method, that
the lens ascends, and getting behind the pupil prevents the light from reach-
ing the retina.  An effort of coughing, an inconsiderate movement on the part
of the patient, a thousand other causes may produce this effect.
   If the cataract has been  depressed  in mass, two methods may then be fol-
lowed.   We may leave it and wait for  its absorption; but this generally
takes so long a time,  that it is generally better  to depress it anew, which
should be done as in the first operation.
   In some cases the cataract has so great a tendency to ascend,  that M. Du-
puytren has been obliged to depress it as often as four times in a month; but
he has observed that the operation diminishes in danger in  proportion as it is
repeated on the same individual.
   Under these circumstances, the lens is generally found softened and downy
on its surface;  a proof that the absorbents had begun to act upon it.
   We have also seen the lens which as first depressed in  mass,  after a time
ascend, not wholly but partly; the remainder having either been  absorbed, or
spontaneously detached, remaining plunged in the vitreous humor.
   The cataract may also reappear behind the pupil, even when the depression
has been effected with division ; in this case it is formed by  the reunion of the
portions of the divided cataract, which ascend, mingle, and collect behind the
pupil.  The absorption  of this species of cataract,  which might be called 
CLINICAL SURGERY.
25
cataract by agglomeration, is generally more easy and rapid  than that of an
entire  cataract.  We  see, then, after some time, according to the age and
state of the absorbent  forces of the patient, some  transparent spots appear,
and extend until the pupil becomes completely clear. The sight of the patient
is restored, increased,  and strengthened  in the same proportion, and as  they
daily improve, they daily make discoveries which give them as much pleasure
as the  attack of the disease had caused sorrow.  Sometimes, however, frag-
ments  of the cataract obstinately remain, and impair sight more or less.  We
must then remove and turn them out of the axis of the visual rays.
   The crystalline lens, continued M. Dupuytren, has its functions which are
well known;  if it  is retracted, depressed, or  destroyed, vision is no longer
natural.   Some near-sighted persons obtain, by the removal of the lens, an
ordinary degree of  sight;  but far-sighted individuals see with more difficulty
than before the formation of the cataract.   The latter need, an artificial lens,
placed before  the eye.   The patient should not be  permitted to use glasses
until a long time after the operation, otherwise  the intensity of the impres-
sions they cause, would inflame the eye, and he would lose  its benefit.
   The lens is held  firmly in its place in the capsule during health;  but when
it  has lost its transparency, it appears to become more susceptible of displace-
ment.   Sometimes  it  is  displaced entire, and passes into one of the two
chambers, most frequently into the posterior;  sometimes, remaining partly
fixed,  it  is detached for a greater or less  extent, and, floating by one of its
edges, completely obstructs the pupillar opening. Thus it happens in similar
displacements in patients affected with cataract,  that they have  suddenly
recovered sight, after  a quick movement or  a blow upon the head  or eye.
Sometimes it plunges into the vitreous humor during the attempt at extraction,
or it passes into the anterior chamber during depression.  Lastly, some cases
prove  the power certain individuals possess of transferring, as it were, the
diseased lens  from one chamber of the eye to  the other.  The most remark-
able of these, related by the professor, is certainly that mentioned by M. De-
mours, in his  Treatise on Diseases of the Eye, which  is here detailed: " I have
sometimes seen," says M. Demours, " the opaque lens pass through the pupil
into the anterior chamber, and  thence return to its place.  Some patients can
communicate  to it this alternating displacement.
   Drs. Tillard and Busnel were at my house  on the  3d of July, 1819, when
M. Gastel, affected with  cataract,  in their presence, made the opaque lens
pass into the anterior chamber, and repass behind  the iris.  The  disease in
the right eye  began six years since, the lens has gradually descended behind
the iris, about the period  of puberty, (his age is now about thirty-one.)  It
was invisible  at the age of eighteen, and plunged into the disorganized vitreous
humor.  At nineteen,  during an active military life; it passed in front of the
iris.   The continual pain which he suffered, procured his discharge.   I had
intended to extract it; but the patient fearing the operation, I advised him to
drop into his eye, the aqueous solution of the extract of  belladonna, to dilate
the pupil, and facilitate the return of the opaque lens behind the iris ; to  favor
this passage,  by laying for twenty-four hours on  his back, and during this
time, now and then, to depress the top of the  head; lastly, to drop into the
eye, as soon as the lens was no longer visible, some vinegar, in order to create
an artificial inflammation, which would arrest the dilatation of the pupil, and
              4 
26
LECTURES  ON
 even render its diameter smaller than before the use of the belladonna; a
 treatment which I have sometimes found  successful.   He followed my advice
 with the result I had expected.
   M. Gastel remained eight and a half years free from this singular affection,
 which recurred two years ago, as often as three or four times a month.   If
 he inadvertently stoops forward, the lens passes in front of  the iris; he then
 suffers, and can do nothing until laying on the  floor, with the chin elevated
 and the head depressed, he  restores it by strong friction on  the ball of the eye,
 by means of the upper lid.  I shall probably some day extract it."
   It will be seen, said M. Dupuytren, that all  these pathological varieties re-
 quire certain modifications in the operation or the treatment, according to
 their causes and nature.  If the  contraction of the pupil  is produced  by an
 acute inflammation, antiphlogistics, leeches to the angle of  the eye, cups  to
 the temples, and above all,  venesection in the foot will dissipate it; but if the
 affection has become  chronic, if no sign  of inflammation  exist, these moans
 will be  of no use;  then,  we use with advantage frictions of belladonna, and
 especially cherry-laurel  water, in order to sufficiently dilate the pupil, and
 render the operation easy.
   Observation has  taught me that cataracts accompanied by considerable con-
 traction of the  pupil,  are often complicated with adhesion of the crystalloid
 capsule  to the posterior face of the iris. In this species of adhesion, if we see
 the case when the effused lymph has merely begun to condense, and caused a
 simple agglutination easily  separated, the  belladonna may still  be very use-
 ful ; for the iris extending suddenly by the action of the remedy, thus destroys
 a large part  of this recent adhesion, and  but little remains  for the operator.
 But if these adhesions become organized, it is necessary to carry the couch-
 ing needle between the two membranes, and destroy their union before de-
 pressing the lens. The adhesion of the iris to the ciliary circle presents  many
 varieties in different persons; in some, it is so extensive and  intimate that
 they are with difficulty  separated, when we  wish to produce an artificial
 pupil; in others, the  iris will  tear before separating; lastly^ in  some, it is
 detached without the least  effort.
   In displacements of the  lens, whether  opaque  or not, M.  Dupuytren lays
 down as a general  rule, that whatever situation it may occupy, so  long as  no
 inflammation is evinced, we should  not meddle with  it; but operate as soon
as the least inflammatory symptom is manifest.   Indeed, we gain nothing  by
extraction if it is not opaque, and in the contrary case, nature takes upon
herself to depress it.  When the lens is plunged into the  vitreous humor
there is  nothing to  do  but to leave it there, as  a  similar result would be ob-
tained in the operation of depression, and the lens is subjected  to the action
of the absorbents.   When it is in the anterior  chamber of  the eye the opera-
tion is easy.  In the majority of cases a small incision is made in the cornea,
and the  foreign body  falls  out spontaneously, or is extracted with a needle.
 Such is  the general plan of  practitioners.
   M. Dupuytren first deviated from the beaten route in a similar operation in
 1819, in an  unusual manner, and till then unexampled.  A soldier, thirty-
four years of age, admitted  into the hospital on the 2d of November, had the
anterior chamber of the left eye completely filled by a round body, of a pearly
 white color,  formed by the  opaque crystaline  lens, which  had spontaneously 
CLINICAL SURGERY.
27
passed the pupil at the instant it appears, that the man had suddenly bent for-
wards  his head.  The  eye  was red, inflamed, painful, and  weeping, the
cephalalgia intense.  These symptoms yielded to general bleeding and purga-
tives, and two days after, M. Dupuytren performed the operation in the man-
ner we are about to describe.
  The patient being in bed, his head raised by pillows, the needle was intro-
duced  at about two lines from the union of the transparent cornea with the
opaque cornea;  the operator made  it traverse the posterior chamber, pene-
trated  the anterior, seized the lens, made it repass  into the posterior chamber,
at the  bottom of which he held it for some time, and then withdrew the needle.
The patient could see the hand that had restored  his sight, and the persons
who assisted  at  the operations.  The result was happy.  The man left the
hospital in six days, with a perfectly clear  pupil, seeing very distinctly, and
free from pain.  In  this case, the operator  traversed with the needle the
sclerotica, the posterior  chamber, returned to the  anterior, seized  the  lens,
brought it into the posterior chamber, and then depressed it in the vitreous
humor.  We will give the opinion of the professor on this operation, hitherto
unknown and adapted to a particular case, when an opportunity is  offered to
him to enlarge upon the subject.
  We have now given  the principal notions of M. Dupuytren on cataract.
In the following pages we shall  detail  cases  which tend to corroborate the
correctness of these general principles.
                          CHAPTER  IV.

                  ON ENGORGEMENT* OF  THE TESTICLES.

  Inflammatory, Scrofulous and  Venereal Engorgements.—-The skill of the
surgeon does not alone consist in separating parts condemned by nature, but
also in preserving those which the ignorant practioner would not hesitate to
amputate.  How many wretches return from the field of battle, more mal-
treated by the surgeon than by the enemy!  We might mention many hospitals,
where a host of victims have been sacrificed to this mania of operating.  How
many surgeons, for instance, amputate a limb affected with a white swelling,
without inquiring, if the lungs be the  seat of tubercles or other  lesions !
This desire of operating has never been more  strikingly manifested than in
engorgements of the testicles. We cannot, however, avoid seeing, that sorrow,
chagrin, and melancholy, almost  always end the days of the victims of  this
cruel mutilation.   This deplorable result did not escape M. Dupuytren,  and
thus,  for many vears, he has succeeded in preventing the operation in a great
number of case's, by attacking the origin of  the disease.
  About one hundred individuals are yearly admitted into the Hotel-Dieu at-
tacked with this malady; the greater part of whom, leave  it cured without an
operation.  A large number of patients are at present in the ward of St. Martha.

  • The original term is here retained, as it has become entirely anglicised, and conveys.
more correctly the meaning of the author, than any word in our language.-TitANS. 
28
LECTURES ON
 In some the engorgement is seated in the epidydimis; in others in the body of
 the testicle itself; and lastly, in some in both the epidyidmis and testicle.  In
 these different cases, the disease has resulted three times from a Menorrhagia,
 twice  it has occured without any previous discharge.
   About two month ago, one of these patients, forty years of age, was  ad-
 mitted for a tumor occupying the right testicle.   The organ was six times its
 natural  size.  On touching it, a hardness was perceived  such  as does  not
 exist in  hydrocele;  whilst its surface  presented, wrinkles, and inequalities
 which are almost characteristic of schirrus.   The weight was considerable, on
 questioning the  man as to its origin, he attributed it to cold.  In the greater
 number of cases, said M. Dupuytren, I have  observed  that engorgement of
 the testicles proceeds from external violence, an  old venereal disease, a
 scrofulous diathesis, or some internal affection ; therefore I never operate
 without using for a month or six weeks the treatment I  think  appropriate to
 the disease.
   The first account  given by the patient, made M. Dupuytren conclude that
 the engorgement arose  from external  violence, and that the antiphlogistic
 treatment would  cure the disease.   The man  showed no signs of scrofula ;
 therefore he advised  the application of  leeches to the tumor, emollient  poul-
 tices, a bath, and extreme moderation  in his regimen.   He returned to  the
 hospital without  having received any benefit; and could not be pursuaded to
 try the same remedies a second time.
   He was again  admitted a month ago (11th of November).  A half extorted
 confession gave  rise to a suspicion of an old venereal  taint: therefore  the
 professor prescribed  the  anti-venereal  treatment which he has successfully
 pursued  for many years.  He was placed on  the use of  the decoction of sar-
 saparilla, the smilax china, and guiacum, with the  addition of four or five
 ounces of sudorific syrup; three times a day took the following pill:
   Deuto-chloride of  mercury              -       -       1-8 to 1-2  gr.
   Opium gum      -      -       -      -       -       1-2 gr.
   Extract of guiacum      -       -      -       -       2 gr.
   Experience  having taught  M. Dupuytren that fractional doses act  more
 efficaciously than stronger ones, he gives every day three pills containing 1-8
 or 1-6 of a grain of corrosive sublimate, so  that the patient attains gradu-
 ally its entire dose, one half of a grain.
   Almost always in one or  two months the symptoms disappear under this
 treatment; but in this case it was of no advantage whatever.
   The size of the testicle had, on the contrary, increased; it was heavy and
 corrugated.   The man experienced  lancinating pains, extending alon°- the
cord to the loins.  In this situation, M. Dupuytren thought it dangerous  to
delay longer the  operation.  I think I am not mistaken, added the professor,
in announcing that there is a layer of effused fluid in the tunica vaginalis, but
this symptomatic hydrocele is not the  disease ; the principal affection is  the
 engorgement of the testicle, in consequence of the alteration of its substance
proper.   It is probable that this degeneration is not  much advanced; for, if
we can believe the patient, the  engorgement has only existed three months.
Had it existed a year, I should not hesitate in saying that we should find  the
testicle softened, greyish, presenting, in a word, the character of cerebriform
 cancer. 
CLINICAL SURGERY.
29
  How shall we remove the organ ? the answer is easy;  by a method as rapid,
and certain as possible.  We will make an incision, commencing  at  the in-
guinal ring, and extending to the inferior  and posterior part of the  testicle.
Let us explain this incision.  The testicle not only is  affected in schirrous
engorgement, the disease often implicates a portion of the spermatic  vessels;
we, therefore,  extend the incision to the inguinal ring, in order to follow these
vessels;  it extends the whole length of the organ, in order to free  it  entirely
from  its coverings; for if the opening were only two or three inches in extent,
the testicle could not be easily drawn out, and the dissection would be ex-
tremely painful.  The intention of the posterior continuation of the incision
may be also easily understood; if this were not made, the scrotum when brought
together would form a sac in which pus might accumulate.
   After the incision, the vessels should first be tied, as contraction, and the
impression of  air, might cause  them to retract, and we should have  to dread
hemorrhage.  After this step in the operation, we seize the testicle, draw it
out, an assistant holds the scrotum, the cord is dissected ; if any vessels are
divided, they  are to  be secured, because  the flow of blood might cause infil-
tration, inflammation, or abscesses, and we should at last be  obliged  to have
recourse to the ligature.  All the cellular tissue enveloping the testicle, cord,
membranes, and cremaster muscle, should be carefully removed.   If the cord
be healthy, it must be divided above the  testicle; if diseased,  beyond the
affected  part.
   Different methods are used for the extirpation of the testicles of  animals.
Some twist the spermatic cord and drag out the gland; some distend it and
tear it out without twisting the cord.  It will be easily seen how painful this
operation is, by the position of  the animal, and the care with which they con-
tract the length of  the  abdomen.   The extraction  is indeed followed by no
hemorrhage, but this advantage does not appear to us to counter-balance the
severe accidents to  which it might expose man.  In Normandy, the  testicles
of horses are removed by compressing them between two short sticks (clamps),
gangrene causing the  separation of the parts.  This dangerous method kills
many horses.
   In man the removal of the testicle is effected in two ways.  A simple in-
 cision might  occasion  hemorrhage;  besides the parts have not  so  much
retractile  force as  in animals.  We  are, therefore, obliged to embrace the
 cord in a general ligature.  This comprises the vas deferens, the cremaster,
 and  the vessels.  It must also include the nerves of the testicles, spermatic
 vessels  and cord.  But this  method is very painful, and  it is better to use
 partial ligatures.  If the section of the cord be effected before the ligature is
 applied, this is a difficult matter. We should be careful not to divide the cord
 too near to the inguinal ring, for  fear of internal hemorrhage.  In  order  to
 prevent the retraction of the cord, the ligature  is  generally used, but this is
 painful, and it is more simple to hold the cord by means of a tenaculum.  It is
 then divided  below this instrument.  The  surface is  then wiped free from
 blood, and the ligatures applied.   If the operation has been  short, and the
 ligatures well applied, the wound may be healed by the first intention.  But
 the tissues of the scrotum enjoying retractibility and extensibility, the lips  of
 the wound separate, shrink inwardly, and the skin alone remains in  contact.
 This disposition  is a great obstacle  to  cicatrization; therefore, M. Dupuy- 
30
LECTURES ON
tren generally makes use of two or three stitches.   This dressing has the
advantage of hastening the cure and preventing hemorrhage.
   Extirpations of the testicle are very rare in the Hotel-Dieu of Paris, whilst
they are common in other hospitals; we have above given  the reasons.  We
will add that the treatment in the Hotel-Dieu, does not prevent the operation;
whence results the important precept, not to extirpate a testicle reputed can-
cerous, without being well assured that the disease does not depend on an ex-
ternal  cause,  a scrofulous  or  syphilitic affection, or an  internal disease.
Without this indispensable  precaution, we might, after a time, find the other
testicle also engorged.   The  following is a striking case of this:
   M....., forty years of age, a gardener, has had  for two years an engorge-
ment of the left testicle.  This man, formerly a  soldier, has had venereal.
However, its size, hardness, and lancinating pains, left no doubt  as  to  the
nature of the engorgement; it was thought scirrhous; its proposed removal
acceded to by the patient, and performed by Dr. C---  The cord, and  in-
guinal  gland, were healthy ; the wound rapidly healed; but, after the  expi-
ration of a  month, the right testicle began to swell.   Was this a relapse?
Was it proper to remove also this organ ?  Was there no fear of the  disease
extending into the abdomen ?  The case was very embarrassing.  M. Dupuy-
tren was then consulted. His experience, and habit of carefully questioning
the patient,  and  subjecting him to  a treatment conformable to the supposed
cause of the engorgement, induced him to prescribe anti-venereal remedies.
Scarcely had a month elapsed, when the engorgement diminished, and soon
completely disappeared.
   The following is a different case, and proves how careful the surgeon should
be in his diagnosis.
   In 1827 a man was admitted into the Hotel-Dieu, with a considerable en-
gorgement of the left testicle.  Lancinating pains existed in the tumor, and
extended along the cord to  the groin and loins; the patient much emaciated.
No symptom indicated hydrocele, or a scrofulous or venereal engorgement; but
on the contrary, scirrhous.  M. Dupuytren observed, that if the hydrocele was
complicated with a cartilaginous thickening  of the tunica vaginalis,  that a
mistake  might be made, as  had often been the case.  To prevent a similar
error,  added the professor,  we will make a longitudinal incision into the skin,
and having exposed  the testicle, make a puncture through the tunica vaginalis,
towards the centre of the tumor; if no fluid flows,  or a  little decomposed
and fetid blood, we will seize the cord, tie it, divide it, and proceed to secure
the separate vessels. We shall thus avoid reproach.  If, notwithstanding
appearances, water alone fills the sac, we shall act accordingly.  The opera-
tion proved the correctness of the views of this sound practitioner, for in place
of scirrhous, there was found  a hydrocele with a cartilaginous thickening of
the tunica vaginalis testis.
   In inflammatory engorgements sometimes the body of the gland, sometimes
the epididymis, is the seat of the disease, sometimes both ; in the former case,
the swelling is more pronounced, and more easily discussed; that of the epi-
didymis is  less volumnious,  harder,  more difficult of cure.  The anatomi-
cal structure of the parts explains the difference.   The testicle is indeed an
organ  formed of a soft,  pulpous, parenchymatous tissue, one in which conse-
quently, fluids are  quickly formed  and  dispelled.  The  epididymis on the 
CLINICAL SURGERY.
31
 contrary, much more complicated in its structure, and presenting internally
 a mucous surface, perhaps also a muscular membrane, and externally a fibro-
 cellular tissue; engorgements are formed in it more slowly, and are more diffi-
 cult to dispel.  In patients affected with this latter disease, the anterior part is
 soft and supple, proving the testicle to be sound; but posteriorly, we find a hard,
 unequal body, evidently belonging to the epididymis.  Leeches, baths, emol-
 lient  poultices, generally  cure inflammatory  engorgement of the testicle;
 whilst they are of much less use in swelling of the epididymis.
   M. Dupuytren recommends at first the antiphlogistic treatment; if this be
 unsuccessful, he substitutes discutients, and then revulsives.   Such are the
 three fundamental bases of his therapeutics in similar cases. Thus, in the acute
 stage, the antiphlogistic  method, will mostly dispel the disease.  One, two,
 or three bleedings, according to the strength of the patient; twelve, fifteen, or
 twenty leeches, repeated several  times; baths, emollients, and severe diet,
 will  effect a cure.  These  means  are so powerful, that an engorgement will
 disappear sometimes in eight or ten days.  If the engorgement has been first
 seen  in the chronic stage, or, if from the  acute, it has passed into the chronic
 form, we must begin  by the use of emollients; afterwards  discutients, such
 as plaisters of diachylum, or the soap of vigo with mercury, but the cure will
 be slow and  difficult, without the use of purgatives  every two or three days.
 Calomel so often abused, is here an excellent remedy.  In place of it, we may
 administer the castor oil,  about ten or eleven o'clock at night,  in the doses of
 one, two, or three spoonfuls, according to circumstances.  Other purgatives,
 such  as the sulphate of soda, seidlitz water, &c, may be given with advantage.
 These means almost always succeed in  resolving engorgements of the tes-
 ticles, but when they are  notpersevered in, the organs degenerate into cancers
 and must be removed.
   The causes of engorgement of the testicles may depend on  a scrofulous  dis-
 position, and  it does not  seem difficult at first to distinguish  between them
 and those engorgements arising from venereal or cold.  I must  however observe,
 adds  M. Dupuytren, that  they begin precisely like the rest, and it is only after
 some time that their true character can be known.   Generally the latter do not
 yield  to ordinary treatment, they are indefinitely prolonged, and often co-
 exist  with other affections of the same nature, depending on a scrofulous con-
 stitution.   Tuberculous degeneration, is one of the  principal characters of
 this species of engorgement; in the  majority of cases it affects the  fibro-
 cellular tissues  surrounding the epididymis ;  it also appears in the substance
 proper of the testicle.   These tubercles are slowly developed, and may last
 three  or four years; their development, progresses, and duration point out
 their  nature.
   These engorgements are  softer than the scirrhous, and harder than the in-
 flammatory kind.  They  are free from heat or redness, and cause a sensation
 of heaviness and  numbness; the  sub-cutaneous  cellular tissue  is generally
 free.   The tumor is commonly unequal and irregular in its  general configu-
 ration ; whilst in scirrhous  engorgement the testicle is globulous,  and  the
epididymis uneven ; the spermatic cord is sometimes healthy, sometimes dis-
eased.  As tht; disease advances, there form in the anterior of the organ points
which soften ; to the touch,  it presents the sensation of a soft body.  Soon we
see appearing on the surface little projections, corresponding to bluish points.
These points ulcerate and exhale a serous pus, a  carious  matter, yellowish 
32
LECTURES  ON
and pultaceous, evidently produced by a scrofulous affection.   Fistulae are es-
tablished, giving issue to a serous and ill formed pus.   At this stage we can
no  longer doubt as to the nature of the disease.   It may last for years.  If
its  cause  is attacked and subdued, happy changes soon appear in the organ;
but should the efforts of the  surgeon be  unsuccessful, the  testicle becomes
soft, fungous, and similar to the tissue formed around articulations affected
with hydrarthrosis.   From the scrofulous it may pass into the cancerous state,
but this is rare.  When it has reached this degree of disorganization, every
one  understands that extirpation is indispensable if it is confined to the
gland.
  When the scrofulous nature of the engorgement is ascertained, should any
inflammatory symptoms exist, they should be subdued,  and afterwards the
patient subjected to general hygienic measures, which  are  often more effi-
cacious than remedies.   He should choose  an elevated situation, dry, and with
a southern exposure.  He should be covered with flannel from head to foot,
and use  dry friction over the whole body.   He should exercise in open air,
and as much as possible in the sun; live on a generous diet, eat black meat,
game, antiscorbutic  vegetables, such  as water cresses, black radishes, arti-
chokes (cinara cardunculus,) and celery.  He must forbid himself all acids,
mineral and  vegetable, and  especially farinaceous food.  His drink should
consist of an infusion of wild endive {cichorium intybus) and the tops of the
leaves of the hop {humulus lupulus.)  If he is highly  lymphatic,  he should
take  the syrup of gentian prepared with water, taking care to proscribe that
made with wine or ammonia.
  Other  remedies- may also  be  administered.  Latterly, the  iodine and its
preparations have been highly celebrated.  It is  given  in the dose of one
eighth, one-sixth, one-fourth,  or one-half  grain, in  distilled water aromatized
by  mint.  The virtues  of iodine, like that of all  new therapeutical agents,
have  been  much exaggerated;  it sometimes  succeeds, but is not a panacea.
Externally it is used in the form of hydriodate of potash in ointment or lotion.
When we do not wish to use this remedy, we may have recourse to sulphurous,
salt, aromatic, or stimulating baths.  Also, local applications  of these  same
means. It will be also useful to  inject these fluids  into the fistulous passages,
taking care that they are not extravasated. But it is better to direct upon the
affected parts a stream of sulphurous, salt, or ioduretted fluid. By means of
these remedies long continued, and by the cautery, we  will often  succeed in
curing scrofulous engorgements.
  But if, notwithstanding  our efforts, the  testicles reaches an  advanced  dis-
organization, tending to scirrhous degeneration, or if it becomes soft, pulpy,
and contains many scrofulous abscesses, we should not hesitate to extirpate
it, after having surmounted any internal affections.   Without this precaution,
the patient might fall a victim to consecutive disease, such as pleurisy, pneu-
monia, suppuration of the liver, &c.
  If, after the operation, we examine the changes in the organ, (without com-
plication of cancerous degeneration,)  the healthy parts are found separated
from the diseased; here and there  we find many scrofulous  degenerations,
and a whitish, half-fibrous, half-cellular matter, containing coagulated albu-
men.   Tubercles or collections of tuberculous matter, contained  in  mucous
cysts, or without them, are also seen.  These alterations are generally seated 
CLINICAL SURGERY.
33
in the  cellular tissue surrounding the epididymis  in the epididymis itself,
sometimes in the testicle, more rarely in  the cord.
  Besides the two species of which we have spoken, a third exists, the vene-
real engorgement. Latterly, said M. Dupuytren, this disease has been treated
exclusively by antiphlogistics; but two circumstances have been overlooked,
the inflammatory and syphilitic principle.  Sometimes  this  method entirely
dispels the symptoms; but we should fall into a great  error by supposing it
was radically cured.  As long as the syphilitic virus remains, a relapse is to
be feared.  I might add, continued the professor, which  would clearly prove,
that  individuals laboring  under venereal diseases, and who would not  use
appropriate remedies, have been affected with ulcerations of the throat, exos-
tosis, engorgement of  the  testicles,  which have yielded  to anti-syphilitic
remedies.  No one of you has forgotten  the history of  the three  pupils who
inoculated themselves some years ago with the pus of a venereal  ulcer.  By
the antiphlogistic treatment all the symptoms manifested rapidly disappeared.
But after some time, the signs of secondary syphilis broke out with so much
violence that one  put an  end to his life; the other two consulted me,  and
were  cured  by  anti-syphilitics*  How  is the venereal engorgement to be
known ? Every day we see patients with a swelling of the testicles, to which
they can assign no  cause.  They have had no blow, no  fall, the swelling  has
disappeared and passed into the opposite testicle, or has continued always in
one.  If the tumor is elongated, having a cylindroid form, if it causes no
lancinating pains, if the patient has had any venereal affection, such as blen
norrhagia, bubo, chancre, treated by the cautery,  the worst of all methods; if
he declares  that the testicle, after having  been  affected for six months, a year,
or eighteen months, has returned to the natural condition, and that the other was
attacked, the presumption is strong in favor of the venereal nature of the
disease; for if  the engorgement were scirrhous, this metastasis would  not
take place;  it is even a pathognomic character of this kind of tumor.  Ano-
ther not less  important observation is, that in the  case of relapse, when we
have removed a cancerous testicle, the cord is generally affected ;  whilst in
syphilitic engorgement, it is the remaining gland.   If a general examination
reveals other symptoms such as pustules, exostosis, there can be no doubt.
When a certain opinion cannot be  formed, would it not be  better to use for
six weeks or two montffls, an anti-venereal treatment, than to perform a cruel
and useless operation ?
   In latter clays the existence of the venereal virus has been doubted, as we
have already said; however, experience has indubitably proved the contrary.
This belief, so generally established, has been shaken only by a mass of sub-
tleties.  Admitting that syphilis was an inflammatory.disease, how  has its
communication in an immense majority of cases been overlooked ?  Was not
this  a characteristic symptom distinguishing it  from  other  inflammations ?
The distinction  established, added M. Dupuytren, of the two elements of the
disease is  essentially practical, and  explains easily why  so many persons
treated on the antiphlogistic plan, have seen constitutional symptoms develope
themselves six months, a year, or even longer, after their pretended cure.  Is
not the history of the three  pupils, related above, the most conclusive answer
that can be  made  to the dangerous hypothesis of  the  non-existence  of the
venereal virus ?   It is, therefore, a real, positive virus, which may be com-
                   5 
34
LECTURES  ON
municated  like that of small  pox.   Woe to those who regard it only as in-
flammatory ; by attacking that alone, they, indeed, destroy the effect, but the
cause remains.
                            CHAPTER V.

                       ON TRAUMATIC  EMPHYSEMA.

   1st. Emphysema produced by Fracture of the Ribs and Laceration  of the
 Lungs and Pleura.—On the9th of last December, two individuals were brought
 to the Hotel-Dieu, affected with traumatic emphysema, of different degrees of
 severity. One of them was a water-carrier, sixty-eight years of age, who, during
 the day, had been struck by a blow from the pole of the wagon of a wood vender.
 He was thrown nearly transversely under the wheel which passed over the left
 anterior portion of his chest.  Although the wagon was empty, the weight of
 the wheel was sufficient to produce the accident  we are about to describe.
 This man had cough, great oppression, his pulse was full and frequent.  A
 careful  examination of the right side of the thorax discovered no injury; but
 on the  left, he had acute pain, and great sensibility  in the precordial region.
 The hand, when applied, received the manifest sensation of a crackling, similar
 to the ends of fractured ribs coming in contact during the respiratory move-
 ments of the thoracic parietes.  This sound was equally perceptible  to the
 ear, which could also perceive a noise analogous to that produced by the rapid
 dropping of water.   There  was also  on the same  side, considerable tume-
 faction  but without any  change in the color of the  skin, or the least sign of
 inflammation; which tumefaction could be  displaced and driven away by
 compression. This was not all; on pressure, a distinct crepitation was heard,
 such as  takes place in animals whose cellular tissue  has been  filled with air
preparatory to flaying them.   These are undeniable symptoms of fracture of
the ribs, and  emphysema formed  in this region, that is, the infiltration  of at-
mospheric air into the subcutaneous cellular tissued  However, the life of the
patient  does not appear to be in  danger; the emphysema  is inconsiderable;
thus far it is limited to the  left side of the chest; nothing evinces its having
attacked the  internal organs; and'experience demonstrates  that when this
 phenomenon  is limited  in extent, the infiltration  is reduced to a  few cubic
inches of air, and absorption soon takes place.   It is far otherwise when the
air has reached  not only the whole extent of the cellular tissue of the surface
but also that of the internal organs and the abdomen, when there is not only
infiltration, but effusion of air into the great serous cavities; such is the state
of the patient of whom we will hereafter speak.  In the case just related, the
accompanying injuries, the direct cause of the emphysema, must not be forgot-
ten. It has certainly happened that the fragments of the ribs thrust against
the lungs, have  torn the pleura, and perhaps the air vessels ; thence results an
 organic  lesion of the lungs and the rush of air towards the thoracic parietes.
 In this patient the small quantity of extravasated atmospheric fluid leads to
 the supposition that the laceration is inconsiderable. 
CLINICAL SURGERY.
35
  Let us now explain how this  infiltration  takes place.   When, on account
of former pleurisies or pleuro-pneunomia, adhesions exist between the pleura,
and that thus a continuity of tissues is  established between  the surface of
the lung and the thoracic parietes, emphysema is easily understood ; the air
passes directly from the interior of the lung into these newly organized cellu-
lar meshes, travels gradually through them, and thus reaches the fractured
spot, even in the subcutaneous cellular tissue.  When there are no adhesions,
the air inspired escapes partly by the aperture in the surface of the lung, and
is first effused in the neighboring tissues and the  pleural cavity.  Driven
thence by the alternate expansion and contraction of the agents of respiration,
and by its own elasticity, it is gradually infiltrated in all the external and in-
ternal organs;  so that, if the quantity effused be considerable, it invades not
only the parietes of the thorax and abdomen, the superior and inferior extre-
mities, the  scrotum,  neck and  head, but also the  pleura,  two  mediastina,
even the pericardium, and the cellular tissue uniting the different organic ele-
ments of which the lungs are composed.
   The patient in question was bled on the day of his admission into the hos-
pital ; the following morning M. Dupuytren  prescribed a second bleeding and
some additional treatment; compresses saturated with a  discutient solution
were applied to the  injured  side, and  the  body surrounded by a bandage.
The extention  of this last remedy was to suspend  the action of  the external
respiratory  muscles, and oblige  the  patient to breathe by the diaphragm, in
order, on the one hand, to favor the union of the  fractured ribs, and on the
other, to prevent as much as possible the emphysema. After having described
the different agents and the mechanism of respiration, he proved  by example
the possibility of breathing by the external muscle  alone.  Such, indeed, is
the case in  lesion of  the superior portion of the spinal column, when all the
external muscles are  paralyzed.
   The other patient,  older than  the preceding,  in a quarrel was thrown down
by his adversary, who not content with  his victory, kicked him repeatedly in
the chest   Several ribs were broken,  and fragments of these ribs, driven
violently inwards, wounded the lung seriously; an enormous emphysema en-
sued, attacking first the shoulder, then the whole of the anterior and posterior
region of the thorax,  the neck, which was considerably swollen the day after
the accident, and lastly, the abdominal region and testicles.  The  man also
labors under an old  asthmatic affection, which is at present peculiarly unfa-
vorable.  Emphysema to such an extent, remarked the professor, is always in
itself an exceedingly serious  disease; the infiltration makes rapid  progress,
the atmospheric air invades quickly, as we  have  said, the cellular tissue of
the internal organs, and the patient can soon no longer breathe.   I have seen
many perish in extreme agony from suffocation, due to  no other cause than
that just pointed out.  Judge what must  happen, when the respiratory func-
tions are the subject  at once of a severe asthma and an emphysema, such as
you  see.  The patient then, generally, quickly perishes ;  thus we despair of
the life  of  this old man.   You  have, indeed, seen to-day, the great anxiety
under which he labors in his futile efforts to articulate a few words in answer to
our questions; at each inspiration a new column of air escapes from the lung
and aggravate* his situation; there is not only infiltration, but also effusion of
atmospheric fluid into the great cavities; his expectoration is bloody, announc- 
36
LECTURES  ON
ing a deep injury  of the lung; his pulse is small, corded, and convulsive.
The efforts of art are here useless.   What, indeed, could  we do ?  Use  the
same means as in the first case ?  It would  be only to hasten  his end;  for
here a bandage would  produce the most violent anguish.  Incisions m  the
skin have been advised, to give exit to the infiltrated air;  without the least
confidence in the measures, they have been made in different parts of the body,
principally over the pectoral is major muscle, rather  in conformity with esta-
blished precept than in the hope of beneficial result; they have  been  useless,
and  I think it superfluous to explain the reasons.  In an inconsiderable and
circumscribed emphysema in which we might hope to subdue by appropriate
treatment the cause which produced and maintains it; and in which, there-
fore, the organic  lesions are not beyond the resources of art, it may  be sup-
posed that incisions over the spot in which it is seated, might prevent a greater
infiltration of air, by giving it issue externally; but in cases analogous  to  the
present, the insufficiency of this plan is too evident to occupy us longer with
the subject.
  The prophecy of M. Dupuytren was but too well founded ; the patient sunk
in a few hours,  and a post mortem examination, completely confirmed  his
diagnosis.  Externally, general  tumefaction,  color of the skin unchanged,  the
latter unequal, soft, very  easily compressible, and accompanied by  its cha-
racteristic crepitation.  Internally, we observed  the  large  quantity of  air
contained in the  anterior and posterior mediastium, and the presence of this
fluid throughout the whole extent of the interlobular tissue;  as the professor
had declared.  Three ribs were fractured  on the right side, and the lateral
surface of the lung  of that side presented a large and deep laceration.
  Our first patient,  on the other hand, went on improving.  In the course of
five days, he  no  longer felt any pain in the affected side  when he coughed;
the expectoration  was not at all bloody; the infiltration had nearly disap-
peared, the pulse was good, respiration little impeded, his appetite began to
return, in a word, he is in the way of complete recovery.
  In both patients we see how important a part of their malady the  emphy-
sema constituted; it was the most manifest symptom, and carried to  such an
extent in one, that independently of the serious lesions, of which it was  the
result, it formed of  itself a grievous disease.   In some cases it only makes its
appearance among the secondary symptoms, and is not easily recognized.
  However, it should be clearly  recognized, in  order to oppose its  further
progress, and as it also enables us to appreciate the concomitant disorders.  A
man, aged forty-one, of a strong constitution was jammed against a wall  bv
the pole of a carriage; when taken to the Hotel-Dieu, it was observed  that his
breathing was exceedingly short  and laborious;  on the  left side no lesion
could be perceived ; the sternum was transversely fractured at  the junction
of the upper two-thirds with the lower, and the upper fragment  deeply sunk
into  the mediastinum.  On the  right side of  the  chest, the fourth, fifth, and
sixth ribs, at about four or five finger's breadth from the sternum, were  much
depressed, and a crepitus was heard, which evidently indicated their fracture,
and  perhaps that of their cartilages.  The projecting ends of  the external
fragments could be even distinguished by the fingers.  A little below the seat
of these fractures there was  an ecchymosis, about the size of a five  franc
piece, (one and a half inches in diameter.) 
                           CLINICAL SURGERY.                         37

  The features of the patient were marked with deep anxiety, his  answers
were short and impeded, his pulse rapid, and almost imperceptible,  his skin
cold.   By  feeling in front of the fractures, a crepitation was perceived,
resembling that produced by  air  traversing the cellular tissue; but what
was most remarkable, every time inspiration took place, the tumor increased
considerably, and extended from the lower part of the sternum to the seat of
the fracture;  it diminished, on the contrary, during respiration; on a level
with the depression resulting from the fracture of the ribs, the skin  rose and
fell in the same manner, but formed a much smaller tumor.  The least pres-
sure gave rise to the  emphysematous crepitation, and was sufficient to reduce
the tumor.  In the  two  inferior thirds of the right cavity of the chest the
stethoscope detected a very distinct gurgling (gurgouillement.)  The patient
was bled, compresses were applied to the seat of the emphysema, and a band-
age was put round the trunk.  At first this treatment promised well—the pain
was greatly alleviated ; but on the fourth day, suddenly, the  oppression was
redoubled ; the cheeks assumed a hectic  flush, the pulse became small, hard,
and quick.  He was again bled.   Ten  days thus passed over, with alterna-
tions  of better and worse, as to the suffocation; the tumors of which we have
spoken disappeared, and no trace of  the emphysema remained; a large and
very black ecchymosis extended, however,  from the base  of the chest to  the
upper and exterior part of the thigh.  The chest became more and more em-
barrassed, and on the twelfth day the man died.  On examination of the body,
old and strong adhesions were found between the pleura; the upper  fragment
of the sternum fixed in the pericardium ; the right ventricle of the heart torn
by it, to the extent of two-thirds of its thickness; a great  quantity of bloody
serum, and of pure black blood was found  in the pleural  cavity of  the right
side ;  the fourth, fifth, and sixth ribs were broken, and their cartilages  detached
from the sternum; between these there  was  a lacerated opening large enough
to admit the finger easily.
   2d. Traumatic Emphysema of the Eye-lids.—The introduction of air into
the  subcutaneous or  intermuscular  tissue is  not peculiar to penetrating
wounds of the chest;  it may take place  in any of the  parts connected  with
the respiratory system.   Emphysema of the eye-lids is by no means rare, it
 is mentioned by several authors, and we have had more than one case of it in
 the Hotel-Dieu.
   Case.  Emphysema of the Eye-lids,  from  supposed  Fracture of the Os
 Planum of the Ethmoid Bone or of the Os Unguis.—A laborer was struck on
 the forepart of the  head, neck, and chest by a quantity of earth which  fell
 upon  him; on being extricated, he only complained of a slight pain at the root
 of the nose, to which he  paid but little attention and went on with his work.
 About a  quarter of  an hour after, on blowing his nose, a  considerable tume-
 faction of the eye-lids immediately ensued,  the whole eye was covered up by
 it.  What is  the cause and nature of this swelling; is it erysipelas ?   The
 skin was, indeed, bright and tense, as in that disease, but there was neither
 the redness nor heat which characterize it.  The eye-lids retained  their na-
 tural color and temperature.  Was it oedema ?  CEdema never is formed so
 rapidly; and, on the other hand, we do  not discover that doughiness (empate-
 ment) of the  tissues peculiar to serous  infiltrations.  Was it an effusion of
 blood in consequence  of  some violent contusion from  the blow he received ? 
38
LECTURES ON
 But this would have been known by the pressure of numerous violet-colored
 ecchymosed spots, and by a brownish hue, more or less deep, of the eye-lids.
 From these  :iegative signs, we could  not  but suspect that it was an infiltra-
 tion of air;  in fact, upon touching the parts, emphysematous crepitation was
 perceived, not at a single point, but throughout their whole extent.   In  such
 cases, whenever incisions are made in the  skin, a certain quantity of air makes
 its escape.   On  the bodies of individuals  who have died  either from the
 severity of the emphysema itself, or the injury  of the other organs involved,
 the presence of air has  been demonstrated just as crepitation had been noticed
 during life.   Having had to treat an individual in whom this phenomenon
 was very manifest,  we  were  induced to make some  incisions in  the  part
 affected, upon which a  considerable quantity of air rushed out.  In fact, there
 can be no doubt of the fact; the only question in the present case is, how to
 account for  the infiltration.  Now, I think, that the fall  of  the earth having
 compressed the face, rupture of the os planum of the ethmoid, or of the  os
 unguis has ensued, through which aperture the air made its way from the nasal
 fossas into the interior of the eye-lids.  It was remarkable that the emphy-
 sema did not occur immediately after the accident, but only after the lapse  of
 some time, and subsequent to the patient's efforts in blowing his nose.   The
 reason of this is evident; the fracture of the bone did not cause immediately
 a laceration of the soft parts, and the latter excluded the air; but as soon  as
 the patient forced a column of air against  them  in his efforts, they gave way,
 and the communication was thus established between the nasal fossae and  eye-
 lids.  We were curious to know, said the  professor, if after the  accident any
 drops of blood were shed by the nose; it having occurred  in all the  other
 cases of the kind I have seen.   In this instance it does  not appear to have
 taken place.
  The treatment consisted in general bleeding, and the topical application of
 compresses steeped in  a resolvent solution.  The patient was desired to use
 no effort in attempting to blow his nose, to avoid  coughing as much as possible,
 and to do nothing that would tend to re-open the unnatural passage of the air.
 On the third day, the crepitation had  much diminished ; on the fourth, it was
 almost insensible; and on the fifth, the eye-lids were nearly  in their natural
 condition.  The following case is very analogous to the preceding, and varies
 only by a slight difference in the seat of the injury.
  Case II. From a Supposed Laceration of the Pituitary Membrane.—A young
 man  who had received a violent blow from a  plank striking him  on the nose,
felt at first only an acute pain; but in the course of a few hours, upon vio-
 lently blowing his nose, he perceived, as it were, a line of fire passing  from
the side of the nostril to the inner canthus of the eye, and thence spreading
 itself into the two lids of the left eye.  So great a swelling immediately en-
 sued, that the eye was  closed, and the passage of the luminous rays entirely
intercepted.    He was received in the Hotel-Dieu.   The eye-lids were much
 distended and resisting, but indolent, and without any change in the  color of
 the skin.  Emphysematous crepitation was very distinct.  The same treat-
ment as in the preceding cases effected a cure in four or five days.   M.  Du-
 puytren thought that the blow received, had caused a rupture of  the pituitary
 membrane opposite the  lateral cartilage of  the nose, which had been detached
 from the lower edge of  the bones of the nose. 
CLINICAL SURGERY.
39
  Case III. Emphysema of the Temples, from Fracture of the Frontal Sinus.—
Emphysema may be produced  in parts remote from the respiratory organs,
by causes much more serious than those of the preceding cases.  The follow*-
ing is an instance:
  A man received a fall on his forehead.   Some time after a tumor of consi-
derable size appeared in  the  temporal region.  The nature of this tumor
seemed unaccountable to some persons who saw it; but when  it was slightly
compressed,  it might be made to pass to  the front of the forehead and  thus
disappear.   It was owing to the passage of air  into the  surrounding  cellular
tissue, in consequence of fracture of the frontal sinus which created an
opening under the  skin.
  We might readily  multiply examples  of traumatic emphysema, resulting
from  penetrating wounds  of  the chest, or from a communication of some*
other kind,  forcibly formed with the air passages.  But those already cited,
with the  remarks we have made, may probably  suffice to give you precise
notions of this curious malady, its diagnosis, and the treatment it requires.
A few words may be added  with  respect to the infiltration which some-
times takes place in  some of the highest points of the respiratory system.
Besides the crepitation, called emphysematous, and the negative signs already
noticed, it may be still recognized wl?en there is doubt about the nature of the
disorder, by desiring the patient to blow his nose, when an evident augmen-
tation of the eye-lids or other parts affected will be perceived.   If the patient
be in such a state as to be unconscious of what is required  of him, by pressing
his nostrils, an  immediate increase of the tumor  will be observed, owing, no
doubt, to the column of expired air, which not finding egress by the natural
way, is forced into the one newly established  by the injury.  In every case
of emphysema of the eye-lids, the swelling takes  place with rapidity—owing,
no doubt, to the great laxity of the cellular tissue  of which  they are composed.
                           CHAPTER  VI.

      ON CARIES  OF THE  VERTEBRAL COLUMN ; ON FISTULOUS SINUSES AND
                         SYMPTOMATIC ABSCESSES.

   About two months ago, a woman came to the Hotel-Dieu to be treated  for
 an abscess situated on the upper internal part of the thigh.  This woman had
 besides, a curvature of the spine, concave inwardly, convex outwardly.  It is
 known that the  spinal marrow  is never compressed unless the curve be right
 angled, and  that, consequently, no paralysis of the lower extremities  takes
 place.  Such is the state of this patient, in whom the  bodies of the vertebra
 were carious. The tumor on the thigh opened spontaneously, and discharged
 some pus.  On  the opposite side, another tumor formed, less voluminous, but
^evidently due to the same cause.  It is manifest that these abscesses commu-
 nicate  by fistulous passages with the  caries.  This patient had been treated 
40
LECTURES  ON
 for three months with iodine, and  thought cured; but she was  far from  it.
 The caries followed its course, and she came for our assistance.   Moxas were
 ordered to the sides of the curvature.  A month ago, she seemed to have much
 improved, when suddenly, either  from change of temperature or perhaps ab-
 sorption of pus, she  was seized with symptoms of pleuro-pneumonia.  This
 was ineffectually combatted  by repeated teachings to the affected part,  a
 blister to the sternum, and topical emollients, &c.; the patient died on the 15th
 of December, seven or eight days after the attack of the pleuro-pneumonia.
   Autopsy ;  thirty-six hours after Death.  General Appearance.—Body ema-
 ciated, projection of the spinous processes of  the eleventh and twelfth dorsal
 vertebra; marks of  cups  on  the  right side of the chest.    Head: nothing
 remarkable.  Thorax; considerable sero-purulent effusion, with  false mem-
 branes, free and adhering; the corresponding lung collapsed without pneumo*
 nia engorgement.  Abdomen; some organized adhesions on the lower,  and  in
 the lower pelvis are the only vestiges of an old peritonitis.  The gastric mu-
 cous membrane was pale and  congested in its  most depending portions.
  The body of the eleventh dorsal vertebra was entirely destroyed by caries.
 The vertebral canal was not diminished, and the spinal marrow was healthy.
 The bodies of the tenth and twelth vertebra, partially denuded,  were the
 seat of a superficial caries. A vertical section, following the antero posterior
 diameter evinced no  softening;  in  front of the  eleventh dorsal vertebra, the
 cellular tissue and periosteum were condensed and hypertrophied, forming a
 sac with thick,  resisting  parietes,  internally  of a greyish color, in contact
with pus and  purulent false membranes.  This sac also adhered to the  bodies
of the diseased vertebra by some strong fibres.  From this sac proceeded on
either side a fistulous passage  contained in the sheath of the psoas  muscles  of
 which the fleshy portion was atrophied and discoloured.  These sinuses were
filled with pus : the one on  the right side would admit several fingers, con-
taining a serous, ill-formed pus, composed of thick  false membranes, beneath
which was formed a smooth apparently mucous and roseate membrane.   This
sinus was dilated as far as  the crural arch, narrowed under this arch, dilated
again in the  upper part of the thigh, where it formed a  large sac, in which
 were formed the lesser trochanter, and other newly formed  osseous parts. The
fistulous opening in the skin communicated with this abscess.  The left  fistula
proceeded also  from the  ante-vertebral sac, transversed  the fleshy fibres of
 the psoas, and reached their  anterior and internal  part, on a line with the
 superior strait of the pelvis; thence it passed under the  crural arch, and
opened on the interior of the thigh, without being at all dilated.  Its internal
 surface was of a greyish color, covered by a newly-formed mucous membrane,
 under this  membrane, there existed a whitish, resisting  and fibrous  tissue.
 The canal was almost entirely composed of this tissue ;  formed at the expense
 of the cellular tissue, through which the pus was at first diffused.   Then this
 canal returned upon  itself, could not receive the little finger, and in  some
 points, was almost capillary.  Every thing, in a word, proved that nature was
 endeavoring to cure the fistula.   (Reported by M. Loir.)
  Hunter first pointed out the formation  of these canals apparently mucous.
 M. Dupuytren, has since added to, and thrown much light on Hunter's opin-
 ions.  According to M.   Dupuytren,  the canals establishing a communi-
 cation between a carious point and any part of the body,  those between the 
CLINICAL SURGERY.
41
urethra and perineum, in the vicinity of the anus-fistulae of the duct of steno,
canals communicating from the air  passage externally, all present the same
nature and organization.  Accidental and abnormal, they however  supply
natural channels which have  been destroyed, perforated  or  diminished, by
giving passage to fluids which before flowed through them.   These accidental
canals are formed at the expense of all the parts with which the pus or extra-
vasated fluid comes successively in contact.   Then fibrous, nervous, osseous
and mucous tissues, may enter into their composition.  This has been evident-
ly proved by the examination of the  fistulous passage in the case we have
detailed.  There could be there distinguished the mucous and the osseous
tissues, the nerves, veins, and cellular tissue.  Each of these parts, form a
simple element, the cellular tissue  in which are  formed  the  granulations
uniting them together.   Soon these passages being traversed by fluids take on
a  mucous  structure.   In  the  case,  for example, of caries of the vertebral
column, the following is the mechanism by which these canals are organized :
Caries being once established, the pus  remains  some time in the carious part
and those surrounding it, and especially in the cellular tissue.  First a cyst
forms, in which  matter collects.  When  the quantity of  pus becomes  con-
siderable, the cyst takes a dependent position ; it elongates, and extends either
on one side of the column, or on  both at once; it then travels on, pushing
before it the lower end of the cyst; if it meets with an obstacle, it dilates, it
diminishes under pressure, and again dilates when  that  pressure is removed.
Having at letigth reached the skin, after the pus projects and  forms a tumour
which terminates in an abscess.
   This purulent collection, known by the name of abscess by congestion, and
which M. Dupuytren calls more justly symptomatic abscess, is a very  serious
disease, and  generally thought fatal.  Some  well authenticated cases prove,
however, that these abscesses may dry up, close, and entirely disappear, when
the caries has been cured.
   Caries may be arrested and cured when actively treated by cautery,  moxas,
internal remedies, and a regimen appropriate to its cause.  But will the abscess
terminate as  favorably ?   Should it be left to  nature, or be the subject of some
surgical treatment?   The ordinary course of the disease should be our rule,
in this respect.
   These abscesses remain stationary for years, without any bad symptoms ;
the pus is gradually absorbed, and no traces of it remain; at other times the
skin covering it inflames, opens, and gives exit to the pus which flows out, and
is never reproduced.  Sometimes the pus, having remained a  long time in the
abscess, is converted into matter resembling adipocere; chemical experiments,
proving in fact, that such  is the nature of the substance sometimes formed in
this kind of  abscess.
   Many years ago, M. Dupuytren  had under  his care  a young  man. affected
with a conjested  abscess, proceeding from caries of the vertebral column, ac-
companied with considerable curvature; the caries  was cured  by the repeated
use of moxas, the cautery, &c.  The abscess  did not disappear, and  only
diminished slightly in size. Five  or six years after, he perished by a pleuro-
pneumonia.
   On  examination, the caries of  the spine  was found entirely  cured, the
curvature alone  remaining; the abscess converted into a fatty, soft, unctuous
           6 
42                            LECTURES ON
matter, presenting the physical and chemical qualities of adipocere; the canal
extending from the carious points of the column to the abscess, was diminished,
obliterated in some spots, and some of this matter found in it.
  It is considered dangerous  to open a symptomatic abscess, resulting from
caries of the spinal column, which has yeilded to reriledies.   This would ex-
pose us to a relapse of the principal disease, and the  loss of  the  benefit of a
long and active treatment.   Hence it is better to leave them  to  nature, even
should our endeavors to cure the caries prove ineffectual.
  We have seen the organization of fistulae of  the  spinal column; we shall
find the same mechanism in the formation of urinary fistulae.  Let us suppose
the urine to be collected in a sac, and in considerable quantities; after some
time it forms  an abscess.   This soon  opens, there  then remains  a fistula.
From that time an accidental canal of a mucous nature is organized in  this
passage.  We now see the consequences of this  formation.  If, when the
abscess first, opens, we introduce a sound into the urethra, the fistula is easily
cured ;  but if it remains for six months, or a year, without using this remedy,
its cure is almost impossible, because a definite organization is established.
Thus, at fit--.t the parts are too weak to resist; but after six months, or one or
two years, the fistulae are so  completely organized, that they remain and furn-
ish a matter nearly analogous to that of mucous membranes.
  At first, they have not the characters  they afterwards assume. They gen-
erally  commence by  an abscess, from whose  aperture  there  issues a pus
which, vo iable as its cause,  is sometimes white and well formed,-sometimes
dull and flaky, sometimes pure, sometimes mixed with some natural secretion ;
only a small number of fistulas begin in this manner;  they are those made by
a wound  in a excretory duct.;  in this case  the fluid flowing  through the
wounded duct, follows  generally the course of the weapon, and the  fistula
which remains is a simple passage.   In the first case,  on the contrary, that is,
whenever nature alone presides over the development of  the disease, the
accumulated liquid may open at one or several  points.  If the abscess is near
the surface of the body, the opening communicates immediately with it, and
the fistula  is only as  long  as the thickness of the  parietes of the abscess.
When the latter is deeply seated, either a single fistula is  formed opening
externally by one or several apertures, or several  fistulae uniting in one, or
opening each separately.  Such is the first stage of  their formation.
  If their course be very short, the phenomena of the second stage are very
simple; the inflammation disappears, the edges of  the fistulous opening are
habituated to the contact of the foreign fluid; they cicatrize without closing,
and the fistula remains. If  the abscess  be very deeply seated, the  part be-
comes the seat of remarkable, phenomena.  Its parietes contract but do not
adhere, and to it corresponds the original extremities of the fistula.   The ex-
ternal  opening, which, like the  first, may be single or numerous, contracts,
is rounded, and soon appears under the form of a little red fungus, having in
its centre an opening often difficult  to find, narrower than  the canal, and
furnishing  a quantity of pus beyond  all proportion with its apparent size.
At the same time throughout the whole extent of the fistula, an accute inflam-
mation takes place, in which  the neighboring tissues share, and which loses its
force as the parts become accustomed to the impression  of the irritating mat-
ter.   Soon, without  entirely  disappearing, this inflammation yields to  a 
CLINICAL SURGERY.
43
process under whose  influence the whole canal becomes organized, isolated,
and transformed into an excretory duct; this canal presents the same char-
acters, in whatever tissue it  may be  formed; generally  simple, sometimes
bran   ed at its extremities, sometimes straight, sometimes tortuous, and lined
as has been before said with a  true mucous membrane, which cannot, indeed,
be separated, in some  rare cases, but which may always be known by its ap-
pearance, by the fluid which it furnishes, the organic elements  composing it,
and differing only from natural mucous  membranes by the absence of follicles,
and aa epidermic layer.
   When the inflammation is passive, the canal becomes so completely organ-
ized, that  is, covered exteriorly  with  a cellular tissue,  analagous  to  that
arou.ui natural excretory ducts, and to which anatomists have given the name
of sub-mucous cellular tissue; but in the majority of  cases, the irritation
remains in the surrounding tissues, and these passing into a state of induration
form  masses, more or less volumnious, through whose thickness the fistula
passes.
   I have said that these accidental canals resembled natural mucous canals;
the case before you proves the truth of the remark.  Thus, you see here a
false  membrane analagous, to  that formed in esophagitis.   By scraping, it is
removed, and the subjacent membrane is red like all other mucous membranes;
it is  like them soft, and villous; examined  by the microscope, the villi are
easily distinguished, less evident, undoubtedly, than in the natural state, but
still easily recognized.  Pursuing the comparison, externally we find a fibro-
celluiar membrane, similar to that surrounding the mucous membranes.
   Nature sometimes  cures  these fistulous  canals in the following manner:
The mucous passages  ceasing to be moistened by a fluid  (of whatever nature
it be^ the tissues composing it, endowed with contractility, like the other tis-
sues of the organism,  contract, their parietes approach each other, unite and
form  a fibro-cellular cord, which after some  time partly or entirely disappears.
How  do these canals disappear?   In the same manner as they are formed;
that  is. at the expense of all the  tissues they had traversed, by taking  from
them the  elements of their organization; they disappear by restoring  what
they lidd borrowed.  The truth of the assertions has been abundantly proved
by pathological anatomy.  Persons cured of symptomatic abscesses, and after-
wards dying of other  diseases, have, in some  cases, shown the fistula trans-
formed into a cord, as we  have  said; in others, this  cord was no longer
continuous, and presented only some fragments here and there throughout its
track; lastly, in others it had  entirely disappeared.   The following case is
very remarkable as regards this latter remark.
   A woman came  to the Hotel Dieu with a strangulated hernia occasioning
an artificial anus.  No one could deny that, in this  case, the intestine adhered
to the rbdominal parietes.  Two years afterwards, she was again admitted
into the hospital for another disease, of which she died; on examination, M.
Dupuytren thought that he had been incorrect in his diagnosis,  for no adhe-
sions  were found ; but on unfolding the convolutions there was found a cord
which terminated at the upper  part of the crural arch, and extending to the
intestine; thus his opinion was verified, that in  many  similar cases these
accidental canals restore to the neighboring  parts the elements they had bor-
rowed from them. 
44
LECTURES  ON
   In the first case we have mentioned, the old passage was diminished in size,
while the recent duct was much larger.  The parietes of the  former almost
touched each other; internally an albuminous matter  similar to that of false
membranes was found; these were the means by which the reunion had been
effected.  It is true, that natural mucous ducts are not easily obliterated,  but
it is sometimes the case; thus the proposition of Bichat, though true generally,
admits some exceptions.  Accidental canals, on the contrary, are more easily
obliterated; the reason is that the former possess a highly developed secretory
apparatus, whilst it  exists but feebly in the latter.  Thus a square of natural
canal will present a hundred villi, but in  the same space of  an accidental
passage we will find only five or six.
   The remarks first made, show the necessity of opposing immediately  the
organization of accidental passages, and of establishing, as soon as possible,  the
natural course of the secretion by appropriate means.  But when this cannot
be effected, the same means become insufficient and even inapplicable; it then
remains only to remove the parts.
  The cautery may  be still used advantageously, but  actual cautery should
be  direct,  and follow exactly the canal.   In other  cases, we must  have
recourse to injections of nitrate of silver, diluted nitric acid, taking care that
these fluids are not extravasated.  M. Dupuytren used for these  injections,
twenty or thirty grains or a drachm of nitrate of silver  to a pound of distilled
water.   He has observed that these injections frequently succeed, when  the
fistulae are of a scrofulous nature.
                          CHAPTER VII.

                          ON HYDRO-SARCOCELE.

   Case Remarkable for the Difficulty of its Diagnosis.—Some time ago, said
M. Dupuytren, a surgeon of the navy consulted me for an affection of the left
testicle.   Some medical men  having examined it before, pronounced it to be
hydro-sarcocele.   The following is the history of the  case:  Since child-
hood, his  left  testicle  had  never descended into the scrotum.  A tumor of
variable size  frequently appeared  in the course  of  the spermatic  cord,
descended more or  less,  sometimes as far as the  testicles, and, ascending
gradually, disappeared anew  at the inguinal  ring.   At  last it fixed itself
without the abdomen.  It was thought owing to a  hernia,  for  from his
youth, the patient  had constantly worn a bandage.  Therefore, remark this
fact, which  has powerfully influenced the modifications  which afterwards
took pl.ice in the organs.   It may be admitted as a principle that whenever a
bandage is not useful, it is  almost always  hurtful;  it maintains a constant
pressure,  whose effects are almost  always injurious; and often determines
scirrhous  engorgements.   However, the patient now  thirty-two years old,
has not worn it for many years.  Another circumstance to be remembered, is,
that the tumor frequently  presented sensible  variations  in size.  During a 
CLINICAL SURGERY.
45
long cruise, it increased considerably.   On his return, a fluctuation could be
felt on the anteriorand inferior portion ; above and behind this fluctuation a
hard spot.   When I first saw the patient, I thought, indeed, that there was a
collection of fluid;  but  the difficulty was  to  determine which  organ was
represented by the hard body of which I have spoken.  I was inclined to think
it an engorgement with hernia by adhesion ; and prescribed only rest, baths,
emollient topical applications, and endeavored  to  reduce it, but without
success.
  The patient being obliged by his profession to make long voyages, desired to
be freed from his disease at all hazards.  The case was very embarrassing for
the surgeon. The only thing certain was, that there was a collection of fluid,
beyond that all was obscurity.  At first sight it is often difficult to distinguish
hydrocele, complicated with a cartilaginous thickening of the tunica vaginalis
from sarcocele; but,  moreover,  it  was here necessary to ascertain  if this
hydrocele  was simple or accompanied by sarcocele, an  engorgement of the
testicle, or a hernia; or if this hernia had, or had  not, contracted adhesions; for
one or other of these circumstances might exist.  Every day these complica-
tions are met with, and they should regulate our conduct.   We first intended
to make an exploring puncture; but. this step demanded reflection.  The
trocar,  inoffensive and useful  in the case of a simple  hydrocele, would have
been very dangerous if the tumor was formed  by  an engorged testicle, but
without degeneration or by the intestine, one of them  might be wounded.
On the  other hand, in the case of sarcocele the puncture would be useless.
  These considerations determined us to open the tumor with the bistoury.
An incision, about an  inch long, was made in the integuments at the inferior
portion, prolonged a little posteriorly, and carried gradually and with caution
as far as the sac containing  the water.  This  sac presented a bluish aspect
and was resisting.  Having punctured it with a bistoury, a fluid escaped,
entirely similar to that of simple hydrocele.   Desirous of preventing the infil-
tration  of this fluid in  the cellular tissue, we enlarged the incision; and about
eight or ten ounces flowed  out. The tumor lost only two-thirds of its volume.
It was  then evident, that the hard  portion was formed by the testicle itself.
But in what state was it ?  This was  an important question.  In the first
place, was  this engorgement  due to  a venereal, scrofulous,  or rather some
external cause ? The patient declared he never had any thing more  than  a
running for five or six days; on the other hand, although he presented some
 characters  of scrofula, they were not sufficient to account for the develop-
 ment of this affection; the patient has a good constitution and  has  always
enjoyed excellent  health.  We  were,  therefore, induced  to think that this
engorgement resulted  from the compression, kept up for many years upon the
testicle by the bandage applied for the support  of the hernial tumor.  Lastly,
 even should the cause have been venereal, must the operation be abandoned,
the  wound healed, and the  anti-venereal  treatment employed?  Having
carefully examined  the testicle, we found on  its surface some wrinkles and
inequalities; it was  hard, nearly indolent;  this  hardness  was especially
remarkable in the  epididymis, which  had acquired a considerable size.
   These were  strong reasons  for suspecting a degeneration of a great portion
 of  the  organ, and we determined to remove it.  But beforehand, wishing to
ascertain the state of the upper part of the spermatic cord whose integrity was 
46
LECTURES  ON
 recognized, and that of the inguinal ring, we reached this ring without diffi-
 culty, and found it  open  and perfectly free.  Then we could conceive why
 the  volume of tumor  had so frequently increased and diminished;  it was
 evidently caused by alternations of a hernia and the spontaneous reduction
 of a fold of intestine.   But how was it with such a state of the  ring that the
 tumor containing the fluid could not be returned  into the abdomen, despite of
 our  attempts ? The  state of the epididymis explains this circumstance; being
 placed at the entrance of the ring, where it was thrust by the tumor, it closed
 it completely.  It is known that in dogs a reflection of the peritoneum, placed
 there like a valve, opposes  the return  of injections thrown  into the tunica
 vaginalis.  In this patient the epididymis fulfilled occasionally  this natural
 function in dogs.
   On account of this peculiar disposition of the  ring, the operation might be
 followed by two equally grievous accidents.  On the one hand, a portion of
 intestine might protrude from the abdomen, and be engaged in the wound, as
 sometimes happens  in  the operation  for strangulated hernia.  On the other,
should hemorrhages  supervene, the blood being effused into the  peritoneum,
might produce inflammation  of this membrane.  In order to prevent this we
thought it proper to tie  carefully the vessels of the cord, and also  those of  the
integuments.
   Let us recapitulate the circumstances of this interesting case.  This tumor
was  formed both by a collection of fluid by the abnormal size of the tes-
ticle, and accidentally by the protrusion of a fold of intestine.  The fluid
amounting to eight or ten ounces,  was the product of the morbid  secretion of
the tunica vaginalis,  and constituted a true hydrocele. Although  the inguinal   *
ring  was widely  open, the communication  of the tunica vaginalis with the
cavity of the peritoneum not being free, owing to a peculiar disposition of the
inferior portion of this  canal, it was  impossible to reduce  the sac containing
the fluid.  As to the  removal of the  testicle, it was thought correct.  The
operation, indeed, was painful, long, and difficult; but all this doe3 not equal
the accidents which would have resulted from the progress of the disease,  or
an operation done with a different intention.  Lastly, an examination of the
morbid part, shall decide  whether we acted well or ill.  The  testicle, three
times its proper size, on being divided, presented a carcinomatous  appearance,
in the first degree, that is, without degeneration and softening (ramollissement).
This was a fortunate circumstance, and favorable to  the radical  cure  of the
patient.  The epididymis, at least quadrupled in volume, was in  the same
state.  The general constitution of the individual, the integrity of the cord,
the supposed nature of  the affection, all led us to believe that the cure will
be complete. 
CLINICAL SURGERY.
47
                          CHAPTER VIII.

                     ON  PROLAPSUS OF THE  RECTUM.

   Treatment of M. Dupuytren.   General Considerations.—It is  daily re-
peated that surgery is a science carried to the last degree of perfection; yet daily
it is enriched with discoveries of greater or minor  importance as regards the
operative part of it.  A few years ago, M. Boyer succeeded in curing fissures
of" the anus  by  simple incisions,   The procidentia of the mucous membrane
of the rectum,  if not a very grievous disease, certainly a very inconvenient
one, had  been  treated until  the  present day by  remedies mostly  useless,
or merely palliative.  We have  succeeded  in  curing  it completely by an
operation as simple as it is safe and certain.   It is known that this  disease,
more common in infancy and old age, than any other time of life, consists in
the inversion of the intestine, of which the upper portion is invaginated in the
lower as far as the  anus, and continuing outwardly, projects two, four,  five,
and even six inches.  Generally, this prolapsus takes place when the patient
has a stool, and sometimes when he remains long erect.   This disposition of
the organ appears  often to be connected with a soft, feeble, lymphatic, and
hemorrhoidal constitution.
   The first thing which occurs to the mind, is the reduction of the prolapsed
intestine; this  is sometimes  but not always easily affected; sometimes the
action of the sphincter is so great, and the tumefaction so enormous, that the
gut is strangulated, and immediate relief is demanded.  The latter, displaced
is sometimes doubled and tripled in volume, becomes ecchymosed,  of  a
violet  color, and  is  sometimes threatened with gangrene.  In  such cases
reduction should be immediately attempted, and in the following manner:  The
patient laid  on  his belly, the pelvis elevated by pillows, so that the anus is the
highest part of  the trunk.   After having enveloped the tumor with wet cloths,
in its whole  length, and placed a compress in the centre of its external extre-
mity, we press  gently on its base, in order to  diminish its size, and endeavor
to return  it gradually with the  finger,  The reduction thus  begins by the
porfion which protruded last; if this cannot  be accomplished, some surgeons
advise scarifications; but  as they cause wounds, and consequently inflamma-
tion of the large intestine, we should abstain  from them as much as possible.
The same remark applies to leeches, which may  occasion internal or external
hemorrhages and intestinal ulcerations.
   Even when the reduction has been effected, the disposition to again pro-
trude  still exists;  thus this  remedy can be considered only  as a palliative
measure.
   Lotions and  cold baflis have also been  used as  a curative measure, with the
intention  of strengthening the action of the sphincter, and opposing the  pro-
lapsus of the rectum.  Cold baths sometimes  succeed, but they require much
time, perseverance, and cause disagreeable sensations which all patients  can-
not bear, and which forbid their  continuance.   Astringent  lotions, pressure
made  by a  sponge covered with  fine linen,  and supported  by a T bandage, 
48
LECTURES  ON
  suppositories of different kinds, &c. &c. are sometimes successful in children
  after some  time, but frequently fail  in persons advanced  in age.  We must,
  in this case, have recourse to the operation, and remove the tumefied part or
  a portion of this part which projects, and any hemorrhoids which  may  exist
  on the mucous surfaces.  But  this excision, for which  Sabatier and many
  others have taken much credit, is obnoxious to accidents, and  especially a
  hemorrhagy which may be serious and  sometimes fatal.  The removal of a
  greater  or  less portion  of  this mucous tumefaction and the hemorrhoidal
♦ tumors,  followed by the cautery with a red-hot iron, independently of the
  acute  pain may occasion violent inflammation of the intestine and neck of the
  bladder.
    These reflections have induced M. Dupuytren to seek a new mode of treat-
  ment,  which, free from the inconveniences of the old method, offers  more
  certain results, and a few years ago he invented an ingenious plan, which we
  shall describe after a short description of the anatomy of the parts.
    The skin  covering the margin of the anus, is  thinner than that  of other
 parts of  the body, and of a different color;  it contains very numerous mucous
 follicles, which secrete an oily matter of a  peculiar odour.  This skin forms
 projecting folds, separated by grooves, converging from the circumference of
 the margin  towards  the centre of the anus;  these folds are  engaged in the
 anus itself,  and  are numerous and projecting in proportion to the  projection
 of the latter; disappearing when it is dilated ;  it may be conceived that their
 use is to facilitate the dilatation of the anus, and assist the expulsion of the
 fecal  matter.  Beyond the  skin, there is  a layer of a fibro-cellular nature,
 above  the external and internal sphincters, two organs  constituted by cir-
 cular fibres  and of a muscular nature.
    We will  now  explain  the  operation of  M. Dupuytren; the patient being
 laid on his belly, the head depressed, the pelvis, on the contrary, elevated by
• pillows, the thighs are  widely separated, in order to expose the margin of the
 anus and the anus  itself.  The operator  holding injiis left hand a pair of
 dissecting forceps, of large size in order to  give less pain, seizes successively
 on the right and left, and even before and behind, two, three, four, five, or six
 of the radiating  folds, sometimes obliterated,  or more or less projecting;
 with the right hand, armed with scissors curved on their flat surface, he removes
 each fold as he  lifts it;  the  incision should be prolonged as  far as  the anus
 and even within  it, in  order that the effect may extend beyond the aperture ;
 if the  relaxation is considerable it may be  carried as far as half an inch, but
 generally a  few lines are sufficient, if the relaxation  is moderate one, two, or
 three  folds  on each side, are generally removed ; if  very great, more will be
 necessary.
    This operation gives but little pain, and offers no objection,  is not  followed
 by hemorrhage, for  the cutaneous vessels  alone pour out blood, and at most
  the extremities of the  hemorrhoidal arteries are implicated.  If however the
  incision  be  very deep, the internal  hemorrhoidal  arteries might give out
  much  blood.
    The consequences of this operation  may be easily deduced from the ana-
  tomical structure ; there exists excessive irritability of the anus ; we propose
  to  cure  it by retrenching one of the tissues  entering into its  composition,
  and strengthening others;  the double  end is attained by the  excision of the 
CLINICAL SURGERY.
49
skin and subsequent inflammation.   The cicatrix formed both by the junction
of the edges of the wound, and the formation of an accidental tissue, evi-
dently contracts the antis.
  By this  method a new,  and compact skin has been substituted for a skin
of which  the  adhesions were  very loose.   The  inflammation  also which
follows this simple operation,  extending  a  little above into the sub-mucous
cellular tissue of the  intestine, assists in  increasing the adhesion of the
mucous with the muscular coat.
  No dressing is necessary; the pain causes instantly a contraction of the
sphincters ; the inflammation is soon communicated from the incisions to the
cellular tissue and  the sphincters.   Generally the patient has no passage for
the first few days; the inflammation  subsides, the sphincters momentarily
relax for the passage of  fecal matter, but contract on the least exertion; the
cicatrization is complete in a few  days,  and then the excrement acting no
longer on  ulcerated surfaces, the opening is diminished and the cure perfect.
M. Dupuytren first adopted this plan  many years ago; he has since operated
frequently, and always successfully; he has never seen a relapse except where,
by his own account, the operation had been imperfectly done, on  account oi:
the struggles and cries  of the child.  The  merit of the invention is certainly
due to him. That performed by Hay (practical observations) for the cure of
a patient  laboring  under piles* complicated with procidentia of the mucous
membrane, differs from  it in many essential points.  It may be seen, by the
observations of this surgeon and others, that it was only by accident, that
patients affected  with prolapsus of the rectum, were cured  by an operation
exclusively intended for hemorrhoids, and which could be applied only  when
the prolapsus was the sequence of a hemorrhoidal affection.   M. Dupuytren's
method, on the contrary, is applicable, especially to prolapsus of the rectum
without complication of hemorrhoids.  He is convinced that nothing but the
excision of the margin of the  anus can relieve the patient of his disgusting
infirmity.
  The following case shows us  the application of these principles:
  A young woman of a good constitution, laboring under procidentia of the
mucous membrane of the rectum for many  years, was admitted into the Hotel-
Dieu  in May,  1830. She could attribute it to no cause.  During her stay in
the hospital, no hemorrhoidal affection existed, but the prolapsus of the rectum
presented this peculiarity, that it appeared monthly, when the bowels of the
patient were moved, and lasted a few days, then did not  reappear  until the
following  month.   The  inconvenience  experienced by its prolapsus was very
great; pain, tenesmus, and  the flow of a glairy bloody fluid, &c, annoyed
her excessively, which induced her to submit to the operation.  The  patient
being laid on a bed, the pelvis elevated and the thighs separated by an assis-
tant on each side, M. Dupuytren  seized  a  fold of the  margin of the  anus,
raised it, and removed it, prolonging the incision as far as possible into the
rectum.   Four duplicatures were thus  removed.   The pain of the operation
was not great; no hemorrhage followed; no dressing was applied; and on
going to stool some days after, the rectum  did not come out.  In fifteen days,
the wounds were cicatrized and the woman left the Hotel-Dieu.
  Case II.  In the latter part of November 1831, a child about three years of
age, of a good constitution,  was brought to  M. Dupuytren.  It had, for a long
            7 
50
LECTURES ON
time, been affected with inversion of the intestine, with prolapsus of the rec-
tum, after every evacuation of the bowels.  This  child, which enjoyed good
health, was of a lymphatic temperament.  The operation was done precisely
as in the former case;  the patient laid on  a  pillow, the thighs and buttocks
separated  by assistants, three folds were successively removed as far as one
or two lines from the anus.  But little blood followed.  The next day, on going
to stool, the gut came out, a rare occurrence, but not at all serious.  Fifteen
days afterwards the child was brought back entirely cured ; the wounds were
nearly cicatrized, and suppuration existed merely in a few spots.
                           CHAPTER IX.

                         ON NERVOUS DELIRIUM,

  An operation is skillfully performed;  the assistants are astonished  at the
dexterity of the surgeon;  yet accidents  the most serious may supervene and
threaten the life of the patient.   Sometime a violent inflammation seizes the
extremity which has been operated upon  ; or some internal organ is attacked
and the patient carried off at the very moment success seemed certain;  some-
times purulent absorption  sets in, announced by shiverings and erratic fever;
and  again the nervous system being irritated, gives rise to painful spasms,
which frequently terminate in fatal tetanus; or finally, the brain, agitated by
pain, by fear, nay, by joy, forms conceptions which are no longer in corres-
pondence with external objects, and reason quits the patient at the very time
when her presence would be most valuable. It is on accidents of this nature,
said  M. Dupuytren, that I wish to-day to fix your attention.  Obscure in its'
course, variable in its progress, and frightful in its symptoms, nervous delirium
seldom proves fatal, when it is met in time by proper remedies.
  Before entering upon the  consideration of this disease, we will cite some
cases of this  complication of wounds and operations, in order that the reader
may have clear notions concerning it.
  Case I.—On the 15th of December, 1831, a man was brought into the Hotel-
Dieu, having had  his leg broken in a quarrel  at a cafe.  The fractured limb
was in a very disordered condition; the upper fragment had torn the soft parts,
and  made a triangular opening in the skin.  The fracture was reduced, but
during the whole night the patient uttered the most distressing cries.  At the
visit of the next morning,  he seemed as if he was buried in  a fit of intoxica-
tion ; during the  dressing he uttered the same cries again.  M. Dupuytren
remarked, that this want of courage or excessive sensibility of the patient was
an unfortunate circumstance, through the  influence of which grievous acci-
dents might ensue.   He was bled three times;  the next day he was a little
better, but on the following was delirious; his ideas were incoherent and con-
fused.  This was the day  on which his  friends were  allowed  to visit him;
patients on these occasions almost always receive food unsuitable for them, or 
CLINICAL SURGERY.
51
circumstances occur  which tend  to  aggravate their  condition.   Was the
change now observed in the patient due to this cause or some other ?  It was
found that he had experienced some vexation arising from some private  busi-
ness in which his  mind was engaged; and during his deiirium  constantly
repeated, that his stay in  the hospital would  ruin  him.   Leeches, anodyne
potions, and an enema of asafoetida were administered; but all in vain;  on
the morning of the 9th he expired.
  The death of this man gave rise to several  important questions: Was he
the victim of one of those internal inflammations which frequently give no note
of their presence, except by the  fever or  delirium they produce ?  or had  he
perished in consequence of the fracture, or the profound lesion which it caused
in the nervous system ?  Besides, justice interfered in the business; the pro-
fessor was called upon to answer whether the  fracture was occasioned by a
fall in the scuffle, or caused directly by kicks inflicted on the leg.
  At the  post mortem examination, M. Dupuytren took occasion  to observe
how difficult it was to conceive that such a fracture should  be occasioned by
a mere fall; that in this case it did not seem probable; and to be barely pos-
sible, it would require the concurrence of a variety of  circumstances, which
could not be easily appreciated.  On the other hand, a fracture of this kind
might result from many different causes, such  as a fall from the first story of
a house, the passing of a carriage wheel over the legs, &c.  It was, therefore,
impossible to decide how the accident had occurred; the case affords a good
example of the necessity there is in such circumstances  of proceeding with
caution, when reports are to be drawn up for the purposes of justice.
  Inspection of  the fractured  limb showed that the  parts had been violently
dissevered; the  tibia broken in  fragments; the fibula divided, the soft parts
contused and  lacerated; the left pleura contained a considerable quantity of
blood; the brain was healthy.
  Case  II.—M. R. C...., a  tradesman,  aged  twenty-five, of a  lymphatic,
nervous  temperament, and  of little  moral  energy, was operated on  for a
voluminous sarcocele.  Alarmed by the  fear of hemorrhage, he was restless
the whole of  the  succeeding  day.  On  the following  day his agitation in-
creased;  the least movement, gesture, or word annoyed  him.   Every  thing
went on well; but he soon began to complain of pain in his limbs  and chest;
his eyes became  bright; respiration hurried; he called for food, and wanted to
get up.   His intellect  became disturbed; he repulsed his nurse, and Joudly
called  for his family, who were  not near him.  The whole body was in mo-
tion.  His cries, brilliant eyes, immovable pupil, his face  covered with per-
spiration, and his pulse calm and regular, in the midst of this agitation, left no
doubt of the presence of nervous delirium.  The patient complained loudly of
pains in the chest, though no examination could detect their nature.  M. Du-
puytren then ordered, what he generally does in similar cases with great suc-
cess—namely, a semi-lavement with six drops of laudanum, which was given
immediately;  some of his friends, alarmed by  the accident, were sent away;
the patient ordered to be kept  strictly by himself.  He now ceased  to  be
talkative, and  fell asleep; awoke the next day entirely free from the delirium.
The cure was  complete in twenty-five days.
  Case III.—Langlois, a mason, aged twenty-six, came to the Hotel-Dieu in
May, for fracture of a rib occasioned by a fall from a house.  A bandage was 
52
LECTURES ON
put tightly around his chest to secure the immobility of that part—a proceed-
ing necessary for the cure. Those fractures generally go on so favorably that
no attention was paid to the patient; but he was seized on the third day with
delirium, which gave him no rest.  He was agitated in a thousand ways ;  all
his muscles were in a state of continual tension ;  his eyes bright, and skin
covered with sweat; his pulse alone was calm.   Langlois thought he saw
figures floating in the air;  fancied that physical experiments were performed
on his bed,  and that all the patients in the ward were undergoing the  same
treatment.   This disturbed him much ; and he knew not whether to submit or
resist.   Being of a sanguineous temperament, he was bled, with no effect; an
enema with ten drops of  laudanum was then administered, with better suc-
cess.  Next day the dose was doubled, but with no great improvement   His
cries disturbing his neighbors, and being excited by the movements and visits
in the ward, he was put into  a separate chamber.  The laudanum was  in-
creased to forty drops, and under this treatment the delirium subsided.
  But the man had suffered so much by the continuance of his agitation at a
time when repose was required, that the pleura, irritated by the roughness of
the fractured  rib, became  inflamed, and the lungs were attacked.   Cough,
with bloody expectoration, showed the presence of intense  pneumonia, evi-
dently aggravated by the repeated occurrence of the original cause during  the
violent  fits  of coughing.   He was treated by  venesection, calming potions,
and revulsives. He seemed to be cured, but his convalescence was not satis-
factory; he  was  pale and  feeble,  had frequent cough, oppressive fever;
and on leaving the hospital, after a residence of two months, he appeared to
be laboring under chronic pneumonia.
  Case IV.—Vincent Francois,  aged thirty-two, a chasseur in the 3d regi-
ment of royal guards, of a bilious-nervous temperament, having  met with some
annoyance,  determined to destroy  himself.  He  got drunk,  went into  the
church of Notre-Dame, and cut his throat.  He was carried immediately to
the Hotel-Dieu.  The integuments were divided from one angle of the jaw to
the other; some of the muscles  were cut;  and the weapon had penetrated
even to the pharynx,  between the hyoid and thyroid  cartilage.  He was
dressed and guarded.  On the second day he was attacked with delirium  and
confined in a strait waistcoat. A calming potion, consisting of half an  ounce
of syrup of diacodium produced but little effect.  However, at  last, he became
rational ; but the disturbance of  the previous twenty-four hours, gave rise to
severe accidents ; smarting pain, and a feeling of strangulation, with a violent
 cou^h, a id purulent expectoration, all came on  rapidly.  The wound assumed
 an ill appearance on the fourth day, and on the  seventh delirium returned.
 The s-me  remedies were used  with  success.  These  accidents and some
 others gave rise to many fears as to his safety;  however, he was cured in fifty
 days.
    Case V.—L. Le N...., aged thirty-five, a hair-dresser, having spent in a
 short time a considerable sum of money, which  he had been long and painfully
 amassing, gave himself up to a profound melancholy.  The loss of his place,
 too in the house where he worked, augmented his despair, and  in a moment
 of fury, he inflicted on himself seven wounds with a pair of scissors—three of
 which were  of considerable depth.  Being taken to the Hotel-Dieu, he was
  immediately bled, treated  with a  ptisan of linden flowers flavored  with 
CLINICAL SURGERY.
53
orange, and an anodyne draught.  The  delirium  was not calmed, on  the
second  day a new bleeding was practised, without  improvement in the state
of the patient; he  thought he was pursued by the police, and wishing to escape
them, he was confined.  Yet, notwithstanding all this disturbance, the pulse
was by no means frequent; the tongue was clean, and the body covered with
an abundant sweat; the appetite was  good, only he would notieat for fear of
the police.  For two days this state of things continued, although other bleed-
ings  and antispasmodics were tried.
  On the fifth day, M. Dupuytren  prescribed two lavements with ten drops
of laudanum in each.  They were scarcely administered when the delirium
ceased, and at the end of six days  it had entirely subsided, in consequence of
the lavements.
  About a  fortnight after, Le N...., was  brought back to the hospital  for a
second  attempt on his  life.   The number of  blows with the scissors was so
great that  they resembled the marks of scarifications.  Nervous delirium
again occurred, and he was cured  by the same means.  (Case reported by M.
Mirambeaud.)
  Case VI.—Marianne R...., when about fifty-eight years of age, found  her
sight gradually impaired ; at sixty-one she was unable to distinguish day from
night.    Admitted  into  the  Hotel-Dieu, both crystalines  were  perfectly
opaque.  Every thing  being  favorable for the operation, after  fourteen days
of preparatory treatment, M. Dupuytren operated on her by keratonyxis in
his usual manner.
  During the  day of the operation, she suffered from frequent vomiting, but
this  was entirely subdued.  On the third  day she had headache and burning
tears; four foot-baths  and two enemata were  ordered.  On the  next  day,
intense inflammation of the eyes and eye-lids set in.  A portion of the catar-
act rose behind the pupil and formed  an opaque semilunar curtain.  On the
left, the pupil assumed a square  form,  and behind it, portions of the lens
and  its  capsule could be seen, of a deep red color; other portions of the same
bodies were in the  anterior  chamber; the patient  can  no longer see, suffers
acute pain  (seton to back of neck.)
  On the night of the fifteenth day, very intense nervous delirium ensued, the
strait waistcoat was applied.   The next morning the patient recognized the
assistants,  and complained of the pretended bad treatment she had undergone,
answers illy all  questions,  (antispasmodics, sinapisms to the  legs,) no  im-
provement. On the seventeenth day, a quarter  lavement with eight drops of
laudanum ; on the eighteenth, the same with ten drops brought on sleep, and
by a continuance of the remedy the disorder was completely removed.
  This terminates the subject under consideration.  We may,  however, add,
that divers other  accidents happening to the organs of sight, the patient  left
the hospital in a very satisfactory  state.
  Case VII.—E. M...., aged fifty-four, performing  an awkward evolution on
coming down stairs, missed his footing and fell on his left side.  He could not
get up, but was carried to the Hotel-Dieu, when the house surgeon recognized
a fracture of the inferior extremity of  the fibula, with rupture of the internal
malleolus at its base.   The limb  was placed  in the bandage ordinarily used
for fracture of the leg; the pain was intense, great  swelling.  The next day,
M. Dupuytren applied his apparatus and  administered resolvents. 
54
LECTURES ON
  On the third day the pain ceased, and the swelling diminished; on the
fourth, violent delirium came on; required  the  strait  waistcoat; a quarter
lavement with from eight to ten drops  of laudanum ; the next day the deli-
rium having disappeared, the remedy was discontinued.  On  the  sixth day,
the disease returned, lasting until  the  eighth,  and then  yielded, perma-
nently, to  the repeated administration of enemata.  The fracture went on
favorably,  notwithstanding  the different disturbances;  consolidation  was
complete on the thirty-sixth day,  and the limb was free from any  deformity.
  The preceding cases will  serve to introduce what we have to  say of the
history of that complication of fractures and operations which M. Dupuytren
calls nervous delirium, or, as some call  it, after the exciting cause traumatic
delirium.
  Its approach, sometimes indicated by the gestures, disordered and thought-
less movements of the patients and incoherent expressions, is most  frequently
sudden and unexpected.  It is manifested by a singular confusion of  ideas
about places, persons, and things.  Harassed with sleeplessness,  the patient
is generally overpowered by some prevalent idea connected  with  his profes-
sion, passions, taste, age, and sex.   He  labors under  perpetual jactitation.
The upper  parts of the body are covered with profuse sweat;,  the eyes glisten
and are injected; the face brightens  up, is flushed, and menacing words are
uttered with extraordinary loquacity, and alarming cries.  Such is the insen-
sibility which  some patients display when thus  affected, that we  have seen
them,"when laboring under comminuted  fractures of the lower extremities,
tear off the  bandages and walk about, without betraying the least pain ; others
with fractured ribs shake themselves and sing;  and lastly,  some who have
undergone  the operation for hernia,  introduce their fingers into the wound,
and coolly amuse themselves with  tossing about their intestine, as if they
were handling those of a dead body.  But, serious as are these symptoms, the
pulse tranquil and calm, experiences no other  disturbance than  that which
arises  from the disorderly  movements.   There is no fever;  the excrementi-
tial  functions proceed  with their accustomed regularity; but the appetite
fails;  and  after two, four, or five days, the complaint terminates in death,
but much more commonly  in recovery.  If the latter be the result, it occurs
without  a  crisis, and  as suddenly as the disorder began.  Exhausted by
fatigue the patient is seized with a  deep sleep;  from which he awakes with
perfect intelligence, but unconscious  of what has  passed ;  weak and very
sensitive ;  the appetite returns, the former complaint resumes its course, and
every  thing proceeds with  its usual regularity.   This  delirium may  return
two or three times, after the interval of a day or two, but is  weaker in each
succeeding relapse.
   The tranquillity of the circulation, and  absence of  all febrile  symptoms,
are  the most  remarkable features of the disease. You see a patient furious,
distracted, the sweat pouring down  his face, his voice  raised to the highest
pitch, you  think him the victim of  burning frenzy;  approach him, his pulse
is calm, regular, and the state of the skin"banishes all idea of inflammation.
This is a true mania, differing from that commonly, met with only in its dura-
tion ;  rarely lasting longer  than five or  six days.
   Nervous persons of a pusillanimous nature, whose brain is affected by some
vivid fancy, are most exposed to this delirium.  It was  so frequently the case 
CLINICAL SURGERY.
55
with suicides, that some have thought it peculiar to them.   Nor are the athletic
exempt from it.   Women are seldom attacked by it; and it never has been
observed amongst children.
  Nervous delirium may of itself be dangerous.  I have seen (said M. Dupuy-
tren) a young man, of vigorous constitution, who was seized with this affec-
tion, in consequence of a simple excoriation of one of the toes, sink under it
in eight and forty hours, the primary affection not seeming to have had any
influence  in  causing  death.  However, in the great majority of cases, the
severity of the disease is proportioned  to  the accident.   Thus a more unfa-
vorable issue may be anticipated when it arises from fractures of  the extremi-
ties, or of the ribs, or after wounds of the throat, than when it  results from
simple wounds, such as are in themselves trivial*.
  Inspection after death, moreover, discovers neither in the cerebrospinal
system nor other internal organs any material lesions that would  explain the
symptoms  during life, nor  give any satisfactory reasons  for death.  Treat-
ment.—Sedatives of all sorts, bleeding, pushed even to  fainting, revulsives,
and all other means which I have seen used, and been for a long  time in the
habit of employing, have all proved  inefficacious in this disorder; for they
neither affected its progress nor intensity.  Narcotics, the liquid laudanum
of Sydenham, have not been more beneficial; it is easy to explain this want
of action, by a physiological reason. The stomach, destined to elaborate the
first element of nutrition, is endowed with powers of digestion, and contains
juices which disorganize more or less, the substances which come  into con-
tact with it; so that much of the medicinal matter introduced into  the stomach
remain inactive being: mingled with the food.  This is the  reason why so many
medicines of  the vegetable class more especially, are uncertain in their action,
and often  useless.   It was owing to  the  evident inutility of those  divers
remedies, and the conviction I had of the  effect of the stomach on  remedies,
that I was induced to make trial of a method which has constantly succeeded
in my hands, and which, indeed, may almost be looked upon as specific.  This
method, as simple as it is powerful, consists in merely adding to an enema a
few drops of laudanum.  Five or six drops to a quarter  lavement, are more
effectual  than triple  the dose introduced into the stomach.  The reason  is
known; but we may add, that the rectum, destined to receive the residue of
digestion, absorbs and does not digest; and hence the medicines committed  to
it, especially when they are retained for some time, must more certainly reach
their destination.  These enemata should be  repeated twice, thrice, or four
time, every six hours.  When they are retained, they are perfectly sufficient
to subdue even the most furious delirium.

  * It is singular that habitual intemperance should have been omitted among the causes
enumerated ; the nervous delirium of M. Dupuytren, appears to be precisely similar  to
the delirium tremens of other writers—Tbans. 
56
LECTURES ON
                           CHAPTER X.

 ON FRACTURES OF THE INFERIOR EXTREMITY OF THE FIBULA, AND LUXATIONS
                              OF THE  FOOT.

   General Considerations.—Although  weaker and more exposed to external
violence than the tibia, the fibula, however, is much more rarely fractured
than the former bone.  This peculiarity is explained, by the species of iso-
lation in which  it is found, relative to the  line in which the weight of the
body is transmitted  to the foot.  The elasticity which it enjoys, even in ad-
vanced  age, the slight exertion it makes in its whole length, the protection it
receives in front, by the muscles  filling the interosseal space, and the tibia
itself, behind, by the  common mass of the gastrocnemius and soleus muscles,
externally by the lateral  peroneal,  are so many  circumstances  tending to
weaken the effects of blows received upon it, and diminish the frequency of
its fracture.  We should, however, observe, that some of these injuries have
been frequently mistaken, and others often confounded with luxations of the
tibio tarsal articulation, so that they are actually more common than is gene-
rally admitted  by a majority of  authors.  Thus,  M.  Dupuytren estimates
fractures of the inferior extremity of the fibula alone to be to fractures of the
bones of the leg:: 1: 3.
  Among the forces  producing a fracture of this bone, some act upon it im-
mediately; others through  the intervention of the  foot; thence  result two
kinds of fractures, those  taking place in the middle and upper parts of the
bone, and those of its lower extremity:  they differ from each other in the
triple ratio of their causes, effects, and treatment necessary for their cure.
  The  situation of the shaft of the  fibula on  the  outer  side of the leg,  its
delicacy, the space between it and the tibia in the middle of the leg, its arti-
culation to the  tibia by its  extremities  ; all would induce us to suppose that
it would frequently be fractured in its middle ; this, however, is not the case.
Two causes oppose it; the protection the fistula  receives from  the  lateral
peroneal muscles, and the  rarity of circumstances  capable of producing a
solution of continuity by a direct cause.
  These fractures, therefore, follow generally direct blows, resulting from a
blow by a contusing of cutting  weapon, gunshot wounds, the fall of heavy
bodies  on the exterior of the  leg, &c.  They suppose and require no mus-
cular agency.  Thus they occur without being ordinarily preceded or followed
by  any turning of the foot either outwardly or inwardly, and are generally
cured by rest, without being accompanied by any of the accidents which so
frequently complicate luxations of the foot.   These  fractures have a remark-
able analogy with those of  the ulna, which are never singly produced, but
by force directly applied.
   However the force may be applied, a fracture of the shaft, or  of the upper
extremity of the fibula, when  the tibia is untouched, is followed by no alte-
ration as to length; the foot preserves its natural position, and at the  seat of 
CLINICAL SURGERY.
57
fracture, there may be felt with  difficulty a depression  caused by a slight
sinking of the bony parts.  Thus the diagnosis of injuries of this kind is very
obscure, especially if much swelling exists.  The circumstances accompanying
the wound;  the violence of the blow; or the weight of the body  falling on the
limb; an extensive ecchymosis;  a  severe  contusion  on  the  spot; the  ease
with which the finger carried over the surface of the fibula sinks at this spot,
and depresses the fragments towards the tibia, are  the principal symptoms
which must guide the surgeon.
   Motion of the foot, or of the extremities of the bone, scarcely ever evince any
appreciable crepitation, on account of the small size of the fragments and
the exactness of their opposition.
   Fractures of the fibula are never  accompained by shortening of the limb,
because the tibia serves as a sort of splint.  They are seldom serious, except
the injury to the soft parts be considerable.  In simple cases, nature generally
effects the cure.  The indications of a fracture of the shaft of the  fibula, are
to maintain  the limb immovable, by means of the  ordinary bandage for the
leg; and to apply the proper dressings to the contusions and wounds, which
may accompany the fracture.  The consolidation generally takes place in
thirty or thirty-five days, and mostly, entirely free from deformity.
   History.—But  the solutions of continuity of the malleolar portion of the
bone, of which we are about  to treat, are dangerous, and lead  to much more
serious  results.  For a long time they were Confounded with luxations of the
foot.  Duverney, and J. L. Petit, are the  first modern surgeons, who  have
spoken  of them. Petit, especially, remarked, that lateral lux^ions of the tibio-
tarsal articulation could  not take place without rupture of one of the malleoli.
David,  Fabre, Bromfield, Pott, Pouteau, Boyer, and Charles Bell, have since,
by their observation, thrown more light  on fractures of the lower end of the
fibula.   However, the  history of these injuries was very incomplete; the
mode of treatment, seldom obviated the deformity they so frequently cause,
when M. Dupuytren gave his attention to the subject, and  made their treat-
ment as efficacious as that of other fractures.
   Causes.—The  inferior extremity of the fibula may be broken, either by
direct causes, of which we have spoken, or a  contre coup  by violence to the
foot.    The  mechanism  of the former species of fracture, presents  nothing
remarkable; the latter, however, demands the attention of the  practitioners,
because it is highly important to recognize  the causes of the accident, in order
to ascertain, in doubtful cases, the possibility of the existence of this injury.
A pebble, an excavation, or even a simple inequality of the ground, a fall  from
any height on  the feet,  when they bend inwards  or outwards, are the  most
common causes of this accident; it is the immediate result of  the action of
the weight of the body, and muscular contraction acting suddenly on the in-
ferior articulation of the leg, at the moment when the foot has deviated  from
the vertical  line.
   Let us now inquire how fractures of the fibula may take place, in  the vio-
lent lateral motions of the foot.   It is evident that the cause of  the rupture is
a change in  the line of support of the body.  When the foot is turned inwards,
the line, instead of following the axis of the tibia, and falling on the astragalus,
cuts obliquely, from within outwards, the lower end of the tibiaj the articula-
tion of  the foot, and is extended to the external side of the limb, after having
            8 
58
LECTURES  ON
 crossed the external malleolus.  The external malleolus, and lower  end of
 the tibia, are thus obliged to support the weight of the body;  therefore, in this
 case, the external malleolus, or the inferior extremity of the  fibula, yields to
 the traction of the external lateral ligaments;  a traction so much the more
 powerful, as these ligaments then take a direction perpendicular  to the  mal-
 leolus, and this  latter rests on the sharp edge of the astragalus, which is
 forcibly thurst from within outwardly by the tibia.  This latter bone stronger
 and thicker than the fibula, ordinarily resists, and if, as it sometimes happens,
 its malleolar is broken, and, as it were, torn off;  it is not primarily, and from
 the sprain, but secondarily, and from the effect of the outward displacement
 of the  foot, that this malleolus, and  sometimes the end of the tibia itself are
 fractured.
   In the second case, that is, in the outward movement of the foot, the centre
 of gravity of the body, instead of following its usual line, traverses obliquely
 the inferior part of the fibula, the articulation of the foot, the malleolus, or the
 internal lateral ligaments, and meets the ground, at a greater or less distance,
 from the inner edge of the foot.   These ligaments and the malleolus, to which
 they are  attached on the one hand, and the  lower end of the fibula  on the
 other,  therefore, support the weight of the body and the action of the muscles;
 they are  either torn or fractured; first, the lateral ligaments, or the internal
 malleolus; and secondly, the inferior extremity of the fibula.
   Characters.—Two orders of characters, designate the disease  under  con-
 sideration ;  some belonging to fracture of the fibula, others to the luxation of
 the foot; a useful  distinction, since fracture of the fibula  may sometimes
 exist without luxation of the foot.
   They are of two  kinds:  presumptive and characteristic.
   The presumptive characters, according to M. Dupuytren, are the nature of
 the accident, a noise, or sort of crackling heard at the moment, a fixed pain in
 the inferior part of the fibula, the difficulty, or even impossibility of walking,
 swelling  around the articulation of  the foot, and principally around the ex-
 ternal  malleolus and inferior extremity of the fibula.
   The characteristic signs are: inequalities, an  unnatural mobility of some
 point of the inferior extremity of the fibula, a crepitation more or less distinct,
the power of moving the foot transversely, the ease with which the fibula  may
 be brought near the tibia, a change of the point of meeting of the axis of the
leg and the foot, the deviation of the latter, outwards, inwards, and sometimes
backwards, an angular depression more or less evident at the external inferior
part of the leg, the projection of the internal malleolus, the disappearance of
these signs on  an attempt at reduction, and their instantaneous return, when
this attempt is discontinued, and, especially, when the limb is put in a state of
 extension.
   Let  us now  consider in detail, these divers signs, and above all, the char-
 acteristic  symptoms.    The  fibula  is hardly fractured,  when  remarkable
 phenomena ensue in the tibio-tarsal  articulation.  The  external  edge of the
 concavity which receives the astragalus, having  lost  its solidity, resists no
 longer the muscles which tend to throw the foot outwards,  and which, there-
 fore, overcome their antagonists.  Then the outer edge of the foot rises, the
 inner edge sinks, the dorsal surface  is  carried  directly upwards, the plantar
 region inclined outwardly; the pulling of the astragalus is  directed upon the
• 
CLINICAL SURGERY.
59
internal malleolus, and sometimes makes a projection easily recognized through
the integuments; the external malleolus, on the contrary, makes a vibratous
movement on the tibia, by which its summit is elevated, and the superior ex-
tremity of the fragment which it terminates, is brought near to the axis of the
limb.  From that moment the foot is placed without the  centre of the inter-
malleolar space; and by producing the axis of the tibia, it will fall on the
inner edge of the tarsus, and the weight of the body be supported by the
internal malleolus, and the ligaments attached to it.  This outward displace-
ment of the foot, is the only one which necessarily results from fracture of the
fibula, and  is the more marked, in proportion as the bone is broken low down,
and the patient afterwards endeavored to use the injured limb.   In the case
where fracture has resulted from the violent inward  inclination of the foot,
muscular action soon draws it outwardly, and effects in its relations with the
leg, the changes indicated.
  ^Should the rupture of the lower extremity of  the fibula  be mistaken  or
improperly treated, the accidents accompanying it go on advancing, muscular
action gradually turns the foot outwards, the astragalus  is carried above the
internal malleolus, the corresponding ligaments are put on the stretch, the soft
parts inflame, and become altered, and the synovial  capsule being opened,
caries attack the articular extremities and destroys them. In the most favor-
able cases, the patient unable to trust the weight of his  body to a weakened,
deformed,  and painful limb, whose extremity presents to the ground only the
internal malleolus and inner  edge of the foot, is obliged to use crutches, or a
wooden leg.  Many cases attest the unfortunate consequences which may
follow a fracture of the fibula when not recognized at first.
   It is, therefore, important to establish the diagnosis of these lesions.  After
a knowledge of all  the accidents capable  of producing  them,  we should ex-
amine attentively the lower part of the leg, and the tibio-tarsal articulation. The
presumptive signs, undoubtedly, may belong to a simple sprain, or one compli-
 cated with rupture of the ligaments ; but may also render probable the exis-
 tence of a  simple  fracture.  If there is  diplacement, it is almost always
 possible to recognize, inequalities produced by the fragments.  Running the
 fin«-er  over the  whole extent of the lower portion  of the fibula, we may per-
 ceive, at the seat of the fracture, an abnormal mobility, which must be dis-
 tinguished from the elasticity of the bone, and whose existence  is rendered
 more manifest'by grasning the tibia with the four fingers of each  hand  and
 applying successively the thumbs to the fractured portions.  Crepitation is
 rarely evident and often it cannot be heard.  On  grasping with one hand the
 tarsus, and with the other the lower part of the leg, we will find, if the nbula
 be fractured, that the foot may alternately be carried outwards and inwards.
    The  first of  these movements causes  the internal  malleolus to project,
 removes the external malleolus from the joint, and  also in a manner the astrag-
 alus from  the  line  in which the weight of  the body falls upon it; the latter
 movement restores the parts to their natural situation. As we have above
 remarked, the  foot, left  to  itself, inclines  inwardly; the internal malleolus
 projecting considerably; the integuments covering it are tense ; the axis of
 the le- falls on the inner  edge of the tarsus  instead of corresponding  o its
 middle part; the space between the malleoli is increased; on the external side
 5"theiticiatSm! the skin is  transversely wrinkled, the external malleolus 
60
LECTURES ON
seems sunken;  above it and at the seat of the fracture, a sudden depression is
almost always observed, with an antero-posjerior direction, a sort of hatchet
blow, according to an  expression of M. Dupuytren, which is a pathognomic
sign  of a fracture of the  bone.   This depression, however,  should not be
confounded with that formed by the fibula immediately above the malleolus,
and between the anterior and lateral peroneal muscles.
  In some cases, the foot has been so forcibly turned inwards that it remains
inclined despite of the  fracture of the fibula; but then  the upper extremity
of the lower fragment raises the skin, and threatens its laceration, the finger can
perceive the irregularities of the fracture.  After the reduction of the luxa-
tion, the phenomena  above indicated, are manifested, and  the disease  cannot
be mistaken.   Its chief characteristic is the facility with which all the symp-
toms may be reproduced, after  having been made to disappear by giving to the
foot its natural  position.
  Prognosis.—Fractures of the lower part of the fibula are grievous, in pro-
portion to  the severity  of the concomitant accidents.  A simple  fracture,
which is soon recognized, and properly treated, is generally happy in its ter-
mination, and  free from  deformity.  They become dangerous only from the
effects of io-norance which  mistakes them, or unskillfulness which  does not
apply the proper remedies.
   Species and Complications.—Fractures of  the fibula are divided into simple
and  compound.
   They are simple  when  limited to a solution of continuity of this bone,
without any other lesion.   Under this form, it is extremely rare, and can only
happen at  a certain distance from the  inferior extremity of the fibula, and
when the cause producing it, exhausted immediately after, has been incapable
of producing other  effects; or when another cause, consecutive to the first,
has not occasioned other lesions.
   It is very difficult to recognize a fracture of the  fibula in this state of its
greatest simplicity.  We have nothing to guide us but presumptive signs.
   One of the most  frequent causes of the rarity of this species of fracture,
consists in the efforts made by the patient, immediately after the accident, to
rise and walk  home, or to some neighboring place.   Sometimes it has lost its
primitive character of simplicity, long after the accident, by the imprudence
of the patient, who, fatigued by constant rest, has endeavorad to walk and
leaned on the broken limb.  It may thus be perceived how important  it is, in
these cases, to keep them quiet, and make them abstain from all motion.  This
treatment and some resolvent application, generally effect a cure in  a short
time.
   This species of fracture presents two  varieties.   In the first the fibula is
 broken at more than three inches distance from the top of the external mal-
 leolus.  Its distinguishing sign, is that it is unaccompanied  by displacement
 of the foot.  This is owing to the length of  the inferior fragment of the bones
 and the integrity of thetibio fibular-ligaments.
   It is generally found in fractures from a direct cause, and scarcely ever in
 those frpm an  indirect blow.  The reason is that the latter is always preceded
 by  a violent motion, or a displacement of the foot.   This variety is not dan-
 gerous,  and requires merely rest and the  demi-flexion of the limb.   The
 second  variety consists of those cases in which the fibula is fractured by a 
CLINICAL. SURGERY.
61
direct or indirect cause, at less than three inches from the externa malleolus
and without displacement of the foot.  It may take place at all points of this
space ; but when the foot has been violently turned outwards, it  is generally
found about two and a half inches from the malleolus, because there the fibula,
weaker and thinner than any where else, and curved inwardly by the weight
of the body and action  of the muscles, offers less resistance.  If, on the con-
trary, the foot has been forcibly flexed inwardly, the fracture generally takes
place below this point, and on the part of the bone, lodged in the groove of
the tibia.  What particularly distinguishes this variety from the preceding,
is the facility with  which  the foot is displaced.
   The  complications of fractures of the fibula are numerous, and give them
a serious character, which of themselves they do not possess.  Let any cause,
for instance, produce a violent outward flexion of the foot, the effort of flexion
and extension which will fracture the fibula, is first exerted on the soft parts
of the internal face of  the articulation, and the inferior extremity of the bone,
and brings about the rupture of the internal lateral ligaments, or even fracture
of the internal malleolus; or, lastly, should the fracture be occasioned by the
inward  flexion of  the  foot, and  the individual then  endeavor to walk, and
lean on the foot,  it will be carried outwardly and the same accidents take
place.   Thence follows  the  first  complication.   Sometimes instead of the
 lateral ligaments and the internal malleolus, the inferior extremity of the tibia
 is fractured.  This  fracture  whether preceded  or followed by that of the
 fibula, is generally «blique and  accompanied by displacement of the foot.
 Luxation of the foot,  is a third complication always met with, except in very
 rare cases.  It takes place in different ways, inwardly, outwardly, backwards,
 and sometimes upwards.  The first is  so  common and so intimately con-
 nected  with fracture  of the fibula, that it is one of its most certain signs;  it
 consists in a displacement of the head of the astragalus, which  is carried
 below and on the  inner edge of the tibial malleolus, a displacement resulting
 from the prolonged action of the  causes producing  the fracture,  from the
 action of the abductor muscles of the foot.   The second is owing to  the action
 of the Gastrocnemius and soleus muscles, which acting on the foot,  no  longer
  restrained by the external malleolus, cause the astragalus to slip from  before
  backward on the lower end of the tibia, and communicate to the inferior frag-
  ment of the fibula, a  motion by which its inferior extremity is carried back-
  wards, and the superior  forwards.
    The third species of luxation  is most rare, and difficult to explain.  The
  astragalus is  then carried  on the side of and below the fibular malleolus,
  whilst  the  outer  edge of the foot is depressed, the  sole inwardly, the inner
  edge upwardly;  the tibial malleolus is concealed  and disappears between the
  foot and the leg at the  bottom  of a receding angle, situated at its internal
  edo-e, the external malleolus forms with the astragalus a salient angle, rounded
  outwardly.  From this disposition of the parts, the foot presents the appear-
  ance of congenital club-foot.  The professor desiring to account for this extra-
  ordinary displacement,  examined successfully the organization of this portion
  of the louver extremity, the  relative action of the  antagonising power, the
  equilibrium which governs  it, and its effects.   On the one  hand, in rest and
  sleep, in the case of club-foot, and the major part of false steps and sprains
  which  ensue from it, the foot  being constantly directed inwardly, and the 
62
LECTURES  ON
 astragalus outwardly, the displacement of these parts, should almost always
 take place, in the same direction after fracture of the  fibula and the lower
 extremity of the tibia;  on the other hand, the study of the respective powers
 of their antagonising muscles, proves that in a majority of cases, the abductors
 should, and in fact do, overcome the adductors; thus it  is observed that the
 outer edge of the  foot is generally turned outwardly and  the astragalus in-
 wardly,  whether there be fracture of the malleolus and the  inferior extremity
 of the fibula, or of the two malleoli at once, and at the same height; lastly, in
 fracture  of the tibia alone, at its extremity, although the  foot  has  no inward
 support, and preserves, on the contrary, that furnished  by the fibula and its
 malleolus, there is almost always a more or less sensible inward displacement
 of the astragalus, which can only be attributed to  the  superior power of the
 abductors.  From all these considerations, we must conclude, that the outward
 luxation  of the foot (in which the astragalus is carried outward, and the foot
 inward)  can  occur only from very peculiar, unusual and rare  circumstances.
 Reason and observation show that these circumstances  consist  in the  obli-
 quity of the fracture  of the  tibia, and  the greater or less resistance of the
 inferior fragment of the fibula,  the obliquity of the former by influencing the
 direction of the displacement, and the  muscle9 capable  of effecting  it; the
 resistance of the latter, by preventing the foot from being carried outwardly
and  consequently favoring the action of the abductors.
   The last species of  luxation, that of the foot outwardly and upwardly, which
had  never been  observed, has been remarked but  once by  M. Dupuytren, in
 a practice of upwards of fifteen years, and two hundred cases  of fractured
 fibula.  But it has been so well  described, that hereafter it can never be mista-
 ken ; in  this species, the astragalus, at first, luxated outwardly,  afterwards
 mounts along the external face of the tibia.  In the example cited by the  pro-
 fessor, the astragalus, external  malleolus,  and foot, were  first carried  on the
 external  side of the leg, and then ascended, for the space of two inches along
 the tibia, still remaining together, like parts  naturally widely joined  to each
 other. It may "be perceived that this can only take  place with fracture of the
 fibula, and complete laceration of the tibio-peroneal ligaments.
   If  the tibia be fractured at once in several places and  different  directions,
 which generally happens when it is caused by a heavy blow, or the passage of
 a wheel over the leg, a compound fracture results, with puncture, tension, in-
 filtration, laceration of the soft, nervous, tendinous, aponeurotic, and cuta-
 neous parts, and subsequently,  pain, inflammation,  eschars, convulsive move-
 ments, and  tetanic spasms,  &c, endangering the life  of the  patient,  and
 rendering the treatment long and difficult.
   But this species of complication, however serious it may be, is  not to be
 compared with that frequently produced internally, and  concealed  by the
 skin.  These are sometimes such, as to make us despair  of their reparation,
 did experience not teach us that they are often cured, and  that in a short time.
 Thus we see both the  tibia and  fibula broken, or one of them,  at a single or
 numerous  places, with acute  cutting;  spiculae driven into  the  flesh;  the
 articulation opened, and its cavity filled with bloody synovia; the internal,
 lateral tibio-fibular, and external lateral ligaments  lacerated ;  the  tendinous
 sheaths of the muscles opened;  the tendons themselves and the nerves tense,
 twisted,  compressed, displaced, and partly, or  wholly  divided;  the arteries 
CLINICAL SURGERY.
63
and veins, and especially the great saphasna, compressed, ruptured, and sur-
rounded by effused blood ; the cellular tissue torn in every direction, and filled
with a reddish serum, and more frequently with blood, extravasated as far as
the toes on the one side, and the knee on the other.  Add to all this the vari-
ous displacements, which the long parts may undergo, and you may form a
faint  idea of the disorder sometimes accompanying this kind of fracture.
The arteries or veins may alone be wounded, without this  formidable aggre-
gate of  lesions we have just enumerated, and cause an extravasation of blood
into the meshes of the cellular tissue, an effusion of this fluid into sacs, formed
at the expense of the  cellular tissue, which separate the soft parts, surround
the fragments of the  bones, extend around, and sometimes penetrate  the
articulation.  This kind of lesion, constitutes a new complication, one of the
most  common, indeed, of fractures in general, and of the fibula in particular;
it ought to be especially distinguished  on account of the serious accidents
which result, and the treatment proper to it.
  Frequently, the skin has been carried away, opened in one or several places,
by the extremities of the fragments of  the fractured bone; these openings,
commonly irregular, with  ragged edges, contused and  disorganized, some-
times embrace the bone, hold, and as it were, cap  it; sometimes are free  and
pour out a blackish blood, or fragments of flesh, and half disorganized tendons.
They are produced in  various ways, either primarily, as we have pointed out,
or secondarily, by the effect of inflammation, the  falling of eschars, or a pro-
cess of elimination, by which nature endeavors to expel the blood and  pus,
and all  parts foreign to the organization.  These  lesions of the  integuments,
are another species of complication, so  serious in  their effects, that fractures,
otherwise unimportant, may become very dangerous, whilst we  should never
despair of the cure of internal injuries, however  great they may be, as  long
as the skin is uninjured.  The most dangerous  are those produced imme-
diately  by the fracture, on account of the subsequent inflammation, the pain,
fistulous sinuses, exfoliations, necroses, and a host of other accidents, result-
ing from the  formation and infiltration of pus.
   The  tumefaction, tension, and strangulation, subsequent to fractures, are
different degrees of the same complication, and the result of the afflux to the
nervous, fibrous, and other parts, distended, stretched or torn, by the bones,
and the displacements they have undergone.  When these symptoms are not
immediately dispersed, the tumefaction and tension, may acquire,  in a  few
hours, a high degree of intensity, and give rise to great  danger; phlyctenae,
filled with a reddish serum, appear here and  there; the limb becomes livid,
cold  and  insensible;  and if the disease be not arrested at this stage, strangu-
lation takes place; and excessive  distension of the external, and  not less
violent compression of the internal parts, bring on gangrene, and the limb
 partly  or wholly becomes  dead.   The  development of these phenomena,
reaches their highest degree without any signs of inflammation, a circumstance
 owing, undoubtedly, to the rapidity with which it takes place.   But in other
 cases the inflammation succeeds  the  afflux of which we have spoken  and
follows then two different courses; sometimes  the symptoms gradually in-
 crease; the pain, redness, heat, swelling, and tension the local and general
 fever reach their greatest height, and are  followed, as m the preceding  case
 by numbness, lividity, and icy coldness of the limb, the cessation of pain, at 
64
LECTURES ON
which the patient, ignorant of the cause, rejoices, and gangrene.   The  skin,
and with it, the cellular tissue, the tendons, nerves, ligaments, and  sometimes
the whole foot, becomes  mortified.   Sometimes  this inflammation takes the
form of  a mild, but tedious, phlegmonous erysipelas ;  after some days, the
symptoms increase, the fever is higher, the tongue  dry, diarrhea comes on;
soon an  obscure fluctuation is felt under the  skin, and the crepitation of
elastic fluid;  phlyctenae  appear; beneath them a slough is formed, which
opens and gives exit to a mixture of pus and elastic liquid.  The sub-cutane-
ous cellular tissue mortifies ; the skin separates for some extent; a slow fever
>ets in, the strength declines, and  the patient exhausted by the fever, sup-
puration, or diarrhea, perishes  sooner or later.
  The displacement of the  bones, the puncture, laceration and distension of
the parts, determine and maintain a permanent secondary pain, which inflam-
mation, and its different stages increase, accompained by  fever, insomnia, rest-
lessness, and which at last, by its intensity, or the peculiar sensibility of the in-
dividual, may cause convulsions and tetanus.   The convulsions generally
disappear, as  by enchantment,  on the reduction of the fracture, according to
the axiom, sublata causa,  &c.   But tetanus, when once declared, resists the
most active treatment, and even amputation rarely arrests it.
  Nervous Delirium is another complication  of fractures of the fibula and
surgical diseases in general, too common and  important to be passed over in
silence.  For a particular account of this affection, see chapter VI.
  If, by the effect of perforation or destruction of the soft parts, the bone  is
exposed to the air,  or if inflammation and suppuration destroy the life of the
splinters, or detach the periosteum which nourishes them, then these  splinters
die, and necrosis of the bone  follows, constituting another  complication of
fractures of the fibula.  Nevertheless, this necrosis seldom attacks  the frag-
ments of the  fractured fibula, but  very  frequently the  tendons of the lower
extremity of the leg.  The reason is because the tendons are  more exposed to
the disorders subsequent to the fracture.  They do not occur immediately,
but after  some time.  Then we perceive pain, redness, heat, swelling, ten-
sion, and an obscure fluctuation along the affected tendons ; the skin  becomes
thin and  breaks, the pus escapes through the aperture, filaments issue from it,
and are renewed until all the parts destroyed by the  necrosis are expelled.
Lastly, a  frequent complication of fractures of the fibula, when followed  by
inflammation, is an adynamic affection, which, according as it is true or false,
essential  or symptomatic, demands such different treatment and care, that
the  safety  of the patients depends almost always on the distinction which
is made.
  Treatment.—Even until  the present  day, there  was perhaps no surgical
disease, whose treatment presented more ur certainty and inefficiency, than
fractures of the fibula accompanied with luxation of the foot.  Yet, there are
none, which, on account of  their frequency and  seriousness of the accidents
which complicate them, demand more imperiously a fixed treatment, certain
in its results, and  founded  on experience.  This imperfection of the thera-
peutics of this accident is owing to two causes, one of which may be called
theoretical, and consisted in the insufficiency of the knowledge of the disposi-
tion  and  respective uses of the multitude of organs  composing  the lower
extremity of theabdominal limb, and of the mechanism of the causes producing 
CLINICAL SURGERY.
65
this  fracture  and luxation.   The  second, which may be  considered as a
consequence of the first, consisted in the imperfection of the means of reduc-
tion, and especially of maintaining  the parts when reduced in  perfect rela-
tion.   Indeed, if we compare the former methods with the mode of action of
the vismotrix  of the limb, wc will  see that none of  them were sufficient to
maintain the reduction.  Pott, who, of all the predecessors of M. Dupuytren,
has alone pointed out the manner of reduction without difficulty and exertion,
has indicated  no means of prolonging this reduction.  The number of failures
from the preceding causes, was also prodigiously increased by the error of
opinions formed concerning the proper time of the reduction according to the
nature of the  complications.   M. Dupuytren has reformed this theory, esta-
blished the gentle and easy process  of Pott for reduction on its true founda-
tion, and discovered a method, as certain in its effects as it is valuable in its
results, in order to maintain the parts reduced in exact relation until their
perfect consolidation.
   Indications  of Cure.—The first indication presented is to prevent any dis-
placement of the  fragments.  Rest and immobility are  sufficient for this end
and for the  cure, whenever there is merely a  simple solution of continuity,
whether it takes place at more or less than three inches from the lower extre-
mity of the fibula.   These means, joined to reduction, will also suffice, if the
fracture is  merely complicated  with a  simple displacement of the foot,  in
whatever direction this latter may  occur; and they should immediately be
used,  if we desire  to prevent  deformity,  and the  accidents  which result.
But there is a question which it is important to answer,  as on it the safety of
the patient sometimes depends:  Does there exist any kind of complication of
 fracture of  the fibula which contra-indicates reduction ?  All the species of
disorders we  have heretofore described, are the immediate effect of the forces
producing the fracture, or the consecutive effect of the  fracture itself.  De-
parting  from this principle,  conformable to  the  nature of things,  and the
observation, that in both cases the  bad symptoms are kept up, increased, and
urged to the last degree of intensity by the very cau^e which has determined
 them, and must become more serious the longer this cause persists; M. Du-
 puytren admits as a general  rule, that  the most certain and prompt way to
 arrest them, is to reduce the parts in all stages of the malady.  It was also the
 opinion of Desault, who performed  the reduction, if necessary in the height of
 an inflammation of the parts,  but whose  apparatus for maintaining the reduc-
 tion, cannot be here offered as a  model.
   Reduction.—There is no reduction more easily effected, than that of frac-
 tures  of the fibula accompanied  by  displacement of the  foot, when the resist-
 ance of the muscles has been once overcome.   The obstacles presented by
 this resistance, have exercised the genius of surgeons from the days of Hippo-
 crates down to the present.  Now,  it is sufficient simply to flex the leg on the
 thi-di, and attract suddenly elsewhere the attention of the patient.  The mus-
 cles lo-c their tension, the resistance ceases as by enchantment, and the parts
 resume, almost without effort and  spontaneously, their  natural situation and
 relation*.   Nevertheless, however  exact the reduction  made in this manner
 may appear, it is alwavs  incomplete, the fragments of  the  bone remain de-
 pressed towards the tibia, the foot  has a constant tendency to y,eId to the
action of the  lateral peroneal muscles and to incline outwardly.  A method 
66
LECTURES ON
is wanting to raise the fragments, separate them from the tibia and place them
as near as possible in apposition with each other.   What shall it be ?   it is
impossible to act upon the superior fragment which is never depressed, but,
on the contrary, always projecting;  and we can operate on the lower, only
through the medium of the foot.  Now, there is so strong a union between the
foot and the malleoli, that  when it is inclined to  either side, one malleolus is
elevated and the other depressed in the same ratio.  We see, therefore, that
the inferior fragment may be elevated, by exerting upon it an oblique traction,
that is, by forcibly adducting the foot. The external lateral ligaments, yield-
ing only to a certain point, will exert upon this  fragment a tension  the more
efficacious, in  proportion as the foot is inclined inwardly.  In this manner
the inferior extremity of the tibia sinks  into the depth of the articulation, the
astragalus is thrust from within outwardly,  the lower end of the  fibula per-
forms  on the  latter  a vibratory movement, in a direction  contrary to that
which  displaced it, and  thus it takes its proper position under the superior
fragment.
  Means of Retaining theReduced Parts in their Proper Position.—It is evident
that the position which so  much facilitated  the  reduction of the fracture, is
also the first which must be used to keep them in position.  But it would be
very improper thus to abandon a fractured  limb to itself, and some retentive
apparatus  is necessary to keep the bones in contact until their union is com-
plete.  This apparatus will, of course, be  modified,  according  to the nature
of the luxation accompanying the fracture.
  That used so successfully by M. Dupuytren, for five  and twenty years, in
fracture of the fibula, with inward luxation, consists simply  in a pad, a splint,
and two bandages. The pad made of linen and two-thirds filled with chaff, should
be two and a half feet long, four or five inches wide, and three  or four thick.
The splint eighteen  or twenty inches long, two and a half inches wide, and
three  or four  lines  thick,  should be made of compact and inelastic  wood.
Lastly, two bandages made of half-worn linen, and about five or six yards in
length.
  The pad, folded  on itself in the shape of a wedge, is applied on the inner
side of the fractured limb and extended along the  tibia, its base downwards,
resting on the internal malleolus without going beyond it, its apex  above on
the internal condyle of the tibia.   The splint applied on  the pad, should pro-
ject three or four inches below the inner edge of the  foot.   These  first por-
tions of the apparatus are fastened to the upper part of the leg by a few turns
of the bandage.
   In this situation, the splint extended beyond the base of the  pad like an
arrow, leaves between it and the foot  a space equal to the thickness of the pad,
that is, of three or four inches; this end of the splint serves  as a point d'appui
for the inward inclination of the foot.  In order to effect this, a second  band-
age is carried  successively from the  splint  over the instep, the outer side of
the foot, under the  sole over the splint, then from  this latter over the instep
and under the heel, continuing in this way until the  bandage is exhausted.
By thus including in the same circles,  which may be shortened at pleasure,
the splint and the instep, the splint and the  heel, alternately, the  foot is placed
in such a state of adduction that the outer  edge becomes inferior, the sole is
directed inwardly, and the inner edge  upwardly.  Therefore, as the foot 
CLINICAL SURGERY.
67
yields to the action of this apparatus, the tibia, pressed upon by  the base of
the wedge, represented by the pad and upon which all the apparatus bears,
is  driven outwardly as well as the  astragalus.   The  lower fragment  of the
fibula, pressed above by the tibia, and drawn below by the external lateral
ligaments, performs on the external edge of the astragalus, the see-saw motion
of which we have spoken, and by which it is brought to its natural position.
If we wish to effect a complete reduction, we should  not be content merely
to bring the foot under the leg, but continue our efforts until it is drawn in-
wardly as much as it had been displaced outwardly by the fracture.
   This  apparatus, besides  the advantage  of reducing without effort, and
almost without pain, and of maintaining the parts  in  their  proper situation,
possesses still another advantage.   By leaving between the bandages a con-
siderable space, exposing the articulation and the seat of the fracture, we can
apply such topical remedies as may be required.
   The same apparatus is equally applicable to all cases of fracture with simple
outward luxation of the foot.   In cases of outivard and upward luxation, it
will be necessary to place it outside, that is, along the fibula.
   There is much more difficulty in cases of  luxation backwards ;  both in the
reduction and maintaining  the  parts reduced.  In the first, this difficulty
arises from the resistance of the muscles, to the  elongation of the parts, and
the restoration of  their natural relations; in the second, the superior face of
the astragalus, convex antero-posteriorly, is so  that  the tibia can scarcely
rest perpendicularly to this bone, and has a constant tendency to be carried
forwards, whilst the astragalus itself, drawn incessantly by  the extensions of
the foot, which are more powerful than the flexors, tends continually to fall
behind the lower extremity of the tibia.   To M. Dupuytren, is owing the in-
vention of a method, adapted to the conditions of this case ; and which consists
merely in a modification of  the apparatus above described, and  its mode of
application.  To it, is added a small pad of a few inches square, filled with
horse-hair or chaff.  The large pad, folded as before, is placed on the poste-
rior part of the leg, extending from the heel  to the hollow of the ham, with its
base downward.  The splint is laid on  the  pad, and fastened to  the upper
part of the leg by a bandage; a second bandage embraces the lower extremity
of the splint and the leg; this is the truly effective part of the apparatus.  The
small pad is intended to cover the tibia, and protect it from the bandage ;
this latter, bearing on the splint and the tibia, carries, at the same time, the
heel forwards, and the tibia backwards.  Its efficacy is such, that we have
only to fear its overaction.
   Fractures, complicated both with luxation of the foot inwards  and back-
wards, are almost always cured by the treatment suitable to the   predominant
displacement.  In the contrary case, it is easy to combine the two apparatuses
we have described, so as to fulfil the double  indication.
   In order to confirm the principles we have just, advanced, we will now detail
some cases, and the most prominent features of their treatment.
   Case I.—Presumptive Symptoms alone Present; Subsequent  Development
of the Characteristic Symptoms.—M. D., was walking on a narrow causeway,
when the earth gave way under his left  foot, and his body lost its support on
that side; a sudden movement brought  the  weight of the body on the right
leg; but the ground still yielding, he slipped from  the top  of the causeway, 
68
LECTURKS ON
 into a ditch, and fell on the inner part of the right leg, which was doubled up,
 and demi-flexcd under the breech.   He  felt  an acute pain at the  moment
 of  falling, and was unable to rise.  He was carried home without having
 made any attempt to walk or lean on the injured limb.
   Sent for, eight or ten hours  after the accident, M. Dupuytren  found the
 foot and leg in their natural position.  The foot presented no unnatural mo-
 bility, nor the malleoli, the slighest symptom of fracture. The patient suffered
 no pain in the  situation of demi-flcxion, which he had instinctively chosen,
 nor in the examination made by his surgeon.   However, he could not bear the
 slightest weight on the foot,  without  experiencing  acute pain  above the
 external malleolus ; even the application of the finger to this point caused him
 great suffering.  At that point, there was an ecchymosis, extending upwardly
 along the fibula, and downwardly around and  below the  external  malleolus,
 as far as the corresponding side of the  foot.  But there was no perceptibl::
 mobility or crepitation, nor  displacement of the foot, the  only characteristic
 signs of fracture  of the fibula.   The professor, however, suspected that
 one  existed, but without displacement, and prescribed  demi-flcxion of the
 limb, resolvents and rest, means equally indicated in a simple sprain  or  con-
 tusion.
  After some  days, the patient, at the instigation of  a friend, got  up, taking
 care to scarcely touch the ground with the wounded  limb, and  felt but little
 pain.  Encouraged by this attempt, next morning he went further and tried
 if the limb could support his body.   He had hardly made this dangerous ex-
 periment, when an acute pain, accompanied by a sensible crackling and lace-
 ration  was perceived; he  fell, unable  to rise.  Being again sent  for, the
 professor found outward displacement  of the foot, mobility and crepitation.
 He applied  the apparatus  we  have described and the patient was  entirely
 cured in six weeks, notwithstanding some inflammation which was subdued
 without suppuration.
  Cas;: II.—Fracture;  Inward Luxation of the Foot;  Serious Symptoms;
 Treatment by the Neio Method; Complete cure without Deformity.—Jean Tro-
 nille, by trade a smelter,  26  years of age,  slipping on a damp and greasy
 pavement, fell upon his right side, with the foot adducted, and the leg  bent
under the breech.  He felt a smart pain in the lower part of the leg, and
endeavored  to'rise; but being unable to walk he was carried home, and the
next day brought to the  Hotel-Dieu.
  Symptoms.—Outward displacement of the  foot so  great, that the axis of
the leg produced below the inferior extremity of the  tibia, instead of falling
upon the astragulus, would have left on the right this bone and  the entire
 length of the tarsus, rotation of the foot upon its axis, by virtue of which its
 inner edge was directed downwardly, its outer edge  and dorsal  surface up-
 wardly; considerable projection of the tibia and internal malleolus; opposite
 to this, extreme tension of the  skin phljctenae filled  with  a  reddish serum.
 On the opposite side, deep depression and transverse corrugation of the skin,
 two  inches above  the external malleolus; sudden  disappearance  of all the
symptoms by  the least effort  at reduction, and spontaneous return of them
 on ceasing this effort.
  In addition an acute pain towards the lower part of the fibula ; inequality,
 mobility, crepitation,  sensible  displacement of the fragments,, and the foot 
CLINICAL SURGERY.
69
could be carried transversely with so much ease, that the malleoli and their
ligaments might  be supposed to be destroyed ; all indubitable symptoms of
fracture of the fibula with inward luxation of the foot.
  Accidents.—A large ecchymosis, extending  from  the seat of the fracture
and  the internal  malleolus to the corresponding surfaces of the foot and leg;
considerable tension and swelling around the articulation; pain acute, but
moderated by restoring the foot to its natural  position.  The house surgeon
merely applied a poultice; on the  next morning an  (Edematous  swelling of
the flesh had  increased the tension.
  M. Dupuytren  effected  the reduction, and applied his apparatus.   The
patient was feverish, (venesection, sweetened drinks, anodyne draught, diet.)
  On the third day, the pain ceased, he slept during the night, but the swell-
ing remained;  this was attributed to  the  pressure of the bandages, which
were loosened ; on the fourth day  the same swelling, shooting pains, redness,
heat around the external malleolus,  and fever; some  leeches were  applied
along the fibula ; the fifth, fluctuation observed in the centre of theccchymosis,
fever, removal of the leeches; the sixth, the  swelling  and tension diminish,
less  fever, fluctuation  more apparent; application of sedative resolvents,
acetate of lead  ;  the seventh, still improving, but there could  now  be per-
ceived a large abscess filled with fluid and fluctuating matter, extending from
the head of the fibula towards the seat of the  fracture.  It was supposed  to
be  filled with  effused  blood;  resolvents, with  the addition of stimulant
(camphorated spirit;)  the ninth,  still  better, the  absorption of the  blood
apparently commencing.
  On the tenth day, some imprudent movement of the  patient deranged the
apparatus, and  the limb  rested on the  folds of a  rumpled sheet; from this,
there resulted  pain, deep marks  upon the  skin, blisters  in different  spots,
fever; on the 13th, all these  accidents  had  disappeared, and the blisters re-
placed by superficial  ulcerations ; the swelling having nearly entirely disap-
peared, it was found that the internal malleolus had been fractured at its base.
The absorption of the  blood  is no longer doubtful, the abscess reduced one
third.  On the 15th, the limb, fatigued by the position in which it was kept, was
alternately laid on its internal and external side.
  On the fortieth day,  the fracture was consolidated, no deformity, the appa-
ratus was removed.  On the sixtieth, entire convalescence.
  Case  III.—Simultaneous Fracture of the Lower Extremities of the Tibia
and Fibula; Very  serious Consequences;  Treatment  by the New Method;
Cure with a Slight Deformity.—F. C. Michel, forty-eight  years of  age, on
descending a stair-way, suddenly  twisted his foot, and at the moment felt a
smart pain in  the  external inferior part of  the leg.  The limb  turned out-
wardly and bearing, both on the internal malleolus and the knee, had to support
the whole weight of the body, and caused a  new pain more violent than the
preceding, at its lower internal part.  The patient was immediately carried to
the Hotel-Dieu.
  There existed, pain, swelling, unnatural mobility, crepitation; and  besides,
1st, outward displacement of the foot, an obtuse and  depressed  angle, with
ecchymosis, mobility and manifest crepitation on the lower and external sur-
face of the leg, characteristic signs of a fracture of the fibula; 2d, backward
displacement "of  the  foot, extension of it  on the leg, a  projection at the 
TO                           LECTURES ON

distance of an inch and a half from the articulation, formed  by fragments
belonging to the body of the tibia; 3d, lastly, displacement of the inferior ex-
tremity of this bone backwards, which  had accompanied the foot in  this
movement;  evident fracture of the tibia.
  The house surgeon merely performed the reduction and applied the ordinary
apparatus for fractures of the leg.  A very painful inflammation supervened,
blisters appeared.   The next morning the effects of the reduction were small.
M. Dupuytren effected it anew, applied his apparatus, covered the parts with
sedative resolvents, and prescribed venesection and refreshing drinks.
  On the third day, the pain  was less violent, the progress of the  swelling
arrested ; the phlyctenae covered with  cerate.  On the  fourth and fifth, the
suppuration  from them began  to diminish; the projection of the upper frag-
ment of the tibia appearing to be about returning, the professor endeavored to
push the foot and inferior fragment forwards.  On the eighth, eschars on the
upper projection of the tibia and opposite  the fracture of the  fibula;  the
patient is uneasy;  tonic drinks were ordered.  On the twelfth, swelling less,
the sloughs began to fall off, the bones do not appear denuded, but the extensor
tendons were exposed.   On the thirteenth, the pus remaining under  the skin
was expelled by gentle pressure and proper dressings; the apparatus for frac-
ture  was removed.  On the sixteenth, the double displacement of the foot,
outwards and backwards, and the  projection of the fragments were  repro-
duced ;  the apparatus was reapplied with the addition of a piece under the
foot, in order to bring the inferior fragment of the tibia beneath the  superior
fragment.
  From the  sixteenth to the  twenty-first day, the dressings were  renewed
twice in twenty-four hours.   From the  twentieth to the twenty-fourth, the
pus, notwithstanding all our care, remained between the  tibia and fibula, and
an abscess appeared in front of, and below the fracture of the former. On the
twenty-sixth, the abscess was  opened,  and the  pus escaped.  On the thirty-
first, the skin had healed, the swelling had nearly disappeared, the limb was
in a very good state. On the fortieth  and following days, pains in the outer
side of the leg, opposite the fracture of the fibula, which were attributed to the
weight of the limb and the compression made on  part of the  wound.  The
apparatus was removed, and the limb laid on the opposite  side.  On the forty-
fifth day, the foot  was again displaced, showing that as yet consolidation had
not taken place; the forty-seventh, the apparatus was reapplied as on the six-
teenth day.  From the forty-seventh to  the fiftieth, flexion of the foot  was
painful; it was diminished.
  On the sixty-sixth day, the tendons  of the extensors began to exfoliate; the.
callus seems to have acquired solidity;  the apparatus was  removed and re-
placed by paste-board splints over the whole limb, sustained by a bandage.
  Sixty-ninth.  The foot yet appears turned outwardly; the apparatus was
applied for a third time and kept on for  forty successive days, and removed
only about the one hundred and tenth day, when the callus was found entirely
consolidated.
  Some time afterward, the patient began to  walk with crutches.  A  stiffness
of the joint, very analogous to a false anchylosis, the adhesron of the extensor
tendons to the cicatrix, a slight deviation of the foot backwards and outwards,
and  a projection in front of the superior fragment of the tibia rendered tho 
CLINICAL SURGERY.
71
convalescence long and difficult.   The patient left the hospital, after a lapse
of one hundred and eighty days, with the use of his limb, although it still was
less supple than the other, and presented some incurable deformities.
  Case IV.—Results of the Old Method in some Cases without serious Acci-
dents.—M. J. P. F. C....., a student of medicine, was running a race with one
of hfs companions, when they came to the edge of a ditch which they had not
perceived, and  fell  from a height of  about thirty feet upon dry and  stony
ground.   Both fell on  their feet, one had  merely a sprain, and the other,
M. C.....,  a fracture of  the fibula and internal malleolus, with double displace-
ment of the foot inwards and backwards, characterized: 1st, the fracture of
the fibula, by a depression on the outer and lower part of the leg above the
malleolus, and by the projection of the latter ; 2d, that of the malleolus inter-
nus by another unequal and ragged projection of the inferior extremity of the
tibia under the skin of the  inner and lower part  of the leg, and by a depres-
sion also unequal and ragged, at some distance below the tibia, formed by the
malleolus itself, which was carried outwards and downwards ; 3d, the luxa-
tion of the foot inwards and backwards, by the outward deviation of this part,
the upward direction of its external edge and dorsal face, its  internal edge
downwards, the sole outwards; and lastly, by the projection  of the inferior
extremity of the tibia at the interior part of the joint.
   Assisted by his companion, M. C. himself reduced the fracture, endeavored
to maintain the reduction by a handkerchief placed in figure of 8 around the
joint, and was in this state brought to Paris.   During the ride, considerable
swelling of the articulation took place, especially on its inner surface, with a
slight displacement of the foot.  On his arrival, the parts were replaced, and
the ordinary apparatus  applied, with this  difference that  the lateral  splints
went beyond the sole of the foot, and the bands placed at  the height of the
malleoli were tightly tied.   He was bled ;  however, the swelling  increased,
fever set  in, and he was delirious.
   On the second day, the apparatus was removed for the dressing, the swell-
ing extended to the knee and thigh,  the foot  retained its usual  position;
(emollient poultice and re-application of the apparatus ; he was bled  twice.)
Third day, spasmodic  contractions ; syrup of diacodium, which gave some
rest and induced sleep.  Fourth, phlyctenae on the anterior and internal face
of the  articulation; engorgement of the inguinal glands.   Fifth and sixth,
engorgement diminishes; the pain in the heel calmed by the application of a
wet compress under the tendo-achilles.  Seventh, the pain and inflammation
still diminished ;  but compresses wet with camphorated  spirit having been
substituted for the poultices, excited again pain  which  was followed  by
erysipelas.  Eleventh, small ulcerations take the place of the blisters and are
dressed with resolvents and emollients.   Fifteenth, the swelling  of the foot
sufficiently diminished  to manifest a depression of the fibula, accompanied  by
a  projection of the  external malleolus, no  endeavors were made to replace
these parts in their natural position, and nothing was done  but tighten the
band situated over the fracture.
   Twenty-fourth  day, little pain  in the instep,  none in the heel, the ulcera-
tions had healed.  Thirtieth, the apparatus was  removed, the parts  in the
same state as  before.   Forty-fifth,  apparatus removed, and  replaced by a
bandage in figure  of 8 around the  joint. 
72
LECTURES ON
  The depression of the fibula towards the tibia, the projection of the external
malleolus outwardly and of the internal inwardly, remain; the leg is, as it
were, atrophied ; the movements of flexion and extension very limited ;  those
of adduction and abduction still more so.
  Fiftieth day, the patient got up, and experienced acute pain on putting his
foot to the ground.  He walked for a month on crutches.
  Eightieth day, the movements of flexion and extension are yet embarrassed
and walking painful.  Acute pain still remains in the articulation of the foot,
that of the tarsus and metatarsus, in the heel, and especially  in  the internal
and anterior ligaments of the tibio-tarsal articulation.
  At  the end of eighteen months,  that is, twenty-one months after the acci-
dent,  notwithstanding exercise, and the use of  emollient, and sulphurous
pediluvia, opiated poultices, liniments of divers kinds,  the movements of
the limb, says the patient, the subject and narrator of this rase, were  still
limited ;  if I walk, or stand  for some  time, I sutler especially in the liga-
ments of the tibio-tarsal articulation ; the extremities of the tibia and  fibula
are larger; the limb  has very gradually recovered its volume, and  is at pre-
sent some lines smaller than the left.
  Such was the result of the old method applied  to  a fracture of the fibula
but little  complicated, treated by one of the first surgeons  of Paris,  and
seconded by the courage and skill of a patient then initiated in the art he has
since  adorned by his talents.
  Case V.—Result of the Old Method in cases of Fracture without Remarkable
Complication.—Lefebvre, being at  work on a bank, was thrown from a height
of twelve feet, by a mass  of earth under which  he  w:ts buried  for  some
minutes.   When extricated, he had at the inferior part of the  leg  a fracture
accompanied with  inward luxation of the foot, and twisting of this part on
itself, so  that the sole looked outwardly, the outer edge upwardly, and  the
inner  downwardly.   A large  quantity of blood was effused and  extravasated
around the joint; the skin otherwise sound.  The parts  were reduced, and
the limb placed in  the ordinary apparatus; the patient  being young and of a
sanguineous temperament was bled several times, and put on strict diet.
  The dressing was  only removed after eight days, a considerable outward
displacement of the foot had  taken place, a large abscess  existed on a level
with the internal malleolus ; it was  opened, and a large quantity of bloody and
fetid pus escaped.  Its cavity was filied with lint.  The  apparatus was  re-
placed by a circular bandage, some splints placed on the sides of  the joint,
and a flat piece of wood, were to be relied on to keep the foot in its situation.
From this moment the displacement knew no bounds, acute, continual  pain,
enormous swelling, violent fever with delirium were developed ; the skin  be-
came  tense, inflamed, mortified, fell off in flakes, and displayed the extensor
tendons of the toes, which exfoliated, and the ends of the tibia and fibula, both
fractured, the former at its base, the latter two inches from its malleolus.  A
very  copious  suppuration  was established, the patient  lost his sleep and
strength, and was  seized with fever and colliquative perspiration.   Amputa-
tion appeared indispensable, but was not performed.  Opium, bark,  numerous
dressings, but especially his youth  and good constitution, saved him.  After
some  months, the violence of the symptoms abated;  some shells  of bone were
separated from the tibia and fibula, at the time of the accident, others formed 
CLINICAL SURGERY.
75
by necrosis were carried out by the suppuration.  The actual cautery was
also several times applied in order to hasten the exfoliation.
  At the end of a year, the suppuration began to lessen, fleshy and vascular
granulations were developed on the bones, and the fractures consolidated.
After eighteen months the cicatrix, formed partly by the union of the edges of
the skin and partly by the production of  a new cutaneous tissue, covered the
seat of the injury.  The limb was then demi-atrophied, the foot entirely inca-
pable of furnishing any support to the body, and was,  moreover, displaced as
on the first day of the accident.
  Two years afterwards, the patient having at first used a compressing band-
age, then a dog-skin stocking, baths, and shower-baths, the limb began to
regain nutrition and strength.
   Forty-two years after his accident, he consulted M. Dupuytren for a cuta-
neous disease.   He then presented a perfect specimen of the disease of which
we are treating.   Moreover,  he walked with difficulty, the movements of
flexion and extension of the foot were extremely weak, those of abduction and
adduction impossible;  there existed, besides, numerous varices,  a chronic
tumefaction, which increased on the least exertion.
   Case VI.—Fracture with inward Luxation, and  Wound on the Outer Side
 of the Joint;  Treatment by  the  Old  Method;  Consequences of a Frightful
 Nature;  Amputation;  Death.—Madame L..... quite young, was riding in
 her carriage, and finding the  horse pulling back without being able to stop
 him, jumped, fell upon the inner side of the left foot, experienced an acute
 pain in the lower part of the leg, and was stretched  on the  earth unable to
 rise.
   A displacement of the foot was found, so that the inner edge  was directed
 upwardly, its sole inwardly, and the astragalus outwardly; a large and deep
 wound on the outer side of the joint, between the tendons of the lateral
 peroneal muscles, on the one hand; and on the other, the  peroneus  brevis
 and the  extensor communis  digitorum pedis;  the  projection  through  this
 lacerated wound,  of the fractured  tibia and  fibula, the latter at two  inches
 from its extremity, the former at the base of its malleolus; the patient suffered
 agonizing pain.
    After  the reduction, the bandage of Scultetus was applied, the limb placed
 upon a pillow, extended on the thigh.  On the second day, the  dressing was
 removed, the pain still remained as violent as ever: she was sleepless and had
 continual spasms.  A consultation proposed amputation, but it  was rejected
 by the parents.   The bandage was reapplied, the limb placed as before; she
 was bled, and anodynes administered.
    Third and fourth days.  Insomnia, pain, spasms, cries of  the patient.   On
 removing  the dressing, a resisting and elastic tumor was  seen around the
 joint; a mixture of pus and altered synovia, covered the surface  of the wound.
 Towards the eighth day, the preceding symptoms were much aggravated, and
  nervous sensibility became much exalted.
    In the evening of the ninth day, there came on involuntary painful and
  permanent contractions in the calves of the legs, the masseters, the pharynx,
  and the  posterior  part of the neck; closing of the jaws, difficulty in degluti-
  tion, continual expectoration, inclination of the head backwards; respiration
             10 
74
LECTl'RES  ON
painful, short, unequal, hurried ; pulsations of the heart frequent, tumultuous;
pulse quick, rapid, and bounding; cold sweat over the  whole body;  dis-
placement of the fragments, accompanied by intolerable pain, at each tetanic
spasm;  cries continual jactitation, expressions of deep grief on the features
(laudanum, in the dose of several  drachms daily); no relief.
  On the tenth, the  tetanic  affection  extended to nearly the whole body,
which was bent to an arc of a circle, at each spasm, resting  on the  occiput
and the heels (narcotics in larger doses, but without success).  Eleventh, the
apparatus removed, a phlegmonous inflammation was discovered on the inner
side of the tibia (emollients, narcotics).  Twelfth and thirteenth, all the tetanic
symptoms persist, and there is so great an excitability, that the slightest
noise, ray of light, or breath of air, the contact of unequal surfaces, is suffi-
cient to bring on spasms.  The abscess along the tibia was  opened, a large
quantity of pus escaped.  It was decided then, that the limb  should be left to
itself, and  the  laudanum  given by spoonsful during  the day, both by the
mouth and enemata!
  Fourteenth and fifteenth days, the foot forms with the  leg  a right angle.
The tibia and fibula protrude  from the wound ; the tetanus and its concomi-
tants, seemed to have reached their greatest degree of intensity, and to have
extended to  the alimentary  canal; indigested  liquids are  rejected  by the
stomach, and thrown out of the nostrils; the abdomen is as tense  and resist-
ing as a board.
  Sixteenth and seventeenth days, the opium is given in enormous doses, but
far from producing  narcotism, gives not the least relief.   Attempts were
made to reduce the extremities of the fractured bones which projected, and on
which, at each spasm, the  patient leaned with a  force that redoubled her
agony;  but  in  vain.   In  this  desperate situation, amputation,  which  was
considered a few days before as useless, was now resolved upon, as the only
chance of a  cure.  It was  performed.   The muscles were hard, very tense,
black, and apparently carbonized, as if they had been exposed to the  air.
Some vessels alone poured out blood; from the others not a drop flowed, and
left the wound perfectly dry.
  The symptoms still persisted.
  On the eighteenth day, towards evening, there was a remission but falla-
cious.   The patient expired at eight o'clock.
  Case  VII.—Reduction Deferred on Account of the Symptoms.   Unfortunate
Consequences of this Erroneous Principle.—A servant of  M. T., fell  from a
tree upon the inner edge of the right foot, he felt some pain  in the leg,  and
articulation of the  foot, and considerable swelling immediately took place in
the parts.
  A  country surgeon was  called, who  thought it merely a sprain, and pre-
scribed  venesection and some resolvents.  Another more  skillful, called in
on the fifth day, recognized, notwithstanding the swelling, the true state of
things;  but he decided on the internal use of some diluents, emollient topical
applications, leeches, an enlargement of the  wound  should it  be  necessary,
the opening of the abscess should one form, and on delaying the reduction
until the cessation of these symptoms.
  The symptoms remained unabated, several points of the skin and cellular
tissue were threatened with gangrene, a copious suppuration took place around 
CLINICAL SURGERY.
75
the joint, the life of the patient was endangered, and M. Dupuytren was called
in consultation.
   Struck with the extent of the displacement of the foot, the projection of the
internal malleolus and astragalus inwardly, the outward deviation of the foot,
the depth of the re-entering angle resulting from the depression of the inferior
fragment of the fibula, and the grievousness of the existing symptoms, con-
vinced that they  were owing alone to the disorder  indicated, and would
disappear on reduction, proposed the immediate attempt of this operation.
   The attending surgeon, however, rejected the proposal, considering the re-
duction as useless and dangerous; useless because, it might be effected at a
later period without difficulty;  dangerous, because the parts were not in  a
state which would bear the manipulation necessary to reduction.  The treat-
ment was therefore continued as before.  Large sloughs appeared opposite the
projection of the internal malleolus, others opposite that of the superior fragment
of the fibula, which not having followed the movement of the inferior fragment,
elevated the skin in a very painful manner.  The whole sub-cutaneous cellu-
lar tissue, was in a state of suppuration.
   The violence of the symptoms having diminished, and  a slight remission
occurring at the end of three weeks, it was considered proper to attempt  the
reduction.  It was  done by extension  and  counter-extension,  which were
painful, and almost useless; and afterwards, the ordinary apparatus applied,
so that the. inner splint did not go beyond the malleolus of that side;  and the
external was depressed below the corresponding edge of the foot, and a pad
doubled  for the length of two inches, pushed this part from without inwardly.
In vain! the foot could not  be  replaced  under the  leg, whether the means
were inefficacious, or the soft parts yet swollen by inflammation, changed in
texture and incapable  of yielding, would not allow the bones to assume their
proper position.
   These attempts were several  times  renewed during fifteen days,  with  so
little success, that they were abandoned. However, the patient after having
incurred a  new  danger from  erysipelas of the leg, bilious fever, excessive
suppuration, colliquative sweats and fever, was cured.  He is  still  greatly
deformed, and therefore walks with difficulty.
   Effects of M. Dupuytren''s Treatment.—1st. Its  most important effect, and
that on which the others, in a manner, depend, is the return of the foot to its
natural situation and relations with the leg; and the second, not lesslmportant,
is so exact a reduction of  the fragments of the fracture, that notwithstanding
the degree of displacement, after the cure is effected, in scarcely a single case
does there remain a vestige of the disease, or of the deformity it has occasioned;
3d, in the almost instantaneous cessation of the pain, caused by the displace-
ment and tension of the parts; 4th, in the rapid diminution of the swelling,
tension, and strangulation, occurring around the  articulation; lastly, in  the
annihilation of all the causes capable of producing a host of secondary symp-
toms.   In  short, it prevents  spasms,  involuntary contractions, tetanus;
inflammation and  suppuration  are  much  more rare,  and  always  less
dangerous;  gangrene  is  never developed;  the effused  blood is  easily
absorbed : the lacerations of the skin  are not so  serious,  and cicatrize like
ordinary wounds; internal affections  have  the means of getting well, and
the  necrosed parts of separating;  lastly,  this method, deprives  these 
76
LECTURES on
different consequences of their serious characters,  when  it cannot prevent
them.
   General Results.-r-The duration of the treatment, that is from the application
of the apparatus, is generally from twenty-five to  thirty-five days in simple
fractures, and in the  majority of those complicated with inward, outward, or
backward displacement; infiltration or effusion of blood, separation of  the
lateral ligaments, from  the  summit or the base of the internal  malleolus;
from forty to sixty days, in  those complicated with extensive injury of  the
soft parts, either internal  or external, inflammation, suppuration, abscesses,
&c; from sixty, eighty, one hundred days, or even more, in fractures compli-
cated with numerous scales from necrosis of the tendons and bones.
   Whatever may be the nature of the fracture, the time of convalescence is,
in general, double that of the treatment.
   In all  cases, the  foot is more or  less adducted, after  the removal of the
apparatus.  But the action of the muscles, or according to  circumstances, the
application of the dressing on the outside, are sufficient, the former after some
days, the latter in a few hours, to restore the foot to its natural position.
   Of two hundred and seven patients, treated according to  M. Dupuytren's
method, two  hundred and two  were cured; five only died, three of  them
of affections depending on the malady itself, and two of diseases independent
of it.
   In all those cured, the limb has preserved its shape,  with the exception of
two, in whom the heel was slightly elongated, and the inferior extremity of the
tibia projected forward.
   All recovered the free use of the foot;  one alone was affected with anchy-
losis of the tibio-tarsal articulation,
                          CHAPTER XI.

               ON FALSE ANEURISM OF THE BRACHIAL ARTERY.

  Venesection is commonly supposed to be so simple an operation as not to
be deserving of much notice.   That it is so considered is only an instance of
the low opinion generally entertained for the offices of minor surgery.   Hence,
however, we can account for the accidents which have so repeatedly occurred
within our observation, during the last twelve or fifteen years.  The hospitals
are filled with students who neglect bleeding; and these are followed by a
still greater number of young men,  who  are admitted  to practice without
ever having performed venesection.   How often may we see in the clinical
wards, five or six punctures in the skin, before the vein is opened.
  It is to this awkwardness that the phlegmons are to be  attributed  which
ensue in those cases; it is to this, that we  must likewise attribute the great
number of  cases of phlebitis,  latterly so common, and formerly so rare.  The
unfitness, and uncleanliness of the instruments, are frequently the cause of
these disastrous consequences.  But it is chiefly to inattention to a few simple 
CLINICAL SURGERY.
77
principles, that we must  trace  the  occurrence of those  arterioso-venous
aneurisms, diffused and circumscribed, to which we have so frequently called
your attention.  Towards the end of the year 1831,1 showed you two persons
who had been operated on and cured of those aneurisms; and we shall cer-
tainly have occasion to show you some more in  the course of the present year.
I can safely say, that for the last fifteen years, there has scarcely a year passed
without my being consulted at least twice for affections of this kind; and if
the same thing occurs in  the practice of  other surgeons, it is easy to infer the
frequency of these accidents.   Yet, very simple precautions, would seem to
prevent them.  1st, The operation should never be performed until the beat-
ing of the artery is felt;  2d,  the vein should never be opened in front of i
this artery ;  3d, other veins  should be preferred.  It is true that the latter
are sometimes difficult to be found, and that frequently they do not yield as
much blood as may be wished; but these inconveniences are trifling, compared
with the accidents, to which we at present allude.
  It has long been usual to appropriate the name of false aneurism to a tumor
formed of blood,  confined either within the arterial sheath, or in the cellular
tissue, which surrounds the vessels conveying red blood.   Atone time the
disorder shows itself immediately after a wound ; at another an interval more
or less protracted occurs after the infliction of the wound.   There are  two
kinds^-the primitive or diffused, and the consecutive or circumscribed, differ-
ences founded on the time and mode of the effusion of blood from the artery.
There are also other differences founded on the parts  constituting the  aneu-
rismal  cyst;  but they belong to the  false consecutive  kind.  Sometimes the
walls of the sac are formed by  the surrounding cellular tissue.   The lamellae
of this organic element, distended by the blood, which is extravasated slowly,
or drop by drop, are pressed against one another, and form a cavity of varia-
ble magnitude, opening into the wounded artery by a small aperture.   In
other cases the arterial  sheath is cicatrized during the employment of the
compress, while the lips of the  wound of the interior coats are still apart or
connected but with  an imperfect cicatrix.  When the compress  is removed
the lateral pressure of the blood raises up the  filamentous sheath, isolates it
from the fibrous tunic, and  disposes it into the form of a cyst.   In still other
instances the lips  of the wound in the artery are closed by a  membrane of
new formation, resulting from the exudation of albuminous  matter.  There
are cases on record of arterial  wounds, which after having  been  for  a time
staunched by a small clot supplying the  solution of continuity, upon this clot
being  displaced  by some accident,  a  false  circumscribed  aneurism,  was
formed.
  We have  seen persons  affected with encysted false  aneurisms, which it
was attempted to  cure by Anel's method,  but  in vain ; none of them were
operated on a second time, and in one case amputation of the limb was neces-
sary.
  True aneurisms of the brachial artery, at the  bend of the arm, are very rare;
the case reported  in Pelletan's  Clinique is  probably the only well authenti-
cated one on record.  The two cases  of  Paletta  and Plajani,  related  by
Scarpa, are not sufficiently precise; the same  may be said of those given by
Saviard and Hodgson.
  The same remark  does  not, however, apply to false aneurisms whether 
78
LECTURES  ON
 primitive or consecutive, occupying  this region; in  fact, these  were, for a
 long time, the only aneurisms known.  Galen, Celsus, jEtius, have described
 them, and given directions for their treatment.   It is rather surprising  that
 operations of this kind should have been practiced so  often without discover-
 ing  the  laws of the general circulation.  Long after this great  discovery,
 much  ignorance prevailed as to the course the blood  took on the application
 of ligatures to the arterial trunks.  Heister first pointed out the anastomoses.
 Before his time,  the process was explained by supposing a  second  brachial
 artery.  Sharp asserted this opinion as a matter of fact;  but  soon after,
 Molinelli, in the Acta Bologna, and Charles With demonstrated clearly the
 agents of the collateral circulation.  Later the injection of an arm in which
 the brachial had been spontaneously obliterated, furnished Pelletan an oppor-
 tunity of displaying the anastomotic passage.  Half a century has given  rise
 to many improvements in this  branch  of science; at present every thing
 is foreseen and  arrested, and the  surgeon knows perfectly what must take
 place.
  We have said that the lesion of the vessel in phlebotomy was one of the
 most common causes of this species of aneurism.  This accident is often the
 effect of a mistake.  There are persons in whom the artery lies so superficially,
 its volume, its color through the  skin, &c, are so striking that the operator has
 often been tempted to puncture it, until he fortunately recollected the caution
 required.  On laying his finger upon the vessel, the pulsations are immediately
 perceived,  the vein is found to lie more deeply at its side.  Whenever a vein
 is thus situated—running alongside of  an  artery, it ought to be treated with
 great caution. MM. Sauson and Begin in their excellent treatise on operative
 surgery,  lay it down as a rule, that we should almost never bleed where the
 artery  passes; for  my part, I should say, we ought never to open  the vein in
 such a situation.   How often have I denounced the practice of bleeding over
 the brachial ? I have constantly inculcated the propriety of choosing any vein
 but the one which is there placed.  Even when the fold of the arm affords no other
 sufficiently eligible, I recommend bleeding  in the fore-arm or even the  hand.
  Injury of the brachial artery by the lancet may take place in several ways.
 Sometimes the instrument meets the artery and  vein  at a point where these
vessels are not exactly in juxta-position, and an effusion of blood  follows.
 Again, they communicate by the wound, and  form an arterioso-venous aneurism,
 called also  varicose, because the vein is distended by the arterial blood.  This
species differs essentially from all the  others caused by the same means.  The
following is the case of false aneurism which has more  immediately given  rise
to the preceding remarks.
  Case I.—False  Consecutive Aneurism of the Brachial Artery from Vene-
section.—A man, aged about forty, of a good constitution, was bled about  two
months ago by a midwife, who pierced both the vein and brachial artery. The
blood immediately spouted out with violence,  and was of a bright red  color.
 Generally a jet from a vein does not extend more than one or two  feet, rarely
three ;  but when an artery is opened the jet is more energetic; we sometimes
 see it carried to the distance of  five or six  feet,  often reaching the ceiling or
the opposite wall.  The mode in which the fluid  issues is characteristic ; it
comes  in jerks, not in  the regular  stream which generally marks the venous
 flow.  It may happen, however that this  peculiarity  depends on  the vein 
CLINICAL SURGERY.
79
being placed immediately over the artery ; for, in this case the movements of
the latter may be communicated to the vein, and at first sight it may seem
that the artery is opened.  Several years ago I was called upon in great haste
by a distinguished physician who had just bled a patient.  Seeing the blood
come out in jerks, he thought the artery was touched ; but I presently ascer-
tained the cause, although the  physician, to this day, is persuaded that the
artery was injured.  It would appear that in the case under consideration,
the midwife was aware of the mischief she had done, for she  used very pow-
erful compression and applied a tight bandage.   The patient felt the parts
benumbed, and found  his forearm and hand swollen, owing apparently  to the
bandage;  he also perceived the existence of a considerable ecchymosis, caused
by  the effusion into the cellular tissue ; but there was  no tumor immediately
formed.  The puncture in the artery was apparently very small, and the com-
pression must have  closed it. But in about three weeks the aneurismal tumor
made its appearance;  at first very small, and marked by movements of dila-
tation and contraction synchronous with the pulse.  In the course of four
weeks it was about the size of a pigeon's egg.  On examination  one half was
found prominent while the other was buried in the substance of the arm.
  But how has the  tumor been formed ? When an artery has been punctured
as by a lancet, the margins of the wound must  be  brought  into contact by
compression;  but as soon as  the latter ceases, and the patient uses the limb,
the effort of the blood again opens the wound; it infiltrates, and  pushes before
it the lamellae of the  cellular tissue, with the skin  and forms a pouch ; this
increases and communicates with the artery by  the  small aperture.  This is
exactly what happened in the case before  us; the blood was at first repressed,
then it made an effort, a pouch was formed, it presently grew large, and all
the characters of aneurism are  now manifest.  If you  notice the tumor with
attention, fixing the eye on a particular point, you will observe the movement
of  dilatation and contraction;  and if you lay your  finger on its summit, you
will feel  it alternately raised  and lowered. By flexing the arm, the move-
ments are  very visible; but by firmly extending it,  they are  by no means so
apparent.  It was formerly thought that these two signs infallibly proved the
presence of aneurism, but we now  know  that the mere vicinity of the artery
will often  give rise to them; and still more so, if the tumor be situated over
the track of the vessel; so that suspension of the movements on the occur-
rence of compression, is not  a positive sign. A further examination  shows
that the tumor  is pointed, and that the integument at the point is very thin.
A  slight inflammation at this spot might cause us to fear an opening, attended
by a fatal hemorrhage.  In order then, to prevent so grievous an accident, we
                                               \   Compression has been
                                                treatment is tedious, and
must  adopt some prompt and efficacious method
already tried without effect; besides, this mode of
may lead to gangrene; and  in the present instance.it is inapplicable on
account of the wasting of the integument.  Ligature, is the proceeding that
remains to be adopted.  How shall we apply it ?  It would certainly be safer
to use two one above, and the other below the wound, because in this way we
avoid the communications which are sometimes formed when Anel's method
is used   But this operation involves several serious inconveniences.  In fact,
when we have suspended the  circulation in the part by compression, we have
then to cut through the  integument over the tumor, open the sac, empty it, 
so
LECTURES ON
and find the aperture in the artery (often no easy matter);  then tie the artery
without including the nerve, also difficult owing to the flow of blood from all
parts.   Even supposing the operation  performed as successfully as possible,
the extensive wound in the integuments may occasion a phlegmon.  The flow
of blood, I have said, may much embarrass the operator; this is a point of so
much importance as to deserve a few moments' attention.   In the course of
any operation, we are almost always sure of being able to suspend the  course
of the arterial blood by compression ; this, however, is not the case with  regard
to the venous blood; simply for this reason:  in the former case the compres-
sion acts on a single vessel; in the latter, it should act on a multitude of dif-
ferent  branches, at one and the same time, in order to be effectual.
   Since, then, a ligature to both ends of the artery, though more certain, is
tedious and troublesome, and often very difficult, we may with reason have
recourse to the  method which consists  in the application of a single ligature
above the tumor.  This method is much easier  than the other, for, we avoid
by it the infiltration of blood, and the greater  part of the obstacles just alluded
to.  It is accordingly the process most commonly employed ;  yet we  should
not omit to add, that when it is applied to arterial parts which  have numerous
anastomoses, it  fails. This is particularly observed to be the case in aneurisms
of the primitive carotid and its divisions; the ligature placed below the tumor
puts a  stop to  the pulsations  at first, but they soon reappear; and the same
thing may occur at the bend of the arm.
  The  reason why we have  established a distinction between simple false
aneurisms, and  those of the arterioso-venous kind, is, that  in the former, the
method of Anel arrests the pulsations, while  in the latter, it has not the same
effect.
   We  shall now briefly describe the part which  is the seat of the disorder.
The arm is composed of several  layers in the following order: First, (pro-
ceeding from without inwards,) we find a smooth envelope, then a fatty cel-
lular layer, permeated by a great number of veins, lymphatics, and superficial
nerves; a third layer common to the whole contour of the arm, is composed
of brachial aponeurosis; more deeply there are three sheaths, the outer and
upper of which, as  well as the posterior, belong  to different muscles; the
third, the most important in our present  inquiry, is common to the  biceps
placed  superficially to the  coraco-brachial and  anterior brachial  placed
beneath; while between them is perceived  the  external  cutaneous  nerve
which perforates the coraco-brachialis  above.  At its outer and  inferior side,
this sheath contains the trunk of the radial nerve and an arterial branch; at its
inner side along its whole length, it embraces the brachial artery with its two
attendant veins, along with the median nerve, the relations of which to these
vessels are of the highest  importance; above, this nerve is external;  in the
middle it is anterior; and below it is internal.  Thus we must seek the artery
above,  inside the median nerve, and  outside the cubital; in  the middle, we
must avoid, with the greatest care, touching the median nerve, which the
artery  crosses in passing one time in front and other time behind.  Below, we
must constantly seek the artery outside  this nerve, the cubital having now no
longer any relation to it.   Lesion or  ligature of this nerve would  occasion
numbness or palsy of the limb. The internal edge of the biceps is also  a good
director in finding the brachial artery; on opening the sheath of this muscle, 
CLINICAL SURGERY.
81
towards its internal part,.the  artery is soon seen in all its relations to the
median line.
  In performing the operation, the patient was put in a horizontal position on
a bed,  the arm semiflexed; an incision, three inches in length, was made to-
wards  the lower and inner part of the arm;  the skin, cellular substance, and
aponeurotic layer were successively divided.  Having reached the sheath of
the vessel, it was raised with  the forceps and opened;  this aperture beirig en-
larged for two or three  lines with a director and  bistoury, the end of the
flexible silver  sound was passed beneath the vessels by means of which the
ligature was conveyed.  In  order to prevent the lesion  of the nerves and
veins,  the instrument carrying  the  ligature should always be introduced
between them.   M. Dupuytren  at first moderately tightened the ligature, the
pulsations ceased;  he  then slackened it, they returned.  Certain then that
the diseased  vessel was included, he tied  it with  two simple knots.   The
wound was then cleansed and brought together by a bandage.  He recom-
mended a delay of  the dressing until all danger of hemorrhage should have
passed over. For two days pressure was maintained  by means of a pyramidal
compress, which was- removed in order to examine the tumor; it had dimi-
nished, and was entirely free from pulsation.  In five days more the wound
had united with the exception of the point of passage of the thread.  Every
thing promises  entire success, and that the patient will  be cured as the one
whose  case we will now detail.
  Case II.—(Communicated by Dr. Marx.)—A pedlar about thirty-two years
of age, of a strong dry constitution, being bled  for a violent headache, had the
brachial artery opened along with the vein.  The surgeon saw the accident by
the vermillion color of the blood, by its alternate jerks, and permitted  it to
flow until syncope came on.  By  means of  compression he then endeavored
to prevent a recurrence of hemorrhage, and  desired  the patient to continue it,
without, however, informing him of the injury he had met  with.   The wound
in the  arm cicatrized, the patient thinking  he had  nothing to fear, omitted
the compression; a tumor appeared  at the bend of the arm and increased
daily.
  On coming to the Hotel-Dieu, the tumor was as large as the closed hand,
with all the characters of  its  aneurismal nature; the pulsations very evident
when the arm was flexed, disappeared on extending it.  Compression above
the tumor made them cease;  below, rendered  them  stronger and more appa^
rent.  It  was inferred from  these facts: 1st, that the opening in the artery
was not large;  2d, that there  was a defect of parallelism between this opening
and that of the aneurismal sac; 3d, that the tumor received its blood only
from one quarter; 4th. that the greater part  of the blood contained in the sac
was coagulated, and that consequently a well managed compression would
effect a cure.  It was accordingly  employed  and assisted  by the use of ice;
but as  there was not much benefit derived from it, at the  patient's request, the
operation  was agreed upon.                   .......  .     i. ■  c  •
  It was performed in the amphitheatre, the patient sitting m a chair facing
the spectators, and  the professor placed behind the arm affected. The several
steps of the operation were  similar to those of the  preceding case; but the
patient having fainted when the ligature was  applied, and about to be partially
tightened, it was necessary to wait for some  time, lest the  nerve should  have
                11 
82
LECTURES  ON
 been included.  Then being assured that the ligatureVas in its correct situa-
 tion and that the pulsation of  the tumor could be arrested it was tied.  The
 wound was brought together by adhesive strips, and dressed with a perforated
 piece of linen, spread with cerate, charpie, compresses, and  a bandage; the
 patient carried to bed, and the tumor covered with  ice.
   During the evening the skin of the arm recovered its natural temperature;
 the patient passed a good night, and complains of nothing but a pricking sen-
 sation in the fingers.  The next morning, pulsation returned in the radial
 artery, then ceased, and again returned.  The  ice  was continued.  On the
 fifth day the dressing was removed, and an erysipelas found to extend over the
 arm and  forearm.  The ice was  suppressed.   The erysipelas  treated by
 blisters to the most inflamed spots, and by this means soon disappeared.
   Eighth day, the tumor opened and discharged a mixture of pus and blood,
 which  lasted for several  days.  Tenth  day, the ligature came away without
 any hemorrhagy.   Fifteenth day, the different openings in the aneurismal sac
 were enlarged.  The  clotted  blood in  the tumor was removed, hemorrhage
 came on, the wound  was plugged with lint.  Suppuration  was  afterwards
 established in the tumor, the dressing removed,  and  pus alone escaped.
From this  time, the wound diminished daily;  that of the ligature healed;
nothing remained but a small opening leading to a narrow sac, the remains of
the aneurismal sac; the motion of the arm  and hand returned;  the patient
could write;  and in two months was perfectly cured.
  It may probably be asked, whether forced  exclusion of the arm, kept up
 for some time, and assisted by ice and compression, might not have  rendered
the operation  useless.   But continual extension would have been very fa-
 tiguing and painful, and might have caused anchylosis,  which would  have
 been a very serious affair.
   Compression and ice would undoubtedly have been useful; but they must
 have been continued for some time, and are not free from some danger-  The
 operation which we have described, was adopted by M. Dupuytren, after an
 examination of the tumor had removed all idea of a varicose aneurism.  The
 length of the operation was owing to  the  fainting of the patient and the
 fatiguing position of the operator.   The arm being extended horizontally,
 the blood fell in sheets upon the deep seated parts, and discolored them uni-
 formly.  Thus, observed the professor, the  difficulties which I created for
 your instruction, should be a guide to you.  In  this operation  the patient
 should be laid on a bed; the arm supine, and freely extended, then presents
 to the surgeon a conspicuous surface, easily accessible to the fingers, eye, and
 instruments.
   The circulation returning so quickly, made us fear that the operation had
 been useless; the application of  the ice  was continued in order to prevent the
 reflux of blood in the tumor.
   M. Dupuytren  has first pointed out the phenomena, which occur in the
 anastomotic  circulation.   He  has  proved that the blood arrives below the
 ligature long before  the artery begins to pulsate. The distension of the
 vessel, its elasticity, are the first stages of the recurrence of  the circulation-
 Later a slight agitation is  perceived, very irregular in force  and quickness.
 It re-appears after some time and indicates certainly the return of the heart's
 influence.  This latter phenomenon, which is always looked upon as the crite- 
CLINICAL SURGERY.
83
rion of the success of the operation, may disappear after a longer  or  shorter
time.   Thus we have seen the circulation suppressed at the end of 15 days,
one, two, and three months, and gangrene follows.  But not a single  case of
gangrene has followed the ligature of the brachial  artery,  when  the  nerves
has not been included.   The most frequent of these  accidents is  the re-es-
tablishment of  circulation in the tumor; when this takes place, both ends of
the artery should be tied.  Erysipelas is generally successfully  treated by
blisters.  We  will make but another remark concerning  the ligature; it
generally comes away on the 10th day; whilst in another patient operated on
for aneurism of the crural artery it remained until the 25th  day;  it  will be
understood that the time varies according  to the  calibre of the  artery, the
degree of pressure  exercised  by the thread,  and the quantity  of cellular
tissue embraced by the ligature.
   Case III.—A young man, twenty-two years of age, a pork  butcher, was
bled by a physician in the median basilic vein ; the operator crossed the vein
from side to side, and punctured the  artery; bright red blond issued forth  to
a great distance.   Perceiving  the  mischief that was  done, having taken the
requisite quantity of blood, he was anxious to apply a steady compression on
the wounded part.  The  hemorrhage was  at  first arrested, but did not fail
presently to begin anew.   The patient became uneasy, and came to the Hotel-
Dieu.  Nine days after the accident, the  tumor  had attained the size of a
walnut;  it was soft and  fluctuating, and  presented pulsations  isochronous
with those of the heart; and there were movements of expansion and  con-
traction, observable at the bend of the arm.   On compressing the artery above
the pulsations  ceased; and increased when compression was made below.
The existence of  aneurism was thus  well  established.  The wound in the
vein cicatrized, nothing remained to  show that it communicated  with the
artery.  Ligature, being considered the best operation, it was performed next
day.  The patient was kept in bed, his arm in a state of supination ;  and in-
cision, two inches and a half in length, was made above the  fold of the  arm,
and along  the  course of the brachial  artery.    The sub-cutaneous  cellular
tissue was found infiltrated with blood ; the fibro-cellular sheath surrounding
the median nerve and brachial artery, was dense and  thick, but easily lacera-
ble ; a very large vein that ran across the incision was divided.   The sheath
was opened, and  the ligature  passed, as it seemed, between the  nerve and
artery, by means of a canuletted sound, and needle-shaped  stylet.   But the
patient suffered a sharp pain, and numbing sensation, when  the ligature was
tightened, which showed that the nerve was not free.  This led to a  new
search and re-adjustment of the ligature.   The pulsations ceased, and no pain
was felt on its  being tightened the second time.  The arm was dressed  as  in
the preceding case.
   No accident occurred in the after treatment.   The fore-arm preserved all
its temperature and natural color.  On the third  day, pulsations began  to be
perceived in the radial and ulnar arteries, but  none in  the  tumor.   On the
tenth day,  the  ligature came off, and the wound was nearly healed, one angle
alone discharged a tittle healthy pus.  On the nineteenth clay, the patient was
able to leave the hospital.  (Case by  Dr. Paillard.)
   Here was another successful instance of the benefit of a single ligature,
between the injury and the heart.  However, we are not always so fortunate 
84
LECTURES ON
in managing so easily this dangerous affection ;  in a great number of cases it
becomes necessary to tie both ends.   The following case  from the private
practice of M. Dupuytren, will serve as an example of this remark.
   Case IV.—An envoy from Brazil, who had arrived not long since in Paris,
while mending a pen, and cutting the  nib  on his  thumb nail, let  the  knife
slip out of his hand.  It was thrown  upwards several  feet, and then  came
down perpendicularly on  the anterior and exterior  surface of his left arm,
as it laid on the  desk;  the blade was very sharp, pierced the skin and
subjacent parts,  and opened the  radial artery.  An abundant  hemorrhage
took place.  A surgeon who was immediately called in recognized  the  acci-
dent.  Hoping to succeed by  compression  alone, he methodically applied
compresses, and a roller from the tips of the fingers to the seat of the injury.
The  dressing remained  undisturbed  for  several days, and there was  no
hemorrhage during the time.   When it was at length removed, to the surprise
of all parties, the wound in the integuments was perfectly well ; but mean
time aneurismal tumor was formed, which it was hoped to subdue by bandages;
but in vain, the tumor increased every day.  I was  called in, and  proposed
the ligature of the artery; the patient consented.  It was done. One ligature
was used, and the moment it was applied the tumor ceased to beat,  as-did the
radial and ulnar arteries.   The wound was dressed, but  this was scarcely
finished,  when the  circulation was  re-established in the lower part of  the
arteries just mentioned,  and  the tumor began  to  pulsate very distinctly.
Another  ligature was  now  applied below the tumor,  when the  pulsations
ceased altogether.  In about a fortnight, the patient  was quite well of his
double operation.
   Case V.—A wine dealer, aged forty-five, of good constitution, but subject
to haemoptysis, had himself bled by his medical adviser.  The lancet was
scarcely  withdrawn from his arm, when the blood spouted out in arched jets;
strong compression was immediately tried, but without success; and in  the
course of a month, when  the patient came  to me, he had at the bend of the
arm an enormous tumor.   The operation was imperiously required, and per-
formed at once.   The moment the ligature was applied, the pulsation ceased
in the tumor; some persons, however, fancied  they perceived feeble oscilla-
tions in  the  radial artery.   The night after the operation,  the patient had a
violent attack of haemoptysis, which made it necessary to bleed him twice.
Indeed, it is not rarely observed that, after  the  ligature of a large arterial
trunk, symptoms of plethora and hemorrhagy appear.  There  are sometimes
palpitations,  uneasiness,  temporary defect of  tight oppression; sometimes
epistaxis, haemoptysis, &c; one or two bleedings in these cases, are generally
successful.
   In this man it was remarked that pulsations were rapidly perceptible in the
radial artery, in  consequence no doubt, of the state of the capillaries; in  the
tumor, however, they never re-appeared.   This was probably owing to the ex-
istence of a clot, between the artery and the tumor. The case, however, warns
us to be prepared for the recurrence of pulsations in the tumor, when the anas-
tomoses are numerous, and the circulation is soon  restored to the  vessels in
which it had ceased.  The patient, in the present case, was fortunately not
in this predicament; he got well rapidly, and left the hospital about four weeks
after the operation. 
CLINICAL SURGERY.
85
  I shall conclude with an observation, to which I attach some importance—
namely, that ligature of the arteries, performed above their lesion, is almost
always successful when that lesion is recent, and when the edges of the open-
ing in the vessel  are fresh, and disposed to unite; but that this operation
presents far fewer chances of success, when this lesion is old, the edges cica-
trized  and, therefore, incapable of adhesive inflammation.   Ligature of the
upper end of the artery suffices in  the former  case, whether the centre of
effusion be in communication with the external air or not; whilst in the latter,
ligature of both ends of the vessel is required.   There is no exception to this
rule, unless where the injured artery is situated at the extremity of a limb, its
numerous and varied communications then render indispensable the  ligature
of both ends.   This important theory explains facts, which, till the present
time, it has appeared difficult to understand.
                          CHAPTER  XII.

                     ON FRACTURES OF THE PATELLA. '

  Fractures of the  patella present many interesting points, on which authors
are as yet divided in  opinion.  Such  are particularly the manner in which ,
they take place, the most appropriate mode of treatment or apparatus,  the
formation of callus, and above all, the  possibility of effecting the  complete
reunion of the fragments.
  Six patients, affected with this species of fracture, have been treated in the
Hotel-Dieu, since the commencement of the present session.   All  presented
the transverse fracture; not one, the vertical.   Five were perfectly cured,
without the least deformity, and recovered the entire use of the limb.  One is
as yet under treatment.  In his case the fracture was the result of a fall on
the' left knee ;  it was accompained by pretty considerable swelling, owing to
the effusion of blood  in the soft parts, and of  bloody synovia in the articular
cavity.   However, the injury was recognized at once.   The finger carried
over the patella, met with a wide space, dividing the bone into two fragments,
one superior, the other  inferior;  besides,  both could be moved in contrary
directions, and crepitation was evident;  notwithstanding the serious accidents
complicating the fracture, the patient has rapidly progressed towards a cure.
But, as frequently happens, the uniting bandage acts  only by having some
point of support on  the  skin, the  latter  carried  from before backwards, has
formed a fold, interposed between the fragments, like a wedge, and which has
kept them separated.   A new plan has been adopted.
  Fracture of the patella may be produced  in two ways;  either by a direct
blow on the anterior part of the knee, or by violent exertion of the extensor
muscles of the leg.  However, it sometimes happens without any considerable
increase of muscular exertion; cases of this  accident  are  related, resulting
from jumping, attempting to kick, or prevent  a sudden fall backwards.  In
all these circumstances, the patella touches only by a single point the anterior 
86
LECTURES  ON
face of the condyles of the os femoris, at the same time the thigh being demi-
flexed.the lower ligament of the bone and the  extensor  tendons, draw its
extremities strongly backwards.  During the exertion which then takes place,
the femur serves as a fulcrum to the  powers which act  above and below on
the patella, and fracture of the latter bone takes place.
  A large number of these  fractures have  been improperly attributed  to a
fall on the knee.  It has been forgotten that the weight of the body, almost
entirely, is borne by the projection of the tibia, to which the ligament of the
patella is affixed; on account of the flexion of the leg at a  right angle, this
projection first strikes the ground and receives the  blow, whilst the  patella,
held up by the rectus femoris muscle, and as it were, preserving its vertical
position, can only touch the ground at its inferior extremity.  Falls upon the
knee, are, therefore, very frequently the result, and not the cause of fractures
of the patella.
  Sharp and contusing weapons directed  against the knee,  may fracture di-
rectly the patella into a greater or less number of pieces; this accident  may
happen in a fall, if the  leg is strongly flexed on the thigh, and the bone strikes
violently  against the inequalities of the earth; but even  in this case, the
muscles play a conspicuous part.  We know, indeed, that the slightest  blow
upon the knee, will produce contractions of the rectus  femoris, and without
much force they will fracture the bony fibres of the patella;  it is probable
that to this cause, is to be attributed the frequency of transverse  ruptures,
and the rarity of those in a vertical direction.
  As  we have already said, there are remarkable differences between fractures
of the patella produced by muscular exertion, and those resulting from direct
force  applied to the knee.  The former are rarely complicated by contusions,
lacerations of the soft parts of the articulation, unless from a subsequent fall;
the latter, on the contrary, are often accompanied with extensive disorder of
the surrounding tissues ; sometimes the patella has been, as it were, crushed,
and reduced in many fragments, scattered in every direction, and at the same
time, the  articular capsule has  been opened and filled with effused blood.
These complications aggravate seriously the principal disease; the  following
is a case in point.
  An old man, laboring under fracture of the patella with  slight separation,
but accompanied with serious complications,  perished  during the month of
November last, from cerebral and enteritic  disease.   The knee was carefully
examined. At first sight the fracture could scarcely be observed, the patella
was movable, the groove formed by the  separation, imperceptible to the  eye,
was sensible only to the finger;  the articulation being opened was internally
of a deep red color, filled with a bloody and purulent matter, and in sufficient
quantity to be collected with the scalpel; there had  been,  therefore in this
spot, inflammation terminating by effusion.   As to the blood, it was owing  to
the contusion received at the time of fracture.  The synovial membrane was
extremely red, on account of the development of the blood-vessels.   The
cartilages were also inflamed.   These disorders of the joint, account suffi-
ciently for the symptoms of which the patient died.
  On the inner face of the patella, the transverse groove could be perceived,
but it was lower than the outer groove.  The bone had, therefore, been broken
transversely, from below upwards, and from in front backwards.  The two 
•
                           «T.INICAL  SURGERY.                         87

fragments had closely united ; no trace of fracture could be perceived on the
tibial side, and it was very slight on the side of the fibula.
  On the preservation or destruction of the fibrous  covering of the  patella,
there depends equally a very remarkable difference in the facility with which
the fragments can be kept in their  proper  situation and the solidity of the
parts after  the  cure.  This fibrous covering form a kind of sheath, which
contains the fragments, opposes  an immoderate separation, and  serves, as it
were,"as a basis for the substance which is afterwards to unite them.  It will
be seen how carefully they should be treated, and how improper are the move-
ments of extension so often made, in order to ascertain the existence of the
fracture of the bone which it protects.
  Although the vertical fracture is much less common than the others, it does
sometimes occur, but is rarely treated of in  modern works on surgery.   The
oldest  case, and probably the most precise, is  to be found  in the treatise of
Lamotte.  The fracture resulted from a fall from a high place; the two por-
tions of the bone were slightly separated, although the limb was demi-flexed ;
it was  completely extended, the knee covered with resolvent compresses and
a moderately tight bandage.  In twenty days the consolidation was  perfect,
and  the man went about  his ordinary business.   Nearly twenty years ago, a
middle aged man, was admitted  into the Hotel-Dieu, who having fallen from
a considerable height, had fractured a great  number of bqnes; the knee was
much contused and deformed.   He died on  the third day.  The examination
of the knee showed a longitudinal fracture of the patella.  The bone was
divided in almost equal portions; the fragments gave a very manifest crepita-
tion, and  could  be moved at will  in every  direction, the cavity of the joint
contained a large quantity of sanguineous fluid.
  Six months after a man was brought to the hospital who had been thrown
down, when drunk, by a carriage; the wheel had passed over  the right leg,
knee and thigh, and fractured the patella  vertically.  The crepitation was
evident, as also the vertical displacement of the fragments; it was treated by
position  and an  appropriate bandage.  He was nearly cured, when he was
attacked by a  pleuro-pneumonia, which carried him off on the twentieth day
after the accident.   The parts  were  carefully examined, and a well formed
callus found, uniting the fragments, and allowing only a very  limited move-
ment.   The relation of the articular surfaces was exact, and every thing pro-
mised  a perfect cure in less than a month.
  Three years from this  time, a  man was admitted into the Hotel-Dieu, for
varicose ulcers of the leg.   On examining the diseased limb, the patella was
found  larger and presenting  a  considerable  vertical projection.  Nothing
similar existed in the other leg.  Being questioned as to this deformity, the
patient said that several years previous he had fallen and broken his leg and
thio-h in several  places.  The patella had  also been fractured and  its size
evinced  a pretty considerable development of callus.   When the extensors
of the le»- were relaxed the motions of the bone on the condyles of the femur
could be "easily effected ; but then, a pretty well  pronounced projection was
felt against the condyles.  The  fracture had evidently been vertical, and this
irregular union had resulted from  the attempt of nature alone  to cure the
disease or an improper position of the parts.
  The following  is a striking case of this species  of fracture: 
 88                            LECTURES ON

   A servant-girl, nineteen years of age, small and of a  weak  constitution,
 laboring for a long time under a pulmonary catarrh, with very copious mucous
 expectoration, fell from the second story upon a grated glass partition,  which
 gave way under her.   On reaching the pavement of the court, she was wounded
 in the left knee and slightly in the head.  She rose, but was unable to lean
 on the injured limb ; she was laid in bed, the wound brought together and dry
 dressings applied.  Brought afterwards to the Hotel-Dieu, the dressing was
 removed and the wound found ununited, the patella broken into two unequal
 fragments.   The bruised parts being the seat of considerable sanguineous
 infiltration;  suppuration was copious, and  the patient  suffered acute  pain
 throughout the whole  limb.
  Her general situation was unfavorable ; the tongue was  furred, red at the
 edges and point, covered at its  base and middle by a white exudation, her
 ideas confused, skin hot and dry, great thirst; complete anorexia, sleeplessness
 which yielded only to opiates.  Moreover  the abdomen was indolent, there
 was no diarrhea, expectoration copious, and merely mucous. The patient died
 from the internal disease.
  It follows that vertical fractures of the patella are not very rare;  and that
 the facts observed, prove that they always depend on the direct action of
 external causes, and are generally accompanied with wounds and contusions,
 which demand special attention on the part of the surgeon.
  The diagnosis of fractures of the patella is generally easy.   In the trans
 verse  fracture, if  the patient is standing, he  falls, unable to rise,  or if he at-
 tempts it, he immediately perceives that the  limb  has  lost its strength  and
 solidity ; he cannot walk, but drags himself backwards, with the leg extended
 and uses the sound limb.  These circumstances indicate already the existence
 of the fracture; but on examiningthe knee, it is found deformed and flattened,
 and by placing the finger on the patella, it is easy to  feel  the separation of
 the fragments of the bone, the upper one is drawn by muscles, whose  tendon
is inserted into it, whilst the other is kept down by its ligament.   By extend-
 ing the limb,  and raising the whole extremity on the pelvis, the muscles of the
anterior part of the thigh are  relaxed, and the separation nearly entirely dis-
appears.  At this time crepitation may be perceived.  The swelling of the
knee is scarcely ever an absolute obstacle to the establishment of the diagnosis;
the thinness of the integuments and the softness of the tumor, generally
allow  us to reach the patella, and recognize its solution of continuity.  When
it is oblique or longitudinal, it demands a more attentive examination, on ac-
count of the  smallness of the separation of the fragments, which are unin-
fluenced by muscular exertion.   However by semi-flexing the leg on the thigh,
 we  can produce, as did Lamotte, a more evident disjunction of the portions
of the bone.  In all cases, if serious accidents, as a considerable tumefaction
of the joint, prevented a certain recognition  of the fracture, it would not be
here more inconvenient than in  the other  species of fractures,  to apply to
them proper remedies, before proceeding to the reduction.
  After the remarks made, it will be soon perceived what should be the basis
 of the treatment of these fractures.   It consists in the application of means
 appropriate  to the accidents which complicate them, and the attempt to pro-
 cure the re-union,  as  exact  as possible of the portions of the bone.  Rest,
 general  and  local bleeding, emollient topical applications, and  refreshing 
CLINICAL SURGERY.
89
drinks, generally accomplish the first intention.  We must not lose  sight of
the general state of the patient, of the digestive and  cerebral organs, whose
functions are often disturbed in consequence of the  agitation, or from idio
syncrasy, of the wound itself.
   As to the union of the fragments in cases of transverse fracture, their sepa
ration being  caused'and maintained by the action of the extensor muscles,
which are inserted into the superior fragment, and by the flexion of the leg,
the first indication is to neutralize this muscular power, and place the limb in
a proper position.  This position, absolute rest, until perfect consolidation of
the callus, and the application of an apparatus suited,  on the one hand, to
keep the fragments in  exact apposition, and on the other, to resist the contrac-
tions of the extensors, resulting from the inconsiderate or involuntary move-
ments of the patients,  are essential  to  a perfect  union.  The apparatus
of M. Dupuytren is  the following.   It  is composed  of—1st,  an  inclined
plane formed by pillows placed upon each other,  and extending from the
heel  to the  tuberosity of the ischium, having  the  double intention of op-
posing the contractions of the flexor muscles of the  leg, and by position of
relaxing the  extensors; 2d, two compresses, about twenty inches long and four
wide, made of unbleached, thick, strong linen; they should be sewed at the ends
and slides, one having slits (fenetres) at one end, these slits being also sewed ;
the other is divided into three strips at its opposite  end; 3d, two  bandages
of three fingers breadth, and nine or eleven yards in length ; 4th, some gradu-
ated compresses six or seven inches long, and seven  or eight lines thick.
   We begin by inclosing the foot in some  turns of the bandage, placing on the
part of the turns corresponding to the dorsal face of the foot, the end of one of
the long compresses; it is to  be  fastened with pins  and  a few  turns of the
bandage, and then extended on the anterior surface  of the leg.  That done,
the bandage  is continued along the limb, as far as beneath the patella; at this
point its extremity is brought  down parallel to the leg.
   Whilst an assistant supports the posterior muscles of the thigh, the operator
passes around it, at its middle, three turns of the  second bandage; places
then the end of the second long compress, on its anterior surface, fastens  it
by two or three new turns, brings down the  upper end, makes two or three
circular turns, and then continues the bandage as far as the upper edge of the
patella; what remains of it is spent upon the thigh. We then  place above and
below the patella, the graduated  compress, and passing the  strips of one of
the long compresses  into the corresponding slits of the other, the fragments
are brought together by drawing on the strips.  Lastly, the two ends of these
compresses are fastened, one upon the thigh, the other upon the leg.
   The dressing being finished, the limb is placed  on the inclined plane, of
which we have spoken, in such a manner that the heel is  much higher than the
knee  and thigh.
   It will be seen that this apparatus, although consisting of four pieces, each
having a distinct action, together tends to but one end;  nevertheless with all
its advantages, it would be useless  unless  seconded by  the docility of the
patient.  About three weeks ago, two  patients were cured at the  hospital,
both affected with fracture of  the patella,  one of them disorderly and unman-
ageable, constantly moved about and several times removed the dressing; in
his case there was a separation of nearly an inch; the  other bore with fortitude
           12 
90
LECTURES  ON
 and patience, the rest and compression of the bandage, and was  discharged
 with a small groove scarcely admitting the head of a common pin.
   This fact and many others observed by M. Dupuytren, during a long and
 extensive practice, have left no doubt in his mind as to the possibility of pro-
 curing a close union of the fragments, by the formation of an  osseous callus,
 if the parts are kept in  perfect contact during the whole time necessary for
 their consolidation.
   Generally,  union  takes  place  by  means of a  fibro cellular  substance.
 Astley Cooper and other surgeons, have observed,  with much attention, frac-
 tures of the patella, and the neck of the femur;  and after having exposed  these
 bones to the action of turpentine, have found between the fragments a trans-
 parent  fibrous  or  fibro-cartilaginous substance.  When this  celebrated
 English surgeon  was in Paris in 1829, I exhibited to him some specimens of
 an immediate reunion, and in which this fibro- cartilaginous substance could
 not be seen.   This was owing undoubtedly to the long interval of  time  after
 the cure ; the callus had time to become strong.   Observe what takes place
 in vertical fractures; here, as there is no  separation, the callus  is always
 osseous after six months or a year.  It is, therefore, this separation, produced
 by muscular action, which opposes the ossification.
  But however firm and well applied the apparatus may be, its action is  con-
 stantly weakened by the relaxation of the bandages, and the shrinking of the
tissues it incloses; whilst the muscular power increases in the same ratio.
 Again, the compression becomes sometimes insupportable, and we are obliged
 to relax or entirely remove it.   Sometimes it produces serious accidents, in-
 flammation, tumefaction, and excessive tension of the parts, and even gangrene.
 These results follow the more easily if we apply the dressing soon after the
 accident.  Therefore, at first we  should  be careful  to  apply it moderately
 tight, and then watch the patient attentively, in order to prevent the  unfortu-
 nate consequences of  which we  have  spoken.   In confirmation  of these
 precepts, we will detail a case  recently published, and which must have cost
 the surgeon many bitter regrets that he had not followed them.
  A man forty-four years of age, fell on the  right knee, and fractured the
 patella; he was carried to a hospital in Paris.   The next morning the  joint
 was much swelled, and very painful; however, an apparatus somewhat  simi-
 lar to that of M. Dupuytren was applied; so tightly that even  in the evening
 the patient could not bear the suffering; he passed the night in agitation and
 crying continually; no attention was paid to it on the visit of the third  day ;
 and it was only on the fourth day after the accident, that the violent and con-
tinual  cries  of the patient determined the  surgeon to remove the dressing.
Ecchymoses were formed in different parts of  the  leg and foot, some brown
 spots appeared ;  the bandage was, however, again applied, but  was obliged to
be removed the day after.  Numerous brown spots then existed on the  back
of the  foot and  leg; gangrene came on with delirium, the skin was hot and
pale, the lower part of the leg became cold, insensible, and mortified.   On the
 sixth day, there was  but little  hope of saving his  life  even by amputation,
 it was, however, performed, but the patient expired on the following day.
  The fracture,  on examination, was found to be transverse,  the  fragments
 separated about one inch ; but was still held together by the common tendon
 of the  extensors, which had not  been divided, and  by little  fibrous bands 
CLINICAL SURGERY.
91
which  came from the interior and not  the  surfaces of the patella.  These
bands were at first supposed to be of recent origin, but this idea Was incon-
sistent with their strength.   The fractured surfaces were free from asperities ;
these seemed to have been absorbed.   Between the two fragments a reddish
substance existed, whose consistence increased as it approached the fractured
surfaces.   At this point it was almost cartilaginous, and appeared incorporated
with the patella.
   The treatment of vertical  fractures demands,  also, rest, immobility, and
complete relaxation of the muscles.
   It has been advised to cause contraction of the biceps extensor, in order to
bring together the two fragments.  This theory is erroneous, and experience
proves, that by making the  articulation  project, the fragments are separated,
probably on account of the anatomical disposition of the osseous surfaces and
the insertion of the capsule of the joint around these fragments.  The tension
of the soft parts are not more suitable to these  cases than  to longitudinal
wounds of the muscles.  These ideas are purely speculative and not justified
by practical results.   The  best  plan  is, to keep them as much relaxed as
possible and this principle is applicable to all analogous lesions.  Besides the
passive state is the only one supportable; and it  must not be forgotten that
the patient is soon unable to maintain a  permanent contraction.
   The limb, therefore, should be kept elevated by pillows, and protected by a
 hoop from the pressure of  the bed-clothes.  In this position the fragments
 cannot separate, and the formation of callus goes on regularly.
   In this species of fracture, as in those of the neck of the os femoris, for ex-
 ample, consolidation of the  callus takes place in sixty or eighty days or even
 more.   At this period, if the state of the  soft parts will allow, the patient should
 be permitted to take gentle exercise, for the disposition of the fragments can
 create no alarm as to the elongation or rupture of the callus.  Besides, by the
 application of a cap to the knee or a simple circular bandage, the joint may
 be rendered sufficiently solid.   Again,  experience and observation prove that
 by a longer confinement to bed,  we obtain the formation of an osseous cicatrix
 almost  imperceptible  and  much firmer; in a word, that the  extent of the
 groove or separation observed after the formation of the callus, is in an inverse
 ratio to the continuance of this  plan.   For example:—A man having had a
 comminuted fracture  of the patella  by a fall, and at the same time of the
 upper part of the thigh bone and of the cranium, was obliged to remain five
 months in bed.  For a month or six weeks, the ordinary apparatus was applied,
 removed as often as the relaxation of the bandages required.  At the end of
 the five months the patella was so exactly and solidly united, that no apprecia-
 ble trace of  the fracture remained; there could only be felt some slight and
 very hard inequalities on its surface. 
92
LECTURES  ON
                         CHAPTER  XIII

    GENERAL CONSIDERATIONS ON THE  TREATMENT OF FRACTURES OF THE
                               EXTREMITIES.

   Description  and Mode of Application of the Bandages.—There are few
 positions in which the surgeon  can be placed, that require of him  a greater
 share of acquaintance with the details of his profession, than the treatment of
 fractures in general.  It is by no means  sufficient that he exercise a correct
 diagnosis, and employ those means which form the general basis of his man-
 agement ; he must be further familiar with the conduct required for the different
 complications he has'to deal with, and the  several circumstances connected
 with each particular lesion.  Nay if he be really accomplished, he will not dis-
 dain to  stoop to those  minute particulars which some people may think of
 little importance, yet the neglect of which may lead to serious consequences.
 Thus the precaution to be taken in stripping a patient of his clothes, and in
 transferring him from one  place  to another, so  as  to avoid cruel sufferings,
 and the aggravation of injuries already done to the soft parts, the situation in
 which the patient should be placed, the manner in which  the  surgeon should
 proceed to dress him and apply the necessary bandages, the means of ascertain-
 ing the consolidation of the callus, and the advise to be given'to the patient;
 all  these are points which  experience  shows must be attended to, and that
 with no inconsiderable degree of diligence.  In the observations  which I am
 about to offer, I shall call your  attention  in the  first place, to the kind of
 bandages which I usually employ in fractures of the extremities.
  When the fracture is seated in one of  the  thoracic  extremities and is
 unaccompanied by any wound,  the roller bandage is to be preferred.  Some
 compresses are placed across the limb, where the  fractured point is prominent,
 and over the splints, whether they be of metal, paste-board, or wood.
  If the humerus be fractured,  the patient is seated on his bed; one, two, or
 three  compresses are applied, over which  some turns of the bandage  are
made; other compresses are then  introduced, both above and below; after
 which splints are put on the four sides of  the limb, taking care that they shall
not press on the osseous prominences of the joints.  A general bandage is then
applied over all.
  In the  case of fracture of the fore-arm, the apparatus required  is—a ban-
dage four or five yards long, graduated compresses, two splints of the length
of the forearm, or a little longer—at all events broader.
  The patient being placed in a  sitting position or lying down, the fore fingers
of the hand are grasped by an assistant, another takes hold of the lower  part
of the arm, and the fore-arm being now reflected a little towards the humerus
 extension is attempted.
  The surgeon by means of well directed pressure on  the anterior and pos-
terior aspect of the limb, collects the  muscular substance of  the flexors and
extensors into the inter-osseous space, to which  he thus restores its natural 
CLINICAL SURGERY.
93
dimensions, the fragments of the radius being thus separated  from those of
the ulna.  The fore fingers and metacarpal bones are rolled in a bandage up
to the wrist.  This part is now committed to an assistant; and the o-raduated
compresses, previously steeped in Gouland's lotion, are applied to the dorsal and
pulmar surfaces of the parts, encroaching somewhat on the wrist and tuber-
osities of the humerus.  The two splints are applied above these, the bandage
at the wrist is resumed from the hands of the  assistant, and continued  from
the wrist to the elbow.  The antero-posterior diameter is thus enlarged, and
the inter-osseous space necessary for the movements of rotation preserved. If
the fracture should  be complicated with a wound, we use the bandage of
Scultetus, or one analogous.
   In fracture of the radius, I am in the habit of using, in addition, a splint,
which  I  call  the  cubital splint.  It  consists of an iron plate, curved at its
lower extremity and its concavity having several buttons.  The upper extre-
mities of this metallic plate is laid along the ulnar margin of the fore-arm; and
a compress, folded several times, being placed between the  inner side of the
wrist and the convexity of the splint, the hand is drawn towards the metal,
and made to grasp the radial margin of the first, by means of a handle formed
with a compress, placed between the thumb and fore finger, and the two  ends
of which, being furnished with  two strings, are connected  to the splint by
means of one  of  the buttons which are upon it.  When  the olecranon is
fractured, I prefer the bandage which is used for the union of  wounds trans-
versely, rather than that in common use, and as in extension of the limb, the
upper fragment or olecranon  is the only portion that has a tendency to be
displaced.   I only put compresses above that portion; I also employ the an-
terior splint, but the one I use is straight*
   Scultetus's bandage is the one I almost exclusively use  in fractures of the
leg and thigh, where the  roller-cannot be kept adjusted, but is displaced by
every movement.  It is composed of the following pieces; 1st, several pillows;
2d, several  folds of muslin; 3d, the tapes; 4th, a splint cloth;  5th, a many
tailed bandage; 6th, transverse  compresses; 7th,  longitudinal compresses;
8th, graduated compresses in case of prominence of the bone; 9th, a perfo-
rated linen covered with cerate, charpie, or diachylum in case of  a wound;
10th, pads filled with chaff; 11th, immediate splints; 12th, mediate splints;
13th, a body  roller; 14th, a support for the thigh, and foot board.  Let us
examine each of these parts in detail.
   The pillows are for receiving  the fractured limb, and  while they support,
they receive the serous or bloody discharges which would otherwise soil the
mattrass.
   The folded cloths, doubled several  times, are placed upon the pillows, in
order that the blood and pus may not touch the latter ;  this precaution is above
all things necessary  in hospitals, where, if neglected, the foul cushions  may
become nests of infection.
   Over the  cloths  come the tapes, which are intended for keeping the several
parts in their proper position,  and incorporate the whole; there are three for
the leg, and three  for the thigh.
   The splint-cloth should be as  long as the limb, and folded double; it is
placed crosswise over the tapes,  intended to receive the splints on the extre-
mities and to support them. 
94
LECTURES  ON
  The bandelettes are placed upon the splint-cloth, and forming by the eighteen
tailed bandage, either united or separate.  If there be a wound and blood or
pus discharged, they ought to be separate, so that they may be changed occa-
sionally when soiled.  If there be no wound the tails need  not be separate,
every ten or twelve of them may be connected by overlapping ; that  is, the
first should be half covered by the second, the second by the third, and soon.
They are applied commencing from below upwards, for if we began from the
upper part there would be numerous wrinkles, which should be  avoided.  The
tails should be long enough to go nearly twice round the limb.
  The transverse compresses are placed the lowest at the most elevated part;
they must be merely a double fold, for if triple, their application  would be
more difficult, and  they ought to be as  long as the bandelettes.
  If there be a wound the compresses must be removed without changing the
apparatus.  It is in such cases that the advantages of the longitudinal com-
press is  felt, which  must  be removed when it is soiled.
  Compresses of various forms, but generally square, and two, three, or  four
in number, are then applied around the limb; nor is it less  useful  to place
graduated compresses on the length or breadth of the limb.   If the tibia, for
example, be  fractured, and the fragments project outwardly, the compresses
are to be applied along the sides of the  leg; or transversely, if the upper frag-
ment projects in front.
  It is also in  similar  cases that we require the splints which I have  called
immediate ; for they act directly on the  fragments from which they are sepa-
rated by the graduated compresses alone.   These splints should be made of
paste-board or light wood—if they are  inflexible, they would injure the parts.
We must not forget, always to interpose one or two compresses  between them
and the fragments.
  Every thing being thus far settled, we  apply the transverse  compresses, and
afterwards the bandelettes around the  whole limb, taking care always  to di-
rect obliquely forwards  so that they may partially cover each  other.  Next
come the mediate  splints, between  which and the  limb  we place  the bran
cushions; their length  should exceed a little that of the  limb, and their
breadth be about five or  six inches.  They ought to be modelled according to
the shape of the part,  by diminishing their thickness when there is convexity
of the limb, and on the other hand, increasing where there is a concavity.
  The apparatus is now to be combined into one piece by the  tapes connected
to the external splint; the knot should be simple,  and tied on the outside. A
stirrup made of a long compress, or a leather sole with strings to it, and which
may be  fastened to the sides of the splint-cloth, will serve to  support the  foot
in a steady position.
  Lastly, some hoops should be placed over the extremity so as to protect it
from the weight of the bed-clothes.  But this is not all.  In order thoroughly
to prevent the motions of the limb, a cloth, folded  like a cravat, is fastened to
one side of the bed, then passed over the leg or thigh (whichever is fractured)
and the other end tied at the opposite side.  If it be fracture of the thigh,
then  is  to  be  placed around  the  pelvis  a body-roller, encompassing the
haunches and upper end of the external splint.  This last is  a  precaution of
so much importance, that in cases of fractures of the upper part of the neck of
the femur, the patient cannot get well without a curvature of the bone.  An 
CLINICAL SURGERY.
95
apparatus arranged in the manner we have described, is of exceeding firm-
ness, and not liable to disturbance, even should the patient be delirious.
  I will further add, that the bed of the patient should not be very soft; it
must be perfectly even, and should be a hair mattress, both for the comfort of
the patient and to secure his cleanliness.  Lastly, there should be no head
board nor raised feet.
  Having thus described the several  parts of which the bandage we employ
consists, and their mode of  application, I now call your attention to the care
which the patient requires immediately after the accident has happened.
   If he be carried on a litter, you need be in no hurry to remove him from it;
he ought to be stripped on it while his bed and the requisite dressings are
preparing.  His boots and stockings ought to  be slit up, not drawn off, in or-
der to avoid all unnecessary pain ; the limb should be washed, so that the bed
may not be soiled afterwards by the process.  All this done, an assistant must
take the patient round the  body, another by  the two  extremities, whilst  the
operator must take charge of the fractured member.  In this  way the patient
is carried to his bed, and there deposited; his pillow should have little or no
elevation, so as to avoid slipping downwards  in the bed; a very slight eleva-
tion, however, may be advisable, in order to support the head, and not to favor
 the occurrence of sanguineous congestions.                  •
   When applying the bandages, the operator  is placed on the outer side of the
 fractured  limb; an assistant on the inuer side is exclusively charged with
 supplying him with each piece of the apparatus.   Another assistant holds the
 foot, with his left hand in front and over the instep, and with his right holding
 the back part just above the heel.  A third assistant at the knee or haunch, as
 the case may  be, holds the sides of the condyles of the femur or tibia, taking
 care not to press on  the vessels or popliteal nerves; for if there be a wound
 the pressure  may occasion hemorrhage.   After  this, compresses steeped in
 Goulard water, or some other resolvent, are held by two of their angles by the
 operator, while the first assistant holds the other two; they are then laid on
 the limb smoothly.   If there  be a wound, it is either dressed with  diachylon,
 or a perforated compress spread  with cerate, and over this charpie is  laid.
 Lastly, the several pieces of the apparatus are applied in the manner just now
 described.
    If there be no wound, we should proceed on  the following day to a fresh
 dressing, with the removal of the bandages;  for it is not unusual to find, after
 four and  twenty hours, that considerable swelling or perhaps gangrene, has
 ensued.  But this being done, it will be enough to visit the patient every fifth
 or sixth day, unless he feel pains, when it will be necessary to see him more
  frequently.                                               .
    Duration  of Treatment.—The  apparatus  may be  kept on in general, tor
  twenty-ei"-ht or thirty days in cases of children; forty ^ays for  adults, and
  mucl/lonler for  aged  people.   It  ought never be removed until we have
  ascertained that the consolidation is complete.
    In order to be sure of this, the operator lays hold of the two fragments, and
  cautiously tries if he can produce any motion between them  Ii the cal  us
  yield, the apparatus must be immediately  reapplied; but  if it  do not, the
  bandages need not be put  on  again, but should be left in readiness by the side
  of the limb for three or four days.   At this period, it will not be safe to allow 
96
LECTURES ON
the patient to walk immediately, for the callus may give way to the weight of
the body or the action of the muscles; he must remain in bed for ten, twelve,
or fifteen days longer.   He may then  sit up  in  his bed, or in an arm-chair,
with his foot laid on a pillow, and  the whole  limb wrapped in a roller for
about three weeks.  Crutches may now be given him,  and should be tipped
■with cloth, lest they slip on the  floor.  The  patient ought, if possible, to be
kept in a chamber on the ground floor, and he should  avoid walking on un-
even pavement, smooth sanded walks being much preferable.
  I have thought it thus necessary to  dwell  at  length on  these minute and
apparently trifling details, because experience has taught me how very im-
portant they are  for the practitioner, and, at  the same time, how generally
they are misunderstood, and frequently, also, how  improperly they are
practised.
               #          CHAPTER XIV.

               ON THE EXCISION  OF HEMORRHOIDAL TUMORS.

   The inferior extremity of the rectum is, in many persons, the seat of san-
guineous tumors designated by the name of hemorrhoids.
   These tumors may exist  during a long life, without creating any distress;
but are also often the cause of serious accidents endangering the life of the
patient, and which would infallibly terminate in death, were they not subdued.
The celebrated  Copernicus and Arrius perished by  hemorrhagy from the
bursting  of piles.  Borden and Benjamin Bell relate cases equally unfortu-
nate.  This fatal result was  known to the ancients, and they had devised
several plans of  treatment, amongst others, the ligature.  Hippocrates in his
book de ratione victus in acutis, recommends us to tie them with a thick and
solid woolen thread.   You must tie, continues he, all the tumors except one;
you must not cut them  off, but hasten their destruction by appropriate topical
application.  Paul iEgineta inculcated the same doctrine.  Celsus thought
it proper to scarify with the nail or the scalpel the  hemorrhoidal tumor.   I
merely mention these opinions, to prove to you that the ancients were well
acquainted with the dangers of this disease.
   Before reviewing the different  kinds of treatment which have been em-
ployed, it will be proper to say a few  words concerning their nature, anato-
mical structure, and the cases in which the operation of which I shall treat in
this chapter is applicable.
   Many  opinions have been advanced as to their nature.   Some, with Mon-
tegre, think that the discharge comes neither from the arteries nor the veins,
'out from capillaries intermediate to these two orders of vessels.
t<  Laennec, and Abernethy, considered them as depending on the formation of
new vessels. According to Duncan, Le Dran, Cullen, MM. Recamier and
Delaroque, they are formed by cysts into which arterial blood has been effused. 
CLINICAL SURGERY.
97
Lastly,  Stahl, Alberti,  Vesalius, Morgagni,  J. L. Petit, Pinel, Boerhaave,
considered them to be veins dilated and varicose ; such also is my opinion.
  On examining the composition of hemorrhoidal tumors, we shall find that
they may be divided into internal and external.
  The internal species, covered by the mucous membrane of a violet  color,
form a kind of partition in the rectum.  There  are  between them  fissures
which facilitate their isolation, and which sometimes disappear from inflam-
mation.   The tissue of  this membrane  presents venous swellings, like the
head of a pin, which pour out, when torn or cut, venous blood, givin°-  it the
aspect of a sponge.   On removing the mucous membrane, we perceive organ-
ized false membranes or a cellular tissue;  lastly, the muscular tissue consti-
tutes the most external coat.   Large arterial trunks often ramify over  them.
  The external piles form a kind of crown around the anus, and are composed
1st, externally, in a great measure by the rectum, and somewhat by the skin;
2d, by the false membranes which often exist in the internal tumors, or  by the
venous coat which appears  to  be continued with the fascia superficialis ; 3d,
by the dilated veins constituting hemorrhoid ; 4th, by the external sphincter
which embraces their pedicle, and  sends some of its  fibres there; 5th, by
nervous filaments distributed over their surface;  6th, lastly, by the fat placed
sometimes between the skin and these tumors.
  After  these remarks, let us examine in which cases the  surgeon  should
interfere, and in which he should refrain.
  It would evidently be highly improper to cure hemorrhoids, in individuals
affected with organic disease of the  intestines, the liver, and especially the
lungs.  It is  a fact well ascertained, that in persons laboring under phthisis,
the destructive  action of this disease has been suspended  for a longer or
shorter time by the presence of these tumors, and that in consequence of their
suppression,  the disease has progressed with all its former energy.
  In women, towards the latter period of pregnancy, or  by the efforts of labor,
hemorrhoids are often developed; they are owing to an evident cause, and dis-
appear with it.
  When those hemorrhoids have not degenerated  in  their tissues, and give
rise to no hemorrhage, or abundant discharges of purulent  serum, plunging
the patient into an anemic condition,  surgical means should not be applied to
remedy the accidents, or rather the inconveniences they cause, antiphiogistics
alone are sufficient.   But when the life of the patient is threatened, when these
inconveniences demand prompt relief, and the tumors become  disorganized,
antiphiogistics no longer suffice; and no plan but that of excision can be fol-
lowed by success. This chapter is, therefore, devoted to disorganized hemor-
rhoids demanding an operation.
  The two kinds, internal and external, may, or may not, occur simultaneously;
they form a circular band of tumors, either internally or externally, and have
been  hence  called by  M. Dupuytren, internal and external hemorrhoidal
tumors.   The external are known by a circle of smooth and round  tumors,
of a brownish color, where  they are covered by the  skin, of a bright red
where the mucous  membrane forms the envelope;  rarely ulcerated on their
outer surface, they are frequently so on the inner, and give rise to hemorrhage
more or less copious, and purulent or  sero-purulent discharges, which tend to
weaken the patient.
           13 
98
LECTURES ON
   The internal, situate above the anus, and often strangulated by the sphinc-
 ters, in consequence of the engorgement or prolapsus of the internal mucous
 membrane of the rectum, give  rise to the same accidents, and are  known by
 the red color of the tubercles.   Both varieties sometimes appear in the same
 patient.
   Individuals affected with this disease, walk with difficulty; the  acuteness
 of the pain arrests them at every step; they constantly apply their hands to
 the nates, or sit down on posts, in the hope of returning the hemorrhoid; some
 rub themselves against the wall; but these means  procure only a temporary
 relief, and the return of pain follows the protrusion of the tumor.
   Exhausted by the copiousness and frequency of the  loss of  blood  or the
 sero-purulent discharges, the patient becomes thin ; his skin pale, discolored,
 and dull, resembling wax; he falls into a state of deep sorrow and melancholy;
 his intellect becomes impaired, and he frequently attempts his life.   Still the
 disorganization progresses, a scirrhous affection of the anus and lower part of
 the rectum takes place, and death closes the scene, unless prompt and  effi-
 cacious treatment puts an end to the  march of the disease.
  Recourse must then be had to an operation.  To which shall the preference
 be given?  Compression, the ligature, the  actual cautery, recision  and exci-
 sion have all been used by different surgeons.  Let us examine in detail their
 respective merits.   Compression would cause the hemorrhoids to waste and
 perish, but the spot is unfavorable, therefore itwas abandoned.  The ligature,
 as has been seen, was anciently used ; the objections to  it are very serious, as
 it  exposes the  patient to  inflammation, insupportable  pain, and sometimes
 death, as in a case related by J. L. Petit.  The cautery has been frequently
 used.  Of undoubted utility when conjoined with excision, it would produce
 horrible pain, and great danger if applied to  large tumors, requiring the pro-
 longed action of the hot iron.  Recision has been praised by some. It consists
 in scarifying the tumors with scissors; but such  a  plan apparently would
 produce hemorrhage, leave the tumors, and excite inflammation, and does not
 warrant the praise accorded to it.  There remains, therefore, excision, which
 with us has been highly successful.  We will now explain how it is to be done;
 and  speak afterwards of its inconveniences, its dangers, and the  means of
 overcoming them.
  The diagnosis being established,and the operation decided upon, the patient
is  laid on  the edge of the bed on his side, or upon his elbows and knees, the
 legs separated, or still better, one of them flexed upon the thigh, and the other
 extended.  If the tumor is internal, we request him to strain, as in the act of
 evacuating the bowels;  it thus projects; it is then to be seized with  a large
 forceps, whilst an assistant separates the thighs, and removed by  a few strokes
 of a pair of large scissors curved on their flat side.  I generally remove only
the portion of the tumor projecting outwardly; for, the  removal  of  the whole
 of it, might cause serious hemorrhage, and subsequent contraction of the anus.
 I thus leave, apparently, a large mass in the margin of the anus,  and it might
 be supposed, that a sufficient portion had not been removed ; but  cicatrization
 restores every thing to order, and the opening returns  to its normal state.
 The same thing happens in excision of the tonsils.
   The excision  of the internal tumors is less  easy; in order to make them pro-
 ject, the patient should be placed in a warm  hip-bath, and requested to strain 
CLINICAL SURGERY.
99
violently; as soon as it projects, he is put to bed, in the position above men-
tioned, the operator seizing them suddenly, and allowing no time  for their
re-entrance, removes them entirely.
   Before the operation, M. Dupuytren prescribes  a  mild laxative and an
enema;  we shall hereafter see the motive of this precaution.
   Excision is not without danger, nor free from objections, but the latter are
not important,  and the former may be prevented by proper care.
   The danger  consists  alone  in  the hemorrhage which follows; when the
tumor is external, it is soon perceived, and arrested by the cautery.  We must
also resort to the same remedy where it is internal; but here its application
is more difficult, and the hemorrhage less easily seen.
   It may be known by a sensation of heat in the abdomen of the patient, which
gradually ascends,  as the  blood fills  the  intestines; or rather colicy pains,
and always a peculiar uneasy sensation, resembling tenesmus.  The abdomen
becomes tender, especially on the.left side, and iliac  fossa.   Respiration  is
painful, and interrupted; the pulse at first intermitting and irregular, becomes
afterwards small  and frequent.  The skin is pale, and the face covered with
a cold sweat.  Despair soon  succeeds the uneasines felt  by the patient,
anorexia and vomiting ensue, convulsive contractions of the limbs, vertigo, &c
   When this accident is  recognized,  the intestines  must  be immediately
evacuated, by desiring the  patient to make efforts similar to going to stool, and
a cold enema administered;  these efforts always bring the  wound  outside,
and by means of  an iron at a white heat, the spot from which the blood pro-
ceeds is cauterized.  M. Dupuytren has caused two irons to be made ex-
pressly for this purpose, one is called the bean-shaped iron (en haricot); the
other the reed-shaped (en roseau).  This always arrests the blood, and  I have
never seen it followed by any dangerous consequence.  I always leave the
patient in charge  of an intelligent assistant, who on  the slightest indication of
hemorrhage, applies the cautery and prevents all danger.
   Dr. Marx has proposed  the following question to  me;  whether we  should
not always use  the cautery immediately after the operation, rather than run the
risk of hemorrhage.  I think out of a great number of cases on which  I have
operated, both in  public and private practice, that internal hemorrhage took
place in two-fifths of the patients who  had not been  cauterized ; on the con-
trary, not once in those  who had been.  The question then is, Do the  objec-
tions to the  cautery, outweigh the  danger  to  which  the  patient is exposed?
It has been remarked that no comparison  can be instituted  between  them;
that the inflammation, and  swelling which follow the cautery,  the  irritation
extended to the rectum and urinary organs, generally yield to simple remedies.
and never cause fatal results;  but internal hemorrhage  certainly endangers
the patient's life.   Let us suppose a case in which the  cautery has been ne-
glected, internal hemorrhage comes on, the patient dies,  and  the operator has
the painful remembrance of not having prevented it by the application  of the
iron.   Again, since this hemorrhage occurs in the greater number of  cases,
and as it is impossible to determine a priori, whether the accident will take
place or not, why should not this principle be admitted, that the cautery should
be always used  ?  I confess that these  remarks are just, and that they will
some day induce us to modify  the plan, we have hitherto followed.
  Another method, but less certain, of arresting hemorrhage is to introduce<into 
too
LECTURES ON
the anus a bladder, which is afterwards stuffed with charpie.  Although some-
times successful,  it is  very inconvenient,  and almost always involuntary
expelled by the patient.
  The other consequences of the excision of hemorrhoidal  tumors are  less
serious  and important.   There is  always excited a considerable swelling of
the cellular and adipose tissue of the  anus;  the  principal inconvenience re-
sulting  from this  is an  irritation  of the  rectum,  on account  of which  the
patients are unable for five or six day after the operation  to  evacuate  the
bowels;  but the laxative and enema they have taken, the strict  diet to which
they are subjected, moderate  this  desire, and deprive  the constipation of its
unpleasant effects.   This swelling  may occasion retention of urine, but that
is easily cured.  As to the  tumefaction itself, it  promptly yields to leeches,
emollient fomentations, baths, &c.
  The pain produced by excision is acute but almost instantaneous, and  this
inconvenience inseparable  from the  slightest operation cannot be compared
with the pain and  danger of the disease.  In consequence of the operation,
the  patients are exposed to  divers accidents, which should be the particular
object of the surgeon, and which it is  in his power to  spare him.  We have
seen persons affected with  degenerated hemorrhoidal  tumors reduced to a
state of complete anemia, and asthenia produced by the abundance  and fre-
quency of the hemorrhages or sero-purulent discharges.   These evacuations
to which the patients have been long accustomed, are  not suddenly arrested
without  a reaction  of the whole economy; a general state of artificial plethora is
established, sanguine  congestions take place in the lungs, liver or brain;  the
patients  are often  attacked with syncope, spasms, vertigo, and fall into  an
alarming state of insensibility; the arteries beat  so violently that they would
seem to  have taken on an aneurismal character,  if these abnormal pulsations
did not at every moment change their position and character.   What is still
more remarkable, this state of plethora is coincident with a pale yellow.or an
earthy color of the skin, and especially of the face, with a peculiar weakness
of the patient.
  Repeated bleeding, for some time at shortintervals, if the patient be of asan-
guipeous habit, young and healthy, and formerly subject to bloody evacuations
from  the anus; the formation of an issue,  if these evacuations were of a
purulent nature; both combined, if necessary; gentle laxatives often admin-
istered, is the most appropriate and rational prophylactic treatment which  can
be  employed.  When the  excision of the external tumor is once done, the
cicatrix which forms, either by the constriction of the sphincter itself, or the
tension  of the integuments  and the radiating folds of the anus, suffices, in the
majority of  cases,  to effectually prevent the projection of the internal tumour
and the latter may then remain.  Excision may sometimes be followed by
contraction of the  anus. J.  L. Petit relates a case, in which the pipe of a
syringe could hardly be introduced.   This may  be prevented by introducing
into the intestine,  bougies of sufficient size  and  remaining there until a per-
fept cure is effected.
   Some cases shall now furnish the application of the preceding principles:
   Case T.—A shoemaker about thirty years of age, was admitted for hemor-
 rhoids, which gave him a great deal of uneasiness.  His trade obliged him to
 be constantly in a sitting and bent position; but he attributed his  disease to 
CLINICAL SURGERY.
101
residence in Champagne, wnere he had drunk very freely of the wine of the
place.  Then, indeed, he first perceived some tumors at the  maro-in of the
anus.  They were at first small, and not painful, and projected only when he
went to stool.  They afterwards largely increased.  As in manv similar cases
these tumors had two  epochs; one of which may be called that of inertia,
during which there was no discharge, or only a slight serous exudation, and
presenting no inflammatory character; the other, designated by the name of
hemorrhoidal crisis, was manifested by swelling, inflammation,  sharp lancina-
ting pains, a copious discharge of blood, and bloody serum.  These crises
were more frequently  renewed,  and lasted longer; the patient suffered
intensely, and his health was visibly impaired.
   On his admittance, he was feeble, thin, and yellow; he walked in a bent
position, unable to be erect.   This  position was owing to the large mass of
hemorrhoids around the anus, at least equal in size to the fist of a child seven
or eight years old, and composed of two tumors, one internal  and the othei
external.   He was  besides  affected with an obstinate constipation, which is
often the result of an  irritation extended to the rectum, and retention of urine,
a complication not less frequent than the preceding.
   An enema and a bath  were prescribed; by this means the retention of
urine ceased, but that of the fecal matter persisted.  The swelling of the
hemorrhoids had greatly diminished, they were less red, the patient did not
suffer so much.   There was no doubt but that the actual crisis might be cured
by leeches, emollient fomentations, baths,  enemata,  rest, and appropriate
drinks; but this treatment  could  only  be palliative, and the unpleasant
symptoms would again occur, according to the state of the patient's consti-
tution.
   It may be asked what impropriety there is, in using  the palliative method,
at the return of every crisis ?  It is adopted by many physicians, and many
patients who fear the operation.  It sometimes happens, indeed, that tempo-
rary cures retard the return of the crisis, and render it more rare ;  but in the
generality of instances these crises happen more frequently,  and impair the
health of the patient.   This motive, however  plausible it may be,  is nothing
in comparison with  the effects of the disease; often the tumors, both internal
and external, become scirrhous, ascend beyond reach  into  the rectum, and
disorganization takes place in the interior of the intestine.  From all these
different consequences, I think the operation of excision to be generally pre-
ferable ;  but do not understand me to say, that it should be  performed  in
every case, as I have  above  indicated the cases in which it is contra-indi-
cated.
   After  the  preliminary  remarks, the patient was introduced.   He was
placed on a bed, on  his elbows and  knees, his thighs separated, and the
hemorrhoidal tumors removed by means of the scissors.  The  wounds were
not cauterized.  The resident surgeon was desired to watch him very carefully,
and in case of hemorrhage, to immediately apply the cautery.
  The dressing  was delayed  for several hours after the operation,  lest  it
should prevent the outward  flow of the blood, and cause it to re-gurgitate
into the upper part of the intestine.
  As had been expected, hemorrhagy came on; the surgeon was not mistaken
as to its symptoms, and had immediate recourse to the proper means. He
administered an enema, which brought  away a large quantity of blood, and 
102                           LECTURES ON
         \
a second caused the expulsion of a considerable clot; desiring the patient to
btrain, in order to  favor the escape of the remaining blood, to relax the
sphincter, and expose the wounded parts, he then applied the actual cautery.
The bleeding ceased, and he had no return of colic, nor syncppe.
  It has been said that, three, four, and five pounds of blood, have been lost
after this operation.  It ascends to the descending, the transverse, and ascend-
ing colon, as far as the ccecum, but never beyond this last.
  The patient  whose  case has just been related, seemed destined to present
a complete collection  of the symptoms of the disease, and the consequences
of the operation.   The  cautery produced retention of urine, for which the
catheter was necessary.   After  the evacuation'of a large  quantity of water
from the bladder, he experienced sharp pains, which ceased only when the organ
became again filled.  Another remark yet remains.  It is known that indivi-
duals  affected with piles, are subject to obstinate costiveness;  in this case it
lasted several days, and was increased as sometimes happens, by the operation;
laxative  medicines  should be given only when the inflammation and swelling
have,  diminished or disappeared,  because before this time the fecal matter
cannot be expelled without acute  pain, and  an increase  of irritation, and
danger of laceration of  the parts.  On  the sixth day after  the operation, all
unpleasant symptoms  had disappeared,  the bowels were opened without pain,
an»l the man demanded his  discharge.
  Case II.—About fifteen years ago, a banker, forty-five  years of age, of a
bilious temperament, consulted M. Dupuytren for bleeding piles.  The dis-
charges had reduced him to a very weak and anemia condition. Pale and wan,
he daily grew thinner; and was unable to pursue his business.   He  could
scarcely bear to write a letter.  An  internal  hemorrhoidal tumor was per-
ceived, its excision proposed, and eagerly accepted by the patient.   A few
days  after it was done in the following manner.
   The gentleman having taken, and passed an enema, came out of a hip-bath
and was laid on the  edge of the  bed; his thighs separated;  violent efforts
caused the projection of the tumor, which was seized and excised, after some
difficulty, by the scissors. No hemorrhage followed.  M. Dupuytren remained
with  the patient;  in a quarter of an hour, he saw him become pale and exces-
sively weak; his pulse was small and corded; Ins body covered  with a cold
sweat; and he felt in  the abdomen a sensation of heat gradually ascending;
these symptoms indicated internal  hemorrhage.  He then desired the patient
to endeavor  to expel the blood hardly yet coagulated;  cold  enemata were
uselessly tried; the hemorrhage was not arrested; a bladder was  then intro-
duced into the anus, and stuffed with charpie, which succeeded perfectly; but
a difficulty was found in keeping it in its place, on account of the  involuntary
efforts of the patient.  He was exceedingly weakened by the bleeding, which
would have been fatal if assistance had not been at hand.  His recovery was
 rapid.
   Case  III.—The banker  above mentioned, had a brother at Berlin affected
 in the same manner;  the latter having heard of the cure of his brother, wrote
 to M. Dupuytren.  He advised excision.  But the accident which  had hap-
 pened to his brother, induced him to desire a more efficacious plan of arresting
 the hemorrhage,  and  consequently of obviating the greatest danger  of  the
 operation.  He, therefore, wrote down the rules to be observed, and advised
 the cautery with an iron, en haricot, if  hemorrhage came on. 
CLINICAL SURGERY.                       1Q3
   The surgeon in Berlin neglected this advice.  He left the patient imme-
 diately after the operation.  Very soon symptoms of internal hemorrhage were
 manifested; the patient became weak, pale, and bathed in cold perspiration.
 One of his young brothers, who had been present at the first operation, recog-
 nized the cause of the danger; the surgeon could not be found ;  this youn<*
 man had then the presence of mind, to introduce, as he had seen done, a blad*
 der into the anus stuffed with charpie, and thus succeeded iu arresting the
 hemorrhage.  But the loss of blood had been so great, that the recovery of the
 patient was extremely tedious.
    Case IV.—A broker, the father of a large family, had been for many years
 affected with external and internal hemorrhoids; they at last became so an-
 noying, that he could not walk sixty paces without being obliged to stop, and
 lean his nates  against a post  in order to  find a temporary  relief.  Finding
 himself under the necessity of giving up his employment, and unable to pro-
 vide a maintenance  for his  children, he consulted M. Dupuytren,  who
 examined him and found a double hemorrhoidal tumor of two and a half inches
 in diameter in every direction ; it constantly discharged blood and pus, and
 scirrhous seemed  on the  eve of appearing.   Excision was proposed.   He
 dreaded the operation, as some unfortunate cases in the hands of other  sur-
 geons had come to his knowledge.  With a good deal of difficulty, however,
 he was encouraged and  convinced that cautery of the vessels would obviate
 every unpleasant event. He at  last consented, but wished  to be admitted
 into the Hotel-Dieu, in order, as he said, to be better watched, and that any
 accidents might be relieved at its onset.   The excision was performed, a
 few vessels cauterized, and on the twelfth day he left the hospital entirely
 cured.
   Case V.—M. Ex....., a Scotchman,  and an officer in the  British cavalry,
 forty years of age, of a sanguineous temperament, had experienced for three
 years great  suffering from  internal hemorrhoidal tumors, which  projected
 whenever his bowels were moved.  As his profession increased his distress,
 he came to Paris to consult M. Dupuytren.
   According to the advice of this  surgeon, the  following operation was per-
 formed :  The patient was laid on his side, the upper  thigh raised by an
 assistant, each tumor was successively seized and removed.  These tumors,
 three in number and small, gave issue to but little blood.  The cautery  was
 thought unnecessary.  An assistant remained with the patient, who was per-
 fectly tranquil.   Five hours after the  excision, the characteristic symptoms
 of hemorrhage  were manifested;  anxiety, shuddering, anorexia, cold sweat,
 sluggishness of the pulse, convulsive contractions of  the limbs, inexpressible
 anguish, vertigo, syncope; the tenesmus increasing,  the patient got up, and
 the expulsion of a large quantity of partly coagulated blood, produced decided
 relief; a cold enema  was administered; it soon passed  away, and was re-
 placed by another which remained  sometime.  However, after the lapse of an
 hour, the accident returned with more intensity than at first, unmanning  the
 patient entirely; he asked for a notary and desired to make his will, resolved
 rather to meet his death,  which  he  considered inevitable, than submit to  the
 actual cautery,  which he saw preparing.  This was not a time to yield to his
 wishes.   Drs. Paillard and Marx took upon themselves the responsibility of
attempting violence in order  to save his life.  He was held, and it may be 
104
LECTURES ON
conceived how difficult the operation  must have been  in  such  a situation.
However, by means of a perforated  speculum (fenetre)  introduced into the
anus, and turned round, the spot furnishing the blood was discovered, and the
discharge arrested by the application of aniron bent at the end, beaux-shaped
and at a white heat. The blood stopped, the alarming symptoms disappeared;
the inflammation  and dysuria resulting,  yielded  to the use  of  cataplasms,
enemata, and the hip-bath; a bougie was kept in the rectum, and in a few
days, the patient was entirely cured.
  Case VI.—M. Joseph Cur....., forty-eight years of age, had for many years
suffered much pain in the expulsion of the fecal matter; this resulted from the
presence of internal hemorrhoids, as large as a hen's egg.  During the act of
defecation they projected, but were  soon  most painfully strangulated, and
could not be reduced without much difficulty.
   These tumors were not accompanied by an habitual or periodical discharge,
except when the patient was constipated ; the hard excrements then caused
erosions from which issued a little blood.         \
  He came to Paris to  consult M. Dupuytren, who advised him to enter the
hospital for a few days previous to the operation.  The patient being  placed
m the proper position, the tumors, three in number, were drawn out and  ex-
cised.  What was remarkable in this case was, that notwithstanding the large
size of the tumors, the excision caused the loss  of but little blood, and  did
not need the cautery.   A year after his cure, we chanced to see the patient;
nothing  had occurred to mar the  success obtained  with  a  rapidity truly
astonishing.
   Case VII.—A man, about forty-seven years of age, small, of a sanguineous
temperament, came to the Hotel-Dieu to be treated for hemorrhoids, under
which  he had labored for fifteen years.  They were so painful that he could
use no violent exercise, without their  projecting, and becoming  irritated  by
the friction of his clothes.  Repeated inflammation ensued, and a discharge
sometimes bloody, and at others purulent; the  act of defecation was a conti-
nued punishment.
   For fear of the consequences sometimes following excision, must the patient
be left a victim to his disgusting disease ?   Every renewal of inflammation
would hasten the disorganization of the tumors;  and gradually the bloody and
purulent discharge would undermine the constitution of the patient.  There
could  be no hesitation; the operation was indicated for its dangers, were not
unavoidable;  whilst those of the disorganization would necessarily result in
death.  The operation was agreed  upon, and the man prepared by all the
means appropriate to  insure success.
   He was bled in order to prevent the violence of the inflammation following
the excision of the tumors; a blister was applied to his arm, to  divert the
danger sometimes following the suppression of a natural issue; lastly, he was
placed on a light diet, and the evening before  the  operation, the intestinal
canal was emptied by means of a purge.
   A tumor, composed  of seven or eight brownish tubercles, surrounded the
anus externally.   When the man was tranquil, the tubercles were grouped so
as to form an uneven and brownish tumor about as large as a walnut. When,
on  the contrary, he contracted the  abdominal muscles, the external tumor
opened, and discovered a second circular tumor, formed also of seven or eight 
CLINICAL SURGERY.
105
small tubercles, but of a different color from the former, as they were uni-
formly of a rosy hue, and completely covered by the internal  membrane of the
rectum.
  The patient was then laid on his abdomen upon the bed, and requested to
strain as in defecation.  The internal tumor  then  projected was seized and
removed; the same was done with the external tumor, and  an  iron at white
heat was immediately applied upon the bleeding points of the wound.
  The patient was then put to bed, and a few hours afterwards a small bougie
covered with cerate introduced.   He could not retain it long.   During the
day he had a slight attack of colic.  (Diet, diluent drinks, an  anodyne draught
in the evening.)
  On the next day, the colic was more frequent, and of longer duration, the
margin of {he anus was swollen and painful;  he passed water with difficulty,
some fever. (Venesection, diluent drinks, anodyne.)
  On the third, fourth, fifth, and sixth days after the operation, the pain de-
creased, the urine passed freely, the fever disappeared; appetite was returned,
some food permitted.
  Seventh  day,  the  patient's  bowels have not been evacuated since the
operation;  he took an ounce of castor oil which had a good effect;  he had five
or six stools during the day, accompanied by excessive pain  of  the anus, and
yet after each of them, the patient was relieved.
  The next day he had a free and natural passage; the colic less  frequent.
  Twelfth day, the colic returned and with it diarrhea.   Cause unknown.
(Gum-water.)
  Next morning, in the same state. (Theriaca,* one ounce.)
   Fourteenth day, the diarrhea has  ceased, and with it the colic.  (Rice-
porridge.)
  Fifteenth day, the patient is doing very well; some food  is  allowed him.
He is radically cured of his hemorrhoids,  and the circumference of the anus is
free, in whatever position he may be.  Defecation is performed without  dif-
ficulty.  He left the hospital perfectly free from his disease.
                          CHAPTER XV.

ON LUXATION OF THE VERTEBRA, AND ON  MALADIES WHICH SEEM TO PRESENT
                            THAT CONDITION.

  Luxations of the different parts of the body have been so well observed, and
so carefully described, and this department of surgery brought to so  high  a
degree of perfection, that it would seem as if nothing more were to be desired;
that the facts already ascertained were sufficient, and that we had only to fol-

  * Theriaca Andromachi.  An opiate electuary prepared for the emperor Nero by the
physician Andromachus.  First known to Mitiiridates of Pontus,  and by him considered
as "an antidote to poison.  A drachm contains nearly a half grain of the extract of opium.
              14 
106
LECTURES  ON
low the principles laid down by  writers.  Yet it is not  exactly with  this
branch of the medical art as it is with others, the precise boundaries of which
are apt to escape the eye of the observer until certain difficulties are sur-
mounted that concealed them from his view.
   The  vertebral articulations, placed  as they are, in consequence  of their
limited action, and the nature of their mutual connections, at the bottom of the
scale of those combinations of bones which are endowed with motive powers,
have always been thought particularly  safe from luxations, which are so  fre-
quent about parts which have a more extensive range of movement; and if
the luxations of the first conical vertebra or the second be excepted, they have
been  either  not  noticed at  all, or directly denied  by the generality of
authors.
   Many of the older authorities, it is true, have spoken of these luxations;
but as they have not given us the post mortem examinations which could alone
corroborate their remarks, we cannot attach much importance to what they
say—or rather, we should reject  them  altogether.   It is  especially since
pathological anatomy has enabled  us to trace morbid effects to their causes,
that the idea of the possibility of these luxations seems  to  have been
renounced.
   And, in truth, the number and strength of the ligaments which unite  the
vertebra, the almost vertical or slightly oblique direction of their apophysis,
the mutual adaptation of their upper and lower processes, the extent of sur-
face by which these bones touch  each othei^ and their very limited motion,
all this would seem to render vertebral luxation very difficult.   Then, if we
consider the facility with which the bodies of the bones break during life, in
consequence of efforts  made  by the spinal column ; or, after death, as  has
been ascertained in numerous experiments; we shall  not be greatly surprized
at the opinions which  most of the moderns  have advanced relative to  the
nature of this disorder.
   The arrangement, above all,  of the articular apophyses of the vertebra,
presents such obstacles to luxation of those bones,  that some authors have
found it difficult to conceive how it could happen as long as these apophyses
exist.
   There is much plausibility in this opinion; and  it will derive no small
weight from the cases which I shall presently relate;  although in two of them
the luxations might have occurred  without the previous fractures, which is
clearly proved by the third  case, the most important that I have hitherto been
able to procure.
   These remarks are chiefly applicable to the dorsal vertebra, and  perhaps
still more so to the lumbar, which have a more  substantial body than  the
others, with apophyses ranged vertically, that is to say, in the direction of the
principal movements of which the parts are capable.   Thus, it is the opinion
of most practitioners, that cases of luxation of the dorsal or lumbar portion
of the vertebral column, characterized  by a sharp angular, sometimes rectan-
gular, and a permanent curve of the  parts, with or without paralysis of the
lower limbs, perceived for the first time after a blow on the trunk, or a fall,
and from which the patient sometimes recovers, though the spine retains  its
deformity—are in reality fractures of those parts.
   But if authors reject the notion of luxations of the bodies of the vertebra, 
CLINICAL SURGERY.
107
 they admit on the other hand, those of the articular apophysis, and particu-
 larly that of the atlas with  the axis.  In order the better  to understand the
 mechanism of the latter luxation, I shall say a few words on the mutual rela-
 tions of these two vertebra.
   The atlas is articulated anteriorly with the odontoid process of the dentatus,
 and latterly with the corresponding parts of the same vertebra, having articular
 surfaces.  The connection of these two bones, consisting only of a capsule and
 a transverse  ligament, destined  to complete the ring in which the odontoid
 apophysis  is received, would expose them to frequent accidents were it not
 for a special ligamentous apparatus, extended  from the  occipital to the axis,
 and composed of the two lateral ligaments of the odontoid, and their accessory
 ligaments, with the  suspensory also,  and the transverse, and  above, all the
 great ligament extending from the basilar process to  the posterior surface of
 the fifth vertebra.   This is the apparatus which  gives much strength to those
 articulations; confines the  movements  of the head's rotation  within proper
 limits; and which, in fine, by its elasticity, prevents these  articulations from
 producing solely flexion of the head, which is, in fact, the joint action of  par-
 tial movements executed by the other cervical vertebra.  Luxation of the atlas
 upon the axis  may take place from a violent bending of the head, or a forced
 rotation of the part.  Always attended  by laceration  or compression of the
 spinal marrow by the tooth-like process of the dentatus, it is immediately
 mortal, and beyond the aid of  art.  The cases recorded  of recovery from
 accidents of this sort, have been nothing more than luxations limited to the
 articulations of the articular process of some of the other cervical vertebra.
   Luxation of the other  cervical vertebra is usually limited  to  one of the
 articular processes.   It is often produced by too  sudden a movement executed
 for the purpose of working behind.  It  has also  been occasioned in  children
 standing or tumbling on  their head, while the neck too weak  to sustain the
 body, is at once twisted and turned away, which is essential in producing this
 species of luxation.
   The attempt to reduce luxation of this nature  is very dangerous, the patient
 has often perished in the act, in consequence of  the compression and elonga-
 tion of the spinal marrow.  Petit Radel  saw a child die under the manoeuvres
 practised for reduction.  It  is at the present day a sort of general rule to
 leave such cases to themselves.   The pains gradually subside, but the patient
 has ever after crookedness of the neck.
   The details which I have now submitted to you, will enable you the better
 to understand the difference between true and  false luxations, in the cases
 which shall presently be laid before you.  We shall in  the  first place give
 some cases illustrative of luxation of the bodies  of the vertebra.
   Case I.—Laceration of the Ligaments of the Body of the Vertebra without
 Luxation ; Death.—A man, aged fifty, was waiting at the  end of a cart, his
 body fixed, his head and neck outstretched, in order to have a quarter of beef
 laid  on his shoulders.   The load  slipped from the butcher's hands, and  fell
 with force on the porter's neck, the man was at  once  struck to the ground.
 He was  taken  to the Hotel-Dieu, where I  saw him  the next  day deprived
 of all feeling and power of moving the lower part of the body.   The posterior
and inferior part of the neck painful to the touch and to the least movement
presented a considerable  ecchymosis, though without any  swelling; and at 
108
LECTURES  on
this part, a  distinct  crepitation was perceived upon turning or raising the
patient's head.
  The anus, parietes of the chest, abdomen, and lower limbs, were destitute
of motion and sensation; there was paralysis of the bladder, and retention of
urine.   The diaphragm  muscles of the neck and face, were alone endowed
with contractile  power, respiration was effected with difficulty, yet the voice
was scarcely altered.
  This state continued for two or three days, when suddenly, the respiration
became  exceedingly difficult and laborious, the pulse irregular, the eyes pro-
minent, the skin red and livid;  the man died with all the symptoms of a true
suffocation.
  On examining the body,  a very large ecchymosis was found in the region
of the last cervical vertebra.  The inter-vertebral substance uniting the fifth
and  sixth,  was  completely lacerated, while the  bodies of  these  vertebra,
remained quite safe.  The transverse and articular spinal processes of the fifth,
sixth, and seventh cervical vertebra were broken, and a luxation from before
backwards, could readily be effected, of the upper upon the lower portion of
the vertebral column.  At first  sight,  the spinal  marrow seemed uninjured,
notwithstanding the  disorder of the  surrounding parts—it  only  appeared
somewhat more  volumnious than usual; but upon slitting it in the length, the
centre was found mashed and mingled with decomposed  blood.
  Case  II.—Laceration of the Ligaments, with Luxation.—A man, aged from
forty to forty-five years, working in a quarry, received a mass of earth on his
loins, under which he fell, after having made some efforts to extricate himself.
He was at first carried home, where he remained three days  deprived of all
power of motion or sensation in the lower  part of his  body; and  it was not
until the fourth day, that he was taken to the Hotel-Dieu.  The upper part
of the loins was then found to be much swollen, soft all  around, while the
centre of the tumor felt hard, and a distinct crepitation was perceptible.
Through the abdomen could be felt  another tumor, resisting at  all points,
running in the direction and along the line of  the  vertebral column.  The
abdomen was evidently shortened, the base of the chest coming as far as the
crests of the ilia; there was at the same time, complete paralysis of both,
sensation and motion, in the lower limbs and parietes of the belly; the bladder
distended and paralysed, allowed the  urine to  flow involuntarily.  No fecal
matter  was  discharged, though the belly was  large and soft, the pulse was
small and corded, respiration short and difficult.   The patient complained of
dull pains in the dorsal region ; the intellect was unimpaired.
  All these symptoms evidently indicated a solution of continuity, with luxa-
tion of the vertebral column.  On the  fifth and sixth days of the accident, the
palsy extended to the left  arm, and the motions of the right began to be slow
and uncertain.   On the seventh, respiration was more  difficult, and only took
place by the diaphragm.   The patient perished  by asphyxia.
  Upon opening the body, we found the transverse and articular apophyses
of the last.dorsal vertebra, and the two first lumbars, broken;  the body of the
last dorsal and of the first lumbar vertebra separated  from their processes,
and  from the body of the second lumbar, had passed in front of the latter, and
overlapped  it to the extent of above an inch. The spinal  marrow was lace-
rated, and  the crura of  the  diaphragm  were  torn;  a' large ecchymosis 
CLINICAL SURGERY.                        109
rounded the vertebral  column.  An attentive examination of the displaced
vertebra, showed, not a fracture of their body, but a laceration of their inter-
vertebral substance, which, only in one corner, had carried away a very small
portion of the lumbar vertebra.
  Case  III.—A woman, aged fifty-six, full and  corpulent, in  coming down
stairs, met with  a  heavy fall, the  lower and back part of her neck striking
violently against a step.  She had descended twenty steps in the fall, and
was taken  up deprived of all  sensation and  motion of the parts below the
neck.  She suffered much during  the night from pain in the seat of the injury,
and excessive thirst.  Her bowels were not opened.
  Next morning, on being brought to the Hotel-Dieu, she complained greatly
of the painsin the neck, which were greatly increased  by the slightest touch
and motion of the part.  The head and neck were bent forward, and a  little
to the right, the lower part of the  neck was depressed, while the upper  part
of the back was prominent.  The lower extremities, rectum, bladder, and
parietes of the abdomen, were deprived of sensibility, and all was dead up to
the diaphragm.   Above this part, the thoracic members only labored under a
partial paralysis, respiration was  frequent and  laborious, but the voice, the
senses, movements of the  face, and the intellect, had experienced no altera-
tion ;  the pulse, also, was  full  and unimpaired;  the  tongue was dry, and a
little brownish, and the skin natural as regarded exhalation and vital heat.
  From these  appearances,  it was not difficult  to conclude that there was a
serious injury of the spinal marrow, caused by a solution of continuity of the
spinal column, with luxation.
  The patient was bled in the arm, and in the evening the respiration seemed
better;  the thirst had abated, and the tongue was less dry; yet it was  clear,
that  no hope of recovery could be entertained.  On the following night the
respiration became stertorous, speech embarrassed, the face swollen, and the
patient  sunk thirty-four  hours after the accident, her intellect remaining
perfect to the last.
  On examining the body, we found  an ecchymosis, and bluish  suggillations
on the back part of the neck, a projection backwards of the dorsal column,
with a projection forwards of the  cervical at the same place.  The cellular
tissue and subjacent muscles were bathed with blood.  The parts immediately
in contact with the vertebral column were destroyed, and allowed the upper
articular apophyses of the seventh  cervical vertebra to be seen, whilst the sixth
vertebra was perceived to  be inducted half an inch before the seventh.  In
the interval of these two bones, the spinal marrow could be seen spread later-
ally and compressed.   The spinal column, examined in front, presented a
very remarkable prominence on the part corresponding with the sixth cervical
vertebra, and it was enveloped in blood.  The anterior ligaments of the  part
were  destroyed, and the pharynx lacerated.
  Upon dissecting the  cervical portion carefully, the  yellow ligaments were
found to be torn, and so were the anterior and posterior ligamentous envelopes,
and the  intervertebral substance between the sixth and seventh cervical  ver-
tebrae.  This substance was ruptured in such a  manner,  that  two-thirds of
its thickness adhered to the  seventh vertebra, while the sixth held only the
remainder.
  With regard to the bones themselves, it was  perceived  that the seventh 
110                          LECTURES ON
 vertebra was perfect in every respect; that the end of the spinous process of
 the sixth, was slightly broken,  as well as the  margin of its lower articular
 process.  All the articulations of the vertebra, above the luxations, were in
 their natural condition;  that of the seventh cervical with the first dorsal was
 much more free than usual.
   Of the three preceding cases, the  first  presents an example of laceration
 of all the ligaments of the vertebra and of fracture of the articular apophyses,
 yet without luxation; the second an  instance of the same injury with luxa-
 tion ; and the third a pure and simple luxation, without any fracture of any
 part of  those bones.
   In all the three cases the vertebral column received a shock while in a state
 of tension,, which must have been augmented at the moment of the accident.
 There was a percussion, and not merely  a distention of the  part; and the
 determining causes of the injury were all  applied to the posterior part of the
 vertebral column.
   In all the three cases,  the intervertebral substance was ruptured, and the
 body of the vertebra remained uninjured ;  but in  the  two first,  the spinous
 processes, and the transverse and articular processes were broken and  sepa-
 rated from the body of the bones, whilst in the last all  the parts remained
 uninjured.
   In  the first case, the power which operated on the spinal column, seems not
 to have  been sufficient to cause a luxation; in the second, it produced lacera-
 tion of  the ligaments, fracture of the apophyses, and  an enormous luxation
 in the thickest part of the vertebral column.  In the third case, finally, the
 power produced a remarkable laceration of the ligamentous  substances, and
 a very great luxation in causing the articular apophyses of one of the vertebrae
 to slide  over those of the other.
   In all the three cases, the fatality arose  from injuries  to  the  spinal cord.
 All the parts below the lesion were equally paralyzed, although the injury to
 the bones was  materially different.   In all the three patients, the affection
 which was at first limited to the parts below the injury, soon extended upwards,
 until  it reached  the origin of the diaphragmatic nerves.  The  respiration,
 which, till then, was executed without much difficulty, became suddenly la-
 borious, and the patient died, by the  successive interruption of the different
 respiratory phenomena.   This  termination so  promptly fatal,  is generally
 observed, when the lesion has taken place above the origin of the diaphragmatic
 nerves; whilst life may be more or less prolonged, if it have occurred before
their origin; and thus we find that the position  laid  down by certain authors,
 that luxation of the bodies of the vertebra is impossible, does not  hold  good.
 Was further proof needed, I would recommend you to examine the Antomical
 Museum of the  School of Medicine, and  the  Garden of Plants;  you will
there find additional corroboration of the facts already detailed.
   Having now concluded  my remarks relative to luxation of the vertebra,
and the  disorders arising from those solutions of continuity; and  shown  the
 difficulty which  sometimes attends the diagnosis;  I  shall  proceed to offer
 some observations, descriptive of a complaint,  which, as it strongly resembles
 luxation of the vertebra,  has more than once  deceived even skilful practi-
 tioners.
   Case T.—Rheumatic  Affection,  Simulating  Luxation of the  Cervical 
CLINICAL SURGERY.
Ill
vertebra.—A boy of fifteen, was brought to the hospital on the 30th of January
last, by the direction of several practitioners, who advised that I should be con-
sulted on what they conceived to be a luxation of the first vertebra upon the
second.  The boy, it appeared, had two days previously, in taking off his shirt,
made a violent movement.  He felt at the instant a sharp pain in the cervical
vertebra, and heard a distinct crackling noise.  His head was turned to the left
and fixed there.  Medical men being called in, thought they  recognized an
incomplete luxation  of the first cervical  vertebra upon the  second; and
advised the lad to be taken to the Hotel-Dieu.  Upon examining him, I found
the head strongly bent to the left, with the  spinous processes of the first ver-
tebra prominent; the neck was convex on  the opposite side,  sharp pains were
felt in the part, and were augmented on the slightest effort  to  straighten the
head.  The boy complained, moreover, of feeling a numbness  and twitchings
in the right  shoulder  and arm; he  swallowed  with  difficulty,  and  could
neither flex, nor turn his head.
   Many  of those who were present at this examination participated in the
opinion of the boy's medical attendants, but I was of a different opinion, and
did not hesitate to pronounce it the effect of rheumatism.  I observed, on the
occasion, that there were certainly apparent reasons for supposing a luxation,
and that, therefore, I should explain the grounds of my opinion.  I have often
seen symptoms of the  same  description in persons, who,  being subject to
rheumatism, felt all of a sudden a sharp pain in the neck, from the fixation of
the erratic rheumatismal principle.   Thus  persons, while dancing, have been
seized with a sudden pain in the calf of the leg, which by no means depends
on the rupture of the  gracilis  muscle, as some  have  supposed,  though the
patients have been unable to walk for two or three days.  It  is not unusual to
find those pains, when they subside in one  place, making their appearance in
another.   Some persons, in stepping into a carriage, feel a sudden pain in the
loins, and the common mass of the sacro-lumbar muscles; a pain so acute
that  they become alarmed,  thinking they were struck with a stick  or a
sword.
   Now, what induces me to believe that this lad's case is of similar nature is,
that he is employed in  selling wine, that he is obliged  to go  down every day
into a cellar,  and  remain there for several hours, and that he has had rheuma-
tism.  We shall cup him on the left side of the neck.
   On the following day, the improvement was so great that no one could any
longer entertain the idea of any vertebral disorder.  The patient could  bend
and turn his head without much difficulty.  There was no longer any feeling
of numbness on the right side.   Nothing  more was done, except to apply a
few cataplasms and flannels to the  part, and in a fortnight he was as well as
ever, and left the hospital.
   Case II.—Distension and Engorgement  of the Intervertebral Ligaments of
the Cervical Region.—A man came to the Hotel-Dieu complaining of pain in
the neck.  He  said that in " the days" of July, he had received some blows
from the  butt of a musket on the head and  neck ;  but he confessed that some
months previously he had had a fall, which gave him sharp pain, but did not
prevent him from  work.  Upon his admission, the neck was convex posteriorly,
and concave anteriorly; and consequently was changed in form, the upper part
of the cervical column was prominent, and the spinous processes could be readily 
112
LECTURES  ON
felt. He could not, by any means, turn his head, and when he desired to turn
round to look at any one, he did it in such a way that it seemed as if the head
were soldered to the body.  If he  attempted to turn suddenly, he felt pain.
The complaint was aggravated by work, and there was evident engorgement
of the ligaments uniting the vertebra.  The first application of cups did much
good; they were again  tried on the opposite side but without equal  benefit.
A moxa was applied to the nape, which was so efficacious that the patient him-
self begged for another.  A cure was effected in this way, and  the man had
eventually no obstruction in the movement of the parts.
   Ca«e III.—Apparent  Luxation of  the  Vertebra;  Cure.—An old man
recent ty came to  consult me for an affection  of the spinal column,  which
seemed, at first sight, to be a luxation.  The neck was convex posteriorly and
concave in front; and so great was the stiffness of the parts that no move-
ment could be effected.  There was also observed  in the vertebral column a
vicious curvature, attended with pain on the least attempt at motion, and im-
mobility of the articulation.   It was supposed that there must be in this part
a disease of the ligaments, which, in the effort to extend them might cause a
spontaneous luxation.  Leeches and emollient poultices were applied.   Two
moxas were placed on the sides of the gibbosity, which succeeded in produc-
ing a decided improvement,  the patient could turn his head right and left;
but, for a radical cure, he was obliged to continue under treatment for a con-
siderable time.
  We shall add one other case, which, though not exactly analogous to the
preceding, is still, perliaps, sufficiently  interesting to be introduced into the
present lecture.
  Case IV.—Engorgement of the Occipital and Vertebral Ligaments ;  Para-
lysis and Atrophy of the Left Half of the Tongue.—A man, aged thirty, whose
employment it is important to notice, as it materially influenced  the develop-
ment  of his disorder, was admitted  into this hospital in the course of last
year.   He was a weaver, and was accordingly obliged to work in cellars and
on cold and damp ground floors.  Persons of this trade are very subject to
rheumatic affections, and swellings of the ligaments of the joints.
  Three years ago, this man was seized with very sharp pain in the left pos-
terior side of the head, which totally prevented motion of the  parts, and also
sleep.   In the course of five or six days they changed their position and set-
tled in the left side of the upper part of the neck.  The pains were not now
so violent but motion of the head was still impossible.
  Lateral flexion of the head, it is true, was partly performed by the totality
of the cervical column ; and the head could, moreover, be slightly bent for-
ward and backward by the same means.   The seat of the malady was evi-
dently  in the vertebra themselves, it was not in the muscles; a supposition,
which, as we shall see, was inadmissible.
   The next peculiarity observable in this case was, a difficulty in speaking,
at first inconsiderable, but increasing gradually to such an extent, that, at the
end of two months, the patient could not be understood.  He said that  the air
passed  by the  left side of his tongue  with a whistling sound, and when he
wanted to say je he could  only utter ze.   There  was some pain at the angle
of  the jaw and in the cheek of the left side;  but no paralysis of the muscles
in that quarter. 
CLINICAL SURGERY.
113
  Another symptom now became remarkable.  The tongue began to diminish
in bulk on  the  left side, and the diminution soon  amounted  to a perfect
atrophy.  The organ at this part appeared to be formed of nothing more than
membranous folds, which could be rubbed  together, without feeling in any
degree muscular; it felt like an empty leather purse.   When the tongue was
thrust out, its  right side seemed sound enough;  and the atrophy of the left
which was most visible at the end and middle portion  was inconsiderable at
the base.  The right side seemed also to enjoy an unusual degree of strength
and activity, as is observable in other parts of the body when the correspond-
ing parts are paralyzed.  There was a curvature to the right side when the
tongue was thrust out.
  It was only during the first months that articulation was difficult c* impos-
sible ; when examined at the hospital he could speak as if no atrophy existed.
This must have been the effect of practice ; for it is known that speech can be
effected by this meaus with half a tongue, nay, with a less portion,, a third, a
fourth part, and even with a stump scarcely visible.
  I was anxious to find what changes had occurred in the sense of taste; and
with this view, made four watery solutions of sugar, sulphate of quinine, com-
mon salt, and  an acid.   I tried them first on the healthy subject; some of the
pupils submitted to the experiment.  Keeping the  tongue motionless, a few
drops of these solutions were applied to the tip, there was no taste perceived;
they were applied then successively to the middle and base, when the different
flavors were perfectly distinguished.
  Repeating the experiment, it was found that there was no sense of taste, at
the tip of the atrophied side; but in the middle portion, and according as the
base was  approached, the more acute  and perfect was the sense.  Thus it
appeared that though the muscles were gone, the sense of taste remained  in
all its perfection, a remark of very great importance.
   By considering next, what nerves are distributed to these muscles, we were
still further able to form an opinion of the seat of the disorder, and the  cause
of  the atrophy.  These nerves are the lingual glosso-pharyngeal, and  the
hypoglossal; the lingual being distributed to the nervous papilla of the sur-
face ; the glosso-pharyngeal to the back part and lateral portions of the pharynx;
the first is subservient to the  taste, the second to the motions  of the organs.
Now the sense of taste being unimpaired, the lingual was sound ; and if there
had been an  alteration in the glosso-pharyngeal nerve, the functions of the
pharynx, would have been impared,  and the base of the tongue more or less
atrophied.
   The nerve  of the ninth pair, the great hypoglossal, then remains; and it is
important to consider its origin.  It arises from filaments situated between
the corpora-olivaria, and pyramidalia or the sides of the medulla-oblongata,
 and issues from the skull by the anterior condyloid foramen, at the internal
 and  posterior side of the foramen lacerum.   The eighth pair, in like manner
 passes through  the same place ; but does not appear to have been involved in
 the disease, for the functions of the stomach and alimentary canal remained
 unimpaired.  The nerve of the ninth  pair receives  and gives off numerous
 branches ; some of these are distributed to the muscles inserted into the hyoid
 bone; others supply the middle cervical plexus; and accordingly in the present
 case the left side of the neck seems not to have been so well supplied as the right.
            15 
114
LECTURES ON
 This nerve, in short, which is the true mover of the tongue, is terminated every
 where in muscular parts.
   So much then being premised  relative  to the different functions of the
 nerves of the tongue, we shall  now consider whether the atrophy depended
 on the brain or the nerve.
   The acute pains felt by the patient  at  the commencement of his disorder,
 were simply external or superficial; there  never was  any disturbance of the
 intellectual functions, nor in the locomotive powers; there has been no palsy
 in parts supplied  by the cerebral nerves, nor does  the  medulla-oblongata
 appear to be the origin of the affection, for there have been no palsies, pains,
 convulsions or contraction in parts supplied from that source.  Nor  can the
 spinal marrow be considered  as the cause of the malady.
   Taken  in every point of view, the  disorder in this case appears tome to
 result from a lesion of the nerve of the ninth pair, not within the skull but
 after its departure from that cavity.  This opinion seems corroborated by the
 lesion of the occipito-vertebral articulation.  The inability to execute motions
 of the head seems to point out some affection  existing between the vertebra,
 the cause of which  is probably rheumatism, and the seat of the ligaments.
 The disorder began on the left side, it descended on the same  side; the point
 of departure is therefore between the occipital and the first vertebra,  perhaps
 also between the first and second vertebra.
  Diseases of this kind are by no means rare.   There are in the collection of
 the School and Museum of Comparative Anatomy, ten or twelve cases of
 stiffness, with or without luxation, of the first vertebra with the  condyles of the
 occipital bone.
  Thus, in the present  case, there was inflammatory engorgement, acute or
 chronic, of the ligaments uniting the vertebra and occipital bone ; and as the
 nerve of the ninth pair passes out by the foramen  in front of the occipital
 condyle, this nerve  must have  been either  compressed, or  altered in  its
tissue at the point of exit;  it must then have become atrophied, and hence the
paralysis and atrophy of  the left side of the tongue.
  The treatment in this case  was energetic; for as the disorder appeared to
vanish from the left side, it was found to  have  some tendency to  migrate to
the right, the patient  beginning to complain of similar, although slighter pains,
 on that side.  Cupping was freely practised, and frequently repeated behind
the mastoid processes, and the moxas were afterwards employed.  The results
 were satisfactory.
  I have only to add, that this case of palsy and atrophy of half the tongue
appears to me to be  a very important one.  I have never met with  another
example of it, and are not aware that other physicians have given an  account
of any similar complaint. 
CLINICAL SURGERY.
115
                           CHAPTER XVI.

                                ON BURNS.

   On their Causes, Different Degrees,  Complications, Anatomical Characters,
 and Treatment.—The subject which we are about to consider in this article,
 is one of those, which have been treated with  most skill and  success  in the
 Hotel-Dieu of Paris.
   Burns, formerly ill-defined as to their different degrees, their complications
 but little studied, their anatomical characters unknown, their treatment, either
 empirical or abandoned to the old routine, have since undergone an important
 reformation.  Thus, the opinions of M. Dupuytren, are now generally adopted.
 It is these opinions we here intend  to offer to the reader, with such  recent
 remarks, as were suggested to the lecturer, by new cases since  the commence-
 ment of the session.
   Every year, but especially  in rigorous winters, the  surgical ward of the
 Hotel-Dieu, are  filled with individuals affected with burns of more or less
 importance.  Old women covered with rags, in the  evening retire to their
 dirty garrets, narrow and without any chimney, and after having taken a dose
 of wine or brandy, place beneath themselves or the bed-cloths, foot-stoves or
 chafing dishes filled with lighted charcoal; the heat, the  liquor, or the vapor
 of the coal, makes them drowsy; their cloflis take fire, and often when they
 awake, the fire has so far progressed, that their whole body is  burnt  more or
 less.  Porters and servants obliged  to sit up late, and overcome  by sleep in
 analogous circumstances, often meet with similar  accidents.   Old  men,
 leaning against a stove, and clasping the pipe with their knees, fall into a kind
 of coma; their cloths are burnt, and with them, the skin, muscles, aponeurosis
 as deep as the bones.   Add to these  causes, a host of others, equally acci-
 dental and unforseen, as  conflagrations, or those arising from the  business
 followed by so many  workmen, such as blacksmiths, founders, glass  blowers,
 brewers, &c. and you will not be surprised at the immense number of burns,
' which are yearly admitted into the hospitals of Paris, and especially the Hotel-
 Dieu.
   The organic lesion, called  burn,  ustion, combustion, &c, is the effect of
 the action of  concentrated caloric upon the living tissues.  Its characteristic
 marks are due to this cause, and they distinguish it from every other kind of
 injury.  They are always the  same, whatever may be the  part of the  body
 affected, and partake  at once of the nature of inflammation, of wounds, and
 of disorganization.
  But these effects of the action of caloric present very great differences as
 regards  their intensity or danger, according as they have been caused by the
 heat radiated at different distances, or  the direct  action of the flame; lastly,
 by the immediate contact of the ignited mass.
  The pathological lesions, resulting from the  radiation of heat, are  more  or
 less serious in the ratio of the intensity, and duration of its action.   When
 moderate, but continued  it thickens considerably the epidermis, hardens the 
116
LECTURES  ON
 skin, blunts its sensibility, and renders it of a brownish color;  such are its
 effects upon persons habitually exposed to the solar rays, or to large furnaces,
 as blacksmiths.   We know that many of the latter class, can handle with im-
 punity, iron even at a  red  heat.   This thickness  also,  either natural or
 acquired, of the epidermis, and the insensibility of the skin, gives to men who
 pretend to be incombustible, the power of bearing, after some preparation, a
 very high degree of heat.
  When more intense, it produces on the skin blotches of different shades,
 irregular, and marbled, cracks and ruptures of the  epidermis;  which  often
 end in ulcers very difficult to heal;  such as are seen  on  the  legs of  old  men,
 who are always seated by a hot fire, and women who  use foot-6toves and open
 chafing dishes.
  When still more active, either on account of the quantity of caloric emitted
 by the ignited body, or its close approach, it may give rise to the phenomena,
 characterizing the first and even the second degree of burns.  We have seen
 women, who, when  excessively cold,  having  placed under them  very hot
 chafing dishes, have had, in a few hours, the posterior and internal surface of
the thighs covered with blisters.
  Insolation sometimes  produced the  effects of serious burns,  especially in
hot countries.  Cases are related of persons, who, sleeping exposed to the sun,
have been severely burnt by its influence.   Gangrene soon followed a vio-
lent inflammation, and they died in four or five days.
  As regards flame, it not only burns instantaneously, but also tends to cause
animal substances to partake of the combustion which  has produced it.  Under
 its action, they are soon dried, as  it were boiled, become horny and  are con-
sumed by producing a  new  flame, which, added to the  first, increases its
activity, and its ravages. It  is well known how deeply burning cloths will
 effect the subjacent parts; the lesion is often so great,.that  death is  the con-
 sequence.  To these species of causes, must also be added, the burns  produced
 by the combustion of certain gases,  and especially of hydrogen, by the explo-
 sion of steam-boilers, and of gunpowder.  Generally, these gases produce
 merely superficial, but extensive burns, because  they act instantaneously on
 la.ge  surfaces.  Sometimes, however, they penetrate  beneath the skin.
  The degree of the burn, varies also, in  proportion to the physical or chemi-
 cal qualities of the ignited body,  which comes in contact with  living parts,
that is to say, in proportion to  their peculiar nature, their density, their capa-
 city for  caloric, and their facility  in  communicating it.   Thus all  boiling
liquids do not burn  to the same degree, because they do not all boil at the
same temperature.  On this account the action of greasy bodies, such as soup,
o\'., grease, tallow, &c. is much more energetic than that of water.   But ano-
ther difference is owing  to the  adhesive qualities of the former.   If it be true
that strong acids, and concentrated alkaline solutions, at  the boiling point,
produce more serious injuries  than other fluids, it is, undoubtedly, because
by being more dense, they have acquired a greater capacity  for caloric.
  Solid bodies give rise  to deep burns if their combustion is very rapid, as in
the case of phosphorus, sulphur, and the resins;  in  the contrary case,  their
effects are proportionate to the degree of heat, the length of  contact, and the
susceptibility of the  tissues, &c.    All things being equal, the  burn  is  less 
CLINICAL SURGERY.                        117
deep in parts habitually exposed to the air, than in those covered by the cloth-
ing, and  where the epidermis is very delicate.
  It results from what we have said, that the action of fire, according as it is
feeble  and momentary, stronger and  prolonged,  excessive, and a long time
continued, has, as a general effect, either  a simple inflammatory irritation
which tends of itself to resolution, or an  inflammation which  must end  in
suppuration, or lastly the complete destruction of the vital properties of the
parts.  Under this point of view, authors have considered burns, in order  to
classify and divide them into a greater or less number of degrees.   Thus,
some, amongst  them Hildanus and Boyer, reckon three degrees; others,  as
Hiester and Callisen, describe four;  and a modern writer admits but two,
those with inflammation, and those with immediate disorganization.
  In all these divisions the intensity of the  symptoms of the burn itself, con-
sidered in a general manner, has alone been considered, and not  the nature of
the organs affected, or that of the tissues injured or destroyed.   It is, never-
theless, evident,  that the effect is first upon the skin,  and afterwards  is
extended  to different depths; it is  in the direct ratio  of this  depth, that the
three orders of phenomena above enumerated are presented;  and, therefore,
if we wish to establish the  classification of burns on exact principles, we must
take as our base the different species of organs subjected to the  action of the
caloric.
  These  considerations have, for a long time, induced us to adopt  another
classification, and we have divided  burns into six degrees, thus characterized:
1st, Erythema, or superficial  phlogosis of the skin, without the  formation of
vesicles.   2d, Cutaneous  inflammation with desquamation of the epidermis,
and development of  vesicles filled with serum.  3d, Destruction of a part of
the thickness of the rete mucosum.  4th, Total disorganization of the skin  as
far as the subcutaneous cellular tissue.  5th, Sloughing of all the superficial
parts of the muscles'to a greater or less distance from the  bone.  6th, Total
carbonization of the whole thickness of the injured part.
  The first degree is generally produced by the action of the radiated  caloric,
burning gases, or by  the contact of bodies not very highly heated.   The parts
then appear of a lively red color, not circumscribed, similar to erysipelas, and
disappearing under the pressure  of the finger; the patient experiences a sen-
sation of smart burning, as long as the disease lasts.  Often in  a few hours,
always in a few days, the redness, heat, and pain disappear, and the inflam-
mation terminates in desquamation of the part.
   However slight may be  the burn  of this degree, we frequently, when it has
extended over a large surface, find the pulse rise and become  frequent, the
tongue redden, and  the phenomena of gastro-intestinal irritation developed.
When the head is injured, the irritation may extend to the encephalon, cause
insomnia, delirium, convulsions,  coma, and  even death.
  The second degree is owing to a more active cause and an action of longer
duration  than the first.  An acute and burning pain is felt, and  sometimes  at
the same  time, but mostly after some hours, one or several vesicles are formed
over the surface, and filled with  a clear and limpid serum; the pain then be-
comes a sensation  of tension. The vesicles are opened, the serum discharged;
the detached epidermis dries, and some days after desquamates, discovering 
118
LECTURES ON
the rete mucosum covered by an epidermis of new formation but still reddish,
thin, and delicate.
  Sometimes the epidermis, instead of forming vesicles, is primitively lace-
rated and detached from the rete mucosum which remains exposed. The most
acute pains result from  this accident, which is always followed by a slight
suppuration.  But at last the denuded surface dries, and there soon remains
nothing but a redness which spontaneously disappears, and leaves no  trace
behind.
  Combustion of the rete mucosum and the papular surface of the skin, which
constitutes the third degree of the injuries of which we are treating, is evinced
by  the  presence of  grey, yellow, or brown patches, thin, flexible, insensible
to gentle pressure, but which are very painful  when roughly handled.  They
are formed by  the  rete mucosum deprived of vitality.  The vesicles which
generally  cover the disorganized part, in this degree, ordinarily contain a
lactecent brownish serum, sometimes covered by the blood ; and this appear-
ance is  a good means  of diagnosis.  In these cases, sometimes the slough is
separated  in  a  mass at the usual time, sometimes it falls off in parcels, and
discovers beneath ulcerations of more  or  less extent  but superficial, whose
cicatrices, always free, will almost always be conspicuous, on account of the
white, dense* and shining layer, which replaces the destroyed surface of the
skin.
  To this degree belongs the  greater part of burns made by gunpowder, of
which the scars are  blackened by the substances composing it, and, therefore,
easily distinguishable from those produced by other causes.
  Whatever form the  burn may at first assume, in the  course of a few  days,
the reaction takes place;  an climinatory inflammation is developed, the eschar
separates and falls, and the wound soon  dries leaving the white cicatrix of
which we have spoken.
  It is proper to remark here, that the pain of burns  is*much more intense,
when the skin  is only injured superficially, that when deeply affected; this
fact is important as regards the prognosis.
   When an ignited body is in contact for a length of time with living parts,
an acute pain follows; but ceases when the cause of the burn  is removed.
The epidermis, rete mucosum, the whole thickness of the skin, and sometimes
also a superficial layer of the subcutaneous  cellular tissue, are  killed and
reduced to a deep yellow or blackish slough,  dry, insensible to the touch,
harder, and more tense in proportion to the darkness of its color.  The sound
skin surrounding it is wrinkled and puckered; the radiating folds it forms
round the burnt spot,  indicate the degree of incomation (raccomissemenl) v
which the latter has experienced.   After two or three  days, the pain returns,
an  inflammatory circle is formed around the eschar, which generally falls off
from the fifteenth to the twentieth day, the bottom  of the wound is composed
of  the subcutaneous cellular tissue; the suppuration is copious, and the gra-
nulations vigorous.  Such are the characters of burns  of the fourth degree.
   But here we must remark a phenomenon peculiar, as it were, to burns; it
is the force with which the circumference of the wound is drawn towards the
centre.  However  widely separated the edges may be, they constantly tend
to come in contact.  It  is this tendency of the organic power which  causes 
CLINICAL SURGERY.
119
all the vicious modes of cicatrization, which frequently engender impotency
of the parts affected, but which may be almost always prevented by a proper
course of treatment.  These results never take place when the burn affects
the posterior part of the trunk, because the  motions of flexion  being  most
natural, oppose the contraction.  The same remark is applicable to the limbs,
according to the situation the injury occupies.
  Burns of the fifth degree differ from the preceding merely in reaching
deeper  seated  parts, and may  be followed by very serious consequences.
Sloughs comprising the aponeurosis, muscles, tendons, and in which we some-
times find vessels and nerves which have resisted the destructive action of the
fire, are  sonorous, black, friable, and depressed, and require  a much longer
time for separation.  When soft or caused by boiling fluids, they present a
greyish, insensible mass, which may be depressed  by the finger without pain.
Suppuration is much more abundant, and the cicatrix in which the organs of
motion have been included, remains deformed, adherent, and  causes irreme-
diable loss of motion.
  The characters of the sixth degree are very  easily recognized.  The sur-
face of the limb is then carbonized, hard, insensible, sonorous on percussion,
easily broken, and the slough, after its detachment, leaves a more or less irre-
gular stump, according as the fire has reached the different organic elements
at different distances.   MM. Roche, Sanson, and  Begin, relate a case  of a
young man who, whilst crossing a foundery stepped into the  trench which
conveys the fused metal; and withdrew from this rivulet of iron, a limb want-
ing the foot and the  lower  part  of the leg.   He  felt no pain, and had not
perceived the horrible mutilation he had suffered.
  Such is the most scientific and correct theory, based on the nature of things
and the observation of facts, conceived and explained by M. Dupuytren, and
now generally  admitted.  This classification differs essentially  from  those
hitherto proposed, in as much as it distinguishes  the shades of disorganiza-
tion of the skin and  subjacent parts, which the majority of authors had con-
founded in their third or fourth category; whilst the six degrees are established,
as we have said above, according to the depths of the changes experiences by
the living tissues; and each one may be recognized by peculiar phenomena
which it is so important to distinguish in practice.
  However, it must not be supposed, that in the different degrees of burns, we
are to find only  the phenomena peculiar to each.  They are rarely found
alone,  and from  the simple erythema, may be complicated from the  most
serious to the most trifling.  Thus, from the point  in which  the slough is
deepest, in which  it  may extend to the bones and the whole  thickness of a
part, it becomes gradually superficial, until at last it comprises  only the rete
mucosum and epidermis; the principal eschars are often surrounded by smaller
ones; often between the disorganized parts or in their neighborhood, larger
or smaller vesicles exist, and beyond these as well  as in the intervals between
the  deeper lesions, we find only the erythematous  redness of the first degree.
Lastly,  in general burns, we  find commonly all the degrees in the different
parts of the body.
  We have still to remark,  that the  characters of these  degrees  of organic
alterations produced by burns, although well determined, are, in many cases,
very difficult to  distinguish immediately after the accident.  Thus, at the 
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LECTURES  ON
same time, that the caloric has disorganized  the parts on which its violence
has been principally spent, it has always caused such injury to the subjacent
tissues, that, without being entirely deprived  of vitality, they cannot support
the inflammation which must ensue, and must  therefore die. It results, thence,
that the greater part of burns appear, after the separation of the eschar, deeper
and larger than they were at first thought to  be.  From  these  facts may be
deduced an important principle in legal medicine; it  is, that in burns of the
third degree and beyond, we should always wait, in order to pronounce upon
their danger, until the sloughs are separated, the extent of the  disorder may
then be ascertained.
  Each of the different degrees which we have established may, according to
its extent, be a purely local malady, or cause constitutional symptoms endan-
gering  the life of the patient. The latter are the immediate result of a general
irritation determined by the action of the caloric, or the secondary effects of
epochs of inflammatory reaction, suppuration, and discharge which succeed
each other in the  progress of burns, and they have  on  that  account been
divided into primitive  and consecutive.  Let us now examine them both.
  The immediate and acute pain necessarily  accompanying the  action of con-
centrated heat on the animal parts, may be so intense as to cause  instantaneous
death, of this we have  seen several cases.   The nervous encephalic system is
then the seat of a violent irritation.   The greater part of the phenomena of
congestion and engorgement of almost all the organs of the great cavities are
observed.   This  sudden termination  generally happens  in  children and
nervous women, rarely  in adults, and scarcely ever in old persons.  It can
neither be attributed to inflammation, nor any other disease that the burn can
aggravate; it is a death from excess of pain.  M. Dupuytren is of opinion that
too great a loss of sensibility can destroy life, as well as too great loss of blood
in hemorrhagies.   The patient is in a horrible alternation of excitement and
exhaustion and generally expires in this latter state.
   But if the irritation of the skin, which is reflected upon the nervous system,
and then on the circulatory apparatus, is not sufficiently intense to cause im-
mediate death, other phenomena appear;  sometimes we have excessive agi-
tation, insomnia,  spasms, convulsions,  and intense  fever; sometimes the
patient is in a profound  state of stupor and  exhaustion ;  the pulse is  small
and rapid ; the skin cold and pale in  parts not touched by the fire;  respiration
is slow; the limbs  are immovable; he answers your questions,  either  not at
all, or but slowly and imperfectly.  This kind of annihilation generally ends
in a sudden death, and sometimes in  a general re-action.
   When  the burn is superficial, and  does  not exceed the second degree, if it
occupies a surface of  but little extent, but especially if the subject  be  pecu-
liarly irritable, the formidable symptoms enumerated are not  observed, but
a  general  re-action follows, analagous to the phenomena of erysipelas;  the
pulse becomes frequent and strong, the skin hot, and irritation of the digestive
organs is evinced by the redness and dryness of the tongue, thirst, nausea or
vomiting, want of  appetite, &c.   These symptoms generally yield to appro-
priate remedies.
   In many cases of deep burns, of the third and fourth degrees,  no remarkable
symptom is manifested daring the interval between the occurrence of the ac-
cident and the commencement of the eliminatory process.  But at this period 
CLINICAL SURGERYc
121
generally on the fourth day, the inflammation develops pain acute, in propor-
tion to the density of the skin,  and the abundance of its blood-vessels and
nerves.  If^it affects a large surface, we have then the symptoms of nervous
and gastric irritation,  already indicated in burns of the second degree, but
much more intense, and sometimes resulting in death.
   We have observed that the patients often labored under great oppression
and difficulty of respiration.  This depends on the injury at first done to the
organs of circulation and respiration, and on the secondary development of
an acute bronchial irritation, or a considerable pulmonary obstruction.
   But this is not all.  Should the patient happily escape all these accidents,
he still incurs other dangers.  Whenever burns  are very large and deep, and
consequently, after the separation of the slough, give rise to extensive wounds,
the abundance and long duration  of the suppuration, often exhaust gradually
the strength, cause great emaciation, and lastly an incurable marasmus.   This
period of suppuration  and exhaustion is, in burns characterised by phenomena,
similar to those accompanying the last stages of all chronic diseases.
   To these serious complications  of burns, we must still add  the  appearance
of erysipelas, and especially of diffuse phlegmon.   All the phenomena  cha-
racterising this complaint, are joined to the already serious symptoms of the
primitive lesion;  and if its progress be not arrested, abscesses form, the pus
is infiltrated through the cellular  tissue in the interstices of the organs;  large
desquamations of the skin result, an excessively copious suppuration follows,
and amputation, our only hope, generally offers but a doubtful chance.
   It then results from  these facts, that when burns are too extensive or  pro-
found to cause merely local injuries, that the life  of the patient  may  be
endangered at four different stages, designated under the names of stage of irri-
tation, stage of inflammation, stage of suppuration, and stage of exhaustion.
   Besides the numerous and important improvements introduced by M. Du-
puytren into this interesting branch of surgical pathology, he has, after having
ascertained the  sympathetic relations uniting the external tissues with the
great viscera, defined  the  nature  of the injuries which the latter secondarily
experienced, and they explained the cause of the general symptoms which
destroy the greater part of the patients. His numerous necroscopic researches
have thrown great light on this subject.
   Thus, it has been  demonstrated by the  examination of subjects, that when
the individual has perished in a  general conflagration, in the midst of the
flames, or in a few moments after having been withdrawn, that inflammation
has not had time to be  developed  in the digestive canal, but the evidences  of
a violent congestion, and considerable afflux are found there.  The mucous
membrane not only presents  red  blotches of greater or less  extent, is,  as it
were, injected and gorged with blood, but its cavity contains a certain quantity
of this fluid, effused in it by means of exhalation.   The brain is  deeply in-
jected with blood; the serosity of the ventricle has taken on a red color, which
is also often the case as regards that moistening the cavity of the pleura,  peri-
cardium, and peritoneum.  The bronchial tubes contain also a bloody mucus,
their mucous membrane is, in many points, of a  lively red, and studded  with
injected  capillaries.  It seems as if the blood, driven internally by an irrita-
tion as general as sudden, has endeavored, under the  influence of the exces-
sive stimulation of the heart and vascular apparatus, to escape through all
the free pores of the internal  surface.
           16 
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LECTURES ON
  If some days have elapsed after the accident, if the patient, after having
resisted the first effect of the fire, dies from the third to the eighth day, in the
second  stage, after having evinced during life all the  phenomena of acute
visceral irritation, we find, on opening the body, all the well markfd signs of
gastro-enteritis, ordinarily accompanied by inflammatory changes of the ence-
phalon and lungs. These latter organs are often affected by latent inflamma-
tion, so well  described  by Stoll, and the more distressing, as, in the com-
mencement they elude the observation of the physician.  Lastly, if the patient
dies at a more advanced period, during the course of the suppurative process
and exhaustion, we find in the viscera, and especially  in the digestive canal,
profound alterations, attesting the long inflammation to which they have been
subjected; the  mucous  membrane is studded with patches  of a deeper or
lighter red, ulcerations more or less profound; the mesenteric ganglia  are
generally engorged, &c.
  After the preceding details, you will be able to conceive on what basis your
prognosis should  be founded.   It should  be evidently deduced from the  ex-
tent of the injury, its depth, seat, nature of the cause, the age, constitution,
and temperament of the patient. Thus, a  burn caused by a poisonous caustic,
which may be  absorbed, is more serious than  that produced by any  other
cause.   Vigorous, sanguineous, and young subjects, are more exposed than
others  to  the consequences of inflammation.  A burn, even though super-
ficial, which attacks a part or an organ of delicate texture? will  be more serious
than one seated in a  less important part,  or one more capable of resistance,
either on account of its natural structure,  or a disposition acquired by labor or
habit.  The vesication, tumefaction,  and burns of the third degree,  leave
scarcely any traces;  whilst those of the fourth, comprising all the thickness
of the skin if  left to themselves, cause shapeless cicatrices, vicious adhesions,
especially if  seated  in the eyes, face, neck, hands, feet, &c, because they
possess so great a tendency to contractions.  Thus we often  see  the fingers
reversed on the carpus, and united to it;  the hand fixed to the forearm;  the
forearm to the arm;  the head to the shoulder; the chin to the sternum;  the
ears to the corresponding parts  of the head, &c. &c.
  The disorders occasioned by  burns  of the fifth degree, are  generally very
serious, and it  may be easily conceived  when we examine the member and
functions of the organs it affects.   By the destruction of the tendons and the
muscles the limb becomes useless; from  the thickness of the tissues it  has
disorganized, an excessive suppuration ensues and threatens the patient with
exhaustion; by exposing the bones to the  atmospheric air,  they are in danger
of necrosis; by opening the synovial capsules of the joints, inflammation of
these cavities follows; in one of the large  joints the most favorable chance for
the patient is a cure by anchylosis or  amputation.    The  following  is a
case m point:
  Case I.—Burn of the Knee of the Fifth Degree;  Lesion and Copious Sup-
puration of the Joint.—The man is a shoemaker of whom we have  already
spoken.   On his admission into the hospital, he had on the inner side of the
knee, a black, hard, sonorous, insensible eschar, as large as the palm of the
hand, and apparently very deep.  After repeated questioning, he informed
us that he fell  asleep whilst clasping tightly an earthen  pot full of boiling
water.  He was probably drunk, and, therefore, only  awakened by the pain 
CLINICAL SURGERY.
123
 when the knee had been deeply burned.   His clothes interposed between the
 part and the pot, were uninjured.  This case should then be classed amongst
 those caused, not by the immediate application of an ignited body, but of a
 body completely saturated with caloric.
   When the slough came out, it was seen  to extend as far the patella and into
 the cavity of the joint.   You have, indeed, seen ensue a copious suppuration
 of a greyish, grumous, fetid matter, and a discharge of pus, mixed with a cer-
 tain quantity of synovia.  However, his general health and the injured parts
 greatly improved.  This improvement did not last; the patient grew weaker;
 we have a faint hope of effecting a cure by anchylosis, but he will probably
 perish from inflammation and suppuration  of the cavity, as amputation appears
 almost impracticable.   Lastly, this operation is the inevitable result of burns
 of the sixth degree.
   A  burn of the first degree of great extent,-often  produces death at the mo-
 ment of the accident or in a few hours after; we will give some cases.  But
 after the first twenty-four or forty-eight hours, resolution begins to take place,
 and the danger is over.  When the burning mass  has been very hot, and its
 application rapid, it may cause a kind of tumefaction of the epidermis;  if it
 occupies a large surface, it constitutes a very serious injury.  This sometimes
 happens in a bath which is too hot. About two years ago, the mother of a poet
 of our day, perished in this manner.
   In  burns of the second degree, the same accidents are to be dreaded; and,
 besides, the inflammation of the internal organs is more imminent, the  danger
 of its development lasts longer, and ceases only when desiccation commences.
 We will here mention an important fact, never to be forgotten, when forming
 an opinion of the probable consequences of a burn;  it  is, that in all cases,
 women and children, nervous and irritable patients, bear less easily the pain
 inseparable from  these injuries, than persons of  blunted sensibility, and san-
 guineous temperament, than adults and old people.
   In  the third degree, the causes of pain  and  irritation  following each other
 from  the moment of the accident until its termination, the patient is exposed
 not only to all the dangers presented in  the two first degrees, but also to all
 those which may arise from the period  of eliminatory inflammation;  in  the
 former case, to  a sudden death, caused by an excess of general irritation, to a
 primitive gastro-enteritis to nervous diseases as tetanus, spasms, convulsions;
 in the second to the same phenomena, and to all the  symptoms of a violent
 secondary gastro-intestinal inflammation.  Moreover, the more extended the
 more  serious it is;  and when it affects a large cutaneous  surface, two or three
 feet square; for example, it is most commonly fatal at the period of the eli-
 minatory inflammation of the eschars, or of the establishment of the suppura-
 tion ;  but the formation of the cicatrix is subject to none of the inconveniences
 of the fourth, fifth,  and sixth degrees.
   In burns of these latter degrees, the irritation and pain last only as long as
the cause acts, but the patients during this time may  perish.  If they resist
it, sometimes they are  plunged into a deep stupor; an icy coldness attacks
them, and they  die some hours after the accident; sometimes they recover for
a time, and are carried off, from the fifth to the ninth day, by the inflamma-
tory reaction; lastly, sometimes the excessive abundance of the suppuration,
the length of the disease, the invasion of hospital gangrene, or a malignant 
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LECTURES ON
fever, exhausts and kills them.  Burns of the fifth degree, even when circum-
scribed, present always a real danger, on account of the reaction which inevi-
tably follows.  But what adds greatly to the clanger of the case, are burns of
almost all degrees which usually happen, exciting in the economy a disorder
which cannot be remedied ; fever comes on; diarrhea, redness of the tongue,
and vomiting, soon indicate a gastro-intestinal inflammation.
  Burns offer different chances of cure, according to the organs affected.  If,
for instance, they have attacked the organs of sight, and the injury has not
extended beyond the conjunctiva, an acute ophthalmia ensues, runs its course,
and in many  cases terminates in albugo.  But if they are still deeper, the
cornea may lose its transparency, and the eye itself be entirely disorganized,
either primarily or secondarily.  When the cornea preserves its transpa-
rency in some points, sight may be restored by  the operation for artificial
pupil, as was done in  1811, oh a man whose eyes were burnt by  gun-
powder.       •
  We  will now  detail  some examples of the  numerous facts  mentioned
already ; they will corroborate the principles which have been deduced  from
them.
  Case II.—Burns of the Fifth and Sixth Degrees  (from the Clothes taking
Fire,) of the  Whole Surface of the Body ;  Death during the Stage of Irrita-
tion.—A child, three and a half years of age, named Leroy, was brought to
the Hotel-Dieu, in the month of March, about eight o'clock in the evening,
having just been rescued from a chamber in flames.  His mother,  who was a
washerwoman, made a large fire in order to dry the linen, placed the child near
the hearth, and went out leaving it alone. His garments having most probably
taken fire, the little patient must have communicated it to the linen, and was
soon surrounded by the  devouring  element.  He uttered most horrible cries.
Persons hastened to him, and were obliged to force the door in order to get
to him.   He was brought to the hospital by his preservers.  He presented a
piteous appearance; he  was burnt from head to foot, and had on a few  half
consumed rags; sometimes he was stupid, and merely uttered some plaintive
sighs ; at others, excited, and cried most violently.
  Except the toes and a portion of the  feet covered by the stockings,  there
was not a spot of sound skin on all  his body.  A burn of the first and second
degree was found on his back, neck, the anterior and  superior parts of the
chest; his hair and eyelashes were burnt, his cheeks covered with eschars;
his arms  carbonized; his skin deprived of life, black, sonorous, opened in
some spots, and ready to crack in  others; the thighs  and  legs more injured
than the cheeks, the fingers contracted, and incapable of the least motion; the
genitals nearly entirely destroyed.
   There could be no hope of saving his life, and it was certain that he must
soon expire.   However, the rags which covered  his neck and shoulders were
removed, and he was put into a warm  bath.  His  respiration at  first embar-
rassed appeared to become more free.  He was left in the bath for an  hour;
reacted slightly, complains  of heat every where, and cried loudly for his
mother.  He was covered then with blotting paper spread with  cerate, and
wrapped  up in a fine  cloth.  About eleven o'clock he fell into a profound
stupor, and the next morning at two o'clock, six hours after the accident,
death released him from his sufferings. 
CLINICAL SURGERY.
125
  Autopsy.—The corpse appeared like that of a child who had been subjected
to the heat of an  oven at a very high  temperature.  The eschars were too
numerous to be counted.  On the arms, one alone might be said to exist, com-
prising the whole of its surface;  and also the muscles, nerves, tendons, apon-
euroses and bones.  Some of the joints of the fingers were opened; those of
the wrist, elbows, and shoulders were red, and filled with effused blood.  The
veins and arteries were empty.   On the lower extremities the burn extended
also as far as the bones, but on the thighs only as far as the  muscles.  From
an examination of  the genitals, the sex of the child would never have  been
discovered, they were entirely destroyed.  In the cranium a peculiar dryness
of the membranes  was observed; the ventricles contained bloody serum, and
the brain was injected.  The same degree of dryness was observable in the
pleura and pericardium.  The lungs were gorged with blood, and thebronchiae
of a lively red color.  The peritoneum  resembled the pleura, pericardium,
and the meninge-s.   The stomach and intestines were of. a well defined uni-
form redness.   All the vessels were injected, the liver filled with black blood,
and the bladder distended by a large quantity of turbid urine.
  Case III.—Burns from the  First,  to the  Fifth Degree of  Almost the
Whole Surface of the Body;  Death from Asphyxia During  the Period of
Irritation.—On the 4th of February about 11  o'clock  at night,  a porteress,
twenty-seven years of age, in the fourth month of pregnancy, had placed beneath
her feet  a chafing dish  filled  with  live coals  or lighted charcoal.  Being
fatigued she fell asleep; her clothes took fire ; and she awoke only when nearly
enveloped in flames.   She immediately opened the door and rushed into the
yard, thus increasing their violence.  On her admission into the Hotel-Dieu,
her clothes consisted of merely a few half-burnt  rags, adhering to the  surface
of her body.  Her stockings and feet had alone escaped injury.  The face
suffered less than the rest of the body.  Her eyelashes and eyebrows  were
destroyed.
  The greater part of the surface of the body was either covered with blisters
(second degree),  or  stripped of its  epidermis and  rete  mucosum (third
degree).   Such was the state of the anterior surface of the legs, and nearly
the whole of the abdomen and thorax, which were of a lively red.  In  other
places; the burns had reached the fourth and fifth degrees; here  the eschars
were soft and of a whitish, color; there, they  were hard, sonorous, and of a
brick color; the left thoratic extremity, and the posterior part of the thighs,
presented, throughout their whole extent, one or other of these  changes.
  The unfortunate woman was carefully stripped of her remaining rags, and
placed in a bath of a temperature of 84°. On  first entering it, she had a
very acute smarting, but soon felt better, and afterwards complained of  great
coldness,  which she attributed to the water which had been thrown  upon her
in order to extinguish the flames.  This chilliness lasted about half an  hour.
On its leaving her, she became very sleepy.  She was  then taken out of the
bath, covered with fine linen spread with cerate, and wrapped in  warm clothes.
She took an anodyne draught and some whey.  The night passed tranquilly,
and she slept a little.
  The next morning, from the  immobility of the face, and  almost  tetanic
tension of its muscles, M. Dupuytren saw, before it was discovered, that she
was affected with a general burn.  He again prescribed baths, but the patient 
126
LECTURES ON
 opposed it so much, on account of her weakness and pain caused by moving
 her, that but one could be administered.  The draught was continued.  The
 day passed without very great pain, she slept continually and her  intellect
 was unimpaired.  In  the evening she was again dressed.  During the night
 a good deal of jactitation, but no delirium.
   On  the  second day, she was found to be considerably exhausted;  had
 suffered from cough, and inability to swallow.   The attempt to swallow a few
 drops of fluid, was accompanied  by a gurgling threatening apoplexy.  Some
 moments afterwards her speech returned, and her intellect remained sound until
 her death,  which took  place about 11 o'clock, A. M. of that day; thirty-six
 hours after the accident, from asphyxia,  that  is cessation of the  respiratory
 functions  The child of which she was pregnant, being only four months old,
 and  therefore not viable, nothing  was done as regarded it.
   Autopsy*—Twenty hours after  death.
   Considerable rigidity of the body; almost the whole of the skin, scarified,
 hard, and coriaceous.  The eschars were white on the anterior part of the
 trunk, black  on the loins and back; on the  posterior part of the  thighs,  the
 skin, cellular tissue and enveloping aponeurosis, had been deprived of vitality
 the muscles of this part were red  and firm, but unchanged.   The hair cover-
 ing the pubis was burnt, and the skin of the greater labia carbonized.  The
 pia-mater was highly injected, the arachnoid sound, but dry; the  cerebral
 substance firm and equally dry.
   The lungs  free from  adhesions were engorged with blood; the bronchiffi
 filled with mucus, and  their mucous membrane deeply injected.   In  the  left
 cavities of the  heart,  was observed a concentric hypertrophy  already far
 advanced.
  The stomach near the pylorus, presented  a  quantity of small  ulcerations,
 almost miliary; some as large  as a lentil,  and of a greyish brown color.
  The ileum throughout was of a deep  red;  the liver and spleen were
engorged;  the peritoneum very dry.
  The bladder contained a small  quantity of turbid and whitish  urine; and
a similar fluid was found in the pelves of the kidnies.  The uterus, which
ascended three inches above the pubis, contained a well formed foetus,  about
seven inches in length.
  The heat was remarkably preserved in this region.  A  separation  of three
lines  existed between  the pubic  bones; the sacro-iliac  articulations were
equally relaxed and movable.
  Case IV.—Asphyxia from  Charcoal; Burns of the First Four Degrees,
or Several Parts, from Boiling Soup and Flame; Death During the Stage of
Reaction.—Bisson, Angelica F..., forty years of age, subject to epilepsy for
many years, was seated near the fire, when being seized by a fit, she fell upon a
kettle of boiling soup.  The left side of the face, and the whole of the right
hand, were  burnt in  the first two degrees; the  left elbow and  upper and
lateral parts of the chest, which had come in immediate contact with the flame,
were burnt in the third  and fourth degrees.
  The burn of the first degree, was marked by a very lively red  color, that
of the  second by numerous blisters, and  those of the third and fourth by
large and deep eschars.  Unfortunately they were all very extensive;  the
patient was in a state of general anxietv; and uttered  piercing crie9, caused 
CLINICAL SURGERY.
127
 by horrible suffering.  She was sometimes strongly convulsed; and at others
 delirious.  (Copious venesection, anodyne draught, diluent drinks, diet abso-
 lute; dressings of fine linen, perforated and spread with cerate; charpieand
 poultices.)
   For three days all went on well.   On the fourth all the symptoms were
 increased, insupportable pain, delirium almost continual, erysipelatous redness
 over the whole body, tongue red and dry,  extreme anxiety.  She  was again
 bled, but the symptoms were undiminished and she died during that day.
   Necropsy.—The pia-mater and braift slightly injected; the gastro-intestinal
 mucous membrane inflamed in many points, and  the internal surface of the
 veins, presented a remarkable redness.
   Case V.—Burns of Different Degrees, from Inflamed Garments; Tetanus
 Produced by the  Inflammatory- Reaction ; Death.—Roger, J. B. thirty-three
 years of age, a day-laborer, was admitted into the Hotel-Dieu, for a large
 and  deep  burn, of two day's standing, produced by the combustion of his
 clothes,  in a drunken fit.   Assistance being near, his  clothes  were  pre-
 vented from being entirely burnt.  The burn occupied the posterior, inner,
 and  outer sides of the thigh, extending from the  fold of the thigh to the
 ham.    The  skin sphacelated  over the  greater  part  of  this  surface, was
 dry, hard, sonorous, of a faded white hue.  Around  the eschar the burn
 was less intense, and its different degrees could be distinguished, forming a
 belt of nearly two and a half inches in width.  The pulse was  sufficiently
 full, but the skin was cool.  He was bled, and emollient poultices applied to
 the eschars.
   Fourth day, the febrile reaction was more marked. (Baths, opiated poultices,
 anodyne draughts.)
   Sixth day, the eschar had softened, an inflammatory swelling surrounding
 it on all sides, fleshy granulations could be perceived;  but the patient expe-
 rienced the most violent pain, and was unable to  sleep; his pulse was very
 frequent.
   Ninth day, pain in the forehead.  Tenth, it became  excessively severe;  the
 lower jaw in close  contact with the upper; the patient complains of difficulty
 in the motions of the neck and of stiffness of the right arm; abdomen tender,
 pulse frequent, corded.  (Venesection in the arm, fifteen leeches  behind  the
 the ears;  anodyne draught with fifteen drops of laudanum.)  In dressing the
 wounds, care was taken to expose them as short a  time as possible to the  air.
   Eleventh day, the patient is worse;  insomnia, greater stiffness of the jaw
 and muscles of the neck, the left arm begins to be rigid.  The jaws are sepa-
 rated with great difficulty; copious perspiration.  (Bled until he fainted, bath
 every three hours,  opium by the mouth and by enema; opiated embrocations
 on the masseters and muscles of the neck.)
   Twelfth day, the neck is thrown backward, muscles of the pharynx con-
tracted, momentary aphonia.
  Thirteenth day, a spoon can hardly be introduced between the jaws;  the
body strongly bent; perspiration copious; pulse  corded, very frequent; no
delirium.   (The wounds are dressed with opiated cerate; six drops of lauda-
num in an enema, every two hours; continue the  embrocation  to  the lower
jaw, neck, and abdomen.)
  The suppuration was not abundant, the granulations of a vermillion color; 
128
LECTURES ON
pain in the neck, augmented on the slightest pressure ; epigastrium very ten-
der; respiration embarrassed; symptoms becoming more and more alarming.
(Twenty-five leeches to the back of the neck.)   Up to  this time, the man
continued to pass his water and fecal matter;  his intellect remained perfect;
the pulse almost imperceptible.  He died at seven o'clock  in the evening.
   Necropsy, thirty-six  hours  after  death.—Great  rigidity  of  all  those
parts of the body which had not been affected by tetanus; but the muscles of
the neck, shoulders, and in general all  those regions in  which the tetanic
rigidity had existed, were completely relaxed.  The skin of the thigh covered
with eschars for the space of a foot  square, was removed, and  discovered a
large and well looking wound.
  The veins of the  interior of the cranium were highly engorged with  black
blood.   The arachnoid  was of a slight  opal color, detached with difficulty
from the cineritious portion of the brain, which was the seat of a considerable
afflux of blood  giving  it an uniform roseate hue.  On  squeezing it,  there
exuded drops of blood, without, however, diminishing its redness.   Beneath
the cineritious portion, the medullary substance was studded with blood; but
at the distance of an inch from the gray matter, this discoloration diminished
so much, that near  the ventricles, the  vascular injection  completely disap-
appeared.  On  each side of the surface of the central hemispheres there was
a patch as large as the  palm of the hand.  The ventricles contained  but a
small  quantity of serum.  Injected vessels, in considerable number, were
spread over the surface of the corpora striata, and the thalami nervorum opti-
corum; internally these parts as well as  their prominence, presented only a
very feeble vascular injection ; otherwise, the brain was  pretty firm.
  On opening the spine, the veins were also found filled with black blood.
The spinal marrow carefully examined, appeared of ordinary consistence.
The grayish substance found in its centre, was remarkably injected and red,
especially a little below the cervical enlargement, and a  few inches lower, on
a level with the eighth or ninth dorsal vertebra; so that, in the spinal marrow,
as well as  in the brain, the cineritious portion was found injected, and of an
uniform red color.
   Digestive Apparatus.—There was some redness towards the great curva-
ture of the stomach, for  the space of two inches square, though but slight.
The ilium  was generally red;  the ascending color here and there discolored;
the liver and spleen were healthy.
  Respiratory.—The bronchia were sound, the lungs adhering posteriorly by
some old cellular filaments, and were but slightly engorged along their poste-
rior edge.
   Circulatory.—Heart and vascular system healthy, the large veins  filled
with blood.
   Genito- Urinary.—Nothing remarkable.
  Case VI.—Burns from the First to the Third Degree;  Diffuse Phlegmon,
Ensuing in the  Stage of Reaction, and followed by Symptoms of Gastro-enteri-
tis, Meningitis ; Death.—Magin.a servant woman, sixty-three years of age, of
a feeble constitution, and in bad health, was seated  near a wood fire, alongside
a furnace filled with burning charcoal.   The gas of the coal stupified her, she
fell into the fire, and was severely burnt in the right heel and thighs.  Assist-
ance was  immediately procured.   Being taken immediately to the Hotel- 
CLINICAL SURGERY.
129
Dieu, she exhibited no remains of asphyxia; but suffered a good deal in  the
parts burnt;  on each thigh there was a large eschar, white, hard, sonorous,
surrounded by numerous vesicles (third and second degrees); a lively, erysi-
pelatous redness was diffused over the thighs, and posterior part of the body,
(first degree.)  Another burn was observed on the lower part of the right in-
ferior extremity ; above the heel was an eschar as large as a five franc piece;
on the back part of the leg, an erythematous redness; in other places, vesicles
filled with serum, (third, first, and second degrees.)   Bath,  dressing with
linen spread  with cerate, anodyne potion.
  During the night the patient was tormented by frightful dreams, the next
day she complained of a violent headache. (Venesection.)
  Third day, acute pain in the burnt parts.  As the patient habitually laid on
her back, as is  most frequently the case with old people, she was desired to
remain constantly in the contrary position, on account of the seat of the burn.
This precaution was very important, for the weight of the body often may
increase the  extent of the sloughs, as in certain diseases, it alone will produce
gangrene.
  Fifth day,  the  sloughs began to separate at their edges, and  do not seem
very deep.   The patient demanded food, which it was thought improper to
grant. During  the evening she was seized with chills, fever, pain in the whole
right lower extremity.   The burn of the first and second degree  had disap-
peared ;  but consecutive inflammation ensued, and an erysipelatous redness,
accompanied by engorgement, spread itself over the limb.
   Sixth day, this inflammation has taken on  all the characters of diffuse
phlegmon, and  extended as far as the upper part of the thigh ; the articulation
of  the knee  was very  painful.  Twenty leeches were applied to the limb.
The burn is  doing very well; the sloughs almost entirely separated, suppuraj
tion not very copious.  .
   The phlegmon appeared  stationary during thirty-six hours; but  delirium
then ensued, the features were contracted, the  tongue and lips became  dry,
the fever reappeared with increased intensity, the patient was attacked  with
vomiting and diarrhea, and expired on the eleventh day of the  accident.
   Necropsy.—Thirty-six hours after death.
   Cranium.—The  brain firm,  presented no  morbid appearance.   The  ven-
 tricles contained a large quantity of reddish serum.  The meninges, especially
 the arachnoid, were inflamed.
    Thorax.—The right lung was hepatized at its base;  the bronchiae deeply
 injected and filled with thick mucus.  The pleura of the right  side contained
 a slight  effusion; heart  large; dilatation of its cavities and thinness of its
 parietes.   The pericardium presented  internally some white patches, indicat-
 ing former inflammation.
   Abdomen—T\\e mucous membrane  of the stomach was very red ;  the gall
 bladder contained about thirty small calculi.  The mesentery was filled  with
 hard tubercles.  The liver very large.
   Case VII.—Asphyxia from Charcoal;  Bums of the Second and Fourth
 Degrees;  Appearance of the Menses from the Wound;  Different Occurrences
  dfter the Stage of Suppuration and Exhaustion; Death at the End of Eight
 Months.—.Marie Touchu, aged forty-two years, was  boiling  water on some
               17 
150
LECTURES  ON
lighted charcoal, fell down in a state of asphyxia, and was severely burnt on
the lower part of the back; the skin of the thighs was wasted and rendered
similar to horn.  After  four or five days, large eschars occupied the whole
burnt surface.
  Eight days afterwards, her menses appeared.  A discharge of blood took
place at  the same time  from the ulcerated surface, (we will -give hereafter
another case of this deviation of the menstrual flux.)   The pains were very
acute, a copious suppuration came on, her pulse was weak and small, and the
patient much prostrated.  Tonics were presented.  She was very patient and
laid constantly on her abdomen.  The suppuration was with  difficulty dimi-
nished, the cicatrization remained stationary, and made no perceptible pro-
gress.  A host of accidents followed each other; erysipelas, abscesses of the
joints, symptoms of gastric irritation, &c.  The  patient fell into a state of
marasmus and complete exhaustion, and died in  eight months  and thirteen
days after the  accident, at a period  when the cicatrization although nearly
completed, was not quite perfect.
  This case presents  the termination by  death  at one of the most distant
periods at which it can happen.
  Case VIII.—Burns of Both Feet, from the First to the Fourth Degree, by a
Foot-bath; Diffuse  Phlegmon; Death on the Seventh Day.—A female lace-
maker, seventeen years of age, enjoying good  health, learning that  her mar-
riage with a young man to whom she was violently attached,  was broken oft,
resolved to destroy herself, shut herself in a close room, filled two chafing dishes
with burning charcoal, and fell into a state of asphyxia;  how long she remained
without assistance is not known.   A person coming to see her heard some
groans, broke open the door and found her apparently dead ;  she was carried
to the Hotel-Dieu, after fruitless endeavors to restore her to animation.
  The surface of her body was of violet color, respiration imperceptible, the
pulse could not be felt at the wrist, but the temporal arteries pulsated very
feebly.  The patient was laid  on a bed near an open window, and her body
rubbed with hot vinegar, she then gave some signs of life.  A vein in the arm
was opened, from which at first only a few drops of blood flowed ; but the
fluid soon spirted out  and twelve ounces  were  taken.   She  was much im-
proved. A pediluvium containing mustard was prescribed ; instead of making
it of the ordinary temperature, the nurse of the ward plunged the feet of the
unfortunate girl into a bath of boiling water; after half an hour, the patient
began to converse, complained of the heat  of  the  water and  a sensation of
numbness in her feet; she was carried back to her bed.
  The next morning, she was greatly agitated and complained of violent pain
in her legs ; they were examined, and to our astonishment, we found a serious
burn of both feet, extending three fingers'breadth above  the  malleoli; the
skin of the toes was gone; yellow and hard eschars covered the dorsal aspect
of the parts and the ancle joint; on the lower part of the leg,  the limits of the
burn were defined by numerous vesicles, filled with a reddish serum ; higher
up, on each leg, was seen a deep redness accompanied by slight swelling and
intei/se pain.
  On the third day of the accident no symptoms of the asphyxia remained;
but the  vital functions have been  deeply  injured; the  pulse was small and 
CLINICAL
SURGERY.
131
 weak, the eyes lacking lustre, the cheeks flushed, the patient exhausted. The
 parts were wrapped in linen spread with cerate, laid in poultices, and placed
 upon pillows.
   Fifth  day, the inflammation of  the  legs  has progressed  considerably.
 (Thirty leeches to each and a bath.)
   Sixth day, an obscure fluctuation existed  in the right  limb;  the phlegmon
 has reached  the  knee and  thigh.  The patient's countenance  changed,  her
 mind wandered,  delirium came, on, and she  died at two o'clock  on the morn-
 ing of the seventh day.
   Nccropsy.->-The different degrees of the burn were distinguished; some
 deep sloughs were beginning to be detached at their  circumference.  All the
 articulations, and especially those of the foot and  leg, were inflamed;  the
 synovial membrane was red, injected; in the right tibio-tarsal articulation a
 considerable effusion of bloody serum existed.  Above the burns the skin was
 separated for some distance, and on the  right were two deep  abscesses, of
 which the pus was effused between the muscles,  which were dissected as far
 as the knee.   Pus was also  infiltrated into the cellular tissue of the thigh and
 the inferior and posterior  part of the trunk.   Every  where the cellular tissue
 was of a Iardacious appearance.
   The large cavities offered nothing  remarkable, except a well defined injec-
 tion of the meninges .and  the cerebral substance.
   All the preceding facts have been  selected from a large  number of cases
 which have occurred in the hospital  for many years  up to the present date.
 Wc have designedly chosen unsuccessful cases  in order to  demonstrate  the
 causes of death in the different stages of burns, and the appearances presented
 on dissection.  We shall  hereafter detail the treatment appropriate to this
 serious malady and its equally serious complications.
   Let us resume the most striking, and at the same time the  most instructive,
 of the foregoing  cases.  In all, the burns were  severe, deep, and extensive.
 In the first two they occupied nearly the whole surface of the body, and pene-
 trated through  the skin.  Thus these two patients (second  and third cases)
 perished from an excess  of general irritation;  one, aged three and  a half
 years, in a few hours ; the other, thirty years of age, on the second day.   A
 third patient (fourth case) could  not support the inflammatory reaction, and
 died  on  the  fourth  day in  the beginning of the stage of elimination, with
 symptoms of violent inflammation of the brain and digestive apparatus. The
 fourth patient was attacked  in the same stage  by tetanus, which carried him
 off on the twelfth day.  Autopsy showed serious lesion of the organs of sen-
 sation, the brain and spiral marrow.   In  the sixth and eighth cases, diffuse
 consecutive phlegmon was developed with the eliminatous  stage, producing
 large abscesses, the separation of the skin to a great extent, the inflammation
 and  suppuration  of the joints, which, after  having sympathetically reacted
 upon  the internal organs, caused death,  in the first case,  on  the eleventh
 day, and in the second, on  the sixth.  Lastly, the woman,  in the  seventh
 case, experienced ahostof bad symptoms for eight months; suppuration went
 on during all that period ; cicatrization could not take place, and she died in
a state of marasmus and  exhaustion.—After these remarks, M. Dupuytren
proceeded to  treat of the therapeutics of burns. 
132
LECTURES ON
  Burns have been at all times subject to the most absurd attempts of empi-
ricism.   Everyday has had its sovereign remedies, which, after having been
more or less praised, have been superseded by others, and these in their turn
have fallen  into the oblivion of their predecessors.  Nothing has  hitherto
been able, nor ever will be, to disabuse those who seek for an  infallible
remedy for burns.  As obstinate  as  those who pursue the quadrature of the
circle,  they constantly are desirous of discovering this panacea.   A remark-
able circumstance, and one which imposes on the crowd, is the absolute con-
fidence and assurance of  the possessors of similar secrets.
  Case IX.—A few years ago a young woman was admitted into the Hotel-
Dieu.  The combustion of her clothes had produced a frightful burn, extend-
ing nearly from her head  to her feet.
  From the  absolute insensibility of the parts  burnt, the destruction of the
epidermis, the disorganization of the rete mucosum, the tension, and brownish
yellow color of the corion, it was easily  seen that the whole thickness of the
skin was injured.   From  the weakness of her voice and pulse, her immobility,
cold and desperate insensibility, it was foreseen that her malady would be
fatal; that if she escaped the dangers of this  state of dejection, she could
not be  able to support the consequences of the eliminatory inflammation;  and
that in no case her strength would be sufficient for the suppuration, or the
perfection of the cicatrix.
  However,  a lady,  respectable  on account of her age and behavior,  had
accompanied the patient,  and desired to treat her under our inspection.   She
said she had inherited for more than four hundred years, from generation to
generation,  a secret by  which  thousands had  been cured without  a single
exception.
  I observed to her that the patient was affected  with an incurable and mortal
burn;  and I vainly endeavored to persuade her, for the credit of the remedy,
to wait for a more favorable opportunity.  She,  however, urged her request
so vehemently that, after assuring us that it contained nothing hurtful, she
was permitted to use it.   Nothing could equal the zeal and devotion with
which she anointed the patient several times a day.
   There soon followed a reaction caused by inflammation, which  she hailed
as a salutary effect of her remedy.  Circles  of inflammation surrounded the
injured parts, and she asserted that the disease would be cured.   Large  por-
tions of the  tissues separated every day, still she was  of the same opinion.
Lastly, death alone, which happened on the fifteenth day, seemed to throw a
doubt  on her mind as to the efficacy of her hereditary secret.
   To what then is owing this unlimited confidence on the one hand, and on
the other this blind credulity of the multitude, shared,  it must be confessed,
by so  many  well informed persons ?  It is because burns are considered as
simple in their nature and phenomena, constant in their progress and effects,
and which ought, therefore, to be easily cured  by a remedy as simple and
invariable as these.
   Such is the foundation of all the hopes and promises of inventors of secret
remedies.  The destruction of so prejudicial an  error  is a  service  rendered
to humanity.  Far from  being a  simple disease ;  burns, on the contrary, are
 very complicated, whose numerous and various degrees constitute  as many 
CLINICAL SURGERY.
133
affections presenting distinct characters, variable consequences, peculiar com-
plications, and hence requiring different modes of treatment.
   It will suffice to recall to your memory the numerous effects of caloric upon
the living tissues, which we have described, in order to be convinced of these
truths.  Compare the immediate and material effects of the action of caloric
to the  secondary effects  which ensue; to the  eliminatory suppuration, and
ulcerative inflammation;  the local and  general fever ; the innumerable com-
plications accompanying them; accidents of all  kinds  to which they give
origin ; pain, spasms, convulsions, tetanus, &c; the care sometimes required
by a cicatrix, whose cure must be retarded  in order to avoid  deformity, and
sometimes hastened to avoid death; and you will be able to judge of the inef-
ficacy  of all secret and infallible remedies.  It will soon be seen that pro-
found  knowledge, an  exact  acquaintance  with the organization, and  the
alterations it may undergo, and lastly, a consummate experience in the means
of restoring it to its primitive condition, can alone with  certainty effect a
cure.
  The treatment of these injuries  is based upon the following indications:
1st, to remove the cause; 2d, to arrest the inflammation, moderate and calm
in the first two degrees, the pains and cutaneous irritation developed at this
moment of the accident, and  direct their effects from the internal organs;
3d, to limit the secondary inflammation which presides over the  separation
of the  slough, and the establishment of suppuration; 4th, to favor and direct
by proper means the cicatrization of the wounds; 5th, to oppose the forma-
tion of vicious adhesions  which might embarrass more or less the movements
of the  parts, or even deprive them of their functions; 6th, and lastly, to sub-
due the general primitive or consecutive symptoms which  may arise in the
course of the disease.
   The indication for removing the cause of  the injury is seldom presented to
the surgeon, except in cases of burns produced by caustics, when a portion,
as yet  unconfined, remains adherent to the wound.  It is fulfilled  by means
of lotions made with reagents which will neutralize  the offendim»; substance,
and which chemistry alone teaches us.   In the majority of cases, water is quite
sufficient.
   In burns of  the first and second degrees,  unaccompanied by denudation of
the epidermis, the practitioner should endeavor to subdue  the inflammation,
and prevent the formation of vesicles or eschars whose presence would increase
the length and difficulties of the treatment.  All means endowed with proper-
ties slightly astringent or repellant, sedative and not stimulant, appear to us
to fulfil this indication.   The immersion of the part in cold water, Goulard's
lotion, alcohol and water, or water slightly acidulated ; and when this immer-
sion is impossible, fomentations long continued and  frequently renewed with
the same liquids, or with ether, alcohol, a solution of sulphate of iron, almuine,
potash or ammonia, &c,  produce very happy effects.  But  these latter sub-
stances cannot be used when the epidermis  is  removed, for then they would
increase instead of calming  the  irritation, and  give great pain.   It is very
important to preserve the skin over the  burnt parts; and, therefore, the clothes
should be removed very carefully, and even cut away.   If vesicles exist, they
should be opened by a simple puncture, with a needle or the point of a lancet,
at their most depending part.  If the irritation and pain are very considerable, 
L34
LECTURES  ON
we will derive advantage from calming potions, and anodyne topical applica-
tions.
   If the patient be young, vigorous, and sanguineous, the abstraction of blood,
either local or general, will tend to restore tranquility and prevent inflamma-
tion.  Moreover, the remedies will be more efficacious in proportion to  their
prompt  use.  In all cases the patient must be  subjected to  a  diet severe in
proportion to the seriousness of the injury, and should use mucilaginous, acidu-
lated, and diluent drinks.
   Lastly, if, notwithstanding all our care, inflammation ensues, it must be
moderated,  prevented  from attaching  the sound tissues, and  by becoming
excessive, from terminating in gangrene, or from  reacting too powerfully on
the internal  organs, and giving rise to the formidable  sympathetic accidents
which we have described.  Then we should  quickly have recourse to emol-
lient applications, poultices of a similar nature, local and  general bleeding".
Should the pain be very intense, we should add to the preceding, the anodyne
balsam,* laudanum, decoctions of hyoscyanus, solanum nigrum, poppy heads.
   The same indication is presented in burns of the third and fourth degrees,
in the commencement of the process of eliminatory inflammation.  If too vio-
lent, this inflammation  should be repressed, and excited if too tardy.  But it
must not be  forgotten, that in these cases stimulants which are too powerful
or long continued often cause an erysipelas, which commencing at the edges
of the wound, attacks  successively the whole body, and is  frequently fatal.
Wc have generally succeeded in arresting it  by the application of a blister
over the very part affected.
   But other  cares become necessary at this time.   The burn should be covered
with fine linen, perforated and spread with some unctuous substance, as simple
cerate or Goulard's cerate, over which we place a layer of lint, in order to
absorb the pus.  Emollient poultices should be applied to the sloughs, to make
them separate.   When they are nearly detached, and are united to the bottom
of the wound  only by a few filaments, these  last should  be divided by the
scissors as closely as possible.   Sometimes, when the eschar  is deep, as in
burns of the fourth and fifth degrees, pus  collects beneath them ; of this we
are informed by the fluctuation, and it  should be immediately evacuated, so
that it may not infiltrate in the adjacent cellular tissue.  When, by the fall of
very superficial eschars, or the separation of  the  epidermis  constituting the
vesicles, the derma, being exposed,  is very painful, the  opiated cerate, and
saturating the dressings with a solution of the gummy extract of opium, are
the most appropriate applications.
   The  dressings  should  be promptly applied, in  order  to prevent a  long
exposure of  the parts to the air; and with care  and gentleness, in order to
avoid pain, which is sometimes dangerous.   To  do this, we should  at  first
uncover a part of the  wound, and dress it before removing the remainder of
the apparatus; and for this purpose the bandage of Scultetus is far preferable
to the roller.

   * Anodyne balsam. Take of the green leaves of hyoscyanus, cynoglossum, and nico-
tiana, each one pound ; put them into three pints of wine, and boil down to two  pints ;
squeeze  in a strong cloth ; add an equal quantity of olive oil, boil over a slow fire, until
it is reduced to one half; let it settle, decant  and  preserve  it.—Extracted from Foy's
Formulary by the Thais s. 
CLINICAL SURCERY.                        135
  After extensive burns, and especially burns of the fourth and fifth degrees,
the suppuration is generally very copious, and two or even three dressings are
required daily.   But the patient is apt then to fall into a dangerous state of
prostration and weakness; and his strength should be  maintained  by sub-
stantial food, and especially tonics, such as bark administered  by the mouth,
rectum, and topically.
  In burns where a greater or less destruction of the tissues exists, cicatrices
result, which are  often unsightly, and sometimes embarrass the freedom of
motion of the parts they occupy, and prevent the exercise of its functions.  It
is, therefore, important  to prevent these deformities  which are sometimes
hideous, by taking care to give to the  cicatrix nearly the  same extent as the
original skin, and opposing its contraction.  This may  generally be done, by
carefully cauterizing with lunar caustic the granulations when too prominent,
by  position,  well directed dressings, and  by  a  firm  apparatus.  Thus the
limb should not be kept flexed, if it be burned in the direction of flexion; nor
extended, if injured in the direction of extension; we should introduce bougies,
tents, canulas or  sponges in natural openings,where contraction would have a
tendency to diminish or close up.  We must separate by means of compresses
and pledgets, kept in place by bands of sparadrap, organs, such as the fingers,
which might form unnatural adhesions.  In  the face of which the tissues are
so movable and extensible, art does not always  succeed in preventing  defor-
mity ;  we should  endeavor to prevent it, as  far as possible, by means of adhe-
sive straps, and such other means as the nature of things may suggest.  But
in all cases, if  a good cicatrix can be  obtained, only at the cost of pain, which
might be fatal to  the patient, it must not be attempted.
   When a limb,  or part of  a  limb, is completely  destroyed, amputation is
indispensable.  It substitutes a simple wound whose suppuration will be short
and whose cicatrization will  be regular and  easy, for a  slough which is long in
falling, and which leaves after  it  an  irregular solution of continuity, with  a
projection of the  bones, and all  the deep seated parts which have suffered less
from the action of the fire.  Besides, by removing the burnt parts, the patient
is spared the  secondary inflammation, which is  not always without danger.
Nevertheless, before deciding  on this  step, the surgeon must examine atten-
tively the age, constitution and strength of the  patient, and whether he is
able to bear the eliminatory process.   It is evident that, if  the patient is in a
state of stupor, as is frequently the case, or if  the local inflammation has had
sufficient time to be developed, if fever exists, &c. we  must wait until these
symptoms disappear, until suppuration is established, and then take as the rule
of our conduct, the general state of the patient and that of the wound.
   When the cicatrix is complete, the tissues preserve a rigidity which prevents
the free use of the functions of the part.  The patient should then use fomen-
tations, frictions, oleaginous embrocations and local baths.   On the other hand
his exercise should  be  moderate, lest the cicatrices  should break, as often
happens, especially when  they are seated on the  inferior extremities.
   It  now remains for  us to explain, in a few words, the general cases  de-
manded by the patient according to the seriousness and  different stages of the
disease.  A slight superficial and circumscribed burn,  giving rise to no consti-
tutional derangement, requires no internal  remedies.  But if although super-
ficial  it is very extensive, the patient should at first be kept on a strict diet, 
136
LECTURES ON
diluent  and refreshing drinks, placed in a remote cool place, far from any
physical or moral excitement.  The same means are proper for deep burns.
Acute pain demands the free use of opium; fever and inflammatory symptoms
may be  subdued by venesection, especially if the patient is strong and ple-
thoric;  but bleeding is less required, when large and deep eschars threaten a
very copious suppuration; for, weakened by this cause, the patient could not
resist this suppuration, and would perish from  exhaustion.  Drinks, diet,
and rest are here the only suitable means.
  Suppuration  being established and the fever removed, we may give some
light nourishment, but in small  quantity.  In suppurations which are very
copious and of long duration, threatening the patient with  exhaustion and
marasmus, the ferruginous preparations and the bark are very useful.
  If symptoms of marasmus and colliquative diarrhea appear, we should give,
three or four times a day, the following pill, composed of—the extract of opium
half a grain, sulphate of lime one grain—a combination we  have always seen
attended with the happiest effects.
  Lastly, if inflammation of the viscera of the great cavities takes place, it
must be treated by appropriate remedies.
  Case X.—Patient Affected with Epilepsy;  Burn of the  Third and Fourth
Degrees of the Posterior Part of the Right Lower Extremities ; Complete Cure
on  the  One hundred and forty-fifth day; No Attack of Epilepsy During the
Treatment.—Lampet, D ..., thirty-six years of age, epileptic  from infancy,
was shut up in  a room with a chafing dish filled with burning charcoal.  She
soon fainted and fell on the dish, in such a manner that the posterior part of the
right thigh was exposed for some time to the flame.  There resulted thence a
burn of the third and fourth degrees, extending from the superior third of the
thigh as far as the middle of the leg, and involving more than half the circum-
ference of the  limb, especially on a level with the popliteal  space ; the skin,
subjacent cellular tissue, and  the  surface of the muscles were consequently
deprived of vitality.
   The  first treatment she received was the application of compresses spread
with cerate, and antispasmodic drinks.   She thus passed the first seven days
at  her  own house.   Already the inflammatory process had commenced ;  the
line of  demarcation was established between  the living and dead parts, and
extensive  sloughs, divided into fragments, seemed to adhere to the limb only
at a few points, when she was admitted into the Hotel-Dieu, on the twenty-
ninth of April.
   Perforated compresses spread with cerate, charpie, emollient poultices, and
anodyne potions was the treatment followed here.   After  three  days the eli-
minatory process was completed, all  the sloughs had separated, and  given
place to a wound of a vermillion color, whose surface presented  very healthy
granulations.
   The same dressing was  continued;  but in order to prevent contractions,
 which might have embarrassed and deformed the limb, it was placed in the
 apparatus for transverse fracture of the patella.  The limb being thus  forci-
 bly extended, the cicatrization could go on in a regular manner.
   The suppuration being very abundant the wound was daily dressed twice ;
 but as it gradually diminished cicatrization progressed from the circumference
 to the  centre,  and the wound was soon considerably smaller. 
CLINICAL  SURGERY.
137
   However, as is often the case, this progress was retarded by the excessive
growth of granulations.   Although they were carefully repressed by a solu-
tion of nitrate of silver,  they daily grew out again; and notwithstanding all
our efforts, a complete cicatrix was effected only on the one hundred and forty-
fifth day.
   The limb had  not lost any thing of  its natural  shape, and subsequently
recovered the free use of all its functions.  The patient left the hospital on
the eighth of September.  During her stay she had not had a single attack of
epilepsy.
   Case XI.—An Epileptic Patient; Bums of the First Four Degrees of the
 Whole of the Right  Side of the Face, Neck, and Upper Part of the Chest;  Dan-
gerous Symptoms ;  Copious Suppuration;  Cure on the Ninety-fourth Day;
 Twelve Attacks of Epilepsy During the Treatment.—Floret. M...., Forty  years
of age, of a delicate constitution, epileptic for many years, having already
suffered five times  from burns, in consequence of this affection, came to the
Hotel-Dieu on the  second of May, with another burn occupying the whole
right side of the neck, and  the superior  anterior third of the  chest of the
same side.  Having fallen, in an epileptic  fit, into the fire, she remained for
some time in contact with the coals.   There resulted  burns of the first four
degrees on the parts before mentioned.  The eschars were large,  deep, black,
and  hard.   The burns of the  first  two degrees were not extensive.   The
patient was in a state of  great general  excitement; delirious ; her pulse was
very small, corded,  and rapid ; respiration short and interrupted ; mouth dry;
great thirst;  extremities  agitated by convulsions.
   We had  at first recourse to a general bleeding, and the application of
leeches to the back of the head; to revulsives  and anti-spasmodics;  sina-
pisms to the  feet, and injections  of ten drops of laudanum.  The eschars
were covered with  large  emollient poultices in order to hasten their separa-
tion ; and the burns of the second degree were covered with fine linen spread
with cerate and perforated in many places, above which a slight layer of lint
was laid, intended to absorb the product of the suppuration.
   The patient soon felt much improved. The eliminatory process began, and
the dead parts were shortly separated.   -Nothing unpleasant occurred during
this  stage.  On  the separation  of the  sloughs there appeared  a wound of
healthy aspect.  The suppuration being very copious  it was dressed twice
daily; but after  some time it  diminished, and  the cicatrix began  to  form.
A large number of granulations  covered  its surface; they were carefully
repressed.
   The cicatrix became daily more extensive ; the suppuration was less abun-
dant ; the  poultices were suppressed,  and the  wound was  merely dressed
with simple cerate,  lint above that, some compresses, and a suitable bandage.
  On the ninety-fourth day the cure was complete.  There had  been twelve
attacks of epilepsy  during the treatment.
  Cask XII.—Menial  Alienation;  Voluntary Bum of the Right Hand in
the Fifth Degree; Cure of both Diseases.—Chirard, a servant, thirty years of
a"-e, regular, and of a good constitution, became crazy on account of violent
grieV.  An active treatment restored her to reason, but she remained always
o-loomy and dejected.  She left her native country and came to Paris.  Her
employers  soon discovered the state  of  her intellect; used her like a crazy
           18 
138
LECTURES ON
person, and threatened to discharge her.  Being left alone on the evening of
the seventh of November, she  made  a large fire in  the kitchen stove and
placed her hand upon the burning coals.  Some one by chance came in ;  she
appeared much agitated, but did not change her position.  This, and the smell
of burning flesh, declared her mental aberration.  She was with difficulty re-
moved from the stove and put to bed.   She  cried all night, and wished to be
put to  death  by some friendly  hand, as she alone could not effect it.  The
next morning she was taken  to the Hotel-Dieu.   The right hand appeared
wasted as  far as the bones; it was covered by black, thick,  hard  eschars,
separated from each other only by a few cracks, from which issued no blood;
on the dorsal surface they only extended as far as the middle of the meta-
carpus ; the remainder of the hand was covered  by a large blister filled with
serum.  A deep red circle surrounded the  wrist.   The motion of the radio-
carpal  articulation was free;  the fingers  and thumb were flexed upon the
hand;  two of the joints,  namely,  of  the  annular and  little  finger, were
exposed.   The patient was extremely agitated;  her face animated;  eyes
immovable; delirium continuous;  the strait waistcoat  became  necessary.
(General  bleeding, pediluvium  with mustard in it, dressing with perforated
linen spread with cerate, large poultice covering the whole hand, opening of
the vesicles without laceration  of the epidermis.)
  Third  day,  same  state,.  (Fifteen leeches on each mastoid process, pedi-
luvia, enemata.)
  Fourth day, no improvement.  (Seton to the  nape  of the neck, purgative
enema.)
  Seventh  day, the eliminatous process progresses: the sloughs on the palm
of the  hand, and the dorsal surface of  the  fingers, began  to separate;  fetid
pus in small quantities was discharged.  (The  poultice continued, and two
maniluvia daily.)
  Eighteenth day, the cries and vociferations of  the patient have ceased; she
sings  in  a low voice, speaks  in a whisper, and if her  attention is strongly
attracted she answers.
  Thirty-eighth day, the mental  alienation has entirely  disappeared; and
she is much grieved at what has happened, but remembers nothing, and was
exceedingly surprised on learning the circumstances of her case. The extent
of the burn is definitively fixed.   The last phalanges of the  little fingers
have fallen off, as well as the sloughs.   Cicatrization has commenced in some
spots; small pieces of dead tendon have been  removed ; the  flexion of the
fingers is less.  They were placed upon a splint in order to effect progressive
extension, and they were dressed separately in order to prevent any improper
adhesions between them.
  From this time no accident interrupted the cure.  Cicatrization went  on
slowly ; the wounds were several  times cauterized with a solution of nitrate
of silver.  It  was perfect on  the  twentieth of  February, one  hundred and
three days after the accident;  no symptom of mental  alienation  remained;
and on the fifth of March, the patient left the hospital entirely cured.  She
was advised to wear the seton, which we had placed in the back of the neck,
for some time longer.
   Case XIII.—Burns from the First to the Sixth Degree, of the Left Side of
tlie Face;  Of the Fifth Degree of the Outer Part of the Left  Shoulder; 
CLINICAL SURGERY.
139
Destruction of a Portion of the Parotid ; Salivary Fistula; Necrosis of Part of
the Os Malac and the Zygomatic Arch ;  Cure.—A porteress, forty years of
age, of general bad health, and subject to vertigo, was seated, on the evening
of the fourth of April, near a stove highly heated by means of charcoal.  She
does not remember what happened to her; but, probably, becoming asphyx-
iated, she fell against the stove, with which her left shoulder and the left side
of her face remained some time in contact.  She was afterwards extricated
from this situation in a complete state of stupor, which  had disappeared the
next morning on her admission into the Hotel-Dieu.
   Two deep  burns existed in the  parts mentioned; the first extended from
the zygomatic  arch  to the base of the  lower jaw, comprising the external
angle of the eyelids; and from the commissure of the lips, as far as the mea-
tus anditorius  externus.   All  the soft parts included  between  these  four
points were transformed into a black, hard,  sonorous scar, cracked on its sur-
face, formed apparently at the expense of the skin; subcutaneous cellular tis-
sue, a part of the parotid gland, and extending as far as the bone.  A deep
red circle circumscribed it.  The angles of the lips and eyelids were drawn
to the left and  backward.  The second burn occupied the left shoulder; its
whole surface was scarified and black;  and  M. Dupuytren was  of opinion
that it had penetrated to the muscle.  The patient had  some fever; the re-
mainder of the face was very red.  She labored under cephalalgia, and acute
pain in the parts not deprived of life.   (Copious bleeding, stimulating pedi-
luvia, enemata, anodyne draughts, diet.)  But little change during the first few
days; the pulse has maintained its frequency.  (Another bleeding.)
   Fifth day, the patient says she has a sensation of a dry and hard body on
the inside of the cheek.  It  might be that the slough had destroyed all the
soft parts ; but by introducing the finger the mucous membrane was found to
be uninjured.
   Sixth day, the eliminatory process has commenced ; a red line was observed
separating the living and dead  parts; a slight suppuration was established,
and the edges of the sloughs separated.
   Eighth day, considerable  fever; swelling of the eyelids; appearance of
erysipelas on the  face ; delirium.  (Twenty leeches to the neck,  emollient
poultices.)  The delirium ceased, and the erysipelas was discussed.
   Twelfth day, the slough on the  cheek has separated to  a large extent.
   That of the shoulder fell off in the beginning of May, that is, in about a
month; there then remained merely a large surface covered with granulations
of a healthy aspect; simple dressings, and a  few applications of caustic,
effected a complete cure  in the early part of July.
   The cheek did not progress so rapidly ; the eschar did not entirely fall off
till the sixteenth of May.  A portion of  the os  malae and the  zygomatic
arch were then exposed, and  found to be necrosed, and a portion of the pa-
rotid destroyed; during the dressings  there  flowed from the wound an  ino-
dorous,  transparent, ropy fluid, increased in quantity by mastication ; it was
saliva.  This did  not seem, in the opinion of M. Dupuytren, to increase the
danger, and he said that this fistula would be cured by the cautery.
   On the twentieth of May the osseous, necrosed  parts, appeared to be  in a.
state proper for their removal.  A spatula, used  as a lever, served to detach
a  portion of the malar bone and zygomatic arch, which were articulated
together.   A little blood followed this operation. 
140
LECTURES ON
  From  this day the wound gradually diminished, but the salivary fistula
remained.  It must be remarked that it took place from the parotid, and not
the duct  of steno.   It was first cauterized on the twenty-third of May with
the red precipitate.
  May 28th, the patient loses less saliva.   Again cauterized on the second
and fifth  of June.  Diminution of the discharge.  Compression was then em-
ployed on the part  of the gland furnishing the fluid; the wound is about as
large as a five franc piece.
  June 9th, the saliva merely drops.  July 29th, the burn and fistula are
entirely cured.   There remained a large radiated cicatrix with depressions,
a paralysis of part  of the cheek, and a torsion of the angle of the lips, and
external  angle of the eyelids.  She left the hospital on  the thirtieth of July.
But, a  month afterwards, the cicatrix burst open at the point corresponding to
the fistula, and the saliva again was discharged through it. She returned to the
hospital,  and, by the same treatment, was cured in about three weeks.
  Case XIV.—Bum  of the Fourth Degree of the Whole  Upper Extremity ;
Copious  Suppuration; Deviation of the Menses by  the Wound;  Cure.—A
cook, eighteen years of age, enjoying good health, fell asleep on the 23d  of
August near a candle.   Her right sleeve caught fire and was entirely burnt.
Awakened by the pain, she cried out violently, succeeded in stripping off her
garment, and fell senseless.   Carried to her  bed she recovered, but suffered
great pain.  She had a severe burn, extending from the deltoid muscle to the
fingers of the right arm, deep eschars occupied the  forearm and lower  back
part of the arm, the  hand was covered with vesicles filled with serum ; there
were also some on the  left hand.
  She was bled; put on the use of emollients, and the burns carefully dressed.
The stage of irritation and  the  commencement of  the eliminatory process
passed  over without any bad symptoms.  But suppuration became so copious,
after the separation  of the eschars, that it was feared she would die from ex-
haustion. The bark  was now given.  Very soon the whole limb, with the
exception of the hand, which quickly got well, was but  one deep red wound.
Her general health improved, but  cicatrization advancing  very slowly, the
patient was admitted into the Hotel-Dieu, on the 11th of the following Octo-
ber, forty-five days after the accident.
  The  wound was still large, much inflamed throughout, suppuration copious,
its numerous granulations were higher than the level  of the skin ;  at the  bend
of the elbow there existed a newly formed cutaneous tissue.  M. Dupuytren
prescribed baths, large and thick emollient poultices, and absolute rest.  Her
menses have not appeared since the accident.
  The  inflammation soon disappeared.   The wound  was then dressed with a
thick layer of fresh  cerate, pledgets of lint applied upon that, and, above all,
long compresses, easily renewed; the wound was daily  touched with a  solu-
tion of  nitrate of silver, but only partially, in order not to excite inflammation;
in short,  all possible precautions were taken to avoid the contact of the air.
  December 16th.   The patient had fever, the wound changed in appearance,
became red and covered with red clots of blood, having  the color and odor of
menstrual blood.  This phenomenon coincided with that of the usual appear-
ance of the mentrual  discharge, which, as we have remarked, had not taken
place since the accident.  A few leeches were, therefore, applied to the vulva,
for several days in succession.  The fever soon disappeared, the wound  n« 
CLINICAL SURGERY.
141
longer discharged blood, and  had recovered its  vermillion color.  But this
new species of irritation increased considerably  the suppuration, which did
not diminish for nine or ten days.
   From this time, cicatrization progressed favorably, but slowly; on the 15th
of April, of the following year, there remained a  wound of about two inches
square on the inner part of the forearm.  Otherwise, the girl was well, her
appetite was good, and she slept well.  The flow of blood from the wound
was renewed  twice; the menstrual discharge not being established, it was
supplied by the loss of blood.
   The phenomenon of the  discharge of the menses from a wound in the arm,
resulting  from a burn, is  too remarkable to be passed over in silence.   Men-
struation  is one of the most simple functions; it is merely a sanguine exhala-
tion.  It  is not, therefore, absolutely necessary that there should be an  organ
for this especial purpose;  in the whole organism, there  are exhalants or tis-
sues permeable to the blood, when the molimen is directed towards them.  It
is otherwise with the secretions;  this function is performed by means of spe-
cial  organs, whose structures becomes complex, in proportion as the humors
separate from  the blood, differ in character from this fluid.  Here there are
mucous follicles whose organization consists in a simple vascular fasciculus
and  a quantity  of peculiar tissue, no nerves have  been discovered  in  it.
There, these are cryptae of a more complex organization formed of a species  of
erectile tissue, and an expansion of a nervous filament; and we can discover
the rudiments  of an excretous duct.   Lastly, these cryptae unite and form a
gland, of  which there are different kinds.   These anatomical details are suf-
ficient.  It  follows, that secretions are complex  functions, performed  by a
special organization more or less complicated; and that exhalations, on the
contrary, are very simple functions, and may be  performed whereever there
are exhalant or pervious  tissues.
   There may, therefore, occur aberrations in the latter, which cannot take
place in the former.   How rare are deviations of the former and how difficult
it is  to supply  them.  The  skin sometimes furnishes urine, but always imper-
fectly, we cannot urinate entirely by the skin.  Menstruation may, however,
take place from  the skin and all the tegumentary surfaces.   The interstices
of the organs of females, may frequently be the seat of an afflux, and the  blood
being then far from the surface and unable to be discharged externally, com-
bines with the tissues, and  produces more or less dangerous inflammations.
   If menstruation can take place  in all the tissues of the system, in the nor-
mal  state, it would certainly be more easy in tissues more  or less  inflamed,
and  favorable for the reception of the molimen hemorrhagicum.  However,
it is not so; the organic modification  constituting inflammation, is not favor-
able to sanguine exhalation, much less to attract  a physiological exhalation,
and  take  the place of a natural  function.  This does not accord with the
opinion of those  who attribute disease in general to an exaggeration of health,
and  inflammation to  a very exalted  degree of excitement.   Menstruation,
from the surface of a wound is, therefore, a very rare and remarkable pheno-
menon, since  nature must be deceived twice in order that it may occur.
  We 'would have wished to conclude this article by a statistical table, on a
laro-e scale, from which general  propositions might have been deduced, and
the^frequencv  of burns compared according to the age and sex of the indivi- 
142
LECTURES  ON
duals, their situation, their different degrees, causes of death, and  result of
the treatment.  Being obliged, however, to confine ourselves to a single year,
we have chosen that of 1828, a year most fruitful in accidents of this nature.
   Number of patients admitted and  treated for burns in the  Hotel-Dieu,
during the year 1828,  50.
   Men, 10; women, 40.
   Under five  years, 2; from eight to  ten, 1; ten to  twenty, 8; twenty to
thirty, 14; thirty to forty, 9; forty to fifty, 8; fifty to sixty, 6; sixty  and
upwards, 2.
   Situation—Burns of the head, 8;  of the neck, 4; right upper extremity, 7;
left upper extremity, 16; of the thorax, 13; of the abdomen, 9;  right  lower
extremity, 33 ; left lower extremity, 23.
   Thus, supposing the body to be divided into two halves,  one superior from
the head to the epigastrium; and the other inferior, from  the epigastrium to
the feet, we have
       Burns of the superior half of the body  -    -    -   - 48
         ««     "    inferior  «««««.    -    -   -  65
   But these results are on many accounts very variable.
   Degrees.—In many patients, the six degrees have been distinctly observed ;
in others, the different shades were mingled together; in the greater number,
the different degrees were present from the lowest to the highest  by twos  and
threes, &c.  Which gives
                          (Rubefaction).....37
                          (Vesication)      -    -     -     -     -  41
                          (Eschars of the rete mucosum) -       -  20
                          (Eschars of the whole thickness  of the skin)    4
                          (Eschars as far as the bones)                2
                          (Total combustion of any part)             1
                          -Individuals cured     -     -     -     -  44
                                «    died      ....    6
   Causes of Death.—Of the latter, three, amongst them two children, three  and
a half years of age, perished from excess of pain.  (Stage of irritation.)   Two,
from diffuse phlegmon and cerebral  symptoms, during the process of elimina-
tion.  One, from the consequences of an excessive suppuration and symptoms
of enterites.
Burns of the 1st degree	
a <(	2d "
<< <<	3d "
c< <<	4th "
<« <<	5th "
it <<	6th "
Result of the	Treatment
CHAPTER  XVII.
ON THE DIFFERENT CAUSES OF  PERMANENT CONTRACTION OF THE  FINGERS,
                  AND THEIR CHARACTERISTIC  DIAGNOSIS.

  It was remarked, in the chapter on contraction of the fingers, that many
different causes may tend to produce this disease, and much stress  was laid
upon this observation, inasmuch as the same remedy is inapplicable in all
cases.   It is evident,  for instance, that if contraction of the  palmar apon-
eurosis were confounded  with  abnormal alterations of the tendons, a very
great error would be the consequence.   (See chap. I.) 
CLINICAL SURGERY.
143
  In order to enable you to establish the characteristic diagnosis of different
diseases which might be erroneously attributed to an affection of the  palmar
aponeurosis, we will present to your view, a large number of patients labor-
ing under flexion of the fingers, produced by different causes.—The first  is
an old porter, seventy-four years of age, who has been for some years, a sca-
venger.  Five or six years ago, he was wounded in the palm of the hand,  by
a piece of wood ; but, it is only during the two last years, that he has per-
ceived, the middle and ring fingers  of the right hand beginning to contract,
since then the disease has rapidly progressed.   He refers it to cold, during
a very severe winter.   The fingers are now flexed one fourth of a circle,  he
is unable to straighten them.   Two tense, projecting and hard cords, proceed
from the middle of  the palm of the  hand, as  far as the bone of the contracted
fingers.  Any effort to extend the  latter, causes the cords to project still
further, and the tendon of the palmaris longus  can  be seen tense along the
lower part of the fore arm.  I have selected this example of real contraction,
in order that the presence of the characteristic sign,  may serve as a standard
of comparison, by which  you may  appreciate its difference, from  diseases
resembling it.
   In other cases, one or several fingers may be flexed upon the hand, without
any contraction of the aponeurosis; the cause may be a change in the phalanges.
Such is the case in the two following individuals.
   A boy, fourteen years of age, has lately been admitted  for white  swelling
of the ankle-joint.   He  was also found to have a  contraction of the little
finger of the right hand.   The finger was curved in the shape of a semi-circle,
the first phalanx immovable on the second, and the second on the third.   It
was impossible to move them upon  each other, but the articulation of the first
phalanx with the fifth metacarpal bone was perfectly  free.  It can be strongly
reversed, as well as if it were in its natural condition.  On giving to the joint
these different movements, no cord  can be traced from the palm of the hand
towards the base of the fingers.  Here then is  an affection of the phalanges,
and not of the aponeurosis.
   The second case presents  precisely  similar  symptoms; thus in these ex-
amples the absence of the cord, the mobility of the metacarpo-phalangial arti-
culation, the immobility of the second  phalanx upon the first,  and  upon the
 third are signs which characterize the disease,  and point out an anchylosis of
 these articulations.
   A cicatrix from a wound may resemble this  cord,  but it is superficial, and
 its cause is known.  In the fourth individual under our  notice, the  two  last
 fingers are constantly flexed towards the palm of the hand.  They can, how
 ever, be easily extended; no cord exists; all the articulations of the phalanges
 between themselves, and those of the finger, with the metacarpus, are perfectly
 free.   What then is the cause of this continual flexion ?   The man had  re-
 ceived a sabrecut on the back of  the hand;  the extensor tendons of these
 fingers were divided, and never re-united ; the flexors, therefore, meeting with
 no opposition, keep the fingers constantly bent on the palm of the hand. Con-
 sequently we have here, not a contraction, but a passive flexion of the nngers,
 and an impossibility of extending them by a section of the tendons.
    A contused wound may produce similar  effects, as in the case  now offered
 to your observation.   This man has contraction of the little finger;  the other 
144
LECTURES ON
articulations are all movable ; no cord can be felt in the palm of the  hand;
the flexor and  extensor tendon of this finger are sound.  The contraction
depends in this case, on an affection of the skin, which was destroyed in con-
sequence of a carriage wheel passing over the hand.  The cure of the wound
took place with approximation of its  edges,  and not by the  production of a
new cutaneous tissue.  Thence there has resulted a narrow cicatrix, prevent-
ing the extension of the little finger.
  Burns of the  palm of the hand often produce this effect; when improperly
treated, adhesions result from them, which greatly oppose the movements of
the hand, and produce contractions; but in  these cases, there are no projec-
ting, hard and tense cords in the palm of the hand.
  Contraction on account of deformity of the articular faces of the phalanges,
caused by certain professions, is very common.   Women, for instance, who
knit constantly, are obliged to Keep their little finger separated from the rest
and bent in order to hold the thread, or yarn, are often  affected with a con-
traction of  this finger.  Caused by an alteration in its  articulation.   This-
deformity was formerly more frequent than  now.  It is, however, said to be
common in  Germany,  where the ladies of Berlin and Dresden, walk out with
their knitting needles in their hands.
  Here we 6ee, a strong healthy young girl,  a lace  maker, in whom the last
four fingers of each hand  are  contracted.  This is incurable, for it depends
on a change in the articular surface of the extremities of the  first and second
phalanges, produced by the kind of business  the girl was employed in.
  Here again, is another case of flexion of the finger, altogether independent
of any affection of the aponeurosis.  This man is a tailor.   Persons of his
trade are obliged to have the fingers of the right hand constantly flexed.   He
is  unable to extend the ring-finger, the attempt gives  him  great pain ; but
nothing indicates any affection of the  palm of the  hand.  The cause of  the
disease is in the articulation of  the second phalanx with the  third; a  serous
tumor has been formed of  the same nature as those called accidental synovial
cysts;  the nature of this affection  is obvious; it is, therefore, impossible to
confound this flexion of the finger with that produced by any other cause.
  Contraction resulting from wounds of the flexor tendons, might, at first
sight, be mistaken  for  a real contraction; but  the  projection formed  by the
tension of the aponeurosis  is much  more  superficial, and yields to no effort
of extension. Whilst in the disease of which we are speaking, by attempting
to extend the fingers, the  tendon of the  palmaris longus is depressed, and
the projection almost entirely disappears.
  You  have before you a  seventh patient, affected with contraction  of  the
medius   This finger is curved to a demicircle; from its  tips  there extends a
cutaneous cicatrix under  the form of a membraneous  prolongation, and in
which may be felt  a  round, hard, resisting cord ; this  is  the tendon.  The
patient had a whitlow, and his surgeon made a deep incision  into the medius,
and opened the sheath of the tendon, thence ensued displacement and con-
traction of the finger.
  The  wound of a joint is also among the  numerous causes of contraction.
Such is the case in this eighth patient.  He has flexion of the right fore finger.
It consists in a  strong inclination towards the palmar face of the third phalanx
upon the second.   The joint is entirely incapable of motion.  The anchylosis 
CLINICAL SURGEAY.                       145
is  complete.   The man had been wounded  by a cutting instrument, which
opened the articulation; inflammation and suppuration ensued, and it has
remained fixed.
  An engraver, living in Paris, received a pistol-shot from a  robber, in the
forearm.  The ball passed through the flesh, without injuring the bone.   The
ulnar nerve was divided, and the inner part of the forearm, as well as the
two fingers to which this nerve is distributed were paralyzed.  Beino- called
immediately, I enlarged the wound in order to prevent any strangulation, and
applied a simple dressing;  the cure was complete in a month.   The paralysis
alone remained, accompanied by contraction or the two last fingers towards
the palm of the hand, on which they rested.  The joints of the finders and
phalanges are very movable;  but it  is difficult to extend the fingers, the
patient complains of great pain, and considerable tension in the cicatrix.  The
flexor muscles having not much of their substance have contracted, and
produced a permanent and unnatural flexion of the last two  fingers of the
hand.
  Thus in the cases first shown to you, with the intention of establishing a
characteristic diagnosis between the different kinds of contraction of the fin-
gers, we have some produced  by a corrugation of the palmar-aponeurosis, by
an alteration  in the articular surfaces of the phalanges, by the division of the
extensor tendons, by a cicatrix of the skin, the destruction of the fibrous
sheath of the tendons, and lastly, by the loss of substance of the flexor muscles
of the fingers.
  I had wished, continued M. Dupuytren, to exhibit to  you a pathological
specimen, which should leave no doubt in  your  mind, as  to  the seat of the
disease of which we are speaking; and have been fortunate enough to procure
the arm and  forearm of an individual, affected, to a  remarkable degree, with
this malady.   It has been carefully dissected, and you shall yourselves judge
of the correctness of the opinions I have advanced.   The tendon of the pal-
maris longus  and  the palmar aponeurosis, have been separated from the sub-
jacent parts ; and I now call your attention to the effects of the experiments
I am about to make.   For instance, if the flexor muscles  had any agency in
the production of this  disease, by pulling them, as  I now do, they would
certainly increase this  contraction; such, however, is not the case; for  no
perceptible change can be effected.  On the contrary, if I extend the phalanges,
upon the back of the hand, the cord in front of the two last fingers, becomes
well marked, the  flexor tendons, however, obey but slightly this movement.
Moreover, if the flexors had any influence in this disease, their section above
the wrist would put an end to the contraction of the fingers ; but this, you
see,  does  not take place.  The same result is obtained from  the section
of the tendons of the palm of the hand.   But if the tendons do not influence
the contractions of the fingers, it is not so  with the aponeurosis  palmaris; for,
vou perceive, that the slightest traction upon this, increases the curvature of
the finders;  on extending  the fingers the cord  becomes stiff, tense, and is
formed exclusively by  the aponeurosis; the latter is completely isolated, so
that it is easily observed, that it is  the only impediment to the extension of
the fingers.  You must be all  convinced;  but should  any  doubts  exist,
another experiment will dispel  them; it  is  the section of the aponeurotic
expansions going to the fingers.  This section is, indeed, scarcely performed,
           19 ° 
146                           LECTURES ON
when the flexion disappears,  and the fingers recover nearly their  natural
position.  It is evident, that in the living patient, the apparatus  I  employ
would effect a complete cure.
  On the first opportunity, I shall treat of contractions of the toes, which are
also  caused  by a corrugation of the aponeurosis plantaris.
                          CHAPTER XVIII.

         ON A PARTICULAR KIND OF FIBRO-CELLULAR ENCYSTED TUMORS,

   Known under the Name of Nervous Ganglia  or Tubercles.—The remarks
 we have to  offer to day, shall be devoted to the subject of those fibro-cellular
 encysted tumors, so vaguely treated of by authors, and which have been im-
 properly attributed to certain affections of the nerves.
   Every accidental membranous  production, in the shape  of a  closed  sac,
 containing a foreign substance, and developed in the interior of the body by
 some morbification is called a cyst.  There are two grand divisions of cysts;
 one including all  those which  become organized  around a liquid or  solid
 foreign body; the  other, such as are formed spontaneously, and previously to
 the substance contained within them.
   Among the substances which may form the nuclae of the first sort of cysts,
 are effused blood, grains of shot, bullets, urinary calculi, foetuses developed in
 the fallopian tubes or ovaries, and hydatids.   In the second sort, which  exist
 before the matter contained'in them, we reckon serous cysts, synovial, meli-
 ceric, steatomatous, atheromatous, fatty, mucous, gelatiniform, and a small
 hydatid tumor, described  by ourselves, and which has hitherto been observed
 almost solely at the articulation of the  wrist, on the pulmar side;  sometimes,
 though very rarely, in the neighborhood of the articulation of the instep;  but
 always in connection with synovial membranes or tendons.
   There is a third class in which are ranged fibrous productions, characterized
 by a  dense, whitish,  and rather  tough tissue, most frequently exhibiting a
 linear structure, and many of which are  composed of  membranous pouches
 of the fibrous or fibro-cellular kind.
   It is with this last class that the little  encysted tumors we are about to
describe appear to  have the greatest analogy.  They cannot be confounded
with either of the preceding classes, in their  nature, shape,  seat, or results;
for they are  fibro-cellular, nearly round in form, seldom  larger than  a  pea,
situated for the most part beneath the skin, along the limb, and terminating in
a cancerous  softening.
   At  first sight, it  would not  seem very obvious to  consider this little tumor,
which the eye can scarcely distinguish, as the  cause of violent pain, and as
the origin of one of the most grievous affections of the body, cancer; yet, obser-
vation warrants us  in forming that opinion; and such  is the  conclusion at
which we have deliberately arrived.
   Several authors  have  described pretty accurately  the nature of these
tumors, but they have supposed them to be formed in the tissues of the nerves, 
CLINICAL SURGERY.
147
or in the course of these organs more especially.  Thus, Antoine Petit, in his
Essay on Pain, after stating that the ramifying extremities of the nerves are
more sensible than their trunks, says:  " The nervous ganglia are very little
understood;  we see them in the shape of small bodies about the  size of a
bean, very hard, movable, colorless, making their appearance in places which
have been injured, and often without any apparent cause ; giving rise to cruel
pain on the slightest touch, orwhen smartly moved, or on a change of temper-
ature.   No application relieves them, and they are cured by extirpation alone.
Dissection displays a white tubercle, enveloped in a fibrous membrane, com-
monly attached to the skin, liberally surrounded by cellular tissue, which is
observed to be connected with nervous filaments, of which it is the termina-
tion and development.  Most of those  on which I operated were in the legs;
one only was in the arm."
   Cheselden (Anatomy 10th edition, p. 136) after describing the structure of
the skin, adds, that he had twice seen  beneath the cutaneous integument of
the tibia a small tumor about the size of a pea, excessively sensible and hard;
from the pain in both instances, it was supposed to be of a cancerous nature;
but was cured by extirpation.
   Camper  follows Cheselden  in describing  this malady, in his Anatomico-
Pathological  Demonstrations, book the  first, p. 11.  "It is not unusual," says
he, " to notice in the cutaneous nerves  small hard tubercles, which are true
ganglia, though they do not exceed a pea in size; day and night they occasion
lancinating acute pain, and  mtist be removed with the scalpel.  I have fre-
quently  met with  them in the human subject; they  are white internally,
elastic, as hard as cartilage, and seated in the tunic of the nerves.
   Chaussier, in his Synoptical Table of Neuralgia,  thus  speaks  of them:
" Nervous tubercles or ganglia are seldom larger than a bean,  often smaller,
oblong, flat, hard, cartilaginous, whitish, sometimes brownish on their surface,
and within.  Enveloped  in a fibrous membrane, movable in the cellular tis-
sue, they seem to be attached merely by nervous filaments.   The pain which
accompanies them is sharp, more or less permanent, and renewed by pressing
on the tumor, or moving the part in any manner, and often without any appa-
rent cause.  They are seen most frequently in the leg, but are observed some-
times in the  back.  They are found in the substance of the skin,  or in the
cellular tissue, in the track of a nerve.  The pains  to which they give  rise
radiate from  the tumor as a centre, and extend to a greater or  less  distance,
according to the distribution and connections of the affected nerve.  Excision
is the only remedy." Finally,  in a Dissertation on Local Affections, defended
in 1822 before the Faculty of Paris, the author observes, in speaking of these
little tumors, which he calls, as the English do, 'painful subcutaneous tuber-
cles.''  " They are developed beneath  the skin; they are ordinarily surrounded
by cellular tissue, and not adherent, except  by nervous filaments.  In other
instances, they are situated in the body of a nerve, the filaments of which are
distended, and spread  around  them."
   Thus we  find all these authors speaking of the nervous nature of these-
tumors, without founding their assertion on any positive fact.  Some of them,
no doubt, say they have remarked on the surface, one or two nervous fila-
ments  after extirpation; but they give no anatomical  proofs.
   By this rapid glance at the works of preceding authors, you will see that 
148
LECTURES  ON
the history of fibrous encysted tumors  is far from being complete.  But re-
peated and numerous observations have convinced me, that they have nothing
whatever to do with  the nerves.  I have dissected several of them, with the
greatest care, in  the dead body; and, the better to assure myself of their
nature, I have sometimes, in removing them from hardy persons, taken along
with them  a  sufficiently large  quantity of cellular tissue, and I have never
found the smallest nervous filament adhering to their surface.  Their struc-
ture is evidently fibro-cellular, a little albuminous, and  in  time they may
become scirrhous.
  Nor are these tumors, as authors have said, confined to the limbs; I have
seen them in the breast.  They have  the form of grains of wheat, coffee, or
peas, and arje sometimes oblong; they are also lenticular, flattened, and never
larger  than a Windsor bean; smooth on their exterior, opaque, and hard.  If
suffered to fall from  a height on an even and resisting surface, they  rebound
as an elastic body.
   This tissue is homogeneous, of a dull white color, without any vestige of
cavity  or cells; their consistence is fibrous, fibro-cartilaginous, or cartilagi-
nous simply.  If the nail be pressed into their substance, a slight crackling is
heard; their envelope is  dense,  opaque,  and fibro-cellular, forming a true
cyst, which opposes  their further  growth, giving rise, as it would seem, to the
sharp pain felt by the sufferers.
   These tumors have never been found affected with inflammation, nor even
redness.  The cellular tissue surrounding tnem presents  no unusual appear-
ance.  The skin  about them is in general sound, without  any attachment, in
the greater number of cases, and  preserving its color; it is, however, occa-
sionally altered in texture, violet and strongly adherent to their surface, so as
to render them immovable.   No  nervous filament can be found in their sub
stance, any more than on their exterior; they are, in fact, quite independent
of the nerves.  Here is an illustrative case :
   Case I.—A woman came to show herself to  me, complaining of dreadful
pains  in the cheek, which had distressed her for several years; they were
supposed by some to be rheumatic, by others, to  be  owing to sub-orbital
neuralgia.  Leeches, bleedings,   blisters,  Meglius's pills,* had  been  tried
without effect.  One of her medical advisers  had been  so confident that the
sub-orbital nerve was affected, that he divided it at its egress ; but this instead
of doing any good, only aggravated the pain;  it was  insupportable, when we
 saw the patient for the first time.  Tracing the seat of the pain with the fin-
 gers,  we  felt a small hard tumor, movable beneath the skin, which was not
 altered in its color.  Pressure on it  excitad the severest pain.   I extirpated
 the tumor, and the patient was immediately relieved; she has been  perfectly
 well ever since.
    It  is evident that had the tumor in this  case  been  connected with any

   * Meglius' Pills.
             fSr.      Ext.  Hyoscyam :  Nig.
                    Ext.  "Valerianae :  Officin.
                    Ext.  Fumariae : Officin.
                    Zinc. Oxydi             ana jj
    Mix and divide into pills each containing 4 grains.
    Dose.—One daily, increased gradually to six or eight.  Given in neuralgia of the face.
  —[F. Foy.]                                                      Tbans. 
CLINICAL SURGERY.
149
nervous filament belonging to that branch of the fifth pair which had been cut,
the division of the nerve would  have removed the pain at once, whereas it
only continued the more obstinately, and disappeared only with the tumor.
  The description given in books  of the first stage of cancer, or  scirrhus, is
exactly similar  to that of the tumors in question.  M. Cruveilhier in  his
Pathological Anatomy, says, in treating of scirrhus, that it is formed of fibrous
or cellular tissue, penetrated  with albumen.  These tumors, moreover,  be-
come softened; like scirrhus, too, they are painful in the greatest number of
cases, while they remain indolent in others.
  Case II.—A woman, about  seventy years of age, had a small  tubercle of
the shape and  size of a flattened pea, superficially situated beneath the skin,
a little above the inner front of the right knee.  It was circumscribed and
very movable; and the skin above it was in no wise altered. The patient
said that the  pains caused by this little body were excessive, and made her
life burdensome to her.  Eighteen years had elapsed since she first noticed
the presence of the tumor ; and its volume had not in all that time increased.
It was only during the last eighteen months that  she suffered from it.  The
part was removed, and the pain ceased immediately, never to return.
  Had this tumor been formed in the track of a  nerve, or in its substance,
would it have remained insensible for nearly seventeen  years ?   The case is
well  suited to show the correctness of our opinion on the subject; but there
are others equally conclusive.
   Case  III.—A woman, aged fifty-nine, had a small tumor  immediately
beneath  the integuments of the anterior of the forearm, just  in  front of the
radius, and about three inches above the wrist. This tumor, which was mode-
rately movable, and about the size of a large pea, felt hard to the touch, and
was exceedingly  sensible.  The patient, however, suffered only when pres-
sure was made upon the part; and the pain then spread from the part towards.
the  trunk, and not towards the  fingers.   It grew larger insensibly during
seven years, and  then was stationary for a year.  Extirpation was performed ;
and it presented  all the characters of an encysted tumor.
   The slow and chronic progress of these bodies  is explained by .their firm-
ness, and the nature of their envelope.  Lastly, their tendency to ramollisse-
ment, after a longer or  shorter period, is another proof of  their scirrhous
nature.  After becoming degenerated, even should they be removed, the dis-
order spreads to the neighboring lymphatic  glands." I removed one which
had been already softened from the upper part of the arm.  In the course of
some time the glands in the axilla enlarged, and  the complaint was renewed.
   The a«-e and sex of the patient seem to have an influence on the develop-
ment of tiiese tumors. Women are more subject  to them  than men;  and
they are most frequently met with in  persons  of from thirty-five to sixty
years of age.. Their existence is most commonly attributed to blows, or falls
received on the parts affected.  In some cases they seem to  have been pro-
duced by punctures.
   Case IV.—A shoemaker pricked his  finger with his  awl.  Not long after
he felt a sharp pain in the part, and noticed the growth of a small flimor.   In
the course of seven years he suffered more and more acute paroxysms. Caustic
was  applied  in vain; but  extirpation was successfully practised? and the 
150
LECTURES ON
 patient suffered  no more inconvenience.   The tubercle was small, hard, of
 cartilaginous firmness, and contained in a cyst.
   On some occasions these tumors  have  been observed to arise  under the
 influence of rheumatic affection,  and to disappear as soon  as the principal
 malady is relieved.
   Case V.—A medical student slept in a bed which was laid in a damp alcove.
 In a short time after he suffered from an attack of inflammation in the joints
 of his great toe;  and presently there grew beneath the  skin covering the in-
 ternal saphena and the nerve, a hard  tumor about the size of a grain of wheat,
 which, whenever it was touched, caused pain like that of an electric shock.
 The pupil having procured a better sleeping place was in the course of a few
 days  cured of the tubercle and the neuralgia.
   In  general, the occasional causes of these tumors are very obscure, and
 most  frequently their origin cannot be discovered.  Fibrous encysted tumors
 usually grow in the extremities, and especially in the  lower ones. They have
 also been  noticed  in the back, .the scrotum,  face, and  breast.  They are mostly
 solitary ;  when several exist  together, they are  perfectly distinct from each
 other.
   Pain is  most usually felt in the affected part long  before any enlargement
 or tumor is perceived.  Soon the least rubbing of  the clothes, or the slightest
 pressure  on the  skin, gives rise to darting pains.  At the end of  a  period,
 which is  generally very long, they are detected beneath the integuments,
 which they sometimes elevate, and  then they are readily seen.  Most fre-
 quently they  are  movable,  hard,  and the least  pressure is insupportable.
 The skin preserves its natural color, in  the majority of cases.  The pain
 returns at irregular intervals in most instances, and is sharp and darting as in
 cancer.  That occasioned by pressure is like  the effects  of an electric shock;
 it often radiates from the tumors;  but this is when  they ai£ situated in the
 neighborhood of a considerable nervous  trunk, and act mechanically.   At
 other  times the anguish is continual, and  allows the  patient  little rest; and
 the health suffers from want of sleep.   When the pains affect the lower limbs,
 they hinder  and positively prevent locomotion.   Some  irritable individuals
 during the paroxysms are affected with regular convulsive  spasms.   I was
 consulted by a young woman who had for a  long time a tubercle about the
 size of a  pea on the upper and back part of the thigh.   She suffered dread-
 fully from the  time it made its first appearance ; the least pressure on it threw
her into convulsions.  It was removed, and from that moment all  her pains
ceased.  In numerous cases they remain indolent, and  are  unaffected even
by pressure during many years.
  Diagnosis.—When fibro-cellular encysted  tumors are so small as to  be
invisible, the pains to which they give rise have often been confounded  with
those  from rheumatic or neuralgic affections; and on the latter supposition
patients have  been tortured in vain by leeches, flying vesicatories, and even
more violent remedies. The two women, whose cases  I shall presently notice,
suffered legchings and blisterings along their limbs, although the tumors were
very perceptible, both to sight and touch.
  In neuralgia the pains are sharp, and extend all along the nerves affected;
 they return generally at stated and regular periods: hourly, daily, or weekly, 
CLINICAL SURGERY.
151
and pressure has no effect in producing them.   But the pains from fibro-cel-
luLar  encysted tumors do not recur at regular intervals;  they are sometimes
continual; they do not always extend in  all directions; pressure renders
them  intolerable;  and by pressure,  alone, very frequently the  patients are
warned of their  existence.  It is seldom  several hours elapse without a
paroxysm.
  The fact of their  being called ganglia by some authors, might occasion
their being confounded with  those tumors which grow in the sheath of ten-
dons, most frequently at the  wrist, and which have been called by the same
name.  But the indolence of the latter, their situation, their mobility during
the action of the muscles, their immobility beneath the skin, the existence of
a cavity in them, lined by a synovial membrane, and filled with a fluid like
that which lubricates the joints;  all these characters are fully sufficient to
enable us to  avoid an error which, after all, would perhaps  be of  no great
consequence.
  Small  lipomas have sometimes been  seen, which, after undergoing carcino-
matous alterations, give rise to very  severe  pains.  But  their softness,  and
especially the cellular structure which thus present, containing a yellowish,
fatty matter,  lardacious in some points, fibrous  in others, serve to afford us
the means of diagnosis.  M.  M. Sanson  and Begin, in their last edition
of Sabatier  Medicine Operatoire, mention the case of a woman  affected
with a lipoma which gave her such  pain as materially injured her health.
Finally, it might perhaps be more easy to  confound these fibro-cellular en-
cysted tubercles with those tumors which  affect the nervous  tissue, and are
called neuromas.   The latter, however, possess a cavity filled by a substante
more  or less liquid ;  whilst the former have neither cavity nor cells.  Neuro-
mas may attain a considerable bulk; fibro-cellular encysted  tumors, on the
other hand, acquire but  little volume.  Neuromas most  usually exist in the
great nervous  trunks ; the others are almost  always  sub-cutaneous,  and
remote from  the large nerves; the former  are commonly numerous in one
place; the latter are in general solitary.
  Prognosis.—This  is favorable, where the tumor is movable, the skincover-
ino- it natural in its hue, the situation remote from important organs, such as
a vessel or nerve of some size; where, in short, the tumor is simply sub-cu-
taneous.   If, on the contrary, it be immovably adherent to the skin, which has
become violet-colored, and it begins  to soften we cannot  expect a favorable
issue; for the malady has a tendency, as we have said, under these circum-
stances,  to propagate itself to the lymphatic glands in the vicinity, and the
patient soon  presents all the symptoms belonging to the cancerous diathesis.
   Treatment.—Caustics have sometimes  been used, with a view to destroy
these tumors; but they only favor the softening, while they do not remove the
disorder.  The practice in some rare cases would seem to justify the  appli-
cation of narcotics,  in treating some  individuals  who dread the use of the
knife   A female sixty years of age, had one of these tubercles in the inner
and posterior part of the knee.  She would never consent to  any operation,
notwithstanding the  severity of her sufferings.  By the steady application ot
narcotics to the part affected, the pains were assuaged and they have not since

^Extirpation, however, is the surest, readiest,  and least painful  method. 
152
LECTURES ON
When these tumors are very small, a simple longitudinal incision, made along
the spot which they occupy, will be sufficient.  If they be somewhat larger,
the size of a large pea, for instance, a T shaped incision will be necessary.
In either case, we must seize the tumor, after exposing it, with a double hook,
and then with a bistoury, separate it from the cellular tissue which attaches it
to the surrounding parts.  The lips of the wound are then brought together,
and kept in contact by means of sticking plaister.
  If the skin above the tumor be bluish and adherent, both must be removed
together;  if the tumor be already softened, we must on no account whatever
meddle with it.
  I shall conclude this lecture by relating some cases illustrative of the prin-
ciples I have advanced.
  Case VI.—Maria Hareng,aged fifty-nine, married, came to the Hotel-Dieu,
on the 18th of October, 1828.  She complained of pains, which were  sharp
and continual, with exacerbations at irregular intervals.   Her constitution was
good, she traced this disorder eighteen months back ; being obliged to expose
herself to cold and moisture, she thought she had contracted rheumatism ; and
for this supposed affection had undergone all the methods of treatment which are
usually employed.   The pains persisted, and were  aggravated  by the least
fatigue. They presented two principal features; first, their continual severity;
and second, their repeated attacks, recurring about four times in the four and
twenty hours, and continuing at each period from a  few  minutes to an  hour.
There crises would be brought on by pressure of the parts, or by a blow on a
tumor which was  situated on the right  inner and upper part of the  thigh.
They consisted in darting and numbing pains, directed from  the upper part
of the thigh towards the knee.   So severe were they, that the Woman  could
not answer when spoken to; she was agitated, uttered cries, and said she felt
the parts torn from her where the pains were situated.   On examining  her, I
soon found there was no rheumatism in the case, but that there was a fibrous
sub-cutaneous body.  I removed it on the 20th of October, by making a T
incision over it, when the tubercle was found imbedded in fat; it was  white
and readily removed with the bistoury.   The pains immediately ceased, and
the wound was dressed with a little sticking plaister.  The  patient left the
hospital on the 8th of  November, radically cured.
  Case VII.—An old soldier, otherwise in good health, came to consult  me,
in February last, about a small tumor, which he had on  the outer and  upper
part of the right leg, just over the articulation of the tibia with the  fibula.
He could not recollect the origin of the  tumor, it was only of a few month's
standing; but the pains were of the most acute character; they darted from
the tumor towards the neighboring parts.  Having  no doubt about the nature
of the case, I removed the morbid part by excision. The pains ceased, and
great was the astonishment of the soldier, when he saw what a little substance
had proved so great an enemy to his peace.
   Case VIII.—Madame P------, the wife of a wine merchant, suffered ex-
 cruciating pains in her right leg for about three years.   They came  on three
 or four times a day, and at last every recurrence was attended with  syncope.
 Much medical advice was followed, and all imaginable methods of treatment
 were employed in vain.  I was at length consulted, when I  found  on the
 middle and anterior part of the leg, on the crest of the  tibia, a small  fibrous 
                           CLINICAL SURGERY.                        153

tumor, of about the size of a cherry kernel.  I cut down upon it, and pressed
it out.   It was of a fibrous structure, and enveloped in a fibro-cellular cyst.
The pains vanished at the moment.  An erysipelas continued about the little
wound, but yielded to a few laxatives.   The lady was quite well in ten days,
and has never since had the slightest recurrence of the disorder.
                          CHAPTER XIX.

          ON STRANGULATION AT THE NECK OF THE  HERNIAL SAC.

  It was for a long time believed, that all cases  of strangulation in inguinal
hernia, were owing to a constriction exercised by the ring upon the intestine.
This erroneous opinion has more than once led to fatal consequences. Acting
upon this principle, surgeons enlarged the inguinal  ring, and restored the
parts into the abdomen, thinking that they had  removed  the strangulation;
but the bad symptoms persisted, became aggravated, and the patient perished
without any evident cause for his death.
  These unfortunate results, soon attracted my attention,  and became the
subject of reflection; presently, I  was induced to think  that  the abdominal
ring was not the only  seat of stricture ;  and dissection has since proved  to
me, that, in a great number of cases, the neck of the sack is the cause   Time
has corroborated my views, and I  believe that I  may  now affirm, that out of
nine cases of strangulation, eight are owing to a  constriction exercised by the
neck of  the sac.  This remark applies particularly to inguinal hernia; for
this disposition is rarely met with in crucial and umbilical hernia.  The struc-
ture of the parts explains the difference.
   In order to be correctly understood, let us explain what we mean by stran-
gulation. Nothing, in our opinion, gives a more correct idea of it, than the
action in any part of our bodies, of a foreign  or natural  body which presses
with more or less force upon the bodies which are in the sphere of its power.
The consequences of  this  pressure may be easily inferred, the action of the
parts is increased, the vital functions are altered, or they are extinguished and
gangrene takes  place.  Strangulation may take place at all points, but is most
frequent when openings exist in which the parts may become engaged; such
are particularly the inguinal  ring and crural arch.
   Some strangulations are external, others internal.  I have  seen fifteen
cases of the latter kind ; but it must be confessed, that in general, the greater
number is external. Art has a positive power only on external strangulations,
and is nearly useless in the internal species. But between these two species,
there is  another which may be called mixed, and is such as results from the
reduction in mass of a hernia.  Some years ago, the body of a female was
brought to  our dissecting rooms; externally, nothing remarkable could be
observed; but on opening the abdomen, we found  behind the crural arch a
tumor formed by the  intestine, and about as large as the fist; of a livid red
 color; a portion of  the epiploon was contained  in the hernial sac.   On exa-
 mination of this tumor, it was perceived that a fold  of the gut had become
               20 
154
LECTURES  ON
gangrenous.  The stricture was at the neck  of the sac.  I was afterwards
informed, that two days previously the woman had had symptoms of strangu-
lation ;  the taxis was successfully employed, and the hernia supposed to be
reduced when all the symptoms suddenly reappeared, and the patient died in
a few hours.
   I have seen other cases, in which the cause of strangulation was  primarily
in the abdomen. In a man affected with strangulated hernia, I performed the
operation, but only found a portion of epiploon in the sac ; I drew out the in-
testine  and  found the stricture was on the inner  side of the pubis;  it was
divided and the man did well.
   But how does strangulation of the neck of the hernial sac occur, and what
are the anatomical dispositions which favor it ? When the intestine inclines
forwards, it carries  before it the peritoneum which forms a  species  of  funnel
of which  the apex is directed  downwards, and the base or mouth  upwards;
but however small  may be the progress made by the tumor, the aspect of
things is changed, and the base descends.  This change is owing to  the situa-
tion of the ring.  As the hernia increases in volume, the  neck of the  sac is
wrinkled and thrown into folds by the weight of the tumor, by the  tendency
of the displaced peritoneum to  return  upon itself, a tendency which  some-
times produces obliteration of the tunica vaginalis, the form of the epiplocele
then on the side of the ring, voluminous at the bottom of the sac.   But  the
principal cause of this circular groove, this contraction of the neck arises from
the application of a bandage over the hernia; the compression it  exerts on the
neck of the sac, corrugates, contracts, and even inflames it, and  also the cre-
master muscle  and the cellular tissue; whence there results a contraction
and a  stricture, if not fibrous,  at least one which  gives it a great degree of
resistance.  The neck may also become cartilaginous.
  The diameter of the neck and its anatomical structure contribute also to
the strangulation. Generally, the aperture is not more than three or  four lines
iii diameter; its edges being thin, cutting, and formed by the folded perito-
neum, render strangulation more dangerous than that of the ring which  acts
less forcibly on the intestine; but, moreover, an anatomical reason  increases
the facility of strangulation at the neck; it is the state of persons in whom the
testicle has descended at a late period, and who labor  under scrotal hernia;
for the word congenital applies only to that form occurring-at birth.  Examine
a scrotal hernia, and you will always find the following state: The  orifice by
which the parts  have  protruded is very narrow, its edges are very sharp ; be-
low, you perceive the neck, the inguinal ring being of its usual dimensions,
and the kind of bag in which the portion of the protruded  intestine is con-
tained.  If, then, you pull the intestine in the sac, strangulation takes place
spontaneously, and you can understand what takes place during life.
  We have first proved that  strangulation generally takes place at the neck
of the sac ; it is important to determine whether this neck is fixed or movable.
  Observations prove it to be always movable,  because the elements composr
ing it, are joined to the neighboring parts by a very loose cellular tissue.  The
slight adhesion of these parts, their delicate union with the aponeurotic open-
ings, explain the ease with which the hernia protrudes and i3 restored.
  Do symptoms of strangulation at the neck of the sac exist ?  We answer
without hesitation  in the  affirmative.   We  will  even  add that there are 
CLINICAL SURGERY.
155
different kinds of symptoms.  Large external herniae are less subject to stran-
gulation at the neck than cylindroid herniae.   But congenital herniae, more
frequently than any other species, present this disposition.
  Diagnosis.—Whenever the strangulation is at the neck, we can return in
mass, and without noise, the  whole, the third, or fourth of the hernia on the
abdominal side,  and cause it  again to protrude; but, in order that it may so
return, it  must be cylindroid, the canal must be large, and  the peritoneum
not adherent.  I  have in more than forty cases, seen the hernia returned in
mass, without a cessation of the symptoms.  If the tumor were at the ring, in
the canal, or the superior orifice, this movement could not be given to it, be-
cause these parts are nearly inflexible, whilst the neck, on the contrary, enjoys
great freedom of  motion, on account of the looseness of the parts. I should
add, before proceeding further, that we should particularly  guard against this
apparent  reduction which has deceived many practitioners, because then the
consequences of strangulation always remain.  When called to a similar case,
we should endeavor to draw the tumor out by all means in our power; if they
are fruitless, the ring must be enlarged, and the gut drawn down.   I have
been obliged to  do this operation  in this hospital more than ten  times, and
always with success.
   In this  kind of cases, the tumor preserves  its tension, and on touching it,
we can generally recognize a painful spot corresponding nearly to the seat of
the hernia.   Thus, for instance, after the operation, we are enabled  to point
out the  spot by a tenderness more marked at that place.   Hence, the tumor
and painful  point, announce that here then exists a hernia reduced in  mass.
   When  the strangulation takes place at the external ring,  the tumor, formed
by the hernia, does not extend above this point; the whole extent of the ingui-
nal canal is empty, soft, and not tender to the touch ; the ring appears con-
tracted, hard, and tense. On the contrary, when it occurs at the neck of the
hernial  sack, that is to say, at the height of the upper orifice of the  inguinal
canal;  the latter is always full, hard, painful, and communicates  the  sensa-
tion of  a  cylindrical tumor, directed from below upwards, and from within
outwards. * It is even sometimes possible to insinuate one's finger  between
the displaced parts  and  the  ring,  so far is the latter from  being the  cause of
stricture*
   In some  persons the  strangulation exists  throughout the whole length of
the canal, which must be opened  from one end to the other. Sometimes there
are two strictures instead of  one  to remove ;  a slight contraction exists at the
rino-, and at the same time a  stronger one at the neck of the sac.
   When  the  sac possesses great mobility, the strangulation ascends more or
less above the inguinal canal.  It may exist  still further from the ring when
the hernia has been reduced  in mass.   We are here led, by a natural transi-
tion, to say a few  words concerning strangulation in the abdominal  cavity
itself  The danger in this case is much greater.  The reason of it is evi-
dent' the'seat of external  strictures is known, and the disease follows  a
well  'known course; there can be, therefore, no error in the diagnosis;  whilst
 internal  strictures, on the contrary, have no  fixed  situation.   They do not
 depend on constant organic  dispositions, but on accidental and very variable
 circumstances.   There is, however, species to which we have given the name
 o  mixTZI which is the most  frequent and easily known ;  it is that which 
156
LECTURES ON
results from the reduction, within the abdomen, of herniae strangulated by the
orifice of the neck of the sac containing them.
  It may be objected that these distinctions are useless; our answer is sim
pie.   I suppose that an individual  has stricture at the neck of the sac, the
inguinal ring is divided, the same thing will happen, that I once saw occur;
the ring being divided, the parts were instantly restored.  I should here state
that  I thought the  success of the operation doubtful.  The  symptoms of
strangulation continuing, the surgeon took it to be peritonitis.  The patient
died, and an examination showed the neck of the sac to be the cause of the
malady.   The ring  had  been divided, and still the parts were not  the less
strangulated.  You can hence  perceive how important it is to ascertain ex-
actly the seat of the stricture.  To do this, we must draw out the  gut, and
carry the finger along the protruded portion, in order to ascertain the nature
of the obstacle.
   Does strangulation, occurring at the internal ring, differ  from that seated
in the lower part of the canal ?  Yes, it differs  from it evidently, inasmuch
as, in the first case, the parts become gangrenous  much sooner, because the
edges of the upper orifice are so thin that they exert a strong compression on
the neck of the hernial sac, whilst the edges of the inguinal ring being blunt,
and  its aperture larger, strangulation takes place more slowly, and the gut
is less strongly pressed upon.
   As strangulation at the neck of the hernial sac soon occasions disorganiza-
tion of the parts, we should operate immediately, because the hernia returns in-
completely, and with difficulty; and because the sharp edges of the neck are a
constant cause of gangrene.   The resistance of the  tissues  here deserves
attention; the peritoneum sustains pressure for a long time ; but  the mucous
membrane is  soon cut through ; if the strangulation has lasted two or three
days, the cellular membrane, in its turn, gives way ; lastly, in some cases the
peritoneum itself  is divided, so the least  effort suffices to separate  the ends of
the  intestine, and thus produce gangrene.  We see then that in operating on
similar hernia, the gut should not be drawn out before having freely enlarged
the  passage, for we might draw out only one end, and thus occasion effusion
into the abdomen.
   I shall now relate some cases in support of the doctrine I have  endeavored
to establish:
   Case I.—Inguinal Hernia Strangulated at the Neck of the Sac ;  Operation;
Peritonitis ; Death.—A man, about forty years of age, of small  statue, and
pretty good constitution, came to the Hotel-Dieu on the eleventh of January,
of this year, for a strangulated  hernia.
   He had had for four or five years a tumor in the right groin.  He gave the
following account of the origin of his disease; he was carrying a bag of flour
tied in the middle; the anterior portion being the heavier pitching him forward,
he threw himself  violently backwards in order to prevent his falling; he im-
 mediately felt in the left side of the chest an acute pain proceeding from the
 extension of the muscles,   This got well; but in a short time he perceived a
 small tumor in the right groin, which returned when he was lying down, but
 protruded on his rising; on the left side another tumor of the same character
 appeared.  They were two inguinal herniae, the first larger than the  second.
 He then used a double truss, by which means he escaped, for some time, any 
CLINICAL SURGERY.
157
accident.   Yesterday he removed it to make water.  Probably he used inor-
dinary effort, for the hernia of the right  side became larger than usual, hard,
incarcerated, and irreducible.  From this moment the patient had colic, nau-
sea, anorexia, and vomiting; and, besides, an obstinate constipation.   Some
efforts at  reduction were uselessly made.  He was put into a bath, and  the
taxis  again employed, but  as  fruitlessly as before. What was to be done;
wait for a spontaneous reduction ?  If this happy termination does sometimes
occur, how often are not gangrene, peritonitis, and death, the consequences of
an operation too long delayed.  I have been always more successful in  pa-
tients on whom I have operated in the first twelve hours, than after that period.
Moreover, strangulation at the neck of the sac is a powerful motive to hasten
the operation, for we know that of ten cases of this nature, scarcely one is
reducible.  The  softness of the tumor  has no doubt  some influence in its
reduction, but, in the present case, it was hard and tender to the touch.
  The operation  being imperiously required, I did not hesitate to perform it.
The patient was  carried to the operating theatre, and the operation done in
the following manner: the skin covering the upper part of the tumor being
raised, and laid in a transverse fold, which I held myself by one end between
the thumb and finger of the left hand, giving the other to an  assistant.  I
made an incision into it, and  passed  the bistoury from one end to the other.
The incision was then extended upwards and downwards.   The layers of the
subcutaneous cellular tissue were then successively divided.  A small artery
having been cut, it was secured.  On reaching the hernial sac, I found, fortu-
nately for the operation, that it contained a good deal  of fluid.  The sac was
scarcely opened, when this fluid  gushed out, and the intestine was seen  of a
violet red color; some spots more highly injected seemed  to show that the
attempts  at reduction had been accompanied by some violence; the intestine
was then drawn slightly out of the belly, and the discoloration found to  have
ascended into the abdomen.  The finger introduced into the wound confirmed
the truth of the  diagnosis; the hernial sac was  drawn down, and its neck
being divided  upwards and parallel  to the meridian line, the strangulated
 portion was immediately  returned;  he was dressed in the usual  method.
 Enemata, administered immediately after the operation, brought away  very
 copious discharges.
   On the following  days, the belly became tender.  He was ordered  an infu-
 sion  of camomile; discharged a great deal of flatus and was relieved.
   On the fourth day of the operation, he appeared to be doing extremely well.
 The dressing was removed, the wound was healthy, the sub-peritoneal cellu-
 lar tissue a little swollen.  (Diluent sweetened drinks.)
   Fifth day.  The patient was suddenly seized with  delirium without fever
 or heat of skin.  An anodyne draught was administered; and an enema with
 ten drops of laudanum.  The cerebral symptoms left him, and had not re-ap-
 peared on the seventh day; he did well, and until the 1st of February,
 nothing peculiar was  observed.   At this time, the  nineteenth day of the
 operation, on examining the wound, and carrying the hand above the iliac fossa,
 we found a hard, resisting tumor, in the  centre of which was a fluctuating
 point. What was its nature ? a  stercoraceous abscess ? but the  hernia had
 been strangulated only twelve hours, when it was reduced.  There was reason
 to think it was inflammation developed in the cellular tissue surrounding the 
158                           LECTURES ON
 hernial sac, and thence extending into the thickness of the abdominal parietes.
 If left to itself, it might cause an internal effusion.   If seated in the abdomen,
 and opened before  adhesion  had  taken place between its parietes and the
 abscess, a fatal effusion might result.  I have seen in more than twenty cases,
 these abscesses discharge themselves through the inguinal canal; and  some-
 times have assisted it by the introduction of a female catheter, as far as the
 abscess.  Therefore, on the 3d of February, I followed this plan in the present
 case, but could not reach the abscess with the catheter or even  the stylet;
 I then determined to  wait  some time, in order to observe the attempts of
 nature, and to aid her.   Soon, suppuration approached the skin.  Certain then,
 that adhesions had  formed  sufficient to prevent all effusion,  on the 20th of
 February, I made an incision into it.  At first, only a little healthy pus issued,
 but plunging the bistoury in more deeply, and enlarging the incision, a copious
 discharge followed, but the engorgement had not entirely disappeared. A fine
 bougie covered with  cerate, was introduced into the wound.   21st, much more
 pus  was discharged; 22d,  it  had  diminished slightly,  the man was better.
 24th, he was suddenly attacked, during the evening, with pains in the  belly,
 nausea, colic, and vomiting.  (Leeches to the abdomen.)
  On the next visit, the symptoms had abated a little, but the  patient's face
 was clayey, his eyes sunk, and his countenance cadaverous. 25th, he was dead.
  Autopsy.—There  was nothing remarkable in the head and chest.   The
 peritoneum presented  evident  marks of inflammation.   There was a  small
 quantity of pus  between the circumvolutions of the intestines, which were
 slightly adherent to each other.  A fistulous  orifice was perceived near the
 external ring, situated between the peritoneum, and  an abscess in the parietes
 of the abdomen.   Another  perforation corresponded to the external  opening
 in the integuments, but was closed by intimate adhesions of the ccecum.   The
 abscess seemed to have originated in the  inguinal canal, and  afterwards
 reached the abdominal parietes; it was bounded, internally, by adhesions of
 the intestines to the  parietes of the belly, and externally by the cicatrix.  It
 appeared as if the adhesions had been  torn, and effusion taken place  through
 the first fistula of which we have spoken.
  This case gives rise to several important remarks. Persons laboring under
 hernia are anxious to use a truss; but think they may lay it aside occasionally,
 either to evacuate the bowels, or to sleep.  In the former case it often happens
 that a violent effort causes the protrusion and  strangulation of the  hernia; in
 the latter, it also takes place whilst getting into bed ; we cannot then  enforce
 too strongly upon such  persons the necessity of constantly wearing their  truss.
  In the above case the  hernia was  inguinal and voluminous; a large  fold of
 intestine appeared strangulated, but the external ring, and the  canal,  exerted
 no constriction upon the intestine,  which could be made to  move  and easily
 ascend to the upper part of  this canal; the stricture was then, at the cutting
 edge, formed by the peritoneum, at the commencement of this sac; the opera-
 tion proved the correctness of the diagnosis.   Every circumstance  announced
a favorable termination, when the occurrence  of one  of those abscesses which
 so frequently take place in the cellular tissue surrounding the neck of the sac,
 complicated the disease, and occasioned a fatal peritonitis.
  The following case is one of those to which  I have given the name of invagi-
 nated. 
CLINICAL SURGERY.
159
   Case II.—Invaginated Inguinal Hernia, Strangulated by the Neck of the
 Sac.—Fournier, Abel, twenty-three years of age, thin, of a lymphatic tem-
 perament, has had since his infancy, an inguinal hernia on the right side, which
 he was not in the habit of guarding against; a slight exertion caused its stran-
 gulation, hiccup, nausea, vomiting and colic supervened; the patient endeav-
 ored  in vain to  reduce  it; forty-eight hours  after the  occurrence of  the
 symptoms, he was brought to the Hotel-Dieu in the following state:
,   The hernial tumor was about the size of a small hen's egg; capable of a
 partial reduction ; but when left to itself, regaining its ordinary volume; a long
 and very hard body occupied the whole length of the inguinal canal;  the
 belly was swollen, tense, and  tender; the  man vomited incessantly a bilious
 matter; was tormented with colic, could not evacuate his bowels, pulse small
 and very  frequent.  He was put immediately into a bath and the taxis tried
 in vain.   The operation was the only resource.  It was proposedto the patient
 who refused to submit; he was bled several times, kept in bath several hours,
 and during the day a large number of leeches applied to the anus and abdo-
 men.  On the second day, the symptoms were aggravated ; vomiting of stur-
 coraceous matter; pulse frequent and corded, greater tension of the abdomen,
 much  thirst; the patient was requested not to drink a great deal in order to
 keep up and even increase the vomiting, and to  be satisfied with wetting his
 tongue with slices of an orange.
   Third  day, increased tenderness  of the  abdomen, extreme prostration,
 general paleness; still he refused the operation.
   Fourth, pulse almost insensible; great weakness; deceptive relief; slight
 remission of the  symptoms; on  touching the hernia* a kind of crepitation is
 felt shewing that the parts within are gangrenous.  Fifth day, the hiccup
 which had almost ceased the previous evening, returned with greater violence;
 the extremities grew cold.
   Sixth, continual hiccup, pulse insensible, coldness of the whole body.   The
 next  day, the  patient demanded the  operation,  but the  visit was scarcely
 finished, when he had ceased to  exist.
   Autopsy, twenty-four hours after death.—The abdomen was not quite so
 tense as during life ; no rigidity of the body.  I performed the operation, as
 though he had been living; the soft parts being divided successively down to
 the sac, the latter was  opened  at is anterior inferior portion.  A brownish
 serum, of a gangrenous smell escaped ; a fold of a small intestine  three and
 a half to four inches  in length, of a grey slate color, was softened, and crushed
 between the fingers  like a piece of white  paper.  Above- the intestine, the
 anterior extremity of the testicle was perceived ;  the finger can be easily in-
 troduced into the" ring and carried as  far as the upper part of the inguinal
 canal to the seat of  stricture, which was caused by a falciform circular neck,
 adhering anteriorly and posteriorly to the intestine, in the  extent of  about a
 line.   Above the strangulation, there was a perforation of the intestinal canal,
 towards the upper end of which the gangrene had ascended for three inches.
 To this, succeeded a violet color, which could be traced as far as the stomach.
 The lower portion, distant only six inches from the ccecum, was folded upon
 itself,  as well as the whole of the large intestine,  which was scarcely as large
 as that of a child, of six years of age.
   The upper portion contained a large quantity of liquid fecal matter, which 
160
LECTURES on
would have been effused into the abdomen through a small aperture in the gut,
had it not been for an adhesion formed at this spot.  On dividing the stricture,
there was seen a well marked  circular depression on the intestine, which in-
ternally, appeared to be deprived of its inner membranes.  The adhesions of
the intestines by means of recent false membranes were very numerous.  The
lower pelvis contained  a good  deal of pus.  On opening the abdomen, there
escaped a quantity of purulent serum, and a very offensive inflammable gas.
The  lungs were slightly engorged  posteriorly;  the  remainder of the organs
healthy.                                                               •
  The escape of inflammable  gas on opening the abdomen confirms this im-
portant  fact, that inflammation of the membranes, produces a remarkable
change,  not only in the quantity, but also the nature of their secretions.  The
gas,  in this case, was probably  carburetted hydrogen.
  We have shown, that internal strangulation resulting from the reduction in
mass of hernias strangulated at the neck of the sac, may  be  almost always
recognized, both by symptoms  of the previous existence of a hernia primarily
situated  externally, and by existing symptoms. It is, however, sometimes
difficult to ascertain it,  especially if we were not present at the reduction of
the hernia.  The uncertainty is still greater, if the patient  labors under  a
double hernia, reduced  at the same time, and  of which neither present any
mark of strangulation.
  Case  III.—Double Inguinal Hernia;  Strangulation at  the Neck;  Opera-
tion; Cure.—Geoffroy, (T.,) a blacksmith,  forty years of age, was  affected
with two inguinal hernias, the left, for twelve years; the right, for three ; he
had  for  seven or eight years worn a truss on the left side, but never any on
the right. One day, whilst walking, he felt his truss give way;  carrying his
hand to  the part he found the tumor painful, and increased in volume.  On
his return home, he endeavored in vain to reduce it, and experienced all the
symptoms of strangulation.   The next morning he prescribed for himself two
grains of tartar emetic, and sent for a surgeon, who, after some attempts suc-
ceeded in reducing it;  but the  symptoms continued, and, on the fifth day he
was brought to the Hotel-Dieu.  The next morning, I examined him  very
carefully; the abdomen was painful, he  had attacks of hiccup, stucoraceous
vomiting, and constipation.
  The symptoms of strangulation existed; but a peritonitis might be feared;
the diagnosis was rendered more  difficult by the reduction of both herniae,
which presented  no tumor behind the inguinal ring.   We had, besides, no
other data of the previous existence of these herniae  than the dilatation of the
rings, and the contradictory accounts of  the patient.  I hesitated performing
the operation before being assured that it was his only chance; but on the
next day, his death appearing to  be fast  approaching, it was  determined
upon.
  Observing a tumor in the  right  inguinal region, and the patient  suffering
more pain on that side, I was induced to seek there the cause of the stricture.
   An incision was made into the skin in the direction of the axis of the hernia;
under it was a small tumor which might, at first,  have been taken for the
spermatic cord, and afterwards for the hernial sac, on reaching a smooth cavity
whence  escaped a large quantity of serum.  It  was a serous cyst, placed in
front of the true sac. The latter was small and contained neither intestine nor 
CLINICA . SURGERY.
161
omentum, but merely some albuminous  floccali, floating  in a little serum.
The finger introduced into the abdomen distinguished adhesions of the intes-
tines either amongst each other, or to the  abdominal parietes, certain symp-
toms of peritonitis.  I immediately performed the operation on the other "side ;
the layers covering the tumor were divided carefully; a sac was opened con-
taining a fatty substanee, which I at first thought was omentum; but per-
ceiving beneath a fibrous layer, and desiring the man to cough, I saw this layer
rise, as also some subjacent ones.  Immediately a bloody serum escaped, and
I felt assured that the stricture was on this side.  A small  reddish fatty mass
was found in the sac, and recognized as swollen omentum.  On introducing
the finger  a circular stricture was felt pretty high up.  The sac was drawn
out, and with it a small portion of  inflamed  intestine; whilst an assistant
fixed the edges of the incision in the  sac, the probe-pointed bistoury was car-
ried along the finger, and the stricture divided upwards and outwards.  The
patient was then dressed, and put to  bed ;  he spent a pretty comfortable d«y.
He was ordered whey,  and small enemata fomentations to the belly; his
countenance was red, pulse accelerated, tongue coated with a brownish fur.
(Venesection.)
   On the next day, the vomiting had ceased, colic still frequent, pulse acce-
lerated, face purple; he  was bled several times during that day and the fol-
lowing.  In short, the pains in the abdomen ceased entirely, and the patient
was perfectly cured.
   Case IV.—Double Inguinal Hernia; Strangulation  at  the Neck; Opera-
tion; Cure.—A man was brought, on the 27"th of  September, to the Hotel-
Dieu,  in apparently a dying condition;  his  extremities  were  cold;  face
discolored; pulse extremely small, scarcely perceptible; abdomen tense and
painful, especially at the inferior portion; he had, besides, hiccup, vomiting
of inodorous matter; he  could scarcely state that he had for a long time been
laboring under double inguinal hernia, and that he could not tell when they
had become painful.   He was  put in a bath.  From his condition, we were
reduced to the existing  symptoms which  could not indicate positively his
disorder;  was it the  peritonitis, or an internal strangulation ? I prescribed an
enema  and  venesection.  During the evening he  had a copious evacuation,
and also others in tffe night; the vomiting ceased, but the  hiccup was almost
continuous.
   The next morning, pulse quickened, face red, belly flaccid, the patient was
rational, and gave the account of his  disease.   He had had, for nearly eleven
years, two hernia which followed each other at an interval of six months.  He
wore a bandage with a double cushion, they sometimes protruded in  spite of
this, but were easily reducible.   They had never given him any uneasiness,
except on the evening before his admission, when  he made some violent exer-
tion ;  they both protruded and became painful; he  himself reduced the right
hernia,  and sent for  a physician who  reduced the left, and prescribed some
chamomile infusion.   The symptoms  of strangulation increasing he was then
brou-ht to the Hotel-Dieu.  What was to be done ?  Most of the symptoms
of strangulation were present; but he had no vomiting of  fecal matter; the
alvine evacuations were easily effected.  He was desired  to walk;  the left
hernia protruded, but was soon reduced.
  The operation does not seem  to be required.   Evening, same condition;
           21 
162                          LECTURES  ON
the patient's bowels had been freely opened; no vomiting or hiccup; belly
soft and sensible on pressure, especially in the hypogastric and iliac regions.
Persuaded of the great advantages of the operation, if there is strangulation,
I determined  to perform it; and chose the right side, because the hernia,
which, according to the account of the patient, came out more easily on this
side than on the other, when he was in health, had not re-appeared on account
of the walk.
  An incision two and a half inches in length was made in the skin, in the
direction of the ring;  and there immediately appeared a kind of cylindrical
cord which had  been felt  through the integuments.   It  was cautiously
opened, and the hernial sac reached; on introducing the finger, I recognized, at
the upper part of the cyst, a cul-de-sac; a catheter carried in the same direc-
tion, penetrated the cavity of the abdomen, and caused the flow of  a hloody
serum.  The opening  in the sac was enlarged; this latter was drawn out, and
its i^eck found to be corrugated and contracted as if by a kind of cicatrix.
The neck was divided, and I could then discover no longer any strangulation.
The patient recovered without a bad symptom.
  These  two cases are highly important, and deserve the greatest attention;
and afford me  the opportunity of developing more fully, the general notions
I have previously advanced.  Indeed, you may easily conceive the embarrass-
ment experienced by a physician who is called upon to relieve a patient labor-
ing under a strangulated hernia which has been reduced in mass.  The first
difficulty consists in determining, in the absence of all appearance of hernia,
whether there  is a strangulation, or not; and when its existence is proved, the
second arises from the difficulty of getting at the strangulation, which having
retired into the abdomen, is beyond  the reach of surgical instruments.  But
are these symptoms by means of which, after the reduction of the hernia, we
can decide whether stricture exists or not within the abdomen ?   Observation
has answered the question in  the affirmative, by shewing that both the antece-
dent and  existing symptoms almost always point out the lesion.   The former
consists in the large size of the ring, the mobility of the consequent  hernia,
the reduction in mass  which  has been its result, and the want of remission ia
the symptoms.  But perchance  these may not have been carefully observed;
we  must then have recourse to. the existing symptoms alrediy mentioned, but
to which  I again call your attention oh account of the difficulty of the diag-
nosis ; they are, a fixed and circumscribed pain in the epigastrium,  which is
felt behind the opening through which the hernia has protruded and  receded,
and a tumor more or less apparent in this region.   Let us consider,  for a few
moments, this last symptom, which has many interesting peculiarities.  When
the hernial tumor has  been reduced in mass, it cannot wander  about in the
abdomen, because it is composed, at  least in part, by the  peritoneum, which,
although  movable, remains always in the region to which it belongs, and there-
fore confines the tumor.  The hernia is thus constantly behind and within the
aperture  through which it protruded.  Surrounded by the cellular tissue which
connected the peritoneum to the parietes of the abdomen, and which was dis-
placed in order to receive  it; it is  covered  besides, by a second  layer of
peritoneum, being that which it has detached from the posterior surface of the
abdomen; so that to penetrate into the hernial sac, by an  incision  into the
parietes of the abdomen, the peritoneum would be cut twice, and its cavity 
CLINICAL SURGERY.
16S
opened before  reaching  that of the sac,  unless we follow the steps of the
operation for the ligature of the external iliac artery, by raising and separa-
ting this serous membrane.
   This might be done, but I never have had recourse to it.  There is fortu-
nately  a simpler  and less dangerous  method; it consists in seeking and
drawing out the hernia, through the opening by which it has passed into the
abdomen, for we are certain to  find  it applied to the inner  surface of this
opening, to be  able to seize, it with forceps and  draw  it  out, either  with  or
without dividing the ring.   Jf we examine the tumor  through the cavity of
the peritoReum, we will find it lodged in the iliac fossa,  in crural hernia a little
more outwardly, in ingainal more deeply and inwardly.  It presents a narrow
and tight aperture, in which are engaged  extremities of intestine, forming a
fold in the cavity of the  sac.  It is at this point, that the intestines are  com-
pressed, contracted, thinned, strangulated, and gangrenous,  the  upper end
more frequently than the lower; the  former much dilated, and on the eve of
rupture; the latter thin, empty  and similar to those of  a child.
   Having made known the anatomical relations of the tumor,  let  us pass to
the  other symptoms.  The pain and  tumor are not the only ones indicating
strangulation in the abdomen; by pressure on the abdominal parietes, we meet
with greater or less resistance either at the ring, or by introducing the finger
into that opening, or by desiring the patient to cough;  the effort of the tumor
to protrude, by dilating the canal, and sometimes raising the skin covering it,
 should also be  taken into consideration.   But a still more characteristic mark,
 is the continuance and especially the nature of the vomiting.  Nausea does
 not establish the existence of internal  strangulation.  To dispel all doubt,
 copious vomitings are »ecessary, presenting a peculiar character.  Mucous or
 bilious matter  would indicate an irritation, gastritis or enteritis  as well as a
 strangulation; but vomiting of a gleatinous, yellowish matter, of a fecal odour,
 leaves no uncertainty; when this symptom is added to the preceding, we will
 be convinced that the hernia has re-entered and been strangulated internally,
 as it previously had been externally.
   We will conclude these cases by the account of one, which was admitted
 into the Hotel-Dieu, towards the  latter  part of March of the present year.
 The patient, about forty years  of  age, of middle  stature, and a pretty good
 constitution ; had had for fifteen or twenty years, a tumor in the  right groin.
 At  first it spontaneously protruded and retired.
   About eight years ago, he laid aside  his truss, the tumor did not completely
 retire, even in the horizontal position, and when he endeavored to reduce it.
 On the 24th of March, 1832, after having  eaten largely of beans, the tumor
 became tense and more voluminous ;  nausea and vomiting soon followed with
 all  the symptoms of  strangulation.  The taxis was employed in vain.  He
 was then brought to the Hotel-Dieu.  He was put into a bath, the taxis again
 attempted, buf with no success.  Leeches were applied to the  tumor, the bath
 an-ainused, without any improvement;  on the morning of the 25th, twenty -
 four hours after  the  strangulation, I ordered him to  be bled, and carried to
 the amphitheatre in order to undergo the operation.  The hernia was in  the
 following state: it had descended  into  the scrotum on the right  side; at its
 lower part, was soft and transparent, indicating the presence of some fluid:
 above the rin«* a hard tumor could  be felt;  and I gave  as my opinion, that the 
164
LECTURES  ON
 strangulation had taken place at the  neck of the sac, in which my colleague
 M. Sanson coincided.  An incision about three inches in length was made
 over  the  tumor, and the layers covering the hernia successively  divided ;
 several branches of the external pudic artery were  cut, but immediately
 secured.  Having reached the sac, I opened it very carefully, at first a little
 serum escaped; the opening was enlarged, a bloody fluid issued, but in smaller
 quantities than I had  anticipated; the sac, however, was distended  by an
 enormous portion of omentum, which appeared to have passed into it entire;
 the intestine was red, but exhibited no sign of gangrene ;  the stricture was at
 the middle of the neck, and easily removed; but there remained to be reduced
 this mass of omentum, which fortunately was free from any adhesions,  I was
 obliged to make the opening still larger, the reduction of the omentum was
 difficult, and I feared impossible,but was at last successful.   You know, that
 in  similar cases, we  are advised to remove a part of the omentum, but the
 partial ligature of the arteries is  very tedious, often we do not secure them all,
 and there is danger of hemorrhagy; if  the whole mass be included  in a liga-
 ture,  inflammation, suppuration, and very  grievous symptoms may arise;
 besides, the omentum often forms adhesions  with the wound, which  are very
 troublesome and painful.  It is, therefore, better to attempt to restore it to
 the abdomen.
   Inflammation is indeed to be feared, but the heat of the abdomen frequently
 is sufficient  to prevent its occurrence.  Moreover, it may be subdued by local
 and general bleedings, emollient applications, baths, &c.
   Before proceeding to the consideration of the  treatment, I beg leave to
 occupy your time with one more remark relative to strangulation of the neck
 of the hernial sac.  Although this cause  of stricture exists more frequently in
 inguinal hernia, I have also seen it in crural hernia;  I  could give you  many
 examples of it, but as they resemble so closely those already treated of, it will
 be unnecessary.
   I shall  now proceed to consider the general rules of the treatment of these
 diseases which are so common and generally  so serious.
   It will  be perceived that there must exist many modifications, according to
 the seat of stricture.  Should it  take place at the lower  orifice a simple  in-
 cision is sufficient to dispel the symptoms; but this cannot be the case, when
 they are produced by the neck of the sac ; for if the ring alone were divided
 the hernia would be reduced, but the stricture  still remaining, the patient
 would shortly perish.   The finger must  then be introduced into the sac, and
 carried as far as its upper extremity.  But this is not always easily done, we
 must then enlarge the aperture, the finger then slips with facility and reaches
 the upper part of the sac, which represents  a  species of vault, there is no
orifice and the stricture is recognized. In this case we are obliged to operate
on the parts  removed from sight.  In order  to  do this the surgeon takes a
 probe pointed bistoury, carries  it on the flat side along his  finger; having
 reached the  opening, he makes the enlargement forwards  and  upwards, as if
he were making the simple incision.  Some persons use a director, but I have
 often  seen accidents result from its employment, as the bistoury may slip from
 its groove and wound the intestine, giving rise to peritonitis ; and after death
 you will find a small opening in the healthy portion.  This accident is  not to
 be feared  when the finger is  the guide.   The shape of the bistoury  is of no 
CLINICAL SURGERY.
165
importance; but  it is absolutely indispensable for safety, that  it should be
probe-pointed.  At what height are we to look for the stricture ?
  No positive answer can be given to this question.  In some cases it is on a
level with the internal ring, sometimes lower; we have shown that it is also,
sometimes  higher up.  We should, in order to be  more  certain, attempt to
draw out, with all the caution  and dexterity possible, a portion of the intes-
tine, in order to be well assured that  no impediment remains.  Sometimes I
have found the stricture as high up as the finger could reach, without being
able to draw it down ; but in these cases, a probe-pointed bistoury, covered
throughout, with the exception  of two or three lines of its edge, was sufficient
to remove the cause.
  It is useless to observe that when the hernia is reduced, we must endeavor
by all the means in our power to make it again protrude; the patient should
be desired  to cough, to  walk,  &c. in short, the reappearance of the hernia
should be facilitated as much as possible.
                          CHAPTER XX.

ON THE CYSTS WHICH APPEAR IN THE BONY TISSUES, AND  OF THEIR DIFFERENT
                                SPECIES.

   I  long ago, said M. Dupuytren, demonstrated for the first time, that
there are open developed  in the bones, tumors generally of a fibro-cellular
nature, which by increasing, raise and lower the bone, so  as to reduce it to a
mere lamella, resembling  a plate of metal which has been beaten out with a
hammer. On examining the bone after death, we frequently find in it acavity,
containing a fibro-cellular  matter. This is, apparently, a newly formed tissue ;
but what is remarkable, the  bone  is  neither swollen, nor softened, but only
widened and thinned; this as will be hereafter seen, is an important remark
as regards the diagnosis.
   Thii following case will  furnish some accurate notions of the disease, and
serve at the same time as an introduction to a knowledge of our ideas of cysts
of the bones.
   Case I.—A young girl  about seven years of age, was admitted into the
Hotel-Dieu, in  June,  1832, for a tumor  in  the superior  maxillary  bone.
She stated, that  having received a blow upon the cheek, she was, after some
time, attacked by pain in that spot, which was followed by tumefaction; when
we saw her, the  swelling was as large as one's fist.  The right nostril was
obstructed and flattened, the palatine vault thrust aside and upwards, the eye
driven forwards.  During the last month she has become much emaciated.
  At first sight, said M. Dupuytren, this disease might be mistaken for an osteo-
sarcoma.  Indeed it is formed at the expense  of the superior  maxilla, which
appears softened, and it is  known that a peculiarity of cancerous affections is
to enlarge and soften the bones. However one symptom which I shall pre-
sently point out, created some doubt in my mind, and induced me  to  think
that  something might be done towards her cure. I remarked that by pressing 
166
LECTURES  ON
the anterior superior part of  the tumor, I depressed a small lamella, which
by alternately yielding and projecting, gave rise to a rumpling noise  like
that of a sheet of parchment; the same crepitation is observable in the pala-
tine vault, and I hence infer that the tumor is a bony cyst.
  If the girl be so fortunate  as merely to labor under a development of a
fibrous body in the superior maxilla, it is our duty to divide the mucous mem-
brane down to the tumor, and endeavor to extract the foreign body  Hemor-
rhage may take place, but it can be arrested by plugging the part with lint.
I should not be surprised, if the nature of the tumor be changed, for fibro-cel-
lular bodies are ^ry liable to disorganization; the case is then very emba-
rassing.
  Crepitation is not the only sign which should guide our conduct.  The dis-
placement of the organs  is owing to the  development of  the cyst.   It
would have been, undoubtedly, much better, had we seen her seven months
ago ; but on account of the enormous development of the tumor, no time is
to be lost.  Again, if the disease be abandoned to nature, it would degenerate
into carcinoma.
  Two days afterwards an incision was made over the tumor, a puncture then
made with the bistoury, and immediately a large quantity of blackish blood
gushed out.  The bleeding soon stopped ; the operator on introducing the fin-
ger into the tumor, instead of a  fibro-cellular body, found a soft substance
easily lacerable, which  had gradually distended the bone, but was not con-
founded with it.   Carrying the finger in different directions, he discovered a
cyst with bony parietes, hard in some spots, thinned in others.
  The next day the patient was carried to the operating  room, and  an inci-
sion made internally in the most dependent part of the tumor, about two ounces
of blood escaped.   M. Dupuytren detached with his finger, a part*bf the body
filling the cyst.  No hemorrhage occurred during the day ; ten days after the
operation she was much improved, the parietes of the  cyst were lessened, as
also the tumor ; should the cyst continue to close, and the child not swallow
the pus, there is a chance of a cure.
  The products contained in these cysts, added M. Dupuytren, vary greatly;
they are either solid or fluid.   Generally, they are formed by a fibro-cellular
matter; but we also find serosity, either alone, or united with fibro-ceUular
matter, mucosity, adipocerous matter, hydatids, pus  mingled with serum, a
gelatinous substance, teeth, &c.
  Case II.—Solid Products.—Some years ago a young man was admitted
into the Hotel-Dieu, for an enormous tumor distending the  cheek.   M. Du-
puytren examined it carefully, and was convinced that it was seated in the
right  horizontal  branch of the inferior maxillary bone.  By pressing on its
parietes, a slight crepitation was heard, similar to  that produced  by the
rumpling of paper, or rather a piece of very dry parchment.
  The absence of fungus and lancinating pain, the high state of health of the
young man, his earnest desire of its removal, and the  conviction that it was
merely a cyst with osseous parietes, induced M. Dupuytren  to attempt its
extirpation.
  The angle of the lip of this side was freely divided; an incision made along
the ramus of the jaw;  the cyst opened, a little reddish  serosity  escaped, and a
fibro-cellular mass was seen, which was partly extracted; suppuration attacked 
CLINICAL SURGERY.
167
the remainder of the tumor, and by means of repeated injections the cure was
soon perfected.  The sides of the cyst were gradually closed, and a very slight
deformity remained, a slight projection, and a small cicatrix.
  I have said that these cysts may contain teeth.  The following fact, com-
municated by Dr. Loir, leaves no doubt on  the  subject.  This gentleman
presented to M. Dupuytren, a bony cyst developed in the palatine process of
the left upper maxilla, of which the parietes were formed by the two  compact
laminae of this  process; the immediate cause was evidently a reversed tooth.
Indeed, the left canine tooth, instead of penetrating the corresponding  point
of the alveolar edge of the jaw, had opened a passage in the inner part of this
bone, and created a cavity of at least triple its size, in the diploic tissue of the
palatine  apophysis, where  it had grown as it would have done  externally;
the root of the tooth was therefore supported by the outer part of  the alveolar
edge.
  Liquid Products.—These cysts may also  contain liquid products.  The
following is  a case in point.
  Case III.—During the latter part of  April, 1828, the sister of a physician
in the vicinity of Tours, consulted M. Dupuytren concerning a tumor, of the
size of a  hen's egg, and situate in the right horizontal ramus of the lower jaw.
The patient  thought she  labored under osteo-sarcoma.  M. Dupuytren exam-
ined her, and from the absence of every symptom of cancer, such as lancinating
pain, varicose degeneration, &c, added to the crepitation distinctly perceived
by pressing on the parietes of the cyst, he was induced to form  a favorable
prognosis.   The lady then earnestly requested the performance of the opera-
tion.
  The tumor projected more on  the  inside of the mouth  than externally,
thrusting aside the tongue.   It appeared to have been produced by the incom-
plete extraction of a carious tooth.  An incision was made on the inside of the
mouth, and  the cyst opened, when a large quantity of bloody  serum  escaped.
At the bottom of the cyst a solid mass was perceived and extracted by means
of a scoop, and found  to resemble precisely adipocire.  This mass was
undoubtedly owing to the adipose transformation of some of the animal parts
of food, which had penetrated the cyst through the cavity left by the extracted
tooth.  A few injections and poultices upon the cheek, venesection and diet
for a  few  days completed the cure.  There  remained no swelling nor
deformity.
  The causes of this disease are mostly very obscure.  It sometimes proceeds
from external violence.  In one case a blow of the fist seemed to have pro-
duced  the tumor; in another it arose  from  the incomplete extraction of a
carious tooth.  Changes of the roots of the teeth give rise to serous  cysts which
generally are developed in the alveoli of the superior canine teeth, and some-
times become very large.   I have seen  on  the upper maxilla a large cavity
open in front which might have been mistaken for the maxillary antrum, with
which, however, it did not communicate.  If  you then examine the diseased
tooth, its extremity will be found changed, circumscribed by a bony  bulb,
bathed in a  fluid contained in a cyst, united on the one side to this bulb, and
on the other to the bottom of the alveolus.  This cyst  generally  follows the
tooth where it is extracted.  If left in the alveolus, it gives rise to a long con-
tinued suppuration; it contains  a fluid sometimes very thick, sometimes 
168                          LECTURES ON
 serous, its inner surface is as smooth as that of serous membranes.   In other
 cases the origin of the disease cannot be ascertained.
   The first symptoms of the existence of osseous cysts, are uneasiness and
 pain.  The pain sometimes dull, sometimes acute, is seldom accompanied by
 lancination. After a longer or shorter time, tumefaction may be traced, though
 sometimes but slight, it may  be as small as a musket ball, or  as  large as the
 fist.   This swelling of the bones is owing to the separation of their laminae, by
 the presence of the foreign body; it  follows that they become thin, and but
 slightly resisting,  yield to the pressure of the finger, and  communicate the
 sensation of a piece of parchment, or  rather a slight crepitation, which I regard
 as a pathognomonic sign.  The sign is deserving of strict attention; should any
 doubt exist, we should make  an exploring puncture ;  this puncture  and cre-
 pitation are  two tests which leave no doubt, as to  the  existence of a cyst
 of this nature.
   These tumors we have said, are seated in the thickness of the bones;  they
 are found in the ends of the long bones, in the bodies of the  vertebras, most
 frequently in the bones of the face; thus, for instance,  they are met with in the
 horizontal ascending rami of  the lower jaw  ; the alveoli, antrum, and  nasal
 fossae of the upper maxilla ; their shape is generally ovoid, sometimes oblong,
 they maybe flattened.  Their volume is not uniform, and may vary  from the
 size of a musket ball, to that of the fist. Their parietes are formed at  the ex-
 pense of the very bones in whose cavity they occur.
   The diagnosis of osseous cysts, demands great  practice and  experience, but
 the difficulty is partly removed,  when no  osteo sarcoma exists.   It will be,
 therefore, proper here to expatiate on the  diagnosis of this species of tumor,
 and above all to establish the differences which exist  between them and osteo
 sarcoma, with which a superficial examination might confound  them, and from
 which  it is so important to distinguish them.
  Osteo sarcoma is marked from its  onset, by lancinating  pains, a varicose
 swelling, and simultaneous alteration of the surrounding soft  or  hard parts;
 then fungous disorganization  and numerous  inequalities.   In bony  cysts on
 the contrary, the surrounding parts do not participate in the disease; their
 surface is smooth,  equal, and  their increase indolent.  Osteo  sarcoma grows
 rapidly ;  the growth of the latter species is always much slower ;  the interior
 of an osteo  sarcoma is traversed by scales, and fragments of bone, which are
 never found in the others.
  As to the crepitation, which is not observed as we have described  it, in
 osteo sarcoma, and which is a pathognomonic sign of  the  tumors  in question,
 it resembles strongly that which I have observed  in tumors divided into  two
 portions above and below the palmar carpal ligament,  with this  difference, that
in the latter case, the crepitation is owing  to the  concussion  of  the tumors,
which are in our opinion, merely hydatids. To crepitation must be added the
exploring puncture which is of very great importance.  We  have  hence three
orders of signs, by which  osseous cysts  may be distinguished  from osteo
 sarcoma.
  The following practical consequences may be deduced from this  distinction.
 1st, osteo sarcoma, and osseous cysts are essentially different from each other.
2d, osteo sarcoma is the cancerous degeneration of the bone, the bony cyst is
merely the development of the bone, owing frequently to the presence of fibrous 
CLINICAL SURGERY.
169
bodies, like those of the uterus; 3d, when there is no degeneration, we may, by
an incision, reach the tumor, remove it, and have no fear of its return ; such
is not the case in osteo sarcoma; extirpation is here useless, for the disease
is of a cancerous nature.
  The progress of bony cysts is generally slow; some however attain a large
size in a few months, whilst  others are stationary for  many years.  After a
longer or shorter time, they degenerate into cancer, especially those of which
the products are fibro-cellular.
  The material of a cyst is easily re-produced, sometime once or twice, until
they are entirely destroyed.
  Case IV.—A young man,  15 years of age, consulted  me on the 6th of July,
1832, for a tumor of the anterior portion of the alveolar edge  of  the upper
jaw bone.  On examination I perceived a sensible  crepitation, and judged
that  it was a cyst with osseous parietes.  A puncture  gave exit to a flood of
fluid matter.  I then made a large incision, for the following reason. An ope-
ration had been recently performed upon the boy, and according to his father's
account, a  large  quantity  of water was  discharged, and yet  the disease
returned.  Why ? because the part  giving rise to the secretion, had not been
destroyed, and a new product had been  formed.   What was  to be done ?
Destroy the cyst by exciting in it inflammation and suppuration.  This would
have been  done by means  of lint and irritating injections,  if the young man
had not gone away immediately after the operation.
  Case V.—In 1813, a young man, of the same age as the foregoing, came
to the Hotel Dieu with a tumor on the lower jaw.  This tumor occupied the
whole of the right side of the body of the bone, and appeared to extend into
the thickness of the ramus  of the same side.  It  was about as large  as  a
goose's egg, exceeded the base of the jaw, had pushed the teeth inwardly and
was constantly progressing.   M. Dupuytren decided  on its removal.  The
little patient full  of courage, earnestly solicited the operation.   It was per-
formed on the  inside of the mouth;  an incision made into  the mucous mem-
brane, at the level of the base of the tumor ; this base removed  by  the gouge
and mallet; a thin lamella of bone divided; and it  was soon found to form a
shell inclosing a tumor of a different  nature.  On removing this shell a fibrous
substance was seen ;  a large portion  of it was removed, and the patient being
exhausted by fatigue  put to bed.  The remains of the tumor grew rapidly,
as it was soon as large as before.  That which appeared was a second time re-
moved, and a red-hot iron applied.   But it again was re-produced.   The pro-
fessor then decided on a third operation, and this time  in order to  repose the
whole of the base of the tumor, he divided the lower lip  from its free  edge
as far as the os hyoides; turned the flap aside, removed with forceps a fibrous,
round, lobulated  free body, filling an  enormous  cavity in  the ramus of the
maxilla, and then cauterized all the parts of the bone from which the tumor
grew.  The patient was radically cured, the fibrous bodies removed in the
three  operations were precisely similar to those found in the uterus.
  The prognosis  of bony cysts, continued M. Dupuytren, is favorable, all
are cured by the operation.   They may be re-produced, when they have not
been  entirely  removed; it is therefore sufficient to know this tendency to
relapse  in order to prevent and overcome it.  This is not the case when the
fibrous substance  has degenerated into cancer, and the  surrounding parts are 
170
LECTURES ON
implicated; the termination  is then fatal.  Hemorrhage  may be feared in
some cases, the exploring puncture, furnishes the means of avoiding it, and
arresting  it when  it occurs.   If the tumor has caused much deformity, the
most skillfully performed operation, will leave some evidence of the disease,
but this is not to be compared with the consequences of the disease if left to
itself.
  The nature of osseous cysts being known, the best way to cure them, is to
destroy the disease.  This should be done as follows: In the greater number
of cases, an exploring puncture is to be made, in order to ascertain the  kind
of product contained in the cyst;  an incision is then made over the tumor;
when in  the face, this  incision should  be made on the inside of the mouth.
Having reached the centre of the malady, it should be extirpated, especially
when the  product is  solid, and here the actual  cautery will sometimes be
useful.  The effects of the disease being removed its cause should be attacked,
for  there is a tendency to its re-production.  With this intention lint should
be introduced into the wound, and emollient or irritating injections, according
to circumstances, thrown in. These means almost always cause an inflam-
mation of  the parietes of the cyst, and consequently the destruction of the
lining membrane ; the parietes then come in contact, and the cure is complete
after a longer or shorter time.  In some  cases a counter-opening must be
made and a seton passed through the two wounds.
  Case VI.—A man had at the left angle of the lower jaw a tumor, which
was  recognized as an osseous cyst.   A puncture was made on the inside of
the mouth, and a liquid matter escaped.  M. Dupuytren enlarged the aper-
ture, and as it could not be expected, that this opening which would admit the
saliva, food, &c, would  suffice for the cure, a counter-opening was made ex-
ternally and lower down.  The  finger then introduced, discovered a semi-
fluid matter, a seton was placed through the wounds, and in a month after
the operation, the tumor was reduced one half.   It was then of little moment,
how much time was occupied in its entire removal, the most important point
being to ascertain  whether it was formed  by a cyst of this species, or an
osteo sarcoma.
  After the operation, a poultice was applied to  the  tumor, and the  man
ordered to be dieted.  Several bleedings are  often required, to subdue the
inflammatory symptoms.
  Case VII.—-A young woman was admitted into the  Hotel-Dieu, in  July
1828, for  a tumor in the lower jaw.  It was ovoidal,  of the size of a hen's
egg.   Its progress  had been  slow, without lancinating pain, appearance of
fungus, or change in color of the skin; it projected more externally, and its
position required  a different mode of operation.   Crepitation was evident.
On the 11th of July, the patient was taken to the operating room;  a new ex-
amination  confirmed the first; and the crepitation, which had momentarily
disappeared, on account of the depression,  from too frequent handling of the
bony parietes of the cyst, was manifest, the return of it being undoubtedly
owing to the retrograde force  of elasticity of these parietes.
  An incision, about an inch in length, was made along the posterior edge of
the masseter muscle, starting a few lines below its middle, in order to avoid
the  lesion of the vessels and  facial nerve.   This incision extended as far as
the  angle of the jaw; the edges of the wound being separated, the operator 
CLINICAL SURGERY.
171
could more easily see and feel the parietes of the cyst, surrounded by a mem-
brane apparently of a serous nature, soft and velvet-like to the touch;  no
fungus or inequality could be felt on the surface of the cyst; which was per-
fectly smooth  and equal.
  An incision was then made across its anterior portion, and there imme-
diately gushed out a quantity of reddish and bloody serum; no solid substance
could be perceived.  A pledget  of lint was then introduced through the lips
of the wound  and cyst, in order to prevent their union; emollient injections
thrown into the sac, and emollient poultices applied to the cheek.  Venesec-
tion was recommended, should, as probably would be the case, this simple
incision of the soft parts  and the parietes of the cyst, give rise to local or
general symptoms sufficiently intense to require it.
  When suppuration is once established in the interior of this sac, said M.
Dupuytren, if the pus collects and the upper aperture is not  sufficient for its
discharge, a counter-opening must be made in the most  dependent portion,
and this is the  worst the patient can expect, in order to be cured of a disease
which was  long  thought incurable, and of which, in two months scarcely a
vestige will remain.
  We will no longer occupy your time with cases of osseous cysts; what has
been  said of these  symptoms, characters, and treatment, demonstrate suffi-
ciently, that this point of pathology, although new, has been clearly explained
by the professor.  Experience will undoubtedly reveal new products; but it
is doubtful  whether a more efficacious plan of treatment can be substituted
for that which he has recommended.
                         CHAPTER XXI.

OF SEROUS CYSTS  CONTAINING SMALL WHITE BODIES, CALLED  HYDATID  CYSTS.

                   Of their  Diagnosis and  Treatment.

  The history of  serous cysts containing small white bodies of the nature of
hydatids, said M. Dupuytren, was but little known before the observations of
M. Cruveilhier in his essay on pathological anatomy. This distinguished phy-
sician first published my researches on  this species of disease, of which the
existence has since been proved by very numerous cases.
  In those which  have fallen under my notice, I have observed, that these
cysts, almost always appear at the wrist, on its palmar surface, under the
anterior annular  ligament of the  carpus;  I have, however, seen them on the
instep, under the anterior annular ligament of the tarsus; but in all cases, I
found them around synovial membranes and tendons.  In some rare cases they
have been seen on the olecranon, above the acromion, on the tuberosity of
the ischium and outside of the great trochanter.
  Blows,  falls, pressure, distension,  and repeated friction,  are apparently
the  most frequent causes of the development of these serous  cysts, although
they not unfrequently occur without any appreciable cause.
  Those  on the foot generally arise from the use of too tight a shoe.   Add 
172
LECTURES  ON '
again the  causes developing hydatids in other places, and they must then be
sought either  in the  kind of life, dampness of location,  or the delicate and
lymphatic  constitution of the patients.  Some years ago,  I saw in the Hotel-
Dieu, in the case of a young girl, a blow of a whip on the forehead give rise
to a true encysted tumor which I opened, and from which  issued a true hy-
datid filling it entirely.   Their growth is generally very  slow ; and they fre-
quently are stationary for many years.
  Case I.—M ...., was admitted into the Hotel-Dieu on the 2d of Novem-
ber, 1800, for a tumor situated on the palmar face of the wrist.   He attributed
the disease to an attempt to lift a very heavy paving stone,  when he was twelve
years of age.   He felt at that moment acute pain and immobility of the
wrist.   In a few days a tumor  appeared which at first small, increased gra-
dually for six month : it then remained stationary, and caused but slight incon-
venience.
  M ...., became a goldsmith and worked  at this business for three years,
when fearful of the further progress of the disease, he determined to enter the
Hotel-Dieu.  At that time the tumor was seated on the palmar surface of the
wrist: or rather, there were two tumors, one projecting  above the anterior
annular ligament of the carpus, the other below, and  communicating under
this ligament.   Pressure upon one raised the finger applied  to  the  other and
the displacement of the contained matter communicated to the fingers a sen-
sation of friction as if small solid bodies were striking against each other or
against the parietes of the cyst.
  It was then  ascertained that a communication existed between the tumors.
Pressure continued for two days caused the matter contained in the upper one
to pass into the lower.  An incision was then made in the latter, and by
means of slight pressure, a quantity of small whitish bodies, of different forms,
choroidal, cylindrical, and lenticular were extracted ; the  largest of about the,
size of a large pear-seed, the smallest not larger than a  millet-seed, and all
with smooth surfaces.
  This little operation was followed by the consequences which were expected;
suppuration ensued, at first of a bad quality, then healthy, and cicatrization
took place.  The cure, however, was  only temporary ; the cyst had merely
been emptied,  its vitality still remained.  Nothing had been done to excite
inflammation in it, and consequently the tumor soon re-appeared.
  The patient, then twenty-six years of age, unable to pursue his business,
was a second time admitted in the hospital, on the 12th of March, 1813.  The
tumor presented the characters already described, and its nature was clearly
pointed out by the concomitant circumstances.
  Two days after his admission, M. Dupuytren made a  puncture below the
annular  ligament; at first a little serum  escaped.  A female sound, intro-
duced  between  the approximated  flexor tendons, extracted a small white
body, resembling a pear-seed stripped  of its  epidermis.   The  next morning,
the puncture was enlarged, and a quantity of similar little bodies  escaped.
A counter opening was made, and a seton covered with cerate passed through
tne wounds.
  Two hours  after the operation, a chill came on, followed by heat and per-
spiration ; the pulse was strong, the night restless.  The next morning, suppu-
ration had begun; there was  some tumefaction.  Emollient  poultices  and 
CLINICAL SURGERY.
173
 strict diet were prescribed.  Third day the swelling increased, the  pus col-
 lected above and below the apertures.  It was dressed twice daily and pres-
 sure applied  which expelled  pus mingled with white and perfectly formed
 bodies.  Fifth,  An  abscess which had  formed on the back of the hand, was
 opened.  Sixth, Two other abscesses were opened, one on the course of the
 radial artery, the other on the ball of  the  thumb.   Eighth, Severe chill after
 the dressing, followed by internal heat.   The  tongue became covered with a
 yellowish coat, the pulse accelerated, fever very high, the countenance changed,
 and became shrunken, the patient began to despair; the  swelling of  the hand
 was  considerable ; suppuration copious  and fetid ;  the least motion was pain-
 ful and productive of a crepitation giving rise to a fear of disorganization of
 the  ligaments and caries.  These  symptoms lasted for two weeks.   After
 this time, they diminished, as well as the swelling and suppuration, the patient
 was  able to walk about;  his appetite  and  strength gradually returned, the
 openings ceased to discharge pus, some closed, others remained  open longer,
 an abscess formed on the back of the  hand; but he at length was discharged
 cured, with the  perfect use of his fingers and wrist.
   Before the  serious accident which happened after the  second opening, M.
 Dupuytren had  conducted the patient to M. Bose, a member of the Institute.
 Seven or eight of these bodies were extracted in his presence.  When examined
 by a powerful  miscroscope, they did not appear to move.  Forcibly compressed
 between two pieces of glass, they were  reduced to a transparent  membrane,
 having no appearance of mouth nor organs of suction.  M. Bose having learned
 from experience, that  demi-dessication  is a very favorable state  for minute
 examination, it was  done, but with no better  success.   He hence concluded
 that they were not hydatids but fragments of the adipose cellular tissue floating
 in serosity.   M. Dumeril performed the same experiments, with a similar
 result.
   The mistake of these learned gentlemen maybe easily perceived.  Indeed,
 these bodies did not stain any substances with which they came in contact.
 When pressed for a long time  between pieces of blotting  paper  or clean silk,
 no appearance of grease was left upon  them. Again these  naturalists were
 obliged to admit an apparently, individually, independent existence.  These
 considerations and the attentive  examination of these bodies which possess a
 shape nearly always similar, and a very apparent lamellated structure, have
 led me to conclude, that they were distinct from the being in whom they were
 found ; in a word, they were true hydatids.  If they were not organized, how
 could they remain uninjured several days floating in pus ?  I also think  that I
 have several times distinguished motion  in them.
   When examined after the opening of the tumor they are found  to be whitish,
 opaline, transparent, wrinkled in the direction of their long diameter, forming
 a species of sac,  of which one extremity ends in a large round cul-de-sac, and
 the other is contracted like the neck of a bottle; they are evidently composed
of laminffi and resemble pear-seed ; they are sometimes cylindrical, sometimes
conoidal, sometimes lenticular.   Their  consistence is almost cartilaginous.
They seem to have passed  through many stages before reaching their complete
development;  sometimes, I believe,  a cavity has been  found within  them.
These white bodies are surrounded by a thin, smooth, yellowish, and serous
cyst, containing  a transparent serosity. 
174
LECTURES ON
  The situation and shape and the first symptoms indicate the existence of
these tumors.   We have already spoken of the former of these signs.   Their
shape has been compared to a kind of bug.   Indeed, wherever they may be
situated, they are always divided into two parts of more or less equality.  By
pressure the fluid may be dnven from one to the other, and during its passage
a crepitation may be distinctly heard, a noise similar to that produced  by
pouring grains of half-boiled rice from one bag into another.    This sensation
is the pathognomonic sign of the disease,  When it is felt the nature of the
tumor may at once be decided upon.  A few years ago, continued M Dupuy-
tren, I was  called to see a patient with a tumor on  the wrist.  I recognized
this symptom, and instantly pronounced it to contain small white bodies, which
I considered hydatids.   Several gentleman who were present, looked upon my
diagnosis as rather hasty;  they however agreed in opening the tumor. On the
day fixed for the operation, I brought a small phial in order to collect these
bodies to analyse them. This excited the mirth of the surgeons who had not
concurred in my opinion.   The opening was  scarcely effected, when a large
quantity of these little white bodies gushed out, and confirmed my diagnosis.
  Generally without pain, or change of color in the skin, unless the latter be
from any cause whatever secondarily inflamed, these tumors may increase to
such a size as to impede the freedom of motion of the joint, near which they
may be situated, and by thus preventing the patient from following his ordi-
nary occupation, require to be extirpated.
  Case. I.—During the year 1829, a man consulted me, for a tumor on the fore-
part of the wrist joint.  This tumor was hard, resisting, about the size of a
pigeon's egg, projecting above and below the anterior annular ligament of the
carpus.   The color of the  skin  was unchanged, and no  engorgement existed
in the surrounding parts.
  Founding my opinion on the position of the tumor, on its division into twt
parts  communicating with  each other, and especially  on the crepitation, I
pronounced it to be a hydatid cyst  containing a quantity of whitish bodies.
A puncture having been made in the lower tumor, some serum and a consi-
derable number of white bodies gushed out, some round, some elongated, of the
size and shape of a  pear-seed.   A grooved  sound was introduced into the
aperture, passed  under the anterior  annular  ligament ef the carpus, and a
counter opening made at the lower  part of the fore-arm.  A  pledget of lint
was placed in both openings in order to determine the inflammation, suppura-
tion and adhesion of the serous sac.  A small artery was divided in the wrist,
but I did not tie it until the man had lost eight or nine ounces of blood, and I
prescribed also the repeated application of emollient baths and leeches,  if the
symptoms of inflammation should require them.
  The inflammatory stage ran very high, but was soon subdued by an  ener-
getic antiphlogistic treatment.   In a month he was cured, with merelya slight
stiffness of the joint.
  Physicians have frequently erred in  the diagnosis of these cysts.   Thus,
they have sometimes been taken for white  tumors or chronic abscesses.  In
order to distinguish them, we should attend 1st, to their situation on the ante-
rior part of the wrist or instep;  2d, to their sacciform shape;  3d, to the
crepitation above pointed out.
  Let us now  consider the treatment: 
CLINICAL SURGERY.
175
  Experience has taught me the fruitlessness of external agents, in the treat-
ment of encysted tumors; whilst their efficacy has often been apparent in
those which are not encysted.  The opening of the cyst, and  suppuration of
its parietes, are, in the former case, the only means of cure.  But in tumors of
this nature, however small  they may be, this remedy is not  always without
danger.   I have seen very serious symptoms ensue, and even known the
patient to sink under an inflammation which has  extended to the hand and
fore-arm.
  Case III.—In December, 1812, a carpenter, thirty-six years of age, sprained
his right wrist, of which he was soon cured.  In two or three months after-
wards, a small tumor appeared in the palm of the right hand below the annular
ligament of the carpus, and  soon  after another above this ligament.  They
soon became so large as to impede the motions of his hand.  He consulted me
on the 7th of June, 1814.  An examination of the tumor soon convinced me
of its nature.   The next day, an incision was made in each tumor, and a
quantity of small whitish bodies discharged;  the aponeuroses of the hand and
fore-arm were freely divided, in order to prevent inflammation with.strangu-
lation ; a seton  was introduced, and an emollient cataplasm  applied  to the
hand.  During  the evening and night following the operation the pain was
intense; on the 2d, 3d, and 4th days it increased with the swelling; a grayish,
flakey pus was  discharged  from the wound; on the 5th day the seton was
removed, the inflammation extended to  the arm, and  even to the  armpit.
The constitutional irritation was very great.  Eighth day, the gangrenous
aponeuroses were  removed, and an abscess which had formed between the
first and second metacarpal bones was opened, and the pus, which had infil-
trated the fore-arm and hand, was expressed.  Tenth and eleventh days, chills
with chattering of the teeth, lasting ten minutes;  pus extremely fetid, general
debility, resisting the most powerful stimulants ;  death took placeon the 15th
day of the operation.
   Experience and  reason, have taught me, that when the opening of these cysts
is determined upon, a large incision should be made in each half of the tumor.
It suffices, indeed, to recollect the anatomical structure of the parts.   On the
instep, but especially on the palmar face of the wrist, the cysts are developed
under aponeuroses, in the midst of tendons, vessels, numerous nerves, and  a
fibro-cellular tissue.   Hence,  if  a  small  opening be made, the swelling,
produced by the suppurative inflammation of the parietes of the cyst, almost
always causes strangulation; this extends more  or  less to the surrounding
parts  along  the fibro-cellular  sheaths, covering the vessels  and tendons,
whether in the  palm of the hand, or in the fore-arm and arm.  Thence result
numerous abscesses, and sometimes a phlegmonous inflammation of the whole
limb, and even death, as was seen in the last case.  By opening immediately
and freely the two halves of the cyst; we avoid  certainly the cause of  these
inflammations ; no strangulation can then take place, suppurative inflammation
sets in, and generally ends favorably.
   After the incision, a pledget of  charpie should be introduced between the
lips of each incision.  I have sometimes passed a seton through from one open
ing to the other; but have of late abandoned this method, believing it useless
and dangerous.  Indeed, it is sufficient to keep the edges of the wound sepa-
rated, and thus oppose their union, in order  to  excite  inflammation and 
176
LECTURES ON
 suppuration of the parietes of the cyst. The seton excites too acute an inflamma-
 tion which may easily extend very far, and also communicate with the cavity
 of the joint, and thus become the origin of anchylosis.   Were the seton only
 useless, it should  be rejected: but it is dangerous, and should u fortiori, be
 abandoned.
   Incision and suppuration of the cyst are therefore the only means of curing
 these tumors.  It would be impossible to extract them entirely both from their
 position, and the knowledge, that  they adhere firmly to all the surrounding
 parts.  But since the suppuration of the cyst is not always without danger, and
 that notwithstanding the rules I have laid down, as regards the incision, and
 means of preventing secondary accidents, these accidents are sometimes  to be
 feared, and may endanger the life of the patient;  since, on the other hand,
these  tumors are  never painful, and merely embarrass the motions of the
 joint, we  should not have recourse to the operation, except when the size  of
the tumors, prevents the patient from following his ordinary avocation in life.
On the contrary, the surgeon should advise him to bear his inconvenience with
patience;  and if he positively demand the operation, the risks and danger
should be explained to him.  When it has been performed, we should endea-
vor to confine the inflammation to its proper limits ; and when too intense,
antiphlogistic remedies must be immediately employed.
                        CHAPTER  XXII.
                         ON INVERTED TOE-NAIL.

  I had always been struck, said Mr. Dupuytren, with the frequency of inver-
sion of the nail of the great toe, and the reproduction of the disease, notwith-
standing all our  efforts.   Persuaded that, for its  successful treatment,  a
careful  study  of  the causes producing it was  necessary, I  examined  many
patients laboring under this deformity, and at last discovered that there were
two important varieties of the disease demanding entirely different modes of
practice.  Let us now proceed to consider this  subject.
  The first variety mentioned by writers, consists in  the ulceration of one or
both lateral  edges of the  nail;  generally, however, found  on the outer edge.
  Call to mind the shape of the nail, the flattening of its body, the  direction
of its angles, its situation in the skin by which it is covered, and  you will
easilv  perceive that a tight or badly made shoe, by keeping  up a  constant
pressure on the nail, will forcibly depress the angles of the nail, upon the skin
on which it rests.  Gradually these  angles, always  more  or less acute and
cutting, sink into  the skin, the more easily as it thrust upwards and outwards,
and tends to cover them ;  lastly, the irritation  produced, will cause a  very
painful inflammation.   Such, indeed, is generally the cause of inversion of the
outer edge of the nail of the great toe.
  The disease generally commences at the angle formed  by the junction of
the anterior with  the lateral edge.  This seems  to  be owing to this circum-
stance, namely, that as the prominence formed by the flesh, impedes the action    »
of the scissors when we wish  to cut the nail, we mostly desist before having 
CLINICAL SURGERY.                        177
 removed the  whole of the anterior edge, and especially the angle formed by
 its union with the  corresponding lateral edge.  This disposition, allows the
 angle  which has not been touched, to grow; it forms  an acute point which
 punctures and divides the flesh, and soon becomes  the signal of an ulceration
■ which rapidly extends along the corresponding edge of the nail.  This fact is
 so  constant, that this point is always found.   Having pointed out its causes,
 let us  now study the phenomena of the disease.
   Scarcely has the nail scratched the skin which it covers, than the pain
 becomes very acute.  The patient can hardly walk or even stand ; a serous,
 or sero-purulent matter escapes from  the  injured  spot; and  the whole  foot
 becomes tumefied after exercise.  The pain  increases, the discharge is more
 copious, the sanious pus exhales an odor rendered still more  fetid by the
 perspiration of the  feet.  The patient exhausted  by the pain, endeavors to
 raise the nail, cut it from behind, which although productive of momentary
 relief, far  from curing the disease, adds to  the difficulty  of the treatment.
 Lastly, if the disease be abandoned to itself, the  ulcer resulting sometimes
 becomes cancerous, is sometimes covered with enormous vegetations, and not
 unfrequently the- inflammation  extending  to the  periosteum, gives rise to
 caries and necrosis of one or several phalanges.
   This affection may sometimes be mistaken for other diseases.   The marquis
 of  C .... had suffered in this way for eight years,  and during that  time had
 consulted several physicians who treated the disease as gout, without the least
 benefit. He then consulted M. Dupuytren, who pronounced it an inversion
 of the nail, which would be cured by the removal of the cause.   The patient
 consented to the extirpation of the nail, which was divided by a single stroke
 of the scissors, and each portion removed with the forceps.   A simple  dress-
 ing was applied, and the patient cured in a few days.
    When left  to itself, inverted toe-nail is  never cured, on  the  contrary, the
 disease advances.   Besides the intolerable pain, it may  be productive of very
 serious consequences; prudence and experience therefore require its early cure.
   Many plans have been adopted to disengage the nail, and give it a new direc-
 tion.  A portion of the nail, or of the diseased flesh has been removed.   These
 means generally inefficacious, are  ordinarily merely palliative.   If the  flesh
 on the side of the nail be  destroyed, it is  partly reproduced ; and in walking
 the toe is flattened out and forms a fleshy tumor on the side of the nail, which,
 preserving its original direction, may again be d riven into the flesh.  If instead
 of removing the flesh, a portion of the inverted nail be cut away, a temporary
 cure follows; but when it grows, it again takes a wrong direction.   For this
 reason, Desault's plan, which consisted in separating the  nail from the flesh
 by means  of  a small piece of tin, although at first sight, it might appear pre-
 ferable, was in reality not long successful.  What becomes of the  nail, thus
 forced laterally beyond  the  flesh ?  It tends constantly to  roll inwardly on
 itself, and whether  it be cut off on a level with the flesh, or permitted to grow
 and descend on the inner side of the finger, it  frequently happens that it again
 penetrates the flesh.  It may be asked, to  what is  owing the  success obtained
 by physicians, by such different methods ?  Generally, whenever the deter-
 mining cause has been purely accidental, and the structure of the nail itself
 has not occasioned the disease, the success of these methods depends on the
            23 
178
LECTURES ON
 period at which the treatment was commenced.  For instance, if a regularly
 formed nail has been compressed by a tight shoe, or contused by any external
 violence, and Desault's plan be applied in a few days after  the accident, the
 subjacent flesh will not be sufficiently irritated to be much injured  by the
 compression, and the  nail being diverted from its wrong course, there is no
 reason why the disease should  be reproduced.  But,  I repeat, whenever the
 cause of  the disease is in the nail itself, all the plans hitherto suggested will
 generally be found unavailing.
   Struck by these results, continued M. Dupuytren, and reflecting on the
 cause of* the disease, I have for a long time preferred the entire  extirpation
 of the nail.
   This I perform in the following  manner: when the general state  of the
 inflammation of the limb  has been somewhat reduced, and the time for the
 operation appears suitable, I introduce under the middle of the free edge of
 the nail, the point of a very sharp,  straight and firm scissors 5 carry it by a
 rapid motion to the root, and divide the nail by a single stroke, into two nearly
.equal  portions; seizing  then the part corresponding to the ulceration with a
 dissecting forceps, I tear it off' by twining it from within outwards; if neces-
 sary the same is done  with the  other.  When  the  fungus in the vicinity of
 the wound, is too elevated, I apply the actual cautery, and thus secure, as far
 as  possible, the cure of the disease.  After this operation the skin under the
 nail dries, the  ulcerated  part withers, and  cicatrizes in 24 or 48  hours; so
 that in five or six days the patient may resume his ordinary avocations.  Gene-
 rally  the nail is not re-produced in old, but it is sometimes in young persons*
   This might be supposed, at first sight to be a very painful operation ;  yet
 the patient scarely utters a complaint.  When the  nail has  been completely
 removed, the disease returns no more; and only re-appears when a piece of
 it has  been left in the wound.
   Cask.—Inverted Toe-nail, Extirpation of its External Half.—^R...  S...,
 16 years of age, of a good constitution, was admitted into the Hotel-Dieu on
 the 18th of June, 1821.
   For the last six months, he had been wearing shoes which were thicker  and
 smaller than usual, his feet were compressed  so that he limped in walking;
 the external angle of  the  right  great toe was turned inwardly, plunged into
 the adjoining flesh, which was much  tumefied.   It was very painful and made
 him very  lame.
   On  the 3d, of July, after a rest of a few days, baths, and emollient appli-
 cations, he  was carried to the operating room, and M. Dupuytren extirpated
 the inverted portion of the nail.   It was divided with a pair of strong straight
 scissors;  the outer part seized with the forceps, turned on itself and torn off;
 the hard skin covering it removed by the  scissors.  A little blood was lost.
 The wound was dressed with cerate, lint, a  compress and bandage.
  July, 4th, 5th, and  6th, he is doing well; dressing continued.   7th,  the
 cicatrix is complete, the patient was discharged cured, and advised to wear
 a larger shoe, and wrap his toe in a piece of linen spread with cerate.
   The second variety of inverted toe-nail, said M. Dupuytren, had for along
 time been confounded with that we have  just described ;  and I hrst pointed
 out the distinctions between the  two species.  In the latter there is no change 
CLINICAL SURGERY.
17$
of rotation between the parts; the ulceration does not begin along the edge
of the nail, but at its base.; the disease is located entirely in the skin which
produces the nail, and the change in the latter, instead of being the cause of
that of the soft parts, is merely the consequence of it.
  You will easily understand the mode of formation of the second species, after
having examined the anatomical structure of the nail.  Its adberin°- extremity,
the  only one we need here study, is fixed in the skin in a peculiar manner;
the  latter after passing  over the nail, on its dorsal surface is reflected upon
itself; having reached the posterior part, it separates into two parts, the epi-
dermis which covers the whole of the superficial layer, and the derma which
passes under the  nail and is continuous with the skin, covering the free
extremity of the fingers.  The  cul-de-sac into which this part of the nail is
received, is  known by the  name of the matrix.  It is hence very important
to understand this disposition of  the organ, which explains perfectly, Why
inverted nail is, in many cases, produced only by the doubling of the free
extremity in the cul-de-sac.  This change may take place in consequence of
a severe contusion of the great toe.  When this is the case, the patient com-
plains at first of pain in walking, which gradually increases; the kind of cul-
de-sac containing the base of the nail, reddens and becomes inflamed, as well
as the bottom of the folds, which receive its lateral edges; ulceration soon
appears and rapidly progresses; its shape is semi-lunar with elevated and hard
edges, the bottom of it red, violet-colored and livid.  The nail is shortened
and  reduced to  one-half its extent; sometimes, indeed, it totally disappears,
and  in place of it, we see here and there small spots of a horny substance;
a part of the nail is also often hidden under fungous flesh.   This  fungus may
seem to distinguish the disease which results from a primary alteration of the
skin, from that which is the consequence of inverted nail.   When the disease
is produced  by the nail, the fungus is  found  before and on the sides of this
nail; when the disease, on  the contrary, proceeds from an affection of  the
skin, the fungus is always opened at the base of the nail.
  In the cases of which  we are now treating, the color of the nail is gray and
black; in some  cases it no longer preserves its natural adhesions; the wound
is generally bathed by a  sanious or sanguinolent suppuration, and extremely
offensive.  If the patient walk  or  even stand erect, the  fingers bleed;  all
kind of covering is insupportable, and the least friction is very painful.
  These symptoms are nearly constant; sometimes, however, the skin occu-
pies  particularly that  part of the skin  immediately under the  nail.   Little
tumors are then developed which raise the nail, and are painful in proportion
to the pressure.   These tumors may be of different natures, fibrous, cartila-
ginous, osseous  or vascular;  and as a proof that their development is entirely
owing to the alteration of the skin covering the nail; it will be observed that
if they are removed without also  removing the skin from which they arise,
the latter generally again becomes diseased, ulcerates, and sooner or later
requires  to be radically extirpated.
  After  what has been said concerning  this disease, it will  be perceived that
the treatment applicable  to the first species of  inverted toe nail, is useless in
the second.   The  skin is here affected, and if the nail be removed, the seat of
the disease has not been attacked, and  many cases  have  proved  to me, {\&t
such affections never are cured.  If caustic be applied after the  avulsion of 
180
LECTURES ON
the nail, that part of the skin only immediately subjacent to the organ, is des-
troyed, and not that enveloping the root, and sometimes covering it to a great
depth.
   These considerations, added M. Dupuytren, have induced me to remove with
the nails, not only all the ulcerated surface, but also the  fold of the skin from
which it derives origin and nourishment.   In order to perform this operation,
the patient is seated on a chair or bed, and seizing the too with the  left hand,
I make a deep semi-circular incision, three lines beyond the fold of skin which
supports the nail at its root; I then dissect off the flap., nd remove all the
skin which relates to the nail, and assists in its production ;  every vestige of
diseased tissue is very carefully separated.  All the  wh'te  and fibrovs  parts
which are seen in the bottom and angles of the wound, should be scrupulously
extirpated, for these parts are the rudiments which could reproduce the nail,
and keep up the  disease.
  This  operation is very painful, but of very short duration.   The toe is
immediately enveloped in a rag spread with cerate, a thin layer of charpie, and
a compress, complete the dressing. The patient is put to bed, and the leg sup-
ported by a pillow, kept in a state of demi-flexion on the thigh.
  The patient generally suffers some pain during the  few first hours after the
operation; this, however, soon passes away, and at the first dressings, after two
or three days, a healthy pus is mostly found covering the  wound.  The simple
dressing is continued,  healthy granulations soon appear, which  are  to be
repressed if too elevated by lunar caustic. Should any portions of horny fibre
reappear, they are to be torn away, and the skin producing them to be removed;
in a majority of cases, about the  15th or 18th day the cicatrix is complete, and
the patient cured.   If the cicatrix be examined some time after, it will be
found to be formed by a smooth, thick skin, having no nail, but  sometimes
assuming a corneous consistency.
   It is  needless to multiply the number of cases, and I will therefore merely
recapitulate the different doctrines advanced, and present  them under a form
which may be understood at a single glance.
   1st, Generally speaking, when the nail is  altered, it assumes an improper
direction towards the flesh surrounding it and this disease constitutes incarna-
tion of the nail.  Nothing but  its removal will cure this affection.
   2d, The disease characterised by primary inflammation of the skin,  which
seems as a matrix to the nail,  is entirely distinct from the preceding species,
in its symptoms, results, and the mode of treatment required.  The  removal
of the whole of the diseased skin should be preferred to  all other methods; it
is the more prompt, and by far the most certain.
   3d, We should never neglect to use all other remedies, of whatever nature,
in order to  spare  the patient,  an operation  which is  always  exceedingly
painful. 
CLINICAL SURGERY.
181
                       CHAPTER  XXIII.

                    ON  LUXATIONS OF THE  HUMERUS.

Reflections on the Most Important Pathological Points of Scapula-Humeral
  Luxations ;  Old and Recent Luxations, Reduced  by a Plan hitherto New
  in France.

  A celebrated writer has  remarked, in speaking  of  these luxations, that
there were but few diseases in the treatment of which, the science of surgery
had  approached nearer to perfection  than in these. In the course of this
chapter it will be seen, with how little reason, the remark, at that period, was
made.   Indeed, many questions of high practical importance were never sug-
gested, or are still without solution.  Modern  authors admit  the  primitive
occurrence of these luxations in three  directions, of  which that which takes
place downwards, below the glenoid cavity, is the most frequent.  It had been
established that in the orbicular articulations,the luxation is always  complete:
M. Dupuytren has proved by cases that in the  scapula-humeral  articulation
it may be incomplete. The distinguishing marks of luxation and fracture of the
upper extremity of the humerus were but very loosely pointed out, and in many
cases the surgeon was unable to distinguish between  them ; recently the pro-
fessor has had  an opportunity, of characterizing with so  much  precision
these injuries, that error can now be imputed to ignorance alone.  In many
and  especially in old luxations, the plan of ordinary  reduction,  which he has
so happily modified, was yet insufficient in  the  hands of the most skillful
operator.   M. Dupuytren did not hesitate to try recently a method but little
known, and in several  cases he  has been eminently successful.
  Case I.—A beggar  woman, forty-one years of  age, was admitted into the
Hotel-Dieu on the fifth of last August. According to  her account, on the ninth
of the preceding month, she was walking at a  late  hour of the night in the
ditches surrounding the Champ-de-Mars, and  was  attacked by several indi-
viduals.  She resisted as long as she could do so, but was struck down by a
blow from a stick, and rose declaring that her arm was  out of joint.   Being
taken  to  Saint-Lazare, some days afterwards, four successive attempts at
reduction were made, with no other effect than that of increasing the pain she
already suffered.  Since these attempts, she has complained of a numbness in
the fore-arm and fingers from which she had been previously free.
   She was admitted into the Hotel-Dieu a month after the accident.  She then
presented the following symptoms; projection of the acromion, flattening of
the deltoid, the elbow permanently removed from the  side, inability to ele-
vate the arm to  the head, lastly in the arm-pit a projection  evidently bony.
These symptons indicated a luxation; but they  are also the symptons of frac-
ture. The crepitation and mobility of the fragments characterizing  the latter
injury, indeed,  were not present;  but they might have disappeared during
the interval which had elapsed  since the accident.  On the other  hand, the
fracture might have resulted from the blows of the stick, as also the luxation
might have been effected by the manner in'which the patient struck the ground 
182
LECTURES  ON
when she fell; again, the bony projection in the armpit had not the feel of the
round head of the humerus.
  You will see, therefore, that if we be guided only by the rational symptoms
hitherto laid down by all authors as the  distinguishing characters of luxation
and fracture,  it would be impossible to pronounce ^priori on the present case.
  We will, however, attempt the reduction, taking care to avoid the injury
which might he done  to the patient, if perchance there be a fracture; for it
must not be forgotten, that, when the latter is mistaken for a luxation, itmay,
indeed, be reduced, but  when left to itself, the muscular action gradually
reproduces the displacement: and on the contrary, when a luxation is mis-
taken for a fracture, it is seldom perfectly reduced.   In all cases the patient
remains more or less  crippled.   Before proceeding to the  operation, the
patient will be prepared, according to our usual custom by venesection the ap-
plication of cataplasms around the joint, baths, and the administration of a few
grains of the aqueous extract of opium.
  On the appointed day, the reduction  was attempted.  The patient com-
plained bitterly.  In order to divert her attention and thus suspend the action
of the muscles, M. Dupuytren told her that she was accused of having been
marauding on the night of her accident, and reproached her severely.  This
plan, however, like many others, was unsuccessful.   Notwithstanding, it was
ihought that  the flattening of the  deltoid was less  marked.   This  circum-
stance and the fruitlessness of the attempt at reduction gave more probability
to the idea of a fracture; the diminution of the flattening might have arisen
from the callus as yet tender being  pushed out by the efforts of extension, and
in order to increase this tendency, a large pad was placed  between the arm
and the body, the elbow brought as near the latter as possible by means  of a
bandage.  At the  end of four days,  however, the bandage  has  been of no
effect.
  The fact just laid down, gives rise to three important questions.   1st, The
signs already enumerated being insufficient, how shall we establish  the diag-
nosis?   2d, Supposing there be luxation and  not fracture,  and the means
which we have  hitherto constantly used  with success, proving unavailing, by
what  means  can we effect  the  reduction?  3d, Does the interval  elapsed
since the accident, contra-indicate the  operation ?  or, in other words, after
what length of time is it possible to reduce a luxation ?
  The difficulties of the present case rendered itone demanding our most care-
ful investigation. At the same time, a young surgeon, Dr. Malgaigne commu-
nicated to us some ideas which had suggested themselves to his mind, and which
appeared remarkably well founded.  The following was the result of our exa-
mination : In the first place, there  was considerable  elongation of the injured
limb. Now in all fractures of the long bones, if there be no displacement, the
limb preserves its ordinary length;  if there be displacement, so as to occasion
overlapping, the limb is shortened.   This symptom alone, was  an  undeniable
proof of luxation: again, M. Malgaigne pointed out other signs, which we will
now notice.  The first, which is a consequence of the preceding, consists in an
increase of elevation of the anterior fold of the axilla ;  2dly, the head of the
luxated bone oughtto form, in his opinion, a projection in front, where the sub-
clavicular depression is usually seen and the differentappearance resulting from
this on the two sides of the chest is especially evident in thin persons, as was 
CLINICAL SURGERY.
183
 the case with our  patient.   3d, lastly, said M. Malgaigne, by applying the
 fingers immediately beneath the acromion, the deltoid may be easily depressed,
 if there exist a luxation.  Depression, on the coutrary, is impossible  in cases
 of fracture.
   The nature of the injury being now ascertained the question arose whether
 its long standing did not contra-indicate an attempt at reduction.  M. Dupuy-
 tren adduced many examples from his own experience, tending  to disprove
 this position; it was therefore decided upon, and his attention turned towards
 finding  the most effectual means of reducing the luxation.  M. Malo-aigne here
 submitted to his consideration a plan hitherto unused in France,  which  con-
 sisted in making extension, the arm being strongly raised up and consequently
 shortened, instead  of the usual manner. It is merely, said this youno- surgeon,
 the application to the  present case, of a general principle  applicable to all
 nations, namely  to dispose of the bones in  such a manner,  that they  may
 overlap each other, and  that  extension  may restore to the limb its lost
 length.
   We will now, said M. Dupuytren, be enabled to judge of this  method by
 its application  to the present case.   You should, however, understand that it
 is not to be condemned, should it not succeed in a case which  has baffled our
 ordinary plan ; if, on the contrary, it should succeed, it may be supposed to
 possess some superiority.
   The patient having been properly prepared, the reduction was attempted on
 the 14th of August.  Being placed in a supine position, a cloth folded trans-
 versely was placed over the  acromion, the  ends carried to the feet  and held
 by assistants.   The extending band was placed in the usual manner and given
 to two assistants, the luxated arm elevated as much as possible, so as to make
 it parallel  to the axis of the body, and extension then attempted.   The  firs^
 extension  gave but little pain, the head of the bone was very apparent in tlu
 axilla, it gradually  rose towards the cavity to which the extension drew it, and
 the folds of the axilla, which hitherto had been effaced, presented the hollow
 which usually separates them.  The head of the humerus was pressed by the
 fingers and palm of the hand, in order to assist it in regaining the glenoid
 cavity, the arm brought down to the body, but twice this plan failed.
   M. Dupuytren  here took charge of the operation, and pressing strongly with
 the palm of his  hand  on  the head of the bone, whilst extension was made
 parallel to  the axis of the body, he desired the assistants to lower the arm and
 approximate it to the body, at the same time keeping up the extension.  The
 first attempt failed, the second  succeeded entirely, the humerus returned to
 its place without the least noise.  The shoulder recovered its roundness, the
 elbow could easily be brought to the body, the motions of  the joint were ex-
 ecuted with facility, the projection in the axilla had disappeared.  The patient
 was carried to bed, a small pad was placed in the axilla, and the elbow fastened
 to the side. In a few days the pad was removed, and the elbow merely con-
 fined by  a bandage; every thing went on so well, that M. Dupuytren did not
 hesitate to  predict a complete cure.
  Case II.—A washer-woman, 69 years of age, small and very thin, fell back-
 wards down the trap-door of ,a cellar, and rolled along a dozen steps.  The
accident  occured at 8 o'clock  on  the morning of the 27thof last October; she
came  immediately to the Hotel-Dieu.  M. Dupuytren recognized it to be a 
184                          LECTURES ON
luxation  downwards and forwards or sub-coracoidal.  The reduction was
immediately attempted.  An assistant grasped the wrist of the luxated side,
raised  it parallel with the  axis of the body, and drew  directly upwards.
Another  assistant pressed on the scapula in order to make counter-extension.
M. Dupuytren, being seated, directed the  head of the bone with his thumbs.
At the first trial, the  reduction was  effected easily and nearly without pain.
The  arm was  carefully brought down, applied to the body and kept so by a
bandage.  In 12 days the patient was well.
   Case III.—The  third day  after the operation  on the  preceding case, a
women of about 40 or 45  years of age, thin and tall, came to the consultation
of M.  Dupuytren, to  receive advice concerning a luxation of the  humerus
downwards and forwards.   She was laid on a bed, a folded cloth passed over
the shoulder, the ends being carried towards the lower extremity of the opposite
side  and given to two  assistants to make counter-extension; two other assis-
tants raised the arm parallel to the axis  of the trunk and made extension,
whilst M. Dupuytren  pushed the head of  the bone upwards.   The luxation
was  reduced at the first trial, and the patient immediately began to laugh.  She
did not remain in the Hospital.
   In the two last cases, the circumstances were  of the most favorable kind;
the luxation was quite recent, the patients then weakened by age, and without
much muscular energy.  Our usual plan would have been equally successful.
Nevertheless it must be remarked, that it was unnecessary to use any precau-
tions, the patients were not fastened to the ring in order to make extension;
the reduction was easily effected, and with  remarkable ease and promptness.
I think, therefore, that it would be unjust to attribute all these advantages to
the age and constitution of the  patients, and deprive  the method of the share
of credit to which it is  entitled.
   We will apply it again to other cases of luxation of the humerus which may
fall  under our notice ;  and in the meanwhile, request your attention to some
other questions of not less importance.
   If clinical observation  had not established the frequency of these luxations,
the anatomy of the joint, would render it very evident.  The joint enjoys its
remarkable mobility, only at the expense of its solidity.   The  elements of
the  articulation  are, as you know, a cavity  protected by  an osseo-fibrous
vault, a bony head received in this cavity, a capsule  enveloping them, and a
number of muscles  communicating motion to it.  But the disproportion exist-
ing  between the head of  the humerus and the glenoid  cavity, the laxity and
thinness of the capsular ligament, the situation and motion of  the arm, expose
it daily to the influence of external violence, and constitute circumstances
more or less favorable to its displacement.  They would be still  more effica-
 cious if  the scapula which accompanies the humerus in  its movements, did
 not  also extend the limits of the relations of these bones.
   There is perhaps no  subject in surgery with regard to which authors are
 more  divided than with respect to dislocation of the arm.  This is not the
 place to enter into a history of those differences, and I shall, therefore, con-
 tent myself with reminding you that experience and observation have con-
 vinced me that the arm may be dislocated in three principal directions: viz.
 1st, downwards, on  the axillary border of  the scapula; 2d, inwards and
 forwards into the sub-scapular fossa; 3d, outwards  and backwards into the 
CLINICAL SURGERY.
185
sub-spinous fossa.  The presence of the  acromion and coracoid processes,
united as they are by a strong ligament, and the situation of the humeral
extremity of the clavicle,  are opposed to direct luxation  upwards; never-
theless Sir A. Cooper admits a partial luxation  in this direction, the upper
part of the capsule being lacerated, and the head of the bone resting upon the
posterior edge of the coracoid process.
  The dislocation  of the humerus downwards, the only one which, according
to some authors, is primarily possible, is undoubtedly the most common.  It
is generally produced by a fall on the elbow, and still more  on the palm of
the hand, the arm being extended and projecting directly from the body.
The humerus is then inclined on the  glenoid cavity in such  a manner as to
form with it an acute angle.  The head of the bone, thus slipping from above
downwards in the  articular cavity, comes to be pushed against the lower part
of the capsule; this pressed in a contrary direction by the weight of the body, is
torn, and suffers the head of the humerus to escape.  This is then placed on the
inner edge of the anterior border of the scapula, between the subscapular muscle
which is before, and the long portion of the biceps which is behind.   The pec-
toralis major and corresponding muscles act like  a lever, the point d?appui of
which is at the elbow, and  the resistance to which is at  the  shoulder  joint.
The luxation downwards, may also, according to some authors, be produced
by a violent blow on the external part of the  shoulder  beneath the acromion.
But then  it is  often complicated with  fracture  of the scapula or humerus.
It may also be caused by mere muscular action in  a violent effort of the arm
to raise a burden, or in an epileptic fit.  The symptoms of this luxation are—
a lengthening of the arm, its oblique direction outwards, the elbow separated
from the trunk, with inability to approximate it, the head  and body bent to
the affected side ; the fore-arm semi-flexed; impossibility of the spontaneous
movements of elevation or  rotation; pain on attempting these;  deformity of
the shoulder, projection of the acromion, with a depression under it,  a hard
round tumor in the axilla.
  The luxation inwards or forwards  supervenes upon a fall  on  the elbow,
when separated from the body, and carried backward.  The evidence of this
situation when the patient is raised; the presence of a tumor formed by the head
of the humerus, beneath the clavicle and  before the shoulder, which  is less
deformed than  in the preceding case; lastly, the impossibility of bringing the
elbow  forwards without giving great pain, leave  no doubt as to the existence
of a luxation of  this kind.   It is much more rare than luxation downwards; it
is also seldom primary, but almost always consecutive Upon  the first.
  A fall upon the elbow, carried powerfully forwards and upwards, may cause
dislocation outwards and backwards.   This displacement is extremely rare,
and would perhaps be impossible without a vicious disposition of the glenoid
cavity, such asits being inclined backwards and considerably elongated.  In
thisdislocation,-the arm little separated from the breast, is  directed forwards
and inwards, the shoulder is merely flattened  at its anterior part, the head of
the humerus is driven beneath the spine of the scapula, towards the external
border of the anterior angle of this bone.
  I have thought it right to enter into these preliminary details, in the  first
place, particularly with a view to the modifications which I wish to introduce,
of the theories generally received on this subject,  and which I shall give you a
             24 
186
LECTURES OK
resumS.  1 st The oblongatiou of the limb in the dislocation called downwards,
is not a fact newly observed. I have seen it in all those whom I have attended
in a very long practice. But does this elongation take place in all dislocations
of the humerus as some assert, or, on the  contrary, is the arm at  one time
longer, and  at  another shorter, according  to  the kind of luxation,  as others
maintain?  2d, Can the humerus be luxated primitively in one direction only,
and are the other varieties only consecutive? 3d, If it be true that there is but
one kind of primitive luxation, in what direction is it? 4th, Can dislocation only
take place with laceration of the capsular  ligament; or is it sufficient that
this be stretched and distended? 5th, The capsule being torn, can it, by exer-
cising constriction round the dislocated bone, oppose the reduction as main-
tained by Desault?  or are  we to agree with Sir A.Cooper who holds this
obstacle to be entirely imaginary?   Lastly, there  exists disagreements with
regard to the anatomical structure of some of the modes of union of the arti-
culation, each  explaining according to his own views the mechanism and fre-
quency of dislocation of the humerus.   It is thus that some, and I agree with
them in opinion, admitting that the lower part of the capsule  is most feeble,
have considered dislocation  downwards as the most common; whilst others
maintain that this part is the thickest, and only rank dislocation downwards,
in the third degree of frequency.   It would be easy for me  to adduce facts
from my own experience, which would settle most of these opinions, but I shall
confine myself to directing your attention to the various points where  cases
illustrative of  them occur to us.
  It is generally stated that luxations of  the orbicular joints are always cowi-
plete: but pathological anatomy has proved the contrary, by presenting us with
incomplete dislocations of  the arm and thigh.
  Case IV.—In 1824, the surgeon in chief of one of the hospitals of Paris,
presented to the academy a pathological  specimen taken from  a man who died
eight months after a luxation of the humerus, which had never been  reduced.
It showed a  false  articulation made, on the  one side, by the glenoid cavity of
the scapula, and a small portion of the surfaces of the ribs; on the other, by
the head of  the humerus hollowed into a groove in order to receive the  ante-
rior edge of the glenoid cavity, like a kind of ginglymus.  During life the
arm could only be moved slightly backwards.  In  a case of a spontaneous
luxation of the femur, the same surgeon has seen the head of the bone arrested
on  the anterior edge of the cotyloid  cavity and fixed there by means of an
indentation.  Here  are two authentic cases of incomplete luxation of true
orbicular articulations; a luxation of which the possibility, difficult indeed to
accredit, has been universally denied by authors.
  We have already observed the symptoms peculiar to each species of scapula-
humeral luxations ;  we have also shown  that these symptoms  belong also to
fractures of  the upper  extremity of  the humerus, and that in many cases the
diagnosis between these accidents becomes very difficult.
  Every one, continued M. Dupuytren, affected with luxation or fracture of
the upper part  of the humerus, will be found to have fallen on  the side of the
injury; but the position of the limb, at the moment of falling, is not the same
in any two cases; and this difference usually decides the kind of lesion which
results, and furnishes the means of recognizing it.   If the arm being separated
from the body, and carried forwards  or outwards with a view to break the fall, 
CLINICAL SURGERY.
187
there be displacement, then such displacement will be a luxation of the head
of the  humerus without fracture.  If, on the contrary, the arm has been kept
close to  the  side (this patient, for example, having his hand in the pocket of
his pantaloons) it is the ball of the shoulder against which the weight of  the
body impinges; and then, if there be displacement, it is as the result of frac-
ture, or crushing of the head or the upper part of the humerus.
  In both cases there is acute pain at the top of the shoulder, and the patient
always thinks that the fall has taken place on the seat of his  suffering.  But
when it is the result of luxation, the fall having occurred on the  palm of  the
hand, this last is generally soiled, or bruised and excoriated; if, on the con-
trary, the pain is caused by fracture, we observe that the fall has taken  place
on the shoulder itself, by the absence of all marks about the hands, by the
soiling of the clothes, or even of the skin of the arm, which is also frequently
bruised or wounded.
  In luxation, the pain depends on the laceration of  the fibrous capsule and
neighboring tissues; in fracture it results from the contusion of the upper part
of the shoulder and  the injury done to the  soft parts  by the broken bone.
There may be ecchymosis about the arm in either case;  but in luxation it is
produced by  laceration about the inner  part of the joint, and in  fracture by
the contusion of the outer part;  and  thus  the  seat of such appearance is
different, being on the inner side in the former case, and on the outer part of
the arm in the latter.  Besides, ecchymosis is less  common in dislocation, but
almost constant in fracture.
  In both lesions the acromion is saliant, the deltoid flattened; there is avoid
at its inner margin, and in the hollow of the axilla there is now a projection:
but an exact analysis of the symptoms removes the doubts which a superficial
examination  may have produced.  In  fact, the projection of the  acromion is
more considerable, and the flattening of the deltoid greater in luxation than in
fracture, when  this muscle appears swollen.   In luxation we feel,  at the inner
side  of the deltoid, a very great hollow produced by the displacement of  the
head of the bone ; this hollow is less in fracture.  The prominence in the arm-
pit in consequence of luxation is very considerable, while in fracture it is much
less; and in  the former case  its shape is  round, while it is uneven in  the
latter.
  Neither mobility nor crepitation are present in luxation, while they  are
easily observed in fracture.  In short is the humerus luxated ?  Motion of the
member is vainly attempted, though it may move indeed with  the shoulder
itself, as if it were one and the same piece.   Is it fractured ?   There is an
unnatural mobility on a point in the  upper  extremity of the bone, a mobility
which is usually accompanied by crepitation, perceptible  on attempting to
rotate the bone about its axis. In fine, what above all other things distinguishes
luxation  from fracture is, that the former is more  difficult of reduction;  but
once reduced, requires only to have the arm secured to the breast; whilst in
fracture an apparatus is indispensable, in order to keep fragments in contact,
to prevent the muscles from reproducing the displacement, and  to obtain a
cure without  deformity.                                            .
  It sometimes happens that, when the fracture consists merely in a simple
solution of continuity without displacement, it may be confounded with a
violent bruise of the  shoulder.   Our only means of assuring ourselves of what 
188
LECTURES  ON
has actually happened, is derived from the diagnosis afforded by crepitation
and mobility.   We must, however, not let ourselves be deceived by a false
crepitation, which consists in a crackling which is sometimes met with, arising
from a violent contusion of the shoulder, and which is the result of the inflam-
mation of the articular surfaces,  and of the want of synovia.  The following
are some cases calculated to exemplify our views.
  Case V.—Fracture of the Neck of the Humerus, with Slight Displacement
of the Head of the Bone, simulating Luxation.—An  old soldier, at present a
shoe maker, aged 62, while walking along an inclined plane received a fall,
in which the weight of his body came down on the left thoracic member.  He
was taken to the Hotel-Dieu the  day after the accident, when there appeared
a considerable swelling  around the scapular humeral  articulation; a contrac-
tion of the deltoid with increase of thickness and length of the muscle, which,
notwithstanding was  perceptibly pitted ; projection of the acromion  more
marked than usual; inability to bring the arm  in contact with the trunk ; a
crepitation  and mobility, though very obscure;  a rounded tumor, resembling
the head of  the humerus, in the arm-pit; and a  sort of prominence at the in-
ternal part of the shoulder beneath the pectoralis major.  These were compli-
cated symptoms, but M. Dupuytren pronounced without hesitation the existence
of a fracture.   The  apparatus was applied, but two days  after the swelling
was augmented, and it was perceived  in dressing the  patient that the deltoid
muscle was not so large, thick or contracted as it appeared at first; that it
could be depressed;  that there  was a hollow below the  acromion, which was
itself less prominent than it had  been; in fine the absence of all mobility, and
the presence of a perfectly rounded head in the axilla, gave reason to  pause
before finally adopting the opinion of its being a fracture.
   Some attempts were made at extension.  A pad filling the arm-pit was man
aged as in fracture of the clavicle; the arm applied to the pad was then fixed,
by several circular folds of a roller, commencing at the lower part of the limb,
and encircling the trunk, and  so applied as that the  inferior  third  of the
humerus, covered  by the  roller, was  directed a little forwards and inwards,
whilst its superior extremity was turned a little  backwards and upwards, rest-
ing meantime on  the cushion.   In five days the swelling  had subsided and
was  nearly gone;  crepitation was  easily discovered, and  the fingers intro-
 duced into the arm-pit could feel the  inferior fragment which was very rough,
 and seemed to be composed of several pieces slightly movable.   The head of
 the humerus could also be felt:  it was displaced, and turned a little forwards
 and inwards.   The apparatus was reapplied, and renewed at first every three
 days, afterwards, every five or six.   On the fortieth  day it  was removed alto-
 gether : there was no more mobility or crepitation, the limb had resumed its
 ordinary length, and the deltoid and  acromion  their  proper condition.
    Case II.—Luxation of the Right Humerus upwards and forwards, conse
 cutive on  a Luxation inwards.—Hamlin, twenty-six years of age, a glass-
 cutter, was assisting at a fire, and while walking hastily along the roof of a
 house, five stories high, fell into a yard, breaking his fall by striking against
 a wooden shed eight feet from the  ground.  Upon reaching the Hotel-Dieu,
 there were found  on him a luxation of the humerus,  and several  grievous
 bruises.  The arm was placed on a pillow, the  contusions were fomented, and
 a bleeding performed. 
CLINICAL SURGERY.
189
  Next day, the patient lying on his back, his arm was laid  on the pillow at
a right angle from the body; the palm of the hand was turned forwards, there
was detected within and beneath the pectoral muscles a projection formed by
the head of the humerus, separated by only a few lines  from the  clavicle.
By pursuing the examination after this manner, a luxation forwards and up-
wards consecutive on a luxation inwards was readily recognized.  The patient
was  again  bled, to syncope.   On the following day,  before the process  for
reduction was  begun,  M. Dupuytren observed that  it would probably be a
laborious business, for they had  to deal with a strong,  robust, and muscular
man ; and this  sort of luxation was  attended with much more difficulty than
when it was  downwards and  inwards.  This proved to be the  case.  The
reduction was not accomplished until after severe and protracted exertions,
and  turning off the patient's  attention repeatedly by anxious and multiplied
questions.  The arm was then placed and kept  in a semiflexed position, and
attached  to the trunk by the aid of a towel.  Fomentations  were applied  to the
shoulder.  In the course of twenty days the patient was allowed to move the
parts: but it was long before he could recover the full use  of his arm.
  Luxation of the humerus is sometimes attended with fracture of the neck of
the bone.  In such cases even the combination of nature and the resources of
art can do but little; yet a good diagnosis is of great value, in order to direct
the proper  applications.  In order to distinguish the existence of fracture in
such  circumstances, M. Dupuytren's rule  is this: Restore to the limb, by
suitable methods, its natural' form and length; then revisit the patient in  about
seven or  eight hours, and if you find the shoulder deformed, you may be sure
that there is fracture.
  We have seen, continued M. Dupuytren, how difficult it sometimes is, to dis-
tinguish  luxation, even when recent from fracture of the humerus.   This,
however, ought only to stimulate you to acquire precise  notions respecting
the nature of the injury; for  mistakes on this head are commonly only among
persons ill  taught, and little accustomed to practice.  In this hospital we have
often had to treat patients laboring under luxations or fractures, which had
been  mistaken  by practioners in town, although the characteristic symptoms
were quite clear.  But in old luxations the distinguishing signs are much
more difficult to ascertain.  The symptoms of fracture, if ever they existed,
may have disappeared;  there  remain of course, those  common to both  inju-
ries ; but there are, besides, the peculiar symptoms of luxations, which time
does not efface.  These last, it behoves us to make outclearly in doubtful cases.
  For this  purpose we must attend to the diagnostic signs given in the prece-
ding  observations,  namely, 1st, the lengthening of the arms, a sign by no
means new, as we have already said, but of  which hitherto all the importance
has not been appreciated; 2d, the lengthening of the anterior limit of the
axilla ; 3d, the deformity of the shoulder, and the easy pitting of the deltoid
under the fingers.  As to the projection which is observed in front, beneath
the coracoid  process, and the pectoral is major, and which is independent  of
the osseous projection in the axilla, we must not attach more importance to it
than it really deserves ; for it is likewise observed in cases where the fracture
is attended by a slight displacement of the bone.
  In the  latter part of this chapter, M. Dupuytren noticed that subject which
may be considered altogether new in his hands, and which nobody, he  said, 
190
LECTURES ON
had  fully discussed  before himself,  namely, the  question as to how long a
period shall have elapsed after the occurrence of a  luxation,  before we are
justified in abandoning its reduction.  The difference which  exists in the
possibility of reduction of fractures, is greatly modified by this standing.
After several days, the bone aiid soft parts have contracted habits of position*
The ligaments and  muscles surrounding adisturbed articulation, acquire a
stiffness which does not readily yield to reductive  processes; and it may
happen that the  cicatrices after the rupture of the orbicular ligaments, may
have already rendered the return of  the bone into its cavity impossible.
  It is only by repeated, and multiplied experience, observed M. Dupuytren,
that any approach can be made to the solution of the question.   The ancients
thought it improper to attempt the redaction of a luxation after it had existed
for some days; and this rule of conduct was long prevalent in the medical
world.  Benjamin Bell professed it,  though he was well acquainted with the
success which  other English surgeons had obtained by contrary practice; his
authority, however, influenced even Desault; but if  we may believe Bichat,
experience soon led Desault  to a bolder method of  proceeding; in fact the
success which  he met with in treating luxations of from fifteen to twenty days
standing,  led  nim to try what could be done after five and thirty.   Bichat
adds, that he  has even assisted Desault, in the last  two years  of his life, in
reducing luxations of two, three, and even four months duration.
  A memoir containing six cases, by M. Flaubert of Rouen, and published in the
Repertoire d'Anatomie etde Chirurgie would give little encouragement to prac-
tioners  desirous of reducing old luxations.  In  five of the said cases, the
attempt at reduction gave rise to some serious accidents: the tearing of a large
artery,  and nerves and muscles.  These accidents, says M. Flaubert, are the
more to be dreaded, the longer the luxation has existed, and as it may have
been accompanied with more or less swelling, and other inflammatory affec-
tions.   But Dr. Marx, in  the same  journal, has treated the subject with his
usual ability, and arrives at a conclusion altogether different from that of M.
Flaubert.  Whence, then,  the difference?  Is it founded on the age, sex, &c.
of the different patients ?   Is it the different mode of reduction ?   Not this,
certainly, for  at  Rouen, the process is exactly the same as that employed in
the Hotel-Dieu.   The whole  difference, in short, seems to be this, that M.
Flaubert was unfortunate in his cases, he was more unlucky than other surgeons
in the cases selected for examples.
  Of thirty-three cases of  luxation brought forward  to support the views of
M. Dupuytren, twenty-five are of the shoulder in different directions,  five of
the femur, and  three of the fore-arm:  the following is  a tabular view of them:
       5 were  reduced from  the  5th to the 10th  day.
       6         "      "      10th     "  20th   "
       4         «      "      20th     "  30th   "
       5         a      «      30th     ««  40th   "
       5         <«      <«      40th     "  50th   "
       2         «<      «      50th     "  60th   "
       2         "      "      70th     «•  80th   "
       2         "      "      80th     "  90th   "
       I         "      "      90th     "  100   •'
       t After two years. 
CLINICAL SURGERY.
191
   Of the last case an account is given in the Memoirs of the Academy of
Surgery, Vol. 5;  it was a displacement of the thigh which occurred in the
person of a young lady, 22 years of age, at the moment of parturition.  M. M.
Forestrer, Tissot and Cabanis of Geneva, saw the case and recognized the
luxation; yet it is but fair to add, that doubts have been entertained by high
authorities touching the real nature of the injury.
   The tabular view just presented  demonstrates, that the reduction of old
luxations may be attempted and even effected, without, in general, incurring
the risk of the serious accidents which appear to be so much dreaded.  Should
we wish only to  proceed upon  facts, we will conclude that an attempt at
reduction, may be made in luxations of 90 days standing, as proved by the
operation performed by M. Sanson.  But if the attempt be safe at that period,
there is no reason, I think, to suppose that it  may not prove successful even
at a more advanced period.  Let us  hope that facts will hereafter justify this
supposition.
   The treatment of luxations of the humerus, like that of luxations in general,
maybe divided into three principal  stages; the preparatory treatment, the
reduction and consecutive treatment.  Although  generally simple, luxations
of the arm,  may  be complicated with cedematous engorgement of the limb,
paralysis, injuries of the axillary artery, emphysema, inflammation more or
less violent of the joint, symptoms which become the object of special indi-
cations.  The engorgement is generally found, in the  luxation downwards,
rarely in other cases.   It is caused  by the pressure  exercised upon the lym-
phatics and  veins of the arm,  by  the  head  of the humerus; it generally
disappears after  the reduction,  or  should it remain, it soon yields to the
application of a roller, soaked in some resolvent fluid, around the arm.  The
inflammation should be treated according to its intensity, by general and local
bleeding,  baths,  emollient applications  and fomentations.   The partial or
general paralysis of the muscles of the arm, happens when the  circumflex
nerve alone, which is most common, or all the nerves of the brachial plexus
are distended or  contused  by the head of the humerus at the moment of its
escape from  the  glenoid cavity.   Simple compression is generally curable if
attacked immediately by antiphlogistic means and afterwards  by rubefacients,
by blisters, and even the application of moxa above  the  clavicle, over the
origin of the brachial plexus. When on the contrary the nerves have been disor-
ganized, there is no hope of cure: the patient remains affected with paralysis
of the deltoid muscle alone, or of all the muscles of the arm and fore-arm.
Therefore we should not carry too far the treatment recommended for simple
compression, should it prove without effect.  It should always be tried, as it
can never be determined a priori, what is the cause of the  paralysis.  The
lesion of the axillary artery is very rare, it more frequently happens  in the
efforts of reduction, than at the moment of the occurrence of the luxation.
   It is here proper to mention the precautions which M. Dupuytren never omits,
in order to assist  the reduction of old luxations.   The patient makes use for
a longer or shorter time of baths: the affected joint is covered by emollient
poultices, rendered narcotic or stupifying by  laudanum, extract of aconitum
hyoscyamus or belladonna.  If the patient be young, strong, and vigorous, he
is to be bled once or several times. 
192
LECTURES ON
  In order to reduce luxations according to the plan adopted by M. Dupuytren,
the patient is seated on a chair ; the middle of a band made by a napkin folded
like a cravat and having its ends twisted and brought together towards the pal-
mar face  of the wrist  is fastened  above  the dorsal face of the  same.  This
extending band is fastened by>some turns of a roller.   We then  place in the
hollow of the  armpit a pad large enough to prevent the counter extending
band from compressing the great pectoral,  dorsal, and teres muscles: this
counter extending band is made,like the other, its middle part applied to the
pad, the ends brought one before the other behind the chest crossed over the
sound shoulder and fastened to a ring in the wall, and intrusted to an assistant.
  A number of assistants proportioned to the degree of power required, take
hold of the extending band, and the surgeon by a sign indicates when they are
to commence pulling.
  If the luxation be downwards, they first draw in the direction of the displace-
ment, the arm is then brought downwards and forwards, whilst the  surgeon,
with his breast bearing against the outer side of the elbows brings the head of
the  bone upwards and outwards.
  If the luxation  be inwards, extension is made outwardly and backwardly,
and the arm is restored to its natural direction.  When the head of the hume-
rus  is free the operator pushes it outwards.  If the luxation, be  in the infra-
spinal fossa, extension  should first be made from behind forwards, and as the
head of the bone becomes freed, the operator pushes it in the same direction,
and extension is then made more directly outwards.
  Much difficulty is sometimes met with, especially in old luxations, which
proceeds principally from the resistance of the muscles.
  Formerly, different machines and methods were used, as dangerous as they
were useless.  M. Dupuytren has ingeniously substituted another plan, which
consists in diverting the attention of the patient, generally rivetted on his acci-
dent, from the pain he suffers, or from that which he dreads.
  The professor with whom  this idea originated finds it daily of great advan-
tage, as well as others who have tried it.   A practice of twenty-five years
shows  his number of unsuccessful cases to be about  one every two or three
years.
  The noise made by the head of the bone returning to its cavity, the restora-
tion of the shape of the joint, the  facility of the different movements of the
limb, show that the  luxation is reduced.  The arm is then bandaged  to the
side, the  elbow and fore-arm being supported  by a sling.  The accidents
which  sometimes complicate luxation, and of which we have spoken, may also
arise from the reduction, and especially that of old luxations.  Nevertheless,
they are much more rare than is generally supposed.  The chance which gave
toM. Flaubert, in the  short period of three  or four years, some of the most
serious accidents  resulting  from reduction was  very extraordinary, and the
cause  was  undoubtedly  owing  to  some   circumstances  unknown  to us.
Emphysema of the chest seen by this  surgeon has  also been observed by
M. Dupuytren.   In similar  cases  the tumor should be covered with resolvent
lotions assisted by regular compression by a bandage, which, at the same time,
keeps the arm fixed against  the body. 
CLINICAL SURGERY.
193
                       CHAPTER  XXIV.

       ON THE  VITAL AND MECHANICAL DILATATION  OF THE URETHRA.

  Strictures of the urethra have given rise to the most diversified opinions,
and the most opposite plans of treatment.   To be convinced of the truth of
this remark, we need only examine the long list of authors who have written on
this subject.  It is not our intention to give you  a history of these diseases,
but to point out, in the case of the man now under your observation, some im-
provements which we have introduced into this branch of the healing art.
  This man, about 40 years of age, of small statue, is a coachman, and was
seated on his box, when the horses suddenly started.  Being off his guard he
fell astride of the wheel.  He immediately experienced great pain in the peri-
neum, and discharged a considerable quantity of blood from the urethra.
  Unable to follow his business, he entered the Hotel-Dieu, (March,  1832,)
laboring under the following symptoms; tumefaction of the contused parts,
very acute pain along the whole course of the canal, skin of the penis, scrotum,
and perineum, highly ecchymosed.  He could not pass water; on questioning
him, we found that he frequently had a wish to  do  so, that he often had had
blennorrhagia, and that for a long time he had been tormented by a desire to
urinate.
   There could  be no doubt as to  his case;  a sound  was introduced, but only
entered about three inches.  A bougie with a very delicate point was  substi-
tuted  for it with equal unsuccess.
   There then existed two lesions, a stricture and laceration of the canal of
the urethra ; the former must be  dilated or destroyed  ; and in the latter case
if the disease was left to itself, the cure was nearly certain, but stricture ine-
vitable.  It was an exceedingly perplexing case; I have seen twenty or thirty
similar and have always met with  some obstacles  in their treatment.  In order
to prevent contraction,  the cicatrix  should  be formed over a sound of the
largest size.
   About five months ago  an individual having had a quarrel with another, car-
 ried a pair of small pistols in his  pocket.   He fell accidentally ;  one of  them
 had discharged, the ball passed through the urethra  and  testicle, and  lodged
 in the thigh.  If ever any one was in risk of a stricture, this man was  most
 assuredly ; a sound was introduced into the urethra, in three months the wound
 had perfectly healed, and he has  since made water as before.  The testicle
^ecame atrophied.  Let us now return to our former  patient.  It  is evident
That  the stricture required dilating, and  that the 1'aceration also required a
 sound.   This  was attempted, but the instrument could not enter;  I advised
 it to be tried every hour.   The next day the sOtfnd  had advanced, the patient
 could pass water; in three days a middle sized Sound could be introduced into
 the bladder,
   For a long time it was thought  that when there was  stricture,  the obstacle
 should be forcibly removed, in order  to  allow  the patient to urinate; such
 was the practice of Desault; there was at that period  a kind of self-love in
 overcoming all obstacles,  I affirm, that of ten individuals subjected  to this
          25 
194                          LECTURES ON

practice, one  half  suffered from  laceration of the urethra,  tumefaction  of
the penis,  infiltration of urine, and that  even death  frequently followed.   t
This plan is therefore improper, inasmuch as it is not only painful but dan-
gerous.
  Whenever on account of a stricture, there is dysuria, catheterism by main
force should be abandoned. What is then to be done? Experience has proved to
me  that is better to temporize.  Violence should be used only when retention
can give rise to  ruptures, infiltrations, inflammations, and endanger  the life
of the  patient.  But  what is the  proportion of these  cases?  Facts daily
observed at the Hotel-Dieu allow me to establish, that it is not necessary to
have recourse to forced catheterism  more  than  once in  thirty cases.  For
eighteen years I  have followed this opinion and always with success.
  Observe  now what has happened to the patient under our notice ; he had
had three or four blennorrhagiae giving rise to stricture,  the contusion of the
perineum and  laceration of the canal, caused retention of urine.  Was the
least force used?   No.-  Yet we  succeeded in  reaching the  bladder; this
morning, the third day after his admission, a middle  sized sound was  intro-
duced, whilst on the first day the most delicate pointed bougie could not pass.
What  took place ?  the  contact of the sound caused a copious secretion of
mucus, the next day it was still more copious, and on the third day, a  sound
of which the extremity was ten or twelve times as large as that used on the first
day, overcame the difficulty.  As a general rule, when we can  wait  a few
hours,  forced catheterism should not be used ; and aforliori when we have
some  days before us.   We should then be satisfied with introducing a bougie
or sound, as will be explained hereafter, and fasten  the instrument when it
will no longer advance.  This plan I have called slow  dilatation, dilatation
by  disengorgement, vital dilatation.
  We will here  remark that when there is contraction without laceration, and
the urine flows between the sound and the parietes of the urethra, the symptom
is favorable, as it proves that the urine tends to increase the dilatation; in order
to assist this process,  the end of the catheter should be closed.  But  if there
be  laceration of the canal, the passage of the urine may cause  infiltration,
urinary gangrenous abscesses, no water should therefore be left in the bladder.
   The plan which consists in overcoming  stricture  patiently and slowly, is
the only one suitable  to a large majority of cases.  This dilatation is not alone
effected by the method  of which we have spoken; there is another called for
distinction mechanical  dilatation.  We  will explain it  hereafter.
   From many cases we will choose the following, the more curious, as  it n%ty
be  considered as the origin of the plan.
   About eighteen years ago, said the professor, I was called to a wealthy man^
very nervous, and endowed with great vivacity of mind, and prodigious sus ™
ceptibilitv.  He suffered exceedingly from dysuria.   I advised  him to weaj
a bougie In the  urethra.  This advice alone alarmed him  greatly, he  magni-
fied the pain and inconvenience of this treatment, being certain that a bougie
would hurt him, and that if the urine came only drop by drop from the  effect
 of the disease,  for a still greater reason it would not come at all when  a solid
 body occupied all the stricture.   After some explanation, he consented to the
 introduction of a bougie with a  blunt  end, but it  had hardly  entered  the
 urethra, when all his apprehensions were renewed.  It was with difficulty I 
CLINICAL SURGERY.
195
could induce him to retain the sound.  I did more, and introduced it as far
as the obstacle, but meeting an insurmountable difficulty in its progress, I
was obliged, on  account of the fear of the patient, to  desist, and renew the
attempt in a few hours;  and in order to avoid new difficulties, I determined
to fasten the bougie, at the spot it had reached that is in front of the obstacle.
As I had promised, I returned in a few hours; the patient had passed water
easily, and the bougie could be easily engaged in the impediment; some hours
after, it was introduced farther, and before the expiration of the day it had
reached the bladder. In a few days a larger one was introduced. The treat-
ment was then continued without difficulty, and the dilatation rapidlyiincreased.
In fifteen days the patient urinated freely, without pain, and in a large and
strong stream.
   This fact, added M. Dupuytren, was not lost upon me ; I saw that it was
not necessary that a bougie should penetrate the stricture in order to effect the
dilatation, and also all the advantages of this method in pusillanimous patients,
and in cases in  which we are not obliged, from the importance of the  injury,
to surmount the impediment immediately by the introduction of a sound or a
bougie.
  Case II.—Stricture of the Urethra, Dysuria and Incontinence of Urine,
Catarrh of the Bladder Symptomatic of Stricture (Vital Dilatation).—C.....
49 years of age, was admitted on the 20th of February, 1827.  He  com-
plained of making water merely drop by drop, although he  made great efforts,
which  were frequently followed by  an involuntary flow of urine.   He felt
violent pain in the hypogastric region, the  perineum, and  urethra especially
at the time of urinating; the pain he compared  to the presence of a red-
hot iron in the canal; it did not persist after the flow of urine.   The fluid on
cooling deposited a mucous and purulent sediment.  This man had had blennor-
rhagia eleven times; the last was of four years continuance, it had ceased two
months since, and then he perceived for the first time, the difficulty of passing
water; in three years he could not urinate at all; he was treated by dilatation,
and remained well for six years.  Six  months ago, the  dysuria reappeared.
He entered the Hotel-Dieu  laboring under  the symptoms  already  pointed
out.   A bougie was introduced as far as the bulb of the urethra, where it was
arrested by a hard and resisting stricture; it remained free in the canal, was
kept there for twenty four hours, and then entered the bladder with facility;
a small sized gum-elastic sound was introduced  in its  place  immediately;
the patient suffered  no pain.  Four sounds gradually increasing in size to the
largest,  were successively left  in the urethra, and after thirty-two days,
C---left the hospital entirely cured of his stricture, and catarrh  resulting
from it.
* Case III.—Stricture at  the Commencement of the Membranous Portion,
accompanied by Remarkable Spasm of the  Urethra and Incontinence of Urine
(Vital Dilatation).—C .,.., thirty-six years of age, of a good constitution was
admitted  on  the 6th of February,  1827; he had had blennorrhagia but
once; but it had lasted ten years; since seven or eight years when it ceased
entirely, the flow of urine began to diminish, and for four or five months it
passed away guttatim, and he has labored under incontinence of urine.   On
the 7th of February, a middle sized sound was placed  in the canal and pene-
trated  as  far as the membranous portion; there it was arrested by a hard 
196                           LECTURES ON
stricture.   The bougie was left, the patient withdrew it an hour afterwards.
In the evening it was attempted to be re-introduced, but unsuccessfully, the
urethra was in such a state of spasm that it would not pass beyond the fossa
navicularis, and was so tightly grasped by the parietes of the  urethra, as to
require  some force to withdraw it.  On the 9th of February, M. Dupuytren
endeavored to introduce a middle sized, and then a smaller silver sound, but
both were arrested at the fossa navicularis and grasped with as much force as
on the preceding trial.  A portion of a sound, rounded at its extremity was
introduced and fixed in the fossa, it advanced  but slightly at first, but had
penetrated in  twenty-four hours; it was immediately replaced by a middle
sized gum-flastic sound; this was kept in and  the dilatation continued for
twenty days.  Three  sounds were successively used, the last being of the
largest size;  the patient urinated freely and in a large stream.
  Vital dilatation, continued M. Dupuytren, is so powerful, that the sound
frequently enters the bladder in two or  three hours.  This action may be
assisted by turning it from time to time in the canal.   This method does not
require  an instrument of peculiar shape; a silver, gum-elastic sound, or a
bougie,  with the point either large or small, may be indifferently used.  How-
ever, I prefer a gum-elastic bougie, terminating in a sound, blunt extremity,
and of a length proportioned to the depth of the obstacle.
   Whatever instrument may be used, it is introduced and carried down to the
obstacle, and there fastened by any appropriate means.
   It is  not necessary to engage it in the obstacle for its prolonged  stay in the
urethra will effect the desired dilatation.   Indeed, in a few hours, and in less
fortunate cases, in a few days, it will overcome the difficulty without exertion,
laceration, or loss of blood.   The dilatation is such, that the sound or bougie,
sometimes spontaneously enters the stricture, in other cases,  it may be made
to pass  by the  slightest effort,  and again  the dilatation will permit the stric-
ture to receive the end of a conoidal bougie, it should then be treated by the
mechanical means of which we  are about to speak.
   I think, said M. Dupuytren, that there is nothing mechanical in the action
of  these bodies,  I  am  convinced that we must admit some vitality.  I have
already pointed out to you, that a secretion takes place which  facilitates  the
passage of the sound.  Let us examine this subject, and first observe the pheno-
 mena of the contact of foreign bodies with the entrance of a vital canal, the
puncta lachrymalia for example.   The first effect of this contact is so great a
 contraction of the  edges of these puncta,  that a very delicate probe cannot
enter;  but if it be repeated or  continued, they no longer contract; but dilate
 sufficiently to receive the probe, and at that moment, a mucous secretion is
generally seen around the punctum.
   The same thing takes place in stricture of the urethra, the first touch of the
 bougie, causes the canal to  contract so much that it is with  difficulty disen-
 gaged ; this soon ceases, and in a few hours the bougie can  be freely moved
 about.   To this  dilatation is added more or less copious  secretion of mucus,
 and sometimes of purulent matter, which sometimes gives alarm to the patient,
 but which always disappears, either spontaneously or on the withdrawal of the
 sound.  From these two causes, the stricture dilates, and in  a few hours, or a
 few days, the canal which at first would not admit the twentieth of a line, now
 receives a line. 
CLINICAL SURGERY.
197
  Vital dilatation is  not the only one used  to overcome stricture; we have
recourse to another species of dilatation which consists in introducing a very fine
bougie with an extremity  as it were  silken, and then to engage it  in the
obstacle.  This foreign body dilates, separates, by pressure, the tissue forming
the stricture;  this dilatation I call mechanical.
  The instruments I generally use are conoidal bougies, formed of silk, covered
with a layer of gum-elastic, and terminating in a very fine and almost filiform
extremity.  They then gradually increase to the other end which forms the
base of the cone.  These bougies are  introduced  in  the following manner:
The gland is seized by the  thumb and  forefinger of one hand, the penis being
slightly elevated and elongated, a bougie previously oiled, is held between the
thuinb, fore, and  middle fingers of  the other hand, it is then introduced by
slight pressure, accompanied by a rotary motion on its axis.  It soon reaches
the obstacle.  When it is arrested, it bends on  itself, but becomes straight
when freed  from pressure.  These sig^s are sufficient to prove to a skillful
hand that the  bougie has not been able to pass the impediment and this part of
the instrument is so delicate, supple, and flexible, that it cannot, in any case,
produce perforation, laceration, nor injury to the parietes of the  urethra.
  But when the filiform extremity has penetrated the stricture, the  instrument
is gradually felt passing more deeply into the urethra, that is, until the  bougie
of which the size insensibly increases, fills the opening  left by  the stricture,
when the bougie  bends before the obstacle  which it could not pass; it always
tends to spring out of the  urethra when  becoming straight, and the slightest
traction will withdraw it.  In the contrary case, it not only has no tendency
to escape, but is so much pressed and withheld by the spasm or contractibility
of the tissues that some exertion is required to extract it
   When the bougie has overcome the stricture, or has been introduced suffi-
ciently far,  it should be fastened, either around the penis, to a suspensory or
some other kind  of bandage.
   By fastening the bougie, I propose to keep it  in its place until it become
possible and  necessary to introduce it further, or make it keep up continual
pressure against the sides of the stricture.   In the first case, I do not attempt
to introduce it deeper, and leave between the string and the obstacle a length
of the  sound  exactly proportionate to the extent of space indicated.   In the
second case,  I press  on the bougie, bend and tie it higher up, that is,  nearer
its base,  so that this body, which on account of its elasticity, tends always to
become straight, keeps up constant pressure on the obstacle to be overcome,
and to dilate the  stricture.
   The  modus operandi of the bougie  is easily understood.   The mechanism
is that of  a  wedge, fixed in parts which it is intended to widen and separate ;
but whilst the latter acts on inert bodies, the bougie acts on living parts, and
its action  is composed not only of the  thickness of the bougie, but also of its
vital  action  on the parietes of the obstacle.
   As to their effects, experience teaches us that, whenever the filiform extre-
mity will  enter a stricture, the rest of the bougie will certainly follow.  It
may in some cases be introduced immediately; in others, we must wait some
hours or days ; and  that, much less on account of the degree of stricture, or
the  size of  the bougie,  than the. variable extensibility of the tissues forming
the  stricture.  This  extensibility is sometimes great,  sometimes very  feeble. 
198
LECTURES ON
 The mobility which the bougie acquires in a few hours or days, is one of the
 most remarkable phenomena, and one of the most appropriate to prove, if it
 could be doubted, that every thing which takes place in living bodies, even
 when apparently produced  by mechanical causes,  depends  more or less on
 their vitality; or, mother words, that in these bodies, the vital are mingled with
 the mechanical phenomena which  they change, or modify according to rules
 which cannot  be submitted to calculations purely physical.   We will detail
 two  cases of the use of these means.
   Case  IV.—Contraction of  the Urethra, Dysuria (Mechanical  Dilatation).
 D.....aged 61 years,  of middle size, and spare frame, was  admitted on the
 19th of February, 1827.  He complained of a difficulty in passing water of
 two years duration; sixteen years ago, he had contracted ablennorrhagia which
' still existed at the time of his admission ; the dysuria had increased, and the
 flow of urine  after gradually diminishing ceased entirely ; the urine passed
 guttatim, and required considerable effort; the urethral secretion was copious.
 A bath was administered; the urine carefully examined, deposited no sedi-
 ment, and from the symptoms he was supposed to labor under stricture.  On
 the 23d of February a bougie was introduced, but stopped at first at the mem-
 branous  portion of the urethra;  it soon,  however, by  a delicate pressure
 passed on, and was engaged  in the obstacle, and although compressed by it, it
 still progressed, and thus was commenced a purely mechanical dilatation of
 the stricture.
   The bougie after 24 hours was re-placed  by a small gum-elastic sound, the
 scrotum held up firmly, the dilatation continued for 39 days; five sounds were
 used, gradually increasing in size, the last being of  the largest; the whole of
 the urine passed between it and the canal; it was withdrawn on the -4th of
 April; the jet of urine  was easy and large,  and  the patient freed from his
 complaint.
  Case V.—Considerable Contraction of the Bulb of the  Urethra, Dysuria
 (Mechanical Dilatation).—P......,42 years of age, of a good constitution
 was admitted on the 28th of February, 1827.  He labored under dysuria which
 he had first experienced ten years ago; it followed two  attacks of blennor-
 rhagia; the first contracted at 20 years of age, lasted three months, and was
 suppressed by  a drastic purgative; the second  which occurred two  years
afterwards, still existed ; and a white, opaque mucous discharge, owing to the
pressure  from behind forward.  This discharge had lasted 22  years, and may
 be considered  as the cause of the contraction;  however, the  dysuria, began
with a chill, a sensation  of contraction of the urethra at the moment of passing
water; the jet diminished, became tortuous, flowed by drops, especially after
drinking any spirituous Uquor.  During the three months preceding his admis-
sion, the  dysuria had considerably increased.   On the first of March, a fine
pointed bougie was introduced into the canal: at the bulbous portion, it became
engaged in a stricture, which grasped it so firmly, that a considerable traction,
raising the penis at the same time, could not  disengage it; the bougie was
left, and eight hours afterwards, with a slight pressure, it entered the bladder.
On the 4th of March, a  middle sized gum-elastic sound was introduced, and
in 22 days the patient passed his water freely and in a large stream.
  We will end this chapter, with some reflections on the different modes of
dilatation. 
CLINICAL SURGERY.
199
   In every case, at the end of ten or twelve days at most, we may increase
 from the smallest  to the largest sized bougie;  or, in other words, effect the
 greatest dilatation of the worst contraction, by  a gradual increase of size of
 the sounds and bougies.
   The more promptly dilatation is effected, the less durable it is;  so that in-
 stead of hastening, it should rather be retarded ; for it is durable in proportion
 to the slowness of its operation.
   There are other objections to the rapid dilatation of stricture; these are, pain,
 laceration, acute inflammation, gangrene, and the greater or less destruction
 of the canal, accidents which I have also seen follow forced catheterism.  It
 seems that the  tissue forming the  stricture like all other tissues  of the animal
 economy possesses a certain  degree  of extensibility, beyond which it is  not
 safe to pass without risk of laceration, and that it may be developed almost ad
 infinitum when affected slowly and almost imperceptibly.
  Whatever may be the precautions taken to effect the dilatation of strictures
of the canal, it is generally merely temporary, and has a great tendency to
relapse.  This  relapse has induced me, continued M. Dupuytren, to introduce
from time to time, a bougie in the urethra.   It should be.done  every 10,  12,
15, or 20 days,  and left in the canal two, four, or  six hours, or even during the
night, according to circumstances; this plan will have very great influence in
preventing the return of the disease.
CHAPTER XXV

    ON CLUB-FOOT.
    Among the imperfect conformations presented in the organization of man,
 congenital malformation of the foot is one of the most frequent.  This deformity
 had attracted the notice of  the ancient surgeons, and we find in their works
 descriptions of  machines for  curing it.  But in modern times alone has any
 real light been  thrown on the subject.   The anatomical history of the  parts
 was unknown;  all was mere conjecture, because the nature of the disease wat
 veiled in obscurity.
   The most ordinary congenital deformity is that designated by  the ancients
 under the name of varus. The toes are turned inwards and the foot reversed
 so that the patient walks on its outer edge, and sometimes even on part of the
 dorsum of the foot.  The second variety is that in which  the foot is turned
 outwardly, called by the ancients valgus ; this is more rare.   There is still
 another variety, in which the point of the foot  is turned backward  and the
 foot so reversed  that the patient walks entirely on its dorsal surface  '
  The essential cause of this irregularity is the luxation of some of'the bones
ot the tarsus, the ligaments  and muscles merely assume consecutively the un-
natural arrangement which they present.  Thecauses determining or favoring
such deformity in the womb of the mother are unknown.  It has been attributed
to the  irregular  shape of the  tarsal bones, in the want of equilibrium in the 
200
LECTURES ON
muscles moving the foot, in a want of length of some of these muscles, or an
unnatural insertion of their tendons, lastly, to the singular tendency of the feet
of the foetus to turn inwardly.
  Aside  from these explanations, congenital club-foot is a defective confor-
mation in which the  foot is  strongly  turned  inwards, bent  slightly in the
direction of its length and concavity.   Sometimes it is smaller than natural;
there is a change in its nutrition.  The patient is obliged to walk on the outer
edge and when the deformity has reached its acme, he leans on the external
malleolus.
  These external symptoms have been well described by Scarpa; other authors
have treated of internal deformity elucidated by dissections :  but no one had
paid any attention to one of the most important consequences of club-foot, that
is, the change of nutrition and atrophy  of the limb.
  Congenital club-foot may occupy one or both  feet.   If, in the former case,
the child be examined soon after birth, we will find, as has been said, the dis-
eased foot generally smaller than the other,  but the legs of equal length.
When it exists in both feet, they are generally equally developed.
  As the  patient increases in years, the atrophy is easily recognized, and its
cause may be pointed out.  Indeed, the child leans instinctively on the sound
foot; it follows hence, that its nutrition is more active; whilst the diseased foot,
remaining inactive, must necessarily waste away.
  But this atrophy should be distinguished into two species, hitherto confounded '
together, and which it is very important to separate: 1st, atrophy of the thick-
ness of the limb ;  2d, atrophy of  its length.  The first species affects chiefly
the muscles, whence results the thinness  and weakness of the limb.    The
second acts on both muscles and bones: but its action on the skeleton is most
serious and important; for the atrophy of the thickness may always be remedied,
when the club-foot  is corrected by muscular exercise;  whilst no remedial
means are of any avail in shortening of the limb.
   The difference of length increases with  years; not apparent at birth, in a
few years it becomes very evident; at ten years of age, I have always observed
a remarkably shortening.  Examine a man twenty years of age, and you will
find a much more considerable inequality, and so far  above the power of art,
that a cure of atrophy of the length can never be effected.   'The shorteningof
the muscles and tendons, generally less serious, should nevertheless be attended
to, for it becomes incurable after a certain lapse of time ;  thus the tendon of
Achilles, at  twenty years of age, has lost so  much of its length, that even
when the foot is restored to its natural position, the heel remains elevated, and
the patient is obliged to wear a very high  heeled shoe.
   Guided by these principles, said M. Dupuytren, I  have requested parents
always to attend  very early to this affection, and I have  seen children of a
tender age cured in a month or six weeks, and almost immediately afterwards
begin to use the foot.  I have sent  to an orthopedic establishment, children
of six weeks, one, two or three years of age ; the cure was almost  more easy
in proportion to the youth of the patient.  This may be easily  understood. In
a child newly born, the foot  can  be restored to  its normal position  easily and
without pain ; a few months increase the  difficulty. From ten to twenty years
 of age, we must  have recourse to machines, which at a late period become 
CLINICAL SURGERY.
201
 useless; this is owing to three principal causes: the suppleness of the ligaments
 and muscles which diminishes with age; the increase of the deformity and the
 vicious conformation in which the bones are developed.
   It may be laid down as a rule that the cure of club-foot is prompt and cer-
 tain, in proportion as the treatment is commenced soon after  birth.   These
 advantages deserve the attention of practitioners; for, when children are old, a
 year or two is often necessary to the cure.
   This deformity is sometimes cured without the assistance of art.  A case is
 related by Dr. Holtz,  of a  boy born of indigent parents,  with  a very well
 marked inversion of the foot.  Without any attempt at treatment, he was per-
 fectly free from the deformity at twelve years of age.   He endeavored him-
 self to  turn his foot outwards, and as he was obliged to work hard, and carry
 heavy  burdens, he was forced  to  lean heavily on  the  ground.  Exercise
 restored  the equilibrium  of muscular action, and now at the age of twenty
years, he would not be supposed to have ever suffered from club-foot.
                        CHAPTER   XXVI.

    ON THE CENTRAL LACERATION OF  THE PERINEUM DURING  PARTURITION.

   Nothing is more common than laceration of the posterior commissure of
 the vulva, extending more or less on the perineum during delivery.
   It is one of the most simple accidents, rarely requiring surgical assistance.
 But this laceration sometimes reaches the lower extremity of the inferior paries
 of the vagina, throughout its whole extent, even comprising, to a greater or less
 degree, the sphincter ani and the anus itself; it then becomes a most  serious
 injury, to the treatment of which we will hereafter devote a particular chapter.
 At present, we shall treat merely of the central perforation or laceration of the
 perineum,  without lesion of the commissure of the vulva or the sphincter ani,
 and subsequently of the passage of the contents of the uterus through this anor-
 mal route.   Numerous examples are related, yet very distinguished writers,
 considering a delivery of this nature as mathematically impossible, on account
 of the disproportion between the perineum and the head of a child at full term,
 have hence inferred these examples  to be unworthy of confidence. Indeed, it
 is difficult  to conceive, at first sight, how a  part generally merely  of eighteen
 lines in extent, can become so much dilated as to admit abody as large as the
 child's head.  But this reasoning is almost an outrage to nature; how many
 phenomena do we not daily observe, of which the causes and  mechanism are
 unknown to us ?   If the fact exist, the examination of the  means she  uses
 becomes  only a secondary object, from which, however, science should  reap
 some advantage.  A case of recent occurrence, and whose history will  be de-
 tailed, will  leave no doubt, I think, even in the most prejudiced mind, and will
 corroborate the assertions of ancient writers, whose veracity has been ques-
 tioned.   The oldest fact on record, does not belong to the human species, but
 was observed by the immortal Harvey, in a white mare belonging to the queen
of England.  On account of its exquisite beauty, the vulva had been closed in
               26 
202
LECTURES ON
 order to prevent the caresses of the horse.  But whether this  precaution was
 taken too late, or in spite of it, the mare was impregnated.  The term of ges-
 tation being at an  end, the colt could not escape through the vulva, and was
 forced through the perineum.  (Exercitationes de generat. animal.)
   In 1778, Nedey, a surgeon of Besanijon, sent  to the Academy of Surgery a
 memoir on the rupture of the central portion of  the perineum, through which,
 he said, a child at full term had passed without laceration of the fourchette or
 sphincter ani.  This fact, which  excited  the astonishment of the academy,
 appeared doubtful, said Baudelocque, only to those who knew not how much
 the perineum would dilate towards the conclusion of a delivery.
   The following is extracted from the well known case of Contonly.  On the
 13th of January, 1788, this celebrated accoucheur, was sent for to a lady,
 whom he had delivered during the preceding year of twins in the fifth and half
 month of pregnancy.  This lady, says Contonly, appeared on the  very eve of
 being delivered.   The head in the lesser pelvis, pressed so strongly against
 the perineum, which was greatly distended, that all my attention  was direct-
 ed towards  preventing its  laceration.  But the precaution was  useless, the
 central  portion of the perineum was torn; the  head pressed  with the same
 violence against  my hand ;  I was forced to give it passage, and extract by the
 same route a child at full term, as well as  the  placenta which followed im-
 mediately.  I then examined what had taken place.  At  an inch above the
 anus, towards the centre of the perineum, there  was a fringed  aperture,  from
 which departed two lacerations; one following the direction of the raphe, had
 stopped at a short distance from the vulva, the other turned towards the  right
 side, forming  a wound represented nearly by the letter Y.   The sphincter
 ani, rectum, and fourchette, were not included in the laceration.  The wound
 was healed in  five weeks.  Thomas Denman.in  his Introduction to the Prac-
 tice of Midwifery,  relates a similar case, in  which the child passed through
 the part of the perineum contiguous to the anus, the anterior portion and the
 anus remaining  unhurt. The parts united in six weeks, and the woman  was
 afterwards delivered per vias naturales.
  On the 14th of December, 1812, Dr. Foubert was called to a lady, 23 years
 of age, in labor with her first child. The head of the child presented in one of r
 the three last positions. The labor  was tedious, and terminated by the rupture
 of the centre of the perineum.  The  child passed through the wound.  The
 cicatrization was complete in five weeks.  This lady was safely delivered of a
 second child, three years afterwards.
  Meckel, in the Neues Journal fur die  Chirurgie (vol. 4, 1811,) relates a
 case of central laceration of the perineum and delivery by this passage with-
 out injury of the fourchette or sphincter ani.  Another case is to be found in
 the Annales de la Medicine Physiologique (July 1825).  Merriman, in his Syn-
 opsis of  the Various Kinds of  Difficult Parturition (Ath ed, 1826), details a
 ease which occurred to him in  1812.   The history of a similar fact witnessed
 by Dr. John Douglas, is mentioned by him in the Dublin Hospital Reports, (vol
 3, 1822.) On the 3rd of May, 1824, M.Marter of Kcenigsburg, was suddenly
 called to a woman, 25 years of age, in labor with her first child. The midwife
told him the child was passing  though the rectum, and indeed  it seemed  that
 the anterior paries of the rectum and the posterior paries of the vagina had been
 lacerated at the same moment with the perineum, and thus the child was about 
CLINICAL SURGERY.
203
to be expelled through the hiatus.  The vertex presented at this anormal
opening, nearly as it presents at the os uteri; it was impossible to restore it to
the vagina. A strong contraction forced the child through the wound, without
injury to the vulva; the after birth followed by the same route.  Upon exami-
nation, M. Marter found the sphincter and rectum uninjured; immediately in
front of the anus, there was a rupture extending in the direction of the raphe
as far as an inch from the vulva.   To this rupture corresponded that of the
posterior paries of the vagina; terminating also at an inch from the vulva in the
middle of the perineum were two transverse ruptures, so that the wound was of
a crucial shape.  A fleshy bridge, of the thickness of one's finger, was between
the posterior commissure of the vulva and the anterior extremity of the longi-
tudinal rupture of the perineum.  A copious hemorrhage followed the delivery,
but was soon arrested by cold applications. The perineum became enormously
swollen, but it was reduced in fifteen days.  On the 6th day two stitches of
suture were used in order to bring together the four angles of the wound. The
cure was tedious, the woman suffered from a vagino-perineal  fistula, through
which the menses flowed for more than two years.   In 1827,  she was safely
delivered, per vias naturales, of another child.
  In  a case related  by Moscheuer, the child was expelled through the peri-
neum, in consequence of  the gangrene of this  part, caused  by excessive and
prolonged distention; the vulva being at the same time  exceedingly narrow.
  The following  case from  the practice of M. Evrat, and  reported by M.
Moreau, who had charge of the patient from the moment of the accident until
her recovery,  is worthy of being given in  its most minute details.
   Madame D......, 19 or 20 years of age in labor with her first child, sent
for M. Evrat on the 3d of March, 1815.   The head presented in  the fourth
position, engaged without difficulty in the cavity of the pelvis, but when about
passing the perineal strait, it experienced  considerable difficulty in  arising
under the arch of the pubes.  During a severe pain, M. Evrat, thought that
the centre of the perineum against which the palm of his hand was applied, lost
its thickness and  elasticity,  and sensibly yielded to the pressure of the head
of the child.   He was reflecting  how to  prevent  a  laceration, when a violent
pain expelled the child, but in such a manner that the head, instead of opening
per vaginam, passed through  the centre of the perineum. The irregular wound
resulting from the perforation, extended to the right in the direction of the
ascending ramus of the ischium and the descending ramus of the pubes ; passed
in front beyond the posterior  commissure of the vulva,  and behind encircled
slightly the anus, then extending from  right to left,  between the anus and the
vulva, near the tuberosity of the ischium on the left side.   The placenta was
expelled through the same passage.  By introducing  his finger into the rectum,
he ascertained that that intestine was uninjured.
  M. Evrat being obliged to  go to England,  M. Moreau took charge of the
case,  together  with the professor Desormeaux.  The treatment was very sim-
ple.   The patient was laid on her side, the legs and thighs approximated, and
demi-flexed, the wound dressed with lint; a strict diet  ordered ; the  bowels
kept open by  enemata and gentle laxatives, lest the expulsion  of hard  faeces
should break up  the cicatrix as fast as it formed.  In five weeks  she was
perfectly well. 
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LECTURES  ON
   No one, we think, will dispute the truth of the details of the above case.  We
will now relate an analogous case, and one not conclusive, which has lately
occurred under the care of M. Dupuytren, in the wards of this hospital
   Madame B......., 38 years  of age, married  about a year, and  pregnant
with her first child, was taken in labor, on the morning of the 3d  September,
1832.   The head presented in the first position, the labor progressed rapidly,
and was arrested only when the occiput appeared at the vulva, which was very
narrow.  Four hours after the appearance of the first pains, the patient had
two very violent, and the midwife felt at the same moment a laceration of the
perineum, which she was supporting with her hand ; almost at the same moment
the head and  body of the foetus, passed through the  anormal opening.  The
midwife highly alarmed at first, sent for an accoucheur,  but seeing that the
patient  was doing well, and was ignorant of the accident, she told  the phy-
sician that all was over, and did not inform him of the laceration.
   Every thing went on well for two days; but an enema which was adminis-
tered, passing away immediately, the midwife feared a laceration of the anus,
and even thought that a part of the enema had passed out through the wound.
   On the tenth day, M. Guersent was consulted.   After trying several reme-;
dies, he  had recourse  to the quilled suture, by which the edges of  the  wound
were  brought together.  In five days  the wound  appeared  healed, except a
small fistulous point, towards the rectum, and the suture was removed.  The
reunion lasted  two days, but was destroyed by some exertion on the part of
the patient.
   She determined on account  of this  occurrence, to enter the Hotel-Dieu.
On examination she presented the following condition: the skin of the abdo-
men showed the marks, and was of the color peculiar to women recently de-
livered ; the pelvis was of ordinary dimensions; the sexual parts free from
swelling.  On separating the labiae, the opening of the vulva was seen very
far forward :  this observation is important; it explains why the patient expe-
rienced difficulty in sexual intercourse.  Behind this opening there was ano-
ther irregularly round, admitting the ends of three fingers and situated a little
to the left.  Between the openings there was a commissure rather smaller than
the end of the little finger; behind this second opening was the anus, and lastly
could be seen the projection of the  coccyx, which  was  not  much prolonged
forwards, as described by some accoucheurs in laceration of the perineum.
   Here is a  case, said M. Dupuytren, &f which  all the minutiae  are well
authenticated.
   Contonly, one of the most illustrious men in our science, relates a similar
case, and it has even  been said that he was embarassed.  But admitting that
such a man could be embarrassed, it must have been undoubtedly after, and not
before the accident.
  But it will  be said  how can such a fact be conceived ? Of what consequence
is  it, provided it exists ?   Again is it so difficult to explain a delivery by the
laceration of  the perineum.  All who have seen a first labor, in which the
vulva dilates  with so much difficulty, and in which there is so great a tendency
in the perineum to become expanded, and then have more than once dreaded
the appearance of the head of the foetus, through it.   Hence we are induced
to believe that the passage of the head through the perineum, occurs more 
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205
 frequently than is generally supposed, only in the majority of cases, the vagi-
 nal commissure is ruptured, and the accident is called laceration of the four-
 chette.
   Let us now inquire what may be the causes of an  accouchement of this
 nature.
   The anatomist and accoucheur frequently finds the external orifice of the
 vagina, placed  high up under  the pubes, whilst the perineum presents from
 before backwards, a considerable extent.  The  vulva in  these cases is very
 narrow, and individuals who have  not taken into  consideration this state of
 the parts, consider the vagina as badly formed, and dread the chances of
 delivery.  But such is not the case; the narrowness exists only at the vulva,
 the vagina is of  a natural size.  This narrowness is caused by a kind of pro-
 longation of the perineum, which closes a fourth, a third, and sometimes even
 one half of the orifice of the vagina.
   This unnatural conformation is very inconvenient.  Sometimes the husband
 is obliged to have recourse to a physician, to  remove the obstacle.  The
 menses flow with difficulty from the  vulva, the blood remains behind the
 barrier formed by the perineum; this is also the case when leucorrhoea exists.
 The inconvenience is more severely felt at the time of delivery, or in case of
 the necessity of an operation upon the neck of the uterus.  The head of the
 child meets with the greatest difficulty in passing the inferior strait; it im-
 pinges against the perineum; and if the posterior commissure of the vulva,
 offer  less resistance than the centre of  the perineum, the child  cannot pass
 through the  orifice, without a more or less  extensive laceration, which the
 accoucheur, with all his skill, cannot prevent.  If, on the  contrary, the com-
 missure resist strongly, the centre of the perineum yield, is ruptured, and the
 child passes through the unnatural opening.
   This malformation may be congenital or accidental, that is to say, the result
 of the union of the soft parts, in consequence of  a burn, or laceration caused
 by previous delivery, or from any wound whatsoever.   The only remedy is
 to divide  the septum to a proper distance, prescribe rest, and prevent re-ad-
 hesion between the edges of the wound.
   This should be done in the first pregnancy, provided the cicatrix have time
 to be perfectly formed before delivery;  it should even be performed during
 labor, if there be no other means of preventing a serious laceration or perfo-
 ration of the centre of the perineum.
   Another cause, which possesses not less influence over the extension of the
 perineum,  is the position of the woman  during  labor.  Indeed  in the case
 related by Nedey, the midwife finding  the pains slacken,  and the patient
 desiring to  evacuate her  bowels, reversed a wooden chair, placing between
 the legs of it a chamber-pot, and  then seated the patient on this species of
 easy chair.   In  such a situation the head of the child  pressed  downwards
and backwards by the arch of the pubis,  must impinge more forcibly against
the perineum.  It is moreover proved by  observation, that when a woman  is
delivered  in  a perfectly horizontal  position, the child presents much more
favorably at the inferior  orifice of the vagina.   We  may, says M. Moreau,
include amongst these causes, a too great  curvature backwards of the inferior
extremity of the sacrum and coccyx.   This formation,  by increasing the
coccyo-pubic diameter of the perineal  strait, and directing lower down and 
206
LECTURES  ON
 more backwardly the axis of this strait, by diminishing the inclination of the
 plane, which should direct the head of the child from behind forwards, under
 the symphisis pubis, makes it bear more perpendicularly and with greater force
 against this part.   Again, with  as much reason, we might assign a priori to
 these accidents a  host of others, depending  on some malformation of the
 pelvis, or wrong position of the  head; but it is much better to reason  from
 facts alone, and it  is to be regretted  that the authors of the cases which we
 have enumerated, have not given all the circumstances relative to the mother
 and  child, which might tend to resolve this question.
   We will now discuss that part which most particularly interests us, namely
 the treatment.
   In the patient now in our wards, an attempt at re-union was made by means
 of the quilled suture.  Why did it not succeed ?  Because it was removed
 too early; for it  was not applied until the tenth day.  In recent wounds
 re-union may take  place in four or five days;  but in those which suppurate,
 unless the secretion of  pus be diminished, or the granulations be properly
 developed, a longer time is required.
   A still  longer time is,  a fortiori, requisite in a similar case, in which the
 flow of the lochia incessantly opposes the process of adhesion.
   I have frequently, continued M. Dupuytren, used the suture in suppurating
 wounds; but in order to accomplish the union, a much longer time was requi-
 site than in recent wounds.  The following case which recurs to my memory,
 is not without interest.
   I was  called some years since, by M. Gardieu and another physician, to a
 young lady, who had been delivered secretly, out of her father's house; there
 was a complete rupture of the perineum extending to the anus.   Several days
 had  elapsed since, the accident.  I advised and  used some stitches of inter-
 rupted suture; to-day I should  prefer the quilled suture.  In  a month the
 union was not quite complete; I advised the suture to be left in its place,
 persuaded that a cure would be effected.  The advice was followed,  and I
 heard no more  of her.
   In  the  case under treatment,  what is to be done ?  Shall the parts be  left
 to themv.'lves, or-ought the edges of the wound, after being pared off', to be
 brought together and kept so by the quilled suture ?   Is it necessary to divide
 the septum separating  this opening from the vulva?  Before deciding  this
 question, we  ordered the woman to be kept on her back, the thighs fastened
 together by a bandage, and her position on no account,to be altered.  Since the
 ten days that she has been in the wards, we have observed a sensible  diminu-
 tion in the diameter of the anormal opening, the  free edges adhere at  some
 points.  We have,  therefore, a right to hope,  that a complete union will be
 effected without an  operation.
   Indeed, on the 30th of last November, she was discharged, completely cured.
   The  whole  perineum  was  cicatrized.  There still  exist, undoubtedly,
 observed M. Dupuytren, some points of division on the surface of the vagina,
at its junction with  the perineum, but these divisions will entirely disappear.
   This case confirmskthe opinions of different authors, as  to the possibility of
curing this accident without an operation,  and merely by the means we have
 employed.  We have seen cases cured in a month or five or six weeks; such,
indeed, was the time of treatment of this woman. I advised her, to abstain from 
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207
laborious employment, to walk as little as possible, especially to avoid coition,
and every thing which might tend to destroy the adhesions which as yet have
not acquired their perfect solidity.
                      CHAPTER  XXVII.

               ON ORIGINAL LUXATIONS OF  THE 03 FEMORIS.

   Anatomical  Characters; Symptoms ;  Distinguishing Marks;  Causes ;
 Treatment.—Some years ago, M. Dupuytren published a memoir concerning
original luxations  of the thigh;  a case which recently occurred'in the Hotel-
Dieu, again induced him to treat of this affection.  The  individual  in ques-
tion, was a man about seventy-four years of age, laboring under extention of
urine.   Several physicians in the city had  been  unable  to  sound him.  M.
Buschet succeeded the first time, and failed  the second.   I may here remark
to you, said M. Dupuytren, the propriety of always carrying the sound along
the upper surface of the urethra, in order to avoid false passage, strictures and
obstacles which almost always exist on the inferior surface.   I wish,  however,
particularly to direct your attention to the injury  of the joint in this  case; the
heads of the thigh bones are evidently luxated, there is a marked projection of
the hips, and the patient is unable to separate his thighs.  The simultaneous
occurrence of the affection on both sides, indicates a congenital malformation.
 Should he die, as is to be feared from his present weak  state, a faithful
examination of the parts shall be made.
   The  event predicted took place, and the  body  was minutely examined; it
was impossible to separate the thighs, except by causing the  extremities to
describe the arc of a large circle; the trochanters were  much  closer to the
cristas of the ilia, and more elevated than natural; the head of the femur situ-
ated higher up, the knees turned inwards,  the thighs shorter; there was a
complete change of relation and a marked difference in direction and length.
Hence it followed, that the cavity destined  by nature to  receive the head of
the bone, was nearly obliterated, and the head of the bone was deformed.
The upper part of the thigh was increased in size, the trunk bent backwards,
the abdomen carried forwards, the pelvis instead of being oblique was nearly
transverse, the thighs  shorter,  the  buttocks soft  and  flaccid,  which was
explained by the approximation of the insertion of the glutei maximi muscles,
and their state of relaxation.  The gluteus medius, on the contrary, was dis-
tended and elevated, the gluteus minimus destroyed, the  pyramidalis, instead
of being placed obliquely  as in nature, was perfectly horizontal; the  gemini
and quadrati  muscles distended, and the adductors shortened.
   On the left side, the great diameter of the original  cavity was not more than
an  inch ;  it was shallow,  rugose, filled  with a fatty substance, yellow and
nearly of the consistence of oil; it was nearly of an oval shape.  The external
iliac fossa showed  in front of the  sciatic notch a large  shallow depression,
covered by a thick shining periosteum, having nearly the appearance of articu-
lar cartilage; this  spot was destined to receive the head of the femur.   This 
208
LECTURES ON
 head smaller than natural, flattened, unequal, without any vestige of the inser-
 tion of the round ligament, was incrusted by an articular cartilage, which was
 thinner than in the normal state.  The articular fibrous capsule formed a com-
 plete envelope which was inserted in the upper and lower edges of the former
 cavity.   This capsule was in place of an osseous cavity on this side, and from
 its length, permitted the ascent of the head of the femur into the depression of
 which we have spoken.  The space over which it could pass  was about three
 inches.   The thickness of the capsule was considerable; its  density nearly
 cartilaginous.
   On the right  side, the original cavity was somewhat larger;  internally it
 presented the same appearance as the other.   The external iliac fossa, instead
 of presenting, as on the opposite side, a simple depression, shewed in front
 of the  great sciatic notch,  on a level with the space comprised between the
 anterior superrbr and  the anterior  inferior  spinous processes of the ilium,
 a large and deep cavity with bony edges, strongly marked, rugose, and une-
 qual.   The head of the femur larger than that of the opposite side, had some-
 what preserved its  shape;  it was like the other surrounded by an imperfect
 articular cartilage, and the interior of the articulation lined by a synovial
 membrane.  The orbicular ligament was thinner than on the left side, although
 its extent was not confined merely to the circumference of the anormal cavity.
 Hut on  this side, the  head of the femur having reached the bony edge, met
 with a solid support, whilst on the left, the extreme strength of the fibrous
 capsule, limited the ascent  alone of the limb, by its resistance to the weight
 of the body.
   There existed, moreover, an extraordinary mobility of  the articulation of
 the  sacrum, with the last lumbar vertebra; by pressing on the inferior extre-
 mity and holding the pelvis firm, the vertebral column could be made more
 erect by nearly a foot.   The relaxation alone of the cartilage was supposed
 to be the cause of this singular mobility.
   We  rarely have an  opportunity, continued  M. Dupuytren, of examining
 after death this curious species of luxation.   For, as it is of no injury, and
 constitutes  merely an infirmity, incapable of destroying life, I have only been
 able to observe it in a small number of individuals, who perished accidentally
 or by diseases foreign  to the affection of the hip.   I have generally seen the
 following condition obtain;  the muscles inserted above and below the aceta-
 bulum,  are  all  raised  towards  the cristae of the ilia.   Some of  them  are
 remarkably developed,  others  are diminished, or, indeed, slightly atrophied.
 Some of the latter are reduced to a kind of yellowish fibrous tissue, without
 the least semblance of a muscle.
   The upper portion of the femur preserves its natural dimensions and rela-
 tions ;  sometimes the internal anterior side of the  head of the bone, varies
 slightly from its spherical shape, which  arises apparently from  the friction
 against the part not organized to receive it. The acetabulum is either entirely
 wanting, or is merely an irregular osseous projection, without a trace of arti-
 cular cartilage, or synovial capsule, surrounded by a firm cellular tissue, and
covered by  the muscles inserted into the lesser trochanter.  Once or twice,
I have seen the round ligament elongated, flattened, and as it were worn out,
in  certain places, by the pressure and friction of the head of the femur. The
latter is  found  lodged  in a cavity, analagous to  that which is  developed  in 
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£09
 accidental and unreduced luxations of the upper part of this bone, upwards
 and outwards.  This new cavity is very superficial, and almost without any
 margin, is  situated in the external iliac fossa, that is, above and  behind the
 acetabulum, at a distance proportionate to the shortening of the limb, or the
 ascent of the  head of the bone.  As a result, we find in these persons, what
 is seen in  cases  of spontaneous, or very old, accidental  luxations, with this
 difference,  however, that in the cases now under consideration, every thing
 seems to be of older date, and to have originally had the same disposition.
   This original,  or congenital  displacement of the head of the  femur,  of
 which we have just sketched the anatomical characters, has not been pointed
 out by French writers.* By calling your attention to it, it is not my intention
 to swell the already too numerous catalogue of human afflictions, but to spare
 the  practitioner serious errors of judgment, and the patient a treatment dan-
 gerous as it is useless.
   This alteration  consists, therefore, in a transposition of the head  of the
 femur, from the acetabulum to the external iliac fossa, a transposition which
 takes  place from birth, and seems to result from a defect in  depth of the ace-
 tabulum, rather  than  from disease or accident.   This displacement  is  of
 that species constituting luxations of  the femur, upwards and outwards. Two
 varieties are known, accidental luxation, and consecutive, spontaneous or symp-
 tomatic luxation.   Therefore, in order to distinguish from those two species of
 luxation the one now under consideration, we have called it original luxation.
   The  following is a case of this double disease.
   Case II.—Paquier (Joseph), 49 years of age, by trade a weaver, was admitted
 into the Hotel-Dieu, on the 31st of June, 1831, for a chronic opthalmia, with
 which he had been affected since his infancy.  Now and then it became worse,
 and this induced him to apply for relief.   Venesection, a blister to the right
 arm, stimulating pediluvia and purgative enemata cured him in two weeks.
 When about to leave the house he asked for a truss to support a large scrotal
 hernia.  He of course was examined, and M. Dupuytren was not a little sur-
 prised on seeing the  arrangement of the upper extremity of the  femurs;  it
 consisted in a transposition of the head of the bone from the cotyloid cavity,
 into the external  iliac  fossa?.    This  transposition was  characterised by the
 shortening of the  lower limbs, the ascent of the head of the femur into the ex-
 ternal iliac fossa?,  the projection of the great trochanters, the retraction of the
 muscles of the thigh towards the crista) of the ilia, &c, the disproportion be-
 tween  the upper and lower parts of the body was very remarkable: the trunk
 was well developed, whilst the lower  limbs were short and shrunken.  When
 erect, the patient leaned the upper part of the body backwards, the  pelvis was
 placed nearly horizontally upon the thigh bones, and he touched the ground
 with the toes alone.    His walk was  painful and tottering at each step, the
 head of the femur  supporting the weight of the body could  be seen  rising in
 the external iliac fossae, and the pelvis depressed, a circumstance arising from
 the defect of fixedness of the head of the bone, and which the patient remedied
 by means of a girdle.   When in a horizontal position, the  marks of his in-
firmity were less evident.  In this position the affected limbs could easily be
 lengthened or shortened with ease.   All this was effected without the least
  * Paletta, a surgeon of Milan, has published in his Adversaria Chirurgica, some obser-
 vations on this disease, but they are by no means complete. 
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LECTURES ON
 pain, which left no  doubt as to the absence of disease, as well as of a cavity
 capable of receiving and retaining the head of the femur.  This patient, like
 the former one, declared that he was born thus  deformed, and that from  his
 earliest recollection he had always walked in the same manner.*
  In addition to this characteristic case of double original luxations of the femurs,
 we will detail another very curious fact, tending to prove that this malconforma-
 tion may be transmitted through several generations of  the same family.
   There is at present in the town of Nautua (says the author of this communi-
 cation) a family of which several individuals have been, and are affected with
 original luxation of the femurs;  the oldest one is a female of 80 years of age,
 named Margaret Gardas, from whom I obtained the following history.
   Two of her aunts, on the  maternal side, who lived to 60 years of age, had
 been  lame from infancy ; their hips were high, large, suddenly projecting,
 and they  walked  with their elbows drawn back, and  waddled  like ducks.
   Margaret's father had a sister, lame from birth, on the right side, who died
 at the age of 80.  Another sister well made, had a daughter with a shortened leg.
   Margaret herself, is a large and robust woman, very fat, and apparently of
great activity during youth.   The disease did not appear in her until her 30th
year, and the symptoms are  those of spontaneous luxation of the femur.  The
affected limb is one fourth less in diameter than  the other; and three or four
 lines longer.    She has a daughter who labors under a  congenital shortening
of the right limb of nearly three inches.  This girl was married to a well formed
 man, but whose father had congenital luxation of both  femurs; she has had
 four children, of whom two presented this hereditary infirmity.
   The characters of this luxation, as of all those in which the head of the femur
 is carried upwards and outwards, are:  the shortening  of the  affected limb;
 the ascent of the head of the bone into the external iliac fossae;  the projection
 of the great trochanter;  the retraction of almost all the muscles of the thigh
 towards the cristae of the ilia, where they formed around the head of the femur
 a kind of cone, of which the  base is at the ilium, and the apex at the great tro-
 chanter ; the almost complete denudation of the tuber of the ischium deserted
 by the muscles; the rotation of the limb inwards, and the consequent turning
 of the heel and ham outwards, of the point of the foot and knee inwards; the
 obliquity of the thigh from  above downwards and from without inwards, an
 obliquity which increases with age and the size of the pelvis, and from which
 there results a tendency in the thighs to cross below; an acute and re-entering
 angle in the upper internal part of the thigh where it unites with the pelvis, the
 emaciation of the whole of the limb, and especially of its superior part.
   The motions of a limb thus formed, are generally very limited,  and those
 of abduction and rotation, particularly so; whence follow innumerable diffi-
 culties in standing, walking, and the different exercises in which the lower
 extremity are required.   This  affection may be distinguished from others,
 analagous to it in symptoms, but different in origin, nature, and treatment, by
 means of  the following characteristics;  the absence of all pain, engorgement,
 abscess, fistula, or cicatrix; in the majority of cases, the simultaneous occur-
 rence of a luxation on each side ; I say in the majority of cases,  for sometimes

  * We are acquainted with a gentleman of considerable distinction in the literary world,
 who labors under a similar malformation.  The heads of the femora being thrown back
 into the illiac fossae, he Is unable to sit on his  nates, and he is obliged to write leaning
 over a table or desk,.or in a horizontal pasitiaa.   J£ds. Hr.r,. & Lib. 
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211
the luxation is confined  to  one side alone.   In twenty-six cases, the  luxa-
tion was found on one side in only one or two individuals.
  Case IV.—Miss F.....,8 years of age, of a feeble constitution, and lym-
phatic  temperament, came  to the public consultation, at the Hotel-Dieu, on
the 31st of August, 1821.
  The parents said that, as soon as the child  began to walk, they perceived
she was lame.  No accident had happened to her.   Divers remedies had been
used, without avail. When the child stands erect, the thinness of the left leg
is  immediately perceived, as also the difference between the shape and size
of the  thighs, the  projection of the great trochanter upwards and outwards,
and the oblique direction of the femurs.  The vertebral column is exceedingly
curved; the head is carried  backwards, as  if to compensate for the effects
of the transposition from the centre of motion.   The belly projects, the knee
and toe are turned inwards, the heel and ham outwards. This child evidently •
labors  under original luxations of the femur.  The case is remarkable, merely
inasmuch as the deformity exists only on one side.
  Case V.—Miss T___de J....., was born on the 5th of January,  1812.
At her birth  no deformity was  observed in her lower extremities.  At the
age of  14  months, it was attempted to teach her to walk, and then for the first
time perceived that  in walking  she  rolled  from one  hip to the other; the
weight of the  body, instead  of resting on the whole  sole of the foot, rested
merely on the toes, which were turned inwards, as well as the knee, whilst
the heels and ham were raised and turned outwards; the feet were with diffi-
culty raised from the ground, and  the little patient could scarcely separate
her thighs.
  From this time, the parents consulted several physicians,  by whom a host
of various remedies were prescribed, without the least advantage.  The little
patient increased  in  size,  and  the affection also progressed;  the  lumbar
vertebra; projected forward, and impelled by this deformity, the abdominal
viscera became more saliant.
  In 1821, M. Dupuytren saw the child for the first time ;  she then presented
the following appearance:
  The lower  extremities, turned inwards, were remarkably short and  ema-
ciated, having an oblique direction, separated at their upper extremities, and
approximated  below.  The  great trochanters  projected upwards and back-
wards  ; the foot strongly bent; the chest and abdomen projected forward, the
upper part of  the body inclined forward.  No deformity could be discovered
in the body or pelvis.
  The above  symptoms  are observed in the erect posture ; but when in bed,
the weight of  the body resting no longer on the femurs, they  fall to  their
rio-ht place, and the symptoms disappear.   It is a very remarkable fact, that
Miss T___can walk, run, and jump, as well as any other child.
   To the symptoms just enumerated, must be added the history of individuals
affected with  this  luxation; the appearance of  the symptoms at the earliest
attempts to walk,  and the  progressive  development of these  symptoms  in
proportion to the increase of weight of the upper pa*ts of the body.
   Individuals laboring under original luxation, experience no pain in the hips
or knees- and only feel fatigue and numbness, after too much exercise; there
is no eno-oro-ement  around the osteo femoral  articulation, the projection of the 
£21 2
LECTi:rks  on
 great trochanters, and large size of the flesh surrounding the neck of the bone
 have no  characters of it; they proceed from  the ascent of the head of the
 bone, along the external iliac fossa, and the retraction of the muscles towards
 the cristae of the ilia; there is  no abscess,  nor fistula around  the joint;  no
 mark of  a cicatrix, and consequently,  nothing from  which  we  can  infer
 any previous disease of the part; lastly both hips, or that alone which is affected,
 present always the same change of figure;  a circumstance so rare in disease
 of  the superior articulation of the thigh bones, that it may be regarded as
 characteristic of the disease at present under consideration.
  These  proofs are more valuable when added to the history of individuals
 affected with original  luxation ;  they assure us that they never  have suffered
 any pain in the articulation of  the hip, or at the knee, nor, in a  word, any of
 the symptoms  of the painful  and  dreadful disease, which generally termi-
nates in spontaneous luxation of the thigh.
  The history  of these  patients proves also in a  positive manner, the first
 symptoms, progress, development, and  effects  of  congenital luxation of the
 femur.  Called  early to  children affected with it, we find, from the moment
of birth marks of this conformation, such as  immoderate size of  the hips, pro-
jection of the trochanter, obliquity of the  femurs, &c.;  but as it generally
happens, this malformation  attracts the notice of parents only when children
are beginning to walk and our attention is  then first directed  to  it.   Then
children can walk,' run, or jump, only with great difficulty ; sometimes it hap-
pens, that parents think  the child only slow in learning to walk,  and do not
perceive the disease  until three or four years of age, that is, when the defects
and imperfections in the form  and  functions of the parts become so-striking,
as no  longer to  be attributed to  a  tardy development of the  parts or  their
movements.
  The disease becomes more evident when  the pelvis begins to enlarge, then
the balance of the upper part of the body on the pelvis; its inclination forwards,
the  curvature of the spine, the  projection of the abdomen, the circular move-
ments of the extremities  of the  transverse diameter of the pelvis, the want of
fixity of the head of the femurs, the alternate elevation and depression of this
bone along the  external  iliac fossa, become  very manifest, but  the cause and
nature of  the disease being unknown, it is attributed to some external agency,
during the period of infancy, such as a fall,  or too severe traction on the leg,
as when a child is lifted by the  leg or thigh.   Some persons attribute it to a
scrofulous affection which during pregnancy, or after birth, has caused thedes-
truction of the edges of the cotyloid cavity, or of the head of the femur, and
consequently, the displacement of the latter.   It must be  confessed that the
lymphatic  constitution and rachitic  aspect of these  individuals give some
weight to this opinion ; and if we have adopted a contrary opinion, it is because
we  have observed the affection  in children of a diametrically opposite consti-
tution, at the moment of birth, and without any sign of disease;  and also  from
dissections which have excluded all idea of any actual or even anterior disease.
  At  the period, in which the characteristics of the sexes begin  to appear, the
increase of the pelvis, mofe rapid and larger in girls than in boys, renders also
the  malformation more evident in them; but when the pelvis acquires its
greatest size, and the upper  parts of the body their greatest weight, the effects
of the original  luxation  increase rapidly, so as to give rise to the fear of 
CLINICAL SURGERY.
-213
 disease of the hip-joint. This increase is marked by the gradual inclination for-
 wards, of the upper part of the body, the curvature of the loins and the projec-
 tion of the abdomen, &c.;  and if we may be allowed the expression, by the disar-
 ticulation of the femurs,  every time they are obliged to support the  weight of
 the body.  It should be observed, that the phenomena existing on the exterior
 of the pelvis, has no influence over the development of its cavity; the viscera
 contained perform their  functions, and the person is as able to receive and
 transmit the product of fecundation as the most correctly formed individual.
    What is, then, the cause of this displacement ?   Does it arise from  some
 disease of the foetus in the womb of the mother, and cured before birth ?  Does
 it arise from  some violence which has thrown the head of the bone out of the
 cotyloid cavity ? and has the latter been obliterated without disease, and only
 because it has been without use, and consequently, idle? has nature forgotten
 to establish a cavity, for the head of the  femur?  or has this cavity, resulting
 from the junction of the  three pieces composing the os innominatum, become
 imperfect on account of some obstacle to the evolution of the bone, as is the
 opinion of M. Breschet ?   Without attempting to resolve any of these ques-
 tions,we will be satisfied with offering a few remarks.
   Pathological anatomy has demonstrated  that the foetus, during pregnancy,
 is subject to many diseases, which may run their course and end in recovery or
 death, before  birth.  Hence, a disease of this  nature might produce sponta-
 neous luxation of the femur; yet many circumstances oppose this explanation;
 and, in the first place, all the  individuals in whom it has been observed  were
 born  healthy, which does not permit us to suppose that they had suffered from
 so severe a disease ; again, neither at birth, nor at any subsequent period, have
 there been observed the engorgement, abscesses, fistulas or pain which accom-
 pany and so generally follow this species of disease.   Does not this displace-
 ment rather  depend on some violence, which has forced the femur  from the
 acetabulum ?  In a word, would this displacement be accidental and analogous
 in its nature, did it not depend on some special cause, or some cause occurring
 during life, in consequence of falls, &c. ?  But  what, in  such a case, would be
 the degree of violence sufficient to produce such  a displacement ?  Let me here
 make a remark which may  give some probability to  the  explanation.   It is,
 that the  position  of  the  limb of the foetus, whilst in  the womb, is such,
 that the thighs are strongly flexed on the belly  ; the  head of the femurs con-
 stantly presses against the posterior inferior part of the articulation; and this
 continual pressure, of no injury to well formed children, might be productive
 of  serious effects in  others less strong and whose  tissues were less firm.
 Admitting this fact, it  will be  easily perceived  that the  posterior inferior
 parts of the capsule being  obliged to yield and allow the passage of the head
 of the femur,  permit the  occurrence of a  luxation; and then to understand
 the displacement upwards and outwards, it  will suffice to  call to mind the
 strength of the muscle surrounding the joint which tend incessantly to cause
 an ascent of the head of the bone.
  What is the treatment proper  for this affection ?  At  first sight, palliative
 remedies  appear most reasonable, and I confess are those which I have pre-
 ferred.  If we remember  the natural tendency of the head  of the femurs to
ascend alon°-  the  external iliac  fossa, and that  the cause of this ascending
 movement is. in the weight of the body which constantly contributes towards 
214
LECTURES  ON
it, we will understand on what indications the palliative treatment is founded.
As far as possible, the weight of the body should be prevented from bearing on
an articulation which has no cavity, and also muscular action upon the femur
should be moderated as far as is in our power.  Rest is hence a most impor-
tant means, and the sitting posture is preferable, as in it, the weight of the
body rests on the  tuberosities of the ischia.   Individuals  affected with this
infirmity, cannot, however, be subjected to constant rest.  Some method, there-
fore, of lessening the inconvenience of standing or walking must be devised.
Hitherto, experience has pointed out to me, but two ; the first consists in the
daily use of a bath, either of fresh  or salt water, extremely cold, for three or
four minutes, at each immersion. The second is the constant  use, or at least
during the day, of a girdle around the pelvis, embracing the great trochanters
and  keeping them  at a proper height, and which shall constitute, out of these
weakened parts, a more solid whole, and prevent the continual vacillation of
the body on the joints.
  I have succeeded, by these means, in arresting the increase of the incon-
veniences of the luxation, and thus render tolerable the evil which I could not
cure.  Some patients have afforded to me, the most irrefragable proofs of this
assertion ; wearied by the pressure of the belt, they abandoned it, but soon
again returned to its use, convinced that without it, they possessed no solidity
in their hips, or confidence in walking.
  It was at first supposed that extension of the lower limbs  would be useless;
for, even supposing that the limbs could be brought to their natural length, as
the head of the femur met with no  resistance, would it  not be evident that,
when left to themselves, they would lose all the length they had gained?
  This  opinion has been  modified by the labors of M. M. Lafond  and Duval.
These distinguished physicians, in their private hospital atChaillot, subjected
to continual extension, a child of eight or nine years of age, affected with con-
genital luxation on both  sides, and  M. Dupuytren has certified, that  after a
treatment of some weeks the limbs had recovered their length and straightness;
and  after three or four months treatment, he saw,  with great surprise, the
greater  part of the good effects  of the remedy still persist.   No conclusion
can be drawn  from a single case, but still it is  important, and may be more
so, as regards the consequences which may arise from it.
  We will now quote a case from the work of M. Talade Lafond, on  the
deformities of the human body.
  Miss  A......, nine years of age, was admitted into our establishment, in
the year 1828, in  the following condition: she was of ordinary size, well
formed, and enjoyed good health.  The curvature of the loins, the projection
of the thighs backwards, the lateral balancing of her body, caused her walk to
resemble that of a duck.   She stood and walked with but very little confidence.
On examination of the hips the following phenomena were observed ; the but-
tock projected, the great trochanter  approached the anterior superior spinous
process  of the ilium, and when the  foot was turned  outwards, a tumor, evi-
dently formed by the head of the femur,  could be felt  in  the external iliac
fossa; in the usual position  the limb preserved its ordinary straightness, and
could exert the movement of rotation outwards.
  On attempting to extend  the limb, the great trochanter was  depressed, as
well as the whole of the upper extremity of the femur, giving a distinct sound 
CLINICAL SURGERY.
215
of crepitation resulting from the friction over hard and smooth surfaces.  These
phenomena were observed on both sides.
  The ease with which the limbs could be lengthened, suggested to us the
idea of keeping, by means of gentle extension, the head of the bone on a level
with the cotyloid cavity; a belt round the hips, pressed the head of the femurs
downwards, which was assisted by extension at the feet, at the same time that
the upper part of the body was fixed to the extending bed; when standing or
walking  the body was always supported by crutches.   We were induced,
hoping to succeed, to continue this treatment for sometime; but failing in our
hopes, and the patient being very intractable, the treatment was discontinued.
We may add, however, that she walked much better when she left our esta-
blishment.  This  improvement  was probably owing  to the cold,  salt and
sulphur baths, and the use of gymnastic exercises of which she was passionately
fond.
   Original luxation of the femurs, said M. Dupuytren in conclusion, is not so
rare as may be supposed.  I have seen it twenty-five or twenty-six times in the
course of twenty years.   One remarkable and  interesting fact is, that persons
affected with this luxation are generally females: indeed, of the twenty-six I
have  seen, only three or four were males.  Therefore, it cannot be admitted
that chance alone is the cause of this disproportion ; but supposing it constant,
why is the female sex more prone to this luxation than the male ? I confess,  I
am unable to give a satisfactory reason; I can  at most give a general one, it is
that deformities in general,  occur much  more frequently in women than in
men.
                      CHAPTER  XXVIII.

                   ON LACHRYMAL TUMORS AND FISTULAS.

               Treatment of M. Dupuytren, and its Results.

  The disease which produces fistula lachrymalis appears under two very dis-
tinct forms which depend on its successive degrees of development, and which
are, in ordinary language, erroneously included  under the same name.   As
Ion"- as there is no opening externally of the lachrymal sac, there can be no fis-
tula;  but the  sac is then more or less considerably dilated, constituting the
lachrymal tumor; this is the first stage of the disease: the perforation of the
sac or fistula is the  second.
 Ordinarily the lachrymal tumor arises and increases in an almost imperceptible
manner.   It is at first a scarcely appreciable tumor, situated within and below
the greater angle of the  eye,  below and behind the  straight  tendon of the
orbicular  muscle of the eyebrows.   Circumscribed, without change of color
of the skin, free from pain, at the commencement, the tumor is  easily emptied
by pressure, either by the reflux of the contained matter through the puncta
lachrymalia. or through the nostril.
  The epiphora accompanying its first appearance, becomes daily more serious, 
CI6                           LECTlRLS on
 and at last the tears  pass entirely over the cheek.   The eye of the diseased
 side is constantly red, the conjunctiva slightly injected, the eyelids evidently
 swollen, especially at the free  edges, which in the morning  are found glued
 together by a tenacious yellow matter, furnished  by the irritated gland, of
 Meibomius.
   The disease may exist a longtime in this state, without exacerbation ; but a
 period arrives when the parietes of the tumor grow thin; it is no longer emptied
 by pressure; there  is redness and pain in the spot it occupies; and its sur-
 face becomes inflamed.   The inflammation frequently extends to the eyelids,
 cheek, nose and even the forehead.   The eye becomes red, the fluid  which
 bathes it, becomes hotter and more acrid.  The tumor presents the appearance
 of an acute phlegmon, fluctuation is perceptible, and it opens externally.  At
 this period, in the majority of cases, the epiphora diminishes, the tears finding
 a passage through the unnatural opening of the sac.
   The fluid discharged by the fistula presents a mixture of tears and purulent
 mucus.   In many cases, the continuance of the phlegmasia causes the disor-
ganization of the affected tissues, and the extension of the disease to adjacent
parts.   Granulations appear in the fistula, whose edges become  callous;  the
mucous membrane of the sac, and nasal canal softens, becomes fungous and even
perishes to a certain extent, and the periosteum partaking of this destruction,
 the os unguis and adjacent parts of the maxillary bone at  the bottom of the
 fistula are exposed and become carious.  This caries sometimes takes  place
before the disease has  reached the degree of which we have just spoken ; some-
 times it is seen even before the lacrymal tumor has been perforated, and con-
 sequently before the existence of the fistula.
   From what has been said, the diagnosis of this disease will be very simple.
 We  will, however make a few remarks on the cause of the primary injury of
 the lachrymal sac, which is the origin of the  disease.  Scarpa places it in the
 discharge from the eyelids, thus considering the affection of the lachrymal sac
as always secondary to the inflammation of the eyelids.  According to him,
 the purulent fluid,  carried into  the  lachrymal ducts, irritates  and inflames
 them ; afterwards  the sac or nasal canal ulcerates, the disease extends and
 terminates in disorganization of the adjacent parts.  But more recent  researches
 have proved that the lachrymal ducts, like all other excretory canals owe  the
 majority of their diseases to some affection of the mucous membrane which
 lines them.  Some  point of this  membrane is inflamed, immediately the  ex-
ternal fibro-cellular tissue becomes the seat of an  active conjestion, which pro-
 portionably diminishes the area of the internal duct.  This structure becomes
 of itself a permanent cause of irritation, the afflux  of blood is  increased, the
inflamed tissue soften, then ulcerate, and the fistula is established.  The duct
of Steno, the urethra,  rectum, ccecum, oesophagus,  &c,  furnish   the most
 conclusive proofs of this species  of etiology.   All causes, therefore, produc-
tive of a permanent irritation of the eyes, eyelids, or mucous membrane of the
 nasal cavities, are also the remote, causes of lachrymal tumors.   Thus we fre-
 quently see them occurring in leucophlegmatic, pale persons, whose conjunc-
 tiva is habitually injected, and the edges of whose eyelids are red and bleared;
 they often follow rubeola, variola, scarlatina, which so frequently leave  the
 eye  and eyelids in a state of irritation; and that repelled eruptions, an old
 venereal affection, a scrofulous state of the body, by favoring the development 
CLINICAL SURGERY.
217
and continuance of oculo-palpebral inflammation, occasion also that of the
lachrymal  ducts, and, consequently, the appearance of tumors and fistulas
which result from  it.  A purely mechanical cause may lead to the same
termination.
  It follows, therefore, from the pathology of lachrymal tumors and fistulas,
that the antiphlogistic treatment should be used in the commencement of the
disease.    Indeed, it should not be forgotten, that they result, as  we have
observed, from an inflammation either of the eye-or eyelids, or the mucous
membrane of the nose, extending to the sac  and canal which are the seat of
the disease.  This  treatment, is frequently successful without any operation.
  At a more advanced period', when the disease is yet simple, and there exists
but a moderate dilatation of the canal, or a recent perforation  unaccompanied
by callosity, fungous granulations, disorganization of the mucous membrane,
caries of the adjacent bones, the antiphlogistic treatment aided by revulsives,
fumigations, &c, will effect a permanent cure; and even if the disease have
reached a  degree requiring the operation, still a preparatory antiphlogistic
treatment is necessary, should there be any inflammation of the eye, eyelids,
or surrounding tissues.
  The attention of the  surgeon should not be alone directed to the local
affection, he should carefully investigate the  remote causes, the constitution
of the patient, any previous venereal affection.  Should it depend on scrofula,
venereal, &c. the proper remedies should be used at the same time that local
applications suited to the disease are required.
  In  hospitals, we seldom can employ any other remedies than the operation.
Generally, the patient asks for advice, only after having labored under the
disease for a long time, or when the tumor conceals so serious an affection as
to require the nasal canal to be opened, and freed from its obstruction.
  In  order to  perform this operation, according to M. Dupuytren, the surgeon
merely requires a bistoury with a narrow blade and firm point, acanula, such
as will be hereafter  described ; the patient should be seated on a low strong
chair, opposite a bright light, the head thrown back and supported by an as-
sistant.  The  surgeon, then, before proceeding any further, ascertains exactly
the situation of  the maxillary edge of the orbit near the inner canthus of the
eye.  This edge is sometimes found more elevated or depressed, than was at
first supposed.
  Again, the straight tendon of the orbicularis palpebrarum muscle should be
carefully examined, as its direction is not always constant.    Between  this
tendon, which must be left uninjured,  and the  maxillary edge of the orbit
below which a sac is no longer  found, the instrument is introduced.   These
elementary principles  should not be forgotten, as on them the success of the
operation depends.
  CASE L—Chalon,  (Alexandrine,) thirty-six  years of age,  of a lymphatic
temperament,  was admitted into the Hotel-Dieu  for a fistula lachrymalis on
the left eye.   The  disease, for which she  could  assign no cause, had existed
for upwards of six years.
  Durino- the first five years, there was a continual discharge of tears, and,
consequently,  great obscurity of vision,  dryness of the corresponding nostril,
and aphalalgia of the same side.  At the end of this period a small tumor ap-
peared at the inner angle of the eye; it  was compressible and  could be made 
218
LECTURES  ON
to disappear  by pressure.  An erysipelatous  redness soon appeared which
spread to the adjacent parts; the tumor burst and emptied itself.  The open-
ing, however, closed, and a second tumor larger than the first appeared ; it
also opened, and permanently established a fistula.
  The tumor was of the size of a small nutand presented in its centre a fistu-
lous opening which established a communication between the lachrymal sac and
the exterior, and by which the latter was entirely emptied.  There was consi-
derable weeping, the eye extremely sensible and very red, the corresponding
nostril dry, the head painful on the same side, the lower eye-lid elevated, and
covering more  than one half of the eye; the surrounding parts  highly in-
flamed, and the cheek was marked by furrows made by the tears.
  From these symptoms the nature of the affection was very evident.  After
a few days of rest and the use of antiphlogistic remedies, M. Dupuytren per-
formed the operation in  the following manner; the patient  being seated, the
operator divides the lacrymal sac to the  extent of a few lines, plunges the
bistoury into the upper part of the nasal  canal, the  blade of the instrument
being gently elevated and directed backwards ; introduces and passes in front
of the anterior surface of this blade the free and  smooth extremity of a small
canula on its mandrel, then withdraws the bistoury, and  passes the canula by
means of gentle pressure into the nasal canal, which it should entirely fill, so
that its upper extremity may be concealed by the inferior portion of the lach-
rymal sac.  The mandrel is then withdrawn, and the canula left in its proper
situation.  This operation, as may be seen, is one of the most simple, easy, and
rapidly performed that can be imagined.
   In order to be certain that the tube is properly placed, the professor closes
the  nostrils of  the patient and desires him to  make  the effort of blowing his
nose.   The air introduced into the canula by its lower orifice passes through
its base by the opening  in the lachrymal sac  with a hissing noise ; and should
the  patient discharge a little blood or other matter  from his  nose, it proves
most satisfactorily that  the communication is entirely re-established between
the upper part  of the canal and the  nose.  A contrary  results shows that the
 operation has failed.
   In the case under consideration the operation was so successful, that, in four
 days, it would have been almost impossible to say  there  ever  had been a
 fistula.  The small wound in  the sac had healed  ; there was no tumor, weep-
 ing, nor embarrassment in the vision.  In twenty days she was discharged per-
 fectly cured, and  in good health.   The canula used by M. Dupuytren, is made
 of gold or silver,  and always expressly  for the patient on whom he is to ope-
 rate ; it is about eight or nine lines in length for adults and five or six for chil-
 dren, a little larger above than below, having at  its upper extremity a circular
 and thin  projecting plate.  It has a slight curvature anteriorly, in order to suit
 better the direction  of the nasal canal, and  its inferior extremity   The
 instrument is mounted  on a mandrel made of iron wire, bent at a right angle
 The part entering the canula should fill it entirely, the remainder serving as a
 handle may  be longer and shaped like a spatula.  We have already explained
 how the canula should be introduced into the  nasal canal.
   Case II.—Galan, F. L. A., fifteen years of age, of a good constitution, was
 admitted for a  fistula lachrymalis of the right eye.   Seven  years previously,
 without any known cause, she had perceived an unusual flow of  tears.   The 
CLINICAL SURGERY.
219
discharge become daily more copious and inconvenient; a blister had been ap-
plied to the  nape of the neck; and also others to the  arms, but without any
improvement.
  Two months previous  to her entrance into the hospital a tumor appeared
at the inner canthus of the right eye, at first soft, easily compressible and free
from pain, it soon became tense, hot, and painful.
  The inflammation extended to the adjacent parts, an opening formed in the
centre of the tumor giving issue to tears mingled with pus.   Then the swelling
diminished, as also the  weeping, and the patient seemed improved.  The
opening having closed, the tumor again formed and became larger than at first,
the inflammation increased and a new fistula was formed, which existed at the
time of her admission.  The eye was then highly inflamed, discharging tears;
an acrid and burning matter, formed of  pus and tears, flowed over the cheek.
  After three days of  preparatory treatment, the operation as  above de-
scribed, was performed; and in eighteen days she left the hospital entirely
cured  of her troublesome disease.
  Although  the operation of M.  Dupuytren,  is  undoubtedly the  best hith-
erto employed, and fulfils every indication,  nevertheless,  some  inconve-
niences, caused by the  presence of the canula,  have been  represented  as
essential faults.   Far from denying them, the professor himself was the first
to point them out, and give some  cases, in order the better to explain the
means by which he has succeeded  in obviating them.   Among these inconve-
niences, is observed, principally, the ascent of the canula into the  lachrymal
sac. or its descent into the nasal fossae, at the lower extremity of the nasal
canal.  The former accident, after  some time  gives rise to inflammation,
 ulceration,  and abscesses, requiring the extraction of the  canula.  This was
 remedied in the  following manner: A small  steel mandrel, similar to  that intro-
duced into the canula was  made, having the portion which passes into  the
 canula, divided  into two portions, which separate on account of their elasti-
city.  Each division is terminated by a small hook, of which  the points turn
outwards.  At the time of being introduced, they are held together by a small
 ferule, which can be withdrawn at  pleasure.  As soon as the lower extremities
 pass beyond the end of the canula, they separate by virtue of their elasticity,
 the little hooks bear on the edges of the canula, and the mandrel cannot  be
 withdrawn without also  withdrawing the latter.
   The enlargement of the upper portion of the canula, is intended to prevent
 its descent into the nasal fossae.   Still this accident sometimes occurs, and
 then the instrument irritates  and inflames the  mucous membrane of these
 cavities, ulcerates and destroys  it, and even perforates the palatine arch.   In
 such cases  it should be pushed from below upwards into the nasal fossae, and
 extracted through the nostrils with the forceps.
   C *.se III.—A woman had been operated upon according to M. Dupuytren's
 mode, and had worn the canula for eighteen months.  During that time, she felt
 nothing 0f  a disease of  which not a vestige remained.  But a few days since,
 pain and swelling accompanied by redness, appeared at the inner angle ef the
 eye  ' By pressure on this spot, fluctuation and a foreign body were discovered;
 it  was the canula which had ascended into the lachrymal sac.  An incision
 was made below the tendon of the orbicularis palpebrarum, as in the ordinary
 ope-ation  for fistula.  The canula was felt, exposed, and  easily extracted. 
220
LECTURES ON
   The affection soon disappeared,  and she was completely cured  in  a few
 days.
   On the other hand, the accidents of which we have spoken, and which are
 said to be very frequent, are, on the contrary, very rare, and can in nowise
 affect the results of the operation.
   In the second place, this affection is often the effect of general causes, as a
 venereal or scrofulous taint, &c, and if the surgeon, ignorant of these causes,
 because the patient is silent concerning the disease with which he may have
 previously been affected, does not add a general to a local treatment, or if the
 patient neglect the  general remedies, which most  frequently happens, it is
 evident that the failure of the  operation cannot be attributed to the manner
 in which it was performed.   Again, the want of success owing to the imperfect
 manner in which some practitioners perform the operation, cannot be urged
 as an  objection  to the operation itself.  Thus, it has happened that instead
 of placing the  canula in the nasal canal, it has been introduced into the orbit,
 or the maxillary sinus, after having  perforated the inferior wall of the orbit,
 or into the soft parts and in front of the sub-maxillary bones.   The following
 is a curious case of the kind.
   Case IV.—A man had been operated  upon  in the city, according to M.
 Dupuytren's method.  No improvement took place.  On examination it was
 found that the canula had been passed under the skin, in front of the inner
 angle of the eye and on the side of the nose.  The operation was re-performed,
 and the patient cured in a few days.
   Hitherto, we have treated  only of simple lachrymal tumors  and fistula;
 frequently, however, complications  exist requiring a special treatment. Some-
 times  the orifice of the fistula, is surrounded by small fungous granulations;
 these are to be  removed by caustic or the scissors.
   If the puncta  lachrymalia are closed,  the operation does not remove the
 epiphora, and the tears continue to flow over the cheeks; they may be easily
 separated by means of Anel's probe, if the obstruction be but slight;  but this
 complication is nearly incurable, if it result from an extensive adhesion of
 the sides of the puncta lachrymalia.
   Should there exist a simple denudation or caries of the os unguis, after having
 cleared out the nasal duct and placed the canula, the cavity of the sac is to
 be dressed with charpie and the external wound kept open, until the surface
 of the bone be covered or exfoliations take place.
   It is not our intention to describe the different operations, adopted by sur-
geons since the last century, some have been abandoned, others yet want the
test of experience, but over all, that of M.  Dupuytren possesses immense ad-
vantages.  We will finish this chapter with a short sketch of the disease which
has just occupied our attention.
  This affection was known to Hippocrates, Celsus, and Galen.  Their ideas
concerning it were but vague, owing to their want of anatomical knowledge of
the parts.  The disease was first accurately described in the 16th century by
Fallopius and Louis.
  The causes are of three classes; general, such as scrofula, herpes, syphilis
&c;  local, but  not seated in the lachrymal ducts; local, and  situated in the
ducts.
  The tumor is generally developed beneath the tendon of the orbicularis 
CLINICAL SURGERY.
221
palpebrarum  muscle, sometimes  both above  and beneath, so that making
two projections, it appears strangulated by the tendon, and as it were, bila-
ted.   The  progress of the disease is divided into two periods—the  period of
the developement of the tumor, and that of the formation of the fistula.
  The diagnosis is based on symptoms which  do  not allow it to be mistaken
for other diseases, such as hernia or dropsy of the sack.
  The antiphlogistic treatment is proper when  the contraction of the  canal is
owing to  inflammation, should it be insufficient we must have recourse  to
revulsives.
  General  causes, such as scrofula, herpes, or syphilis, must be treated by the
appropriate general remedies.
  Lastly, as to the local treatment, the operation of M. Dupuytren is superior
to all others, as we have previously stated and  demonstrated by the results of
his practice, and it fulfils all indications.
                        CHAPTER  XXIX.

                        ON FISSURE  OF  THE ANUS.

   The diseases which affect the anus and its vicinity demand all the attention
of the surgeon, as well on account of their frequent occurrence, as of the serious
accidents which may arise from an erroneous diagnosis.  The same danger
does not exist in fissure of the anus, but it is generally accompanied  by such
violent pain, that immediate relief is of the highest importance.  The pain is
of a peculiar character, gradually increasing and lasting some time after defe-
cation; sometimes lancinating, generally  of a burning kind; the patient is at a
toss for words to express  his agony.  Generally he compares  it to a red-hot
iron in the rectum, and dreads so much the expulsion of the fceces that we fre-
quently find him resist as long as he  possibly can this imperious desire, and
even abstain from food in order to  avoid  the necessity of it.
   These peculiarities throw abundant light  on the  nature of  the  disease,
and were we to study carefully the special characters of the different dis-
eases of  the rectum, we should there often find most valuable distinguishing
symptoms.
   Consisting in an extended and superficial ulceration, which is developed
towards the margin of the anus, in  the radiated folds of the mucous membrane
of the part,  fissure of the anus demands an attentive examination.  On  open-
ing the orifice and  desiring the patient to  force down the gut, we will perceive
a narrow slit, red at the bottom, and of which the edges  are slightly swollen and
callous.   In order, however, to recognize its full extent, it is often necessary
to introduce the finger.   We find  that it is more generally situated  either on
the sides or  back part of the anus than in front;  a circumstances favorable to
the operation, especially in women, in whom this aperture  is separated from
the posterior commissure of the vulva, only by a thin partition.   The ulcera-
tion seldom  interests the whole thickness of the mucous membrane.
  The severity of this  affection  depends, therefore, chiefly on  the  painful 
222
LECTURES  ON
spasm of the constrictors of the anus; the fissure is merely accidental, as is
demonstrated by the existence of painful constriction without a cleft, which,
according to celebrated  surgeons, is to the other case as one to four.  This
spasm is so violent that the introduction of the smallest body cannot be borne;
and the resistance opposed by the anus to all attempts at effecting it, is ano-
ther symptom characteristic of the affection.
  The causes of anal fissure are numerous ; the constipation and spasm pro-
duced  tend particularly to it, hardened matter, by destroying the  mucous
membrane, and over-distending the gut may give rise to it; the administra-
tion of enemata by unskillful hands; it is met with in persons laboring under
hemorrhoids; the venereal virus, either deposited immediately on the margin
of the  anus in coitus contra naturam, or having flowed back from the genital
organs of women, is a very frequent cause of the disease.
  The known  insufficiency of all local applications in this afflicting disease,
has caused the successive abandonment of the majority of remedies which had
been considered either as curative or palliative, and we now generally have
recourse to an operation  always safe, it is true, and followed by success, but
which  is exceedingly painful, and to which patients do not readily  consent,
namely, the incision of  the  sphincter ani, or the cautery of the  fissure  by
nitrate of silver.
   The discovery  of  a cure for  this disease, without an operation, would be an
invaluable  benefit to mankind.   If the plan of which we  are  now about to
speak  is not always  successful, it has succeeded so  frequently in the hands
of M. Dupuytren, as to be deserving of more frequent trial.
   We have stated, that the disease actually consists in spasmonic contraction
of the sphincter; the fissure is only a secondary phenomenon.   By overcom-
ing the spasm the patient is cured.
   The application of belladona, under the circumstances, is naturally indi-
cated.  M. Dupuytren first used it, and has derived great advantages from it;
 by combining it with the acetate of lead.  The  following is the formula he
 prefers.
              &  Extr.  Belladonnse
                 Acetat. Plumbi.  a a.   3 i
                  Axungiae            3vi
   A small sized bougie is covered with the ointment, introduced into the rec-
 tum, and gradually increased until it becomes as large as the index finger.
   The following case, selected at random proves the occasional efficacy of this
 mode of treatment.
   Case I.—A young woman strong and of a good constitution, began to feel
 a few months  after  delivery, acute pains in the anus.   The agony was  in
 tense when she went to  stool, and especially if the foeces were consistent and
 indurated. At first they  lasted for only a few minutes ; but gradually increased
 to a duration of  several hours.
   On her admission  into the  Hotel-Dieu, the anus was carefully examined,
 and by drawing out the  end  of the rectum, a very superficial fissure was dis-
 covered.   The constriction of the anus was considerable, the  little  finger
 could hardly  be introduced,  and not without the most excruciating pain
 Strips of lint covered with a thick coat of this  cerate were introduced  inUi
 the anus,  and  renewed  several times  during  the  day.   The  pain   wa* 
CLINICAL SURGERY.
223
instantaneously relieved.  In fifteen days she was discharged perfectly cured,
Without a bloody and painful operation.
  Before treating of the  other means of treatment used by the  professor, it
will be proper to examine  the differences presented by the fissures on account
of their situation.   Those which form below the sphincter ani, affecting merely
the cutaneous tissue and not the anal mucous  membrane, occasion a greater
or less pruritus, but interfere very slightly with the process of defecation,
causing no contraction of the sphincter, and, consequently, but little pain.
They are generally caused by some venereal disease.
  Fissures which are seated above the sphincter affect the mucous membrane;
the eye can only discover them by means of the speculum.   By introducing
the finger  in the  rectum, we find  a knotty hard  cord,  exceedingly painful
on pressure.   The faeces discharged are covered with a puriform mucus, and
bloody on the side corresponding to the fissure.  They are generally the pro-
duct of the ulceration of internal piles during the passage of hardened faeces.
Lastly, fissures on a level  with the  sphincter are more severe than the former;
and in this species we observe the painful constriction of the sphincter, and the
other symptoms above described.
  Fissures of the first two species  are generally cured without any operation,
some by means of lint, covered with simple  or opiated cerate,  pomatum of
curcumis, unguentum  populeum,* mercurial preparations, &c.;  others by
emollient and narcotic lotions, made with decoction of althaea officinalis, poppy
heads, solanum, hyoscyamus, belladonna, stramonium, &c.
  But in that form, accompanied by severe  pain and spasmodic  constriction
of the anus, seated on a level with  the sphincter muscle, the most prompt and
efficacious plan is  the operation introduced by M. Bryer, and which requires
for its performance only an  ordinary and a probe pointed bistoury.
  Case II.—A man of 30 years of age, had suffered for more than four months
with pains in the anus, which were much increased by defecation.  Latterly,
the performance of this function was accompanied by most  horrible agony,
which increased after excretion, and lasted four or five hours.   He had under-
gone various modes of treatment without relief, and at last entered  the Hotel-
Dieu. There was  a small excrescence on the margin of the  anus, a spasmodic
constriction of this opening with a fissure on the left.  The excrescence was
removed by the scissors, and an incision made in the anus at the fissure itself.
A piece of lint covered with cerate was introduced into the rectum and placed
between the  lips of the incision.
   M. Dupuytren here pointed out the importance of the incision at the fissure,
instead of at some distance from it.  Indeed, the debridement of the anus, re-
lieved the pain instantly,  permitted the  fissure to cicatrize, and thus effected
a certain cure. A case occurs, however, in which the fissure cannot be incised,
namely, when it is seated in front towards  the urethra in man or  the vagina
in the female.
   When this disease, simple of itself, is of long  standing, it becomes compli -

  *  Unguentum Populeum.—This ointment  is composed of, five  pounds of lard, one
pound of the fresh buds of the populus nigra, four ounces of the fresh leaves of the black
poppy, as much of the leaves of the belladonna,  hyoscyamus, and solanum nigrum.
—Trans. 
224
LECTURE*  O.N
cated with more or less severe local disorder, and so  great a change in the
constitution of the patient as may endanger his life.
   Case III.—Delahage (A), 24 years of age, of a good constitution, regular,
having had several children, was admitted into the Hotel-Dieu  for several
fissures of the anus, with  excrescences.  The disease had existed for several
years.  At the date of her admission into the hospital the anus was contracted,
several fissures existed In its circumference, and also a considerable mass of
excrescences, but not of an unhealthy appearance.  The alvine evacuations
occured but seldom, but were accompanied by dreadful suffering, lasting several
hours after the evacuation.  The faecal matter was generally mixed with a large
quantity of blood and mucus.
   The patient was growing weaker, she was pale and bloated, especially in the
face, and frequently had fevers.  She denied ever having had syphilis, and was
unable to assign any cause for the disease.   After two or three days of prepa-
ratory treatment, M. Dupuytren performed the operation.  Each tumor was
seized with a dissecting forceps and removed by a pair of curved scissors at
one blow; then  with  a straight probe pointed bistoury, introduced into the
rectum, he made several incisions in different directions, of three or four lines
in depth.  A pledget of lint of the size of  the finger was  placed in the anus
in order to prevent the reunion of the incisions.   On the  same day a copious
evacuation took  place, accompanied by considerable discharge of blood, but
without the  horrible pain  felt before the  operation.   Another  pledget was
introduced into the rectum.  This dressing was renewed every day and after
each evacuation.   The patient became tranquil, recovered her flesh, and on
the22d day was discharged perfectly cured.
                         CHAPTER  XXX.

                               ON RANULA.

   I am now about, said M. Dupuytren, to excise two small tumors which a
young man has under his tongue, near its apex. What is the origin and nature
of these tumors ?  Do they belong to the species known by the name of ranula?
I doubt it.  In the first place, ranula rarely arises under the apex of the tongue,
but is generally seen under the base of its free extremity, and it is precisely
on this account, that its diagnosis is frequently difficult, and that it is often con-
founded with other tumors of entirely a different nature.   Tumors similar to
that under which our patient  labors, arise in the following manner: The
skin is furnished with a considerable number of follicles which secrete an oily
matter; this  secretion, slight in man, is  copious in animals having wool; in
birds, especially the aquatic, in which it preserves the beauty of their plumage,
and protect it from the water  and dampness.  Still more copious in fishes:
it covers, their whole surface with a viscid and glutinous fluid. The same takes
place in the mucous  membranes lining the internal surface of  our  organs.
The follicles are there innumerable, and pour out constantly mucus destined 
CLINICAL SURGERY.
225
to moisten the surface.  These follicles, like all the other tissues of the ani-
mal  economy, may become  diseased; their secretion is  then suppressed, or
modified in its nature or quantity; sometimes it becomes  exceedingly viscid;
at other times, the  mucus  may be changed into an oily substance.  The
apertures of these follicles are sometimes closed ; the contained fluid accumu-
lates, and distends them; they inflame, and become of considerable size. The
tumors may be known by their projecting, their transparency, their indolence,
and, especially, the glutinous serosity, with which they are covered. Rarely iso-
lated, generally numerous and in groups, they adhere to each other by means
of this glue.  They are generally met with on the inner  side of  the  cheeks,
in front of the gums, or beneath the tongue. These tumors are, therefore, mucous
rysts, developed at the expense of the follicles of that name, or sero mucous,
formed in the excretory ducts of the mouth.  It is important to distinguish these
facts, until we ascertain, in a positive manner, what is to be understood by
ranula.
  According to the most general opinion, ranula,  of which the name recalls,
either the shape of the tumor, which somewhat resemble the back of a frog,
or the change in the pronunciation caused by its presence, is a tumor resulting
from the accumulation of saliva in  the excretory  ducts of the sub-maxillary
gland, and sometimes in  those of the sub-lingual glands, but the latter is rarely
the case.
  Whatever may be the true state of the case, as yetwe possess no anatomical
demonstration of the seat of ranula, and it is desirable to discover, whether it
be really situated in the  excretory canals of  the sub-maxillary salivary glands;
or whether it consist simply in a cyst formed by a membrane analogous to the
serous tissues,  and containing a watery fluid; or lastly, whether we  must
al ways recognise in it the characters presented by the tumors under considera-
tion. It is, indeed, probable, that tumors belonging to one of these three series
have been indistinctly confounded, according to their situation, under the name
of ranula, by numerous authors, both ancient and modern, who have treated
of them, and even thus designated affections  entirely distinct from  them,<  Thus
Celsus considered this disease as an abscess of peculiar character, and Ambrose
Pare, has fallen into the same error.  Actuarius pretends to have cured the dis-
ease by opening a  vein, on which  account Camper thinks  that we took the
tumor for a dilatation of the vessel. Fabricius ab Aquapendente placed ranula
among encysted tumors, and compared it to  melices. John Murmicks  thought
that we had  demonstrated it to depend on the accumulation of saliva in the
ducts which open by a principal canal under the tongue; the credit of the dis-
covery of which, is unjustly assumed by Warthon, who published his work in
1656, while Berenger de Carpi,  who wrote  in 1521, spoke of it in a clear and
precise manner; and even Galen, Orihasius, Rhazes, Avicenna, Averrhoes, were
not ignorant of its existence.  According to some authors, children  are  pecu-
liarly liable to ranula, and it is even congenital according to the observations
published in the commentaries of Leipzig, and in the work of Vogel. But may
not ranula, properly so  called, have been confounded with those  sub-lingual
serous cysts which are sometimes very large  and descend upon the sternum? M.
Breschet, who has  published an account of the disease  in the Repertoire a
Anaton}ie, gives five cases of this pretended ranula, and has seen that in the*
bodies of newly born children they were merely simple serous cysts distinct
              29                                                    -  ■'  * 
226
LECTURES ON
from the thyroid, or tumors of the same kind, developed in  the tissue of this
glandular body. Camper has observed on a very young girl two large tumors of
this nature; he has also seen ranula on  each side of the fraenum  linguae in
women and several men; but states never to have met with it in children.
   The  occlusion  of the orifice of the external canal of the sub-maxillary
giand, may proceed from inflammation of the sublingual mucous tissue, of
the same tissue of the tongue, from aphthae and ulcerations about this orifice.
In  division of  the fraenum  linguae, the excretory ducts, which open on each
side of this membranous fold, may be cut, and their obliteration result from
the cicatrization of the wound.   Small calculi in the ducts, may oppose the
flow of the saliva.  It is difficult in practice, to determine the  cause of the
disease, as it grows easily, and the patient seldom requires the surgeons atten-
tion before it has made considerable progress.
   In general the symptoms of ranula are so distinct, that we may  very readily
recognise the affection.  It is a soft whitish tumor, regularly round or oblong,
seated under the tongue, presenting  fluctuation, without pain, redness or the
other phenomena of inflammation, yielding slightly to the finger and recover-
ing its  shape on the removal of pressure.   At first scarcely apparent, but
gradually increasing, it  seldom exceeds in size a walnut,  or pigeon's egg,
although it has  been seen as large as a hen's egg.
   As it  increases,  the tumor thrusts the  tongue backwards, displaces or
unroots the teeth, alters the voice,  embarrasses the articulation of sounds,
prevents children from sucking, and others from eating and swallowing.
  It depresses  or thrusts aside all the parts with which it may be in contact,
and at last appears outwardly under the jaw and anterior part of  the neck.
  The cause and  nature of the  disease being well known, its cure is  appa-
rently simple, yet we find that this has but seldom occurred.
  The most  usual method is to puncture the tumor where it appears in  the
mouth, with a lancet or trocar.  If the matter contained is fluid and not very
viscid, and no  concretions exist,  this species of paracentesis  may empty  the
tumor  and give temporary relief, for  soon  after the operation, the aperture
closes, the saliva re-accumulates, and the tumor again appears.   T. L. Petit
relates a case in which  this operation was performed ten times without entirely
removing the disease.
  Indeed, the result to be desired, is not only to empty the tumor after having
punctured it, but  also to prevent a new accumulation of the fluid, and, in
order to effect this, the aperture must be kept open.  This can be  better done
by the actual cautery than by any other means: this, however, does not always
succeed, as we have learned from our own experience, and that of Sabatier
and other distinguished surgeons.   It is surprising that an opening made in a
sac, distended by a fluid constantly flowing into it, should be insufficient, and
that this continual flow should not prevent the closing of  the orifice.   This
is, however, a well known fact, and it would  seem to prove that in the forma-
tion  and maintenance of fistulas, there is something more than the mere flow
of a fluid, since a simple, or one with loss of substance, cannot produce a fis-
tula in the duct  of Warthon, by which the ranula would be  cured ; or else the
return of the tumor, after having been opened, indicates the existence of a
serous cyst, rather than of a ranula formed by the dilatation of the excretory
canals of a salivary gland. 
CLINICAL SURGERY.
227
    The excision of a part of the parietes of the tumor has been proposed and
 executed;  but in many cases it has merely delayed the relapse without effec-
 tually preventing its recurrence.   The loss of substance renders«the cicatriza-
 tion slower, but it as necessarily follows as in a simple incision.  The excision
 should be performed when the tumor is of considerable size, and its parietes are
 thick, strong and resisting.  The wounding of nerves or important vessels is
 not to be feared, and astringents will  generally arrest the slight hemorrhage.
    Such is not the case in  extirpation.   This has been  proposed but never
 attempted.  What could be the design of this operation ?  Were we to remove
 the tumor alone, we would undertake a difficult and delicate operation, with-
 out being certain of preventing a reproduction of the disease.  The gland
 itself should be removed.
    Could the injection of some irritating fluid  into  the  sac, cause the  inflam-
 mation and consequent adhesion of the parietes of the cyst ? The functions of
 the gland would  then  be  rendered useless;  the fluid which  it continues to
 secrete, finding  no exit, would  gradually distend the  ramifications of the
 excretory ducts lodged in the interstices of the lobules  composing its  sub-
 stance, and might cause swelling followed by acute pain, inflammation, suppu-
 ration and an outward fistula; lastly, the inflammation produced by the irrita-
 ting fluid, might extend to the tongue, larynx and other parts.   In fine, if the
 disease be seated in the external canals of the salivary glands, the treatment
 by injection is irrational and  useless; if, on the contrary, ranula is  merely
 an encysted tumor, containing a serous or albuminous liquid, injection  may
 be of service.
   The catherctism of the excretory canals of  the sub-maxillary  glands is dif-
 ficult, and as ranula is owing less to  a contraction of these ducts than to their
 obliteration by inflammation, or by the  presence  of  some foreign body, it
 appears to me that  the employment of small  sounds  or  bougies is entirely
 useless.
   The use of the cautery will be found to have  existed during the earliest days
 of  dogmatic  medicine.   This mode of practice was adopted by Hippocrates,
 Celsus, and Fabricius ab Aquapendente, Severinus and Tulpius, recommended
 the use of the actual cautery, but  only according to the latter, when the
 tumor is hard and  its  parietes xcry thick.   Ambrose Pare is  of the same
 opinion, and thinks that the tumor should be opened with  a red-hot iron.
   The potential has  been represented as preferable to the actual cautery,, inci-
 sion, and extirpation; but there is a danger of being unable to limit the action
 of  the caustic, and preventing the destruction  of the duct  of Warthon  itself.
 Camper says  he  has succeeded by  opening the tumor, and then touching it
 with nitrate of silver, hut confesses that ho was obliged to repeat the applica-
 tion, several times.
   It follows, therefore, from the foregoing statements, that: the curative indica-
 tions of ranula, consisting in giving exit to the contained fluid, and preventing
 the closing of the  orifice, in order to guard against a return  of the disease,
 have been known to the majority of  writers on the  subject, but that none of
 them has had the  desired effect.  All the methods of which we have hitherto
 spoken, are liable to  insurmountable  objections; the following, first practised
by M. Dupuytren, is simple in performance, and  certain in  effect, and  has
been used by him several times successfully. 
228
LECTURES  ON
  This surgeon imagined, that the most certain method of obtaining a radical
cure of ranula, would be to  keep the orifice constantly open, by means of a
foreign  body introduced and left in the cyst;  in short, to treat the disease in
the same manner as he has, for 20 years, treated fistula lachrymalis.
  In order to effect this, he caused to  be made, a  small hollow cylinder, of
four lines in length, and about two in  breadth, through which the saliva was
to flow.  Each extremity terminated in a small ovoid plate, slightly concave
on one side and convex on the side adhering to the cylinder; one of these plates
was to be placed inside of the tumor, the other outside, that is, in the mouth.
The instrument resembles precisely, the  double-headed button, still  used by
some persons to fasten their garments with.
  It may be made of gold, silver, or platina, but the latter metal is preferable,
as being less liable to damage from the animal fluids.
  The following is the first case in which it was tried.
  Case I.—Duch&teau, 24 years of age, a drummer in the Imperial Guard.
of a bilious  temperament, has had for  the last three years, a small  tumor
under the tongue.  It increased slowly without any pain, but impeded greatly
the motions of the tongue.  Wishing to be relieved of it, he came to the Hotel-
Dieu on the 14th of October, 1827.  On  the sides of the fraenum, there was
a small  oblong, demi-opaque tumor, extending in the  direction of the canal
of Warthon, and apparently  produced  by the dilatation of the excretory duct
of the sub-maxillary gland.   Different remedies had been tried, but with only
temporary relief.
  M. Dupuytren performed the operation in the following manner: an open-
ing was made in the sac, with curved scissors;  then, by means of dissecting
forceps, he introduced the little instrument into the opening, so that one of the
plates was left free in the mouth.  From  that time the tumor daily diminished,
the  incision healed over the cylinder of the instrument, and in 15 days, he left
the  hospital perfectly cured.
  M. Dupuytren,  after this operation,  devised some  improvements in the
instrument.   The plates were made smaller, of an elliptic form, and reversed,
so that their concave surfaces  looked towards each  other ; the canal in the
cylinder was considered useless, and therefore closed and made much smaller,
so that its size was reduced to three lines in length, and one or one and a half
in breadth.
  In  the following case, detailed by Dr. Marx,  the  success was perfect
although the instrument had  not undergone the modifications just mentioned.
  Case II.— Tellier, V., 24 years of age, was admitted into the Hotel-Dieu
on the 27th of October, 1820, having labored for several years under a tumor
on the left side of the fraenum linguae, as large as a small hen's egg.  It em-
barrassed greatly his pronunciation, mastication, and respiration.
  The professor seized it with the forceps, and made an incision in it with the
curved scissors.   A quantity of mucous, ropy, and limpid fluid escaped, and
the tumor collapsed.   The  instrument was introduced into the orifice and
there left.  The patient came to the consultation 11 days after the operation,
the saliva flowed freely between the edges of the wound and the  instrument.
Some months afterwards, the instrument was still in its place, and  the  tumor
had not re-appeared. 
CLINICAL  SURGERY.
229
  The following is a very interesting case, inasmuch as it affords a comparison
on the two methods, practised on the same person, affected with two tumors of
this kind, independent of each other.
  Case III.—The woman  Pic, 43 years, of age, came to the public consul-
tation at the  Hotel-Dieu, on the fifth of July, 1824.   She  had a soft tumor
of the size of a small hen's egg on each side of the fraenum linguae.  Her
voice was changed,  respiration and  deglutition  performed with difficulty;
an examination showed  the tumors to be independent of each other.  They
had  existed for three months, and been punctured three times, but as often
re-appeared.                                                      ,
   M. Dupuytren here took occasion to compare his method and the simple
incision.  He, therefore, introduced his instrument  on  the  right  side,  and
simply made  an incision on  the left.  The  latter re-appeared, was operated
upon in the manner of the first and entirely cured.
   Case IV.—T. G. Vilcoq, 49 years of age, a worker in cotton, had felt
for two months some uneasiness under the left half of his  tongue.  He then
saw a small elongated tumor which, from that time, had increased insensibly.
On the 21st of October,  1821, he came to the Hotel-Dieu.  On the left side of
the fraenum of the tongue, there was an ovoidal tumor, having its great diameter
directed from behind forwards, and slightly from  without inwards.  The long
diameter was about fifteen, and the smaller not  more than  six.  The tumor
was soft, fluctuating without change in  the color of  the mucous membrane,
heat, or pain, on pressure.  It elevated the left side of the tongue  and thrust
it towards the pharynx; from which resulted a  considerable embarrassment
in speech, mastication, and even deglutition.                       # #
   The  next  morning, M. Dupuytren, with a bistoury, made an incision  ot
about two lines in  length, at the distance of an inch from the apex of the
tongue very near  the spot where the mucous membrane of the mouth is
reflected over the under surface of the organ; he  then introduced, as usual, his
instrument into the cavity of the tumor.  A clear, viscid,  ropy  liquid, which
only partly escaped at the moment of the incision, continued to flow,  lhc
 tumor became completely emptied.                          .
   On the 3rd day, Vilcoq was perfectly easy, the instrument retained its place.
 On the 25th the instrument had fallen out the evening preceding, and the
 tumor begun to appear. By pressure a quantity of fluid as at  first escaped
 M  Dupuytren endeavored to re-introduce the instrument, but the thickened
 lips of the incision would not pass between the  two plates.  A  new one was
 made, on the plan of the first, but having a stalk two lines longer.   1 his was
 easily introduced on the next morning.
    All  went on favorably until the  15th of January following.  At that time
 some uneasiness began to be felt around the wound.   A small tumor soon
 appeared, situated immediately on the back part of  the plate which mycte
 into the mouth.  This  second tumor was similar in character to the hrst, and
 in ten days  became as large as a hazel nut.
   T"e nmfessor having examined it, found  it to be  independent  of the firs
 and decllrd that this  secondary ranula was multilocular.    He made a small
 Vision in thesac,  by  which a quantity of viscid fluid escaped free from taste
 or  smeV  This evacuation was followed by the disappearance  of the tumor,
 and of all embarrassment in the motions of the tongue. 
230
f.EcTURl.P ON
  From the cases just related, it will be perceived that if the tumor be large,
and  its parietes very thick, it is  better, before applying the instrument, to
make a large incision in the sac, and  even to  remove a portion of it, and
introduce the instrument, only when the wound being nearly healed, presents
an orifice just large enough for its admission.  It will he seen by the follow-
ing case, how rapidly this cicatrization takes place.
  Case V.—Devaux, 40 years of age, a gardener by trade, has had for ten
days, some pain in the mouth under the left inferior part of the tongue.  He
soon perceived a small tumor growing at this spot.   It increased rapidly, and
when the patient came to the consultation at the Hotel-Dieu, it was as large
as a small walnut,  situated on the left side of the lower part of the mouth,
extending to the right and separated in this spot by the fraenum.  Larger in
front than behind,  soft,  fluctuating, of a violet-red color, demi-transparent,
itwas without pain, but embarrassed considerably the movements of the tongue,
and gave the voice a peculiar tone.  The patient said  that when  he talked,
the tumor vibrated,  and caused a buzzing, that extended over all his head.
His general health was excellent.
  M. Dupuytren performed the operation in the following manner: the head
was  held by an assistant, the left angle of the mouth drawn downwards, the
tongue thrust out of the mouth, and turned to the right; the tumor became
more apparent.   An incision was made in its apex,  and a quantity of  trans-
parent, ropy fluid escaped. The canula was then introduced, but the incision
bein<* too large, it fell out.  Several attempts were unsuccessful, and its intro-
duction was postponed until the following day.  The wound was then found
to be nearly closed, and required dilatation with a fine  probe, the canula was
introduced, held down by a pledget of charpie, and  kept in place by bringing
the jaws together.
  The success obtained by M. Dupuytren, in  many other similar cases, with
this  little instument, has been the same, and it. is needless to multiply them.
This  easy  and ingenious method, differs  entirely from all others, without
excepting the bougies, canulas, setons, &c; for experience has shown, that
when D'fse foreign bodies were withdrawn, the orifice closed, and the disease
was  re-established.   But the  professor has not forgotten under these circum-
stances. :iiat in the treatment of other affections, every method  of cure  should
be appropriate to the nature of the  cause of  the malady, and that the expe-
rienced practitioner acknowledges no exclusive plan of treatment.  Wc have
observed in the course of this  chapter,  that inflammation, by attacking the
excretory ducts of the sub-lingual and maxillary glands,  may give  rise to
ranula.
  In these cases, the formation of the tumor is  sudden, its development rapid,
and  the  tension, pain, and redness of the parts, distinguish this species from
that produced by any other cause.
  Here the retention of the saliva is merely  the effect of the inflammation, and
will  cease on the removal of the cause.  Local bleeding, either by  scarifi-
cation or leeches, should precede the operation.   Ranula in such casos may
be compared to a retention  of  urine,  caused by the inflammation  of  the
bladder or its appendages.
  The following case will support these remarks.
  Case VI.—Engrot (M.), 21 years of age, irregular in her menses, had undei 
CLINICAL SURGERY.
231
the lower jaw on the right side, a hard tumor, formed by the sub-maxillary
gland. Since its first appearance, six years ago, it has increased to the size of
a hen's egg. It was painful when handled, and the slightest pressure caused a
jet into the mouth of a mixture of pus and saliva. On the other side, there has
been forminig, for three weeks, another tumor caused by the accumulation of
saliva in the duct of  Warthon.  It was divided into  two equal parts by the
fraenum lingae, hard and resisting; her pronunciation was impeded, and her
voice had that peculiar sound from which the disease takes its name.  Respi-
ration and deglutition were difficult.
   On examination, M. Dupuytren supposed the tumors to be of an inflamma-
tory nature.  His diagnosis was founded on the pain, redness, and resistance
of the dilated duct.   He, therefore, prescribed leeches, emollients and revul-
sives, with such success,  that in twenty-four hours, there was a decided im-
provement, and in six days the patient left the hospital entirely cured of her
unpleasant malady.
   We have said, elsewhere, that ranula may be simulated by tumors developed
at the spot in which it generally occurs, or in its vicinity.  Indeed the inflam-
mation of the sub-lingual and sub-maxillary tissues, may develop tumors of
which the external appearance is analagous to  it.  Such are abscesses, the
serous and sero-mucous cysts of which we have already spoken.  The diag-
nosis frequently becomes very difficult.
   The case with which we shall close this chapter, is exceedingly interesting,
on account of that very difficulty.
   Case VII.—A seamstress, 69 years of age, was  admitted into the Hotel-
Dieu.   For the last four  months, she has had an indolent tumor below and
on the  left point of the tongue, which organ has been gradually thrust aside
by its increase, latterly it has  gone beyond the floor of the mouth, and pro-
 jected  on the upper and left side  of the neck.   Several physicians whom she
consulted, pronounced it  to be ranula.   On her admission into the hospital,
four months after the appearance of the  disease, the tongue was raised and
thrust to the right,  by a tumor of the size of a pigeon's egg, indolent, soft,
and fluctuating. It  extended across the muscular floor of the mouth, as far
as the upper part of the neck.  There it swelled  again and formed a new
tumor,  as large as  an ordinary apple.  Indolent like the first, this also pre-
sented  an«appearance of fluctuation.  Otherwise, the patient's  health was
good, but it was observed that she possessed great physical and moral irrita-
bility.
   The mode of origin of the tumor, its shape, and consistence, might mislead
as to its true nature. It might be ranula, or a lypoma.  In order to remove
 all doubt, M. Dupuytren made a deep incision into it with a bistoury; no fluid
 escaped,  but fatty flocculi projected through the  lips  of the  wound, and
 evinced the lipomatous character of the tumor.  It was extirpated on the 4th
 of July.
   Although this case presented some difficulty in  the  diagnosis, there still
 existed so*me peculiarities, which, independently of the puncture, might  have
 led to a knowledo-e of its nature.   Its size inside of the mouth, was less than
 it generally is  in ranula of long standing, which descends to the upper part
 of the neck.   Before thus pushing before it the muscles forming the floor of
 the  mouth, the tumor formed by the distension  of the duct of Warthon, 
232
LECTURF.S  ON
acquires a considerable size in the buccal cavity, and the more easily, as the
tongue offers less resistance than the muscles of the supra-hyoidal region.
  Another character of this tumor, which is not  remarked in ranula, is the
species of strangulation which  is presented at its middle,  and at the point
where it passed from the mouth to the upper part of the neck.   When ranula
extends thus far, it forms a more rounded tumor, which continues more uni-
formly with that part of itself which raises the point of the tongue.
  Such  are the  symptoms from  which A priori its true nature might be
known.
                        CHAPTER  XXXI.

                ON ABSCESSES  OF THE RIGHT ILIAC  FOSSA.

  Last year, a man was admitted into the Hotel Dieu, laboring under the
symptoms of a disease to which M. Dupuytren has already called the attention
of surgeons, and which  has been very ably described in the essays of M. M.
Husson, Dance, and Meiniere.
  The individual in question was about 40 years of age : he had pain and a
circumscribed swelling in the right iliac fossa; leeches, emollient poultices,
and mild laxatives  produced a most happy effect upon the tumor which was
perfectly cured.
  Long ago, said M. Dupuytren, I have shown that tumors which have appa-
rently an intimate connection with the ccecum are developed in the right iliac
fossa.   These tumors are generally accompanied by remarkable disturbance
in the functions of the large intestine; in  many cases they terminate by reso-
lution;  sometimes by copious  suppuration ; and again they are the centre of
inflammation extending over the whole surface of the peritoneum. Therefore
under these different aspects, they appear deserving of accurate investigation.
One of the first questions  which naturally  arise is, why they  form almost
always in the right iliac fossa ?  Why do we rarely see them in the left fossa ? It
is owing to the configuration of the  intestine and surrounding parts alone.
Buried  in a mass of cellular tissue, the caecum presents at its junction with the
small intestine, so  remarkable a contraction, that at that point (the ileo-caecal
valve) we frequently find a  mass or foreign substance which may of itself be-
come the cause of these abcesses.  This is not the case with the left  side, the
sigmoid portion of  the colon,  presents at  its  points of union no contraction,
and the division of the intestines is perfectly natural.   Lastly, the anatomical
structure of the parts will explain this fact; on the right side the caecum is
free  posteriorly from any peritoneal covering, presents at this point less re-
sistance to the pus, and its  parietes being thinner, when ulcerated soon give
away.  On the contrary, on the left  side, hermetically enclosed in the peri-
toneum, protected by this membrane and the aponeurotic expansion of the iliac
 muscle, the pus, in order to reach the intestine, must raise up the mesocolon
 and unfold its duplicatures.  A more easy exit is offered; it travels towards
 the crural arch and inguinal ring; and here we might be misled, if  we were 
TLIMCAL SfROERY.
not well acquainted with the distinguished  marks of hernia or abcesses by
conjection with which this disease may be confounded.  Again, at this  point
the alimentary matter takes on the excrementitial character, and is obliged to
move in opposition to the laws of gravity ; and, lastly, in this portion of the
intestinal canal, we frequently meet with inflammatory alterations in a majority
of diseases.  Hence, all these circumstances, whether natural or morbid, are
favorable to the production of these engorgements exterior to the intestine, and
explain their frequency in the right iliac fossa.
   These tumors  are often preceded  by symptoms which announce  the  ap-
proaching development of the disease.   After some error in diet, a constipation
or diarrhoea of longer or shorter duration, more or less habitual colic, sometimes
without any of these causes, the.patient suffers from violent colic and pain in
the bowels, with a tendency to concentration in the right iliac fossa: it may also
extend towards the large intestine, or  over the whole  abdomen.   This colic is
generally accompanied by constipation, and sometimes vomiting.   Such  are
the symptoms by which we may predict the  occurence of the tumor.   They
are of very various  duration, sometimes lasting for  a month or more, some-
times for a  few days only.   They are of  course merely relative, as they fre-
quently exist, without any appearance of an  iliac tumor.
   The symptoms peculiar to the disease, are  fixidity of pain in a circumscribed
spot in the iliac fossa, and tumefaction at that spot.   In examination, we will
find it more tense, resisting, and frequently a tumor of variable size, possessing
more sensibility than any other part of the abdomen, and apparently reposing
on the cajcum.   The patient complains of constipation, colic, difficulty in dis-
charging the stercoral gas.  The fever is sometimes high, but there is generally
not much  severe constitutional irritation, unless the disease be complicated.
Thus the fever and anorexia belong to the gastric affection ; the constipation
and diarrhoea, depend, either on the same cause, or on the size of the tumors.
   The predisposing causes are various. Adult age has considerable influence.
Of .*>ixteen cases,  carefully collected, eleven were under 30 years of age ; more
than two thirds belonged,"therefore, toa period of life in which gastric affections
are predominant.  The accounts in  the Hotel-Dieu, show  that the  affection
occurs principally in  the male sex.   It is difficult to account for this singu-
larity, but such is the case both in hospital and private practice.  The season
of the year does  not appear to have any direct influence over the appearance
of the tumors ; they have, however, been observed to be more frequent in the
latter part of summer and beginning of autumn ; this coincides perfectly with
the greater frequency of abdominal affections, and  supports the opinion  of
those who think it originates in lesion  of the mucous membrane.  The exciting
causes arc numerous and important.  The profession of the patient influences
very much its appearance;  painters, grinders of colors, turners of copper,
constantly  exposed to the dust and exhalation of certain irritating metals, suf-
fer from colic, or diarrhoea, which, after  sometime,  give rise to the formation
of the tumor.   Persons leading a sedentary life are also liable to be affected
after havin«- been laboring under much disturbance in the digestive functions
   The place of residence cannot be considered as unimportant; for we have
many patients recently arrived in Paris, who evidently owed their sufferings
to a  residence in that city.   The food  of poor, workmen is so bad, even in
good seasons, that a great portion of those who enter  the hospitals with severe
                  30 
Z34
LECTURES  ON
gastro enterites, may trace their disease to that cause.  Therefore, all causes
which can produce irritation of the intestinal mucous membrane, may deter-
mine phlegmon of the iliac  fossa.  Those persons, also, who have indulged
in the use of alcoholic liquors rendered irritating by the addition of some
acrid substance,  are much more liable to it.  The progress and termination
of these tumors' is not always the same: the most fortunate and frequent is
by resolution.  This generally, is effected slowly, and for a long time a hard-
ness remains, indicating the seat of the engorgement.
  In other cases, a pulsatile pain is felt in  the side of the  turner, which
increases, softens, and at last opens into the intestine.  This favorable termi-
nation is announced by an irresistible desire to evacuate the bowels, followed
by  the discharge of purulent matter, coinciding with  a decrease of size in
the tumor. The cure generally soon follows. These abscesses do not always
terminate by opening into the caecum ; sometimes they open at once into the
csecum and bladder, or into the vagina, and sometimes  externally.  This is
generally an unfavorable termination, for as the opening in front is at the most
elevated spot,  the  evacflation of the pus is slow and incomplete.  In such
cases, I  advise the patient to rest  on his belly, so that the opening in  the
abscess may become the most depending part.
  These abscesses have this remarkable character: that  the purulent matter
may appear in  the  intestine, without  any effusion  of faecal matter into  the
cavity of the abscess. This may depend on three reasons. First, the abscess is
gradually emptied ; the  pressure of the abdomen prevents  a vacuum  being
formed, by which the faecal  matter might be  introduced.   Secondly,  the
obliquity of the opening ;   and thirdly, the separation of the intestine, which
acts as a valve.
  Lastly, in some cases, fortunately rare, inflammation extends rapidly from
the iliac engorgement to the peritoneum, sometimes, at the same  time to  the
port-peritoneal  cellular tissue.   Probably, in some cases, the  inflammation,
attacking primarily but locally the peritoneum, is merely propagated from the
iliac fossa to the rest of this membrane. Death may result from this extension
of the disease, and it demands our most earnest attention
  Having laid down these ideas, let us detail a  few cases tending to support
them.
  Case II.—A young man, 23 years of age,  of fair complexion, delicate,
scrofulous diathesis, and  subject to  hard work, experienced  in  December
(1828), some symptoms of enterocolitis, which at first  were neglected, but
afterwards treated  by purgatives.  He never would attend to his diet.   A
phlegmonous tumor having appeared in the right iliac fossa, it was treated by
emollients.  The patient came to the Hotel-Dieu just when the  tumor was
about opening;  a bistoury was plunged deeply into it, and a copious discharge
of pus took place.   Although the depending position of the aperture ought to
have prevented the stagnation of the pus at the bottom of the abscess, the latter
was  not completely emptied, and the tumor situated inside of the crural arch,
continued to increase.  A counter-opening was made, but "this double issue to
the pus, did not improve the  state  of the patient.   His strength diminished,
the right leg became infiltrated, diarrhaea and hectic came on, and the man died
in the fifth month of the disease.
  The  autopsy  displayed  a large  abscess  situated in  the cellular tissue; 
CLINICAL SURGERY.
235
surrounding the cascum, and extending in the direction of the psoas and iliacus
muscles.  The bones were denuded in some places.  The caecum did not
communicate with this abscess, but was evidently much thinner posteriorly;
its mucous membrane was thickened, of a slate color, and softer than natural.
There was also found a chronic  pleuritis and incipient hepatisation in the
lower lobes of the lungs.   The other organs were free from any alteration.
  Case III.—A tailor, 24 years of age, was admitted  into the Hotel-Dieu,
having in the right iliac  region, several fistulous openings, discharging pus
and  faecal  matter.  The primary disease  treated in the hospital at Orleans,
was a  phlegmonous tumor, neglected at first by the patient, but afterwards
treated by  local emollient applications.  He discharged pus by stool and his
health was partially restored.  The young man came to Paris to complete his
cure, but found the disease to increase; the engorgement augmented, and the
abscess opened above the crural arch.  The malady was accompanied by con-
siderable emaciation;  cough, diarhcea, oedema of the  lower  limb and several
times, since his admission, he has  been at the point of death.
  However, after a treatment of some months, his general state improved, and
after a large number of douches and baths,  the  patient was discharged cured.
  Case IV.—A man, 28 years of age, was attacked with vomiting which lasted
six days, a phlegmonous tumor was then perceived in the region of the caecum.
  An emeto-cathartic was prescribed, which increased  the disease ; leeches,
emollients.  At the end  of three weeks the pus passed into the caecum, and
was discharged per anum.  The  tumor preserved its size, and the surgeon,
desirous of giving exit to the pus, opened the abdominal  parietes without find-
ing the abscess, and thus reached nearly  to  the caecum.  The wound  was
healed.  His health soon began to decline  ; he had  fever, diarrhoea, general
emaciation.   At the end  of six months, after a journey in a very rough  car-
riage, an abscess appeared under the cicatrix, and opened  spontaneously ;  a
quantity  of pus and faecal matter was discharged.—By  proper means he  was
cured in eight months.
  Case V.—Inflammatory Engorgement in the Right Iliac Fossa, terminat-
ing in an Abscess opening into the Csecum.—A young man, 20 years of age,
admitted into the Hotel-Dieu, on the 16th of September, 1827,  has had for fif-
teen days the following  symptoms :  frequent desire to go to  the stool,  like
dysenteric  tenesmus, but  without any evacuation whatever; transient  colic,
accompanied by borborygmi and pain in the bowels;  pain with circumscribed
swelling  in the right iliac  fossa, without fever or general disturbance.  In the
beginning some nausea, and later., some pain and difficulty in  passing water.
  No particular cause had preceded the development of these  symptoms, the
patient was not subject  to constipation, had  committed no excess, and  had
merely had diarrhoea two days before the attack.   (He  was bled  in the  city,
and thirty leeches applied to the iliac  region.)
  On the day of his admission into the hospital, the patient had a pretty copious
purulent evacuation ;  17th and 18th, several of the same nature ; on the  29th
there was still some  pus mixed with the  faecal matter;  the iliac tumor  had
decreased in size, the stools were of more natural aspect, the colic had ceased,
and on the fourth day after the opening of the abscess, the patient  was con-
valescent.
  Reflecting on these engorgements, their symptoms and terminations, we see 
23 G
LECTURED  ON
that they are true phlegmons, developed in the vicinity of the caecum, exterior
to the cavity of the peritoneum, but capable  of communicating inflammation
to this membrane.
   The diagnosis appears to me, said  M. Dupuytren, of sufficient importance
to arrest, for a short time, our attention.
   In the right or left iliac fossa, inflammatory engorgements are often indis-
tinctly seen, apparently having the same situation as the preceding;  but they
really exist in the cellular tissue uniting the fibres of the psoas and iliac mus-
cles, and  beneath the aponeurosis known by the name  of iliac fascia.  This
disease is called by writers psoitis.
   After delivery, engorgements frequently appear in both  iliac fossa*, but in
the  thickness of the round ligaments  whose course  they follow, or they arise
in the cellular tissue, interposed between the broad ligaments of the uterus, and
may extend thence to the whole adjoining  cellular  tissue, and appear in the
iliac fossae.   These abscesses sometimes open into the uterus,  and sometimes
into the vagina.
   Under certain circumstances, the iliac fossae are the  seat of purulent col-
lections, whose origin is sometimes far distant, such are abscesses, symptomatic
of caries of the bones, or  inflammation of the adjacent ligament. The pus then
travels along the psoas and iliac muscles, is  deposited in the iliac fossa, and the
tumor is soft and fluctuating from its first appearance.
   Errors in  diagnosis may nevertheless take place.  Thus  have I seen this in-
flammation  give rise to  the belief of the existence of internal strangulation,
hepatitis, metritis and even peritonitis. In the two last cases, the exact restric-
tion of the disease to the right iliac  fossa, the retention of faeces, the compari-
son of other symptoms, rectified the mistake ;  and  the evacuation of  the pus
per anum, almost on the  day predicted, confirmed the diagnosis.
   The prognosis is generally favorable, since of sixteen cases, observed undei
different circumstances,  one alone  perished.   When  the symptoms yield
promptly to the remedies, the stools become natural, the fever disappears, and
the size of the tumor diminishes, we may anticipate a speedy cure.   When, on
the contrary, the symptoms continue,  and the tumor becomes the seat of fluc-
tuation, at first obscure,  afterwards more apparent,  and the pulsations are ac-
companied by lancinating pains, we must expect to see the pus discharged/>er
anum, and here the prognosis is still favorable, because experience  has often
shown the cure to be not less complete when the disease terminates by reso-
lution.  Should general  peritonitis, occur,  a fatal termination is to be feared,
because the  development of this disease is the signal of the rapid increase of
the primary affection, and their combination is beyond  the power of  human
skill.
   The treatment should be preservative (preservatif)  and wc may nearly
always, when called in time, if not prevent the formation of the tumor, at least
arrest its progress ;  when pain in the iliac region is accompanied by alternate
diarrhoea and constipation ; when we find on examination a deep and illy cir-
cumscribed  hardening of the tissues, local bleeding, emollient, and gentle lax-
atives, or enemata will subdue the symptoms.  Absolute rest and  frequent
bathing are  very  efficacious; strict diet is  also indispensable.   If the tumor
have already attained some size, local and  general bleeding are necessary to
arrest its increase.  If the patient be robust and have fever, he must  be bled 
CLINICAL SURGERY.
237
immediately, and  the tumor be covered with leeches, ami afterwards with a
large poultice; emollient enemata morning and evening, and also veal broth,
containing sulphate of soda or magnesia.   The oily juleps  should be given at
night, and the leeches repeated according to circumstances.
  The diminution of pain, and decrease of the tumor, announce the commence-
ment of resolution, and we  must be satisfied to aid it by emollient applica-
tions, rest, and diet. If, on the  contrary, the tumor preserve its size and sen-
sibility, in spite of the remedies, fluctuation will soon manifest itself. Absorp-
tion should then be assisted, by continuing the antiphiogistics. if the state of
the patient will allow, or the  topical  emollient, until the opening of the tumor.
In this case, some patients have derived  advantage from the Use of mild laxa-
tives, which stimulate the contraction of the intestine, and promote the evacua-
tion of the pus.   Lastly, if  inflammation of the peritoneum should occur, it
must be treated  by the proper  means, which it is not our intention to dis-
cuss here.
                        CHAPTER  XXXII.

       PRACTICAL REFLECTIONS ON THE USE OF  CAUTERIES AND MOXAS.

   The application ot cauteries and  moxas is  followed by  the  most happy
 results in diseases of the bones and articulations.  Their immediate effects are
 more or less severe pain, the formation of a dry or humid eschar, produced by
 the disorganized tissues, combined or not with the cauterizing matter.   The
 secondary result i, a revulsive irritation produced by the pain produced in the
 skin.   Soon after an  inflammation, which  I  have "called eliminatory, takes
 place, followed by loss of substance, and a copious suppuration from the sub-
 cutaneous cellular tissue.  In six or seven hours, the action of the cautery is
 exhausted, and the eschar is formed.  The latter is of a deep brown or yellow
 color,  moderately red at its circumference, swollen and painful.    In a  few
 .lays the swelling ceases, and the separation of the eschar generally takes place
 from the eighth to the twentieth day, and the sore thus produced may be easily
 kept up.                                                       J      "  J
   I do not intend, said M. Dupuytren, to treat minutely of the places proper
 to establish an issue; it will  be sufficient to remark, that we should prefer
 points  well furnished with cellular tissue, remote  from osseous projections
 tendons, and the centre of the muscles.   In the arm, we generally select  the
 slight  depression existing between the inferior insertion of the deltoid  and
 superior insertion of the brachialis  internus muscles.  In the thi<di, the'eau-
 tery is almost always placed at a few fingers'  breadth above the internal
 condyle of the femur, on the cellular line which  bounds in front, the internal
 portion of the cruraeus, and behind, the adductor magnus and gracilis muscles.
 The best spot in the leg, is the space comprised between the inner edge of the
 tibia, and the corresponding side of the gastrocnemii muscles, below the tendi-
nous expansion formed by the sartorious and plantaris muscles. 
238
LECTURES ON
  In many cases, it is useful to produce the slough in the skin slowly, in ordei
that the irritation produced  by the continued action of fire, may be more
severe and  penetrating.   The most  convenient plan for eftecting this, is by
moxa.
  The two  varieties of cautery of which we have spoken,  cause  a wound,
which suppurates  for a longer or shorter time, and which at last cicatrizes.
In order to prevent this  termination and keep up the suppuration, foreign
bodies, such as orange seeds,  issue peas, &c, are introduced.
  This, is  sometimes a good plan,  but I have often seen it  produce serious
symptoms, and even aggravate those it was intended to relieve.
  The  extreme irritation caused  by  the  presence of the foreign bodies,
extends to die joint and diseased parts of the bone.  Fever, thirst,  insomnia,
attack the  patient, and disappear only on the removal of the foreign bodies.
Practitioners,  supposing that these  phenomena are owing to the presence of
these  bodies, fear to use them again, and thus deprive themselves of a valua-
ble remedy. For many years I have ceased to use them.  After having applied
the  cautery and the moxa, I permit  the slough to separate, and the ulcer to
suppurate without stimulating it.  When it has healed, I apply another cau-
tery in the vicinity of the preceding,  until I have obtained the desired effect.
In this manner I obtain all the advantages of these powerful revulsives, with-
out any of  their inconvenient accompaniments.
                      CHAPTER  XXXIII.

      ON  HYDATID TUMORS DEVELOPED IN THE MUSCLES  AND VISCERA.

  I have  frequently seen, said M. Dupuytren, in the course of the muscles,
hydatid tumors, whose development impeded more or less the functions of
the parts  in  which they were situated.  Their effects are singularly various
In  general,  these cysts seem to act on our organs like foreign bodies,
thrusting  aside or compressing the  parts with which they are in contact;
and hence are frequently confounded with several other affections, especially
ordinary encysted tumors, containing merely serum, or albuminous matter of
various aspect.
  The cysts of the acephalo cysts situated in the extremities are particularly
difficult to be distinguished during life, from mere membranous cysts   The
following  case is a proof of the remark.
  Case I.—A man, 27 years of age, was admitted, in the early part of Janu-
ary, 1833, into  the  Hotel Dieu.  He was of a good constitution; lymphatic
temperament, by trade a printer.   Having used more than usual exertion, he
felt, according to  his  account, acute pain in  the left arm, opposite the body
of the biceps; and on feeling it, discovered for the first time, a tumor.  On
his admission, a few days afterwards,  it was as large as a small hen's egjj,
without heat, change of color in the skin, immovable, and still the flexion ot
the fore-arm upon the arm apparently made it diminish in size.  The patient
declared,  it  had only existed 8 or 10 days at farthest.  But it was certainly 
CLINICAL SURGERY.                       239
of older date.   Was it produced by a rupture of some muscular fibres ?  The
patient felt no pain in the muscle.  Was it caused by effusion ?  The skin did
not present that  violet color, distinguishing ecchymosis.   Had  the  artery
been wounded?  The  tumor was free from the dilatation  and contraction
synchronous  with the  pulsations of the heart,  and which are  the essential
symptoms of aneurism.
  Its existence was, therefore, anterior to the accident which occurred to the
patient.  Could it, therefore, be considered as  a scirrhous production ?  The
absence  of lancinating pain, and the existence of an obscure  fluctuation
refuted this opinion.
  By a more  attentive examination, I was led to suppose, that it was formed
by a hydatid  cyst;  and this idea appeared the more probable, from my recol-
lection of an  analogous case.  A young girl consulted me, many years  ago,
for  a tumor in the temple, supposed to have proceeded from a blow.   I made
a small puncture into  it, when a jet of serous fluid, immediately escaped.
By enlarging the opening,  and pressing on the sides, a large white sac was
expelled : it was a hydatid in the belly of the temporal muscle.
  A similar plan of treatment was pursued, in  the case under consideration,
after having used, without  any benefit, resolvents and astringents for fifteen
days, and  in eight days he was discharged perfectly well.
  Acephalo cysts have long been confounded with  all the other species of
morbid vesicles.  Pathological anatomy, however,  demonstrated,  that there
was  a  great  difference between membranous  vesicular tumors, firm,  and
strongly adherent to the tissue of the organs, and softer vesicles, which, free
from all adhesion, roll  in accidental  cavities, which are generally covered by
the former.  The former are membranous cysts, whose texture is analogous
either to that of serous, or fibrous membranes, &c, the latter, on  the contrary,
are true vesicular worms.   The acephalo cyst is one of the  most simple of
all animals.   It appears under the  form  of a  membranous  bladder,  of the
consistence of semi-concrete albumen, and in which the eye cannot perceive,
even with the aid of a microscope, any distinct  organs.
  The structure of  the cysts in which these animals are lodged is rather com-
plex ; their existence is constant, and they can  always  be found.   We  dis-
cover in these cysts a fibrous tissue, composed of fibres interwoven in different
directions, and often very irregularly.  The  interior of the cysts is sometimes
white and smooth, but never presents so polished a surface as the  serous cvsts.
I ts appearance is fibrous, and resembling the aponeuroses.   The acephalo cysts
are generally found in numbers in one cyst.   These worms float in  a fluid
which sometimes entirely resembles pure water, and which is also  sometimes
yellowish, turbid, puriform, and of greater or less density.   Whatever may
be the nature of the fluid  contained in the cyst, that of the cavity  of the
acephalo cysts is almost always transparent and resembling water.
  A cyst rarely contains one  single worm.   The acephalo cyst  is generally
very large, and contains several others in its cavity.   Sometimes, however,
cysts are found containing only one acephalo cyst.   It is probable  that cysts,
in this condition, are of but recent origin.
  There is no well authenticated  case of the development of acephalo cysts
in the natural cavities of the body.  They are always found in a cyst imbedded
in the tissue of the  organs.   It is true, that they have been seen proceeding 
240
LECTURES  ON
 from different natural  cavities, but there are strong reasons for believing,
 that this took place only after the  rupture of the worms contained in these
 cavities.
   Acephalo cysts have  been observed in almost all the parts of the body; in
 the  thyroid gland; the duplicatures of the peritoneum; the lungs; in the
 different parts of the cellular tissue exterior  to the peritoneum ;  between the
 coats of the intestines ;  in the tissue of the liver;  in the  kidneys; ovaria;
 in the uterus, when it constitutes the greater number of  vesicular moles; in
 the os tincae; the parietes of the abdomen ; the intermuscular cellular tissue
 of the back, neck, thigh, shoulder,  and  many other parts.
   The acephalo cyst is not the only worm met with in man.  Many years ago,
 I discovered the cysticercus in the peroneus longus muscles of an individual
 whose case I will hereafter detail.   This worm is always enclosed in acystor
 bladder, and  is solitary.  The cavity of the cyst, covered  by a  membrauiform
 layer, contains besides the cysticercus, which is free, a serosity of the same
 nature as that contained in the candel bladder of the worm.   The cysticercus
 generally inhabits the  muscles, or  rather the cellular substance uniting the
 different bundles of fibres composing the muscles.
   The development of  the cysticercus  in hogs, becomes the cause in them of
 a very serious disease, commonly known by the name of measles.
   Case II.—About thirty years ago, I found in the peroneus longus muscle
 of a man, a vesicular worm.   It was immediately recognized  as  the cysticer-
 cus finnus, presenting some remarkable peculiarities, in regard to  its size, and
 the cyst containing it.
   The ovoid cyst, about eight lines in  length, adhered firmly on its external
 surface to the muscular fibres,  the fat, and  surrounding cellular tissue; inter-
 nally, it was coated, throughout nearly its whole extent, by a yellowish matter,
 not very abundant, pretty firm, friable at certain points, and at others firmer,
 whitish or slightly red, and very  similar  to the  fibrine  of the blood. The
 proper membrane of the cyst was evidently fibrous,  and presented a strength
 and  firmness analagous  to the lateral ligaments of the articulations.  Still the
 fibres were more transparent, more united together, and  for this reason re
 sembled strongly the milky hue, and homogeneous texture of the cartilages,
 from which they differed on account of their  greater pliability.  Tlii> membrane
 was of unequal thickness, and  in some places,not exceeding half a line.  Its
 fibres were tinged, throughout part of its extent, of a reddish color resembling
 blood.
   The vesicular worm contained in this cyst had a body enclosed in the candel
 vesicle, about  five lines in length, and formed  by  thin, equal   membrane,
 without fibres, more firm than hardened albumen.   It was, nearly  throughout,
 of a reddish tint, which rendered it. more opaque, and which seemed to pro-
 ceed  from blood which had tinged  a part of the cyst.  I  sought, on the out-
 side of" the vesicle, the  small  aperture  through which the body is expelled,
 and  developed internally.  I could not, however, find it, owing  probably to
 ihe  worm  having been immersed  for  sometime  in  spirits of wine.  I then
opened the candel vesicle.  The body which it enclosed appeared under the
 form of a slightly elongated tubercle, of a yellowish white color, opaque, and
about the size of  a cherry-stone.  It adhered to the parietes of the vesicle by
 means of a white, opaque, humid  substance, which on pressure distilled 
CLINICAL SURGERY.
241
 some drops of a milky hue.  This  substance was without  form, tuberculous
 externally, and nearly as large as the body to which it adhered.  It appeared
 to have left the  body in the same  manner as we frequently see in the long
 worms, such as the crino, and ascaris lumbricalis.
   Hydatids are frequently met with in dissection, but rarely in the living body;
 and even when their existence is well ascertained, it is exceedingly difficult
 to treat a tumor without heat or redness and which is attributed by the patient
 to an entirely recent  cause.   We should  in such cases, ascertain whether
 ihere exist any contraction or expansion, and then make an exploring punc-
 ture, as the best means of avoiding any  mistake.
   Muscular hydatids cannot be  confounded with those developed under the
 annular ligaments of the carpus and tarsus ; their situation, nature, and symp-
 toms, present well marked distinctions.  As to visceral hydatids, their symp-
 toms are generally so obscure, as not to disclose them during life.   In a few
 cases the diagnosis  may be established.   M. Recamier has  even cured  a
 hydatid cyst of the liver by puncture and the use of caustic potash and injec-
 tions of stimulating fluids. The case  is so curious  that we will  make an
 extract from it.
  Case III.—A man, 20 years of age, a painter by trade, was working in his
 shop, when the floor gave  away, and he fell into a cellar ten  or twelve feet
 deep, stunned by the fall.  The next morning, a yellowish tinge  spread over
 his face, and soon over  the rest of his body.
  Three days afterwards, he felt a dull heavy pain in the right hypochondrium;
 and was unable to lay on either side.
  On the 3d of May, the 7th day of the accident, the patient entered the Hotel-
 Dieu.   In the right hypochondrium there was a rather irregular tumor, ex-
 tending from the ensiform cartilage as far as three fingers' breadth below the
 umbilicus.  An obscure fluctuation was  felt, as also  several bodies  which
 appeared immovable, pretty hard, projecting and  unequal.
  In order to ascertain the nature of the tumor, a puncture was made  into it
 with a fine trocar; a cup applied over  the canula, and a few drops of very
 limpid fluid exactly resembling that of hydatids escaped through the aperture.
  On the following days, a  large  piece of caustic potash was applied over the
 most projecting point in the tumor and in the vicinity of the  false  ribs.  On a
 renewed application of the potash, the tumor on the abdomen opened sponta-
 neously through the wound, and discharged a yellowish and limpid  fluid,
 mixed with a great number of hydatids.   On the same day a mixture of barley
 water and honey was injected into the cyst, in order to prevent the admission
of air.  Afterwards, were used injections of salt water, decoctions of barley
and cinchona, and a solution of chloride  of lime.  The abscess gradually
diminished, and when the patient left the hospital, there remained  only.a nar-
row fistula; discharging a small quantity of greenish fetid pus.  Some fragments
of food and stercoraceous matter had been discharged by the wound.
  The intention proposed in giving to the caustic potash a preference over the
 knife, was to give rise to inflammation, and consequently to adhesion between
the parietes of  the cyst and those of the abdomen, and thus  establish a con-
 tinuous  canal from the interior of the cyst externally, and  thus  prevent all
 effusion into the abdominal  cavity.  Therefore, the parietes of the cyst were
kept in the greatest possible state of tension in order to preserve their immediate
           31 
242
LECTURES  ON
contact with those of the abdomen.   The injections prevented  the intro-
duction of air into the cavity, and the inflammation resulting therefrom.
   We have  said, that in a great majority of cases, the presence of visceral
hydatids could not be detected in the living subject;  the following are some
of the symptoms which have been  observed in persons laboring under  this
affection; their presence in the  external cellular tissue of  the peritoneum, or
in that uniting the coats of the stomach or intestines, gives rise to disturbance
in the digestive functions ; and they sometimes  compress so strongly the
intestinal canal as to determine  a true iliac passion.
   Cysts, situated in the tissue of the liver, occasion various morbid phenomena,
which become serious in proportion to their size.   The most frequent are: a
sensation of weight, rarely of acute pain, and sometimes a visible tumor, more
or less circumscribed in  the right hypochondrium ; sometimes great distress on
respiration; anxiety, a kind of restlessness compelling the  patient incessantly
to change his position ;  sometimes jaundice, vomiting, epistaxis, diarrhoea or
obstinate constipation.  There  is in some cases a trembling compared to the
motion of jelly when shaken.  Acephalo cysts in the kidneys are rarely evinced
but by pain in this region.   Those of the ovaria have precisely the same effects
as membranous cysts, of encysted dropsy, properly so  called, of these viscera.
  The effects produced by hydatids of the uterus are very  various, according
to their  situation in  this viscus ; when deeply seated, in the thickness of the
parietes of this  organ, they occasion a sensation of weight  there ; but when
developed between the internal membrane and the uterus, they dilate the latter,
its neck flattens and widens, and all the phenomena usually attendant on preg-
nancy are present; the acephalo cyst then constitutes the  affection known by
the name of vesicular mole.
  Hydatids of the lungs give rise to more or less dyspnoea,  of which it is often
impossible to suspect the cause.
  Case  IV.—A young man, born of healthy parents, was attacked, at the age
of 18, with a peripneumonia, of which he was perfectly cured.  At 24 years
of a°-e, he had a very violent and obstinate cough, accompanied by acute pain
in the left side, preventing him  from laying on that side.   This pain ceased
with the cough, but both re-appeared on the slightest cause.
  In the month of July, 1800, the pain in the side and a dry cough returned,
and so violently as to prevent the least exertion on his part.   He soon began
to complain of a small tumor seated, in right hypochondrium.   The tumor at
first was scarcely perceptible, but soon became perfectly  evident.   At that
time the dry cough returned anew, accompanied with momentary suffocation.
  In May, 1803, the patient was in  the following state: much emaciated; the
tumor on examination was so large, that the hand could scarcely cover one half
of it, and  so  firm  as .not to yield to  the finger; its surface smooth ; it was
movable and easily displaced either to the right or left.   The pulsations'of
the heart were so violent in the epigastric region, as  to be perceptible to the
eye.
  The patient complained of continual dyspnoea, anda species of  strangula-
tion on ascending a flight of steps.  He had frequent fainting fits,  occasional
cou<di, sometimes spitting blood, and was  in a continual state of agitation.
These symptoms were aggravated by cold weather.  The pulse presented no
remarkable irregularity. 
                             CLINICAL SURGERY.                       243

    Such was almost constantly his situation until January, 1804, when the dis-
  tress in respiration increased considerably, as well as all the other symptoms.
  About the beginning of June,  he  had two very violent attacks, in which he
  was nearly suffocated.  Finding his health growing worse, he came to Paris
  for advice.  He had traveled ten  leagues  in a carriage.   On his arrival he
  felt pretty well, and took a light supper.   A few hours afterwards, he had
  another attack of strangulation, in  which he perished.
    On an examination  after death, we  found in the  left  lobe of the liver,
  a cyst  partly hidden in the substance  of  this viscus, and partly projecting
  into the abdominal cavity, and resembling a bladder which could be displaced
  at will.    The  parietes  of the cyst were  thin, yet  fibrous.   The cavity
  contained:  1st, a certain quantity of yellow fluid;  2d, a number of small
  hydatids, the  greater part not larger than a pea: one or two were of the size
  of small walnuts.
    The parietes of the hydatid cyst situated without the liver, adhered firmly
  to the lesser curvature of the stomach, and yet there was no mark of a cica-
  trix on the external membrane of that organ.
    The chest was of considerable  size,  and so exactly filled, that the  heart,
  thrust downwards,  corresponded to the upper part  of the epigastrium.   The
  two  lungs  compressed,  flattened and reduced to  a thin plate, were thrust
  towards the anterior part of the chest, behind the cartilages of the ribs.   The
  remainder  of the pleural  cavity was  occupied by two  very  large tumors,
  extending from  the summit of the  thorax to the diaphragm, adhering closely
  to the  sides of the whole mediastinum,  and had pushed the heart out of the
  cavity of the chest.  These tumors, equally tense and fluctuating, had a white,
 fibrous,  thin but strong envelop, and  each contained an enormous hydatid.
 These hydatids filled exactly each cyst, and seemed to  adhere to it by means
 of a glutinous matter.   The quantity of fluid contained in each, was five and
 a half pints.  Their length was  about eleven inches.
   Case V.—A woman was admitted  in  1811, into the Hotel-Dieu, for an
 inflammatory tumor at the umbilicus.   I did not wish, at first, to meddle with
 it; but fluctuation  becoming evident,  and the skin being about bursting, an
 incision  gave  exit to a large quantity of pus, and some hydatiform cysts.
 The  woman died, and  on examination,  there was found a communication
 between the umbilicus  and the  cavity of the lung,  by means of a canal
 through  the diaphragm  between  the liver and the abdominal parietes.  The
 cavity of the  lung contained  a  quantity  of hydatid cysts.   This organ had
 evidently been the primary seat of the  disease.
   It will be seen, from the foregoing remarks,  that the symptoms of acephalo
 cysts in many parts of the body,  are precisely  similar to those of many other
 affections.   The  absence  of the  characters of other diseases better known,
 is often the only sign announcing  the existence of these worms; but some-
 times we  may be entirely sure on this point, namely, when some of the cvsts
 containing these  worms, burst into  some of the cavities lined by mucous
 membranes,  or  appear outwardly, as when  they are discharged through an
 abscess formed in the abdominal parietes.
   The rupture  of the cysts of the  acephalo cysts into the cavities lined by
mucous membranes,  is generally followed by a favorable  termination.   Art
has sometimes imitated  with advantage this method of nature.   It would 
244
LECTURES  ON
appear that the disease is sometimes  cured without any natural or artificial
rupture; in such cases, the acephalo cyst probably perishes spontaneously ;
and  then  the  thinnest part of the fluid, in which it floats, is absorbed.  The
cyst closes  upon itself, like an aneurism, after the performance of Hunter's
operation, and after a certain time, nothing remains but a small mass of mat-
ter, commonly turbid and yellowish, in which may be seen some fragments of
the acephalo cyst.
  Visceral hydatids, developed in the cavity of the abdomeu, may be  mistaken
for a host of tumors too numerous to be detailed here, and which have, more-
over, been carefully studied; but there is still one to which  I deem it right
to call your attention, I mean the development of a  foetus in the mesentery
of a  boy of 14  years of  age.
  Amedee Bissieu, was born in 1790, of a  young woman, healthy, and the
mother of another child, which was well made and of a good constitution.
  During  the  night in  which his mother supposes he  was conceived, one of
those alarms then so common in France, caused great  commotion in  the town
and  called the inhabitants to arms.
  During pregnancy, Mad. Bissieu experienced some distress and  frequent
indisposition;  nevertheless, her delivery was without accident.  It was re-
marked that during the  labor, a great quantity of water  escaped  from the.
vagina.   Immediately after  birth  the  child  was given  to  a  nurse, who, on
account of its weakness and ill health, despaired  of  its life for some time;
brought back to his father's house, he began to complain, as soon as  he could
lisp  a word, of pain in the left side of  the chest and belly.  This latter part
was  so large, as to lead to the supposition of his having  tabes mesenterica; but,
on the other hand, its size was so  variable, that it was determined to lace his
pantaloons in  order to  suit these variations.  As he  grew, the fears of tabes
disappeared, but he still was delicate, his face thin and  wan, constantly com-
plained  of pain in the side, his appetite was irregular and capricious, and he
was  subject to frequent indigestion.  One  day, when  dressing him, it was
observed that the two lower left ribs were higher and more projecting than the
other, which was attributed to a habit of sucking the thumb of the right hand,
and  inclinin°- his body to the same side.  Little attention was paid to this cir-
cumstance, as the child was remarkable for his gaiety and precocity.   He was
sent to a boarding school at  Rouen.   After a residence there  of eighteen
months, he  was suddenly  attacked with an acute pain in his side and left
hypochondrium, continued fever with exacerbation and  a sensation of oppres-
sion ; great tumefaction of the belly, in the  part where  formerly had  existed
the  projection, and continual pain. The patient was bled and purged.  The
fever continued; the swelling increased. On the 7th day of his disease, his physi-
cian, M. Blanche, felt distinctly, in the abdomen, a hard and very painful tumor,
extending from the false ribs to the spine of the ilium, rounded and as of the size
of a  large melon.  Emollient applications and soothing  enemata were made use
of.   The pain,  however, still continued until a copious discharge  of purulent and
fcetid matter  took place.  The  release from suffering  and the decrease of
the tumor did  not arrest the emaciation of the patient, and falling into a state
of marasmus he was sent back to his family. On his  arrival, MM. Guerin
and  Bertin Desmardelles recognized  this hard and large  tumor  in the left
hypochondrium, but, in spite of their efforts,  the disease still progressed.  To 
CLINICAL SURGERY.
245
a continual and  obstinate cough with purulent expectoration, there was  soon
added a diarrhoea of foetid matter, in which was found, six weeks before his
death, a small ball of hair.  At last death closed the scene, and  this young
man perished in the 14th year of his age, and six months after the first appear-
ance of the symptoms of the disease.
  An autopsical examination having been solicited by his parents, it was per-
formed on the next day by his  physician.   He found  in the left hypochon-
drium, below the spleen, a very large membranous sac, thick, adhering to all
the surrounding parts, and particularly to one of  the large intestines, which
they presumed to be the colon, and in this sac, in the midst of a purulent, thick,
and yellowish matter, two principal masses of nearly equal size, situated trans-
versely in front of the vertebral column, in close contact with each other, and
yet distinct.  The lower of these masses was composed  of a large quantity of
matted hair, around this were two small balls of hair similar to that which had
been discharged by the patient before his death; the other, situated higher up,
was an elongated, fleshy, and bony  mass, covered with skin.  There was dis-
covered in it a badly formed head,  with hair, teeth, the  rudiments of a nose,
and kind of orbit on one side, and of ear on the other; and on the opposite
side an appendage like a limb  terminating  in divisions having each a  nail.
Lastly, from the middle of this  mass, which seemed to hold the place of
chest and belly, a thick and short ligament extended and was inserted in the
parietes of the cyst.  MM. Guerin and Desmardelles deeming it worthy of
further  research, removed without injury, this  fleshy mass, and also the
stomach,  spleen, and  part of the large intestine.   They stated, that there
existed neither externally nor internally, any trace of female organs, and that
the sex of Amedee Bissieu was purely male.   Lastly  they found on dissection,
1st, that the liver was large, although it had been compressed and thrust into
the right hypochondrium; 2nd, that the lungs were whitish, and contained pus
infiltrated throughout their substance.
  So extraordinary a case attracted  much attention, the preparation was
brought to the Faculty of Medicine at Paris, and I was appointed, to  make a
report on this singular production of nature.
  The first fact which I ascertained, in relation to  the  position of the foetus,
was, that it was lodged  in a cyst of the transverse mesocolon, which had at a
very late period, communicated with the  cavity of the intestine,  from the
destruction of the separating partition.   Continuing  the examination, I found
that the organized mass contained in the transverse mesocolon had many points
of resemblance  with a foetus, but also many peculiarities, some, owing essen-
tially  to malconformation, and others apparently depending on the changes
induced by time, and its stay in the cyst of the mesocolon.
  I then dissected the mass with great care, and found traces of some of the
organs of the senses; a brain, spiral  marrow, large nerves, muscles, which had
degenerated into a kind of fibrous mass, a skeleton  composed  of  a  vertebral
column, head, pelvis, and the  rudiments of nearly all  the limbs ; lastly, an
umbilical  cord, very short, and inserted into the  transverse mesocolon, out-
side of the cavity of the intestine, an artery and vein ramifying at each extre-
mity towards the foetus, and the individual to which it was attached.
  The existence of  the  preceding organs, was  sufficient  to establish the 
246
LECTURES ON
individuality of this organized mass, although it wanted the organs of diges-
tion, respiration, for the secretion of urine, and generation.              •
  It would be necessary, in order to complete our labor, to determine the de-
gree of importance of this phenomenon ; but, for that purpose, its true cause
must be known; then alone could we judge of its importance, by the greater
or less degree of light thrown, as well on the natural process  of generation,
as on the irregularities of this function.   However, looking upon it merely as
one extraordinary case, it does not deserve the less attention, on account of
the  very great rarity of its occurrence.
                        CHAPTER XXXIV.

 ON  FRACTURE OF THE LOWER EXTREMITY OF THE OS HUMERI, SIMULAT1NO
                  LUXATION OF THE ELBOW BACKWA*RDS

   The diagnosis of fractures and luxations  cannot be studied too minutely,
for how frequently do we meet in hopitals with cases which escaped the  skill
and observation of great men.   How many mistakes occur in affections of the
hip joint, luxations of the shoulder-joint, fractures of the lower extremity of
the humerus radius, and in general, all solutions of continuity in the vicinity
o( articulations.
   Nothing is more common, than to see a fracture of  the lower extremity  of
the humerus, immediately above the elbow joint, mistaken for a luxation back-
wards of this joint; it is, however, highly important to distinguish them, as
incurable deformity may depend on their mal-treatment.
   Suppose the fracture transverse, and situated immediately above the  con-
dyles ;  the olecranon is drawn backwards and upwards by the triceps extensor
muscle, the upper fragment is  carred forward and resembles the lower articu
lar surface of the humerus.  The  projection formed by the olecranon is  so
great, that by comparing the two joints, this apophysis of the affected side, ex-
tends twelve or eighteen lines  beyond the other.   Lastly, the antero-posterior
diameter of the arm near the elbow is sensibly increased, and you  have appa-
rently all  the  symptoms of  luxation.   On this  supposition, extension  and
counter-extension are made, and generally the reduction is very easy. A ban-
dage is applied, and we congratulate ourselves on our success.   Soon, however,
the displacement is reproduced, and at the end of five or  six days, we  find
something that is unnatural. This is attributed to some want of care on the
part of the patient. The reduction is again effected, but the deformity follows,
with considerable swelling.  The surgeon feels secure, as long as it does not
diminish; but when it disappears, in a month, six, or eight weeks, he finds his
mistake, but too late, the patient is crippled  for life. Even if the error be dis-
covered in twelve or fifteen days, nothing can be done; the swelling is an
unsurmountable obstacle to a complete reduction,  and the  deformity  is
incurable. 
CLINICAL SURGERY.
247
    Case I.—Fracture of the Extremity of the Humerus, Mistaken for Luxation;
   Malformed Callus, Embarrassment of the Movements of the Elbow-joint.—
   Towards the latter part of December, 1832, a child was brought to me, which
,   had, a month previously, fallen from an ass on which  it was  riding.  Two
   physicians supposed a luxation to have occurred, and treated  it accordingly.
    It appears  that the second physician was consulted for a recurrence of the
   deformity.  On examination I found a tumor in front, presenting inequalities,
   and evidently formed by the inferior condyle of the humerus; the olecranon
   projected backwards. It is very probable, that on account of the youth of the
   patient, there was merely a separation of the  epiphysis; the  fragments had
   united by a mal-formed callus.   What was to be done ?   It was dangerous to
   break up the callus ; but remarking that the chief inconvenience was the im-
   possibility of extending the arm, I applied a machine to effect gradual exten-
   sion ; this partially succeeded, but deformity must forever remain.
    Crepitation is the best distinguishing characteristic of fracture from luxation,
   and to this may be  added, that moderate extension and  counter-extension
   soon restore the parts to their natural position.  Still, it must be confessed,
   that, of all  luxations, one of the most easily reduced, is that of the elbow-joint.
    Crepitation, exists very obscurely, and  even may escape the ear of the sur-
  geon, if any swelling have taken  place.  Then, it is true, the reduction of the
  displacement  is always more  easy than in luxation, and the  mobility greater.
   But who would dare to decide from such  symptoms ?   There happily exists a
   pathognomonic sign which may take the place of crepitation.  Take hold of a
   fragment with each hand, the thumb in front and directed towards the fracture,
   and attempt the reduction.  This simple  means, will generally suffice, espe-
   cially in the first four and twenty, or six and thirty hours after the accident.
   After having  effected the reduction, move the forearm backwards; ii there be
   luxation, the reduction remains; if fracture, the displacement returns imme-
  diately.
    Dr. Malgaigne, who published in the Gazette Medicale, some observations
  on this kind of fracture, thinks, that other means of differential diagnosis may
  be added to those already enumerated.  In luxation, says he, the articulation
  is destroyed, and flexion and  extension are impossible ;  in fracture it is unin-
   jured, and probably these movements are partly preserved.  This can  only
  hold good  very soon after the occurrence of the accident; but at any period
  whatever, there is  an anatomical sign which appears to me infallible, when-
  ever it can be discovered; this is, whatever may be the  projection of the ole-
  cranon  backwards, it is never  more separated from  the  condyles  of   the
  humerus than in the natural state, if there be fracture;  and much more sepa-
  rated, if there be luxation.  Also, in the latter case, the anterior projection is
  rounder and not so wide;  in the  former case, it is  as wide as the  articulation
  itself.   There can be no error;  the diagnosis is as certain as anatomy.
    Case  II.—D.  27 years of age, tall, and of  very robust  constitution,
  fell  into a ditch  on the  left elbow, and was admitted  immediately into the
  hospital, for a luxation of the elbow, according to the opinion of the surgeon
  who first saw  him.
    On his admission, there was deformity of the left elbow-joint; an enormous
  swelling occuoied the lower extremity of  the arm, which was tense and very 
248                           LECTURES  ON
painful.  The forearm was semi-flexed; on examining the tumor, there could
be distinguished, notwithstanding the tension of the parts, a hard,  slightly
unequal, rough projection, occupying the bend of  the  elbow, and raising the
brachialis internus and biceps muscles ;  posteriorly, the olecranon  projected
under the skin, and was  slightly elevated  above  the  level of  the condyles;-
flexion and extension  were totally impossible, and an attempt to effect them
gave the  patient intense pain.  Indeed, the patient labored under  every
symptom of luxation of the elbow backwards; and,  without  a familiar ac-
quaintance with fractures, we  may be easily  imposed on by these signs, and
see only a luxation of the elbow.  However, by moving in contrary directions
the lower part of the arm, and upper part of the fore-arm, an unnatural mo-
bility and distinct crepitation were perceived.  No doubt could then  exist of
its being a fracture of  the lower extremity of the arm, at a very short distance
above the condyles.   In fact, it may be  easily conceived, that the continuity
of the humerus being interrupted, its inferior articulating surface no longer
presenting a solid support, the olecranon should obey the contractions of the
biceps, which  would tend to draw it upwards; and again, on  account of this
ascent (which  explains at once  the projection formed  posteriorly under the
skin by this process, and the forced demi-flexion of the fore-arm), the  lower
fragment of the humerus, intimately united to the ulna, participates in the
traction experienced by the latter; by virtue of their reciprocal direction, it
necessarily experiences a vibrating motion, by which its  upper extremity is
carried forwards, and projects under the brachialis internus and biceps muscles
which it raises up.
   On the day  of the accident, complete reduction could not be effected on
accountof the  pain and tumefaction of the parts.  The limb was merelyplaced
in  a  state of  semi-flexion  on  a  horizontal plane of  pillows, covered with
compresses soaked in  Goulard's solution.  The man was bled in the other arm.
   The next morning the reduction was accomplished ; the  shoulder of the
affected side was held fixed, whilst an assistant made extension on the demi-
flexed fore-arm.   I seized with both hands the lower extremity of the arm,
on a level with the fracture, pushing the  olecranon forwards, and  the lower
fragment backwards.
   The reduction being affected, the arm on the plane of  pillows, in a position
between flexion and extension, was laid on the ordinary bandage of Scultetus;
and some  graduated compresses  applied around the lower extremity of the
arm, so as to correspond to the bony  projections, and take the place of the
fingers which  made them disappear.  Two long compresses were then placed
on these, and  lastly, two lateral cushions, folded on themselves at their inferior
extremity, so  that  by tightening  the apparatus, the splints should bear parti-
cularly on the graduated compresses,  and  drive continually in a  contrary
direction, the olecranon and superior extremity of the inferior fragment.
   On  the 45th day D.... left the ward, able to perform with ease the move-
ments of flexion and  extension, and free from deformity.
   Case III.—P.....,23 years of age, enjoying good health, was  admitted
into the Hotel-Dieu, on the 18th of October, 1821, for an injury of the inferior
extremity of  the left humerus, near the elbow joint, with considerable dis-
 placement, and a wound on a level with the  olecranon. 
CLINICAL  SURGERY.
249
   The accident had been produced by a fall on the pavement. At the moment
 acute  pain;  inability  to  execute  any movement; the limb was carefully
 examined soon after.
   From the displacement and other symptoms, one might have supposed it
 was a luxation of the elbow; but the mobility of the fragments, their crepi-
 tation, and especially the integrity of  the articulation,  soon pointed out, in
 its true character, the kind of lesion which actually existed.
   The fracture was oblique and  situated about an inch from the joint.  The
 wound had been  produced by the pavement, and did not communicate with
 the fracture.  The  case was, however, a serious one.   Inflammation min-ht
 extend to the joint, and give rise to serious consequences.
   The reduction of the fracture was effected by means of extension counter-
 extension and co-aptation.
   The wound of the  elbow was dressed with simple cerate; and I then pro-
 ceeded to apply the apparatus necessary for the fracture.
   The whole  arm was covered with wet compresses, and in order to prevent
 the tendency of the fragments to separate the bandage of Scultetus was applied,
 with  graduated compresses on the anterior and posterior surfaces of the arm,
 cushions folded at the lower  end, and  over all, splints nearly as long as the
 arm.
   The  limb was  laid in  a semi-flexed position  on a pillow covered with  a
 cloth folded several times.  A copious bleeding was performed, absolute rest
 and strict diet recommended, with diluent drinks; the patient felt pretty well.
 That evening  she took in four  ounces of looch blanc *, half an ounce of syrup
 of diacodium, which procured her several hours sleep during the night.
   On the  54th day,  the  patient left the  hospital  perfectly cured, having
 already partly recovered the use of the limb.
   It has been said, and the celebrated Cooper has remarked, that this fracture
 is much more  frequent in children, than  in persons of more advanced age; it
 will be seen, however, by the two cases detailed, to which we might add others,
 that it is met with  at different  periods of life.
   This  being  the  case, what  should be the conduct of the surgeon ?  If he
 be called to a  patient presenting  the symptoms of a fracture of the inferior
 extremity of the humerus, or  of a luxation of the elbow joint, he takes the
 fore-arm in one hand, and the arm in the other,  and generally restores (when
 there is fractures  and no swelling)  the parts to their natural situation with
great ease; but on the  least  movement of the patient,  the displacement is
re-produced as much in front as posteriorly.  Let him be then convinced
that  there  is  consecutive  displacement  in consequence of fracture.  If one
physician should say, there was a luxation,  and another a fracture, he should
side with the   opinion of fracture, because, by that  means he incurs no risk
of deformity, loss of power, swelling and consecutive affections.   The incon-
* Looch Blanc.		
fy Blanched sweet almonds	-	No. 12.
do. bitter do.	-	No. 2.
White sugar.	-	- #•
Powd. Germ. Tragacantli.	-	gr. xv.
Orange flower water	-	- 5U
Water.	-	Jiv.
Mix.-	-Thaws.	
32 
250
LECTURES ON
venience, besides, is very slight, if it be a luxation ; the patient indeed, wears
the apparatus much longer than if there were no fracture, but this is not to be
compared with the consequences of a contrary treatment.
  Having established the diagnosis, what apparatus  shall we apply?  It has
been already spoken of, but we will now give it more in detail.   Extension,
counter-extension, and coaptation having been properly effected, and the re-
duction completed, the limb is placed on a pillow, previously covered with the
bandage of Scultetus ;  position proper for the  arm is one intermediate tu
flexion and extension; graduated compresses, three fingers' in width, and three
or four .inches long, are then applied on the anterior and posterior surfaces
of the humerus.   These compresses are to be kept in place by two Ion* com-
presses.  The many-tailed bandage is then applied, afterwards a cushion, of
which one  end is  folded, in order  to double it  at the point,  where it bears
on the lower part of the humerus.   The same thing as regards the olecranon.
By these means, the humerus is thrust backward, and the olecranon forward.
A short splint is placed on  each cushion, and the tapes are tied somewhat
tightly, in order to keep the  apparatus in situ.  In twelve or fifteen days, there
is no  danger of displacing the fragments.  The swelling  which takes place in
the surrounding parts is an  obstacle to consecutive displacement.  Thus  the
swelling, which in case of fracture, is mistaken for luxation, at the end of a few
days, permits no longer any reduction, becomes, if we are correct in our diag-
nosis, a very important auxiliary in  the cure.
                       CHAPTER   XXXV.

   ON  EXOSTOSIS  OF THE UPPER SURFACE  OF  THE LAST  PHALANX OF THE
                              GREAT TOE.

  When treating of inverted toe nail, I designedly omitted, saying any thing
touching exostosis of the upper surface of the  last phalanx of the great toe, as
it seemed then out of place.   I now purpose detailing to you some cases, and
also offering some remarks on this subject.   A physician of the city lately con-
sulted me in the case of his child, who, he thought, labored under inverted nail.
I examined the little patient carefully, and found it to be an exostosis of the
upper surface of the phalanx, and that the matrix of the nail was unaffected. The
three following cases will tend to give you a more correct idea of the disease.
  Case I.—Emery Louise, 22  years of age, in good health, born of healthy
parents, and declaring that she never had been affected with venereal, consulted
me on  the 28th of December, 1821.
  For  the last two years, she has had, at the extremity of the last phalanx of
the great toe and near its outer edge, a very hard bony tumor, indolent, except
on pressure; its large base has thrust aside the nail, which it has worn away.
  The girl can assign no cause for the disease; it began, more than two years
ago, with pain in the  end of  the toe, not augmenting during the night, but
much  increased by walking and  pressure.  It gradually reached its present
size.  I advised its extirpation, to which she consented. 
CLINICAL SURGERY.
251
  Case II.—Loury Catherine, a seamstress, 20 years of age, has had for 18
months on the external inferior part of the left great toe, a hard, bony tumor,
which has increased but slowly, when we consider the period of its first appear-
ance and its present size, which is not more than that of a small walnut; the
disease can be referred to no known cause.   It gave no pain, but interfered
with her  walking.
  It was removed on the 8th of January, 1822, in the following manner: The
patient being  laid in bed, and her foot held by an assistant, I encircled the
tumor by two  semilunar incisions, and removed nearly all of it at  the first
attempt; other portions were removed successively.  I found the tumor, ac-
cording to my diagnosis, to consist of bone, composed externally of a hard
layer, and spongy within.   A simple dressing was applied.  On the 12th the
wound was suppurating and in a fair way of recovery.
  Case III.—^A young woman, 25 years of age, had been affected, for two
years, with a tumor under  the great toe nail; at first small, it gradually in-
creased,  elevated, and deformed the nail, rendering it exceedingly painful to
walk.  The patient  then consulted an  expert farrier, who thought it was a
wart and cauterised it.  This, far from relieving the disease, exasperated it;
the tumor increased considerably, the nail became more bent, so that its ante-
rior extremity turned backwards, nearly touched its root;  it was, moreover,
rough, unequal, and of a deep yellow color.   The sufferings  of the patient
induced her to enter  the Hotel-Dieu, to receive advice.  On the 3d of June,
it was extirpated in the manner before described.
  This disease has not, to my knowledge, been described by any writer.   It
consists  in a  pyramidal exostosis; arising from  the upper face of the last
phalanx of the great toe, which raises up the nail, deforms it, and renders
locomotion painful and sometimes impossible.
  Although not dangerous in itself, it is very inconvenient, and has frequently
given rise to mistakes which have led to painful and useless  operations.
  In the commencement, the disease is free from pain, but this gradually appears
as the nail is elevated by the tumor.  It is sometimes very severe, and becomes
excruciating if the patient strikes the toe against any hard body.
  The causes  of the disease are unknown; it most frequently occur in per-
sons who have received no blow on the  part, nor worn tight  shoes or boots.
It sometimes  takes place  in the contrary case, syphilis and scrofula do not
appear to excite it more readily than other causes.
  Generally the patient takes it for a wart, and the physician is frequently led
into the  same error.   Under this idea, the tumor is cauterised, and always
with an unpleasant result.   Sometimes it is thought to be a disease of the nail,
and the latter is removed.  As the disease increases, the nail becomes more
deformed, is bent backwards, so much so sometimes that its anterior extremity
is in contact with the root.
  The dissection of the tumor, when it has reached this point, shows it to be
formed by the skin, a fibrous tissue, and a pyramidal bony tumor, arising from
the upper surface of the last phalanx.   This exostosis is formed by a spongy
tissue, covered by a layer of compact substance; it is generally not very firm,
and may  be easily divided,  and removed with a strong bistoury.  However.it
sometimes becomes very hard, requiring the gouge and mallet for its removal.
  If the  disease be allowed to progress, unhealthy ulcerations may appear, 
^52
LECTURES ON
and tend to make it still more painful to walk.   I once saw, a surgeon remove
the last phalanx of the great toe, for a tumor of  this nature, which had termi-
nated in an ulcer.
  The only remedy for this exostosis, is its complete extirpation. The removal
of the nail  is sometimes necessary ; but in a majority of cases, useless. A semi-
lunar incision is made on each side of the tumor.  These incisions surround and
expose the bony tumor, which is then removed by the bistoury, or the gouge and
mallet.  The whole of the tumor must be extirpated, to prevent a recurrence
of the affection.  I have performed this operation, at least in thirty cases, and
have always by these means, effected a perfect cure.
                      CHAPTER XXXVI.

               ON  FIBRO CELLULAR TUMORS  OF THE UTERUS,

         Commonly Known by the Name of Polypus of the Uterus.

   During the month of January last, (1833,) two women, laboring under those
 anormal productions, commonly known" by the name of polypus of the uterus,
 were admitted into the  surgical  wards of the Hotel-Dieu.  One,46 yearsof
 age, stated, that for a month she had had a discharge of  blood from the vagina,
 to which since the last eight days, had succeeded a whitish discharge, sanious
 and slightly fcetid ; she declared that until that time she never had experienced
 any symptoms indicating lesion of the uterus.  Much credence cannot be given
 to this assertion, for there is a class of women, who, habituated, as it were, to
 a host of inconveniences, do not  observe themselves, and cannot relate their
 sensations, except when a general reaction or some accident  prevents their
 following their ordinary occupation.  This woman  was examined in the city,
 and the disease stated to be a cancer of the  uterus. She has suffered, for some
 time, from obstinate constipation, which may  be easily explained by the pres-
 sure of the tumor upon the rectum.  We prescribed some laxative  enemata,
 and the patient was so much relieved as to suppose herself cured.   But  the
 polypus is larger than one half of one's fist; some superficial ulcerations exi9t
 on its surface, but the discharge has not that  repulsive foetor so frequent at a
 certain  stage of the disease.
  The other patient is 48 years of age.   Remark the coincidence of the ages
 of these women; and  indeed, it  has  been observed that a majority of cases
 of organic diseases of the uterus occur about this period of life, or between 38
 and 50 years. This latter patient has had for a year a red discharge, continual
and  copious, which  she calls  her menses, and explains,  without being at all
alarmed, by saying, that it is very common  amongst women about the critical
time of life. Since the  last month  this bloody  discharge has changed into one
of sanies, horribly fcetid.  She has frequently felt pain in the loins, a  dragging
sensation  in the groins and thighs, a  painful sensation of weight about the
anus, and of this last symptom she complains  most at the  present  time.  On
examination we have discovered a polypus as  least as large as the first.   By 
CLINICAL SURGERY.                        253
 circumscribing it with the finger, it was found slightly conoidal at its lower
 extremity, then increasing about the centre, then narrowing and inserted into
 the uterus, by a pedicle nearly as thick as two fingers which takes root in the
 interior of the organ, and is surrounded and compressed by the neck of the uterus
 as if by a ring.
   Let us now compare the two cases. The two women  are nearly of the same
 age ; in both the tumor is nearly of the same size, occupies the same region of
 the uterus, and has given rise to the same external phenomena, a discharge of
 blood, followed by a sanious  and fcetid discharge.  But in one, the  surface
 of the tumor is smooth,  in the other it is unequal; in the former it is hard
 and resisting,  in the latter softened;  in the first, the bloody discharge has
 only existed for a month,  and  is not very fcetid ;  in the second, it has  existed
 for more than  a year,  and the foetor is horrible.  Hence, we  may conclude,
 that the tumor has not yet degenerated in the first case, and  that the opera-
 tion may be delayed for a few days ;  whilst an incipient degeneration in the
 second, warns  us  to perform  the operation as soon as possible, and even then
 our chances of  success are very problematical.
   The second  patient, however, suffers greatly; she has acute pain in the
 loins, vagina, and  rectum.  On the other hand,  whether the pains be real or
 feigned, she will not consent to any operation.  The former, on the contrary,
 is free from suffering; is perfectly resigned ; there is no complication ; no con-
 tra-indication has been observed;  the glands of the groin and abdomen are
 not  enlarged ;  her  general condition  is good; every thing promises success,
 and  we do not hesitate to perform the operation immediately.
   On the 21st of January, the patient was carried to the amphitheatre, and
 placed on the lithotomy table, her legs  and  thighs flexed, widely separated,
 and  held by assistants. The parts were again examined, the forceps of Museux
 introduced and fastened in the substance of the tumor ; a moderate and con-
 tinued traction was commenced; desiring the patient, at the same time, to bear
 down, as if in labor.  The tumor being brought near the external orifice, it
 was  seized by a second pair of forceps, the gentle tractions  still  continuing,
 the neck of the uterus soon appeared at the orifice of the vulva.   The pedicle
 was  then separated  at its root, by two or three strokes of strong curved scis-
 sors, without leaving any trace of diseased tissue.
   The section was accompanied by  no pain, nor  loss of  blood, although the
 orifices of several blood-vessels were observed on the divided surface  of the
 pedicle.
   The next morning, she had lost, perhaps, one or two  ounces of blood,  dur-
 ing the preceding twenty-four hours.  I must confess, that far  from rejoicing
 at this circumstance, which, indeed, refutes triumphantly one of the principal
 objections to the operations, I should have preferred the loss of a small quan-
 tity of blood, which, I believe, is always useful after such an operation, as  it
 tends greatly to diminish the danger of consecutive inflammation.  After my
 remarks of yesterday, upon the harmlessness of the separation, I was anxious
 to see the patient to day ; she has gone on well; there has been no chill, nor
 fever; the general state is most  satisfactory, and as yet nothing indicates an in-
flammatory reaction on the uterus; she must be carefully watched, and  on the
first symptoms,  the  whole apparatus of antiphlogistic remedies  immediately
applied, general and local bleeding, topical emollients, revulsives, &c.  Strict 
254
LECTURES ON
diet has been ordered, and should no serious accident occur, she will probably
be well in a fortnight
  On the 3rd day of the operation, one would have said, the woman was  in
perfect health; she was entirely free from fever, cheerful, contented, and de-
siring something to eat; prudence alone,  prevented a compliance  with her
desires.  Having been without a passage for several days, an enema was pre-
scribed, and the emollient fomentations over the abdomen continued. She was
discharged cured, in the early part of February.
  The second patient, in a much less  favorable situation, encouraged by the
preceding case, consented to the operation, which was performed the next day,
on the 22d January.
  I remarked to you, that in this latter case, a sanious discharge has, for a
month past,  succeeded that of blood, and soon  acquired an extreme fcetor;
that the polypus  mass was soft and fungous, indicating an incipient degen-
eration.  Indeed, after seizing the tumor with the forceps, it yielded and tore
on the slightest effort.   When brought to the external orifice, we saw a gray-
ish, gangrenous,  mass.  After its large diameter had passed the orifice of the
vulva, I introduced my fingers, and had scarcely reached the pedicle, when [
found it so soft, that it would have been impossible to draw it out without a
rupture.   In order to avoid this,  I made the section as near as possible, to its
insertion, but am  persuaded some part  was left, which may lead to serious con-
sequences, as will be hereafter explained.
  This operation, like the first, was followed by no  loss of blood, but a few
spoonfuls had been lost by the next morning; there was no sanious discharge nor
fcetor; the patient had had no chill, presented no symptoms of metritis, per-
itonitis, or phlebitis. She had still some pain in the hypogastrium, and fifteen
leeches were applied to the thighs.  On the fourth day she  was attacked with
a chill, and  complained of great pain about the umbilicus, loins, and  back.
Leeches were again applied.  On the 5th day, she was in an  indescribable
state of uneasiness,  pain in the throat, high fever, repeated chills, general pro-
stration.   This increased, and she died on  the  night of the 27th and  28th,
that is on the 7th day of the operation.
  The operation  was  performed quickly, and without  pain;  there has  been
since no discharge of any kind, but the previous existing symptoms still re-
mained, and even were increased.  The pain and fever became  more acute,
the yellow color of  the face more decided;  still no  symptom was  observed
which might have been a consequence of the operation ; there  appeared no
indication of consecutive inflammation of the uterus, or other organs; she has
therefore perished from the continuance and increase of the  primary symp-
toms, and the consequence of an absorption of  pus, arising from the remains
of the pedicle, which the instrument could not  remove.
  On an examination after death, the  epiploon  was found  perfectly healthy.
A considerable quantity of purulent matter was found between  the  bladder
and uterus,  which latter was very voluminous.  All the organs of the pelvis
adhered together by organized productions, of  a cellular nature, and conse-
quently the effect  of former inflammation, much anterior to the operation.
They must have existed for several weeks, and  the period of their supposed
formation, exactly coincides with the time when the patient first experienced
pain in the pelvis. 
CLINICAL SURGERY.
255
  We have said that the uterus was three or four times as large as natural.
Was  this owing to hypertrophy, or a second polypus inclosed in its cavity ?
This  last opinion is  not without foundation, for fibro-cellular polypi  of the
uterus are seldom  solitary.  It frequently happens that one of them projects
from the neck of the uterus, and is accompanied by another contained in the
cavity of the organ, of which the existence could not be ascertained, and
which was not even suspected.   The first is removed, the patient recovers for
a time; but the second remains, degenerates, and kills the individual.
  The peritoneum being removed the surface of the uterus was of a deep red
color, highly inflamed.  On making an incision into the parietes of the organ,
they were found considerably thickened.  This thickening was evidently the
cause of its unnatural size, for its cavity contained no polypus, nor fluid.  The
internal surface was of the same red color as the external.  On its posterior
face, near the neck, a circumscribed spot was observed, of the size of a piece
of thirty sous, projections, putrescent, fungous inequalities, extending into the
substance of the organ.  These  were  supposed to  be the  remains  of the
pedicle  and its point of insertion, as in  the  bodies of women, recently
delivered, we find the traces of the attachment of the placenta.
   I remarked to you, after having drawn to the orifice of the vulva the tumors
in the  cases just  related, their  grayish, violet, and evidently  gangrenous
appearance.  But, in one, this gangrenous condition was confined to a small
spot on the lower  surface of the polypus, whilst it had attacked the greater
part  of the second.
   In this case, the substance as well as  the pedicle of the polypus was soft
and fungous; both cases were in a state of degeneration, the former much less
advanced than the latter.
   What we have  observed in  these two cases, I have seen in all cases  of
 polypi,  which  left to themselves had reached  a greater or less  advanced
degree of degeneration.  So long as the patient has  a white or red discharge,
there is no fcetor; examine her; the tumor presents an equal hardness; intro-
duce the speculum,  and you find a white  or roseate body, smooth, with a
 polished, equal surface, &c.  Should a sanious discharge occur, a horrible fcetor
 is exhaled, and insupportable gangrenous smell; examine the parts, you will
 find  softness, fungus to an extent proportionate  to the time elapsed since the
 appearance of the last symptoms.
   Now the constitution of the patient begins to suffer; the face becomes of a
 straw color; a general reaction is developed, with continual fever; the patient
 rapidly emaciates, loses her appetite and  sleep, and  is in imminent danger.
   Thus, a very fcetid, sanious discharge,  is a certain sign of the development
 of gangrene in the uterine tumor; consequently it is possible to ascertain pre-
 cisely the period  when this gangrene has commenced.  Of  the truth of this
 remark, the two cases we have been considering are a striking proof; and  it,
 hence, appears that  there is a coincidence between the appearance of the gan-
 grene and the commencement of the cancerous process.   Let us now inquire
 into  the cause of  this gangrene and the error into which many have fallen  as
 regards it.
   Much has been said of the spontaneous fall of polypi in consequence of gan-
 grene, and the cure resulting therefrom.  In the cases under consideration,
 could it have been a means of cure ?  What is the cause of this phenomenon ? 
C56
LECTURES ON
Is it the constriction exerted by the neck of the uterus upon the pedicle of the
tumor when the latter has passed beyond the orifice ? But, generally, the gan-
grene does not attack at once the whole of the polypus; it begins at first near
its apex, and then extends gradually over the whole surface and the pedicle,
which, mostly, does not occur until after some time.
  The softening, therefore, commences on the lower  surface, or that exposed
directly  to the contact of the air.  The body of the polypus is first attacked,
the pedicle last.   Consequently these phenomena can not be attributed to a
constriction of the os uteri as has been pretended.
  But can you suppose that the general reaction, the phenomena of infection
manifested at this period  of the disease, the rapid emaciation, the pain, sleep-
lessness, &c. are  not  without danger to the patient ?   That the latter, worn
out by the continual discharge and fever, can reach with impunity  the remote
and  uncertain period, at which the pedicle of the polypus shall  become gan-
grenous  and detached from the  uterus ?   Gangrene,  hence, becomes  useful
and a probable means of cure, only when it is general,  that is,  when it attacks
the whole of the  tumor;  when partial, it is hurtful and endangers, the life of
the sufferer.
  Again, the pedicle is rarely completely detached from its  insertion in con
sequence of gangrene, some  portions generally remain, and these  furnish the
elements for a reproduction  of the disease, or keep up the existing general
symptoms, and consequently the afflicted situation of the patient.  And here
let  me  observe,  that  the latter is in  the  same  situation, as  after having
undergone the operation by ligature ; for the ligature acts by causing the gan-
grene of the tumor.
  On the other hand, the cases of spontaneous separation of the polypus from
gangrene are extremely rare ; I have never seen  but one, whose history I will
now detail to you.
  Case  I.—Pelegrini, F..., 32 years of age,  of a  dry constitution, men-
struated at  the age of eighteen, mother  of four children;  was  delivered  of
the first, at the age of twenty-two, and of the last, at that of twenty-eight.
From that period  her menstruation has  been pretty regular, but each time was
followed by a white discharge for several days. In the month of August, 1816,
without any known cause, she experienced  copious losses (perlcs);  but felt no
inconvenience about the genital organs, and continued  her  usual occupation,
without observing that fatigue increased the discharge.  This flow lasted for
five months, sometimes red,  sometimes  white, with scarcely a day's intermis-
sion.  About the  month of February, 1817, she felt pain in the loins and  a
dragging sensation  in the groins ; she made  use internally of astringents,
imagining herself to labor under an ordinary uterine hemorrhage, for she had
not as yet been examined.
  She came to the Hotel-Dieu on the 18th of March, 1817.  She complained
of continued and copious discharges, alternately red  and white, slight pain
in the loins, with  intermitting dragging  feelings in the groins; the patient did
not present that alteration of countenance, and pallor following abundant and
long continued losses of blood.   No difficulty in  the  excretion of urine  or
fascal matter; no sensation of weight in the perineum.  An examination, per
vaginam, soon discovered a  cylindroid, soft, and slightly irregular body, of
the size of the end  of the index-finger, extending nearly an inch and a half 
CLINICAL SURGERY.                        257
beyond the os uteri, in which it was engaged; the open orifice of the latter re-
ceived easily the end of the finger, which could completely circumscribe the
body indicated; but the point of its insertion  could not be felt; this body
was therefore a polypus.  As  it was not large, and  not so firm as uterine
polypi generally are, I proposed removing it with the forceps ; the operation
was put off until the  fourth day.   The patient was laid on the edge of a  high
bed ;  on introducing the  finger the tumor could not be felt;  the patient  then
said, that during the  previous evening, she had passed a black elongated body,
which she took for a coagulum, and not having preserved it, she could give no
idea of its shape or size.  As to its consistence, it was firmer than a coagulum
she had previously passed;  on the second day, the red discharge had dimin-
ished; on the third, it had  entirely disappeared, and a white discharge  suc-
ceeded ; it was not very copious and ceased on  the sixth day.  She then had
slight pain in the loins and hypogastrium.  On the  30th of March, the eighth
day of the fall of the polypus, the os uteri had  closed, the uterus  itself was
not larger than ordinary.  On the  2d  of April, she went out nearly cured;
the previous evening she had still  some red discharge.   Six days after her
departure, she passed another body  similar to  the  preceding ones; the  dis-
charge then ceased entirely.
  What opinion can be given  on the disappearance of a polypus, whose ex-
istence had been well ascertained by several persons  ? Did  it reascend into
the uterus ?  The thing may be conceived by those who know how these bodies
arising from the fundus of the uterus, descend  into the vagina; for we know
that they bring  with  them the  fundus of  that organ, and even cause more or
less inversion ;  we know also, that after the section of  the pedicle of the tumor,
the uterus ascends, so that the point of insertion can no longer be felt.  More-
over,  we have lately seen  in this hospital, a case of  uterine polypus, pretty
large, which  alternately  ascended into the  uterus, and descended into the
vagina.
  This polypus may have been spontaneously detached, not, as is supposed
by M. Levrel, the author of an essay on the subject,  because the  pedicle of
the tumor was strongly compressed by  the neck of the uterus, as by a ligature,
but rather, in my opinion, because the frequent examinations to which the
woman had been subjected, served in some degree to lacerate that pedicle.
  There are uterine polypi, which are spontaneously detached, without any
gangrene of their pedicle; they are those developed almost immediately under
the internal membrane of the uterus ; they have scarcely  passed the os uteri;
their  exterior coat,  being very thin,  breaks easily  and they fall of them-
selves, after having occasioned some discharge.  Cases may be found in divers
authors, amongst others Mme. Boivin, and in a memoir on polypus of the uterus,
in the Journal General de Medecine.
  The opinions of medical men are divided, in favor of two operations ; the
ligature and excision.
  Firstly.  The ligature  is not so easily applied as has been pretended,  as is
proved by the great number of instruments successively devised for its  per-
formance.  In  consequence of this difficulty it does  not always include the
whole of the pedicle, from which circumstance results, as we  have said, either
the recurrence of the disease, or the continuation of the general symptoms
           33 
258
LECTURES  ON
   Secondly. I have been led to prefer excision, from the fear of consecutive
 accidents.  The patient does well for two or three days, but at the end of this
 period, a most fcetid discharge takes place, resulting  from the  mortification
 of the tumor; symptoms of infection from absorption of pus appear; an ataxic
 condition comes on, which is in vain combated by tonics and antiseptics, and
 the patient perishes.   After death, evidences of  violent inflammation of the
 uterus, its appendages, and even of the peritoneum, are found; sometimes no
 proof of the existence of this inflammation is found, but we  are convinced that
 the patient has died from poisoning by absorption  of  pus.   I  have seen eight
 or ten  cases of this kind, and have never seen excision give rise  to these con-
 sequences ;  indeed  it cannot, as it leaves no cause of suppuration.
   Thirdly.  The  ligature is very  painful,  which may be  explained by the
 existence of a fleshy membrane around the polypi;  moreover, when the ligature
 is applied, the patient experiences acute pains in the  loins, pelvis, and  groin,
 until it falls off, and the tumor is detached.  Excision is followed by no pain,
and the patient is instantaneously  relieved  of his previous sufferings.
  Fourthly. We often  see the pain  occasioned by the ligature, which gene-
rally ceases when it is very firmly applied, continue; extend into the iliac fossae, to
the connections of the uterus ; give rise to vomiting, and an inflammation which
slowly progresses, attacks both sides and is fatal, after having led to hopes of
cure from the apparent trifling nature of the accompanying symptoms.  The
following is a remarkable case in point.
  Case II.—A  washerwoman, 43  years  of age,  had had for five  years,
a discharge which prolonged her menstrual  flow as long as  twelve days, and
 was succeeded by a very copious discharge of whitish  matter.   She suffered
no pain, nor inconvenience  even in the uterus itself, but daily grew thinner
and weaker.  A middle  sized polypus was found to exist.   A ligature was
applied, and tied pretty tightly.  She was immediately seized with acute pain,
which lasted all day and night, entirely depriving her of sleep.  On the second
day, the pain was less violent behind the pubes, but the left side of  the  belly
was very sensible to pressure; she had fever and vomiting, which were relieved
by antispasmodics;  the ligature was tightened. Third day, the vomiting and
fever returned, belly painful, a reddish matter passed from the vagina.  Fourth,
the patient thinks she  suffers less, her pulse is, nevertheless, very frequent,
the ligature drawn still tighter.  Fifth, the patient is tranquil, but the left iliac
region  is  still very painful,  and  the  pulse  very frequent;  ordered whey and
an anodyne potion.   The eighth day  was reached  without any other symptom
than the pain in the iliac region; the  rest of the belly was indolent.  During
the evening, the ligature which had not been tightened since the fourth day, fell
off.  On the ninth, the polypus was extracted, but with difficulty, for instead of
forceps, which were not at hand, hooks and small forceps were used.  A little
 sleep followed the relief afforded by the extraction of the foreign body.  The
 patient wanted to rise, but pain appeared in the right iliac fossa, and that in the
 left continued unabated.  Three days passed in this state of moderate  pain,
 limited to the iliac fossa, but on the fourth, the 14th of the operation, and sixth of
 the fall of the polypus, a great exacerbation of the symptoms took place; the
 whole abdomen became hard, tense, very painful, pulse hard and very frequent,
 and the patient in imminent danger of  syncope at every moment.  However, 
CLINICAL SURGERY.
259
she had no hiccough, nor anorexia; a bath and sixty leeches were prescribed.
The pain continued, the debility increased, syncope came on, and  she died
on the next morning.   (Journ. Gener. de Med.)
  No case, I think, can better illustrate the dangers of the ligature in general,
and  particularly, of the ligature when successively tightened, without any
reference to the existing symptoms.
  Fifthly. One of the  frequent  consequences of the ligature, is secondary
inflammation of the veins of the pelvis, and especially of those of the uterus.
I have never seen this  occur after excision, in persons whose organs were free
from chronic inflammation.
  Sixthly. The fall of  the ligature is  ordinarily followed by the cicatrization
of the wound, and the  discharges cease immediately, if not kept up by some
other cause.  Sometimes, however, the consequences of the ligature continue
after its separation, and although less alarming, are sufficient to cause death.
Many  cases are  related by writers.  M. Dubois has several times seen  (Diet.
des Sc. Med., art. Polypi) the blood gush out on the separation of the ligature,
and  from this cause has lost several patients.
  Seventhly. The ligature, even in the opinion of its most decided partizans,
should be abandoned when the polypus is formed  of nearly pure uterine sub-
stance ; it is impossible when the polypus is adherent and very large.
  Nothing, in these cases, contra-indicates excision; indeed it is  the only
remedy applicable.
  Eighthly.  These dangers, and these positive  and real  objections  to  the
ligature, being avoided by  the  instantaneous division  of the pedicle, and
removal of the foreign body, there remains only, as an argument against the
latter  proceeding, the  fear of hemorrhage,  which has been over exaggerated.
A long experience and very numerous facts  prove, that hemorrhage is exceed-
ingly rare.  During the last 20 years, I have performed this operation upwards
of two  hundred times, and never have seen  hemorrhagy but twice, once in this
hospital, and once  in  the city.   In both  cases  it was  speedily  and   easily
arrested by the  tampon.  M. Velpeau, in eight cases, has never observed it.
Such are the  dreaded dangers of hemorrhagy.  I have  always preferred the
scissors to the bistoury; the former cutting with some contusion, is  less lia-
ble  to bleeding than the smooth clean  cut of the latter.
  We will recapitulate the comparative merits of the two plans, by present-
ing  to you the  remarks of M.  Malgaigne, in  an essay published by him,
which  is decidedly the best that has hitherto appeared on the subject.
  A comparison of the consequences, says he, of excision and ligature, shows us
that to the latter belong pain, convulsions, fcetid discharges, secondary symp-
toms, inflammation from purulent absorption, slowness and difficulty of apply-
in"-  the apparatus, the  necessity of  keeping the serre-nceud in  the vagina,
&c?.; whilst the former is distinguished by its simplicity, rapidity, and facility of
performance, the almost constant absence of the symptoms above enumerated ;
the   question, therefore, appears answered in a very  satisfactory manner.
Excision should, henceforward, be looked upon as a general method, and the
other operations as exceptions.   Indeed, is there not a flagrant contradiction
to use the bistoury in excision  of the neck of the uterus, in which  the liga-
ture is proscribed, and reject it in polipi whose pedicle is formed of the same
tissue as the neck of the uterus, with merely less thickness and fewer vessels. 
260
LECTURES  ON
   Fibrous bodies  are tumors of various forms, generally more or less round,
composed of an accidental tissue, very analogous to that of the tendons of
the muscles or ligaments of the joints.  They are developed in  all regions of
the body in which the fibrous organic element abounds, where it presents a
firm texture, and  especially where it is  found united to the cellular tissue.
They are most frequently met with in the uterus, and they occupy different
situations, which it is highly important to distinguish, for this distinction is,
as it were, the foundation of  the curability or incurability of these affections.
  First.  Some arise from the external surface of the uterus, between this organ
and its peritoneal covering, by a pedicle sometimes very narrow; this pedicle
and some cellular laminae appear the only means of junction of this body with
the fibrous part of the uterus,  They project into the abdomen, raise up the
peritoneum, and from the smallest size may reach that of a child's head, and
sometimes attain a weight of  10, 15, and 20 pounds.
  Second. Others are formed in the very substance of the uterus, atan equal dis-
tance from its external and internal surface.  The tissue proper  of the organ
enters not into their composition : they are developed by separating the fibres
of the latter, and  never united to it by continuity of substance; they are
sometimes so  isolated, as to  appear  to be encysted; they have no pedicle:
their growth is slow; and although generally  smaller than the preceding spe-
cies, they sometimes become  as large  as the head of an adult.   Occasionally
they grow uniformly in all directions; sometimes they increase more in one
direction than in another.   These tumors  are very common, and admit of no
operation, for the  only possible means of reaching them, would  be through
the parietes of the uterus.
  Third.  Some of these tumors are developed, in the substance of the organ,
but at a point near its external or internal  surface.
  They are then  sometimes  furnished with  a pedicle,  sometimes not. In
the latter case, they  belong to  the  preceding class;  in the  former, they
approach  that class of  which  we are next  to speak.
  Fourth. These tumors are often situated on the internal surface of the uterus,
and  either simply project into the uterine cavity, or, which is most common,
have  a pedicle.  These last constitute the proper fibro-cellular polypus, and
are composed of a root,  a neck or pedicle, and a body, resembling much in
shape, a mushroom. In both cases they are covered by a very fine membrane
formed from the substance called by Bichat,  the mucous membrane of the
uterus.
  When the body of  the  polypus is perfectly round, the pedicle cannot be
discovered,  unless it be much elongated, and the polypus, having  passed
beyond the neck of the uterus, projects more or less into the Vagina.   I call
root of the  polypus, the part by which it is inserted into the  tissue of the
uterus, and through which the fibrous  body receives its principal  nourishment
by means of the vessels composing it.
  It is formed by nutritive  vessels,  veins,  lymphatics, cellular and fibrous
tissue.  This it is important to know ; for if  the polypi frequently reappear,
even  when  they have  been divided as near as possible to the surface of the
uterus, this recurrence must be  attributed to some portion of  the diseased
tissue having been left.  This often occurs in the extirpation of erectile fun-
gous tumors. 
CLINICAL SURGERY.
261
  You have seen that fibrous tumors have occasionally a pedicle, and occa-
sionally none;  and that this difference is owing, at least in general, to their
location.  Thus, there is none in polypi developed in the interior of the sub^
stance of the uterus, and those, which projecting externally or internally,
are still  covered by a layer of this tissue.  A general division may be there-
fore established  between  polypi with  pedicles,  and  those without.  The
former constitute fibrous polypi, the \aitev fibrous tumors of the uterus.
  The length of the pedicles is very various ; some are scarcely distinct from
the body of the  tumor, others are two or three inches in length; moreover, the
latter  is always  in  relation to the extent and  prolongation of the tumor
itself.   The more extensive the polypus, the longer the pedicle.   Thus we
find the longest in those cases, in which the polypus having passed out of the
os uteri, has descended more or less into the vagina ; but they diminish in the
same  proportion, and then if the fibrous body be at all large, they break, and
the latter is spontaneously detached.—(See Case I.)
  Their thickness and firmness are consequently in the inverse ratio of their
length.  Nevertheless  they  are sufficiently  strong  to resist a considerable
effort.  They are generally formed of very dense fibrous tissue; but when less
consistent and  thinned or softened from any other cause, they may be easily
detached by mere torsion.  I have always preferred, even under these circum-
stances,  division,  because the  torsion  always leaves  some remains  of the
pedicle, and the disease is liable to recur.
  These pedicles are formed of arteries, veins, lymphatics, cellular tissue, and
probably of nerves.   Now, if there are arteries, why does not their division
cause hemorrhagy?   This reason has been alledged as giving the preference
to the ligature.  True it is, that these arteries are sometimes very large, yet
hemorrhage is extremely rare.
   The existence of lymphatics cannot be denied ; they can even sometimes
be seen.  As to the nerves, if any exist, they must be extremely small, possess-
ing but little sensibility,  and purely organic;  for the excision of the tumor
never gives the least pain, and  should the patient complain, it is because, by
mischance, some part of the sound tissue has been included in the forceps, or
because the uterus has been too suddenly drawn down.
   The age and strength of the patient have certainly some influence over the
development of polypi, and the degree of their increase; but this increase is
owing much more to the degree of compression, exerted by the body or neck
of the uterus;  and indeed experience has shown, that those which  attain  the
o-reatest size,  are seated on the external surface of the  uterus, where no
obstacle opposes their growth.   But this size varies most singularly.   I have
known them, from the size of a millet-seed, reach that of a man's head ; and
from the weight of a few grains, that of  12  or 15 pounds.   The largest  I
have ever met with in the  dead subject, weighed nearly 25 pounds.   M.
Gaulthier  de  Clanbry  has given an account of  an enormous  mass  36  1-4
inches in its vertical, 29 1-4 in-its horizontal circumference, and weighing 39

P°So lo'no- as the polypus has not degenerated, it has a whitish aspect, a smooth
 surface, Searly resembling that of the uterus in a healthy state;  it is more or
 less ^d when  inflamed:  and lastly assumes a brown, grayish, or black color,
 when it degenerates spontaneously, or becomes  gangrenous from  the effect
 of a ligature or any other cause. 
262
LECTURES ON
   They present various degrees of consistence, but are mostly very firm, dense,
 and cannot be crushed like cellular, vesicular, or mucous polypi.  They areas
 dense as the intervertebral fibro-cartilages, and remarkably elastic, so as to
 rebound several feet from the floor when thrown  upon it.
   Their form  is  exceedingly various;  generally globular or ovoid, they are
 often angular, irregular, when they dip into the vagina, and approach a large
 size; they are almost always divided by external fissures.  I have seen them
 resembling an inverted mushroom, others conoidal, with the apex downwards,
 &c.   These peculiarities are not unimportant, as it is often very useful, in
 forming our diagnosis, to understand the arrangement of the whole  of the
 tumor.  The following case is a proof.
   Case III.—The wife of a gentleman  in the vicinity of Paris, consulted one
 of the most skillful surgeons of that capital.   He examined her, found a tumor,
 observed the fcetid smell, declared the disease  to be cancer, and that she had
 not three months  to live.  I was desired to see her, I examined her and found
 a large tumor, which I could circumscribe with my finger.  Carrying the fingei
 higher I found the pedicle, and lastly discovered its  insertion into the neck
 of the uterus.   I  told the gentleman that his wife had polypus, which could
 be easily removed, and she would be well in a  short time.
   He was perfectly astonished, and after a few minutes of  silence, asked me
 if I was very sure of what  I  asserted, and  begged me to examine again.
 This examination confirmed my previous opinion.  He  then communicated to
 me the opinion of the celebrated surgeon of whom I have  spoken.   Such im-
 posing authority made me, I confess, fear some mistake on my part, and I made
 a third examination still more carefully; but was convinced of the correctness
 of  my diagnosis, and proposed the operation as a prompt and easy cure.   It
 was eagerly consented to, and  in 12 or 15 days the patient was perfectly
 restored to health.
   Let us examine still further the anatomical structure of these polypi:  they
 are composed of a body, a pedicle, a root, the whole covered by a membrane,
 and formed internally of fibro-cellular  tissue; the enveloping membrane is
 lost in  that,  called mucous membrane of the uterus.  It is this membrane
 which gives to the polypi their smooth surface and roseate white hue.
   What apparently proves its mucous nature, and consequently the mucous,
 nature of the internal lining of  the uterus, of which it is only a prolongation,
 is its susceptibility of contracting all the changes peculiar to this species of
 membranes.   Such  as inflammatory, catarrhal, ulcerative affections, mucous
. serous, sanguineous, sanious discharge;  it is capable of a turgescence similar
 to that giving rise to the menstrual discharge, and thence arises a distillation
 or a true flow of blood ; it may  take on exulceration  similar to that observed
 in the pituitary membrane in ozaena, and these exulcerations become the sources
 of puriform,  sanguinolent and sanious discharges.
   These exulcerations are frequently found on the neck of the uterus, and
 especially on the os tincae, and it is highly important  not  to confound them
 with cancerous ulcerations.    They may be  distinguished from  cancerous
 ulcerations, by their redness, their irregularly round form, being white at the
 bottom of  the  cavity, formed of a layer of  fibro-cellular tissue which is not
 easily distinguished from the  tissue proper of the polypus.
   On using the word root, as applied to the polypus.   I do not wish to be under-
 stood that these are prolongations, or ramifications into the substance of the 
CLINICAL SURGERY.                        263
uterus, similar to the root of a tree, but have merely given this name to the ensem-
ble of tissue by which it is connected to the uterus.  These are, arteries, veins
lymphatics,  probably nerves, a fibrous and cellular element, all covered by a
mucous or serous membrane, accordingly as the polypus is situated internally
or externally.   The following is their mode of development, and of the form-
ation of the pedicle: the  polypi arises at some point in the surface of the
uterus, by a process as yet unknown  to us; they constantly increase; are
gradually enveloped by the serous or mucous membrane of the uterus, which
they carry before, as they depart from their origin; but as they increase and
depart, they leave between their strongest portion  and the uterus, a thinner
part which constitutes the pedicle, and which diminishes in size and firmness
in the direct ratio of its length.  Lastly the enveloping membrane of polypi
of the uterine cavity, is, as we have said, the same  which lines this cavity.
Its anatomical characters, its physical and physiological  properties are evi-
dently proved, and it is a most  absurd idea  to suppose that it is formed at
the expense  of the tissue proper of the uterus ; in  fact, it is continuous, and
only forms  a  whole with the internal membrane  of the  uterus ; it merely
adheres to the fibrous body by a cellular tissue, easily destroyed when it has
not become  inflamed  nor  degenerated, subject to the same lesions, and often
presenting physiological phenomena similar to those of  mucous membranes.
Let us, moreover, judge by comparison. Have the fibrous bodies of the exter-
nal surface  any other covering  than the peritoneal coat of the uterus, and
are not those  growing in its substance merely covered by a cellular layer
which separates them from the tissue itself of the uterus ?  This opinion is,
therefore, as untenable as the former.   Let us  now examine  the substance
proper of fibrous bodies.
   More deeply we find that tissue, which I have called  fibro-cellular, and of
which the whole tumor, with the exception of its envelop, is composed.  The
nature,  therefore,  of these tumors is entirely different from  that of polypi,
called cellular, vascular, vesicular  or mucous.  Whilst  the  former are very
common in the uterus, the latter are very rarely found there ; but frequently,
as is well known, in the nasal fossae, on the  margin of the anus, and on the
mucous membrane of other parts.  I have sometimes seen them on the uterus,
but only on  the neck.
   If divided immediately after  their removal, fibrous polypi are of a pearly
white color.   We have said that they were similar to the inter-vertebral sub-
stance.   If  the latter be boiled  for a long time, it  is reduced to a gelatinous
matter; the same  is  true with fibrous polypi.   They are composed of still
another element—I mean  the cellular tissue, but generally more dense and
firm than  is met with in other regions.  These  two  element are  sometimes
united in equal proportions;  but generally one predominates, and to this
excess is owing the majority of the changes which they undergo.
   If the fibrous element predominate, the polypus does not degenerate, or if
at last it  should degenerate, it passes, not into  the cancerous, but  into the
osseous state.
   If the cellular tissue, on the contrary, be more abundant, the polypus passes
into the carcinomatous state.  This tendency to carcinoma is certain and in-
evitable after a certain length of time.   Its substance becomes inflamed and
softened;  the  surface unequal,  irregular, and frequently ulcerated.  Then 
»v
264                            LECTURES ON

commence those horibly fcetid, sanious discharges, certain symptoms of disor-
ganization.   The  patient's  constitution  suffers, her face takes on a yellow
hue, she rapidly emaciates.   The tissue of the polypus is transformed into a
cerebriform substance, in which are found fungi, depositions of pus, effu-
sions of blood, in short, all the products of carcinomatous disorganization.
  Experience has shown that polypi rarely pass into the cartilaginous or osse-
ous states, but generally into carcinoma.
  Between the two elementary tissues of the polypi, of which we have spoken
there exists a greater or less quantity of serosity,  either free or in combina-
tion.   If free, carcinoma  is less to be feared, but  much more  to be dreaded
if the fluid be combined with the fibro-cellular elements.
  Such are the different terminations  to which fibrous polypi tend, from their
peculiar organization.  But their disorganization is often the effect of another
cause, namely, inflammation of their serous or mucous envelop.  The serous
inflammation sometimes spreads over the peritoneum, giving rise to peritonitis
and  all its consequences; sometimes it is confined to one spot in the tumor
and  causes adhesions between it and the adjacent parts, or else it penetrates
more deeply and is the origin of one  of the degrees of the disorganization I
have just spoken of.  If inflammation attack the mucous membrane, it pursues
a similar course; then follow catarrhs, metritis, ulcerations, mucous, serous,
purulent and sanious discharges and invariably carcinoma. But  the distinction
between the effects of these two orders of causes, is, that the disorganization,
which I shall call spontaneous, and which is the necessary consequence of the
organization of polypi, proceeds  from the centre to the  circumference; whilst
that  which is the  product of inflammation, commences at the periphery.
  Cavities are sometimes found  in the interior of fibro-cellular polypi of the
uterus.  These cavities are original and organized, or consecutive and result-
ing from the softening and disorganization of the polypus.   The internal sur-
face of these cavities is sometimes smooth and polished, and sometimes presents
bundles of fibres, like the columnae carnae of the ventricles of  the heart.
  The cavities of the second species, arising from the ramollissement, and
disorganization of  the polypus, are filled with a sanious, sanguinolent, puri-
form fluid.  A  surgeon having applied the forceps  to a similar tumor in order
to effect its depression, the cavity burst, and a quantity of black, ropy, foetid
matter escaped.  A cat having licked up a small portion which fell on the
floor, died the same day with symptoms of cholera morbus.  (Journ. Gener.
de Med.)
  It follows from the preceding facts that all those fibrous, cancerous, fungous,
fibro-cartilaginous osseous,  and stony tumors,  &c,  which had  been con-
sidered as productive of different natures and  arising  from  different causes,
are  merely different  degrees of the successive transformations of the  same
disease.
  The disease under consideration was formerly considered very rare.  When
Levret first turned  his attention to it, in seven  years he only found three cases
to which his method could be applied.  Herbiniaux is  said  to be the second
who saw it at Brussels ; and a dutch  professor, who had  never seen it, pre-
tended  that his country-women were exempted  from it.  But, since, it has
been  ascertained  that fibro-cellular polypi of the uterus is one of the  most 
•
                           CLINICAL  SURGERY.                       265

common diseases peculiar to females. Bayle reckoned at one fifth, the number
of women over 35  years of age,  in whom he found one or several fibrous
bodies.   Portal,  in  1770,  found, out of 20 cases which he examined, 13
containing polypi.  In my opinion, there is scarcely an uterus of an old wo-
man, which does not contain some tumor of this nature.
  I think it useless to waste time in considering the various hypothesis which
have been advanced, concerning the remote and proximate causes of polypus
of the uterus; they can be of no benefit to you, and are not less unknown to
us than to our predecessors.  There are, however, two facts relative  to the
predisposing causes on which experience seems decided.   It appears from a
considerable number of cases collected from different authors, that the period
between 40 and 50 years of age, is most fertile in uterine  polypi; and on the
other hand, that the assertion of Bayle, so often repeated without examination,
upon the influence of celibacy and sterility in the production of the disease is
entirely  erroneous.
   The number of cases I have collected is sixty-two,  taken principally from
the works of M. Velpeau, Mine. Boivin, M. Recamier, M. Bayle, the Journal
General  de  Medicine, volume 101, and the Thesis of Dr. Marx.
   First.  As regards age. Little is generally known of the history of the patient
previous to  her coming under the noticeof the physician.  I have endeavored,
however, to establish two periods in the life of the patient; by the former, which
I consider by far the most important, I mean the date of the first appearance of
the disease. By these means alone, can we correctly ascertain at what period of
life polypi are most common.
   Age of the  patients when the first symptoms of the disease appeared.
   From  the 62 cases, five must be deducted, whose history does not give the
commencement of the disease ; 57 remain.
   Of these  57, the first symptoms of the disease appeared
          In   1 patient of 15    to    20  years inclusive.
10	tt	20		« 29
19	<<	30		39
23	(t	40		49
3	<<	50		59
1	<«	60	and	upwards,
       Total, 57
  Thus the period furnishing most cases, is that from 40 to 50 years;  next,
from 30 to 40.  But by consulting the real age of each patient, we find that it
is from 35 to 45 or 48, that the disease most frequently appears.
  A°-e of the patients at the date of observationand treatment.
       From 20     to     29 years inclusively     8  patients.
             30     «'     39         "           18
             40     "     49         *«           24
             50     "     59         ♦*           6
             60 and upwards         "           5
             Age unknown                       1

                                          Total,  62
  Second.  As regards marriage or celibacy.   We have  of course considered 
•
266                           LECTURES  ON

as married, all those women who have cohabited with men.  It would be truly
ridiculous to consider as in a state of celibacy, girls who have abused coition,
and then pretend that celibacy has great influence over the development of
polypus: that question belongs alone to the municipal authorities.
  Of the 62 cases, the character of. four is unknown.   There remain, there-
fore, but 58.
  Of these 58 patients 54  were married, or  being unmarried had cohabited,
                      4  only were virgins, and  supposed never to have co-
                         habited.
                 Total,  58
     Third.  Let us now inquire if the opinion of Bayle, as regards sterility, is
  better founded than the preceding; we must first deduct from our list the four
  virgins, and seven women and girls, whose fecundity or sterility  has not been
  ascertained, there then remain  51.
     Married women having had from 1 to 10 children,              39?  ^
     Girls having had children,                                    3 5
     Married women having had no children,                       8 >
     Girls having cohabited without children,                       1 $

                                                               Total, 51
     Fourth. State of the menstrual function.
           41 were regular until the commencement of the disease.
            5 were irregular for  some years previous to the appearance of the
              first symptoms.
            6 had been  always irregular.
            1 48 years of age, although regular, had suffered from violent leu-
              corrhoea,  from  the age of  18, and had, nevertheless,  had  six
              children.
            9 The state of this function was unknown.

m    Total,  62
     The reductions  which may be drawn from the preceding facts relative to
  age, celibacy or marriage, fecundity or sterility, are positive, and too evident
  to be passed over  in silence, and I am persuaded, that whatever number of
  cases may be selected, the result will be found very nearly the same.
     The lymphatic temperament; has also been classed among  the  predisposing
  causes, but as yet we have not had sufficient experience to decide.   As to the
  occupation, &c, and  immediate causes,  I can find nothing satisfactory in
  writers.
     Let us  now proceed to another not less  important part of our subject, the
  symptomatology, diagnosis and  treatment, concerning  which, however,  the
  limits of  our  present work  do  not admit of much detail.   No precursory
  symptom  foretells the existence of a polypus;  and even in many cases, this
  anormal organic production can only be ascertained when  it has acquired a
  pretty considerable size; and in others, it is impossible to be positively certain
  of its existence.
     If the polypus be very small and at the same  time situated on the perito-
  neal surface of the uterus, giving rise to no inconvenience, it cannot be known 
CLINICAL SURGERY.
267
during life, and in this case belongs exclusively to the domain of pathological
anatomy.
  This does not obtain  when they are large or project into the  cavity of the
uterus; they then occasion well marked symptoms by which  their existence
is revealed.   But  these  symptoms are  far from being uniform, and differ
widely according to the  situation they occupy.  We must, therefore, study
their symptoms  and signs, according as they are located in the internal sur-
face of the uterus, the thickness of its parietes, or its  peritoneal surface.
  First.  In the cavity of the uterus.  When the polypus arises and grows in the
cavity of this organ, the first symptoms are a sensation of weight in the abdominal
region, a painful dragging in the groins, the region of the loins and inner part of
the thighs, more or  less severe colic,  which is accompanied by a painful ten-
sion in the hypogastric region, and if the tumor has acquired a certain volume,
a sensation of weight and pressure at the fundament.
  Women, who still menstruate, at first become irregular ; the period of the
discharge  occurs more  frequently, is of longer duration, or  returns several
times during  the month  at unequal  intervals.  They are also subject to
copious leucorrhoea and as we before said to menorrhagia.  But  all these
symptoms, merely indicating some disturbance of the functions of the uterus,
may depend upon a cause totally distinct from  a polypus projecting into the
cavity of the uterus,  She is, therefore, generally reduced to mere conjecture
in this first period of the disease.
  But the second period arrives, much less obscure, and furnishing already
some rational signs of high importance ; it is when the polypus having acquired
more or less size and gradually distended the uterus, appears at the internal
orifice of the neck, presses against it, dilates and opens it, and passing through
projects into the vagina.  It is highly important to remember, that, generally
several months, and frequently more than a year elapse  between the first and
second period; and that consequently, when we have reason to suspect the
existence of a polypus, we should not lose sight of the patient, but examine her at
least once monthly, in order to be prepared against any serious symptoms which
may arise.  Women have frequently perished,  for want of these precautions.
  The disease  having reached this point, a series of complete  and constant
symptoms  becomes  manifest; the pain in the lumbar region and groins take
on a dragging character,  and to it is added a sensation of weight at the anus, and
a tendency to constipation.   Walking is sometimes difficult;  and  lastly the
patient complains of pressure, and an unusual  feeling of distress about the
inferior portion of the vagina.  Then appear those uterine contractions, simi-
lar  to pains of childbirth, repeated at various intervals, and sometimes present-
ing the inexplicable character of very regular periodicity.  The following case
will demonstrate at the  same time the difficulty of the diagnosis of the disease
at this period, and how  it was discovered by means of a  manual examination.
  Case VI.—A young woman of 22 years of age, of an opulent family, residing
on the frontiers of the kingdom, came to Paris for advice concerning  a disease
of the uterus.   She was  placed under the  care of two celebrated physicians.
Both  considered  the disease as an  engorgement of the organ and treated her
according  to this erroneous opinion, for more than  two months.   She was
daily  getting worse, and  at the  end of that time, a  celebrated  surgeon was
called  in   consultation.    The attending physician   pointed out to  him a 
-268                            LECTURE? ON
remarkable phenomena, namely, that every day, at the same hour, the  patient
experienced pains like those of labor.  This first awakened his attention, and
made him cautious in his diagnosis.
  The surgeon examined her in a recumbent posture.   Placing her then in
an erect position, the orifice of the uterus presented a dilatation about as large
as a one franc piece; the index finger carried to the opening ahd  circumscrib-
ing its margin, recognized a considerable hardness which appeared to belong
to the parietes of the organ and to be lost in them.  There was a sensation of
swelling and thickening of the neck, and if the examination had  been carried
no further, one might  have easily believed in the existence of engorgement.
Such had been the cause of the error of the first pnysicians, as was proved by
a new  examination, and afterwards by the autopsy;  in fact the polypus deve-
loped on the internal surface of the organ, was exactly  applied  to its orifice
and did hot extend beyond its edges*   On introducing the finger still further,
a pretty large tumor was felt, which could be easily circumscribed with the
finger, and the surgeon announced the existence of a polypus.   Its extirpation
was decided upon, but as the  patient was on the eve of  menstruating, it  was
deferred  until after that  period.  The  menstrual discharge  came  on; but
immediately a violent peritonites took place, and the patient soon fell a victim
to it.   The autopsy verified the diagnosis; the disease was a fibrous  polypus.
(Journ. Comp. des Sc.  Med.)
  This progress of  polypi of the uterus, belongs  exclusively, as you well
know, to those which  are  furnished with pedicles*   But when they are not
pediculated, and merely projecting into  the cavity of the uterus, the symp-
toms are those of the first period, that is to say, very uncertain.
  Sometimes, however, the os Uteri is so rigid, the polypus so much increased in
the interior of the uterus, that although without a pedicle, it cannot open a pas-
sage through the orifice, and the disease remains at  the  second period.  The
symptoms  in that case, are much  more serious  artd dangerous ; the Uterus
dilates, as  the polypUs increases; the efforts of  expulsion are more  violent,
and  may give rise to inflammation of the organ; there is a copious and almost
constant discharge*  Hence, general debility, inability to walk or move, increas-
ing  paleness, bloated  appearance, partial or  general  dropsy,  pulse small,
weak, and rapid, frequent syncope, and if relief be not  obtained, death takes
place in complete anemia and prostration.
   When the polypus has descended into the Vagirta, Or reached its third period
of development, the pains in  the  hypogastrium, generally cease;  but the
tumor presses more on the bladder, and according to its position, occasions  a
frequent desire to make water, or prevents its flow entirely; its pressure on
the rectum, opposes defecation ; on the perineum, prevents the  patient from
sitting; on the parietes of the vagina, causes a chronic irritation,  accompanied
by leucorrhoea, or a sanious  discharge of horrible  odor.  There  are at the
same time, frequent and continued discharges of blood; lastly supervene, all
the general and local symptoms, which we have elsewhere described, indicating
the cancerous disorganization of the polypus.
   The disease in the fourth period, or, when  the tumor had passed out of the
vagina, and is fixed between the thighs,  seldom gives rise to any new symp-
 tom worthy of attention ;  but the situation of the patient is most painful and
 disgusting. One circumstance daserves notice,  namely,  that as the whole mass 
CLINICAL 8URGERV.                       269
is exposed to the action of the air and constant friction, rapiaiy Decumes dis-
organized*   It may sometimes be returned into the vagina, but it is liable to a
new protrusion on the least muscular contraction of the abdomen, a  slight
cough^ a false step, &c.
  From the nature of the facts just related, it is evident that each stage of
the disease, presents different means of diagnosis, and greater or less difficul-
ties.  When fibrous polypi are completely enclosed in the uterus, of  which
the orifice is undilated, we can only form conjectures from the rational symp-
toms ; feeling and sight are inadequate.
  But when they appear at the uterine orifice, and the neck is more or
less dilated, the means of diagnosis are more  numerous  and certain; in the
first rank stand an examination per vaginam, and inspection by means  of the
speculum.
  By an examination we feel the tumor, which appears  between the lips of
the  orifice, round, smooth, of variable consistency, but  generally very firm.
  The question then arises, if it be polypus or an engorgement of the neck ? if
the polypus arise from the edge of the neck, or from its internal surface ? or if
it proceed  from the cavity of the uterus ?  The first question  is not always
easily answered,  especially when the tumor is scarcely engaged in the orifice,
or when the latter is not sufficiently dilated to allow tne introduction  of the
finger, as may be seen by case VI.
   We should then repeat the examination as often as  may be necessary; en-
deavor to introduce the finger into the os uteri, if possible.  Should a polypus
exist, we may circumscribe its surface, discover its pedicle  by the circular
depression which is formed, and even sometimes ascertain its point of insertion,
and portion of the uterus from which it arises.  In engorgement of the neck,
these symptoms do not exist; no depression  or  pedicle is to  be found; the
finger cannot circumscribe the tumor; and we cannot decide  whether there
be°a simple engorgement, or a polypus of the second species*  The same
 difficulties obtain, when the polypus adheres, in consequence of inflammation
 of its envelop, to the surface, or to the neck of the uterus.  Much skill and
 experience in examining are here required.  If the polypus is implanted in
 the edge of the neck, the orifice is free, and alongside of  it is felt one of the
 lips occupied by a tumor, with or without a pedicle.
   Fibrous polypi arising front the neck of the uterus, occasion  considerable
 increase of the size of the part of the neck from which they arise.  This part
 seems to extend and mingle with the polypus.  It  is sometimes difficult to
 distinguish where one begins and the  other ends.   In these cases the neck of
 the Uterus always loses  its natural position.
    When the polypus has extended into the vagina, if it be of moderate  size,
 it  may be  easily recognized by the  finger.   This method of exploration is
 moredifficult and delicate if it be large, and fill the whole Vaginal  cavity.
 We must circumscribe  with the finger, the pedicle of the tumor; if a circular
 groove be felt around, in Which the finger or an instrument can penetrate, and
 if around this groove, thetneck of the uterus be dilated, and its edges free, we
 may affirm that the tumor comes from the uterus. If, on the contrary,  the ori-
 fice be free, but one of its lips continuous with the pedicle, we have to  do with
 a polypus of the neck.                           #
    Sometimes the polypus so completely fills the vagina,  that the finger cannot 
270
LECTURES OX
turn freely around the pedicle; we must then introduce, alternately, the index
fino-er of each hand on each side of the tumor, in order to ascertain its origin,
bv penetrating as far as the neck of the uterus.
 * This  is  sometimes impossible  ; and we then are obliged to follow the
advice of Levret, to seize the tumor with the  forceps, bring it down to the
vulva, and  execute at the same time the diagnosis and operation.
  Case  VII. Jeanne Monconteau, 50 years of  age, widow, of a bilioso-ner-
vous temperament, delicate constitution,  having ceased to menstruate at 46
years of age,  was attacked with a very copious white  discharge,  with acute
colicky, lumbar and inguinal pains. She was slightly relieved by the use of the
warm bath.  A year afterwards bloody discharges came on, twice and thrice
monthly, sometimes more seldom; they were accompanied by weakness,  and
general  langor.  She came to the  Hotel-Dieu on the  18th of April, 1818; on
examination, a large,  smooth tumor, completely filling the cavity of the
vagina and distending its  parietes, was discovered; the  neck of  the uterus
could not  be  felt without great difficulty, and  pain to the  patient; it was
impossible  to feel  around  the tumor with the same finger.  Standing on the
left  side of the  woman,  the index  finger  of  the  hand  of the  same  side
could be insinuated between the tumor and vagina. Having reached the neck
of the uterus, the whole right side of the circumference could be explored, and
the tumor  was found not to be inserted at this point; the same was true of
the left  side.
  She was transferred to the surgical wards on the 21st of April, 1818, in
the following condition :  face pale, ydlow, anxious; eyes dull;  skin dry and
clayey; articulation feeble; pulse small and slow ; little appetite; digestion
impaired; weariness and weight in the loins and thighs; frequent colic; white
discharge from the vagina; a smooth and hard  tumor was felt in this cavity,
completely filling it, and distending its parietes. I found great difficulty in
ascertaining the  point of its insertion, and only succeeded  by  following the
process of my colleagues.
  I then proceeded to  perform the operation in  the usual manner; but
having  brought the tumor to the vulva, and endeavoring to extract it by that
orifice,  I was unable to succeed on account of  its narrowness, as  the woman
had never had children.   The posterior commissure  was then divided for
about half an inch.   The tumor was brought out, and its pedicle divided  with
the scissors.   There was no hemmorhage.
   In a  few days she  was sent to  the medical ward, whence she came, and
was soon after discharged perfectly cured.
   In the fourth period of the disease, when the  polypus appears at the vulva,
or  has  passed beyond it, the manual examination is easy.   Difficult cases,
however, ocasionally occur.
   The  foundation  of the diagnosis is always the exploration of the neck, its
central orifice, and the  circular cul de sac separating  it from  the vagina
Therefore, even  when the polypus has passed out of the vagina, if the uterus
has not been brought down with it, if the pedicle isf^ry long and very large,
 we can ascertain the nature of the tumor, but it is often impossible to  know
 whence it arises, where the pedicle finishes, or where it is inserted.
   Case VIII.—M.  L. Tellier, 51 years of age, mother of two children,  of
 which  the younger is  ten years old, regular,  and enjoying good health, until 
CLINICAL SURGERY.
271
 the appearance of her present disease; began about nine and a half years ago,
 to experience some derangement in the menstrual function.  This discharge
 occurred at intervals of two weeks, a month, and even two months, and was
 each time followed by a flow of mucus which lasted several days.
   Six years after, she felt at the bottom of the vagina, a tumor, which, on her
 making any exertion, descended to the margin of the vulva.  A continual
 discharge of reddish, foetid fluid, took place; the general health of the patient
 grew worse, and she became pale and emaciated.
   The tumor at last reached the level of the lower orifice of the vagina, and
 by its pressure on the rectum, interfered considerably with defecation.
   On the 14th of May, 1826, in an attempt to  evacuate her bowels, the tumor
 suddenly protruded, accompanied by the discharge  of a  quantity of blood,
 and  cute pain in the lumbar region.  On the 18th of May, she came into the
* Hotel-Dieu.   Face pale, skin of a straw color, eyes dull, pulse feeble and
 moderately frequent, debility great.  The upper part of the space between
 the thighs was occupied by a round polypous mass in the shape of an inverted
 mushroom, six inches in diameter, and three in thickness, with a rugged sur-
 face.  Its upper surface presented  a  kind  of umbilicus, from which arose a
 pedicle an  inch in  diameter appearing externally about two inches, and occu-
 pying the whole length of the vagina.  The examination  was  exceedingly
 difficult, on account of the size  of the pedicle; the finger could penetrate to
 the depth of two  or three inches, and  then  met with a circular cul de sac,
 embracing  the most remote part of  the pedicle, without being able to distin-
 guish the lips of the os uteri.
   The nature of the tumor was evident, and  on the next morning it was
 removed in the usual manner;  but on account of the  state of  the parts, I
 thought it  most prudent to pass a  ligature around the pedicle, as high up as
 possible, but without exerting the  least constriction  upon it.  The pedicle
 was  then divided at the inferior orifice of the  vagina.  A  little blood was lost
 from two small arteries, but the discharge soon ceased.  The patient was put
 to bed, and carefully watched, in case of a recurrence of the hemorrhage.
   None  occurred  during  the  day,  but  the patient was constantly in a state
 approaching to syncope.
    (Infusion of linden and orange flowers.)
    A fibrous and scirrhous tissue was discovered in the centre of the polypus,
 presenting a central band continuous with the pedicle; on the circumference,
 for the extent of about an inch, a red and very vascular tissue, furnished with
 veins, some of them as large as a  crow quill.   The firmness of  this tissue
 diminished from the centre towards the circumference.  Parts of the exterior
 were very soft, and On the point of ulcerating.
    The external surface of the tumor, was covered by a thin, flocculent mem-
 brane  composed of mucous membrane.  The pedicle was  similarly organized,
 except that the scirrhous tissue predominated  Its  centre was  traversed by
 an artery,  which, in its passage, gave off several branches, and was finally lost
 in the bodv of the polypus.                                    ,        ,
    Duvin- the two weeks following the operation, the patient was always pale,
 weak"  with a small and frequent pulse, without sleep, and having ~me diar-
 rhoea, the  pedicle of the polypus became inflamed and  doubled in »ze  >t
 surface was covered with a slight suppuration, but which annoyed the patient 
272
LECTURE!'  ON
from its continuance, and excoriated the upper part of the thighs and perineum,
notwithstanding all our care to prevent it.
  On the 21st day, the tumor beginingto diminish, a bandage was applied with
the intention of assisting its ascent into the vagina.  Two days after, the patient
having pushed the pedicle rather roughly, it suddenly ascended beyond the
reach of the index finger.   The suppuration gradually decreased, her appetite
and strength returned, and she asked for her discharge on the 26th day after
her admission, or 25th of the operation.   Since that time I have not heard of
her, and cannot say whether the pedicle  may or may  not  have given rise to
inflammation of the uterus, a relapse of the disease,  or disorganization.
  Notwithstanding all the means of diagnosis which w6 possess, difficulties are
innumerable and mistakes frequently occur.  The following case is a remarka-
ble instance of the  liability of men to error; we see  in it, at every moment, the
opinions of the highest standing in the profession, the most contradictory and
erroneous.
  Case IX.—Mad. L...., 37 years of age, of a lymphatic constitution, worn
out by many years of suffering, first menstruated at the age of 14.
  At the end of this time, after any exertion, a white discharge, at first slight
and irregular,  but afterwards copious and continuous, appeared;  later, there
supervened dragging sensations in the epigastric region, and a feelingof weight
about the perineum.  Several years of her life were passed in this state, the
menses became less abundant, and  somewhat irregular.  Married at the age
of 22, Mad. L. became  a mother a year after; the mucous flow decreased
during pregnancy,  but reappeared very copiously after delivery.  Her health
was pretty  good during the first 10 or 12 years of her married life.
  In December, 1816, she consulted M.  Cavalan; he examined her, and sup-
posing her to be affected with prolapsus uteri, prescribed a pessary,  which could
not however be borne, and it was removed in three  days.
  In  February, 1817, M. Forestier was  called  in.  The patient still expe-
rienced the dragging about the genital organs ; the white  discharge was very
copious, the menstrual flux pretty regular, but preceded by horrible pains in the
loins.   The  menses  were so abundant, that Mad. L.,  called  them losses
(pertes).  The treatment consisted of baths, injections, rest in bed, without
any relief.
  M. Dubois having been consulted, and examined the patient, said that there
was nothing the matter, that it was useless for her to remain  in bed, and that
she could walk.
  M. Ganthier de  Sancy followed  M. Forestier; he prescribed pills of assa*
fcetida and  cicuta,  without effecting any change.  After a year's treatment M,
Ganthier recognized  the  existence of a  polypus, proposed the ligature, and
requested M. Boyer to consult with. In  September, 1818, the latter examined
her, said that M.  Ganthier was mistaken; that Mad. L., was affected with
ulcerated scirrhous of the body of the uterus, and that an operation was im-
possible ; he advised a tonic regimen to support as long as possible the existence
of the patient, whose end, in his opinion, was near at hand.  She was placed
under the care of his nephew, M. Vareilliand.   He at first was of his uncje's
opinion, but in February, 1820, he  ascertained the disease to  be merely an
enormous polypus, and proposed to call  me in consultation.
  I saw Mad. L. for the first time, in the month  of March.  On examination 
CLINICAL SURGERY.
273
I discovered an enormous polypus, pointed out its nature, and gave it as my
opinion, that the small size of its pedicle, offered many chances of success, if
it were removed, but that the operation ought to  be performed immediately.
M. Boyer made a new  examination, and recognized  the  existence of the
tumor, but was disinclined to any operation.  However, the patient consented
to the operation, and it was performed on the 3d of April, 1820.
  ■ Placed as in the operation for lithotomy, two assistants held the knees firmly
against their breast with one hand, and with the  other, separated the genital
organs.   I first introduced one hand in order to distend the vagina; a branch of
the.forceps of Museux was implanted into the tumor; then I drew on it in order
to fasten a second branch, and endeavored to extract, but the tumor was
arrested at the inferior strait, at the moment of passing the ischiatic strait;
applying then a second pair of  forceps, and  assisted by two fingers passed
between the tumor and the superior commissure, it was brought out of the
vulva.   Depressing it with one hand, I divided its pedicle by means of strong
curved scissors.  The operation was completed without pain or loss of blood.
The tumor was unequal,  fibrous, smooth, not ulcerated, about as large as the
head of  a child a year old, and weighing one pound.  In two weeks she was
very nearly entirely well.
   Secondly.  In the substance of the parietes of the uterus.  We have said
that fibrous bodies, situate on the surface of the os tincae, are easily recognized
provided they be as large as a pea or a filbert,  because  they form a hard
tumor, indolent, and projecting more or less into the vagina.   But when these
same tumors  are seated  more deeply in  the  neck  of the uterus  of the tissue
proper of the body of this organ, nothing  indicates  their existence if they are
not large; they may  increase insensibly and acquire  the size of an egg, or
even of the fist, without any sensible inconvenience, provided they be situated
so as not to increase too much the cavity of the uterus. Bayle, indeed, thinks
that this latter circumstance is of little importance after the critical age.   He
says, he has seen women in whom  fibrous tumors larger  than both fists toge-
ther, developed after the 50th  year, have given rise to no serious symptom,
although they had enlarged considerably the cavity of the uterus.
   When we examine a woman who has a fibrous body, not yet very large,  in
the tissue of the parietes of the uterus, we generally find a more or less project-
ing tumor in the centre of the hypogastrium.   Place one hand on that spot,
and introduce the index finger of the other into the vagina; by pushing up-
wards the neck of the uterus, the motion is felt in the hypogastrium, and reci-
procally.  In these cases, the neck is sometimes in its usual state, sometimes
almost  obliterated or slightly deformed; and if the tumor be very large, it is
generally very elevated, as in the sixth month of pregnancy.
   How, therefore, are wc to distinguish, under these circumstances, whether
we have to deal with a fibrous tumor, with pregnancy, a mole, or a spontaneous
increase of the uterus ?   Time and an attentive examination of the progress of
the disease may answer  the questions as  regards the mole or pregnancy, but
nothing  can distinguish between the first and last, unless the tumor project
more or  less into the cavity or the peritoneal surface of the uterus. Fortunately,
uncertainty is productive of no evil consequences, for  the disease, what-
ever it may be, is entirely beyond our control.
          35 
274
LECTURES  ON
  Thirdly. On the peritoneal surface of the uterus.  If the polypi developed
in this region have no  pedicles, we meet with the greater part of the difficul-
ties experienced in the preceding cases.  If they have pedicles, but which are
very  small, nothing  reveals their  existence; if the  pedicle be of some  size,
they are easily discovered.  By feeling the lower part of the abdomen and
introducing a finger into the vagina, we  find a tumor more or less round, move-
able, not painful on pressure, sometimes deeply seated in the pelvis, sometimes
projecting in the middle of the hypogastric  region, or situated in one or other
of the iliac regions, according to its point of origin in the uterus. This diversity
of situation is very important, as regards the treatment, as will be hereafter seen.
  Fourthly. Polypi developed without and around  the neck of  the  uterus.
Particular attention should be given to polypi developed in these parts, be-
cause, on account of  their different situations, the nature and  anatomical
structure of the parts, they occasion remarkable phenomena, and  become the
subjects of very interesting considerations.  Some time ago, being consulted
by a  lady who complained  of general uneasiness, pain in the interior of the
vagina, and above all of having had no children, I examined her and found
around the neck of the  uterus a kind of tumefied band, composed of project-
ing tubercles very close to each other, and also soon  perceived  the  fibrous
nature of these bodies.   But, taught by experience, the almost constant  mul-
tiplicity of polypi growing in these parts, I endeavored to discover another,
and indeed found one situated  higher up on the very body of  the  uterus.
What was remarkable, was the annular  disposition of the fibrous bodies around
the neck, and their co-existence with other fibrous bodies in the uterus. Some
years ago, I was consulted by the wife  of a professional gentleman.   She had
been examined by a number of physicians.   Some inclined to the opinion that
there was a hysterical  nervous affection,  others an organic lesion.  After
several examinations I discovered a tumor on the right  side of the neck of the
uterus.   Yesterday (21st of March, 1833) I saw a similar case;  the  woman
had a fibrous tumor on the  body of the uterus, but  in addition, a second
situated in the  dense cellular tissue uniting the rectum to the parietes of the
vagina.   I opposed an  attempt at any  operation, for which I will afterwards
give you my reasons.
  Many analogous cases might be quoted.  Two important facts follow  from
them ; the frequency and almost constant multiplicity of fibrous polypi of this
region, and their incurability in the  greater number of cases  How can the
first fact be explained?   Is it owing to  the greater abundance and  firmness of
the fibro-cellular element around  the neck  of the uterus  than in  the  body
itself of the organ ?  Let us examine their effects.
   Generally, in this species of polypus, the symptoms  are more  pronounced
than in those of the first three  categories already described.  They present
characters peculiar to their situation.  They cause a sensation  of weight  at
the fundament, pain in the abdomen, at first at distant  intervals, then return-
ing more frequently in proportion as they threaten disorganization,  or as the
woman has frequent connection with other sex ; the pain is greater in walking
and the erect position, when the rectum is filled with faecal matter.
  I have also seen a very remarkable case, namely, a fibrous tumor developed
between the urethra, and the anterior wall of the vagina;  and what was singular 
CLINICAL SURGERY.
275
lar, it gave rise to a red and white discharge, and  caused most acute pain.
I made an incision between the urethra and vagina, I dissected very carefully
the parts, and aware of the great number of blood-vessels in this highly erec-
tile tissue, and the  profuse hemorrhage which takes place, I tied  every im-
portant vessel as it was divided; I reached the tumor, and succeeded in remov-
ing it.  Two years ago, I extirpated a similar tumor; situated in the thickness
of the genital organs, surrounding the uterus, there  was a slight heemorrhagy,
which  was soon arrested.  Let us recapitulate these facts ; fibrous tumors
developed around  the neck, and  in the tissue surrounding the uterus, are
rarely solitary, but most generally  multiple, they are very common, and  the
reason of their frequency is in the nature of the tissues from which they arise;
they are found in all parts of the vagina, in front, behind, on the sides of the
neck, between the vagina and rectum,  or the vagina and urethra.  They give
rise to  peculiar symptoms which facilitate the diagnosis, by  the different
situations which they occupy.  In a very few cases, can they be  extracted;
and if this be possible, it should not be delayed, for we possess no other remedy
In a majority of cases, extirpation is impossible.  Indeed, how could  we
remove tumors deeply seated in the vagina, which project either in the rectum,
the bladder, or above the pubes ?   The hemorrhagy is frightful  and difficult
to arrest; the consecutive inflammation certain, and the  inflammation of the
 peritoneum fatal.
   Prognosis,  As long as  fibrous polypi give rise to none of the general
 symptoms, interesting seriously the constitution of the patient, their existence
 is free from danger.
   The general disorder resulting from the disorganization of polypi or copious
 discharges, are always serious ; the danger is  imminent, and the operation
 urgently demanded.
   A polypus, which, having sprung from the cavity of the uterus, has consi-
 derably increased it by its growth, and which cannot afterwards pass beyond
 the neck of the uterus, will cause serious symptoms, which it is important to
 arrest as soon as possible, by efficacious treatment.
   If the polypus be complicated with a tuberculous or scirrhous affection of the
 uterus,  or any other organ, an acute or chronic inflammation of the latter, or
 its connections, or of the peritoneum, or lastly some lesion of  the viscera
 of the principal cavities, the case is dangerous, and the operation affords but a
 slight chance of success.
    In all diseases which are liable to recur, the success of the operation depends
 essentially on the  complete removal of the affected tissues, all circumstances
 therefore, preventing our reaching the pedicle of the polypus as far as its root,
 are so many circumstances unfavorable to the operation.
    Although, in similar diseases, we can never guarantee a non-recurrence,
 the latter is much more rare, and less to be dreaded, all things being equal,
 when we operate before any cancerous disorganization, than when it exists.
 and that when the patient labors  under the fever of absorption, for a longer
 or shorter period.                                  .      ,
    Polypi of the cavity or neck  of  the uterus, especially when they have
 descended  into the vagina, generally  degenerate into carcimona.   The fibro-
 cartilaginous or bony disorganization attacks those which appear  m the sub-
 stance of the organ, or on its surface. 
276
LECTURES ON
  Voluminous polypi of the body of the uterus, admit of no operation or acci-
dent of their position, as also  those of its peritoneal  surface, from the fatal
consequences which would result.
  We can predict nothing positive as to the progress  and consequences of
polypi, developed  in the substance of the uterus, or on its peritoneal surface.
Some, although small, are very troublesome, others attain an  enormous size
without any inconvenience to the patient, during many years.
  We have seen that polypi developed in the substance  of the uterus, may
present all the phenomena of pregnancy, a mole, or a spontaneous increase of
this organ; that those appearing on the peritoneal surface, may be confounded
with chronic tumors of the ovaries, or other organic lesions, and that the ex-
istence of either, can seldom be positively ascertained during life. They have
frequently been mistaken for cancer, and the neck of the uterus amputated,
when the patient required quite a different treatment.
  Polypi of  the uterus have some analogy with a host of affections, amongst
which the principal are prolapsus and inversion of the uterus or vagina,
and vaginal  hernia.
  The development of  a polypus in the interior of the uterus, often occasions
symptoms analogous to those of incipient pregnancy, such as slight tumefac-
tion or tension of the hypogastrium, weight in the abdomen, general uneasiness,
sensibility, and increase of size of the mammas, &c.
  I have seen several women laboring under polypi, who believed themselves
in the fifth, sixth or eighth month of pregnancy, and physicians have attributed
their symptoms to  extra uterine pregnancy.   When they have reached a cer-
tain development they can rarely be mistaken.
  Generally, the menstrual discharge ceases during pregnancy; in polypus,
it not only continues but is more abundant and occurs several times during
the month.   The  uterus is globular, very hard, sometimes equal, sometimes
not; no ballottement can be detected.
  Some polypi, which attain,  in the  cavity of the uterus itself, a very large
size, on the approach of the menses and during their continuance give rise to
pain and efforts at expulsion similar to those of parturition.  An amollisement
of the neck is the result, and also, during the duration of the expulsive pains,
the projection of the tumor which appears through the os uteri.  Under these
circumstances, examine  the patient when she is not  menstruating;  you find
merely an increase of the size of the uterus, of which the neck is closed.  But
examine her at the period of the discharge, or during a pain, and you will per-
ceive the polypus engaged in the neck of the uterus.  You may suppose this
is a polypus which has reached the second stage.  That is erroneous.   It is
because the polypus has ascended into the uterine cavity. I have  never but
once  seen the efforts of the uterus alone expel a large polypus,  of  which the
patient was soon relieved by appropriate means.
  In  inversion of the uterus, the latter appears under the  form of a  pyriform,
reddish tumor, complicated  with  sero-purulent and even bloody discharges,
like polypus; the  patient complains of  the same  feeling of heaviness and
dragging sensation in the loins ;  experiences the same  difficulty in walking,
standing erect, and evacuating the  rectum and bladder.   But polypus is
indolent, unless its surrounding membrane be inflamed, whilst the uterus enjoys 
CLINICAL SURGERY.
277
some  sensibility.  Inverted uterus is soft, compressible; polypus is firm and
resisting.   Polypus is developed  slowly and with the symptoms we have
described; inversion, on the contrary, takes place suddenly, and from causes
far remote from those producing polypus.
   Inversion is complete or incomplete.  In incomplete inversion, the uterus
represents a convex elastic tumor, and always preserves this shape and cha-
racter ; not so  with uterine polypus; its  pedicle, which may be followed as
far as the neck of the uterus, passing this orifice or implanted into it,  leaves
no doubt as to the nature of the tumor; in incomplete inversion the finger can
penetrate but little between the tumor and neck of the uterus;  the contrary
obtains in  polypus, if indeed the os uteri be sufficiently dilated to admit the
fin°er.   Different writers have laid down innumerable distinguishing signs,
which, taken separately are all insufficient.  M. Malgaigne, in his excellent
essay on this subject, has proposed the following means of diagnosis :
   In incomplete inversion, says  he, the uterus forms a sac with the opening
upwards, in which sometimes the intestines, sometimes  the  bladder, and
occasionally all these viscera are found.   Therefore, introduce a curved male
catheter into the bladder, turn its point backwards, the concavity being below,
and  thus apply this point upon the fundus of the uterine sac; the finger in the
va-rinia should  feel the projection of the instrument as easily as it can be felt
in°the hypogastrium in ordinary catheterism.  Experience must decide on the
value of this new method.
   If the inversion be complete, the uterus is turned like an inverted linger
of a glove ; the tumor is pyriform, and projects entirely from the vulva : the
vao-inal part of the uterine neck, alone free from the inversion, encircles the
 pedicle; above the vaginia, inverted on itself, makes  a second pedicle, but
hollow and inserted in the internal surface of the great lips, the vaginal cavity
 no longer exists ; the diagnosis is consequently easy.  Besides, we have said
 that the polypus is insensible,  and the uterus is sensible.  Polypus is of slow
 growth, and complete inversion of the uterus is always sudden, generally fol-
 lowing parturition.                                    .         ,  .    e
   Incomplete  prolapsus of the uterus without inversion, in  the majority of
 cases, is easily distinguished from a polypus in the vaginia; the circular cul-
 de-sac formed  by the latter, the orifice in the centre of the tumor, which repre-
 sents a cone  of which  the vertex is  below and the base  above, an  onhce,
 throuo-h which a  sound or stylet maybe introduced, are sufficient to prove
 this merely the displaced uterus.   We should not be deceived by  cracks,
 inequalities or ulcerations on the  inferior part of the  polypus as, frequen t>
 hannens: let it be remembered that the tumor formed by the fall of the viscus,
 is narrower above than below, so that it draws the vaginia after it, in such a
 manner that the parietes of this canal, turned upon themselves as incomplete
 Aversion, leave no cavity in which the fingers can be carried around the tumor.
 Sometimes if the neck of the uterus is affected with cancerous disorgamzat on
 we  may experience some difficulty, which is, however, removed by means of

 ^'Fibro'us1 "polypi resemble so closely the uterus in color, and external appear-
 an!e tha s^surgeons have supposed that they had extirpated a cancerous
 utos  wh ch  was Merely a disorganized polypus arising from its cavity.   A 
278
LECTURES ON
 fibrous polypus not yet disorganized, occasionly resembles so much a healthy
 uterus, as to give rise to doubt, which has happened to myself.
   In complete prolapsus uteri, that is to say, when it is entirely beyond the
 vulva, the vagina being also completely inverted, and serving as  an external
 tunic to the tumor, there is no longer  any vaginal cavity ; this  tumor, as in
 complete inversion of the uterus, seems to arise from the internal surface of
 the labia majora.   We cannot err, if  we remember that it should present in
 its centre an orifice which is not found in a polypus.
   Polypi of the uterus are often confounded with cancer of the neck of this
 organ.   I  have seen several  cases cured, in a few days, by excision, which
 several surgeons  had pronounced incurable.   We have related several in-
 teresting cases.   The error is not always so easily avoided  as has been pre-
 tended.  There are, in  fact, cancers which have  pedicles, and polypi which
 have  none, or cancers of  large size and composed of several lobes.   How
 under these circumstances can we distinguish the nature of the tumor ?  In
 the first place, the tumor formed by cancer of the os tincae, is continuous with
 the neck of the uterus ; the latter, on the contrary, forms a projection round
 the tumor when it is a true polypus.  A scirrhous tumor is irregular, uneven,
 very hard ; a fibrous polypus  not degenerated is  also very hard but  exceed-
 ingly elastic, it presents a smooth surface, a regular ovoidal shape.    In scir-
 rhous we have lancinating, deep seated pain, which is not the case in polypus.
 In  scirrhous pressure gives great pain; in  polypus it  causes not the least
 uneasiness.
   The bladder, intestines, and epiploon  when displaced, form sometimes in
 the vagina a tumor, which might be taken for polypus.  An accurate exami-
 nation will guard against this error.   When the bladder projects  unnaturally
 into the vagina, it is invariably at the anterior  portion of this canal.   The
 projection has a large base; it diminishes, evendisappears when  empty, and
 increases in volume if its function be suspended for some time.   It cannot be
 compressed without exciting the irritability of the bladder and the expulsion
 of urine ; polypus  of the vagina presents none of these characters.   A tumor
 formed in this canal by the displaced intestine or omentum, occupies constantly
 its superior or lateral portion; increases when the patient stands erect, coughs,
 cries, or holds her breath : none  of these symptoms belong to polypus of the
 uterus or vagina.
  Inversion of the vagina can be mistaken for  polypus, only by persons who
 have no knowledge of the  disposition of the parts.  In fact,  inversion of the
 vagina forms  a circular tumor which  appears between the labia pudendi and
 sometimes without it.  The finger placed in the centre of the  tumor can pene-
 trate into the remainder of the canal at the bottom of which will be found the
 neck of the uterus.   This viscus drawn  down by the vagina, is lower than its
 natural position. In polypus, on the contrary, itpreserves its normal situation,
 the tumor is isolated from the parietes of the vaginal canal, circumscribed,
 encircled by the neck if it proceeds from the interior of the uterus, or im-
 planted on the side of the uterine orifice if it has arisen externally.
   Treatment.—We have observed, in Ihe course  of our  remarks, that polypi
of the body and peritoneal surface of the uterus may acquire a large size with-
out causing, during a number of years, any very sensible inconvenience to the
economy.   Intra-uterine polypi  in many women reach the second and even 
CLINICAL SURGERY.
279
the third stages, without revealing their presence by any well marked symptoms.
But  frequently  polypi of the  uterine cavity, inaccessible to our senses and
instruments, give rise to distressing symptoms, whose true cause we  cannot
discover, such as copious loss of blood, leucorrhoea, violent  pain in the belly,
loins, &c.;  here medical treatment is required, which although merely pallia-
tive  is not the less imperiously demanded, for  the  life  of the patient is
frequently in  great  danger.   The  indications under these  circumstances are
to keep the bowels free; venesection repeated according to circumstances ;the
application of leeches; baths; emollient, narcotic, or astringent injections either
by the vagina  or rectum ; topical applications of the same kind to the abdomen,
anodynes and tonics internally, and revulsives.
   Such is also the treatment demanded, before the removal of a polypus whose
pressure has been ascertained, if the patient labor under serious general re-ac-
tion.  The  state of the patient's mind should also be attended to.   Rest, diet,
anodynes internally and by injections, slight tonics if the constitution has been
much  shaken, &c.  will prepare them to bear, not the pain of the operation,
which is always trifling, but its effects and impressions on the mind.
   But is there no remedy for these diseases than by an operation  ?  I believe
none,  and experience has too well proved it.  What has'not been tried for the
resolution of these tumors when  developed  in external parts  of the body?
Every thing has hitherto been unsuccessful, and we must not expect it in the
diseases of*the uterus. Cases of polypi, however, occur in  which an operation is
impossible, and here a medical treatment alone can be used in order to sup-
 port the patient through the progress of an incurable disease.  Still there is  a
 rock  to avoid,  namely, to avoid hastening  the termination of the malady by
 stimuli or narcotics.  Hence, whenever polypus  is incurable, we should limit
 ourselves to the treatment of the symptoms.
   Frequently,  when they have attained a certain size, they remain stationary
 and indolent  and merely produce mechanical effects.   I use this term, because
 it conveys precisely the  idea of  the action  of  these bodies on  the  organs.
   These effects have been described; the polypus from its weight, rests upon
 the rectum, the vagina thrusts aside the bladder, urethra, or falling  over the
 pubes, pushes forward the parietes of the abdomen.  From this follow pains in
 the fundament and difficulty of defecation  ; which may  be relieved by emol-
 lient  and narcotic  enemata; a great inconveniene from  weight in the vagina,
 maybe remedied by a pessary; retention of urine, requires the catheter; and
 in the last mentioned case, the belly is to be supported by a bandage.
   When  the removal or destruction of the polypus is determined upon, the
 operation must depend on many different circumstances.  1st, relative to the
 situation of the tumor;  2dly, its species; 3rd, the stage  which it has  reached.
 We  will first treat of the operation in these three points of view, and then, in
 a few words,  speak of the different methods now  in  use.  There  are, the
 cautery, torsion,  breaking up (broiemenl), avulsion  (arrachement),  ligature

 ^FirsT'The' cautery, which  has been attributed to Celsus, and  is performed
 either with caustics,'or the iron, is appropriate neither to fibrous polypi deve-
 loped in the  substance of  the uterus, nor to those  which arising from its cavity
 orPperitoneal surface, have acquired a certain  size,  whether they have or not
 a pedicle  How,  in fact,  can this remedy be used, without the consequence of 
280
LECTURES ON
 serious danger ?   If we use but slight caustics, they must be, for a long time,
 frequently repeated; now, experience has proved that the repeated action of
 such an agent excites and determines the carcinomatous disorganization of the
 tumor.  If the cautery be deeply applied, an intense inflammation extending
 to  the  surrounding parts  may follow, or a metritis or metro-peritonitis fre-
 quently fatal.   If after having  destroyed  the tumor,  some particles of its
 pedicle should  remain a recurrence of the disease is almost certain; if the cau-
 tery be carried deeply enough to remove all vestige of the diseased tissues the
 same danger of inflammation, as before mentioned, is to be feared.
   Nevertheless, however serious be the above objections, it does not thence
 follow, that the cautery is to be prohibited in all cases.  It has been success-
 fully applied to vesicular polypi of the nostrils, and probably might be equally
 so to those  of the uterus.   Sometimes it is very useful after the excision of
 cellulo  vascular  or fungous polypi, either  to destroy  the diseased tissues
 which the instrument was unable to remove, or to prevent hemorrhagy.
   Second. Torsion. The rupture of  the polypus by torsion has been celebra-
 ted  by several  writers; it was successfully employed in a case  by Bondon, in
 which he would not apply a ligature, and in which the pedicle, of the length
 of an inch, was only five or six lines in diameter.   This method can succeed,
 however, only  when the pedicle is small, and not very firm  in substance.
 But the fear of twisting some part of the tissues of the uterus, and producing
 a laceration, has caused it to be thrown aside, notwithstanding the advice given
 to  twist the tumor very gently, after having seized  its pedicle  with strong
 forceps.
   Third. Breaking down  (broiement). This operation originated with M.
 Recamier; if, by this name, we can call the manner in which he once destroyed
 a soft and vascular polypus, inserted into the neck of the uterus and extend-
 ing beyond it about six lines.  M. Recamier pressed it against the paries of
 the uterus, with the index finger reduced it to a pulp, and thus extracted it in two
 minutes; it was of the size of the great toe.
    This method  cannot  be applied to  fibro-cellular polypi, unless  they
 be  very much  softened;  and then  the  only advantage we can expect is
 to  diminish the size of  the fibrous body,  and render another operation more
 easy.
   Fourth.  Forcible  extraction  (arrachement)   should  only  be practised
 under peculiar circumstances;  when, for instance, any other operation is im-
 practicable, and the woman is in  imminent danger from the consequences of
 the polypus.  In order to perform it,  the body of the polypus is to be seized
 with the forceps of Museux, an ordinary  forceps, or  even with  the fingers,
 if it is large and can be reached;  we then practice methodical traction, either
 simple, or combined with slight rotary  movements, until the  polypus be
 extracted.
  Fifth. Ligature.  We have given our reasons  for  having abandoned this
 operation as a general  plan; but in some cases, it is to  be preferred; and
 sometimes should  even precede excision.
  Many instruments have been devised, but that  of Desault is the only one
now in  use.  It consists of two porte-noeuds and a serra-nceud.  The two
porte-nceuds have not the same shape, one which M. Boyer calls  canula-porte-
nceud, is  a straight  silver  canula,  seven   inches in  length, in which  is 
CLINICAL SURGERY.
281
  contained* a silver or steel stem, of about nine inches in length.  This latter is
  divided at one end, in the direction  of its length, into two parts, each  con-
  taining a semi-circle.
    The serra-nceud is a silver stem, terminating in a ring fixed at right angles
  to it;  the other end is flattened having a deep  slit extending in the sense
  of the  length of the instrument.
                                      The annexed is an accurate represen-
                                    tion of  the application  of  the instru-
                                    ment, from Velpeau's Medecine Opera-
                                    toire, pi. 20, fig. 3. It conveys a clearer
                                    idea than can be expressed by any words,
                                    of this instrument  itself, as  well as the
                                    manner of applying it.
                                      Description  of the  figure.   Uterus
                                    opened on its anterior surface, and  con-
                                    taining a pedunculated polypus, to which
                                    Desault's  ligature is applied. The two
                                    instruments brought from behind  for-
                                    wards, cross each other on the anterior
                                    region of  the polypus a, so that the lig-
                                    atures ee,  may strangulate its peduncle.
                                    After having turned them  once or twice
                                    on their  axis, we must  let  go  one of
                                    the ligatures, thrusting the stem h,  into
                                    the  canula  i,  to  open  the  forceps  f.
                                    The  tube-porte  ligature  g,  being re-
                                    moved, the serre-nceud is applied,  and
                                    the operation finished. Although inserted
                                    high  in the  uterus, as  is  shown by the
                                    division of the neck, ee,  the polypus
                                    projects considerably into the  vagina
                                    dd.
                                      After the ligature is fixed in its place,
                                    it should  be drawn  as tight as possi-
                                    ble in  order to completely  arrest  the
                                   circulation in the tumor.   Experience
                                   has shown, that by  these means,  the
                                   consecutive  accidents  are less  to be
                                   feared,and the separation  of  the poly-
                                   pus  is  more rapid.   But frequently
                                   the pedicle is so large  that the  circu-
                                   lation cannot be interrupted at once*  thf>
 .gature should then be gradually tightened, unless it is effected.   We should
tighten the ligature as long as the patient does not complain and never longer •
for a too great constriction has been known to cause excessive pain, convulsions'
and even death from this last cause.   Should any of  these occur, the TZve
  oud be relaxed.   When the ligature is properly applied, the ctS
of the fibrous mass being mterrupted, it is decomposed, becomes gangrenous
 
282
LECTURES ON
from the periphery towards the centre, the thread gradually cuts the pedicle,
and after a longer or shorter time it falls, according to the degree of stricture
exerted, the size  of the pedicle,  &c.  This frequently occurs on the fifth or
sixth day.   In a case related by Leblanc, it did not occur until at the end of
three months.
  The most difficult part of this operation, is to carry the ligature high enough
to tie the pedicle near its insertion into the uterus.  In order to effect this end,
first was devised  the depression and demi-inversion of the uterus, and then
the invention of several instruments.  The depression and demi-inversion of
the uterus, apparently pointed out by nature,  proposed and  performed by
Herbiniaux, and afterwards rejected by other surgeons, has been in later days
taken up and performed by  M. Dupuytren, and constitutes the basis of his
operation of excision.
  The instruments of M. Mayor appear the most simple, ingenious, and easy
of application.   They consist of elastic stems of whalebone or steel, terminat-
ing by claws like those of the crab.   The ligature is placed as  in the forceps
of Desault, and carried in the same manner around the polypus.  In order to
disengage  it, it suffices to  draw on the conducting instrument as soon as the
serre nozud has reached the  pedicle ready to arrest its circulation.
  We have said that in order to avoid the difficulty presented by the applica-
tion of the ligature, the necessity of placing it as near as possible to the root
of the pedicle, has been questioned.  Levret and Segard, and recently M. Gen-
soul supposed, that like the umbilical cord, the polypus would separate at its
point of origin, without regard to the place of ligature.   I do not think so; the
pedicle is sometimes only wholly detached, when tied very near its root; in
other cases, when tied at some distance from its insertion,  the part below the
ligature falls,  but that above it continues to live, increase,  and  reproduce the
tumor; hence the frequent relapses, and one of our principal objections to
the operation.
  The  after treatment  consists,  in removing by antiseptic injections,  the
uncleanliness and dangers resulting from the foetid discharges, proceeding
from the mortification of the tumor, and which are always in proportion to its
size.   The discharge, in fact, irritates the parts on which it falls, and being
decomposed by the heat of the body, it may give rise to symptoms of poison-
ing from absorption of pus.
   Sixth.  Let us  now examine the operation of  Excision and its application
to the various  circumstances of the disease.  I  think  it proper, in order to
facilitate the description, and render it more easily understood, to establish
four general divisions, purely arbitrary, but deduced  from the particular indi-
cations presented by each  one; intra-uterine, extra-uterine polypi; intra or
extra-uterine pedunculated polypi;  intra or extra-uterine non-pedunculated
polypi, small or large.  Those arising in the cavity of the body or neck of the
uterus, and called by  me  intra-uterine, present again different indications,
according as  they are enclosed in the interior of the organ engaged in the
canal of the neck, projecting in the vagina, or beyond the vulva.
  There  is also a distinction to be made between extra-uterine polpyi, situ-
ated on the neck of the uterus, and those of the same species inserted into the
different regions  of the body of  this organ;  and it may indeed  be easily 
CLINICAL SURGERY.
283
 conceived, that the former, whether large or small, pedunculated or not, other
 things being equal, are much more accessible to the resources of art, than the
 latter.
   Extra-uterine polypi are analogous in their nature to those in the cavity;
 but their treatment is widely different.   It would appear, at first sight,  that
 both might be removed with equal facility.  Such, however, is not the case;
 for the removal of the former a very large opening is required, into the largest
 serous membrane of the economy, and that most susceptible of inflammation.
 Their extirpation is very dangerous, and most generally followed by  a rapidly
 fatal peritonitis.
   As regards those developed in the substance of the uterus, and which some-
 times project inwards or outwards, unless they  be very superficial and small,
 admit,  for a still  stronger  reason, of no operation; for the uterus must be
 divided, in order to extract them.  When they appear in the substance of the
 neck, we have a better chance; the operation sometimes however, cannot be
 performed.  In short, in  all cases  of external  polypi of the uterus in which
 excision is possible, the manual part of the operation is the same  as in those of
 the  cavity.
   Polypi of the peritoneal  surface of the uterus, are, as we have said, very
 common ; but one unfavorable circumstance is, that they are rarely solitary,
 but generally several exist at the same time.  You will frequently meet with
 women whose abdomens are filled with tumors of greater or less  volume.   At
 first, indolent for  a long  time,  they  become painful, and very sensible to
 pressure.  The patient, whose  health until that  period was unaltered, feels
 lancinating, deep and acute pain; her constitution is impaired,  she loses  her
 strength, rapidly emaciates, her skin becomes yellow, ascites and infiltration
 of the extremities  follow.
   Guard against tapping in such cases; it is useless.
   These women perish at last, and you find tumors of different sizes on  the
 different regions of the uterine surface and peritoneum,  and the belly filled
 with  serous or sero-purulent fluid.  Open these tumors, and you findall  the
 grades  of  carcinomatous  disorganization.   In their centre, remain some
 traces of fibrous elements,  proving their original nature.   In the substance of
 the uterus you will find  here a tubercle yet in  the fibrous state; there, ano-
 ther beginning to  soften; in another place a disorganization,  which, after
 having  attacked the tumor, has invaded  its peculiar envelop and extended
 to the surrounding tissues, and lastly the uterus itself, the subject of general
 inflammation or disorganization to a greater or less extent and depth.
  These considerations lead us to examine a very important question in sur-
 gical therapeutics ; a new case, just presented, furnishes us the opportunity of
 answering it.
  A woman of small  stature, well formed, thin, from  40 to 45 years of ao-e,
 came to the consultation, on the 26th of this month (March,  1833), complam-
ing of very copious white,  and at times, red discharges, dragging pain in  the
loins and thighs, pain  in the belly, a  very great  sensation of weight on  the
rectum and vagina, &c. I examined her, and found, at about a third of  the
length of the vagina, an enormous tumor, filling  the whole cavity of the upper
strait of this canal.   However, I could pass my finger around it, and found its. 
284
LECTURES ON
surface smooth, its form conoidal; the finger, carried higher up, met with tht
circular depression, peculiar to pedunculated tumors.   There was no doubt as
to its nature.   On examining the belly, I felt several tumors implanted in the
body itself of the uterus, and projecting into the abdominal cavity.  Thus, the
woman presented a case of a multiplicity of fibrous tumors in the same person,
and a large polypus of the cavity of the uterus, co-existent with several other
tumors of the body of the organ itself.  But this is not the most remarkable
part of the case; let us examine the effects of this multiplicity as regards the
treatment.
   It is very evident, that  it would be absurd to attempt a cure by pharma-
ceutical means; on the  other hand, we believe  that  the extirpation of the
polypus of the cavity, although very large, is possible; but is not this opera-
tion contra-indicated, and ought it to be attempted ?   That is a highly impor-
tant question.
   In the first place, the removal of the principal tumor, which is accompanied
by one or several others, does not prevent the latter from following their course,
and reaching their ordinary termination.  Again, a single fibrous tumorwhich
has been extirpated, may  be followed by the development of another or of
several fibrous  tumors, I have frequently seen this occur.  But what is much
more remarkable, and hitherto, as far as my knowledge extends, unnoticed by
writers, is, that a great number of women who have been  affected with uterine
polypi, are attacked, after some time, with cancerous disorganization of the
uterus, even when only a single  tumor existed, which was properly removed,
without any other  having appeared  afterwards.  Those women possess some
general disposition, undoubtedly organic, which renders  them highly liable to
cancerous disorganization.
   Our patient therefore, under whatever point of view she may be considered,
is exposed to a relapse; moreover, on account of the multiplicity of the tumors,
she cannot be radically cured  by the removal of the principal polypus occupy-
ing the vagina.  Are  these  sufficient  reasons to preclude the operation? I
think not.  This  tumor  is of  serious inconvenience; the white discharge is
assuming a  red color, the  latter may become very  copious, continual, and
change in a true hemorrhage; the  abdominal pains  are  very great; an ex-
tremely painful sensation of weight in  the fundament and vagina; the course
of the fcecal matter is interrupted mechanically by the pressureof the polypus
upon  the rectum,  and the discharge of urine constantly excited by the dis-
placement of the bladder; lastly, cancerous disorganization maybe near at
hand, and then appears that train of fatal symptoms described  in another part
of this chapter, which soon destroy  the life of the patient.  By the operation,
we not only suddenly arrest  the present  symptoms, but likewise anticipate
those  dependent on  the progress of the disease.  What will be the result.
that this woman, although bearing other fibrous tumors in her abdomen, will
enjoy for many years repose and comfort, until the appearance of their inevi-
table consequences.  And who can tell how distant the period may be? V*<
have said that fibrous  tumors  may acquire  a considerable  size without any
sensible derangement of the functions  of the economy, that they degenerate
much more slowly than those of  the uterine cavity, and  that  lastly, passing
into the osseous or cartilaginous state, the patient may  live for many years. 
                          CLINICAL SURGERY.                         285
                                                 >
I knew a case of a lady, first affected at 35 years or age, with symptoms of
polypus, who reached that of 84 years without much inconvenience, although
the tumor had acquired an enormous size.
  Polypi of the  cavity of the uterus, can only be recognized when they are
accessible to the fingers, that is, when the os uteri is sufficiently dilated to
permit a sufficient examination.  The first question which is here presented,
is, at what period should they be extirpated ?   The propriety of the operation
depends entirely on the symptoms of the patient., If a copious discharge ex-
hausts her, acute pains cause general reaction, or the disorganization of the
tumor be commencing, in a word, if any important indication exist, no time
should be lost in extirpating the tumor, whatever may be its situation.  In
contrary cases we may wait without impropriety for a more favorable  oppor-
tunity.
  If the tumor be still contained in the uterus, and the operation urgently de-
manded, how is it to be performed ?  One of the two following circumstances
necessarily exists; the neck is either sufficiently dilated to admit the passage
Of the polypus, or is but little or not at all dilated.  In the former case, I am
of the opinion of Griffith, that the ergot may be advantageously used to expel it,
provided always the polypus have a peduncle ; for if the base of the tumor be
large and implanted in  the substance of the  uterus, the  contractions of this
organ  would be entirely useless.  It is superfluous to add, that the  adminis-
tration of the medicine might be dangerous if there were not a dilatation pro-
portioned to the size of the tumor.
  The above remarks have been fully confirmed, by a recent case.   On the 19th
of March, 1833, M. Guessent, junr., was called to a woman, suffering  from
general uneasiness, colic, pains in the  loins and  fundament, in  the uterus,
accompanied by discharges. He examined her, found the os uteri freely dilated,
and in the cavity of the  organ a  round smooth body which he immediately
recognized  as a fibrous tumor.   He prescribed  the  ergot, whose effects were
soon manifest.   The contraction  of the uterus  drove the polypus into the
vagina, where it now is requiring excision.
  In the second case, that is when the neck is but little or not at  all dilated,
some practitioners have advised and attempted to effect mechanical dilatation.
One trial proved the danger of the  experiment.   Some years ago, I was called
in great haste to see Mad. C ...., wife of a banker in Paris.  She was  indeed
in a very distressing situation.  I learned that she had  been affected with
polypus of the uterus, which appeared at the neck of the womb ; but that the
orifice not being sufficiently large, its dilatation had  been attempted  by the
introduction of sponges and prepared root of gentian.  The attempt resulted
in an intense metro-peritonitis, which had progressed  very far when I was
called.
  Again, the ergot, which I think may be useful when there is  sufficient dila-
tation, is totally useless under many circumstances; for the same symptoms do
not here occur as in parturition.
  In the latter case, the neck becomes softer and thinner, and gradually dis-
tended by a continuous effort;  in polypi it preserves all its thickness ;  which
thickness is often increased by a morbid process, and it presents an extreme
rigidity which becomes almost an insurmountable obstacle.  Incision of the neck
which I have frequently done, is here the safest and least dangerous method.
I 
286
LECTURES ON
After this operation, nothing contra-indicates the exhibition of the ergot in order
to attempt the descent of the polypus.
   This incision may be performed in two ways; by debridement from within
outwards, with  a probe  pointed bistoury or the  lithotome  cache, and by
puncture from without inwards.   I have by these means  succeeded in curing
cases which were considered beyond the resources of art.
   After the incision of the neck has been performed, as also when  a greater
or less dilatation of the os uteri exists, the forceps of Museux are to be intro-
duced, the tumor grasped and drawn downwards in order to effect the excision.
But in many cases, whether from the  adhesion of the  tumor, or  its wantol
peduncle or extreme shortness of the latter, this depression cannot be effected,
notwithstanding the best directed efforts.  Nothing then remains but to bring
the tumor to the lower strait, and perform the demi-inversion we have spoken
of;  if this demi-inversion cannot be effected, the neck must be incised, and
the tumor  removed from the interior of  the organ.  The same  indications
exist when the peduncle of a polypus which has descended into the vagina is
tightly embraced by the neck, and that its section cannot be made  above the
os tincse.
   Case.—Tarcois, 49 years of age, by trade a seamstress, never having borne
children, and always  menstruated regularly, came to the Hotel-Dieu, on the
10th of December, 1823.  During the month of the preceding August, she had
had a copious discharge, which lasted several days.  She soon perceived in
the vagina a tumor, which in a few days appeared at the vulva, and projected
from the labia.  She was then attacked with pain in the  belly, dragging sen-
sations in the loins, whitish discharges, weight at the fundament, difficulty and
pain on going to stool.
   At the date of her admission, the tumor was rugose,  reddish, hard, and
ulcerated at several points.   The  finger, introduced into the vagina, easily
distinguished the peduncle which was strongly embraced by the  neck of the
uterus.  Her general health being good, the operation was performed on the
13th of December.
   In the progress of the operation, I found it impossible to divide the peduncle
above the orifice of the uterus, and was obliged to divide the neck of the womb
with a  probe pointed bistoury, by which means I was enabled to remove by
the  curved scissors, the polypus from the  cavity of the uterus.  There was no
loss of blood, and  the uterus  immediately reascended.
   On examining the tumor, it appeared hard, dense, elastic, grayish, creaking
under the scalpel.  In its centre was a pretty large cavity, furnished with
fibrous columns, similar in arrangement to thoseofthe heart.   At some points
disorganization had commenced.
   The patient did not experience a single bad symptom, after the  operation.
On  the 9th day, not having had an  evacuation  for some days and impelled by
necessity,  she made too violent an  exertion; a slight discharge of blood took
place, and lasted  several days.  On the  24th  day of the  operation, she left
the hospital, perfectly cured.
   When  the polypus  had descended  into the  vagina the manual  part of hie
operation  is, in most cases, very simple.  We  have already  sufficiently des-
cribed  it.   It may, however, sometimes be more complicated.  Occasionally
the  uterus is not very  movable, depressed with  difficulty,  or  the polypus 
CLINICAL SURGERY.
287
resists, and its peduncle cannot be brought to the vulva.  The surgeon must
then with the point of a straight bistoury whose blade has been covered  pre-
viously with linen, or with curved scissors, which I prefer, without permitting
the polypus to reascend, divide its  stalk at its  narowest part, following the
instrument with the finger of the left hand in the vagina.  This is also the plan
to be pursued  if the peduncle  be so much softened,  as to lead  to the fear of
rupturing it in the effort to bring it to the vulva.   Before proceeding to bring
down the polypus, the surgeon should ascertain  whether or  not it has  con-
tracted adhesions with the surrounding parts; if it have, these  adhesions are
to be destroyed successively by very long and strong scissors, curved on their
flat surface and of which  the edges are  not very  sharp, which divide the parts
by  contusing  and bruising the vessels which might pour out blood.  Much
prudence and management are  required in  this dissection which is  very
delicate.
  There is another circumstance to be observed,  and  which occurs frequently
at the moment in  which  the tumor escapes  from the external  orifice of the
vagina.   As in parturition a jet of blood escapes with it, which, as in extraction
of nasal  polypi, undoubtedly proceeds from some contusion or laceration of
the vessels of the  vagina.  It is but momentary and of no importance.
  Uterine  polypi are  sometimes so large as to be unable to pass beyond the
vulva.  If  the obstacle depends on  the narrowness of the orifice.  I do not
hesitate to divide  the posterior commissure.  But if it arises from considerable
disparity between the size  of the  tumor and the diameter of the inferior
strait, we must have  recourse to compression by the forceps, laceration  by
hooks, or lastly, its division by the bistoury.
  It has been shown, how little foundation  there is for the dread  of hemor-
rhage.  Some rare cases occur in which I think it advisable to apply a ligature
previously; namely, when  the polypus  contains large vessels which may be
distinguished by  their pulsation.
  In  all cases of tumors without peduncles, seated in the substance itself of
the uterus, in which the operation may be attempted, I proceed  in the follow-
ing manner; first, around (he anterior half of the  base, a semi-eliptical incision
of greater or less depth.  The  retraction of the edges of the wound causes the
tumor to project, a similar incision is then made on the  posterior half of the
base, so  as to meet the  first.   The  tumor may then be easily dissected and
detached with the handle  of the scalpel or the finger, or if it should arise from
the inter-lamellar cellular tissue of the uterus.
  Let us now say a few words  concerning the after-treatment and conse-
quences  of the operation.   As soon as the peduncle is divided, the uterus
quickly ascends  to its natural position, the hemorrhage  is  very slight, and
ceases spontaneously in  a few hours.  The  morbid discharges  cease imme-
diately.  The patient, if not previously much  exhausted by long suffering, is
generally well in twelve or fifteen clays.  It is  most prudent to confine the
patient to a very strict diet for the few first days, even when she is apparently
doing very well.   It should not be forgotten, that even in the absence of all
complications, she is in danger of inflammation, must be closely watched, and
the earliest symptoms combatted by general or local bleeding, emollient cata-
plasms,   baths, &c.  Emollient  injections are  useful in all cases.  If the
patient has been considerably weakened by previous indisposition, diet should 
288
LECTURES ON
be observed only for the time absolutely necessary, and then prescribe a light
but nutritious regimen, increased gradually, added to tonic and strengthening
remedies.
  I have sometimes  seen polypi having a swelling in the cavity of the uterus
to the internal surface of which it is attached by a peduncle.  These are to be
treated in the same manner as those which cannot escape beyond the os uteri.
I have also seen a singular phenomenon observed after the suppression of any
habitual  discharge,  namely, a  very unpleasant buzzing noise in the ears.,
This may be relieved by sinapised pediluvia, the application of mustard to the
extremities, and generally by revulsives.
                       CHAPTER  XXXVII.

                      OBSERVATIONS ON TRACHEOTOMY.

   The introduction of a foreign body into the respiratory passage is always
 a serious  accident.   Indeed, if the patient be  not relieved he may rapidly
 perish.   Even the operation is not always successful.  Under the most favor-
 able circumstances, the foreign body appears at the opening and is expelled
 by a violent  expiration ; sometimes it is extracted, and sometimes appears at
 a latter period between the lips of the wound.  But in every case, the impor-
 tance of an indispensable operation is evident: for the opening in the glottis
 which easily  gives passage to the introduction of a French-bean, for instance,
 in the majority of cases does not allow its egress, and affections of the lungs
 supervene, which always carry off the patient.
   Case I.—One of my friends, observed M. Dupuytren, playing with some
 children, tossed into the air a piece of ten sous, and caught it in his mouth; the
 piece fell into the pharynx at the  moment  of inspiration, and lodged in the
 trachea.   The cough and peculiar sound accompanying it, pointed out clearly,
 the nature of the affair ; the piece was sometimes immovable for several hours
 and then respiration was regular; sometimes it was thrown towards the larynx,
 and  then acute  pain following  the bruising of these delicate parts.   The
 patient hoping that the body would be thrown out, refused to submit to any
 operation.   For five years, the  piece was movable and gave him  a good deal
 of inconvenience; after that  time, it became firmly fixed in a bronchial tube
 and caused but little uneasiness.  Symptoms of phthisis afterwards manifested
 themselvesin Trieste, whether the patient had gone on account of his business.
 He died ten years  after the introduction of the foreign body, which was found
in  the centre  of a tubercle.
  The patient was then 36 years of age, and  gifted with a robust constitution.
  The above case proves, that a small and very hard body, may not find an
exit through  the glottis (and this even most ordinarily the  case), although
presenting a shape favorable to this exit.  Sometimes, however, it is ejected
with some violence.  This case shows, moreover, that when a body of this
nature remains  unextracted, it gives rise to  consecutive  affections so serious
as  to  demand all our skill to prevent them.  The  following case  strongly
corroborates this precept. 
CLINICAL SURGERY.                        289
  Case II.—A Bean in the Air Passages of a Child; Tracheotomy; Expul-
sion of the Foreign Rody; Analogous Facts;  Result.—A little girl eight
years of age, having stolen a red French  bean from a grocer, swallowed it
quickly.   The form and lightness of this body seemed more apt than perhaps
any other  to overleap the opening of the glottis, especially when impelled by
the column of inspired air.  Such was the case of this child,  and immediately
she experienced a violent cough with  threatened suffocation.  The accident
happened  on Thursday at 3 o'clock in the afternoon.  M. Deluas and several
other physicians who saw the patient, prescribed an emetic which vomited her,
but the bean remained fixed.  The night and part of the following day were
passed alternately in tranquility and paroxysms of suffocation.  On the even-
ing of the next day the child was brought to the Hotel-Dieu.
   During the night the paroxysms  were  renewed with a frightful intensity.
At his visit in the morning, the professor ascertained their  nature; he heard
the noise  of the foreign body in the trachea (aspecies of rattling, grelottement,
very easily distinguished on applying the ear above the sternum). The cough
was violent; with nausea and glairy vomiting.  The indication of treatment
was very  evident; the child was carried to the operating room on Saturday, at
10 o'clock in the morning (February 13th, 1830).
   Before  the operation, we again endeavored to ascertain the rattling noise, as
a pathognomic sign of the presence of the body in the trachea; but it no longer
existed, without doubt because at that moment the bean had lodged in one of
the bronchial tubes.   As it certainly had not been spontaneously ejected, the
operation was commenced. An incision of an inch in length  was made exactly
on the median line of the neck, a little above the edge of the sternum.   The
skin and cellular tissue were cautiously divided ; the  muscles covering the
trachea separated ; and the cartilaginous tube reached without the necessity of
securing any vessel.   With a straight bistoury several rings as well as their
uniting membrane were divided  ; the incision enlarged above and below, the
edges of  the wound kept apart by a pair of dressing forceps; .and after some
violent efforts at expiration, the bean  surrounded by bloody mucus, fell out
upon the  breast of the patient.
   The wound was  cleansed of the blood surrounding it, dressed with a piece
of fine linen covered with cerate, and kept together  by  compresses  and a
bandage.  The child cried violently, and preserved her voice even when some
 air issued from the opening in the trachea.   Otherwise there happened no
 accident  dependant  on the operation.   Nevertheless we must mention a
difficulty which may arise.   Between the sterno-thyroid, sterno-hyoid muscles
 and the front of the trachea, is found a space filled with cellular, in which the
instruments become entangled as in the trachea itself.  After making an inci-
 sion into  the elastic rings, it was impossible to introduce the end of the forceps,
 and the operation was not completed.  A little attention shows this false passage.
 The bean was five lines long, and three wide.   It was a little enlarged on
 account of  the swelling of its cotyledons.   Sometimes they have been found
 in the commencement of germination.   The short space of time that this one
 remained in the trachea accounts for its having preserved its size.
   In the  evening manifesting symptoms of bronchitis she was bled ;  passed a
 restless night.   The next day alternation  of calmness and dyspnoea; she
 breathes  almost entirely by the wound, the  mucus adhering to it causing a
            37 
290                           LECTURES ON

rattling sound.  On the evening of the same day, 15 leeches were applied to
the neck, with considerable relief.  The cough less frequent; has  passed a
good  night, free from  fever.
   15th. Respiration easy, a slight hissing heard from the wound the skin retain-
ing its natural heat.
   16th and 17th. Apparently well, sleeps tranquilly.   Speaks with facility,
voice natural.  The issues but slightly from the wound, which may be greatly
attributed to the swelling of the edges.
   20th. The edges of the  wound were brought together; emphysema being no
longer to be feared, as the mucous tissue covers the edges of the incision, and
renders the cellular tissue impermeable.  From this time nothing remarkable
took place; some days after the parents of the child took her home, the wound
was then two thirds closed.  She was brought back to the hospital on the
12th of March, a month after the operation.  At that time, there was only a
small opening by which a very small stream of air escaped.   The patient
returned no more.
   This case presents several important points to  which I would draw your
attention.   And first, as to the position of the patient  during the operation,
for the incision of the external soft parts and the trachea, and that proper after
the opening of this tube in order to favor the expulsion of the foreign body.
   It is evident that if the head is thrown backwards the incision of the soft
parts and trachea is rendered easy.  But this  position is unfavorable for the
issue of air from  the  trachea and much more  for that of the foreign body.
Indeed we have  seen  in the case just related, that the incision did not give
exit to the air, much less  to the bean.   It was probably partly due to its small
size, but also to the  position of the  head,  which  stretched the edges of the
wound, and prevented them from separating.   In the flexion of  the head, on
the contrary, these edges will easily separate and give exit to air and a foreign
body.  It is also during the flexion of the head that any foreign body will spon
taneously fafl out. Thus, after  the phenomena observed in this patient and
others in the  same state,  it may be laid down as a useful precept in the opera-
tion of tracheotomy, that we should throw the head backward for the incision
of the soft parts and trachea, and in order to facilitate the issue of air and any
 foreign body lying loose in the trachea, we should flex the head that the edges
 of the wound may separate.
   As regards the diagnosis of foreign bodies in the trachea, there is another
 sign, which I deem it necessary  to add to those already given, as characteris-
 tic of the presence of those bodies; itis the sensation of their striking against
 the sides of the canal, which may be readily perceived both by the hand and
 the ear.   It does not always exist very distinctly, in  all subjects, nor at al!
 times in the same subject.   Indeed,  it may adhere and then not being dis-
 placed by the air, it does not strike against the parietes of the tube; or else.
 being thickly coated with mucus, the sound produced is less clear than under
 other circumstances.  The mode of  treatment also deserves some  attention.
 The sides of the wound  were kept apart, in order to avoid the danger of em-
 physema.  During the few first days, the cellular tissue is easily permeable
 by air; but after  some  time, being hardened by inflammation and rendered
 compact, this accident is no longer to be feared, and we may hasten the cure,
 by bringing together the edges of the solution  of continuity. 
CLINICAL SURGERY.
291
   Case III.   A child six years of age,  living at Larigny, near Paris, on the
 18th of May, 1822, was amusing himself by throwing beans into the air, and
 catching them in his mouth.  One of the beans passed suddenly over the
 epiglottis, into the  respiratory passage; immediately he was  attacked with
 cough, suffocation, and remained in this  distressing state for nearly an hour.
 Becoming then tranquil, he took some food ; the  same phenomena  recurred.
 A physician was called to the child, and  imagining, for what reason I know
 not, that the foreign body had lodged in the oesophagus ; he sounded this canal
 several times, and exhibited some emetic, but as may be easily foreseen with-
 out any avail.  The patient was still in the same state, having a violent cough,
 and complaining of acute pain in the trachea, which probably induced the
 physician to apply some leeches to the neck.
   On the fifth day, the situation of the patient was so  distressing on account
 of the progress of the disease, that the parents deemed it proper to have addi-
 tional advice.   He was therefore brought to the hospital, on the 23rd of May,
 laboring under the  following symptoms: considerable  anxiety,  produced
 partly  by the disease and the fatigue of the journey; voice entirely lost; face
 bloated; eyes projecting and injected; nose and lips bluish ; respiration hur-
 ried, and accompanied by a loud rattle in the trachea, and  in the bronchial
 ramifications.   During the movements of inspiration, there could be  heard, at
 the bottom of the larynx, a noise similar to that of a valve, alternately opened
 and shut; this peculiar sound could proceed only from the contact of a for-
 eign  body applied suddenly to the  edges of the  glottis, and agitated by the
 column of air.  During respiration a convulsive cough, returning at intervals,
 threatened the little patient with immediate suffocation.   He was in a state of
 asphyxia, and energetic measures were absolutely necessary.  The operation
 of tracheotomy, affording him the only  chance for safety ;  notwithstanding his
 dangerous situation, M. Dupuytren did not hesitate,  but  proceeded to per-
 form  it in the following manner : the child being laid  on his back, the head
 slightly inclined backwards, he made an incision extending from the inferior
 edge of the cricoid cartilage, to the superior  edge of the sternum,  dividing
 the skin and sub-cutaneous cellular tissue;  a second incision exposed  the
 trachea ; then holding this canal firm by means of the thumb and middle fin-
 ger of the left hand,  and introducing the fore-finger into  the incision as  far
 as the trachea, he made an opening with the bistoury into the trachea, which
 being enlarged slightly upwards and downwrards,  the air rushed out  along
 with some blood and mucus.   After a few minutes rest, the opening was again
 enlarged with a probe-pointed bistoury; it was now an inch  or an inch and a
 quarter in length.
   The lips of the wound were then kept  open, in order to favor the expulsion
of the  foreign body, which"twice appeared at the  opening;  the  operator
endeavored  to seize it with the forceps; he succeeded  in extracting a portion
of it,  and the  remainder was suddenly ejected by a violent expiration.  It
was a bean, as the child had said, and had acquired a considerable size.  The
patient experienced immediate relief. A large quantity of thick mucus flowed
out, mixed with blood effused into the air passages during the operation.  The
patient was carried to bed; but although no blood  came from the wound, it
was not thought proper to bring the edges together immediately, for fear  of
emphysema of the cellular tissue.   The wound was dressed with a piece  of 
292
LECTURF.S ON
linen perforated with holes, linge fenetre, covered  with simple cerate, and
over that some charpie, and a compress.   Drink barley water, diet strict.
  24th. To the livid hue of the nose, lips, and cheeks, succeeded a considera-
ble blush of red.  There Mas some fever during the day ; a good deal of mu-
cus discharged through the aperture ; cough frequent;  the patient slept dur-
ing the night;  mucus  rattle  in  the anterior superior part of the lung; the
pulse feeble and miserable before  the operation had acquired strength, and
even  some  hardness and  frequency;  skin warm, respiration accelerated.
Leeches to the lower part of the neck; same dressing as on the preceding
day.   The edges of  the wound still left open.
  25th. This day and the preceding night passed pretty well; the leeches have
somewhat calmed the irritation of  the  bronchi  and trachea; the face less
infected; respiration less frequent and embarrassed.
   Pus mixed with a  quantity of mucus escaped from the wound; mucous rat-
tie ; belly indolent,  somewhat hard, constipation for three days, fever high.
  The edges of the wound were brought together by adhesive straps. A spoon-
iul  of mercurialized honey, barley water, diet.
  26th.  There has been considerable cough; fever much increased during the
day.   The patient greatly agitated, the  bandage has been  deranged by the
efforts of coughing, still he has had some sleep during the night.  Respiration
-.till hurried and accelerated, pulse frequent, skin hot and slightly moist.  An
unhealthy inflammation is feared in the air passages, or of the cellular tissue
of the neck surrounding the wound.  Some spoonfuls of syrup of ipecacuanha;
enema of  mercurialized  honey ;  application of a bandage  with  adhesive
straps and graduated compresses to keep the edges of the wound united, six
leeches in front of the  trachea,  same drink.
   2rth.  Much better; the leeches have been of service; the syrup was not
administered ; cough less frequent; respiration still hurried, but less embar-
rassed ; less fever; a quantity of pus discharged from the edges of the wound;
the mucous rattle much diminished.
   28th.  Continues to improve;  cough considerably diminished in frequency;
apyrexia almost complete :  respiration almost natural, as also the voice; the
edges of the wound  nearly united; no mucus passed; good appetite.  Whey |
 with barley water, bonillon.
   29th.  No fever;  the edges of the wound covered with granulations, a little
 air still  escapes, cough seldom, a little  mucous rattle, appetite, good.  Until
 the 4th of June, nothing peculiar occurred.   At that time the child was con-
 valescent, the wound nearly healed, discharged some pus, but no air or mucus
 escaped;  cough has nearly disappeared, voice natural, digestive functions in
 ■rood  order ;  the pain, loss of blood, and prolonged diet, have weakened the
 little patient who  earnestly desires to return home.  The  country air will
 complete his cure, and he is about ..o be restored to his parents.
    It frequently happens that the foreign body will not escape at the moment
 of the operation, the edges of the wound are then to be kept open by a silver
 canula or simply a  silver or leaden wire.  The application of a cloth spread
 with cerate is indispensable, but no charpie or other light body should be used
 in the dressing, lest it penetrate into the trachea and give rise to very distress-
 ing symptoms.
    An old man was admitted into the Hotel-Dieu, for disease of  the  urinary 
CLINICAL SURGERY.
29S
organs; he soon had attacks of suffocation which were attributed  to asthma,
or spasm of the glottis.  The healthiness of the respiratory functions between
the attacks, banished all idea of any disease of these parts, and he was sub-
jected to no treatment for it.  He perished in one of the attacks.
  On opening the body, the glottis was found completely closed, by a prolonga-
tion formed of the vascular and  cellular tissue, and covered by the mucous
membrane.   It was a true polypus arising from one of the ligaments extend-
ing from the lateral part of the epiglottis to the arytenoid cartilages.  It was
more  than 18 lines in length, and bifurcated at its free extremity.  The poly-
pus was then floating in the lower extremity of the  cavity of the pharynx and
was of no inconvenience.   As soon as by a change of position it was placed
above the opening of the glottis, it produced more or less occlusion, giving rise
to the symptoms above mentioned.
  The operation of tracheotomy is not only performed in order to assist the
extraction of foreign bodies, but has also been successfully practised is  cases
of occlusion of the glottis, by the production of false membrane, or tumefaction
of its  mucous membrane.  The following is  a case of cedematous angina, in
which it completely succeeded.
  Case.—On  the  24th of October, 1832, Mad. B ..., 34 years of age, was
brought to this hospital in a state of suffocation threatening her life at every
moment.  Five months previous  she had been  attacked with  a  guttural an-
gina and intense bronchitis.   For a long time she has felt pain and heat along
the anterior part of the neck, her voice was hoarse, and since several  days
has entirely lost her voice.  Rest, bleeding, leeches, emollient and anodyne
drinks,  allayed  the majority of these symptoms.   Scarcely had this  been
effected, when she returned to former habits, such as singing in church with
her pupils, &c, and fatigued herself greatly.  The symptoms soon reappeared,
less intense but more tenacious.   The patient coughed frequently, had con-
stant  pain and heat in the  larynx, her voice was changed, respiration difficult,
sometimes whistling and convulsive during the night.  There were some in-
tervals of improvement, but at last the patient was obliged to enter the hospital.
She was then in  the following situation: the posterior part of the pharynx was
red, slightly painful and swollen, much uneasiness in the larynx and surround-
ing parts, her respiration  was labored, inspiration  accompanied by hissing,
voice  hoarse and weak, she complained of great pain behind the lower part of
the sternum.   During sleep, respiration was more difficult, and the laryngo-
tracheal whistling more pronounced.
  On the 25th, 26th and 27th, this affection was treated by simple means, such
as balm tea, pediluvia, sinapisms, poultices around the neck, gargling; the dis-
ease increased; Mad. B ... thought there was a foreign body in her throat pre-
venting her from breathing; the duration of the cough was longer; her voice very
hoarse, feeble and interrupted; depression and stupor during the day; insomnia
and great uneasiness during the night; countenance very anxious; pulse quick
without being frequent, and irregular during the attacks of coughing.
  On  the 29th, 30th and 31st of October, 20 grains of ipecacuanha were ad-
ministered daily, seven grains every three hours; there were several  evacua-
tions upwards and downwards, vomiting accompanied by severe symptoms.
such as convulsions, afflux of blood to the head, frequent  cough, and  threat-
ened suffocation.
\ 
294
LECTURES  ON
   These remedies were not more successful than the former; the disease con-
tinued to advance.
   On the 2d of November, the suffocation increased; she was bled largely
from the arm; sinapisms to the thighs ; a purgative enema.
   November 4th.  Same state, SO leeches to the base and lateral parts of the
neck;  in the evening the patient was a little better.  The night of the 4th was
wretched ;  in the morning, her respiration  was very irregular, hard and inter-
rupted, the air can hardly be  heard entering the chest; inspiration is so diffi-
cult that it produces a sound  similar to the bellowing of cows;  the patient is
obliged to sit up.  (Venesection, sinapisms to the thighs.)
   5th. Same state.  I examined the patient, felt the superior opening of the
larynx, recognized considerable engorgement, thought there was oedematous
angina.  (She was again bled, sinapisms to the legs and arms.)
   6th and 7th. The  repeated  attacks of suffocation threaten instant death,
unless relief be promptly procured.   Haematosis  no longer  takes place, the
face is of a leaden  hue, considerable orthopncea.  During the cough the face is
pale or becomes red.   The patient was in a state of indescribable anguish, her
countenance is excessively anxious, and she feels her end approaching.  She
was again bled  in the arm, without any relief, and at  3 o'clock, tracheotomy
was deemed indispensable.
   I performed the operation in the  usual  manner;  a quantity of  mucus was
discharged from the trachea and bronchi;  the patient  felt  immediate relief.
Her respiration and pulse gradually became more regular, the paleness of the
face and stupor diminished, she slept several hours during the night.  On the
morning visit, she said she felt better; the wound is kept open by a metallic
canula.
   On the 9th, the opening was perceived to have a tendency to  contract, and
was partly obliterated by the  drying of the mucus and pus collected around its
edges.   A gum-elastic canula was introduced, and occasionally removed and
cleansed.
   12th. A gentle purgative was administered.
   14th. I put a seton in the back of her neck.
   16th. On closing temporarily the wound, the voice was observed to be less
hoarse,  respiration easier, and the hissing less intense.
   20th of November. I enlarged the opening, by dividing another fibrocarti-
laginous ring.
   Calomel was given in  the dose of eight or ten grains, until  the discharge of
the patient on the 5th of December.   Mad. B ... was doing very well  although
not entirely cured.  The wound was nearly cicatrized, and the affection of the
larynx almost disappeared.
   On the 20th of  January, the patient wrote from Pont-Thierry, announcing
that the opening had  entirely  closed, the cough but rarely occurred, and  that
the hoarseness had wonderfully disappeared.
   On the 31st of  March, she came to the public consultation at the Hotel-
Dieu.    She was radically well, and  enjoying the most robust health.
I 
CLINICAL SURGERY.
295
                      CHAPTER  XXXVIII.

               OF ERECTILE  TUMORS  AND FUNGUS HjEMATODES.

   I was the first who made known, and described in my course on Pathologi-
 cal Anatomy, saidM. Dupuytren, a remarkable tissue, whose existence under
 circumstances of  diseased action had never before been verified; and which I
 have named the erectile tissue.
   In a normal condition  this tissue is recognized in the genital organs of
 most animals of both sexes, and particularly in the urethra, corpora cavernosa,
 and glans penis, upon the head and neck of a large number of thegallinaceous
 tribe, and upon the buttucks of many monkeys, &c, it is of a more or less vivid
 red color, and of variable firmness, according to the state in which it is observed ;
 its temperature is more elevated than that of other tissues; itis provided with an
 elastic  fibrous exterior envelop, whose office is  to surround and isolate it, to
 permit, or to control its  development; interiorly it is composed  of fibrous
 columns interlacing each other in all directions, forming a species of net-work,
 wliich serves to support and  sustain an infinite number of arterial capillary
 vessels extremely attenuated  and very difficult  to inject  without rupture, as
 also veinous capillaries less easy still to fill than the preceding.   In it there are
 also to be found nerves, bestowing sensibility,  the primary  source of its proper-
 ties and  uses.  This tissue is  distended with arterial blood, the immediate
 and material agent of the divers functions which it performs.  Finally, scarcely
 developed in infancy, at which time its functions are null,  this tissue acquires,
 in all parts of the body where it is found, its highest state  of perfection at the
 proper age for procreation, and becomes one of the principal agents of repro-
 duction.   Its redness, warmth, and other properties are lost in consequence of
 debility and disease, and in old age it becomes altered, is absorbed, and removed.
 Such is the structure, the model  and type of a host of accidental tissues, which
 derangements of organization, original or acquired, developed in all parts of the
 body, giving rise to voluminous and extensive tumors, to which belong more
 or less strikingly, the organization and properties of erectile tissues.
   These accidental structures present the same vascular and organic arrange-
 ment, the same envelop and fibrous net-work, only the envelop is more deli-
 cate and the supply of nerves less considerable.  The cutis, and sub-cutaneous
 cellular substance are especially the seat of  these morbid tissues, which how-
 ever are to be met with in all parts of the body.  They are located at times upon
 the face and covering of the cranium. They form the bases of the greater number
 of spots, and marks upon children (cuvies).  Sometimes they engross the entire
 substance  of an organ.  Thus I have  seen,  continued M. Dupuytren,  the
 concha anus and adjacent parts converted into a true erectile-organ.  In other
 instances they constitute larger or smaller tumors lodged in the interstices of
 organs.   Under some circumstauces they appear  the result of degeneration
 of the natural  tissue,and  of  dilatation of its  capillary structure;  whilst in
others they appear to form in fact new organs, located between the other parts,
 In the former case, they are lost on all  sides in the  healthy tissues—in the
latter they separate and compress them, and are isolated from them by a cir-
cumscribing cellular envelop. 
296
LECTURES ON
  The accidental erectile tissues are reddish or yellowish, ordinarily granu-
lated upon the surface and implanted in the skin, sub-cutaneous cellular struc-
ture, or between the muscles.  They are manifested under the form of tumors
depressed or prominent. The skin covering them is sometimes scarcely altered.
They undergo movements isochronal with the arterial pulsations, and diminish
i:i volume by pressure.  Habitually soft, the slightest  irritation brings  about
in them a remarkable swelling and tension.   If increased blood issues so
abundantly from the incision that it is difficult to arrest it, these accidental
productions do not disappear spontaneously, but on the contrary tend to in-
crease.   In a similar  manner  as the natural  erectile tissue,  these tumors
undergo at the same periods,  and by  the operation  of the same causes, a
development well marked, and an  alternation of augmentation and diminu-
tion, which are in accordance with the  state of health or disease, in strength
or debility of the individuals.
  A great number of remedies have been employed for the cure of erectile
tumors.   We will speak in this place only of  compression, cauterization, the
ligature and extirpation.
  Case  I.—Erectile Tissue; Aneurismal Dilatation of the Arteries of the
Ear, of the Temple and Occiput.—D .... entered the Hotel-Dieu the 9th of
April, 1818.  This patient, aged 20 years, born at Villemanoche, department
of Yonne, possessed a moderate robust constitution, a tall, rather slender per-
son, and was of the bilious temperament; he followed the trade of a cart-
wright.   At birth two small spots existed upon  the exterior fold of the right ear,
called commonly wine blotches.  The ear was not deformed, it appeared only
larger and thicker at the place occupied by these blemishes ; a slight itching
v. as the only inconvenience they occasioned, but the youthful patient, rendered
uneasy by this itching, constantly was scratching them, and whenever he did
so  the  skin was  removed, and blood of a vermilion  red color flowed from
t'ae wound.
   He remained in this condition  until his 12th year;  at this period when de-
velopment of the genital organs commenced, the ear increased in size, changed
 its color and became violet.
   Three years after, the patient perceived that it was affected by slight move-
 ment;  it had acquired double its ordinary volume, and the spots had enlarged
 proportionally.  Eight months after the appearance of the pulsation, the first
 hemorrhage came on, and was produced by an  effort to  remove his hat from
 his head.  This loss of blood could not be arrested but by the application of
 very exact compression; it had weakened the patient, but the size of the
 tumor had been  reduced by it and the pulsations were  less forcible. This
 amelioration was but momentary ; the ear soon regained its primitive volume,
 distension and throbbings.  Although but 15 or 16 years old the sufferer with-
 drew from  the amusements peculiar to his age, for  he  had experienced an
 aggravation of his  malady, whenever he used violent exertion as well as when
 he took stimulating nutriment or used wine, &c.
    At this period compression made upon  the ear by means of a tight  cap,
 diminished the volume of the tumor, but this diminution  did not  continue
 longer than the operation of the  compressing  agent, and the ear regained its
 size as soon as it was removed.   Sometime afterwards, a second hemorrhage
 occurred spontaneously; it was considerable, and stopped of itself.  A surgeon 
CLINICAL SURGERY.
297
was then consulted, who applied compresses soaked in an astringent solution,
these had no effect, except that a pricking sensation which the patient expe-
rienced in the ear was diminished.  A third loss of blood took place sometime
after the second, while he was confined to his bed.
  Suffering from the affection, and not being able to pursue an occupation in
which the violent exertions he was forced to make determined the blood to the
head. D.  again, two years  ago, consulted a surgeon who ordered an emplas-
tic application, which produced no change.  Another surgeon better informed
with regard to the nature and dangers of the disease, advised him to go to Paris
to obtain  the advice of the  most  eminent practitioners.  This advice  was
neglected.  A fourth hemorrhage came on, which was arrested by the applica-
tion  of agaric sustained by a bandage.
  It is remarkable that in all these hemorrhagies the blood although vermilion
red,  and evidently arterial, did not come out by jets, but oozed out as is usual
from the surface of a fungus hsematodes which has been cut into.  The patient
at length consented to enter the Hotel-Dieu de Sens, the 5th of August, 1817,
he was then in the following condition: the right ear was three ti^es as large
as the left, an inch thick, and hung down from its own weight.   It was the seat
of pulsations  synchronous with those of the heart, the hairy scalp of the temple
was  corrugated, and the small wound from which  issued the blood first  lost
had  not yet  cicatrized.  MM. Populus  and Retif who had  charge  of  this
hospital, confined themselves at first to methodical compression upon the track
of the arteries of the ear and also upon the temporal and occipital by means of
tents of lint kept in position by a narrow bandage;  but the sufferer not being
able  to  support it, they  determined to attack the disease by ligature, and to
perform the operation of tying successfully the temporal, anterior auricular,
occipital arteries. This operation based upon an attempt of the same kind made
five years before at the Hotel-Dieu of Paris was instituted for the purpose of
intercepting  in detail  from all sources the blood which supplied  the  tumor.
The  ligature placed upon the first of these branches diminished  slightly the
volume of the ear, but the pulsation although  rendered less forcible still per-
sisted, the edges of the wound  were brought together and maintained in  con-
tact.  The ligature came away between  the twelfth and fourteenth day.
  Twenty-one days afterwards, there came on from a small wound of the helix
a fifth hemorrhage which did not yield but to powerful compression ; the blood
was bright red as in the former instances.   A few days after this a sixth hemor-
rhage occurred from  the same wound; upon  the twenty-eighth day a small
slouo-h,  as large as a five franc  piece was formed between the helix and anti-
helix ; the separation of this eschar took place upon the thirty-fifth day; upon
the forty-third day after the first operation  which had only effected some
sli«*-ht amendment, the tying of the occipital artery was carried into execution,
but without happier results than the preceding.
  Finally, still attacking the disease, the two practitioners named,  endeavored
to take  up the  external  carotid, the common origin of all the arteries of the
ear,  temple, and occiput.  It appears certain from the account they have given
me that they did nothing more than tie the trunk of the  superficial temporal
artery which was much dilated.  Be this as it may, the last ligature was not
more efficacious or less inconvenient than the others, and the patient left the
institution after having remained in it three months.
                38 
298
LECTURES ON
   Having returned home the size of the ear commenced to augment anew, as
 also the pulsation.  He  then decided to  come to Paris and  enter the Hotel-
 Dieu.
   The diseased ear was twice as large as the other, an inch in thickness, and
 the helix and anti-helix were effaced.  The contour of the superior extremity
 presented posteriorly a shallow fossa, resulting from the fall of the  eschar we
 have mentioned.  The whole organ was of a deep violet color; it was soft and
 compressible.  The fingers could distinctly feel pulsation at some points, and
 at others movements of expansion  and contraction synchronous  with the pul-
 sation of the heart.  These movements communicated to the ear a general im-
 pulse which alternately increased and diminished the distance between it and
 the side of the head.
   Nearly the whole of the surrounding hairy scalp was of a bluish color, and
 covered with inequalities.   Compression  made  upon the primitive  carotid
 artery, so as to intercept the flow of blood, was sufficient to remove the throb-
 bing in the tumor, which then contracted, grew palid and remained so, until the
 compression fras  removed, then tumefaction and redness re-appeared, and the
 pulsations being  stronger for some  moments, impressed the part with  more
 marked movement.  The ear appeared  warmer to the patient than the other
 parts ;  and he perceived each  time that the heart threw a column of blood
 towards it, a roaring noise, which was very inconvenient and painful.
   In other respects  the general health was good, the patient complained of
 nothing, he did not suffer even pain  in the head, he heard well, and vision on
 the same side  was perfect;  he  only was subjected to the inconvenience of
 being upon his guard  against  chafing of  the part, for fear of hemorrhage.
   Such was  the  condition of our young patient; his affection was  simple in
 character.   The  eye  and finger distinguished in the mass, two very different
 elements, which are found sometimes united, but which ordinarily are distinct
 in the  diseases they  produce.   The first of these two elements is presented
 under the form of large canals;  sinous, unequal, knotted, full  and  incom-
 pressible, ramifying upon the  temple and ear, to which they give  an embossed
 appearance.  {These canals are connected together like the arteries ; the size
 of their trunks being equal to that  of the little finger, gradually decreases,
 becoming in the smaller branches as  contracted as a crow's quill, which latter
 could be traced into the skin.
  The  origin, situation, direction and division of these canals, but above all
 their  pulsatile movement synchronous with  that of the heart,  the force of
 which appears at each moment to  threaten rupture and produce  fatal hemor-
 rhage, are proofs sufficient to convince us, that they are formed by the unna-
 tural  dilatation of the arteries distributed upon the ear, and upon the tempo-
 ral and occipital regions.  This enlargement exists in the trunks, branches,
 and even in the cutaneous ramifications.
  Whatever else in this singular disease, did not appertain immediately to
the dilatation of  the arterial trunks, was attributable to the formation of the
accidental  erectile  tissues, the description of which  has been given at the
commencement of this lecture.
  The  second element of the disease of D.  filled up the interstices of the
net work formed by the occipital,  auricular and temporal arteries;  it conferred
upon  the part its violet color, its elevated temperature, its double movement 
CLINICAL SURGERY
299
of expansion and contraction, it subsided and was rendered palid by the
effect of slight compression, but soon after regained its habitual color, volume
and tension.  Upon  the slightest puncture, or least abrasion, there  oozed
from it red, vermilion, arterial blood, without projectile force, and which had
given rise, upon more than one occasion to alarming hemorrhagies.
  The  little success of the operations already practised, the persistency of
the  pulsations, the increase of the volume of the ear, in  despite of the liga-
tures applied, did not permit us to pursue the same plan of treatment.   Being
certain  that by tying the branches coming from a large trunk, separately, and
at  greater  or lesser distances from each  other,  little advantage could be
expected, because the  numerous  connections and free anastomosis between
the  vessels would constantly tend to reproduce the pulsation, and perpetuate
the  disease.  I therefore concluded that benefit could only be looked for by
taking  up the main trunk, from which all these arteries are derived, and that
by  attacking and cutting off all the sources from which blood upon one side
of the head is derived, the vessels of  the  ear would become obliterated, and
that organ return to its natural state.
  After having announced by a sort of presentiment which was verified by the
result,  that the application of the ligature was less to be relied on  in the
treatment of the accidental erectile tissue, than in cases of simple aneurismal
dilatation of arterial trunks; the primitive carotid was tied upon  the 8th of
April in the following way : the patient being placed upon a bed, an oblique
incision was made along the internal margin of the sterno-cleido mastoideus
muscle, three inches in extent, beginning above and extended downwards and
inwards;  the cellular tissue was carefully divided by means of a bistoury
guided  by a director;  the muscle on one side and larynx on  the other were
kept asunder by assistants.   The artery was  laid bare, and isolated from the
jugular  vein and nerve which accompany it.  Then a directory was placed
under it, a ligature passed round by means  of an eyed stylet, and both instru-
ments were immediately withdrawn.  The necessity of a careful  separation
of the artery from the nerve and other parts cannot be too much insisted on.
It is undeniable that  by including in the ligature, the nerves and veins which
accompany the artery, the dangers of the operation are augmented  in propor-
tion to  the  importance of these parts.  It will not be sufficient in order to
appreciate these  dangers, to add together  the effects of each part separately
tied, but we must take into the account the combined operations of the inter-
ruption  to the flow of blood, and the suspension of nervous influence simul-
taneously induced,  before the effects upon the organs can be appreciated, to
which are distributed the vessels and nerves included in the ligature.   This
careful  separation is no where so important as in performing the operation
upon the  carotid artery.  Its importance is consequent to that of the organs
to which are distributed the nerves surrounding the vessel, to wit: the heart,
luno-s and  stomach,  the functions of which  may  be suspended, or  at least
undergo an alteration serious and irremediable, by the  effect of a ligature
upon the nerves. •  All these parts were avoided, and the artery was successfully
included.   In fact, each time that the artery was compressed by the thread,
the  pulsations  ceased, the ear diminished, without  the heart, brain, lungs or
stomach being disturbed in any of their operations. 
300
LECTURES ON
  This experiment was tried several times successively before the  ligature
was finally secured; at this moment the patient experienced an attack of se-
vere pain  in one of the bicuspated teeth of the right side; this  pain did not
exist previous to the operation, and it was doubtless caused by it,  without
our being able to explain the manner.  Moreover it was the only uneasiness
caused by  the ligature.   The bulk of the  ear although diminished,  did not,
however, appear as much reduced as we had been induced to hope, a circum-
stance which was to be attributed  to the retention  of blood in  the cells of
the erectile tissue.  In other respects, no pulsation or alternate movement in
the tumor of expansion and contraction  were perceived.  The dressing was
applied ; compresses  were used over the ear, soaked in Goulard's solution,
and  lint placed between them and the side of the head.
  To divide  the skin, reach the location of the artery, lay it bare, isolate it,
raise it, place the ligature around and  tie it, only occupied a few seconds;
but the patient fatigued during the day by indiscreet questions and reiterated
conversation, experienced in the evening violent pain in the head.  He vom-
ited, a bleeding was practised, but the affection of head persisted; a species of
numbness was felt in the.superior extremity opposite to the disease;  his feet
were put into a mustard bath.     »
  Second day.  Pain in the head less vivid, but it  had extended to the ear;
the patient compared it to the pricking of a needle; still vomits; in  other
respects no disturbance of the functions of the brain, heart, or lungs; sinap-
isms were applied  to the feet, and gummed  Sedleitz's water, as well  as strict
diet were prescribed.
  Third day. Pain in the head almost removed ; no vomiting; the eye retains
its sight;  the ear, the tongue, and the nostrils, preserve their sensibility, and
have &not undergone any alteration in their functions.  No pulsation in the
tumor, nor in the temporal arteries &c.; the volume of the ear is diminished,
the part is warm and red.
   Fourth day.  The patient eat with appetite and  without inconvenience some
lio-ht broth ; no more vomiting; upon the fifth day the first dressing was re-
moved ; suppuration was established ; it was of a healthy nature;  the wound
was re-dressed in the simplest  manner.
   Sixth day. Patient continues to do well; some pricking sensations  in the
ear; no pulsation ; it has somewhat diminished.
   Seventh and eighth day, same state.
   Tenth day. Still no throbbing in the ear; erectile tissue has lost one third of
 its volume.  The excoriated surface which had poured forth blood before the
operation, now secretes laudable pus.   In the evening the patient had fever;
the  skin was warm ;  pulse elevated and frequent, much pain in the head, and
 embarrassed respiration.  Blood was again detracted under the apprehension
 that this state of excitement, would renew the hemorrhage, or produce inter-
 nal  inflammation.
   Eleventh day.  Patient is better, the night has been comfortable, the pain in
 the head removed.  The ligature about to come away,  all force avoided in
 removing it.
   Twelfth day. The ligature has separated without hemorrhage, having cut
 through the coats of the artery. 
CLINICAL SURGERY.
301
   Eighteenth day. The erectile tissue which up to this date had  gone on
 diminishing, appeared to have re-assumed slight movements of expansion and
 retraction,  although, no pulsation in the contiguous arteries could be per-
 ceived.  Compression was made upon the ear.
   Thirtieth day. Expansive and contractile motion was perceptible to the
 eye; upon the forty-third day the ear was undressed; it  had been com-
 pressed between two pledgets of lint; in some parts only, there existed slight
 movements; in the temporal artery no pulsation was evident.
   Pus was retained at the  bottom of  the wound,  it came out by pressure.
 Evening, pain in the chest, and  labored breathing,  pulse frequent and hard.
 (Twenty leeches applied to the side of the chest.)
   Forty-fourth day.  Patient was better, pain in the  chest has been removed ;
 the wound from the operation has completely cicatrized.
   Forty-sixth day. After reflecting much upon the  obstinate continuance of
 the erectile tissue,  and the recurrence of  its movements, I imagined that
 uniform  and continued pressure would be more effectual than that which had
 been made by the lint sustained by compresses and bandages.  Consequently
 having diminished the size of the ear, by compressing it with the hand care-
 fully and exactly for some time, I covered the organ and the parts  contigu-
 ous with soft plaster of Paris. I hoped  that the plaster in hardening  would
 enclose the ear in a mould, capable of resisting every effort to expand, which
 the disease might exert, but my expectations were deceived.   The expedient
 was not  successful inasmuch as the compressing force, was not equal to the
 power exercised by the tumor, and large masses of  the substance employed
 were raised, and separated.  The plaster laid on the side of the head, to keep
 the ear in contact with it, soon gave way, and that which surrounded the ear
 itself, cracking and separating, suffered the erectile tissue to protrude through
 the crevices, which served to remove to greater distances the broken fragments
 of the mould.  It was in vain that we endeavored to sustain these fragments
 by means of compression, and as little success attended the application of the
 plaster case a  second  and third  time  around the ear, or an increase of its
 thickness.
   The force of expansion in the tumor broke at each  time in a few hours, and
 although  the magnitude of the  part appeared a little diminished, I ceased to
 employ an application unequal to the end designed.
   I next was encouraged to hope that better results would be obtained, from
the application of an apparatus consisting of two valve like plates united by
a hinge; these receiving the ear, and drawn together  by fastenings, at  the ends
opposite to the hinge, could compress it at pleasure. To fix it securely against
the temple, a  bandage  was carried around the head.  This apparatus was
kept on during some time;  it had more power to retain the ear and compress
it  than the preceding method, but it did not succeed  better  in effacing the
erectile tissue.   To cure this  part  of the disease, it  would have been neces-
sary to remove the tissue which composed it, or to have changed its organiza-
tion.  The removal, the only method of  cure, and which we have frequently
 employed in isolated, and less extensive  cases, would have brought about dan-
 gerous consequences.  To change  the nature of the  organization,  was  not
 within our means ;  we could therefore, only confine our efforts and care, to the
removal of  the aneurismal dilatation of the arteries,  and abandon to itself a 
302
LECTURES ON
tissue, which when existing without the  serious complications of which  wp
had  freed  it, could  engender but trifling  inconvenience,  at  the same time
waiting until the diminution of the general forces, should overcome its expan-
sive tendency, lead by degrees to its obliteration, and reduce it to a  state  of
organization, the properties of which, would not create alarm, or expose the
patient to any danger.
   This observation is worthy of attention  in various  points  of view.  The
first consideration presented, is the facility and safety of tying the  primitive
carotid artery, while  at the same time,  it  proves its efficacy in aneurismal
affections of this vessel.   It shows also, that if the ligature is not a  resource
in the treatment of the erectile  tissue, as effectual as in aneurism, it at least
restrains the progress, and diminishes  the dangers of it.   Such is the expe-
rience derived  from the  case  of  D., noted  during  five years after the
operation.
   After the carotid artery had been tied, the tumor was stationary in volume
and color, and no hemorrhage occurred.  The patient informed us in Febru-
ary 1833, that he experienced no inconvenience, but that  he had remarked
that fatiguing exercises, exerted an influence over the  ear, and rendered it
larger.  He had pursued a less  active profession, and the  symptoms had
moderated. We can believe that with the progression of age this tumor will
lose its tension, and diminish in size, and that the individual will  escape a
fatal terminationof a disease, whose nature  and seat will always be productive
of apprehension.
   Tying the main artery exerted in this case a favorable influence, but it
is  not to be concealed that in the greater number of  instances, this operation
has totally  failed.  Such a result seems naturally to result from the free com-
munication between vessels springing from  different trunks.  The influence
of the ligature  then is Limited to  diminishing  the tumor  and for some time
arresting its progress, but the circulation becoming re-established by the nume-
rous vascular connections, the disease  inevitably returns to the condition  in
which it was prior to the application of the  ligature.
   But however small may be the certainty of cure, by tying  the artery, we
believe that this measure should be adopted in cases where  the erectile tumor
has its location in a part, which renders it improper to employ either compres-
sion, cauterization or excision.   I should likewise add, that when the erectile
tissue exists without complication with carcinoma, the disease progresses more
slowly after the  operation.
   Compression  has been recommended for the cure of this  disease.   The
greater number of practitioners reject it,  because it causes great pain, because
it  cannot be exactly  made to operate, and even produces local inflammation;
leading to a more rapid increase of the affection.  We cannot adopt so sweep-
in°- a conclusion, for several cases have fallen under our notice in which these
tumors have been cured by compression.  We have practised it with success
in infants, and  among others in the case  of a daughter of a  lawyer.   This
child was laboring under an erectile tumor  situated below the inner angle of
the eye; methodical pressure  was kept up, and at the end of six weeks,
the  cure was  accomplished.  The  same  effect  has been  witnessed by you
(Feb. 1833).
   The subject aged, 40 years, had enjoyed  good health; nine months ago  he 
CLINICAL SURGERY.
303
 received upon the lower jaw a kick from a horse, which strictly speaking, is
 to be considered as the origin of the disease.   In a short time there appeared
 upon the lower lip a  small tumor which rapidly progressed.  The patient
 being  desirous of getting rid of the inconvenience caused by it consulted a
 skillful surgeon, who aware of the nature of the tumor tied the two coronary
 arteries and a branch of the labial.  It diminished at first, but soon re-assumed
 its  size  and pulsations.  Seeing the failure of  this experiment, the patient
 came to consult me.   From the position of the tumor I thought that com-
 pression gradually augmented in force would  be employed advantageously
 It was brought to operate by means of  two valves, similar to castanets which
 embraced both  sides of the lip, and by means of a screw the  pressure was
 made upon it.  If this had not succeeded, extirpation would have been carried
 into effect.
  Caustic is sometimesadvantageous.  The following observation will present
 some proof of its utility.  M. Wardrop recommended  this mode of treatment
 which he believed to operate by producing ulcerative inflammation  in  the
 erectile tissue and then causing its destruction.
  Case II.—Ulcerated Erectile Tumors upon the Thigh and Left Foot; Cau-
 terization with Nitrate of Mercury.—D....., eight months old, born in the
 country, well formed,  was  sent to  see M. Dupuytren  by M. Marjolin, upon
 the 3d of March, 1828.  This  infant had been  born with  two red  blotches
 upon the body; they  were elevated above the skin, and produced  by an
 anormal development of the capillaries; one of them occupied the dorsal face
 of the three first metatarsal bones of the left foot and extended between  the
 first and second toe round to the sole of the foot, where it covered about an
 inch of the  surface; the other was located upon the external pact of the left
 thigh and was as large as a franc piece.
  For some time these tumors remained stationary, except that when the in-
 fant cried, the sanguine turgescence became deeper colored and more promi-
 nent.   When three months old, the little patient made known its sufferings
 by its  plaintive  sobbings.  Then it was perceived that the  tumor of the foot
 had augmented in  volume, and shortly  after  superficial ulcerations appeared
 between the toes.  At first, no hemorrhage occurred from these ulcers, although
 they daily extended in  depth and breadth.  The  general health became by
 degress impaired, the ulceration extended to the  dorsum of the foot, and after
 having progressed  for five months, this child was sent to Paris in the following
 condition : a deep  fissure existed between the toes,  extending each way, supe-
 riorly upon the foot; inferiorly to the sole it was two lines wide, ulcerated, of a
 grayish leaden hue, and fungoid in appearance; its borders were elevated, tur-
 gescent, hard, violet colored, and formed by the destruction of the erectile tissue.
 The ulceration which had taken place in this tissue appeared to be owing to a
 similar destructive process  as that which produces hospital gangrene.   M.
 Dupuytren, after having examined with care the affection, considered it as a
 degeneration composed of erectile tissue and a production cancerous in appear-
 ance.   The purulent  sanies  mixed with shreds of the ulcerated  tissues,
 exhaled an unusually fetid odor.
  The surrounding parts were tumefied, and the toes  much swollen;  there
 was even cause to suppose  that the disease extended  to the bones beneath,
The tu mor of the thigh had increased, but not ulcerated; it was unequal, violet 
S04
LECTURES  ON
 red, and subsided immediately by pressure; it was twice as large as at birth.
 M. Dupuytren regarded the condition in which it was, as very  serious; he
 thought of practising amputation of the limb, but was diverted from  this idea
 by the fear of relapse, and also by the presence of the tumor on the thigh evi-
 dently  similar to the one on the foot.   These weighty considerations induced
 him to apply the cauterizing preparations of nitrate of mercury, in  order to
 change the nature of the ulcer and promote cicatrization.
   The  first application was made upon the 7th of March, by covering tin*
 entire surface of the ulcer with a dossil of lint soaked in the solution.  It was
 accompanied with pain which lasted during the  application;  a few drops of
 black blood oozed out.  On the next day the wound was  examined, but the
 effect of the cauterization did not appear to be favorable ; the eschar was soft,
 fetid, grayish, and the general aspect of the sore was analogous to hospital gan-
 grene.  The measure however was not abandoned, and seven days after (the
 14th), a new application was carried into affect, in the same manner as the
 first which was as  fortunate.  After this second application of the caustic, the
 ulceration seemed improved; an abscess  formed upon the 20th of March in
 the superior posterior part of the right thigh, which rendered  it necessary for
 us to suspend the  treatment.  This abscess was  opened the 1st of April, and
 soon  healed.   A  third cauterization was made  the 9th of April, its effects
 were very advantagous.   The ulcer lost its grayish aspect, its borders were
 removed,  and the extent of the disease was diminished.   Other applications
 were made, nine in number, with intervals of five days between them.  The
 success exceeded our expectations, and towards the end of May, cicatrization
 of the ulcer upon the foot  was accomplished.
   The tumor upon the thigh however pursued a  different course ;  this, which
 up to the period of the fifth application had remained stationary, now com-
 menced to take on a new aspect; ulcers were formed upon its surface and in
 its thickness, and  there was established in  this  place  a kind of emunctory
 resisting  cauterization, and which on the contrary appeared to progress in
 proportion to the healing of the sore  on the foot.   M. Dupuytren anticipated
 the advantage  to be derived from a counter-issue, and  in order to form  one,
 caustic  was applied upon the left arm.  The suppuration induced was of the
 greatest utility.   Five applications produced cicatrization of  this last ulcer,
 while the general health of the infant remained unimpaired.  The cure was
 complete on the 25th of June.  The infant remained in the hospital awaiting
 the arrival of its parents until the 10th of July, when it went out.  (Communi-
 cated by Dr. Fournier d'Anas.  The first case was noted by Dr. Marx.)
  The removal of erectile tumors by  caustic can  then be successfully accom-
 plished, but it is less sure than the actual cautery, which  is one of the most
 powerful methods employed to get rid of these tumors.  Recourse, however, is
 rarely had to it, on account of the fear that it causes to the patient, and above
 all, since a cutting instrument acts with as much efficacy without being accom-
 panied with the same  inconveniences.  It can be  used, nevertheless, when the
 tumor is too extensive, too thin, or too much blended with healthy tissues to
 allow us to extirpate it.
  The bistoury, then, from the latest  experiments, is the  surest instrument
 which can be  used  to remove erectile tissues. The scissors are sufficient for
some cases.   It should not be forgotten that the greater the distance from the 
CLINICAL SURGERY.
305
morbid  structure, the  fewer are the vessels  to be taken up, and if it is at all
implicated in the excision, the  patient is exposed to a considerable loss  of
blood.  If the tumor is situated upon an isolated part as the finger, lip, &c. it is
practicable, after  milder measures  have been unsuccessfully practised,  to
remove the base alone with it,  as in a cancerous ulcer, and  to re-unite the
bodies of the division.
  Erectile tumors, said  M. Dupuytren,  have a remarkable tendency  to be
re-produced, and the greatest possible care ought consequently to be  taken
not to leave the smallest portion of them.   There is  almost no part of the
body  from which I have not taken similar  tumors, and in all cases I have
obtained a radical  cure  confirming me in my  principles.
  Extirpation being the measure most frequently successful in my hands, and
the one to which we give the  preference. We will now report several
examples of this mode  of treatment.
  Cask  III.—Erectile Tumor on the Lower Lip; Removal; Cure.—L......
eight years  old,  well formed,  stout constitution, entered  the  Hotel-Dieu
January 4, 1828.  This  patient had on his lower lip a small tumor, of the
nature  of  those called erectile.  At the time of birth it was very small, but
had gone on increasing with the growth of the infant.   Its progress had been
slow and little evident.  When the little patient was presented for advice, the
tumor was as large as a filbert; it occupied the  middle of the lip, and pro-
jected slightly; the surface being irregular, its projection was influenced by the
movements of the mouth.  The base of the tumor appeared to penetrate some-
what into the muscular  tissue of the lip; its appearance was paler than  is
usually the case in tumors of this character.  The complexion of the child was
rather palid, the tumor was soft yielding to  the  impression of the finger, and
when the finger was removed, the point upon which it had been applied was of
a dull  white, soon becoming re-injected.   It could by compression over its
whole surface be entirely removed for the time being.   There was no arterial
throbbing, nor any movement of expansion or retraction.
  Many measures might have been adopted  to cure this deformity, which, it is
true, created no uneasiness to the patient, but the increase of which was to be
apprehended.  It  appears as if  compression should first have been adopted,
Imr this was difficult in application, more especially in consequence of the age
of the subject, as its restlessness rendered its use almost impracticable.  The
extirpation of the tumor, the only possible measure, could be accomplished  in
two ways; one with  the curved  scissors, by  which the part could  be removed
entire with one cut, the other by means of two incisions meeting below ; after
this latter method had been practised,  the lips of the wound could be brought
in contact with little deformity.  The desire to  remove the whole  of the erec-
tile tissue  without leaving any remains of the operation  except the linear cica-
trix, induced us to give the preference to this latter method.  Upon the 8th of
January, the operation was  performed in the  following manner: With the
straight  scissors, two incisions were made  resembling the letter V, meeting
towards the base of the lip ; the tumor was thus separated and removed.  Two
needles were passed from side to side, and the lips brought together by liga-
ture as  in the operation  for hare lip.
  The first few days after the operation, the little patient had a little fever; the
needles were withdrawn  on the fifth day ; reunion was complete  on the side
towards the mucous membrane, with the exception of about half a line upw '.he
           39 
306
LECTURES  ON
 summit,  the incision externally was open, and suppuration had commenced;
 this portion appeared to be more extensively implicated than the internal side.
 A uniting bandage was applied  to keep the parts together.   The  cicatrix,
 linear in  shape, was nearly completed when the patient went out, the 11th of
 January, thirteen days after the operation.
   The small tumor  examined after its excision was of a pale yellow  color,
 soft,  yielding, composed of a cellular structure.  The resemblance of this tis-
 sue to a portion of the corpus spongiosum urethra; was very close.
   Case IV.—A man, 43 years  old, of small stature but well formed, had a tu-
 mor upon the right side of his head, which covered portions of the  parietal,
 frontal, and occipital regions, together with the whole superficies of the temporal
 and mastoidal, as also the superior part of the side of the  neck.  This tumor
 projecting at its superior part from two to three inches, insensibly  diminished
 towards the inferior edge, and was entirely covered  with hair.   The head
 being shaved, it was evident that the skin was healthy, and divided into three
 surfaces,  one superior and anterior, separated from the others by a transverse
 line,  appearing to be formed by organized substance of tolerable consistence;
 a second intermediate presenting equivocal fluctuation, and a third, inferior,
 soft, impressed by movements of expansion and contraction synchronous with
 the systole and diastole of the heart.  A most attentive examination could not
 detect  any thing similar in the two other portions of the tumor.   There was
 perceived behind, upon the mastoidal portion of the temporal bone, an irre-
 gular opening, roughened by osseous projections.  It was also thought that
 the zygomatic arch was implicated.  This patient interrogated with regard to
 the history of this tumor, answered that it had existed at the time of his birth,
 that it had increased slowly, and without pain, and that four years before his
 entrance  into the hospital  he had received many blows upon it.   A  surgeon
 being consulted made an incision into it, which produced a flow of  pure blood.
 Since which occurrence, no inconvenience has been  experienced,  and he
 should  not have applied for the assistance of art, had it not been for the fall of
 a mass  of earth upon his head.  This disease  is evidently incurable, and ought
 not to be touched; nevertheless, at the reiterated instigations of the patient, a
 tentative  puncture was made with the  bistoury; arterial blood immediately
 gushed  out which appeared to come from vessels, and not from a cavity where
 it had been confined.   The discharge was  easily arrested.  In a few days
 the patient was seized  with  fever, accompanied  with  nausea,  vomiting and
 great  pain in the tumor; the wound afforded exit to a large quantity of blood.
 Next  day sensation of weight in the head; tumor  softened, painful.  Third
 day, same symptoms.  Fourth day, erysipelas of the scalp came  on, extending
 to the face and  side of the neck. The least touch is painful, pulse small, con-
 tracted. Sixth day, tumefaction has augmented.  Seventh, discharge of bloody
 serosity.  Eighth, erysipelas,   has extended  to the chest (emetised  whey).
 Ninth, abundant discharge (emet. whey and sulphat of soda).   Upon the suc-
 ceeding days subsidence of tumefaction, desquamation, flow of a reddish pus,
return of appetite.  On the twentieth and twenty-first day, frequent  hemor-
rhage, entire loss of appetite ;  fever  continued, infiltration of the legs, deli-
rium;  death the thirtieth day.
  The  autopsy  was made by  M.  Dupuytren, who himself took  down the
 peculiarities presented.
  An injection  thrown into  the right carotid artery in an instant filled the 
CLINICAL SURGERY.
307
 cavities of the tumor and returned through the jugular vein.  That which was
 introduced into the veins, distended a great number of very large veins upon
 the surface and in the vicinity of the tumor.   Dissection clearly demonstrated
 that it was  composed of two  entirely distinct  parts, the one  formed a very
 considerable mass  consisting  of three tissues.  First, a reddish tissue like
 muscle, very friable, and without  linear  arrangement; this structure was
 generally located beneath the skin.  Second, a fibro-cellular tissue forming
 the greater bulk of the tumor, infiltrated with a considerable quantity of sero-
 sity, traversed by veins of large caliber, and by arteries proportionally smaller.
 Thirdly and lastly, in certain portions, a fibro-cellular tissue, redder, and more
 vascular.   It was  in this heterogeneous  mass that the abscesses were formed
 of which we have spoken, and in their places were discovered  very extensive
 pouches, the walls of which were red and studded with villi; from these had
 issued the hemorrhages occurring during  life.
   The second part of the tumor, much  less voluminous than the preceding,
 occupying the mastoid process,  was but the appendage to the  larger situated
 on the cranium, and projected  through the opening observed during life ; this
 consisted of a serous cyst, developed in the thickness of the right lobe of the
 cerebellum, which had entirely  disappeared.   It was united  to  the inferior
 occipital fossa by cellular and fibrous attachments.   Its cavity was traversed
 by vertical and horizontal partitions which gave it  a cellular aspect.   The
 cells were filled by serosity and  membriform  remains, which it was suspected
 were the remains of some disorganized hydatids.  But this conjecture  could
 not be verified in consequence  of the pulpy nature of the fragments.
   In addition to  these two principal  affections, it was  likewise observed :
 First, that  the superior angle of the malar bone was disconnected from its
 union with the external angular process of  the frontal  bone; second, that
 this cheek bone had undergone a fracture from  its superior angle downwards,
 but which had reunited; third, that  the veins  connected with  the  parts were
 varicose, and formed an independent tumefaction existing in this position.
   It is impossible to deny that the cyst and disease of the brain  were preceded
 by other lesions, and that the  projection externally  of the  cyst, w-as not the
 cause of the pulsatile movements observed in this portion of the tumor.   But
 it is impossible to  conceive  how this  extraordinary disease could form, and
 destroy an entire lobe of the cerebellum, without any alteration in the cerebral
 functions, or in those connected with them.   It  is difficult  to determine the
 period at which the erectile tumor commenced.   Did the consolidated fracture
 originate from the blows which the patient received four years before ?  The
 disarticulation of the malar bone  appears  to have occurred at the date of the
 accident.                                       *
   Case V.—A young man, aged between 16 and  17, of good constitution, was
 the subject, six or seven years  since, of a tumor, situated upon the right side
 of the face, in the furrow which separates  the cheek from the upper lip.  This
 tumor at first small, increased gradually and became as large as a filbert.  It
 created no pain; the skin was healthy and unchanged in  color; when compressed
it diminished in size, without entirely disappearing; there existed  no dilated
vessel around it.  This tumor presented neither  throbbing nor  motion.  The
patient  by compressing it, perceived in its  centre a  small hard kemal, and
upon these occasions only he suffered uneasiness. 
308
LECTURES  ON
  The diagnosis presented great difficulty.  At first sight and  before ques-
tioning the patient, M. Dupuytren thought it an abscess, but convinced of the
incorrectness of this opinion, from the details furnished by his account he was
inclined  to  believe that  it was either a fatty, or erectile  tumor.   A lipoma
placed in this situation  might  diminish  and even entirely disappear in  the
canine fossa.  An erectile tumor  likewise would possess characteristics such
as belonged to the affection  in  question;  but ordinarily compression can be
carried to a greater extent, reducing the bulk of the tissue much more than
could be  done in the present instance.  The central kernal, which the patient
said he plainly felt when  squeezing the part, likewise increased the difficulty.
Removal alone could remove all doubt; it was practised December 19th, 1828.
An incision made into the body of the tumor, gave rise to  the flow of a con-
siderable quantity of vermilion  colored blood.  The nature of the disease
being thus recognized by this tentative division, its extirpation was carried into
effect with  every possible  care.   All  the  parts  concerned were likewise
removed, and upon examination, a small osseous  concretion was formed in
its centre, constituting the kernal mentioned.
  The wound bled freely, dressings, and forcible pressure were applied, and
no hemorrhage afterwards occurred.  The cure went on well, only cicatriza-
tion  required some time to  be accomplished, in consequence of the applica-
tion of caustic, least some remains of disease still  existed.  This  man went
out, a complete cure, on the 14th  of January, 1829.
  This case is remarkable for the  difficulty of establishing  the  diagnosis.  It
should render us more circumspect in the judgment exercised with  regard to
these tumors, and convince us that their true character  cannot always be
ascertained before extirpation.  (Communicated by M. Paillard.)
  Case VI.—An infant,  aged nine months, well formed, was brought in 1818,
to M. Dupuytren, in consequenee of a  tumor, situated on the superior  lip,
occupying its left half.  This tumor rounded in form, of a mottled color, as
voluminous as a large filbert, soft in consistence, and indolent in  character,
extended through the entire thickness of the lip.  From this augmentation in
the volume of the superior lip, it resulted  that the left half overlapped the
lower lip, so that the infant was precluded from sucking  on this side.   The
difficulty in the infant had caused a greater development of the left breast of
its mother, which was one third larger than the right.  Beyond this there was
no inconvenience resulting to the infant from the tumor.  It augmented con-
siderably when  the child cried, or took the breast; no pain appeared to be
suffered in consequence ;  pressure pretty forcibly made had no effect of the kind.
  The tumor at first  presented itself under the form of  a very small black
spot, which the mother mistook  during  a whole  month for a bruise, which the
accoucheur had produced  with his  finger nail. At the end of this period,  this
patch became raised, and assumed the appearance of a small vesicle, as large
as the head of a pin.  For some time it did not  increase, but at length it
rapidly became as big  as  a  mulberry in  consequence of  repeated spells of
crying.   Since then, that is to say,  during the last three months, it has con-
tinued to make marked progress.
  This child had two other tumors of the same nature, one situated upon  the
left buttock, the other upon the thigh.   These are sufficiently circumscribed  ;
some what more  consistent, but less highly colored, than that upon the lip, and 
CLINICAL SURGERY.
309
traversed by fissures of little depth, which gives the  idea of a collection of
lobules, such as form the fruit of the raspberry.  The mother asserted that it'
was  in consequence of her desire to obtain this fruit,  that her child was thus
marked.  These last are no more painful than the one upon the face, but they
have not pursued  the same progressive course in  their development. The
parents of  the infant affirm that these  three tumors were of the same size at
the time of birth.  M. Dupuytren recommended waiting  until the period of
weaning had arrived, before the operation should be performed.
  Case VII.—Aubertin, two years  old, well formed, was born with a small
tumor towards the  external commissure of the eyelids  of the left side.  It was
upon a footstalk, red, vascular, and  underwent swelling during crying spells,
and when in great agitation.  It continued to progress without causing anv
pain, not even when pressed.  Its  volume being equal to a large filbert, the
parents brought the child  in 1818, to consult M. Dupuytren.  The external
angle of the  eye was drawn down,  and the  lower  eyelid slightly  concealed
by being overlapped.   These  derangements  in the integuments  would have
become greater by the increase of the erectile body, and the functions of vision
ultimately impaired.
  M. Dupuytren practised excision of this  tumor with the curved scissors.
But  a small quantity of blood was lost, and it was  not necessary to apply
cautery; the wound was simply dressed.  Eight days afterwards the patient
was perfectly cured.  Dissection demonstrated very satisfactorily the vascu-
lar nature of this erectile production.
  Case VIII.—A  man had an erectile tumor upon the head, within the circle
compressed by his hat.   He  constantly therefore carried  his hat  under his
arm.   One day in fit of anger, he suddenly placed it on his head.  The tumor
was torn and bled ; after this mishap  frequent hemorrhages occurred.  M. Du-
puytren was obliged to  remove the erectile  production, which  up to  the
moment of the violence had remained stationary.
  Case IX.—A young man, aged fifteen years,  came towards the last of
March, 1833, to consult  M. Dupuytren.  He  labored under a tumor ont he
inside  of the lower lip; it was violet colored, wrinkled,  and the size of a
filbert.  Movements of expansion and contraction were evident.  It dimin-
ished under pressure, but was not long in regaining its volume. This tumor had
existed the whole lifetime  of the patient.  At first very small, it had taken on
during the two last years greater development.   Excision was practised in the
begining of  April.  Dissection demonstrated that it was formed by an exte-
rior thin fibrous membrane, and by numerous small arterial and yeinous vessels.
The cure was complete at the end of eight days.
  If extirpation in the majority of  cases, is the best  means  of curing these
tumors, it ought nevertheless, not to be practised when they have not attained
considerable size, and when they occasion neither pain nor embarrasment. Ob-
servation has evinced that they will  continue  stationary a long time, and even
finally contract and be removed.
  The erectile tissue, often congenital,  sometimes accidental, is found to exist
without appreciable cause, or is induced by external violence, as for instance,
continued attrition.  It arises  as we have said, in all parts of the  body,  but
shows  itself more generally upon the lips, without doubt, in consequence of
their spongy and vascular structure.   It is  met with upon the arms, legs, 
310                          LECTURES ON

scalp, ear, cheeks, labia, pudendi, in the thickness of the skin, muscles, peri-
osteum and bones, in the kidneys, liver, &c.   In short, erectile tumors  can
invade successively an entire limb.  Such is the experience of Samortier;
the skin, the muscles, the bones tliemselves, were affected from thcfingers to
the shoulder.

                           FUNGUS H^MATODES.
   The erctile tissue is not always presented in the state of simplicity which
we have just noticed, the second case excepted.  It is often commingled with
cancerous substance, and to the joint production of these two elements, it is,
that I have given the name of fungus haematodes. Sometimes the cancerous
substance predominates, while at times, on the contrary, the erectile tissues is
i n greater abundance.  This difference in the proportion of these two elements
is not a refinement in  description, or of  minor importance in the treatment.
According to the predominance of one  or the other of them, the disease will
have  a different termination;  thus,  for example, if the scirrhous  tissue is
more developed, degeneracy will be prompt in  proportion,  a return of the
disease more easy,  and extirpation will be far from presenting  favorable
results.   If the erectile tissue  is in excess, removal  in nearly all cases will
terminate successfully.
   Fungus haematodes in some cases is enveloped by a cyst, more or less ex-
tensive, and containing sometimes a quantity of serosity, which at first sight,
frequently  is deceptive as regards the nature of the disease.
   Case I.—Tumor in the Substance of the Left Breast; Fungus Hsematodes;
Extirpation.—A young woman, aged 20, laboring under a tumor  in the  left
breast entered the Hotel Dieu about the 1st of August,  1829.   She attributed
her disease to strong pressure made upon the part two  years  previous.  The
tumor was as large as the fist;  the skin which covered  it was healthy; sharp
pain was experienced in it;  and  marked fluctuation existed.  M. Breschet,
who at the time had charge of the wards, plunged a bistoury into  it; some
quantity of blood was discharged; dressings were lightly applied.  During the
next 24 hours, two hemorrhagies profuse in character occurred; they were
arrested by means of agaric and forcible compression.
   M. Dupuytren conjectured  that  the  case was fungus  haematodes.  He
allowed the agaric to remain some days upon  the wound.  Upon the 7th of
August it came off,  and between the lips of the wound which were widely
separated, there was  perceived to arise a spongy fungus body of some size, and
easily allowing the escape of blood.   This appearance of things no longer per-
mitted the nature of the disease to  remain  doubtful; removal was  the only
measure which could be employed.   It was performed the 8th of August.  A
crucial incision was made over the tumor, which being laid  bare, the finger
was  introduced between it and the  surrounding  parts.  M. Dupuytren per-
ceived that it was contained in a cyst, intimately adhering to  the surrounding
parts.  The removal of the tumor from  the cyst was  easy and  prompt, and
consisted in fact of a sort of enucleation.  The  interior of the  sac was  ex-
amined with care, and did not appear to contain  any remnant of the disease,
the part of the cyst from which the disease seemed to  spring was extirpated
entirely.    The  sac was filled with  lint,  and lightly compressing  bandages
placed over the breast. 
CLINICAL SURGERY.                       311
  The intention of M. Dupuytren, was to cause suppuration in the cyst, and
thus obtain the cohesion of its parietes.  The tumor which had been removed
was nearly the size of the fist, and composed of matter resembling the sub-
stance of the brain, but much more consistent and  traversed in its different
portions, by an innumerable quantity of vessels crossing each other in all di-
rections.  A cellular tissue very abundant, dense, and even fibrous in certain
points, contained the varied elements of the tumor.   This was nearly pale as
to color, and the recent coloring contrasted strongly with  that which existed
prior to removal.  (Communicated by M. Paillard.)
  Fungus haematodes, developed in the breast, is a very rare affection, and M.
Dupuytren has met with it but seldom in his practice.  The following fact, in
this respect merits consideration.
  Case II.—A  woman living in Paris (rue St. Denis), was affected with a
tumor of some volume in the substance of  the breast.  M. Dupuytren  being
consulted in the case,  thought that it was scirrhus, and recommended an ope-
ration.  He performed  it himself; upon the first cut  made by the bistoury,
there  issued an enormous quantity of transparent serum.   M. Dupuytren per-
ceived the error in the diagnosis, and thought that  it was  an  hydatid.  The
serosity having flowed off, simple dressings were applied, but shortly after-
wards a very abundant hemorrhage manifested itself.  The  bandages were
removed, the wound enlarged, and at the bottom of the serous sac there was
discovered a bloody tumor; it was formed of erectile tissue, and cancerous
matter.  In other words it was a fungus haematodes.  Extirpation was prac-
tised.   The whole of  it was  not removed at once, for  another  hemorrhage
occurred some days after, from the wound  occasioned by the operation.  The
opening was therefore enlarged  anew, and  all the diseased points carefully
removed.  After this.no more loss of blood ensued, and the wound healed
without accident.  The patient  being  perfectly restored to health, has  since
suckled several children, and continued to enjoy good health.
  The cysts surrounding  fungus haematodes  are fibrous  and cellular  on the '
exterior, and adherent  to the contiguous parts ; interiorly they present the
organization of serous membranes, and from the surface is exhaled serosity.
Sometimes it is from a single point within  the sac that the fungus arises, and
to which it is adherent; in other cases it attaches itself to the whole internal
surface of the cyst which contains it; in this case the cyst is completely fibro-
cellular.
  Placed beneath the  skin, at a greater or less  depth, and without involving
this tissue, or altering it in  any manner whatever,  fungus haematodes some-
times deceives the surgeon, and leads  him to mistake it for other distinct dis-
eases.  It may present the insidious characters of manifest fluctuation, and
persons well skilled in their profession have so considered it.  But instead of
pus which had been expected to issue from a puncture, there flows out blood,
then a fluid tinged with a reddish color, and  finally a bloody fungus excres-
cence grows out, and  rapidly advances.
  Fundus nematodes is confined to young subjects, and those who have reached
adult lffe.  It  follows blows, falls, or  any external  violence, and may result
from rheumatic or gouty swellings.
  In  the locality where the disease  is  about to   manliest itself, there is 
312
LECTURES  ON
developed a painful tumor, over which the skin is at times uncolored, at others
red or violet.  Pulsations are soon perceived, deep seated at first, but augment-
ing in violence until they give sensible motion to the part; these pulsations are
synchronous with those of the arteries, but without sound.  Sometimes they
are accompanied with expansion in every sense of the term, when the disease
h;is made some progress.   These movements cease completely, when  the ar-
tery between the heart and tumor is compressed.  Pressure upon the tumor
with the finger at some points, gives rise to a sound resembling that produced
by folding parchment on a dry membrane.   Upon other points the finger pene-
trates to some depth without  meeting with any resistance.  The  pulsation
observed in all these tumors, which is sufficiently forcible to be compared with
ihatof true aneurismal tumors, results from the synchronous movements of dila-
tation and contraction, in all the small arteries which supply the diseased part.
From all such partial, but simultaneous  movements, results an universal pul-
sation.
  Fungus haematodes is a very serious malady which cannot be cured but by
extirpation, when practicable, or by amputation.  One of the elements which
enters into its composition can, under certain circumstances, be  modified by
tyinjj; the main trunks of the arteries, whose terminating branches  carry on the
circulation of the tumor, but  the other  element (the  scirrhous, cancerous,  or
encephaloid substance) which is found in more  or less abundance, and which
unfortunately in the generality of cases  preponderates, is a powerful obstacle
to the cure by ligature.   Nevertheless,  this measure can diminish to a con-
siderable  extent the malady, retard  its progress to disorganization, and con-
sequently prolong and render supportable the life of the patient.  I  have had
recourse to it with advantage in the two following cases.
  Case III.—R...., 39 years old, slender, lean, tall, complexion pale, had not
suffered from disease, except tinea capitis, which continued from his childhood
until he was twenty years of age ; when thirty-two, a tumor commenced to make
irs appearance upon the internal superior part of the  right tibia just below the
articulation of the knee.  When the hand was  placed upon this  tumor, there
were perceived  pulsations in it synchronous  with  the pulse.   It had aug-
mented considerably in volume, and on  the 9th of February, 1819, the patient
entered the  Hotel-Dieu.   During the  last year  only  he perceived  that the
right leg  had lost its power,  and that  it often bent under him, that a small
tumefaction existed below the knee, and in this point he experienced shooting
pain.  He consulted a physician who directed him to apply emollient cata-
plasms.  To this was added the application of leeches, and finally a blister.
This treatment was not productive of any relief; the tumor went on increasing,
and the skin which covered it became red ; upon his admission into  the hos-
pital he was in the following condition:  The tumor occupied  the  superior
external part of the leg;  situated upon the superior portion of the external face
of the tibia, extending internally; its length is  somewhat less than  that of the
palm of the hand.  This tumor was not circumscribed ; the skin which covers
it is red and thin;  it presents at all points pulsations synchronous with those of
the heart, which cease when the crural artery is compressed, but re-appeared
as soon as compression is removed; the  pulsations of the anterior tibial artery
are also distinct.   After having questioned the patient and examined him with 
CLINICAL SURGERY.
313
great care.   M. Dupuytren thought that this tumor was occasioned by dilated
capillary vessels,  and perhaps also by the alteration of the soft parts and of
the bone.
  The treatment was commenced by applying compresses, soaked in Goulard's
lotion, upon the track of the femoral  artery, and confining thein by a circular
compress, but the vessel slipped from under the  pledget, so that the desired
effect could not be obtained.   This  mode  of treatment  continued  until the
10th of March, but not being productive of any amelioration, or diminution
in the volume of the tumor, M.  Dupuytren determined to tie the crural artery.
Upon the 15th of March, the skin being divided in the inside  of the thigh, to the
extent of three inches along the external edge of the sartorius muscle, the parts
being then dissected, the artery was reached, covered by the  facia of the adduc-
tor minus, which was divided by means of the director and bistoury ; the vein
and nerves  being separated, the director was thrust beneath  it and a waxed
thread passed round.  To be certain that it was correctly placed, he drew the
two ends of the  ligature  together, and completely obliterated the  pulsatile
movements in the tumor.   The ligature was then tied, and was productive of
no pain.  The wound was brought  together by means of adhesive strips, a
simple dressing  applied, and the leg demiflexed, placed upon a cushion and
surrounded  with bags, filled with hot sand.
   In the evening a bleeding to the extent of two bowls-full was practised to
prevent any sanguine congestion in some one of the principal  organs.  Next
day, the tumor did not present any pulsatile movement;  it was diminished in
volume, and the limb enjoyed all its sensibility and mobility.  Upon the sixth
day, the dressing was removed ; the wound had united throughout its length,
except where the ligature issued from it; pulsation was no longer perceptible
in the tumor, and the patient generally was  as well as could be.  During the
night of the fourteenth day, there issued a slight bloody discharge.  On the fif-
teenth day,  the ligature came away without pain, and without hemorrhage. The
next  day, some  pulsation was evident in the tumor, and during the ensuing
night an hemorrhage to the extent  of two bowls-full occurred, which was
arrested by means of the circular compress, placed by the patient himself abof e
the wound,  upon the track of the crural artery.   He,  however, removed it in
opposition to the most express  and reiterated warnings, and upon the twenty-
second day another hemorrhage took place;  the patient with coolness and cour-
age, again suppressed it without assistance.
  °From this time until his  discharge upon the 30th of April, the compress was
kept on.  Diet, blood-letting, constant continuance of the same position on the
left side, with the two hemorrhages, had so  diminished the strength  of R., that
the limb became infiltrated, but the pulsations  had completely disappeared.
The  place where the tumor had existed still was a little swelled, but no indi-
cation of motion in it existing, the  aneurismal  character had disappeared;
engorgement alone remained.
   Seven years after this operation, the tumor commenced to augment anew.
Upon the 1st of August, 1826, the man determined to  enter a  second time the
Hotel-Dieu.  There  then  existed upon the superior part of the right leg near
the knee joint, a tumor which extended some distance  downwards.   This tu-
mor projected more in  front than behind, the veins which coursed along the
skin  were  much  enlarged, the cutis was  so thin as  to threaten rupture in
            40 
314
LECTURES ON
several places.   No  pulsation was evident, the tumor was thirty-two inches
in circumference.  Flexion of the knee was  impossible; the general health
was good, although the patient was emaciated, pale, and somewhat of a yellowish
tint.
   Aug. 5th. M. Dupuytren  who  recognized  the nature  of the tumor, per-
formed the operation of amputation, this being the only chance of cure.  The
operation was  performed in the usual way.  A great number of vessels were
taken up,  and the patient  put to bed.  No accident ensued  ; the bandages
were only soiled with a little blood.
   6th. Slept,  no pain, no fever during the day.  In the evening a little fre-
quency in the pulse.
   7th and 8th. Some heat of skin, and frequency of pulse in the evening only.
   9th. Sharp pain in the stump; no fever; (tenth  since  the  operation,; the
patient has not had a stool;  continues the  same. (Injection.)
   11th.  Sixth day after  the operation, the apparatus was  removed  for the
first time;  there flowed from the inferior angle of the wound a large quantity
of bloody pus  ; union had commenced in several places.
   12th.  Stump looks well; general condition well.
   18th.  Up to this  time the  patient has  gone on  well; some nourishment
being  permitted, he was seized with slight diarrhoea; there is a little warmth
of skin and frequency of pulse. (Diet rice gummed.)
   21st.  Diarrhoea continues, still a little warmth of skin and frequency of
pulse ; the stump still secretes pus;  it is of good quality; the wound is unit-
ing  finely. (Rice gummed, thirty grains of diascordium.)
   22nd. Same condition ; refuses to take the  diascordium.
   26th.  Diarrhoea continues; tenderness of  the belly; tongue red at the
edges ; skin warm, and pulse frequent in the evening ; complexion very palid;
stump improves; during the dressing several  ligatures came away.
   28th.  Twenty-fourth day of the  operation; all the ligatures have been re-
moved ;  the wound had a good appearance; it had almost  entirely cicatrized;
the diarrhoea had been removed; the tenderness of the abdomen  was less; the
redness  of the tongue had diminished ; nevertheless, there was some warmth
of skin and frequency of pulse.   The man desired  to be removed from the
hospital; M. Dupuytren agreed that he should return to his home (a Francou-
ville).
   The thigh was nearly well and there remained but slight marks of irritation
in his digestive organs.
   Anatomical Examination of the Limb after the Amputation.—The diseased
member had been examined with  care by MM. Dupuytren and Breschet.
This last named practitioner after  having procured a  model in wax byM.
Dupont, placed it in the Anatomical Museum of the Faculty of Medicine; the
dissection  and the preparation were made by M. Laillard, assistant at the
Hotel-Dieu.                                       .     P              \
   The tumor  was thirty-two inches in its greatest circumference.   Viewed
exteriorly, the amputated limb presented an enormous  tumefaction formed
by the extraordinary development of the superior extremity of the tibia.  The
patella concealed in  the thickness of the engorged and indurated tissues, was
of natural size, and just  below it commenced the  tumor proper, which pre-
sented anteriorly in its most prominent part, one or two softened points where 
CLINICAL SURGERY.                        315
  the bony tissue which appeared to form a casing, allowed the pulsations pro-
  duced by enlarged vessels to be plainly distinguished.  The limb in its  two
  lower thirds was healthy.  Although the adipose tissue  was more abundant
  than ordinary, the part above the knee is in the same condition; the prominent
  and softened points, of which we have spoken, had  become flabby and pre-
  sented manifest fluctuation after the diseased limb was removed.
    The skin very much stretched, attenuated and shining, presented here  and
  there bluish streaks.  It appeared about to give way anteriorly;  it was sepa-
  rated posteriorly from the subjacent parts of fatty tissue very abundant  and
  somewhat infiltrated.  There was sudden transition from the diseased  to the
  sound condition at the line where the tumor terminated interiorly.
    The cellular.tissue was in small quantity anteriorly, where the tumor was
  composed principally of bone.   No fat was found  in  this place,  but  behind,
  between  the  skin, and the gemini and  ham string muscles, a  layer of fat
  white, semi-fluid, and of some  thickness was observed.
    The muscles of the thigh, to the extent  of  one  fourth their length having
 been  removed, were natural, not having undergone any alteration, either in
 color or firmness; they were surrounded by a large quantity of cellular fatty
 tissue of a yellow color; the gemini muscles were palid, soft and  attenuated;
 those  of the other portions of the leg presented the same change.
   The popliteal artery possessed its ordinary volume, but it was ossified in
 several places, immediately behind the articulation of  the femur and tibia; it
 was flattened by pressure upon  it.   The articular arteries were not augmented
 beyond the usual size, they rather appeared diminished.  Although the injec-
 tion was thrown into these vessels carefully, it was observed that the branches
 which penetrated the joint from behind, were peculiarly small; among these
 were noticed the superior and middle articular.  The anterior tibial  artery,
 on the contrary, was very large, as also all those vessels supplying the superior
 part of the tibia ; further down they re-assumed their natural state, and did
 not present any remarkable features..
   The veinous circulation of the limb was much increased, the deep-seated
 veins were double their usual size;. the lesser saphena was equal to the  little
 linger, and very tortuous; it did not, however, possess those nodosities which
 are peculiar  to varicose veins; the veins seemed only augmented  in bulk,
 without being in a morbid condition.  Large  branches which in the  healthy
 state are minute ramifications, penetrated into the tumor, enveloped it by their
 connections,  and finally were collected into one common trunk, on the inside
 of the knee.
   The great sciatic nerve was healthy as far as the joint, and enclosed in its
 middle a tolerable sized branch of the ischiatic artery.  This nerve was larger
 than common.  At the point of its bifurcation, the neurilema was separated by
 infiltration into the surrounding cellular membrane, which appeared to con-
 stitute a portion of it, and which was separated with difficulty from the  ner-
 vous substance already commencing to undergo the lardaceous degeneration.
  The lateral  ligaments, exceedingly reduced in thickness, were converted
 into membranes.   They projected unequally at different points, and a com-
 mencing state of carcinomatous degeneration was remarked within the joint,
upon the inner surface of the  tibia.  The capsular ligament containing the
fluid effused into the joint, projected posteriorly so as to form a small tumor; 
316
LECTURES ON
its  fibres were  separated  from each other to admit the numerous arterial
branches, and from its tension and shining appearance resembled a serous
sack.  The ligaments throughout the rest of their extent, intimately blended
with the diseased cellular tissue formed the irregular nipple-like projections
which ordinarily distinguish white tumors.
  The lower extremity of  the femur retained its natural volume, but its sub-
stance was exceedingly  softened and readily yielded to the scalpel.  A per-
pendicular section  in the direction of the axis of this bone, exhibited a very
advanced stage of softening both in it and also in the patella, but there existed
no augmentation in bulk.
  The tibia was enormously enlarged, and distended at the part which forms
the articulating surfaces.   Cut perpendicularly through, the whole interior of
the tumor was displayed.   It was found to consist of  cells separated bv par-
titions,  resembling the  pomegranate;  the anterior cell was the largest and
contained a substance resembling gelatine; its sides were lined with avascular
net-work highly organized. Some of the cells contained the same substance,
others a yellowish matter, dark colored at certain points, and  appeared to be
the result  of putrefactive  agency, or of carcinomatous degeneration carried
to its extreme limit.
  Upon the membrane which lined some of these cells, there were seen vas-
cular web-like expansions, which had been distended by the injection thrown
into the arteries.  This injection was also diffused through some of the lacunae
or larger cavities.  Lastly, others were filled with albuminous layers formed
by  coagulated blood, as is witnessed  in old aneurismal tumors.  The carti-
lages almost unaffected, were simply  loosened from the bony surfaces, and
rendered movable.
  This case is worthy of close examination, on account of the application of
a ligature upon the femoral artery, of the consecutive hemorrhagies which up
to the twenty second day after the operation, of the disappearance  of the
tumor, and of the long interval which elapsed before its re-appearance.
  Case  IV. T...., twenty two years of age, of delicate constitution,but
not having suffered from any disease, except a scrofulous tendency during his
infancy, experienced in the month of  December, 1834, a crackling sensation
in the  right knee, when making an effort to save himself from falling.  Since
that period he has suffered  at remote intervals more or less pain, but to which
little attention was paid.
  In tne month  of September, 1835, he met with the  same mishap, and the
knee immediately became exceedingly swollen.  Forty leeches were applied,
the swelling increased, and the pain was exceedingly severe.  The patient now
made use  of various remedies, and successively employed  unguents, electri-
city,  and  a seton; but all ineffectually.  The affection continued to advance,
and locomotion was completely impeded.  The patient entered the Hotel-Dieu
during  the month of March 1820, and was in the following state.  A tumor
existed upon the  external side of the right knee, nearly as large as the fist,
the skin over it being unchanged ; pulsations were perceptible in it synchron-
ous  with those  of  the arteries.  These pulsations ceased when the popliteal
artery was compressed.  The leg was  half flexed upon the thigh, and motion
produced great  uneasiness.   M. Dupuytren  having examined the patient,
gave it as his opinion that he was  laboring under an erectile tumor at the head 
CLINICAL SURGERY.
317
of the tibia, with degeneration  of the tissues  (fungus haematodes), which
induced him to reject all idea of tying the femoral artery, and to prefer ampu-
tating above the  knee.   The man refused to submit to the operation, and
returned home, where he remained a month.  During this period, the seton
was  continued, but the disease continued on the increase.  A surgeon made
an incision into  the tumor,  from which a flow of  blood  occurred.   The
patient  again entered the hospital upon the 3rd of May; he had then deter-
mined  to permit the operation, but as the cutting instruments were a cause of
apprehension, he had screwed himself up to a degree of courage which he did
not in reality possess.  The tumor still presented the same characters as upon
his first entrance into the hospital, except that its volume was greater, and its
pulsations less  evident.  As  to  his general condition, the patient  was ema-
ciated and pale; the chest sounded well upon percussion ; there was no pain in
the abdomen, no diarrhoea or constipation, but his mental condition was that of
a timid  man who affects determination.
  On the 5th of May, M. Dupuytren practised amputation upon the thigh, in
the ordinary way.   Fifteen  ligatures were applied,  and the edges of the
wound were immediately brought together.  During the day, no occurrence
took  place,  the pulse of the patient was only slightly augmented in frequency
and  his skin became somewhat  hotter towards  evening.   (Infusion of the
flowers of tilia  and orange leaves and anodyne.)
  May 6th. The patient has slept little, but makes no complaint, his mouth is
dry,  teeth a little fuliginous, skin warm, pulse feeble and frequent.
  May 7th. Same as last evening; profuse perspiration; he affects that he is
well; the dressings are a little bloody.  (Emollients, water of mallows.;
  May  8th. Little sleep; has had chills during the night;  profuse perspira-
tion ; face somewhat excited,  pulse frequent and  weak; tongue and teeth
darkly coated ; no pain ; continued all day in the same state, but at four, P.
M. was  seized  with nausea, vomiting and prostration ; the dressings are satu-
rated with blood; the face is pale, and the nose cold.  The man was encour-
aged to bear up,  and the dressings  were removed; the blood was found to
issue in a stream, and its loss estimated at about two bowls-full.  The attend-
ant not being able to seize the vessels which  poured forth the blood, applied
pledgets of lint, covered with rosin.
  The patient continued  weak.  M. Sanson saw him in the  evening and pre-
scribed  six grains  of  the sulphate of quinine in two doses, which the patient
couid not retain, but threw up from his stomach.  At nine o'clock, the  hem-
orrhage had  not reappeared, the exhaustion was the same  (broth, a draught
with syrup of quinine and sulphuric ether).  No change for the bettter ensued
and at three o'clock  in the morning of the 9th of May the man died.
  Autopsy—twenty-eight hours after death.   Examination of the Stump.—
The  bone had been divided four inches and a half above the condyles, the skin
and muscles are of a blackish gray color;  the  bone  is denuded to  the extent
of four  lines, all the ligatures are still on the  vessels, the femoral vessels are
of a dark  appearance; the clot of blood  in  the femoral artery commences
beyond the blackened portion, which seems to  be in  a state of putrefaction;
the clot itself is several lines in extent, and appears to be but slighly adherent;
it is  red and appears of more recent formation than those in the other vessels 
318
LECTURES ON
 of the stump.  The nervous and circulatory system, gave no indications of
 diseased  action; nor was any disorder of the digestive and genito-urinary
 apparatus evident upon inspection.  In general all the organs were pallid and
 devoid of blood.  The tumor was placed in  the possession of the faculty of
 medicine to be injected and examined by M. Breschet.
   Examination of the  Joint.—The tumor was less bulky  than  before the
 operation; it had collapsed at the point which  had been the  most prominent
 during life;  compression by the  fingers, met with  some resistance, more in
 some places than in  others, and by increasing the pressure,  the part yielded
 with a crackling sensation.  As the tumor had been  laid open lengthwise to
 exhibit its nature to the  clinical  pupils, it was plain that interiorly it was
 formed of envelopes, strictly fibrous  at  some points, fibro-cartilaginous at
 others, and lastly, cartilaginous throughout a large extent of its circumference.
 Its superior  portion  was solely cartilaginous; the  fibro-cartilaginous tissue
 tumefied and  softened, indicated the part in which the articulation commenced
 to assume disease; the lateral ligaments were swollen, soft, and at points,
 especially on  their internal surfaces, were in a state of scirrhus or of carcino-
 matous degeneration.  The popliteal artery and its divisions were natural,
 except that their caliber was enlarged.  The  division of the  tumor did not
 permit the operation  of a regular injection, that is to say, with a colored sub-
 stance which would  become solid, it  is  therefore not attempted, but water
 was thrown into the artery, and penetrated into the tissue of the tumor, where
 it appeared by a multitude of orifices;  none came out exteriorly.   This de-
 monstrated that the arterial system of the leg was healthy beyond the affected
 osseous tissue.  An  attentive  examination of  the  immediate tissue of the
 tumor demonstrated,  that it was filled with blood in the portions which had
 been composed of cellular substance, that this blood was collected in concen-
 tric layers, which formed the parietes not of a single cell, but of an infinitude
 comparable to those of a honey comb, but  of larger size.   The exterior layers-
 were less colored, and firmer than  the  central ones, which  had the color and
 consistence of a simple coagulum.  The pure water thrown in penetrated
 into these cells, and clearly evinced that they were  connected with as many
 distinct arteries.  The alteration of the arteries consequently existed less in
 the exterior branches, than in the ramifications which penetrated the bones and
 were distributed throughout their substance.
   The subject of which we treat, is not one of those which can be thoroughly
 understood by one or two observations; the difficulty of diagnosis, the respon-
 sibility of the prognosis, make  us  sensible of the necessity of facts; we are
 therefore contributing our quota in citing the following observation.
   Case V.—L___, aged 33 years, linen  weaver, entered the Hotel-Dieu, on
 the 5th of July, 1825, to be treated for an affection upon the dorsum pedis.
 This woman,  of sanguine temperament and robust constitution, had made a
false step a few months previous  to her entrance, in consequence of which
the foot was  thrown  forcibly backwards, and  the whole weight of the  body
brought to bear upon the toes; she then perceived a crackling sensation in this
part, and  experienced excessive pain.   The foot become rapidly swollen, red
and  painful; leeches  were applied and  the resolvents, but perfect rest of the
part was not adhered to. 
CLINICAL SURGERY.
319
   Three days after the accident, a tumor appeared, corresponding  to the
 second toe; it was according to the report of the patient, both movable and
 pulsatile, and continued progressively to augment during five months.   Before
 coming to the Hotel-Dieu, this woman had consulted several surgeons, and all
 of them were of opinion that the disease was an aneurism.   A large number
 of leeches were applied, thirty or forty, to the tumor itself, and at each appli-
 cation, the pulsations and the pain were diminished, re-appearing however in
 two or three days.  Emollients as well as resolvents were as unsatisfactorily
 employed.  When the patient was examined, the tumor was found  upon the
 back of the foot over the second and third metatarsal bones; it extended laterally
 from the first to the fourth metatarsal bones, and longitudinally from  within
 an inch of the ankle joint to the toes, it projected forwards an inch in  height,
 and was adherent by its  base, without increased warmth, redness or altera-
 tion of the skin.  Upon the first inspection, it was supposed  that the tumor
 was of a strumous character, and the patient was questioned, to  ascertain  if
 she had suffered from the venereal disease, but she stated that she had expe-
 rienced nothing of the kind.  Upon making still further investigation, the tumor
 evinced pulsatile movement, which were deep seated and obscure, but  still
 perceptible.   M. Dupuytren at first thought  that the  movement was only  in
 the course of the anterior tibial  artery, and that the tumor was  an abscess  to
 which this vessel imparted the sensation of pulsation.  Some of those present
 thought that it was more likely  to be aneurismal or fungoid in its nature.   In
 short, evident pulsation was discoverable, as is the case of aneurism, and through-
 out its whole extent, the artery displaced and  thrust towards the internal
 side of the tumor, permitted its  pulsation to be felt, distinct from those  of the
 tumor, itself.   Upon laying the  hand over the whole surface, it was raised up
 by the expansile motion which was synchronous with  that of the pulse, and
 ceased totally when the artery  was compressed.  The patient complained of
 very  acute  pain, which disturbed her rest, but her general health did not
 appear to have been impaired in consequence.
  Examined again by M. Dupuytren;  the diagnosis was less clear and easy
 to establish ; he wavered between an abscess and an aneurism.  A change  in
 the relative  situation of the artery and tumor, had no influence upon the  pul-
 sations of the latter,  thereby augmenting the uncertainty and leading  him  to
 suppose that it was an aneurism.  M. Dupuytren brought the  man  into the
 amphitheatre, and stated that he would make an explorative puncture,  which
 would not interfere with the tying of the vessel if it was the seat of an aneu-
 rismal disease. With this design the preparatory arrangements were  made, as
 well as those necessary for amputation if it should be deemed advisable; the
 affection having its location in the bony structure, and being one designated by
 the term fungus haematodes.
  Compression upon the crural  artery being made, a bistoury was thrust into
 the centre of the tumor, and a small quantity of dark colored blood oozed out,
 without any jet; the pressure upon the artery was then relaxed, but  the flow
 of blood became neither more rapid nor more abundant.  The incision was next
increased by means of the blunt bistoury, and a soft fleshy reticulated bleed-
ing tissue was recognized, the partial removal of which was attempted both by
the fingers and by the forceps, but portions only could be extracted, and  it 
320
LECTURES ON
was found to be analagous in structure to the corpus cavernosum of the penis,
or perhaps more like the substance of the placenta.  At this stage, M. Dupuy-
tren  recognized the  character of the disease, and  decided to remove the
portion of the foot affected, which was done according to the method of Cho-
part.
   Half an hour after the operation, the dressings were applied;  the flaps were
brought together and maintained in contact by three strips of adhesive plaster;
and the ligatures were placed atthe superior angle of the wound  ; nountoward
circumstance occurred ; cicatrization commenced upon the sixth day, but was
not completed until the sixth week, at wliich time the patient left the Hotel-
Dieu, after being provided with a  boot which  concealed the  deformity and
facilitated her walking.
   The portion which had been  removed  was examined with care, and  it was
ascertained that in the place of the second metatarsal bone there existed a
carcinomatous substance, whilst in places here and there, the remains of bony
substance were plainly felt by the fingers.   These fragments of osseous mat-
ter were more numerous towards the  inferior extremity of  the  bone, and the
articulating surface and the cartilage were in a sound condition.   Poste-
riorly the disease had attacked the first, second,  and third metatarsal bones
simultaneously; besides, having  invaded their surfaces articulating with the
cuneiform bones, and at this point, the affection consisted of a softening of the
spongy  or cellular tissue, causing a diminution of it.  This diminution was
carried  so far as regarded the first metatarsal  bone,  that a true anfractious
cavity existed large enough  to  contain  a walnut, closed behind  by a  simple
osseous  lamella,  to all appearance healthy, and supporting  the arthroidal
cartilage unchanged.  The  posterior  extremity of the third was likewise hol-
low, presenting a cavity of  a similar  character; the internal  surface being
covered  with  grumous  blood.    The  first cuneiform  bone  was  partially
destroyed, it was  softened and  rarefied (if this word  can be employed), and its
spongy  substance resembled the vascular tissue of the spleen, which by wash-
ing the fibrous reticulated  structure is all that remains. The second cuneiform
bone was less diseased, and the third still less so;  their change of structure,
however, resembled that of the first.
   Fungus haematodes, to  which has been given a host of names,  as spongoid
inflammation, medullary sarcoma, bloody sarcinoma, and  vascular sarcoma,
is a disease of a very serious character, on account of the elements which enter
into its  composition.   Tying the principal trunk  of its arterial  supply may be
efficacious, when the cancerous matter does not predominate and prevent the
rapid progress of the  disease towards complete degeneration ; it is not, how-
ever,  to be compared with extirpation.   Entire removal is  then the only
definite chance of success in the treatment of fungus haematodes.   Sometimes
the affection will  be  reproduced, although every trace  of  diseased structure
has been cut away, leaving nothing of suspicious character  connected with the
wound.  From this tendency to reproduction, it must be admitted that there
exists an internal cause.  It should not be forgotten in practising the operation,
that  the smallest portion still left remaining may renew the  disease.  An
English surgeon having performed amputation for a similar disease, perceived
a slight extension of the  affection into the parts from which the stump was 
CLINICAL SURGERY.
321
formed this he supposed would be removed by inflammation and suppuration.
His  error was  fatal to his patient, for the tumor reappearing, his endeavors
to eradicate it were fruitless.  The thigh was removed, but it was in vain ;  the
patient died of exhaustion some time afterwards.  Let us not omit,  in bring-
ing this lecture to a close, to remark that carcinoma of the eye or elsewhere,
in which the neighboring veins have been much dilated, and also a great num-
ber of bloody collections have been mistaken for fungus haematodes, but these
tumors have not the most remote  analogy to it,  except by the flow of blood
when they spontaneously discharge or are cut into.   There exists among them
not only difference of species, but also difference as regards their nature.
                      C H A P T E R X X X I X .

                              ON  HARE-LIP.

  There are two important points as yet undecided in the operation  for hare-
lip, generally so simple;  namely the proper time for its performance, and the
treatment applicable to a complication hitherto but little noticed.
  Various opinions exist as regards the first question.   Many have thought
it most advisable to wait until the child was able to appreciate  the deformity.
They relied  on  the  greater thickness of  the lips and the strength of tissue
necessary to support the suture.   Some  surgeons have  preferred waiting
until the end of the third year, except in cases in which the child was prevented
from sucking.  The tissues, say they, having become more solid, without losing
any of their extensibility, can better resist the needles; and at that period, the
child having more reason  submits with more docility to the precautions neces-
sary to the success of the operation.
  Others have  thought it proper to operate on  children immediately after
birth, because  the lips being furnished with blood-vessels, of  which a great
part soon disappear,  heal, at that period of life, more promptly.   Besides
children then  are more  passive, and  have not as yet acquired the habit of
sucking.  But  the operation is not certain so soon after birth, because the
flesh  is too  soft and easily divisible by the needles, and because the general
mortality, independently of any particular reason, is greater at that period of
life than at any other, and it would be imprudent to increase the chances of
death.  Such are the objections, are they counterbalanced by the advantages:
It would undoubtedly be important to  operate so early, in order to give the
^hiltl the faculty of sucking; but this very inclination  to suck, is one of the
most  powerful  opponents of the  success of the operation.  Could this be
avoided, the operation at birth would have a powerful  argument in  its favor ;
but the child sucks  instinctively, even before having taken the breast: the
obstacle is therefore as powerful then as at a later period.
  That, however, is by no means  the least favorable period for the operation:
and I cannot understand why so many writers have preferred the age of  four
or five  years,  alleging  that the child  being reasonable enough to feel the
necessity, and  foresee the success, will submit to the operation with more
           41 
522
LECTURES ON
courage.  Experience must have undeceived  them.  At that age, children
have just sense sufficient to feel and remember the pain, without  reason  to
support  it; they, therefore, endeavor to avoid  it as much as possible, and do
all they can to frustrate the operation.
   At a later period, reason and courage are indeed more developed ; but if
the  bones be implicated, their  increased  solidity gives less hope of success.
In all cases, it is preferable to operate early; the deformity is less, and even
that proceeding from  the separation of the bones disappears.  Therefore, 1
think the most suitable time is at the age of three months, life is  then more
firmly established,  and the chances  of death  less  than at  birth;  the infant
feels the pain, but forgets it immediately, and does not oppose the success of
the operation.
   There is another point in the operation  for hare-lip, to which I would call
your attention.  When  there is a middle tubercle projecting, with two well
defined lateral  divisions, either  the  bony portion supporting is  removed, or
we endeavor to restore it to its place.
   If the median tubercle project in front, we must observe where it is inserted
into the septum nasi, as  on this  frequently depend  the degree of  projection
and the treatment.   When this insertion is near the point of the nose, and the
lateral portions  of the lip are  attached to the  tubercle, the latter is drawn
backward; the point of the nose follows  the  movement; the alae are sepa-
rated, and the nose becomes flattened, resembling more the snout of an animal
than any thing else-   What is the consequence of its insertion precisely into
the  end of the  nose ?  Now this occurrence  overlooked by writers is not
uncommon.  In such  a  case, struck by the deformity which  would ensue, I
adopted  the following plan : The fleshy tubercle was separated from its bony
attachment, the latter removed by the forceps ;  the edges of the fleshy portion
having been pared, it  was raised horizontally  backwards, and used  to form
the septum, or a portion of the inferior septum of the nostrils.   Then whether
we wait for reunion, or complete the operation, the hare-lip is reduced to its
greatest  simplicity, and the operation performed in  the ordinary manner; a
bandage is sufficient to keep the tubercle in place.
   It is only when the labial tubercle is  inserted near the bony nasal spine,
that it ought to be preserved as an integral part  of the lip.  In this case I re-
move a portion of the  subjacent osseous tubercle.  M.Malgaigne in an article
published by him in the Medical Gazette, thinks that this  plan  is liable to
objections.  The most serious, according  to  him, is the removal of the germ
of two, three, or even the four incisors.  We shall  see what  foundation this
remark has.   The  operation, indeed, is not always  free from danger, as may
be judged by the following case :
   Case I.—Double Hare-Lip.  Excision of the  Bony Tubercle. Haemorrhage.
Death.—In the early part of August, a child was admitted into the Hotel-Dieu
with a double hare-lip.  On the right side the  separation involved the whole
lip, the palatine vault  and velum palati; on  the left  side, it did not  extend
so far.  The middle tubercle was inserted  pretty near  the nasal spine, so that
it was thought possible to make use of it in perfecting  the lip.   It was, there-
fore, separated  from the  bony tubercle, and  the latter excised by means of
scissors; it contained the germ  of   two  incisors;  the rest of the operation
was put off to another day.   A little blood was lost at fi; st, the haemorrhage 
CLINICAL SURGERY.                        323
then appeared to cease, but the attempt to suck brought on a recurrence, and
it was cauterized.  The blood which had been swallowed was partly discharged
by stool, and on the day fixed  for the operation, the child being too weak, it
was  deferred.  The debility increased: the median tubercle became gangre-
nous, and the  child perished; an examination was not permitted.  Many cir-
cumstances, amongst which  may be  noticed the great loss of blood, and  its
stay in  the alimentary canal, tended to destroy the life of the patient; but
this  event is  very rare.   Blood is never digested.  If not discharged  by
vomiting, it becomes disorganized, is an irritant, and gives rise to pain and
diarrhoea.   Hence its  expulsion should  be assisted  by purgative  enemata.
The flow of blood  into the mouth causes also  a movement of suction, which
becomes habitual to children, and which may destroy the cicatrix should any
exist.
  Case II,—Double Hare-Lip.  Labial Tubercle inserted into  the End  of
the Nose: Operation perfectly successful.—L. R..., 14 years  of age, was
admitted into the Hotel-Dieu in October.  She had a very complicated  con-
genital  double hare-lip.  Indeed the middle  bony tubercle  formed by the
incisors projected more than six lines beyond the place of the upper maxilla;
of the four incisors which it supported, the two middle ones, very large, and
directed downwards, inclined  forward on their outer edges, so that the junc-
tion of the inner edges formed an angle above; in front of the bony tubercle
was a fleshy tubercle, nearly circular, arising immediately from the end of the
nose, from which it was separated by a groove scarcely perceptible.  Without
this median portion, the nostrils communicated with each other, and  by means
of two large divisions with the opening in the lip.  Behind these two divisions
terminated in a single one, separating throughout its whole length the velum
palati and  the uvula;  so that externally there was a horrible deformity, and
internally a complete communication between the nasal fossae and the buccal
cavity.   On the 5th of October the operation  was performed in the following
manner: the patient being seated, her head thrown back and firmly supported on
the breast of an assistant, I divided  the  mucous  fold uniting the cutaneous
to the bony tubercle, and then with very sharp bone forceps removed as much
of the latter as projected beyond the anterior plane of the upper maxilla.
This stage of the operation being finished, I pared the lateral and lower edges
of the internal tubercle, as also the vertical edges of each lateral portion  of
the lip.   A needle was then introduced at about the distance of a  line from
the pared edge of the left side of the  lip, very near its free edge, directed from
below upwards and from without inwards, comprising one half of the thickness
of the soft parts, and then made to traverse obliquely the other side in a con-
trary direction.  This  proceeding was intended to assist in the formation of a
median  projection of the lip.   The  second needle  was placed  about a line
and a half above the first.  The third, longer  than  the others, was destined
for a more complicated business.  I began by folding the cutaneous tubercle,
bleeding every where except at  its root and external surface, and applied it
to the bony septum of  the nostrils, so that  its  outer surface became inferior,
in order thus to form on all sides a sub-septum  to the nostrils.  This needle,
therefore, comprised at once the upper extremity of each portion of the lip,
and  the  free extremity of this  folded tubercle; lastly, two  stitches of the
interrupted suture united e^ch angle  of this flap to  the labial portions.   The 
324
LECTURES  on
ligatures were applied to the needles in the ordinary manner, over them adhe-
sive straps, the whole being covered  by a  bandage, which, at the same time
that it compressed the cheeks and tended to bring them forward, bore some-
 vhat upon the nose, in order to avoid the dragging of the flap.
  The patient was carried to bed, ordered a very strict diet, and diluent
drinks.   The  first days were free  from pain.   On the 8th of October pain
:ame on, slight at first, but soon almost insupportable.  On the night of the
Jlh some bleeding took place, for which nothing was done, owing to my deten-
tion at home from  sickness.
  The bleeding ceased spontaneously,  the pain seemed a  little  abated,  it
returned  with haemorrhage  on the  following night.  The  next morning I
removed the external bandage.  There was no indication of derangement of the
two halves of  the lip, the needles were not disturbed.  The flap of the sub-
septum was of a blackish grey color, exhaling a fetid sanies, and giving rise
to the fear of gangrene. It  was washed with  wine.  A semicircular piece
removed from  the upper adhesive strap, of  which the edge pressed too much
on the base of the flap, and the bandage reapplied.  Four days  afterwards
the dressing was again  removed, the flap had  assumed a red color, and cica-
trization was going on.
  On the 26th it was nearly complete; but the nasal sub-septum appearing too
large, it  was diminished a few days after, by means of a bistoury and forcep>.
A tent was introduced into  each  nostril  in order to keep them dilated, and
the last  incisions  being healed, the operation was  perfectly successful, and
her face, formerly horribly deformed, was now quite passable.
  The first part of the operation  was intended to remedy the external division.
We will now endeavor to overcome the separation of the maxillary bones by ;i
bandage similar  to that  used  in hernia, and terminating in two pads.  But,
it will be asked, is this approximation possible?  Yes, for  the separation in
young subjects is caused by muscular action alone, and this bandage tends to
overcome that action.
   On the 19th of December the girl was doing very well, the re-entering angle of
the upper lip had considerably diminished, and presented only a slight irregu-
 larity.   She  stated  that she  could  perceive with her tongue some approxi-
 mation of the bones, especially in front.  From this  improvement there i>
good  reason for hoping that perseverance in the pressure will, in a few months,
effect, if not a complete cure, at least a very remarkable improvement.  The
pads should be applied below the  cheek bones upon the deep seated part of the
 naxilla.  There is here an adipose cellular tissue which prevents pain, and if
the bandage does not press so immediately,  it is more easily kept in place.  It
 bears partly on the alveo-dental arch, and partly on some joints of the maxil-
 lary bone.
   Three months after the operation, the girl was  again brought to the hospital.
 The approximation had increased during  that time, by a line and a half, her
 voice had still  a nasal sound, but she  performed perfectly the motions of
 suction and prehension.  The halves, of the palatine vaults had begun to touch
 each  other, and it was expected that the reunion would be  complete.  In six
 months she will again return.
   How can'we conceive the  production of such a state  of things?  It  has
 been  explained recently by supposing a cessation of development.   According 
CLINICAL SURGERY.
325
to this idea the upper lip was originally formed of three distinct portions which
should have united at a more advanced stage of intra-uterine life.   What adds
weight to this opinion is, that the middle portion of the upper maxillary bones,
which ordinarily supports the middle labial tubercle, presents, even in adult
age, marks of separation from the bone to which it adheres, and on this account
has received  from some anatomists the name of inter-maxillary bone.  Such
indeed was my opinion, but distinguished men who have made osteogeny their
peculiar study assure me that they have never found this inter-maxillary bone,
and much less the middle part of the lip, separated from the lateral portions,
bony  or fleshy; and I must confess that I now have strong doubts as to what
I once believed, and thought I  had seen myself.
                         CHAPTER XL.

                              ON ANTHRAX.

  Carbuncle is merely the inflammation of several clusters of cellular tissue
contained in the areolae of the chorion.   In order to understand the mecha-
nism of its formation, it will be proper to say a few words concerning the struc-
ture of this portion of  the skin; it is thick, white, elastic, more dense on its
external than on its iuternal  surface, composed of fibres which, by their inter-
weaving, form areolae placed irregularly side by side.  Each areola is filled by
a portion of cellular tissue, which sometimes being impregnated by a quantity
of adipose fluid distends the cell containing it.  The numerous areolae of the
dermis have all a nearly conical form.  The apex is directed towards the rete
mucosum, and the base towards  the  internal  surface of the skin, which rests
entirely on a layer of cellular tissue.  These  areolae  do not terminate in a
cul-de-sac *at  the  external surface of the fibrous part of the skin,  but by an
infinity of small foramina, having an  oblique direction, and very apparent
after maceration for some time.
  The definition just given of anthrax, shows  that it differs from furunculas
merely in extent,  and the  multiplicity  of clusters of cellular  tissue which
Decome inflamed at the same time.
  Like furunculus, it occurs in  those parts of the  body in which the skin is
thickest, and the cellular membrane most abundant and developed.   It most
frequently attacks the nape  of the neck, shoulders, dorsal region, parietes of
the thorax, and the thighs.
  Anthrax cannot be mistaken for furunculus, as it is always larger than  the
latter.  Furunculus, seldom solitary, opens only at its apex; the skin covering
it is of a light red color.  Anthrax, on the  contrary, is of a livid hue, almost
always solitary, and presents several small openings over its surface.
  Anthrax has been confounded with bubo and  malignant pustule, varieties
of a disease essentially gangrenous; in anthrax on the contrary, gangrene h
a consequence  of strangulation.  The  latter  is  never contagious, the former
are.  Incision  cures  the latter, the former  generally  requires the actual
cautery  or  caustics.   One  is seated  in  the  cellular tissue of the chorion, 
326
LECTURES ON
  the other in the rete mucosum, or the subcutaneous cellular tissue.  An-
  thrax is  not necessarily attended  by an adynamic  or  ataxic state of the
  system.  Malignant pustule and bubo are always  preceded or accompanied
  in some of their stages,  by one or Other of these conditions.
    Prognosis.—This depends on its situation, size, date,  existence, degree
  of inflammation, and the general state of the patient.  When on the nape of
  the neck or back it is  more serious, castaris paribus, than when under the
  clavicle or on the chest.   It is still  more serious if very large, and if it have
  existed for twelve or fifteen days, if gangrene have supervened, or  there be
  acute  inflammation, and if the patient  be debilitated by  previous disease, or
  from any other cause.-
    From a knowledge of the nature of anthrax, its  treatment can easily be
  deduced.  Like  that of all  inflammations with strangulation, it  consists in
  the use  of incisions, which should  extend the whole depth of the carbuncle
  and somewhat beyond the limits of the disease.
    If the tumor is very large, an incision must be made in the length of each
  flap.   This plan puts an immediate end to the strangulation and pain.  By
  pressure a viscous pus is discharged.   A good deal of blood is lost, which
  acts as a topical  remedy and contributes greatly to reduce the inflammation.
  The whole tumor should be covered with an emollient poultice.  The  patient
  is  put on the use of bitter infusions and laxatives.   Should it be on the back,
  the patient  must not lie supine, for gangrene will  then occur in spite of the
  incision.
    Case I.—A man was admitted into this hospital in 1812, having on his back
 a carbuncle  of the size of a hen's egg.   I made an incision into it, dividing
 it  into two parts.   On the upper portion another was made,  perpendicular to
 the former.   An emollient poultice was  applied.   The next day the inflam-
 mation had  disappeared  from the upper portion, but the lower was hard and
 much larger than on  the preceding evening, and the man complained of pain
 in  that part  alone.  An incision was made into it, and all  the  bad symptoms
 vanished.
   Every carbuncle, left to itself, terminates in gangrene,  from which neces-
 sarily results an ulcer, which has an extent proportionate to  the parts deprived
 of  life.  If the edges are hard and elevated, emollients should be used; and
 when they are depressed, they  should  be brought together  by means of
 adhesive plaisters, and dressed with simple  cerate or  dry  charpie, or with
 different remedial agents according to the degree of excitement; the skin is
 generally separated.  If it be thick and  adherent  to a certain quantity of
 cellular tissue, the reunion is almost always effected.  If,  on the contrary.it
 be  thin, deprived  of  adipose  tissue on its internal surface, we generally are
 obliged  to remove it,  after having uselessly attempted  its reunion :  a  simple
 dressing is then applied, and the patient ordered to use  bitters and mild laxa-
 tives; the  aponeuroses and  muscles are sometimes  destroyed, but these cir-
 cumstances do not alter the mode of treatment.  When  the  ulcer is very
 large and suppuration copious, tonics frequently become requisite.
  Case II.—T. B., Cceur de Roy, 49 years of  age, of good constitution, had
 for  two or three  months  pain between the shoulders, when on the 24th of
January 1813 a small  pimple appeared ; his health had however suffered no
change.  The pjmple  increased rapidly, and in less  than twenty-four  hours 
CLINICAL  SURGERY.
327
 an enormous inflammatory carbuncle made its appearance.  It is worthy of
 remark that the patient saw but little with the right eye, and that  immedi-
 ately after the appearance of the carbuncle his sight was restored.   For four
 days he suffered acute pain, the tumor then opened at several points, portions
 of cellular tissue were discharged, and on  the 7th of February the skin was
 entirely destroyed.  On the 15th of  the same month he entered the Hotel-
 Dieu, with an ulcer four  or five inches in diameter, and complete separation
 of the skin around its whole circumference.  The edges of the wound were
 brought together by adhesive strips, a simple dressing applied, takin°- care to
 exercise a slight compression  on the edges of the ulcer, which soon united.
 The patient left on the  5th of April, not entirely cured, although he had
 reached the 70th day of the disease.
   We will terminate this article by the observation that we must continue at
each dressing, and until the perfect discharge of all the slough, the pressure
intended to assist the expulsion of the fragments of the gangrenous cellular
tissue.
                          CHAPTER  XLI.

                     ON BLENNORRHAGIC OPHTHALMIA.

           On Corneal Specks, and Inflammation of the Retina.

   Scarcely a week passes without the  admission into our  wards, of indivi-
duals  affected with venereal ophthalmia.   This serious  disease generally
results from direct inoculation by means of the finger carried to the eye, after
being soiled by the mucus of  the urethra.  In some cases, however,it follows
a sudden suppression of an urethral discharge, especially when the  cause of
this suppression is of a nature to irritate the conjunction,  as  a sudden cold
for example.  M. Boyer thinks this disease is very rare among females.  This
I believe to be erroneous; in hospitals devoted to the treatment  of  syphilis,
this ophthalmia is found to be  more frequent among women than men -T the
wards of the Hotel-Dieu furnish a similar result.
   This disease, always alarming, demands on the part of the practitioner a
constant attention and vigorous treatment.   I  have seen  the inflammation
destroy and empty the ball of the eye in seven or eight days.  A  child at this
moment (April 1833) in the ward, has lost its sight on account of this disease.
The  mother was infected with venereal, the ophthalmio remained without
treatment for a long  time, and her sight was nearly destroyed  when she came
to the hospital.  It has been generally said that when this ophthalmia results
from the suppression of an urethral blennorrhagia, both eyes are equally liable
to it,  whilst direct inoculation affects only one.  My observation  has  not
confirmed this idea,  as in the majority of the cases under my  notice, and
nearly all of which depended on the latter cause, both eyes were diseased.
But be the  cause whatever it may, the  malady demands the most energetic
treatment in order to prevent its fatal termination. 
328
L1CTURES  ON
   Antiphiogistics, such as general and local bleeding, emollient lotions, and
revulsives are generally insufficient.  Without neglecting these means, which
are undoubtedly useful, we should have recourse to a specific and local treat-
ment, for the others are merely accessory.  This treatment consists in blowing
calomel upon the  conjunctiva  of the eye and eyelids by means of a small
tube.
   This is done  once or twice  per  day: and in  addition to this, but only at
night, one or two drops  of laudanum are dropped between the lids.
   Case I.—L......30 years of age, a tradeswoman, small, very fat, enjoying
good health, having menstruated at the  age  of 14 years, had in early life six
children, none of whom she nursed herself; has had leucorrhoea, as  also
gonorrhoea several times.   She states that on the 18th or 20th of January, the
cold air caused her much uneasiness in her eyes, which soon became inflamed.
On the evening of the 20th  the right eye became very painful, as if filled with
sand; she could not sleep,  and the next morning the eyelids were so swollen
that she was unable to open them.  Cataplasms,bath, pediluvium lotion with
infusion  of melilotus ; no  improvement.  On the  22d, a large blister to the
arm:  on the 24th the left eye became similarly affected : the same remedies
were used until the 2d of February, when she was brought to the Hotel-Dieu.
   The eyelids were greatly swollen ; the conjunctiva presented a violet-red
projection very painful, and copiously discharging a green puriform and very
fetid pus :  impossible to discern the cornea.   The  patient sees nothing; both
eves affected with deep lancinating pain: constant ciphalagia, anorexia, fever,
tongue foul.  The  patient had an abundant urethro-vaginal discharge; she
would say nothing as to the origin of her  disease,  but sometimes facts  exist
which are stronger than the answers of the diseased.
   That evening the insufflation of calomel was commenced, a drop of laudanum
dropped into each  eye, the parts well washed with pure water, and the eyes
covered with a bandage fastened to the cap.   She passed a better night.
   By the influence of these remedies, her improvement was rapid, the purulent
discharge lessened, and the pain much less acute.  However, the red projec-
tion formed by the swelling of  the conjunctiva still hides the cornea, so that
it is impossible to say what will be  the result.  The woman had the disease
for ten days before her admission, and I should not be surprised if there were
ulcerations on the  cornea, which might give rise to perforations  causing the
loss of sight.  Two weeks afterwards the left eye recovered its functions.
   Case II.—A woman came to the Hotel-Dieu about a month ago, with gon-
orrheal ophthalmia of the right eye ; both eye-lids were bathed in a greenish
pus, the eye was opened with great difficulty, the conjunctiva red and swollen,
and the pain acute.
   The insufflation of calomel and instillation of laudanum  were commenced
five days after the first appearance of the disease.   A marked improvement
soon took place, and in  three weeks she was perfectly cured.
  Blennorrhagic ophthalmia is frequent among children, in  them called gene-
rally puriform withoutrelation to the  cause.  In newly born infants, it depends
on direct inoculation during parturition; it is always serious and  frequently
followed by the loss of the eye.  The treatment is the same  as in adults, much
care and  perseverance are however required, for the pain gives rise to a spas- 
CLINICAL SURGERY.
329
modic contraction of the orbicularis palpebrarum muscles, and it becomes very
difficult to make the remedies reach the affected parts.
  In modern days, the new ideas concerning syphilis may have thrown some
doubt upon the etiology of venereal ophthalmia.  I believe it contrary to facts
to reject proofs given by authors worthy of credence.  Astruc relates that the
urine of a person laboring under an urethral  discharge, used as  a lotion for
the eyes, gave rise to a very serious purulent ophthalmia.  Merteus giYes the
history of an experiment tried by a physician who had some doubts, but who
was soon convinced of his error.  Chaussier has seen the puriform mucus of
an ophthalmic blennorrhagia produce, by contact with the sound eye, a pre-
cisely similar disease.   Lastly, we have the cases of those unfortunate  medi-
cal students who perished the victims of their zeal for science.
  You have all seen a number of cases of this disease cured in the Hotel-Dieu,
and that  without  any  attempt to restore the urethral discharge.  It must be
however  confessed that too sudden a cessation of the discharge may produce
the ophthalmia, and the best means to preventit is not to arrest the former too
suddenly.   In a majority of cases the two diseases progress simultaneously,
and do not appear to act by mutual revulsion.  These ideas of antagonizing
forces, so beautiful in theory, rarely accord with facts.  Inflammation  of the
skin produces asimilar effect on the mucous membranes.  A serous phlegma-
sia gives rise to the successive development  of one or several phlegmasiae of
the same nature in other serous membranes; and  we are forced  to  believe
that analogous tissues are rather sympathetic than antagonist.
   On Corneal Specks.—For a considerable number of years, I  have been in
the habit of seeing many cases of specks of the cornea, which I have treated
as follows: if there be much irritation, I bleed; if not so much, apply leeches
to the temple ; at the same time giving a mild  purgative every two  or three
days.  A seton is placed in the nape of the neck, and  I generally use one
made of  several strands of cotton thread, preferring it to a riband, inasmuch
as its  size and the consequent irritation can be  increased at pleasure.  To
the above remedies is added the insufflation, repeated morning and  evening,
 of  a pinch of the following powder:
              Prepared Tutty (Oxyd. Zinci, impur. praeparet.)
              Sugar Candy.
              Calomel.   Of each equal parts.
   The patient should neither wash nor wipe the eye after the introduction of
 the powder.
   When there is no disease of the eyelids, no inflammation, nor irritation of
 the conjunctiva, the  insufflation will  generally remove the corneal speck.
 Those which are recent and slight generally disappear in a few weeks.  Those
 of older  date, thicker and larger, are usually removed in a month or six weeks;
 and I have seen specks occupying nearly the whole surface of the cornea,
 and covering the pupil entirely, so as completely to intercept the passage of
 light, removed in a few months.

                      On Inflammation of  the Retina.

   Whilst describing the operation for cataract by depression, I pointed out as
 one of the most frequent and serious consequences of this method the inflam-
             42 
330
LECTURES ON
 mation of the retina, called iritis by those who are more struck with the'
 apparent symptoms than the cause and  true seat of the  disease.  From  this
 affection result long and  obstinate pain in the head, contraction of the pupil,
 dimness of the aqueous  and vitreous  humors, redness of the conjunctiva,
 continual discharge of scalding tears, intolerance of the least degree of light,
 strong contraction of the  orbicular muscles, the formation behind the pupil of
an accidental  fibrous pellicle, to which the iris generally adheres, lastly blind-
ness, which, however, may be remedied after some months, by destroying or
displacing the pellicle above mentioned, by means of a cataract needle.
  This inflammation, which frequently attacks  scrofulous  children,  and is
characterised by a horror of light, may undoubtedly be treated by venesection
and leeches, diluents and  revulsives, such as setons and  purgatives ; but too
frequently convinced of their inefficacy, I have sought for other remedies. I
have derived for the last ten years most advantage from the internal  use of
the powder, and extract of the atropa bella donna.  I give the powder in the
dose of three, four, eight,  twelve, or more grains; the extract in the dose of
one,  two, three, or more grains; both divided into six doses, to be taken every
two hours.
  In  order to  prevent  the  narcotism, whether  local or general, which this
remedy may produce,  I generally accompany its use by that of artificial
Seltzer water.
  It is  needless to remark  that the use of bitter, anti-scorbutic, and anti-
scrofulous remedies, so much praised for the last twenty-five years, but with
so little reason, can only serve to maintain and  increase this inflammation
when children are the subjects of it.
                         CHAPTER  XLII.

                      ON THE FORMATION OF CALLUS.

   There is perhaps no subject of pathological anatomy which has more en-
grossed the wisdom of observers, and  the imagination of those who frame
hypotheses without regard to observation nor experience, than the theory of
the formation of callus.  Two opinions  have, in modern times, divided scien-
tific men, namely those of Duhamel and Bordenave.   The former attributed
the consolidation of fractures to swelling of the  periosteum and medullary
membrane, to  the elongation of each fragment towards the other, to their
reunion and ossification.   He found that this union is effected, sometimes by
means of a simple external ferrule of bone (vrrole), sometimes by means of
a double ferrule, one of which  envelops  the fragment, whilst the other is in
the medullary canal, where it forms a kind of peg or pin more or less elongated.
Bordenave establishes other principles.  He supposes that  the  reunion of
fractures is effected by the same mechanism as the reunion and  cicatrization
of the soft parts.   He thought he detected  cellular and vascular granulations
between the fragments of the fractured bones.   According to him,  these
°ranulations being opposed to each other, united and became solid by means
of the accumulation of calcareous phosphate internally, thus effecting the cica- 
CLINICAL SURGERY.
331
 trization of the parts.  These ideas, more or less modified, had been adopted
 until our time.
   When I undertook, in 1808, to verify the doctrines of Bordenave and Bichat,
 I was astonished to find nothing to justify them.  I multiplied my researches
 and was led from numerous  experiments to establish a theory partly founded
 on that of Duhamel, which I have taught in my lectures  on  pathological
 anatomy.   Let us now point out  the most remarkable phenomena observed
 between the occurrence of the fracture and its perfect union.
   On examination of the injured parts, from the first to the tenth day of the
 accident, we find an effusion of blood around the fragments, between  them,
 even in the medullary canal. This ecchymosis  may extend to distant parts.
 Considerable inflammation  is developed in the  irritated parts.  The  fleshy
 fibres are mingled with the inflamed cellular membrane  and cannot be dis-
 tinguished  from  the other parts.   The periosteum becomes red,  pale, swells,
 softens, and pours out between  and the surface of  the bone beneath it a red-
 dish and apparently serous fluid.  The fibrous structure of the walls themselves
 disappears.   The  medullary tissue becomes tumefied  and inflamed, and
 gradually obliterates the central canal of the bones.  The  marrow becomes as
 it were fleshy and is united to that of the opposite side.  Examine  now the
 fragments,  the clot separating them is, in a few days, absorbed and replaced
 by a gelatinilorm fluid.   From the fourth  to the sixth day the surfaces of the
 fracture are covered by a reddish tomentose substance,  but which does not
 always exist.
   From the tenth to the  twenty-fifth day, the engorgement of the soft parts
 becomes more solid; its adhesion to the substance between the  fragments
 appears every day more intimate ; the muscles recover their appearance and
 functions.  The tumor which I  have, the  tumor of the  callus, diminishes in
 extent and  separates from the surrounding parts.  The tissue composing it is
 homogeneous,  pretty similar to fibro-cartilages and difficult of division.  On
 separating  it,  it is seen  to  be  formed  of fibres parallel to  the axis of the
 fractured bone.  The medullary membrane swollen  and transformed into a
 fibrocartilaginous tissue, diminishes successively  the central  cavity of the
 bone  and finally obliterates  it.  The internal pin resulting from these organic
 operations is lost, on a level with the fracture,  with the substance intermediate
 to the fragments.
   As we advance in the examination of the formation of  callus, we will dis-
 cover other peculiarities.  These  may continue  from  the  25th until the 40th
 and even 60th days.  In weak  persons, the process occupies three  months.
 The lardaceous and fibrous mass constituting the  tumor of the callus, and
 which entirely envelops  the fragments, gradually becomes cartilaginous and
 slightly osseous.  Towards the end of the time, the  fragments are sunk  in the
 centre of a solid ferrule of bone adhering to them throughout its whole surface.
 Externally  this ferrule is covered by a thick periosteum united to that which
 envelops the sound portions  of the bones, and no external evidence is left of
 the fracture.   The surrounding  cellular tissue is still hard and dense, the soft
 substance existing between the fragments has become more dense and adherent
 to the ends of  the bones, but is yet far from uniting them in a perfect manner.
 The centre extends towards the extremities, rapidly increases in consistence,
and soon forms a very solid bony cylinder.   The dressings are generally 
332
LECTURES ON
removed at this period : but this callus does not remain; and I have called it
provisory callus (cal provisoire), in order to indicate that  nature removes it,
to effect by other means the union of the fragments.
   From the  third to the fifth and even  the  sixth month, the tumor of the
callus gradually becomes more compact:  the  central portion undergoes the
same change.  The substance intermediate to the fragments acquires all the
organic characters and consistence  of the compact substance of bone, from
which it is distinguished only by its  peculiar color.  It is this  transformation
of the intermediate substance  into bony tissue which I have called definitive
callus.  In the last stage of the formation of callus, the central part become.
thinner, cells appear in it, and it is changed into a reticulated tissue which
finally disappears  and leaves the central canal of the bone  perfectly free.  A
medullary  membrane at first  lines  the cells, after the completion of the canal
of the bone, it is continuous with the  membrane which lines it and  secretes a
medulla.   The exterior part of the provisory callus at last disappears.   It can
be understood that different varieties of fractures may  cause slight changes in
the callus uniting their fragments.                               -
   In short, the union of bones in ordinary fractures present the  following
phenomena: 1st, effusion of blood and of a viscous and adhesive fluid between
Jhe fragments: 2d, formation  of ecchymosis  in the tissues surrounding the
extremities of the fractured bones:  3d, the formation  of a cartilaginous  fer-
rule, bony externally, and the development, in the centre of  the bone, of a
peg  or pin formed by the tumefied  medullary membrane which undergoes the
same transformations: 4th, ossification of the substance intermediate to the
fragments: 5th, diminution  of the tumor of the callus,  restoration  of the
medullary canal,  and  of all  the parts surrounding the bone to their  natural
state.  It will be seen from what has been said, that the period of forty days.
fixed by many surgeons as the  limit of consolidation, is by far too short, and
that it  should be much longer in oblique fractures, and in  those in  which the
fractured extremities  overlap each other.
   This being granted, let us  establish  the facts wliich prove, that to a  certain
period, we  can, without danger, make a deformed callus yield to our  efforts.
One of the first questions which arise is, Can this be done at all ? This
question we will answer by cases from the Hotel-Dieu, which have  been wit-
nessed by many individuals.
   Case I.—Fracture of the Leg consolidated, with deviation of the Inferior
Fragment  backward, straightened, commencing on the 59th day.—A......
44 years of age, having fallen from  his horse in  the street, was brought imme-
diately to  the Hotel-Dieu, on the 3d  of August, 1820,  in a state of  complete
intoxication.   He had fractured both bones of the leg.  The least motion of
the limb drove the fragments  in every direction, and the crepitation  was most
distinct.  The patient, from  his state,  feeling no pain, moved his leg,  endea-
vored to stand upon it, and without the high and strong boot which supported
it, the fragments would most  probably have  pierced  the  integuments.  On
account of his continued agitation, the reduction was but imperfectly effected
on the first day.  The next morning  on more accurate examination,  the  leg
was found to be fractured near its lower third, obliquely, from below upwards
and before backwards; that the fragment of the tibia formed an acute point,
which raised  the integuments of the  leg and seemed on the point of piercing 
CLINICAL SURGERY.
333
 them.  The lower fragment had ascended behind the upper one, from which
 resulted a shortening and curvature of the limb, by reason of the contraction
 of the  muscles inserted  into the lower fragment.  The limb was laid on its
 external  face  in a demi-flexed position, the reduction effected, graduated
 compresses and a splint placed on the projection of the superior fragment,
 and the limb dressed in the ordinary manner of  fractures of the leg.
   Inflammatory symptoms being feared, he was  twice bled, put on strict diet
 and diluents.  On  the following days pain and great tumefaction took place ;
 vesicles appeared on the skin, an abscess formed on a level with the fracture
 at the  anterior internal  part of  the limb;  this was  opened  and  the wound
 suitably dressed.  The wound and inflammation  permitted us to give but little
 tightness  to the apparatus. The  patient  was very uneasy, would not be
 quiet, and several times the house surgeon was obliged to yield to his desires
 and loosen the dressings.  On the 27th day the wound had healed and the
 apparatus was only applied at intervals.  On the 45th day there was still
 some swelling.  On examining  the limb, consolidation was found to have
 taken place, but it was  also seen  that  the displacement backwards of the
 inferior fragment had not  been succesfully opposed.   The deformity was,
 however,  too trifling to  attract much notice.   A simple roller was applied.
 The patient was allowed to move about in bed and to  sit up.  On the fifty-
 ninth day, on a second examination of the limb,  whether the nearly total dis-
 appearance of the swelling permitted a better view of the parts, or from the
 effect of motion, the deformity  was much more apparent than on the removal
 of the  apparatus; still it was solid and firm.   The limb appeared bent; the
 projection was on its anterior surface  at the seat of  the fracture ; the lower
 portion of the leg and foot were turned outwards.  This malconformation
 must have impeded his walking,'which might also have tended to increase the
 deformity.   We therefore endeavored  to correct it; and in order to effect
 this end,  I made use of  the bandage I usually apply in  fracture of the fibula
 with deviation  of the foot  backwards.   First making moderate  attempts at
  reduction, a large  pad folded like a wedge was placed  over the whole poste-
  rior part of the leg, so that the edge corresponded to the hollow of the ham
  and the  base rested on the  heel.; above that a stiff splint of  the  same length
  was applied.  The whole was  fastened below the knee by several turns of a
t  roller. A little pad was placed on the projection formed by the lower extre-
  mity of the upper  fragment, and several turns of a roller passed around this
  last pad, the  limb, the  large pad and splint.  This last part of the appara-
  tus, the  only one which acted in reality, tended by the same action to push
  the upper fragment backward and the lower forward.  The limb was laid on
.  its exterior  surface, in a demi-flexed position,  in order to relax the extensor
  muscles  of the foot, which were the principal  agents  in the  displacement.
  The apparatus was carefully watched,  and in the beginning tightened every
  three or  four  days,  then less frequently ; the patient wore it twenty-eight
  days, at the end of which time the limb had recovered its natural shape.  Ten
  days afterwards, the patient began to walk with crutches, afterwards without
  any support.   The stiffness which existed  around the  joint gradually disap-
  peared, and the patient left the hospital on the 25th of November, perfectly
  cured.  Four months had elapsed since the accident.
    The case just  detailed leaves no doubt as to the possibility of making the 
334
LECTURES  ON
callus yield, without danger, even after some time.  Now comes the question,
until what period will the callus yield ? Here, only a mean term can be given
as an answer; for many general and individual circumstances must be remem-
bered, such as the age,  state of health or disease, the particular bone, ami
kind of fracture.  The displacement may occur in the length of the bone, in
its  direction,  circumference  or  thickness.  Displacement according to its
direction requires most attention, because it occurs most frequently, and its
callus  can be made to yield more  easily, and at a more advanced period.
This displacement  takes place when the patient leans on his  limb, or wishes
to use it when the  callus has not acquired sufficient firmness, when during
the treatment the limb has not  been equally supported throughout, and has
partly yielded to the forces acting upon it.
  Applying these principles to facts  resulting from our experiments on living
animals, and examinations of persons who have died at different periods of
fractures, we may infer that  it is generally possible  to make the callus yield
until the sixtieth day.
  Many plans have  been  adopted to effect this purpose; the following five are
the principal; 1st,  The rupture of the Callus.  It has been proposed to reduce
the angular canal,  by breaking  it like a stick, or striking upon the point of
union a sudden and sufficiently powerful blow.   Pathological anatomy has
proved  the absurdity of this method, and the knowledge of the provisory
callus proves that there is less question of rupturing a hard and compact  sub-
stance than of making a very elastic body give way.   2d, Permanent exten-
sion.   This is effected by the usual apparatus ; and when there is overlapping
and the callus is still provisory, it is the most rational  plan. 3d,  Compression.
This is principally used in angular displacements ; it is effected by ordinary
splints  or divers mechanical  means.  Its  employment is also limited to the
first stages of callus.   It is the method used in Germany, but mercurial fric-
tions  are there added to it.  4th, Section of the Callus.  This consists in
exposing the callus and dividing it with a saw or chisel.   It is the only plan
to  remedy the  promiscuous  consolidation  of  the  bones  of the fore-arm.
Lastly, the Seton, known by the name of Weinhold's operation.  Here  it is
indispensable  before attempting any thing,  to  understand perfectly the  dis-
placement experienced by the fragments,  as well as the causes which have
produced and kept it up.   When this point is ascertained, it is much easier
to determine the direction in  which the fragments should be carried, and  cal-
culate the degree of force necessary to overcome the resistance of the callus, as
well as the natural resistance of  the  agents of the displacement.
  The  surgeon  should always make the first attempt,  conformable  to the
general rules  for extension,  counter extension and  coaptation.  The limb
should be placed in  a demi-flexed position, and  the muscles relaxed as much
as possible.   The extension should be increased until too great  resistance or
pain indicate  its cessation.  We  can thus generally succeed,  on  the  first
attempt, in making the callus yield  and the deformity partly disappear without
much additional pain to the patient.  After these attempts  have been made,
we must keep the effects produced, and even augment them  by means of
suitable apparatus.
  Let us suppose a  projection formed by the  end of one or two fragments;
the limb is placed between  two inflexible plans, comprc ~ing it in opposite 
CLINICAL SURGERY.
335
directions; the projecting points therefore have a tendency to be restored to
a level with the rest of the bone.  If the projection be increased by some pads,
graduated compresses, leaving an empty space opposite, much more marked
effects might  be  obtained, and even  a deformity in the contrary direction.
We may attain the end, without acting on the seat of fractures by using the
lower fragment as a  lever.   By traction exercised  on  its lower extremity,
it is made to execute a see-saw movement by which  its  fractured extremitv,
carried in an  opposite direction, may be restored and kept in its natural rela-
tion with the  upper fragment.
  Case   II.—Fracture of both Bones of the Leg, with lateral deviation,
straightened on the 29th day.—L.....,27 years  of age, threw himself from
a third story window into the street, and was unable to rise or walk.  Acute
pain, swelling and ecchymosis took place  in the  leg.  Cataplasms  and re-
solvent applications were the only remedies used for 28 days, wdien his parents
brought him to the Hotel-Dieu, on the 14th of February, 1820.
  The patient was then in the following condition; the  left foot much turned
outwards; the leg appeared to be formed of two parts, joined a  little  below
its middle, at  an angle of about 45°, the apex of the angle  turned  inwards.
It  was evident that both bones of the leg were  fractured ;  but union had
already begun to  take place.  The next morning without any previous attempt
at reduction, I applied the internal lateral apparatus for fracture of the fibula,
acting in a direction exactly opposite to the  displacement.   As the bandage
was tightened, the leg insensibly became more straight,  but we were obliged
to desist on account of the great pain he suffered.  The leg was  laid on its
outer surface, the pain ceased, and the apparatus was left.  On the 40th day
the limb was firm, and of a natural shape; a little swelling still existed around
the ankle joint.   On the 56th day the patient left the hospital:  could walk
well, and it would have been difficult to say which was the injured limb.
  Case  III.—Fracture  of  the Radius with deviation towards  the Radial
Side, reduced  on the 25lh day.—Madame L.....,69 years of age, fell on the
15th of November  1821, upon the pavement.  The palm  of the left hand
received all the force  of the fall.  She felt acute pain in  the wrist of that side,
and swelling soon came on ;  but the patient supposing it to be merely a sprain,
consulted no one, and merely used emollient applications to the seat of pain.
Notwithstanding the assiduous  use of these  remedies, she perceived that her
wrist was daily becoming more deformed, and that its motions, far from im-
proving, were more embarrassed.  She therefore entered the Hotel-Dieu on
the 11th of  December 1821.  The following deformity was  then observed:
the hand was strongly abducted, with a depression  at the inferior extremity of
the radius; the movements  of pronation and supination were very painful
and almost impossible.   The next morning (25th day of the accident)  I dis-
covered a fracture of  the lower extremity of the radius, and was of opinion
that, notwithstanding the length of time elapsed since the fall, the limb might
be restored  to  its  natural shape.  In  order to effect this, an assistant held the
fore-arm at its upper part to make counter-extension.  Taking hold of the
hand of the same side, I endeavored  to give it a direction contrary to that
caused by the  fracture, that is, to bring it to adduction.   The fragments of the
fracture were  thus carried outwards, the interosseous space increased, and
the depression entirely disappeared.   The remaining indications were easily 
336
LECTURES ON
fulfilled.  The limb was merely to be maintained in its proper  direction
during the time necessary for consolidation.   The usual apparatus for fracture
of the fore-arm was applied with the addition of the ulnar splint.  The parts
were  by these means  kept in a proper position.  The apparatus was not
removed until the 10th day, and re-applied on the 20th, the limb retaining its
natural  conformation.  On  the 32d day the  callus was thought to be suffi-
ciently  solid to admit of  its final removal.  The patient left the house on the
17th  of January.^ All deformity had  disappeared,  the consolidation Mas
perfect.
  It may be easily understood, that it is always necessary to give to the first
dressing a degree of constriction greater than in cases of recent fracture;
the state of the limb should  be carefully attended to.  If great  pain and
swelling take place, if the heat and sensibility diminish in the parts not com-
prised in the apparatus it is a proof that it is too tight, and should be immediately
loosened.  Even when no bad symptom arises, the apparatus is to be removed
on the third or fourth  day to  examine the limb, and make new attempts at
reduction.   As long as the deformity is not completely corrected, this should
be done every three or four days.   The bandage maintaining what has been
gained each time, we can gradually restore to the limb its natural conformation.
In cases of  shortening we can only use a simple retentive bandage, when the
patient  cannot bear extension.  This extension, however, must not be too long
continued for the consolidation would be prevented from taking place.
   When the parts are brought to their  natural shape, we have only to follow
the ordinary rules for the treatment of fractures. Many authors have supposed
that the duration of the treatment should be short, because an old  fracture i»
sooner cured than a recent one.  Admitting the possibility of this fact in»a
great number of cases, I think it much more  prudent, especially when the
deformity is considerable, to  prolong the treatment, at least as long as for a
recent  fracture.*
                        CHAPTER XLIII.

ON FRACTURES OF THE LOWER EXTREMITY OF THE RADIUS SIMULATING LUXATIONS
                              OF THE WRIST.

  All writers on the subject of  luxations of the wrist have described four
species.  The only difference  to be observed between them, is in point of
number.  We must go back as far as T. L. Petit, to find rational ideas on the
melancholy  consequences of pretended luxations of the wrist negligently
treated, and on the proper treatment in these cases.   Ponteau, in a chapter
on fractures of the  fore-arm,  in consequence of  falls, has  this remarkable
passage.  '•' These fractures  are  generally mistaken for  sprains, for incom-
plete luxations, or a separation of the ulna or radius at their junction atthe
wrist."   Desault also published some cases of fracture of the lower extremity
  * See the  excellent  works of M.M.  Breschet, Sauson, Couveilhier, and Villerme on
Callus. 
CLINICAL SURGERY.
337
of the radius; and observed that they were sometimes mistaken  by inatten-
tive surgeons for  luxations of the bone.   The observations of these surgeons
should have thrown some  light on this obscure point; but M. M.  Richeraud,
Boyer, Delpech, Leveille, Monteggin, Sam. Cooper, and  all our dictionaries
of medicine, have  adopted the  same error, unanimously  recognised  the four
luxations of the wrist, given their symptoms and treatment.  For a long time,
however, I have publicly  announced in my lectures, that these fractures are
very common, that I  had  always seen these pretended luxations of the wrist
changed into solutions of continuity, and that our records, despite of so many
descriptions, do not afford a well marked case of this injury.   I have also
dissected wrists, and never found a luxation in consequence of a fall upon the
palm of  the hand: the only ones  I  have ever  met with were consecutive to
disease of the joint or symptomatic of other lesions.
  I now propose to give a history of the  injury, but in a question which has
been the subject of so many contradictions, and in which so much erudition
has been displayed, let us see if the facts collected  be favorable  to our doc-
trine, and commence with the anatomy of the parts.
  Three  principal articulations  demand  our attention:  the inferior radio-
ulnar; the radio-carpal, and medio-carpo-metacarpal.
  The articulation of the  radius and ulna present  a movement  of  rotation
effected by the radius, in which is a cavity of a quarter of a circle, occupied
by the head of the ulna presenting a wounded surface about equal to half a
circle.   The  pronation and supination of the hand are therefore limited to a
quarter of a circle, but the looseness of the ligaments and synovial membrane
which extends somewhat  farther than  the articular cartilages,  makes this
motion about  equal to two-thirds of a semi-circle.   If at first sight it appear
more extensive, we must remember the rotation of the  humerus  in  the glenoid
cavity, and even a slight movement of the scapula ; all these united make the
complete rotation of the hand nearly equal to three quarters of a circle.
  The skeleton of the  radio-carpal articulation demands  an attentive exami-
nation.  The inferior extremity of the radius, thickened and enlarged, consti-
tutes nearly three fourths  of it.  With  the exception of  some  partial cristae
which limit the excavations of the tendons, the epiphysis of the radius rests
behind, nearly on the same plane as the body of the bone, and does  not project
remarkably: outside, the projection is two or three lines in length, in the form
of a pyramid, with four  faces: this  is  the styloid process which is always
found at the extremity of the great diameter of the wrist.
  The anterior surface is more remarkable.  The epiphysis enlarging, is car-
ried so much forward, that it there forms a transverse crest, or spine, projecting
more than  four lines  above the  plane of the body of the bone.  Below this
crest is a rough surface inclining backwards, at most a line in  height on the
inside: extended on the outside nearly half an inch to the apex  of the styloid
process.   To all this surface is attached  the anterior  capsular ligament, from
which insertion may be imagined its thickness and strength.
  On the lower surface of the epiphysis is the  glenoid cavity of  the radius,
narrowed in front and behind by the insertion of the  ligaments  presenting an
irregularly triangular shape, of which the apex directed outwards terminate*
at the point of the styloid  apophysis.  It therefore  presents a great obliquity
from without  inwards, its  outer  extremity descending  four lines  lower  than
           43 
338
LECTURES ON
 the inner one.   From  all this it follows  that if we let fall the axis of the
 body of the radius upon this cavity, that it will be divided into two very un-
 equal parts;  the posterior forming scarcely one fourth, and the anterior three
 fourths, and which in a full perpendicular to the radius would  have  as a
 support merely the portion of the epiphysis projecting in front of the body of
 the bone.  This  disposition will explain  the frequency of fractures  in  the
 vicinity of the joint.
   The ulna has no immediate share in the  radio-carpal articulation: it is
 separated from it by a triangular ligament whose apex inserted into  the centre
 of the semi-circle presented by the articular surface of the ulna,  is always,
 whatever maybe the relations of the two bones, at an  equal distance from  the
 radius, and consequently never in a state of tension, nor relaxation. By this
 very simple mechanism, the articular surface which receives the bones of  the
 carpus is never altered,  neither in smoothness nor extent.
   The extremity of the ulna presents different aspects according to the move-
 ments of the radius.  What is  called the small head or articular portion of the
 ulna, forms a thick rounded projection, extending three  or four lines beyond
 the plane of the body of the bone, and situated on the side opposite to  the
 styloid apophysis.  When the  fore-arm is in forced pronation, this projection
 looks backwards, and elevates the skin covering it; the styloid apophysis looks
 somewhat forward; the anterior surface of the bone is nearly plane.  When
 there is complete supination, the head of the bone projects forward, the styloid
 process is turned  completely backwards; lastly in the medium  position  the
 styloid process is turned outwards at the extremity of the great diameter of
 the articulation, exactly opposite to the styloid process of the radius.
   Two important circumstances result from this; that which  is called  the
 ulnar  malleolus is not always  represented by the same osseous projection,
 like the radial  malleolus;  secondly, that the  great diameter of the joint is
 subject to remarkable variations.
   We can hence infer the degree of confidence to  be reposed in the  symptom
 given  by Ponteau, as characteristic of fracture of the  radius  or ulna; the
 increase of the articular diameter.  In order to judge if it be really increased
 the joint must be placed in the medium position; we then  find that a fracture,
 at a half inch or inch above the joint, may by the approximation of the inferior
 fragment, separate sufficiently the styloid processes to add  to the  great
 diameter two lines; but to  effect this  the inter-articular ligament must be
 divided.  In proportion as the fracture is seated higher up, the separation is
 less; at the inferior third of the bone it is not more than half a line.
   There is  another important feature which I never have  seen  published;
 that when the diameter of the fore-arm at  the wrist is larger than ordinary,
 without any morbid affection, the understanding is almost invariably weak and
 obtuse.
   Three bones of the carpus, the semi-lunar, pyramidal and scaphoid, united
firmly together, articulate  with  the radius  and  inter-articular ligament.
There is here a disposition which has been overlooked.  The articular surface
of the scaphoid and pyramidal occupies nearly two  faces, the posterior and
superior.  Compared with that of the radius it presents  one  third  more in
extent.   The articular surface of the pyramidal is much narrower,  in propor-
tion to the contraction of the surface of the inter-articular ligament.  We 
CLINICAL SURGERY.
339
 may, therefore, a priori, infer that this articulation only serves inflexion back-
 wards.   And that this flexion is greater towards the side of the radius  than
 that of the ulna.   Now this is in fact the case.  Dissect this articulation with
 its ligaments; the anterior surface of the radius and the first row of the  car-
 pus form a smooth plane, and the flexion of the bones of the carpus in this
 direction is nearly null.  Behind, on the contrary, the motion is so extensive
 that the  radius covers nearly the whole of the  first row, and almost touches
 the bones of the second.  In fact, and it may be examined on one's own hand,
 flexion backwards is much more extended on the side of the thumb than on
 that of the little finger.  This is caused by the disposition of the  musclts :
 the extensors of the carpus, thumb, and index finger, have an oblique direc-
 tion which precisely corresponds  to the obliquity of the flexion ; they draw
 the radial side of the hand backwards and slightly inwards.   The number and
 strength  of these muscles diminish as we proceed towards the ulnar side of
 the hand; the thumb  has three; the index, two proper to it; the middle
 finger, one; the ring finger only its share of the extensor communis; the little
 finger has indeed an extensor peculiar to it, but very delicate; and  its meta-
 carpal muscle, the flexor carpi ulnaris, tends as much to adduction as to exten-
 sion.
   By means of a remarkable mechanism, the movements of  the second  row
 of the carpus, which may be called medio-carpal, are totally opposite to those
 of the former.  The three first bones of the  carpus  present  on their internal
 surface a deep cavity, representing the external three fourths  of their articular
 surface.  The internal fourth is  an oblong, slightly  convex surface.   The
 second row presents outwardly, an articulating head formed by the  os mag-
 num and the unciform, inwardly a surface hardly concave.   When the hand
 is extended in a right line with  the fore-arm, the second row bears such a re-
 lation to the first, that they cannot be flexed backwards on  each other.  Or.
 the contrary, they are readily flexed forwards.   But the flexion  is not every
 where equal; it is evident that the plane arthrosis of the internal side cannot
 have an extent of motion equal to the external enarthrosis.   Thus the flexion
 forwards is most complete on the side of the little finger; there is there also a
 very strong muscle the flexor carpi ulnaris, which is attached to the unciform
 bone, through the medium of the pisiform, in the same manner as the triceps
 surae acts upon the tibia through the intervention of the patella.
   It may thus be seen how inexact are  the terms flexion  and  extension as
 applied to the hand.  Compare the two angles: flexion backwards is equal to
 flexion forwards.   In order to give more precision to the expression, we must
 admit the first row of the carpus as forming a particular portion  of the wrist
 properly  so called.  The second row, united to the metacarpus, notwithstand-
 ing a very limited motion, may be considered as an isolated portion, a simple
 lever called the hand.  The  wrist is  flexed backwards and extended  in a
 right line upon the fore-arm; the hand is flexed forward on the wrist and ex-
tended in the same direction as this last.  It  certainly will not be denied  that
the hand is flexed backward  on account of the flexion of the wrist, and  that
this circumstance may cause some confusion; the  same effect is  found in
other  joints; and without leaving our subject, the rotation of the humerus  dou-
bles the extent of the pronation or supination at the fore-arm, without the action
of either  being confounded with the other.
  Thus, the precise movements of each articulation are, flexion  of  the m r st 
340
LECTURES ON
backwards and a little inwards ; flexion of the hand forwards and a little out-
wards.  To these mnst be added the movements of adduction and abduction.
The former seems to take place more particularly in the wrist; the second in
the hand ;  unless by a premeditated  effort, before flexing the hand, the palm
looks somewhat towards the radius and the little finger towards the ulna; the
contrary takes place in flexion of the wrist, so that the motion peculiar to each
of these articulations is triple, made up of flexion, inclination or rotation of
the hand, and lastly of  adduction or abduction.  We must not consider as
nothing the movements  of the partial articulations of the  bones of the carpus
with each other, and even with the metacarpus ; they may increase the effect,
but are nevertheless of secondary importance.
   These different  articulations  are revealed externally by different folds
which it is useful to be acquainted with, both in amputations and the diagnosis
of fractures and luxations.   On  the anterior surface, a transverse line which
is never wanting, indicates the enarthrosis of the medio-carpal  articulation.
Below this line the hand is divided into the thenar and hypo-thenar eminences;
above is the wrist.  It must be observed that when the wrist is  flexed these
eminences are on the same plane  as the fore-arm; when the hand is extended
in a right line, they project several lines.  The other folds of this surface, ge-
nerally two in number,  are less constant; sometimes the middle one  answers
to the radio-carpal  articulation, and the upper to the transverse crest or spine
of the radius.  On  the  posterior surface they  are less  marked, we can  only
distinctly perceive that making the inter-articular radio-carpal line.
   These preliminary notions on the articulations of the  wrist, indispensable
to the proper understanding of the displacement of the articular surfaces, re-
quire for their perfection, a  review  of the  numerous points of resemblance
presented  by a parallel of the  superior and inferior extremities.   One of the
first is  the analogy of  fractures of the inferior extremity of the radius, with
those of the tibio-tarsal articulation.  This analogy of relation in a pathologi-
cal view  becomes equally striking on a comparison of the upper and  lower
extremities.   The counterpart of the scapula is the os innominatum. The arm
and elbow correspond  to  the thigh and knee, with this slight difference; the
olecranon is continuous with the  ulna, whilst the patella, analogous  to  it, is
held  in its place by ligaments.  The fore-arm and  leg resemble each other
strongly, but here the difference is more forcibly marked.   In  the fore-arm
the bones  have  less strength, length, and  size, than in the leg, because the
former  are organs of motion, the  latter of resistance.   Thus the bones of the
fore-arm require more flexibility ; they are separated by very moveable  arti-
cular intervals, intended to favor  the movements of pronation and supination.
In the leg  these articulations are  solid, because the different movements do
not exist.  Lastly,  the  bones  of  the fore-arm have their  small  extremities
placed in contrary directions ;  it is not so in the leg, the tibia is the principal
support of the thigh and foot, and is merely aided by the  fibula at its lower
portion.  Thus  when a patient falls on his foot, the shock  is borne by the tibia,
which may be crushed  without injury to the fibula.   If the  external violence
bear on the upper part of the tibia, the fibula  suffers no change.  But, it will
be said, the fibula is often fractured ; this is true, but it occurs only when the
foreign body infringes directly on the bone, or when the foot is forcibly twisted
outwards or inwards. 
CLINICAL SURGERY.                         341
   Having established  these  differences  and analogies,  let us examine the
consequences of the disposition of the bones of the fore-arm.  Let us suppose
that a man in walking meets a large stone  or  some obstacle (as generally
happens) the point of the foot rests on the ground, the  impetus  is arrested
below and continued above;  equilibrium is lost and  the individual  falls.
What then happens ?  the hands are instinctively thrown  forward to preserve
the face from the effects of the blow.  If the articulations are  demi-flexed
the force of the fall  is somewhat lost; but if they are in a state of tension,
the force of the fall multiplied by the rapidity of  it, bears  upon the bones.
Two things'may then happen; the individual may have fallen  upon the ends
of the fingers and injured them more or less;  but as the fingers are weak,
they yield easily and transmit to the carpus and metacarpus the  force of the
blow, which is  lost in the numerous movable articulations composing these
parts.  Sometimes however the phalanges and bones of the metacarpus are frac-
tured.  But if,  instead of falling on the fingers, the fall is spent on the wrist,
a different accident occurs ;  sometimes the upper part of the arm is luxated ;
sometimes the elbow is carried backwards; but generally there is fracture of
the lower end of the radius: why ?  because of the two bones of the fore-arm,
one, the radius, is large and contiguous to  the  bones of  the carpus, and the
other, the ulna, is feeble and not immediately articulated with the carpus.  It
follows that in a fall the force is spent on the body offering most resistance;
now the radius, or as it has been called, the manubrium  manus presents this
disposition;  it is the  principal support of the hand: with it nearly solely is
articulated the  posterior face of the first row of the carpus;  its inferior ex-
tremity supports the blow;  upon it is spent  by contre-coup the violence re-
sulting from  a  fall on the anterior part of the wrist; it is therefore not asto-
nishing  that fracture  should  occur in this  part.   But it will  be asked why
does that large bone offer no resistance ? because there is  no part of the body
which is not fractured in a fall where the velocity is multipled by the weight
of the body; add to this the spongy and soft structure of the lower part of
the radius, and that it is the point of concentration of all the violence of the
blow.
  To the reasons just given explaining the frequency of fracture of the lower
part of the radius, we may add others drawn  from the surgical disposition of
the organ.   In  examining the structure of the soft  parts, it will be seen that
it is not the ligaments which oppose the displacement forward of the articular
surfaces, but the tendons of the flexors, deprived of fleshy parts, and reduced to
the fibrous tissue which composes them.   These tendons pass under the ante-
rior carpal ligament.  They then create so much resistance, that falls multi-
plied by the velocity and weight of  the body cannot rupture them; the hand,
in this movement, is forcibly extended, and the tendons applied  to the anterior
part of the joint uniting the carpus to the fore-arm.   If the extension is  more
considerable  the  parts are applied more firmly to the articulation and their
resistance is incalculable.  I do not think a force  of two thousand pounds
could overcome it; this is not exaggerated, for it will suffice to remember the
power of the tendon Achillis.
  Luxation backward from falls on the dorsal surface of the hand is not less
prevented by the tendons of  the extensors.  These are in the  same situation
as  the flexors;  they  have,  indeed, iess resistance, but still present  con-
siderable, kept  as  they are in their sheaths by the posterior carpal ligament 
342
LECTURES  ON
 In short the impossibility or extreme rarity of luxations forward and back-
 ward is owing to the resistance of the flexor and extensor tendons.
   I have said that I had never seen a luxation of the wrist, and that fractures
 of the radius were very common ; the following facts, from the records of the
 Hotel-Dieu will place this beyond doubt.  In 1829, of one hundred and  nine
 fractures treated in the  hospital, twenty-three  were of the fore-arm,  viz,
 sixteen of the radius, two of the ulna, five of both bones.   In 1830, of ninety-
 seven, twenty-two were of the  fore-arm, sixteen of the radius alone, two of
 the ulna, four of both bones.  Fractures of the lower extremity of the radius
 occur at all ages; the fourteen fractures in 1830 were between the ages of
 eight and eighty-eight  years ; both  sexes are equally liable.  An interesting
 question is, which side is most frequently affected ?  In the preceding cases
 there were nine fractures of the right radius  for seven of the  left; out of
 ninety-seven  cases  fifty-nine belonged to the right side.   It may be observed
 that fractures, in general, occur more frequently on the  right than on the
 left side.
   As regards the causes, three were  produced by falls on the  back of the
 hand : the  remaining eleven by falls on the palm.  This result destroys the
 inference drawn by M. Cruveilhier, that fractures appear impossible in falls on
 the back of the hand.  The opinion of Ponteau, that the  fracture resulted
 from the convulsive contraction of the pronator muscles,  does not merit
 serious refutation.
   We have now seen why these fractures are so common.  Let us now exa-
 mine the seat of the lesion.  The observations which we have been enabled to
 make have  proved to us  that they may affect different points of the infe-
 rior extremity of the  radius; most frequently they happen very near the
 wrist joint.  In young  subjects, the separation of the epiphysis is more com-
 mon than the fracture.
   The fracture may occur transversely or obliquely, at three, six lines or an
 inch from the articular surface.  The consecutive displacement will the more
 resemble a  luxation as it approaches nearer to this surface: in some cases I
 have seen a comminuted  fracture, or kind of  crushing of the articular por-
 tion of the radius.
   Many fractures, by radiating, may then be  observed on  this  part of the
 bone.  The injury requires a long time to cure;  there is often considerable
 swelling of the lower extremity of the  fore-arm, difficulty of motion, deform-
 ity.  Generally, fractures of  the  inferior extremity of the radius have an
 oblique  direction from  above downwards, and from the dorsal to the palmar
 surface.  They may, however, occur  in  the opposite direction.  We shall
hereafter see how the displacement of the fragments is effected.
   Hitherto, we have merely spoken of fractures occurring from contre-coup
by falls  on the palm  of  the hand; they may take place from  falls on the back
of the hand, as has been  seen above ;  this is very rare ; there are, neverthe-
 less, some cases of it, and  it will be seen that the blow falls upon the first row
 of the carpus, and through it in a direct line on the radius.
   Before we had made known the frequency of these fractures, and changed
the opinions established on this point, some one must naturally have asked
himself, What is  the nature of  this injury ?  By some it was considered as a
sprain,  by others a diastasis  or separation.  M. Boyer classed it  among 
CLINICAL SURGERY.
343
 luxations.  We have shown how much this view is opposed to facts, and will
 merely add that we cannot understand  how the swelling of the soft parts in
 consequence of contusion or sprain, could make the head of the ulna project,
 and throw the hand towards the dorsal face and one of the edges of the fore-
 arm, whilst fracture, by giving a vicious direction to the inferior extremity of
 the  radius, explains this deviation  of the hand.  A fall on the anterior sur-
 face  of the wrist  may produce a simple contusion of the articulation, and
 great distension of the anterior ligaments, uniting the carpus to the radius
 and ulna; but there is a vast difference between that and our present subject.
   Let us consider for a few moments the two first opinions; I mean diastasis
 and sprain.  A single word will suffice  for the first: no external power can
 separate the radius and ulna, so as to  produce diastasis.  As to sprain, it
 demands  a closer investigation because  it is intimately connected with  frac-
 tures of the lower extremity of the  radius.   It is in reality the first effect of
 the causes producing these fractures; and by admitting what does not appear
 to me to  be true,  the luxation of this bone, the sprain would still be the first
 effect.
   When  an  individual falls upon the thenar or hypothenar eminences, and
 fracture of the radius does not  take place, it may produce tension of the liga-
 ments of  the  anterior part of the carpus; these ligaments are numerous, but
 as we have seen, without much strength, being supplied  with fibres from the
 flexor tendons.  The tension ,of the ligaments frequently causes acute  pain,
 which forces the patient to seek the aid of a surgeon.  At a later period there
 appears a swelling in front when the wrist has been  forced backward.  If the
 fall  has taken place on the dorsal surface, the tension of  the ligaments, pain,
 tumefaction, redness and difficulty of motion occur on the posterior part of
 the wrist.  Here, as in sprains  of the ankle, the symptoms appear on the side
 opposite to that to  which the limb was carried.   The sprain may take place in
 another direction, as,  for example, in a fall on the ulnar edge,  the tension is
 outside  and the sprain external: in a fall on the radial edge, it is  internal.
  Sprains forward and backward are the most common and serious.   The
 pain is generally transient; but it is  often followed by tension and inflamma-
 tion which may  cause suppuration in the sheaths of the tendons between the
 vessels.  The danger of inflammation may be conceived, as it is almost always
 complicated with strangulation; but suppuration is much more serious on ac-
 count of its depth and situation.
  This  affection does not appear under  merely an acute form; it may give
 rise to phenomena of a chronic nature; and to this last class belong especially
 white swellings  (tumeurs blanches).  Examine, in fact, the  diseases of the
 joints called by this name, and you will find that the majority of  them  have
 as a primary cause  the  tension of the ligaments.  A scrofulous constitution
 tends especially to their production.   Since sprains whether acute or chronic
 have such  serious consequences, they should be attended to as soon as possible.
 Should much pain exist,  bleed, apply leeches, surround the part with resolvents
of a sedative nature; the  solution of sugar  of lead is excellent.  This  pain
yields easily to time and remedies, and the patient deceived by this circum-
stance hastens to Use his limb.  This error is productive of serious conse-
quences, for it is the almost infallible cause of those chronic inflammations
and white swellings for which we have so  often to amputate the limb.  When 
344
LECTURES ON
the pain has ceased, it is prudent to place the articulation beyond the power
of motion, by exercising proper compression around it, in short, by treating it
like a fracture of the extremity of  the radius.   Should the inflammatory
symptoms re-appear we must have recourse to antiphiogistics.
   If the inflammation has passed into the chronic state, we must have recourse
to flying blisters, cauteries, moxas, and the means of determining the inflam-
mation to the skin.   Absolute rest is indispensable.
   Generally fractures of the lower extremity of the radius  are simple, they
are, however, sometimes compound.  In some rare cases, the radius has been
fractured, the ulna luxated and driven through the integuments.
   Case.—Double Fracture of the Radius ; Luxation of the Ulna inwards unth
rupture of the Integuments; Resection at the end of eighth months;  Incom-
plete Cure.—B.....,62 years of age, came into the hospital, on the 27th of
February, 1832.  On the previous evening, she made a false step, and fell
down a flight of 60 steps ;  she could not tell how the  fore-arm had met the
floor.  The ulna projected outside.   The left fore-arm was deformed near
the wrist, and presented a re-entering  angle  on the radial side; the radius
was fractured in two places, at an inch above  the joint, and at an inch  and a
half above the first fracture.   On the inside there  was a longitudinal wound
along the edge of the ulna, about four inches in length with regular edges, as
if it had been made by a cutting instrument.  The ulna luxated inwards, pro-
jected considerably; more than an inch of the bone was beyond the integuments.
The internal lateral ligament had been broken, the muscles and other soft
parts were more  or less lacerated and  contused: the hand  and part of the
fore-arm were very much swollen.
   Qn seeing the case, M. Breschet proposed  amputation, but the  patient
positively refusing, he resolved upon the resection of the ulna, which was done
immediately and in the following manner ; the  hand and wrist being carried
outwards, the  ulna was drawn inwards.  The surgeon  separated it  with the
bistoury  from the soft parts which  still adhered to it, and having  passed a
piece of pasteboard beneath, with a saw held obliquely he removed about one
inch and a half of the end of the bone.  No vessel was wounded, the fore-arm
was restored to its natural position, simple dressings applied, and it was fixed
on a splint.  (Strict diet; diluent drinks.)
   The first dressing was left untouched for four days;  at this period, suppu-
ration of a healthy aspect was found to have taken place.   A sero-sanguinolent
discharge  which had  saturated the  dressing, had  tended to diminish the
swelling.
   Three days afterwards, it was again dressed.  The wound was of a fine
red color, but the suppuration not abundant, and some portions of gangrenous
soft parts were about separating.   It was  therefore decided  to dress it every
day.  In order to prevent the displacement of the radius,  some graduated
compresses were applied on the  radial side.   Its  fragments were movable
upon each other.
   All went on well for a few days, the pain was bearable and only returned
at intervals, when on the 9th of March a swelling of the back of the hand was
perceived ; and on examination manifest fluctuation was felt.  An  incision
caused the discharge of about two spoonsful of healthy pus; a poultice was
applied.  We had then two wounds discharging pus.  The first appearing to 
CLINICAL surgery.
345
 communicate with an abscess surrounding the fragments of the radius, the arm
 was placed in a position to make the ulna wound the most depending portion.
 Thus passed several days, without any bad symptom except an obstinate diar-
 rhoea, which diet, enemata, and rice water, could not entirely arrest.  On the
 24th of March the whole fore-arm as far as the elbow was red, tense, swollen,
 and presenting some points of fluctuation.  Several  small incisions were made
 on its dorsal surface, and in  a few days  it was restored to its natural size.
  With time, the diarrhoea ceased, the ulnar wound diminished and discharged
 less purulent matter;  the incjsion on the back of the hand was reduced to a
 small opening which scarcely suppurated.  On the  10th of April, new tume-
 faction and  abscess on the dorsal face of the  fore-arm.  Incisions, simple
 dressings, and poultices.  In three days the swelling disappeared, the general
 health  improved, light nourishment was allowed. 25th. Another general
 swelling of the fore-arm with increased suppuration of all the openings of the
 parts.   This new attack yielded to  cataplasms, without creating abscesses,
 and from that time  the patient began to  improve: on  the 10th of May the
 wound of the back of the hand and that of the ulna  were reduced to fistulous
 points.   The suppuration of the other abscesses began to diminish, the frag-
 ments of the radius were rapidly uniting, the patient could move the fore-arm
 without  pain, the fingers  were capable  of  some motion, the appetite was
 restored, she sat up for several hours during the day.  With these alternations
 of better and worse, less serious as they were remote  from the  time of the
 accident, the patient spent the months of May, June, July, and August, in the
 hospital.  She left on the 25th of August.   The wounds of the inferior and
 inner parts of the wrist were not yet closed.
   In a short time the wounds  healed, and then re-opened : and on  the 17th
 of November 1832, there were two fistulous openings near the wrist and on
 the inside of the fore-arm, giving exit to a small  quantity of pus.  The ulna
 was found  exposed, and exfoliation threatened.   The fore-arm deformed,
 covered with cicatrices, had lost an inch of its length.   Supination and pro-
 nation were entirely destroyed.   The fingers extended by the treatment were
 stiff and could not be bent;  flexion  of the  hand   was  also lost.  A  slight
 mobility  of  the radio-carpal articulation,  gave a faint hope  of  some  slight
 restoration of flexion.  The skin of the fingers was  so tender, that they were
 obliged to be separated by compresses to prevent their adhesion, and the fore-
 arm supported by a scarf.
   Case II.—The subject of this case was an adult woman, of whose previous
 history no information could  be obtained.   The fore-arm appeared  much
 shorter than  natural; the inferior extremities of the  radius and ulna caused a
 considerable projection of  the skin; that of the radius was less prominent and
 did not descend  as  low as that of the  ulna.  The upper extremity of the
 carpus was on a plane superior and anterior to that of the lower extremity of
 the bones of  the  fore-arm.  The hand formed a right angle with the fore-arm,
 and also inclined towards the radius, so much so  that they could  be brought
 into contact  on their external side.  Extension was impossible ; flexion could
 be carried much further than a  right angle.
  On dissection,  M. Cruveilhier found, 1st, all the muscles of the arm atro-
phied, but principally the radial and ulnar muscles peculiar to the articulation
of the  wrist,  and  the pronators and supinators,   muscles peculiar to the
               44 
346                           LECTURES  ON
 radio-ulna articulations.  The tendons of the posterior  radial, and the com-
 mon and proper extensions were received in  a deep groove  wrought on the
 posterior face of  the inferior extremity of the radius, interrupted at this bony
 groove to which they intimately adhered.   The  posterior ulna was reflected
 at a right angle over the ulna and inserted into the fifth metacarpal bone.  The
 anterior ulna atrophied was  inserted into the  pisiform bone.
   2d. The carpus presented a remarkable malformation.   The bones of the
 anti-brachial row were reduced to the state of rudiments, and lost their shape
 and size.   The pisiform alone had undergone no change.   The corresponding
 surfaces of the  bones of the 2d  row were changed;  there existed  mere
 rudiments of the os magnum and os unisforme;  the upper half of the trape-
 zium and trapezoides corresponding to the scaphoid was much diminished.
 The ulnar but little changed, extended five or six  lines below the extremity
 of the radius.   Above its  inferior extremity, at a height corresponding to the
 extremity  of the radius,  a  deep excavation  existed to receive an articular
 process of this last bone.   It  was united to the pyramidal bone by means of
 an extremely long ligament which allowed the hand to be strongly inclined
 towards the radial side of  the fore-arm.  3d.  The radius was  shortened and
 deformed.  The  deformity  was principally at its lower extremity which was
 large, as it were crushed ;  deeply grooved posteriorly in order to accommodate
 the combined tendons of the extensor muscles.   There was a sort of trans-
 position of the articular face of  the  radius, which occupied the outer side of
 this extremity; a projecting apophysis on the internal side, articulating with
 the ulna.   Lastly, the body  of the radius was larger than natural, its lines of
 insertion and processes more projecting; its upper extremity,  instead of being
 hollowed to receive the  small  head  of  the humerus,  was  convex.  The
 possibility  of fracture of the lower extremity of the radius, being now beyond
 a doubt, let us examine by what signs it may be recognised.  On the instant
 that an individual  falls on  the  anterior  surface  of the hand, he  ordinarily
 perceives the sensation of a  crackling about  the wrist; acute pain follows;
 the wrist, lower part of the  fore-arm and hand  soon become swollen.  An
 attentive examination of the part shows more or less pronounced  projection
 of the ulna.  If the fracture is seated at a quarter of an  inch, a half inch or
 more  from the radio-carpal articulation, the superior fragment or  fragments
 lean towards the palmar face of the fore-arm ; the carpus and inferior fragment
are directed backwards :  these are the projections which  give rise to the idea
of luxations.   A  second  displacement soon  follows this primary one; the
wrist  leans towards the inside  of the fore-arm,  the  interosseous space is
diminished and even destroyed,  and consequently, when the  injury has  been
mistaken  the  movements of  pronation and  supination; whenever there is
fracture of the lower extremity of the  radius, a greater or less depression is
 observed on the radial  side,  at the supposed point of fracture.   On examining
the extent of the transverse  diameter of the anterior face of  the fore-arm of
 the sound side, it is found greater than that  of the injured side, whilst the
 dorso-palmar diameter of  this  same side is somewhat increased.  Crepitation
 is distinct.
  By  extension and  counter  extension the deformity easily and instantly
 disappears, but recurs  on  a cessation of the efforts.  To these different signs
 must  be added the displacement of the styloid  process of  the radius, the 
CLINICAL SURGERY.                        347
remarkable swelling of the anterior part of the fore-arm, the flexion of the fin-
gers, the difficulty of moving the  hand,  a pain  which has its precise  seat,
not in the wrist joint, but at  the inferior extremity of the radius, and which
increases on pressure at this spot: whilst  the movements of the radio-carpal
articulation do not influence  it in the least.  Below the head of the  ulna is
another painful spot owing to  the tension of the internal ligament of the wrist
joint.
  These symptoms of fracture are not always found combined;  in a majori-
ty of cases, they are not well marked.   Sometimes, on the contrary, there are
some more pronounced; thus the fracture may be  transverse and the displace-
ment, in the direction of the thickness of the bone, may be considerable; the
hand and inferior fragment are then carried backwards.   The same thing oc-
curs if there be separation of the epiphysis instead of a fracture.
  The displacement of the fragments demands our attention; it may take
place  in  the direction of the thickness or  the length of the bone.   In the
latter direction it affects especially the two fragments which are drawn to-
wards the interosseous space,  which explains the  diminution of the transverse
diameter.   External violence assists in effecting this displacement but the
pronator  muscles contribute powerfully thereunto.
  Displacement in the direction of the length is considerable in  proportion to
the obliquity of the fracture.   The violence of the  fall, and all the muscles
going from the fore-arm to the hand tend  to produce it.
  Lastly, displacement  in  the direction of the thickness of the  bone, which,
as in the preceding case, affects  only the lower fragment, takes place  from
behind forwards in oblique fractures, from above  downwards  and from before
backwards; whilst it occurs in the opposite direction when the fracture is op-
posite.  The muscular action, overlapping, and  especially the exertion caus-
ing the fracture tend to produce it.
  The radius  articulating  with the hand alone,  the latter should accompany
the inferior fragment.  This is indeed what is seen in consequence of dis-
placement of this fragment; the inferior articular surface of the radius slightly
ascends: it leans  towards  the radial edge  of the fore-arm,  and most  com-
monly  towards the dorsal surface,  from which result the anormal projection
of the head of the ulna and the depression  of the hand backwards. The hand,
however, does not invariably lean towards the radial edge of the fore-arm, on
account of the opposition of the internal  lateral ligament of the radio carpal
articulation, which obliges it to take an oblique direction, and in some cases,
incline towards the  ulner  edge of the fore-arm.  It may sometimes happen
that the inferior fragment is thrust from below upwards with so much violence,
that the  inter-articular fibro-cartilage and the internal ligamentous fibres of
the lower radio-ulnar articulation are ruptured.
   The diagnosis of fractures of the lower extremity of the radius demands
our most serious  attention; because they have  been and are yet  often mis-
taken for a luxation of the  carpus  backward.  It is  however highly import-
ant not to commit this blunder.  The treatment of luxation is very different
from that of fracture, and on the proper treatment depends the restoration or
loss of certain  movements  of the fore-arm.  The following  is a case of this
error:
  Many years ago, a mason having fallen from a high scaffold, was  carried 
348
LECTURES ON
to the Hotel Dieu.  He had several severe injuries, among others, a fracture
of the  cranium,  with  an extensive  wound of the  scalp; there was  at the
same time a deformity of the wrist joint.  Many surgeons thought that there
was a luxation backwards of the carpus.  I was of the opposite opinion, and
declared that there was a fracture of the most inferior part of the fore-arm.
The man died  from the effects of the fracture of the skull.  On examination
after death, my opinion was found to be correct.  There was a  fracture, and
the joint was uninjured.
  The same thing lately occurred in a Parisian hospital.  The surgeon in chief
thought there was a luxation  of  the carpus  backwards.   The patient died,
and a fracture was discovered.  The surgeon in chief was M. Maijolin, whose
skill and integrity are well known.
  Among the  affections  which may be mistaken  for luxations, we shall
describe the following,  of which an account has been given in the Dictionary
of Medical Sciences, and which has frequently fallen under our notice.
  There is a variety of  the  radio-carpal articulation which  has not been
hitherto sufficiently studied by  practitioners, and of which workmen  in
particular trades offer striking examples.   It is especially observed in men
whose hands are subject to  sudden, violent and repeated efforts;  such as
printers and packers of cloth or any goods in which a press is used.  Influ-
enced by these continued efforts, the ligaments of the wrist frequently relax
and extend  so  as to allow the bones  more motion  than in the natural state.
The carpus then ceasing to be solidly fixed to the fore-arm, it yields to the
action  of the flexor muscles, and is found in front of the lower extremity of
the radius and ulna.  All the symptoms of luxation are present, but free from
pain or  inflammation.  The only  inconvenience is a greater or less deformity
and weakness of the part.
  When fracture of the  lower extremity of the radius has been mistaken for
a luxation,  or even left to itself, very serious changes take place in the limb;
the interosseous space is obliterated;  the fore-arm instead of presenting at
this point a surface flattened anteriorly and posteriorly, has a cylindrical form;
pronation and supination are lost.
   When the existence  of a fracture  is not known, the swelling of the soft
parts remains for a long time; the joints remain nearly immovable for a con-
siderable period ; in old persons especially this embarrassment of motion is
with great difficulty removed.   If the fracture be complicated with rupture
of the  ligaments of the  inferior radio-ulnar articulation, the unnatural mobi-
lity of  the bones upon each other will remain during life.
   In order to effect the reduction of the fracture, I remove the arm from the
body; the dorsal face  of the hand is turned upwards, and the fore-arm demi-
flexed on the arm.  The assistant who makes counter extension takes hold of
the  arm at its  lower  part.  Another  extends  the hand gradually, combining
the  extension with an inclination of  this part towards the ulnar edge of the
fore-arm.   The surgeon standing on the inside of the limb, compresses with
his hand the muscles on both sides of  the fore-arm, in the interosseous space;
then, acting on the two fragments, he pushes them towards each other in order
 to remedy the displacement in the  direction of the length.  The fracture is
 easily reduced,  but it is not always so easy to keep the fragments in proper
  relation to each other.  Having terminated this first stage of the operation, I 
CLINICAL SURGERY.
349
apply the ordinary apparatus for fracture of the fore-arm ; that is, a graduated
compress on  each side of the arm, and above that a splint extending on the
hand, the whole covered by a roller.   This plan combines all advantages, and
is infinitely preferable to placing a roller first, or graduated compresses, then
the bandage  and splint.  The bandage in this case by compressing the frag-
ments laterally, destroys the interosseous space which has been restored by
the reduction.
  A circumstance of which no notice has been taken by writers, and which
nevertheless  is very important, is presented in fractures of  the lower extre-
mity of  the radius; it is the tendency of the hand and inferior fragments to
incline from the radial edge of the fore-arm.   It is remarkable, I  observed in
my lecture on fracture of the fibula, that in fracture of the inferior extremity
of the radius, the same re-entering angle is observed on the side  of the frac-
tured bone, and the same saliant angle on that of the ulna, and  that these angles
are, in that case, as in fractures of the fibula, one of the most certain signs of
fracture of the radius.  If this be not remedied, and union takes place in this
position, there is deformity and greater or less embarrassment in the  move-
ments of pronation and supination.
  This displacement is sometimes so marked, that a  considerable projection
of the ulna inwards results from it, the bone appears curved, and practition-
ers have frequently supposed there was luxation of its lower extremity.
  At least twenty years since, I remarked the great tendency of the hand to
turn inwards  in fractures of the radius ; but until recently had found no other
means of preventing this displacement, than the more accurate application of
the ordinary  apparatus; but this was insufficient and the displacement was
always reproduced.
  I then added to this apparatus a splint which I called ulnar, formed of an
iron blade, about an  inch in width, of the length of the fore-arm, and which
at its lower extremity was bent  in a  semi-circular shape.  In the concavity
of the circle,  were several knobs at equal distances.  The usual apparatus of
fractures of the  fore-arm being applied, the upper extremity of the metallic
splint was applied against the internal edge of the edge, and between the inner
side of the wrist and the point of the convexity of the ulnar splint, compresses
frequently doubled were  placed  in  order to  separate them  from each other.
Between the thumb and index finger, another compress was placed having at
one end two tapes.  These tapes were carried before and behind the hand,
over the concavity of the splint, and fastened  to one of the knobs.  The hand
which inclined  towards  the radial  side  and  was forcibly separated from the
splint, tended to approach it;  it experienced  at the same  time an oscillatory
movement, by which  it leaned more or less towards the ulnar side, according
to the height at which the tapes had been tied.  The ulna turned inwards,
thrust the two fragments of the radius outwards.   By this modification of the
ordinary apparatus of fractures of the fore-arm, based on  the same principles
as tho^e which led me to devise an apparatus for fractures of the inferior
extremity of the fibula, all possible indications  to effect a cure without de-
formity are fulfilled.
  Case.__Fracture of the left Radius from a fall on the Palm of the  Hand,
untreated for  Twenty days.  Deformed consolidation; Rupture of the Pro-
visory Callus;  Cure ; Discharged on the twenty-fifth day.—L---69 years 
350
LECTURES ON
of age, of a good constitution, came into the Hotel-Dieu,  on the 11th of
December 1820, with  fracture of the left radius, near its inferior extremity,
produced by a fall on the palm of the hand.
  No surgeon had seen the case, the patient supposing it was merely a sprain,
had used emollients for twenty days, without much relief.
  The pain continued; the deformity instead of disappearing increased  daily;
motion, instead of being restored, became more and more limited, and if bony
union had taken place in this position the movements of pronation and supina-
tion would have been lost forever; lastly, the swelling of the limb continued in
the most obstinate manner.
  On her admission into the Hospital, twenty days after the accident, the
limb presented a remarkable deformity; the  hand  was strongly abducted;
there was a deep depression at the lower extremity of the radius  at the  seat
of fracture, the movements of pronation  and supination were almost imprac-
ticable and very painful.
  Notwithstanding the lapse of time since the fall, I thought it would  not be
impossible by proper means to restore to the limb its natural shape. But, to
effect this, the provisory callus must yield to the attempts at reduction.
  On the next morning  this reduction was tried;  an assistant, holding the
upper part of the fore-arm, made counter extension.   Taking hold of the hand
of the same side, I moved it in a direction contrary to that given it  by the
fracture; that is, brought it gradually into adduction.  The callus yielded,
the fragments  of the fracture were carried outwards, and  the interosseous
space increased.
  Nothing more was now necessary than  to preserve the limb in its present
natural shape  during the time requisite for its consolidation;  and in order
to effect this, the ordinary apparatus for fracture of the fore-arm was applied;
to keep the hand in the direction of  adduction, the ulnar splint already spoken
of was also applied.                                                     Jt
  On the 15th of January, she left the Hospital; all  deformity having disap- «
peared, the union perfect, and the  interosseous space restored, the limb was
commencing to be able^ to execute the different movements of which it is sus-
ceptible,  (M. Hatin, clinical report of  the Hotel-Dieu.)
  Case.—Fracture of the Inferior Extremity of the Radius, not recognised
for  twenty-nine days;  Union with Deformity,  and entire restoration.—
Julius Bechet, 10 years of age, fell, on the 29th of September, 1820, from the
branch of a tree, on which he was swinging, a  height of about 15  feet.  Both
hands, knees,  and the chin struck the ground,  but the palm of the right hand
experienced the greater part of the shock; he heard at the same time a crack-
ing noise, but  did not  know in what part of his  body it was produced.   A
surgeon was immediately called, who having examined the right wrist  where
the pain was  principally situated, said it was  merely a sprain,  applied some
leeches, and surrounded the part with discutient applications.   The swelling,
pain, and difficulty of motion continuing, and the parents observing, with much
uneasiness, that the hand and wrist of their child  had not their natural shape,
consulted me,  on the 28th day.  I supposed it to be a fracture of  the inferior
extremity of the radius.   In fact,  the hand was no longer in the direction of
t: ? fore-arm,  but inclined towards  the radial side;  on the  same  side,  at the
distance of half an  inch from the styloid process,  was felt an angular 
CLINICAL SURGERY.
351
depression; and at this point  the transverse diameter of the arm was con-
siderably diminished.   The fracture appeared united, for neither mobility nor
crepitation were present.  Relying upon what I had seen, I thought that  I
could by proper means correct the deformity; this opinion  was opposed by
another surgeon who declared, that all attempts at reduction would be accom-
panied with danger.  The parents, however, decided in favor of  the attempt,
and on the next morning (29th day of the accident), I proceeded to the reduc-
tion  in the following manner: standing on the outside of  the patient, who
was seated on a chair, whilst assistants made extension and counter extension,
I seized and held, with my left hand, the upper part of the fore-arm, carried
in pronation, whilst, with the right, I operated on the wrist and drew the hand
towards me, so as to straighten  it and even  carry it towards the ulna; by this
plan, a direction contrary to that communicated by the fracture was given  to
the inferior fragment  of the radius.  By  means of these efforts, continued
and without violence, the reduction was effective, the ordinary apparatus for
fractures of the fore-arm applied whilst extension and counter extension were
kept up, and in addition along the ulnar edge of the fore-arm the iron  splint
was  fastened, by means of which the hand  was kept in the direction of the
fore-arm and prevented from leaning towards the radius.
  The apparatus was removed on the third  day, when deformity was  found to
have nearly entirely disappeared.  It was again removed on the  8th day;
the conformation of the wrist and fore-arm  was perfectly similar to thatofthe
opposite side: the dressing was then reapplied on the 15th, 23d, 30th, and 38th
days.  At this period every thing being in excellent condition, it was not again
used, and in a few weeks the child could use his arm as well as previously to
the accident.
  Latterly M. Govraud does not bring the end of the graduated compresses
lower than at an inch  above the articulation of the  wrist, and supplies their
place below this point by compresses folded  several times so as to form two
pads of  which the anterior  stops above the  projection of the palmar region
of the hand, whilst the  posterior  descends  as far as is desired on the dorsal
face of the metacarpus.
   From  the  foregoing considerations, and the details into which  we have
gone concerning fractures of  the inferior  extremity of the  radius,  we may
draw the following conclusions;
   1st. Without absolutely denying the possibility of luxation backward of
the radio-carpal articulation, although I never have seen it, it may be admit-
ted as excessively  rare, and that perhaps it has never existed  as a consequence
 of a fall  on the anterior part of the wrist.
   2d.  That luxations  backwards of the carpus on the fore-arm,  described as
such by authors, were probably only fractures of the radius, situated at a quar-
 ter,  a half, or  even an inch from  its inferior extremity, or simultaneous frac-
 tures at this same point of the radius and ulna.
   3d.  That the apparatus for  fractures of the fore-arm still  used  by many
surgeons, and consisting of, first, a roller, before or after the compresses, and
then in the application of splints, as recommended  by many highly esteemed
modern  surgeons; that this apparatus, I say, is highly improper and in  no-
wise fulfils the first  and most  important indication presented by the ac-
cident. 
352
LECTURES ON
  4th. That the tendency to displacement inwards so commonly seen in frac-
tures of the radius, and from which result the inclination of the hand, in-
wards, requires the use of appropriate means to push the fragments outwards
and maintain them  in a proper relation and situation, and that the best plan
is to use, under these circumstances, the ulnar splint.
  5th. Lastly, when the fracture has  no tendency to displacement, the sim-
ple  apparatus for fractures of the fore-arm is sufficient, without  having -'
course to the ulnar splint.
                         CHAPTER XLIV.

                            ON AMPUTATIONS.

  The diseases requiring amputation of the limbs are numerous; some of
them belonging to the bones themselves or to  their articulations, and others
more especially to the soft parts.  As a general principle whenever the injury
of the parts is such, that the loss of the limb, at some period, however remote,
must follow, or that the symptoms threaten the life of the patient, the surgeon
should amputate  immediately.   But is  it proper to apply this principle to
each particular case which is met with in practice ?  Assuredly not; especially
when the case is so serious as  to remove all doubts as to the propriety of the
operation, or when there is still a hope of finding, in the resources of art and
nature, some means of snatching the unfortunate patient from the dangers of
the injury, without exposing him to those of the mutilation. You have more than
once  seen  cases of organic lesions whose extent and severity appeared to
demand instant amputation, and which nevertheless, have been cured without
it.  But you have also seen others,  which, although perhaps less severe, have
made us  regret not having performed the operation, on account of their fatal
termination.   Notwithstanding the temerity of  the  surgeon  is  frequently
justified  by success in organic lesions produced  by ordinary causes, this is
seldom the case  in gun-shot wounds (see chapter on gun-shot wounds).  I
have before  said, and let me  here  repeat it, let us  not be deceived by ill
founded  hopes.  Military surgeons  were formerly accused of performing too
many amputations; but the experience I have acquired principally  in 1814-15
and 1830 has convinced me how unjust is this reproach; and I fear  not to
establish as a principle in compound fractures produced by gun-shot wounds,
that by delaying  the amputation, more  individuals are lost than limbs are
saved.
  A man was admitted, in 1832, into the  Hotel-Dieu, in whom a ball had
traversed the  elbow joint, broken  the  olecranon, the inferior portion  of the
humerus and the superior part  of the ulna.  Notwithstanding this extensive
injury, we  endeavored to save the limb.  Every thing went on well for the
first few  days, but on the 9th the patient became much emaciated ; the wound,
grayish,  wan color, presenting a degeneration analogous to hospital gangrene;
the pus was unhealthy and  the limb was so much agitated  as to displace the
fractured bones.  Three days afterwards diarrhoea came on, then symptoms 
CLINICAL  SURGERY.
353
of an ataxic fever.  Amputation was performed on the 20th, but with little
hopes of success; indeed the patient died on the same  day.   On examination
we found  a phlebitis of the  brachial vein and purulent abscesses in both
lungs.
  On the 7th of July, 1832, a young man 16 years of age, was admitted into
the hospital, who had fallen from a great height upon the floor through the
trap-door of a granary.
  The bones surrounding the  ankle-joint seemed to have been crushed by the
force  of the fall: the tibio fibular articulation was evidently enlarged : their
was a compound fracture of  the leg of the same side,  with  projection of the
fragments ; the lacerated muscles and cellular tissue came out of the wound
which discharged a black blood; so great an injury appeared to demand imme-
diate  amputation. Notwithstanding this, relying on the youth and strength,
we preferred to trust to the efforts of nature.   The different reductions were
effected ; proper dressings applied; he was  bled several times, and leeches
applied ; a strict diet  was ordered, in order to prevent too much inflammation ;
he had no  fever, chill nor swelling of any part, and after a tedious period of
uninterrupted progressive amelioration, he was discharged perfectly well.
  After numerous examples of similar accidents  which had occurred during
the preceding month, and which, simplified or not by amputation, terminated
fatally, this case suddenly contradicted the fatal prognosis which we might
have laid down  as a general principle.  I have seen fractures less complicated
than this require amputation or end in death.  I have seen others of the same
nature get well; so that the  prognosis of this kind of injury is subjected to
great uncertainty.  How can we explain these opposite results ?  By differ-
ence of organization, undoubtedly, whose cause are unknown, whose symptoms
cannot be foreseen, which can be ascertained only by the result.  In doubtful
cases, the age  must  undoubtedly be regarded as  one  of the most important
reasons for delaying  or hastening the amputation.  This case enables me to
point out another contra-indication, founded on the prevailing constitution of
the atmosphere.  Should we decide on an  amputation, otherwise rationally
indicated, when numerous preceding cases assure us, to almost a certainty, of
a fatal result ?   The maxim of the ancients is here applicable, that it is better
to let the  patient die than to kill him, and it is prudent to delay the operation,
however necessary it may appear.
  The fatal influence of the constitution of the atmosphere is not unfrequently
felt in large hospitals.   In the Val-de-Grace, phlebitis has been known to
follow, for°a period of two weeks, the most expert venesection ; and in the
most  simple affections, even in the Hotel-Dieu, consecutive phlebitis has, at
certain periods, been so frequent, that for a long time  we were obliged to lay
aside the use of the lancet.
  If in  general the  necessity  of the primitive amputation result  from the
extent of  the organic lesions, especially when produced by gun-shot wounds,
it may be  said that the excess of this extent is itself a contra-indication.   The
following  is a pertinent  case; a boy, 17 years of age, carrying a bucket in
each hand, after having passed  from the roof of one house to that of another,
endeavored to  enter a  narrow dormer window : unfortunately he had only
calculated on the breadth of  his body, so that on his attempting to pass in,
the buckets struck with so much violence against the sides of the window that
                 45 
354
LECTURES  ON
  he was thrown over backwards.   He therefore fell from the 6th story, without
  any thing to impede his velocity,  and  struck  the  ground with his  feet, from
  which arose a most complicated injury.  The left heel was  dreadfully con-
  tused, the calcaneuin and bones of the tarsus crushed, the fibular and tibia
  separated at their articulation, the extremity of the tibia crushed, and the leg
  fractured at its superior third.  The contusion of the right foot was not  so
  great;  the leg was  fractured at its middle, and  the upper  fragment of the
  tibia, stripped of its periosteum,  oblique and cutting, projected outwardly.
  The extreme weakness of the  patient did not allow us to bleed him on the
  first; it was done on the next, but that day he died.
    This is certainly one of the most severe cases on record.   Still there are
  examples of  individuals having  survived in  similar  circumstances,   if the
  injury here, had been confined to  one side, amputation was the only resource.
  Why was it not performed in this case ?  Because the situation of the patient
  was so dangerous and complicated, that it could not have  been simplified  by
  an operation, which would  therefore have been  useless,  and consequently
  contra-indicated.   It may be said that military surgeons have amputated both
  legs when fractured by a cannon  ball, and  thus saved more than one life.
  The cases are not parallel; in our patient we  must take into account, besides
  the vast injury of the lower extremities, the general disturbance  resulting
  from a fall from so elevated a place, and communicated to the organs of the
  great cavity, and above all to the brain.
    Such are very nearly the  same reasons, for which I  would refrain  from
  amputating in the following supposed case;  a man of middle  age, falls from
  any great height upon the pavement; he  meets with extensive injury; 1st,  a
  large lacerated wound of the forehead, exposing the os frontis, and compli-
  cated with fracture of  the base of  the orbit; 2d, a compound fracture of the
  right thigh, with contusion in front of the patella; 3rd, the left tibia and fibula
  carried behind the condyles of the os  femoris, and the patella broken into
  fragments, three or  four openings   into the joint already full of blood and air.
 Lastly, without speaking of the probable disorder of the viscera, the patient is
 delirious when brought to the hospital.  This case afforded but little hope, and
 indeed he soon perished.  Under  such  circumstances should  amputation be
 performed ?  The nature of the injury of the  extremities certainly  required
 amputation of both thighs ; but after this double operation, we have remaining
 the wound of the forehead; with fracture of the orbit, nervous delirium and
 probable lesions of the  internal organs.   The situation of the patient could
 not be improved, and the  operation  ought  not to be performed.  Much  more
 serious accidents sometimes  follow a  fall upon the feet, from an  elevated
 position.  I have seen a case, where the head of the femur, piercing the cotyloid
 cavity, had passed entirely into the  pelvis ; and  another, where the whole force
 of the blow having been sustained by the spine, the bodies of four vertebras
 have been  crushed, and the spinal column diminished by this enormous space.
   Luxations .with extensive laceration of the soft parts and especially of the
 vessels, are sometimes followed by such severe symptoms, as  to  have been
 early  classed among those cases   imperiously requiring amputation.  The
 agonising  pain produced  by inflammation, the gangrene which frequently
follows and which nothing can arrest, death itself preceded by most intense
suffering, must appear to be reasons proper to justify some general rules as 
CLINICAL SURGERY.
355
 regards this subject.  This rule is,  however, liable  to numerous exceptions.
 If the laceration is not very extensive;  if the luxated bones are not at  the
 same time fractured ; if the nerves and principal vessels are not torn, and
 gangrene does not appear inevitable, the parts should be restored to their
 proper situation, incisions  should be made if necessary, <o prevent extreme
 tension, and we should use antiphiogistics and anodynes of all kinds; prevent
 bad symptoms, or attack them rigorously should  they arise.   But if the  in-
 teguments, tendons, ligaments and articular capsules are much lacerated ; if
 the bones are fractured and  at the same time the soft parts torn  cr violently
 contused, lastly, if the joint is of too little importance to expose the patient to
 secondary symptoms by preserving it,  we should not hesitate  to  practice
 immediate amputation.  Such cases  are frequently met with in the wrist and
 ankle joints.
   The uncertainties obscuring the indications  of primary amputation are "-en-
 era! ly neither so great nor  so numerous as those attending secondary or conse-
 cutive amputations; that is those required by the  progress of the pre-exist; :.^
 disease.
   Exceedingly embarrassing cases, however, sometimes occur.  Among the
 pre-existing maladies which demand  amputation, some affect the joints, others
 the limbs ; some are seated in the bones and  others in the soft parts   It is
 proper to determine what are the  characteristics  of  both, which  leave  only
 this last resource.
   1st. I have frequently performed amputation for white swellings of the joints;
 let us  now inquire for what reasons, for  we cannot here establish,  a priori,
 general rules; it is only from the investigation of  individual  cases, that the
 motives of treatment in analogous cases can be deduced.
   A child of 7 or 8 years of age was attacked with an inflammatory engorge-
 ment of the elbow, in consequence of a fall on the  part.  This  affection, per-
 haps, was badly treated in  the city ;  perhaps  also  the feeble  and scrofulous
 constitution of the patient, contributed to the ill success of the means  em-
 ployed.  From some cause, however, the swelling and engorgement continued
 and increased ; the cartilages and bones themselves were attacked ; abscesses
 formed in several places, and left fistulous openings.   Moxas and the cautery
 were used in vain at the hospital ; the disease progressed,  and a considerable"
 transverse motion took place  as if the articular ligaments  being  destroyed,
 could no longer oppose the  displacementof the bones.  Crepitation was very
 manifest.
   In such a case I thought  the amputation of the  arm indispensable; it was
 performed and the  child got well.
   Let us relate another case of the same nature in which amputation was not
performed, and yet a cure was effected by anchylosis.  It will be easy to infer
 from the comparison of the two cases, the  difference of indication  and the
reasons for the treatment in each.  A young man was admitted into the Hotel
Dieu in October, 1331, for  a white swelling  of the right elbow joint.   The
latter was very large, the ligaments so much softened that  the  fore-arm  was
capable of very extensive transverse movements on the arm, movements, which
in  the °in<ilimoidal articulations, are,  as is well known, a  certain index of
great alteration of  the surrounding soft  parts, and consequently  of an  at?
vanced stage of white swelling.   The least motion  of the fore-arm gave exc€=>- 
356                           LECTURES ON
 sive pain.  Notwithstanding this disease, I preferred before amputating the
 trial of other therapeutic remedies.  Moxas  were several times applied around
 the joint  with advantage.   Several large abscesses formed, which opened  at
 several points and discharged at first a great quantity of pus.  The proper
 treatment was followed.   A remarkable and  progressive improvement took
 place; the joint became gradually stronger and less movable ; and in process
 of time a cure was performed by anchylosis.
    In these two cases the reasons for my conduct were, in the first, the  ineffi-
 ciency  of the remedies, and the unceasing progress of the  disease; in the
 second, the advantage resulting from the  use of those same  remedies.   It
 must not be forgotten, indeed, and this remark applies  to all organic lesions,
 that the removal of the  limb should  always be our  last resource.   Another
 consideration  had  great weight  with me   in the above cases ;  the  second
 patient had a good constitution, his general  health and strength were not im-
 paired ; there were no symptoms of any disease of the internal organs; neither
 fever, nor diarrhoea;  much was to be hoped from the efforts of  nature.  The
 former, on the contrary, was of a scrofulous constitution, a prey to a conti-
 nued fever, a progressing emaciation, and his strength was daily diminishing.
   2d. A  violent inflammation of the articulations or abscesses, following
 chronic inflammation, sometimes demand amputation of the  limb.  The fol-
 lowing is a remarkable case, which has given rise to the double question of the
 propriety of amputations or whether it was preferable to simple resection of
 the diseased bony structure.
   A young man, 20 years of age, having contracted a very well marked syphi-
 litic disease,  was attacked, after three months of  active treatment, with dull
 and deep seated pain in the right  shoulder  joint.   We will observe  here
 that this young man occupied a very damp  chamber.  Enormous swelling
 followed, without redness of the skin, and  there  was soon  total  loss of
 the movements of  the fore-arm.    At a  later  period, the  skin  became
 of a violet  color,  thinned, ulcerated, and a fistulous opening established
 a  communication between the cavity of  the joint  and  the  atmosphere.
 I-.i this state he entered  the  Hotel-Dieu on the  9th of September, 1829. A
 sanious, fetid pus was discharged from the fistula.;the patient was pale, weak,
 and complained of  continual pain.  After having tried, for a few  days, with-
 out advantage the antiphlogistic plan, we were inclined to prescribe  another
 anti-syphilitic course; the affection of the elbow increased  in malignity; the
 pun was intolerable.   On examining the state of the  joint the bones  were
 fund denuded, the articular extremities movable  in every direction,  and
 an  operation was determined upon as the only  means of arresting the  pro-
 gress of the disease.  But was it proper to perform amputation or resection of
 the articular surface?   The chance of both operations having been explain-
 ed to  the  patient, he soon decided the question, by preferring amputation,
 which was performed by M. Breschet on the 15th of October.   On the 7th
 November the cicatrization of the stump was complete.
  Now were we correct in yielding to the patient's wishes? The anatomico-pa-
 thological examination of the limb shall answer the question.  We have seen
 the external appearance of the part and  particularly of the skin: let us
 inquire  further.  The cavity of the joint contained about eight ounces of sani-
ous pus.   The  cartilages were destroyed and the bony surfaces  exposed, 
                           CLINICAL SURGERY.                         C)57

 were  red  and  porous,  the  medullary  canal  of the  bones was  injected.
 The  scalpel  penetrated  easily the  inflamed  bony tissue.  The ligaments
 were  partly destroyed and  the remaining portions  of them softened and,
 as it were, putrified.   No vestiges of a synovial membrane were found.  The
 external cellular tissue was  changed into pus.  Purulent  abscesses were
 found in the surrounding muscles, which were pale and softened.  None of
 the vessels were changed.
   Can an abscess of a joint, resulting from  chronic  inflammation, be cured
 without amputation ?
   It is necessary to know how long the abscess has existed, its extent  effects
 upon  the different parts of the joint, the consequences  of its  spontaneous or
 artificial opening.  A  child of 10  or 12 years of age had  met with a vio-
 lent sprain of the ankle joint, three years since.   From that time a chronic in-
 flammation had constantly existed around the  tibio-tarsal articulation; and
 when the child was admitted into the Hotel-Dieu, in March 182.8, there was
 considerable tumefaction with obscure fluctuation on  the inner  side  of the
 inferior extremity of the leg.   Externally the swelling was less marked.  The
 movements of the articulation were still free.   I thought of opening  the ab-
 scess ; but the fluctuation was obscure ; the disease had existed for three years;
 an-unequal resistance and feeling of fungus was communicated-to the fingers ;
 and I concluded that amputation was the  only  chance.   The le<»- was  there-
 fore removed and the  boy soon  recovered.  The limb was  dissected.  On
 opening the internal abscess a serous and flocculent pus escaped ; the abscess
 was muitslocular; several of the tendons  which had been primitively denuded
 were  covered  with  a fungous matter easily removed by the back  of  the
 bistoury.  The  articular  cartilages  were destroyed, the extremities  of  the
 fibula, tibia, and  astragalus carious.  The external abscess contained a small
 quantity of  the same kind of,pus.
  3d.  We include among the indications  of amputation, caries of long  stand-
 ing, friv\n<r rise  to copious suppuration, whether  situated at .the articular ex-
 tremities of  the bones, or  their centre, and necrosis  of the  same  date, deep
 and accompanied by too copious suppuration.   Caries of the articular surfaces
 often merely demand their resection; we  shall see under what circumstances.
 As to necrosis, it is only in particular cases that it becomes an indication  of
 amputation, as for example when it.affects the whole thickness of a long bone;
 the following is a case in  point.
  A tailor, 49 years of age, of a  strongly marked lymphatic constitution, had
 had in early life a large scrofulous abscess in the middle of the leg, and  of
 which evident traces were left.   Since then he had  always enjoyed  good
 health.  Towards the end of 1829, this same limb became inflamed, and not-
 withstanding an nctive antiphlogistic treatment  an abscess formed, and was
opened by a surgeon.   The wound did not heal, and the patient entered the
 Hotel-Dieu, in the early-part of. November, of  the same year.  There was
great loss of substance of  the anterior and external part of the  leg; a fetid
suppuration and exploration by the probe  soon evinced the nature of  the dis-
ease.   It was evident  that the  abscess,  instead of constituting the original
disease, was  only a  symptom of caries or necrosis.  After having ascertain-
ed as well as possible  the extent of the  disease, amputation  was  proposed
to the patient as his only chance of life.  In the meantime having made sonu; 
358
LECTURES  ON
 slight exertion during the night, the tibia was fractured at the sent of the dis-
 ease.  The general symptoms being then too  severe, our attention  was  di-
 rected to soothing them.  The operation was performed on  the  12th of De-
 cember.  The dissection of  the  limb discovered a necrosis  mingled with
 caries of the tibia, which was diseased throughout nearly its whole thickness.
   4th.  Gangrene or sphacelus forms also one of the most positive indications
 of amputation.  But before deciding, it is of the greatest importance to deter-
 mine the cause  and nature of this gangrene; and from a knowledge of the
 etiology of  the disease  will result the  solution of the question so much agi-
 tated by our predecessors,  namely, whether we should iivsncli cases,  wan'
 until the progress of the mortification be  arrested,  and its limits  defined.
 Thus, when a wound is the cause of this  accident, or when it depends on
 attrition of  the parts, the extent of local disorders, the rupture of an artery,
 or the division of the principal vein and nerves of a limb; when, in short, the
 mortification does not seem  to depend on a general lesion, or some internal or
 hidden  cause, the amputation should be performed without delay.  When,  on
 the contrary, its causes, as frequently happens, is the  complete or incomplete
 obliteration of the  artery or principal vein  of the limb, from ossification  of
 the first, or mechanical obstructions of the  cavity of  either, amputation  can-
 not prevent it from extending, nor limit its ravages.   Such are cases of senile
 gangrene, more properly, in'my opinion, called symptomatic gangrene.
   A man, 36 years of age, in a drunken  fit, fell under the wheel of a cart
 laden with building stone; the wheel passed over his thigh.  There was a com-
 minuted  fracture of the femur, but without  alteration of the integuments.
 Enormous swelling and  violent inflammation immediately followed.   He was
 instantly carried to the hospital. The limb was cold, amputation was proposed,
 but he obstinately refused to submit to it; the fracture was therefore reduced
 and  dressed.   Delirium supervened ; and   the dressing was constantly de-
 ranged  in consequence of  his agitation.   Vesicles  appeared on the foot,
 gangrene took place, extending to  the leg and  thigh, and did  not seem
 about to  cease there.   The patient was extremely weak ; pulse small and fre-
 quent ; delirium continued ;  the straight waistcoat was applied ; the belly was
 tense, painful; the liver  appeared engorged and extended beyond the ribs; the
 skin had a decided icterose hue ; there was diarrhoea.   What was to be done
 in such  circumstances ? Shall  we amputate, and  does  amputation give the
 unfortunate  man any hope of life ? The gangrene, indeed, is not arrested, and
 authors  have laid down  as a general rule not  to amputate until this is effected.
 fiere  this rule is  inapplicable;  the cause,of  the gangrene is  the fracture and
 accompanying injury. Therefore, far from being a contra-indication to the ope-
 ration, it is a proof of its necessity ; but the desperate situation of the patient,
 tiie tension  of the belly,  the  swelling and  engorgement of  the soft parts of
 the thigh, into which blood is largely infiltrated ; the fear lest the contact of
 the air increase still more the inflammation, justify our hesitation.
   However, a slight  improvement took place; the belly became less tense,
the icterose hue  less pronounced, the gangrene was arrested.   The  patient
earnestly demanded  the amputation  of  the  limb, now become insupportahly
offensive to  him.  It was performed on the 25th of April, but it is useless to
add that he soon sunk.  This  case demonstrates clearly how necessary was
tLe immediate removal of the limb, and apart from the  chances always uncer- 
CLINICAL SURGERY.
359
 tain of so serious an operation as amputation of the thigh, it may be said that
 the obstinate refusal of the patient cost him his life.
   Gangrene sometimes appears on  a fractured limb  in consequence of the
 compression of too tight a bandage which has not been removed for several
 days.
   In these cases the cause is entirely local, well ascertained, as amputation is
 required only when all other means  to arrest the mortification have failed.
   5th.  Osteo-Sarcoma, Spina-Ventosa, Tumors called Fungus Lymphatic,
 which are situated in  the periosteum,  Cancer, Fungus Hecmatodes, Hydatid
 Cysts developed in the bones and articulations frequently require amputation.
 Cancer, when it is large, immovable,  extending beyond the  integuments, com-
 prising' the aponeurosis, vessels, nerves and muscles, and a fortiori when it
 penetrates as far  as the bones.  Fungus haematodes, when it cannot be com-
 pletely extirpated, or when it has attacked a very large portion of the limb;
 osteo-sarcoma, if  it embraces  the whole thickness or more or less extent of
 the thickness of a long bone, or if being seated in the articular extremities, it
 has attacked at the same time both surfaces of the joint, and produced serious
 disorganization  of the  soft parts  and copious  suppuration.  As to  hydatid
 cysts, it is imminently dangerous to open them; death has sometimes followed
 the operation, and even when the patient is cured, it  is only after very severe
 inflammation, and hence sometimes follows the necessity of amputation.  But
 this necessity becomes  much more imperious, in  consequence of the degenera-
 tion of  the tumor,  or its transformation into a lardaceous substance.
   6th. Aneurism is  sometimes complicated with  so  much  general derange-
 ment, as to leave no hope of cure by the ordinary means, amputation must
 then be performed.  These cases  are  now rare, thanks to the progress of
 science.  This last resource is indicated when the  surrounding parts  are so
 deeply disorganized  that the ligature presents  no chance  of  success, when
 there exist ossifications of the artery beyond which  the ligature cannot be
 applied; or when from  this cause  or from gangrene  secondary haemorrhage,
 &.c. takes place.
   Tth.  Is amputation an efficient remedy in traumatic tetanus?  I  have ex-
 pressed my opinion on  this subject, when treating of gun-shot wounds.   I then
 pointed out to you how erroneous were the ideas of several celebrated teachers,
 ;.nd how vain were the hopes founded on this remedy.  The bite  of a rabid
 animal is in the opinion of some a good reason for amputation.  A surgeon in
 London recently amputated the arm of a man bitten in the hand by a mad
 dog; the individual nevertheless died of hydrophobia.  It  might be allowed
 if  the bite was in a part of little importance, a finger  or tee for instance, and
 even then it should be performed before the absorption of the virus had taken
 ,-lace.
   8ih.  It has often been my lot, during a long practice, to be requested to
 perform  bloody operations, and amongst others amputations on  individuals
affected with  deformity, either congenital or resulting from  previous disease,
such as false articulations, anchylosis, adhesions, contractions of  the  fingers
or  toes, &c.;  sometimes I have yielded to the entreaties, but more frequently
have refused; and the  following  reasons have  guided  my  conduct  in both
cases.  One very powerful motive which should  teach surgeons the greatest
prudence  is,  that  it is  proved by experience that these operations, called 
S60
LECTURES ON
operations of convenience, are, all  other  things being equal, more frequently
followed by fatal consequences than those required by actual disease or acci-
dent.  We have often seen in this hospital, and elsewhere, the simple removal
of a finger or  toe for a deformity  followed by  tetanus, delirium tremens,
gangrene, and general symptoms which carry off  the patient in a  few days.
Therefore, as a general rule, the surgeon should not operate in these  cases,
unless there be an absolute necessity.   This  necessity exists when  the  de-
formity incapacitates the patient from providing for himself or  his family, or
whenever, from the disposition  of the parts there  must result a  secondary
affection which will render amputation indispensable.   In the  former case it
is an act of humanity, which it is  the surgeon's duty to perform, if not evi-
dently contra-indicated ; if the  latter, it is only an operation anticipated  by
which the patient may be spared the chances of a secondary disease.
  Such are the  majority of diseases  in which  amputation of the  limb may
become necessary.   But the task of  the surgeon is not fulfilled when he has
ascertained that this operation is indicated  by the  nature  of the  injury, its
incurable character,  or the immediate danger of the patient.  He must examine
if there be not other lesions which  conlra-indicate it, render it useless, or
even hasten the fatal  termination.  He  should ascertain  if the disease be
local;  if its ramifications do not extend as far as  the regions of the trunk, or
at least to a part of the limb beyond which the knife cannot be applied ; if it
have not produced sympathetically changes in the viscera;  or if it do not co-
exist with some other organic affection.  In cancerous affections, particularly,
it is known  that  the lymphatic  system undergoes with great  facility a  de-
generation analogous to that of the part primarily affected ; that the ganglia
soon become  the seat  of engorgements, appearing first in the  vicinity, and
afterwards in the thoracic and abdominal cavities.  Thus we must first ascer-
tain the existence or absence of  these ganglionic tumors.  Some patients are
so much exhausted by a  long continued  and copious  suppuration, by hectic
fever or absorption  of pus,  by colliquative  diarrhoea,  that amputation is
impracticable, and  in all cases it cannot be performed without raising  the
strength, diminishing the suppuration and diarrhoea, calming the fever, in a
word, without having by appropriate means improved the general health.  The
organs of the thoracic cavity demand a most scrupulous examination.  We
frequently find bronchial catarrhs  or chronic pneumonias in persons laboring
under diseases requiring amputation.  The cure  should if possible be first
effected, and if not the operation must not be performed.  The same thing is
to be observed if one of these diseases or a pleurisy should occur during the
treatment of the external injury, as is often seen in  hospital practice.  Nothing
is more common than the co-existence of a tuberculous affection of the lungs
with an external injury, which has no resource  but  amputation, especially in
scrofulous subjects.  This affection, sometimes latent and  difficult to recog-
nise, is generally manifested after  the operation by  formidable  symptoms
which soon destroy  the  patient.   Lastly,  amputation  is sometimes  contra-
indicated by the extent and magnitude of the injury itself.
  Among the palliative means  calculated to soothe the agonizing pains of
cancerous and osteo-sarcomatous  affections, I have for a long time observed that
narcotocs, and amongst them the extract of aconitum enjoy apeculiar efficacy.
indeed having prescribed it to two patients in the  dose of a grain to a grain 
CLINICAL SURGERY
361
and a half, they have  felt  so  much relief as to express loudly the  next day
their joy at having tasted a sleep unknown to them for so long a time ; I have
continued its use, combining it with the extract of opium, and the pain has
nearly entirely disappeared.
  The necessity of the amputation being granted ;  writers have debated this
question, namely, what is the period of the disease most suitable for the opera-
ion?  I must confess I cannot understand the interminable discussions  on
this subject.  The solution of the question is necessarily based on the nature
of the indications.  The  symptoms on which these  are founded carry with
them the  urgency of  operating  or the power of temporizing.   If we have
lost all hope of preserving the life of the patient, by preserving his limb, no
reason  can  justify  the  delay;  should any hope remain, it is  because the
necessity of the amputation is not well proved.  Too often, indeed, is the fore-
sight of  the practitioner deceived, but that merely proves  that science is as
yet far from affording us elements of diagnosis capable of preventing similar
mistakes.   Thus, 1st. If we have a serious accident, such as the crushing of a
limb or any other part by a heavy body or a gun-shot wound, which demands
immediate amputation, the danger of fatal symptoms which may arise at every
moment,  by indicating  its necessity,  indicate equally the  urgency of  its
immediate  performance.  Experience, especially of late years, has too well
convinced me how  erroneous is the opinion of those who  think it better to
wait in these cases for the development  of the first symptoms of reaction,
than to amputate under the influence of the disorder and commotion of the
organism produced by the  external violence.  The great difficulty lies in dis-
tinguishing  with  certainty, in the multiplicity of  analogous  cases, those in
winch amputation is or is not of absolute  necessity.  2d. In case of copious
suppuration, as long as it does not influence materially the  general health of
the patient, no indication  exists; but as soon as his  strength diminishes, his
constitution becomes impaired,  &c, notwithstanding all  our exertions to
moderate  the suppuration and  maintain the  organic vitality, amputation is
indispensable, and the surgeon  should not wait for a more  unfavorable state
of things.   3d.  As regards sphacelus, I must refer  you to what has been said
on this kind of  indication.  4th. In  case of cancerous, osteo-sarcomatous
affections, fungus haematodes, necrosis, caries, presenting the conditions we
have enumerated, the proper time for  removing the limb will be when the
disease  has been perfectly understood and declared incurable by any other
means ;  for as we wait it will increase, and  reach  on the  economy, and the
chances of  success be less.  5th. Lastly, whenever any complication  exists,
either internal or external, we  must postpone the  amputation  until it shall
have disappeared.  It is useless to add that if a patient come under your care,
exhausted bv pain, by the extreme abundance or long duration of suppuration,
by repeated haemorrhage, &c, the  operation should not be attempted until by
appropriate treatment he has gained sufficient strength to support it.
   Let us now say a word respecting the preparatory treatment.  Some require
strict diet, others a mild or slightly tonic regimen.   If constipation exist we
must use mild laxatives, enemata; if at the moment of operating the bladder
be full of fluid and the patient cannot make water, the catheter must be intro-
duced • should he be agitated, by insomnia, sleep must be invited for some days
previously by appropriate  remedies, &c.
            46 
362
LECTURES  ON
  When the patient is of a bad constitution, scrofulous, scorbutic, &c, or
when the  amputation is demanded in consequence of long standing disease,
which has given rise to copious and  continued  suppuration, I create, some
time beforehand, an issue, either by a blister or cautery, on some part of the
?ound limb, in order to prevent the accidents which might follow the sudden
suppression of the suppuration.
  A woman, 60 years of age, was admitted into the Hotel-Dieu in  January
1830, for a  carcinoma occupying  almost the whole circumference  of the
lower part of the fore-arm.   The date of its first appearance was wry remote,
it appeared  to  have  been determined by mechanical  irritation, and an old
burn was its original cause.  Twenty years ago, she said she had been thrown
down by a carriage of which the wheel fractured the right humerus ; the fore-
arm was grazed and the cicatrix of  the burn  broken, but she was cured, and
only two years  since the disorganization  had commenced, and she  first felt
lancinating pains.  Neither rest, nor different topical applications could arrest
the  disease.  After having  attacked  the whole cicatrix, it reacted upon her
general  health  and disturbed  the function of digestion.   The fetor exhaled
from  the  fungus, and from which nothing could  protect the  patient, might
have had this effect, independently of absorption.  The copious suppuration
and haemorrhage occurring several times daily, could not add  to her  natutal
spareness.  At the time of her admission into the hospital, the fungous mass,
surrounding  the arm like a  bracelet, was  uneven,  reddish;  black  in some
places, bleeding at the slightest touch, and was the seat of lancinating pain^.
About two inches in width, it stood at least one  inch above the level of the
limb."  The  digestion was very much disordered,  but as yet no diarrhoea
existed.
  I saw no chance of safety but in  amputation.   In  order to avoid the acci-
dents which might follow the sudden  suppression of an old and copious sup-
puration, I applied previously a blister to  the  sound limb. The amputation
was then performed at a distance of three inches from the elbow.
  The fundus arose from the tissueof the cicatrix ; the sub-cutaneous cellular
(Issue, aponeuroses and bones  were sound, the carpus was in a state of forced
flexion.  The fungous mass soon lost its color, it became soft, friable, resembling
cerebral substance.  The patient did very well for  a  few days ; but intense
thoracic and abdominal symptoms  supervened, and she  died  at the end  of
eight days.
  It is the duty of the surgeon to show every kind attention to the miserable
b?ings who are reduced  to  the  necessity of undergoing these cruel mutila-
tions.  Let  him, by every means in his power, gain their confidence, and
animate their sinking courage.
  He will succeed by sympathizing with their misfortune, deploring the im-
potency of the  remedies of art hitherto used to preserve them from thi-s last
alternative,  by  pointing out the chances  of a speedy and certain cure,  in
exchange  foY inevitable  death: by fortifying their  alarmed  imaginations
against the pain inseparable  from  an operation ;  and by  pointing out all the
means which still remain to provide for themselves  or their families.  And
here observe the vast difference in the morale of hospital patients, and of men
wounded on the field of battle!  The soldier, accustomed to entire self-denial,
accustomed  to  fatigue, familiar with  danger and death, is happy to preserve 
CLINICAL SURGERY.
363
 his life at the cost of a limb;  and certain of his pension, he submits courage-
 ously, and even  sometimes cheerfully to the knife of the surgeon.  But see
 that unfortunate workman, farmer, or artisan, whose numerous family depend
 on his industry and labor, haunted by the fear of  the misery that awaits him ;
 his countenance expresses deep sorrow, profound melancholy, and  even
 despair: he  yields reluctantly to the supplications of his surgeon, and often
 obstinately resists at a time when the operation  presents but little hope of
 success.  Wonder not, therefore, at the  difference of the results obtained in
 the two theatres, whose conditions are so widely different.
   Some patients are struck with stupor  and horror, at the  mere idea of the
 operation.   Many, ashamed of their weakness, make a.violent effort to over-
 come it; but they submit then, rather like victims than brave and determined
 men, and remain impressed with the idea that the operation  must necessarily
 be fatal.   No  state of mind can be more unfavorable than this.  As Ions
       ...                                                  *
 as it exists, the operation must be deferred.   The patient should regard the
 operation as the  only chance left to him.  Hope should animate and sustain
 him: if he despair,  and dream only of  death, it is rare  that a consecutive
 encephalitis does not occur, and cause a  fatal termination.
   The  imagination undoubtedly exerts  great influence  over the  success of
 operations, and  much of their danger must  be attributed to the foresight of
 man; that  faculty he possesses of looking  into  futurity, of calculating  its
 chances, and his, proneness to be agitated and disturbed at the aspect of im-
 pending evil.
   Thus, operations  generally succeed better in  children, who,  unprovided
 with this too  often fatal power, bear them without any moral agitation, regard-
 less of the result.
   We should generally mistrust the power of resistance of  those individuals
 who, after having consented with great  reluctance to an operation, suddenly
 decide, at the same time exhibiting marks of extraordinary courage.  Subse-
 quent delirium  and  fatal  exhaustion are  to be  feared.   Mistrust also those
 who hitherto feeble  and pusillanimous, affect a sang-froid almost  amounting
 to indifference.   Nearly always overwhelmed by  the blow, they disguise
 their terror by an affectation of tranquillity  of mind which  they are far from
 possessing.   During  the operation, they  make every effort to repress any ex-
 pression of pain.  But this.struggle having exhausted their strength, they fall
 into a state of stupor  and collapse, from which nothing can arouse them. The
 sensibility resembles  the blood : the fountain of the former may be exhausted
 bv pain and  the moral affections, as well as that of the latter, by too great a
 loss; and  this reflection  should always be a powerful motive in deciding on
 an operation.
   The instruments required are, 1st, a tourniquet;  2d, straight knives, single
 or double-edged; 3d, two bistouries, one straight, the other convex-edged;
 4th, a retractor;  5th, amputating saws.
   The apparatus for  securing the vessels and the  dressing are numerous: 1st,
 dissecting- forceps, a  tenaculum, and armed needles; 2d, ligatures of different
 materials and sizes ; 3d, adhesive straps, six or eight lines in width, and of
.different lengths; 4th, charpie  or scraped lint;  5th, some  long compresses;
 6th, rollers, five or six yards in length, and three fingers' breadth wide; 7th,
 small pieces of muslin spread with cerate to place under the ends of the liga- 
364
LECTURES ON
tures; 8th, fine sponges, warm water, vinegar, and a brazier full of hot coals
to warm the adhesive strips.   The different portions of both series should be
disposed in the order they will be required, which is as enumerated above.
   For a long time amputation, properly so called, was performed by dividing
the flesh  and bone  by means of the knife and  saw,  or when the limb was
small, by sharp  pincers which removed it at one blow; or lastly, by laying
the limb  on a block,  and  separating with a large chisel and mallet.  The
haemorrhage was then  arrested by the actual cautery.   Since  the time of  A.
Pare  ligatures have been in use.   About the middle of the last century th<>
pincers and chisel were  laid  aside, but still the soft parts were divided by a
single blow down to the bone, and the latter divided on the same plane as the
external incision.
   From these different modes of amputating, muscles with long and those with
short  fibres were divided at the same point, from which  followed a conical
stump, inappropriate to the formation of a good cicatrix, as well as numerous
and serious inconveniences.   All the soft parts retired  towards the origin  of
the limb,  as much by the effect of their contractibility as by the irritation
caused bv the instruments, and the necessary consecutive inflammation. The
bones, deep seated muscles, and the whole surface of the wound was exposed;
hence resulted high and extensive, inflammation, acute pain, copious suppura-
tion, secondary sympathetic symptoms','a long and tedious process of cicatri-
zation,frequently necrosis and exfoliation of the bone, requiring anew opera-
tion.  Struck with these objections, the most celebrated surgeons have endea-
vored to avoid them, and  from their labors have arisen the three principal
methods now in use, known by the names of circular, flap and ovdl or oblique
operations.
   T. L. Petit, following somewhat the steps of Chiselden, performed the cir-
cular amputation by first making an incision, interesting only the skin and sub-
cutaneous cellular tissue; he then turned this back for the space of two fingers'
breadth, then divided the flesh and lastly the bone on a level with the incision
of the skin, thus turned back like the sleeve of a garment.
   Louis, thinking that the conical shape of the stump  was owing more to the
contraction of the muscles  than to  thatofthe  skin, divided at one cut the
integuments and superficial muscles, drew  them up as-far as possible,  and
at a second cut divided the deep seated muscles and finally the bone.  Alau-
son be'>-an by dividing the skin circularly, dissected it from the sub-jacent
parts, turned it up when he supposed he had  detached enough  to cover the
whole of the stump, and then at one  cut divided all the muscles, holding the
ed»e of the knife obliquely upwards,  so as  to form a hollow cone.  This plan
was a°-ain modified by B. Bell, and that adopted by modern  surgeons pre-
sents  three stages:   the  first consists in dividing the  integuments  and sub-
cutaneous cellular tissue by a perpendicular incision,  dissecting and turn-
in"- back the flap like Alauson : in the second stage the muscles which do not
adhere to the bone are divided on a level with the fold of skin, and lastly the
deep-seated muscles are divided on  a level with  the retracted surface of the
superficial muscles.  This retraction of the skin and soft parts  is aided by an
assistant who,  grasping with both hands the limb  above  the point of  incision,
draws them forcibly upwards as they are divided.
   Of all these  different plans, some fulfil but imperfectly the end designed * 
CLINICAL SURGERY.
365
others are difficult of execution: and by the modifications adopted in modern
times, pain is uselessly increased.  By first dividing the skin, then dissecting
it, by cutting successively the skin, superficial and deep-seated muscles, and
lastly the muscular fibres adhering  to the bone, the. knife is  evidently ap-
plied three or four different times to the  parts.  The operation is  therefore
long and painful.
  These considerations have induced me to perform an operation, which lhave
since practised in the Hotel-Dieu,  with  complete success.  At one cut, I
divide  the skin and muscles as far  as the bone, generally perpendicularly,
some times obliquely,  after the method of Alauson.  The retraction effected
by the assistant, who grasps the limb above the wound, and the contraction of
the muscles give  immediately to the  wound  the shape of a projecting cone.
At the base of the cone, I then apply the knife and separate all  that pro-
jects.  By thus drawing up the flesh as it  is divided and cutting successively
all that remains, the  bone may be denuded  for the space of more  than six
inches.   By this  method,  the operation  is performed  in  an inconceivably
short space of time, enough flesh is preserved to cover the bone, enough skin
to cover the stump, and the painful dissection of the skin and integuments is
avoided.
   The flesh being divided it is drawn up as far as possible in order to facili-
tate the section of the  bone.   To effect this the retractor with  two or in the
case of the leg or fore-arm with three tails is all sufficient.   A bistoury car-
ried  circularly around the  periosteum serves to divide this  membrane, and
detach it above and below.   That being done, the operator seizes the  limb
with his left hand, placing  the thumb immediately above or  below  the point
which is to bear the action  of the instrument.   The saw,  held  in  the right
hand, is applied perpendicularly.   It is  then carried from heel to point, at
first slowly, afterwards more rapidly as it penetrates deeper and is less liable
to slip out.  When the bone is nearly divided it should be carried very gently.
The assistant  holding the  limb  must be particularly  cautious not to  de-
press the  part too much, lest  the bone break before it is completely divided,
nor to elevate it too much, for fear of arresting the progress of the saw.
   The flap operation consists in making at the expense of the soft  parts one
or several  flaps with  which the wound may be completely covered.  It is
performed in two  ways, either from  without inwards or the reverse.  In the
former we cut  from the skin towards the bone, in the latter we plunge the
knife through  the limb and then  carry it out.  If the former plan be more
regular and certain the latter is liable to  several objections.  One or several
flaps may be made.   The principal  advantages supposed to be presented by
this plan are, a greater quantity of soft parts to cover the bone,  and a greater
certainty of having a  conical  stump.  But the circular operation attains the
same end, and  causes  a much  more simple and less extensive wound.
   The essential character of the oval or oblique operation consists in a section
of the  soft parts, in an oblique plane or like the mouthpiece of a clarionet.
The line described is  represented  by a V or a triangle of which the  apex is
above and the base below.   The point of  this V-like section should pass some
lines beyond the spot  at which the bone is to be divided.   It must also corre-
spond to the part of  the limb least abundantly furnished with flesh, or large 
366
LECTURES  ON
 blood vessels and nerves.  Circumstances do not always permit us to follow
 this principle.
   As to disarticulations, they were well known to the ancients, and by them
 preferred to  amputations, as being more rapidly performed; less blood \va«
 lost during the operation, the means of arresting which were less understood
 by them than in later days.  They had, however, nearly fallen into oblivion,
 when Heister, J. L. Petit, Hoin de Dijon and Brasdor revived them.  Have
 they any advantages over amputations ?  We should not generalise an affir-
 mative answer to this question; but  their advantages are undoubted in some
 parts, doubtful in others,.and in others null if not decidedly liable to great
 objections.  Thus experience has demonstrated the advantages of disarticula-
 tion of the  fingers over amputation of the phalanges; amputation  at the
 articulation of the wrist gets well  more rapidly than those performed above it.
 It is Certain that the disarticulation of the shoulder joint is more easily cured
 and less frequently accompanied by serious symptoms  than  the  amputation
 of the  same limb in its  continuity.  Such, however, is far  from the case in
 other amputations.  As to the coxo-femoral amputation compared to that of the
 thigh, experience has proved that the cure of  the former  is infinitely more
 rare than that of the latter; in consequence, undoubtedly, of the enormous
 wound which is unavoidably made.
   The flap operation is particularly applicable to amputations at the joint;
 many surgeons however prefer the oval and circular operations.   In order to
 disarticulate promptly and certainly we must, 1st. Remember distinctly the
 height and direction of the articular line. 2d. Make the ligaments as tense as
 possible by drawing towards us  the portion of the limb to be  removed and
giving  it alternately movements  to the right, left, backwards and forwards,
 that the knife may  act  upon all  parts of the joint.   3d. Traverse the
 articulation by directing the knife according to the line of  the union of the
 surfaces.
   This short expose of amputations in general appeared necessary to the study
 of particular operations.  We  shall proceed to'treat of each in detail, con-
 fining our remarks to those which appear most important.
   Amputations  and disarticulations of the upper extremities.—1st. Of the
 fingers at the articulations of  the two last phalanges.  This amputation, easily
performed, and always the same, may be executed by a single flap taken from
the palmar face of the finger large enough to cover the whole surface of the
wound ; or two  flaps, one long from the palmar face  and another shorter
from the dorsal.   The intention of this disposition of the flaps is to prevent
the cicatrix from being inside near the palmar surface or in the middle of the
articular surface, but that it may be above near the dorsal surface.  The
operator taking hold of the. portion of the finger to be removed demi-flexes it,
and carrying transversely the blade of a narrow bistoury over the projection
which forms the joint, as if he would split the head of  the remaining phalanx.
divides the skin, and at the same time the posterior part of the capsule.  The
lateral ligaments are then cut, and passing through the joint, the operation is
ended by making from the palmar face of the finger the long flap intended to
cover the greater part of the wound.
  As no flexor tendon is inserted  into the  first  phalanx  of the fingers, some  , 
CLINICAL SURGERY.
367
surgeons have thought that after the removal of the second,.these bones would
remain extended, immovable, and useless.  It has  been proposed to make,
on the palmar face of the first phalanx, a deep longitudinal incision, which
should  penetrate to the flexor tendons of the finger, in order to make them
adhere to the bone in front of which they are  placed, and  then perform the
amputation when the cicatrization is completed.  This  plan  consists in per-
forming two operations, and exposes the patient to inflammation of the fibrous
sheath of the flexor tendons; and  again, why should not the tendons of the
flexor muscles, divided during the operation, contract adhesions with the first
phalanx, and communicate to it motion, as well as after the previous incision
under consideration ?
  2d. Of the fingers  at their metacarpo-phalangial articulations.  This is
generally done in the following manner: the hand being pronated, the adjoin-
ing fingers separated  by an assistant, the operator applies the heel of the
bistoury upon the dorsal face of the  finger, and successively to the palmar
face of the joint, and thus forms a first flap which should  be immediately
raised up.   The corresponding side of the joint being exposed, the bistoury
is introduced, and passing round the articular part of the phalanx, the opera-
tion is ended by making the opposite flap.
  Here   the integuments are  cut  obliquely  to form the flaps..  Hence  an
inconvenience which it is important to avoid, and which has induced me to
commence by dividing  the  soft parte perpendicularly  to their thickness, by
means of a  semicircular incision, directed from the dorsal towards the palmar
surface of the finger.   Again I  have observed that when the ring or middle
finger is  removed and the head of the corresponding bone of the  metacarpus
preserved, the adjacent fingers remain separated  at their base, whilst they
approximate  at  their extremities, from which result great deformity and em-
barrassment in their functions.   In order to avoid this difficulty, after having
made the incision just spoken of, instead of stopping at the phalanx, I carry
the flap  beyond  the joint, and remove the head of  the bone with  the saw.
After the operation the flaps are brought together  and the wound dressed.
There is no necessity  of tying the  collateral arteries which are divided.  In
this manner, the heads of  the  adjoining bones approach  exactly, and  no
deformity nor embarrassment follows.
  3d. Of the fore-arm.  The law which requires amputation to be performed
as far from the trunk as possible, applicable to all amputations of the upper
extremity,  is particularly so to those of the  fore-arm.  The limb, in  fact,
diminishes  gradually  towards  the wrist, and  consequently  the nearer this
point, the smaller is the surface of the stump, and the  more simple the ope-
ration.   Yet some of the most distinguished modern surgeons recommend its
removal at  its most fleshy portion,  in order to avoid the tendons and aponeu-
roses which they do not think capable of furnishing healthy suppuration.  This
advantage does not compensate for the loss of a very useful  member;  and,
besides, since the section at the wrist is successful, why should not the same
thin* take place in adjoining parts ?  Hence the majority of  surgeons ampu-
tate as near to the wrist as possible.
  In order  to perform this  operation by the circular method, which I prefer,
the  patient is placed on the edge of the bed or seated on a chair; the fore-arm
is held by two assistants, one supporting the wrist, the other  the elbow; the 
368
LECTURES ON
 brachial artery is compressed on the inside of the middle part of the humerus;
 the fore-arm is flexed  and pronated.  The surgeon  stands  on the inside,
 makes a  circular incision in the  skin, detaches it  from the cellular tissue
 which binds it down and turns  it back to an extent proportioned  to  the
 thickness of the limb; he next divides the soft  parts, then detaches  those
 which adhere to the bones, and proceeds to the section of  the  interosseous
 tissues, as in the leg.  But as the tendons roll from the edge of the instrument
 its division is less easy.   The best plan  is to slide the knife in a  flat position
 along the anterior face of the ulna, and then of  the radius, so as  to comprise
 before it all the deep seated muscles of  the anterior surface of the fore-arm,
 which are divided by turning the cutting edge of the instrument.
   The periosteum being divided, and the parts protected from the saw by the
 retractor, the saw is applied  first to the radius, as  being the thicker except at
 its upper part, and as offering less resistance.  It  is then made to bear at the
 same time on the radius and ulna, which is done by carefully raising the wrist.
 In order to be able to saw them both at once, the fore-arm must be pronated
 as much as possible.   In another position the ulna comes almost immediately
 below the radius.  Besides these bones vacillate on each other, thus impeding
 the action of  the saw, and  endangering the upper  articulation.   Lastly the
 easy closure of the wound terminates the operation.
   Let me here remark that flap  operations  in  the continuity of a limb are
 banished from surgery.  A well executed circular operation is far preferable.
 It is more easily and  rapidly performed, does not require the preservation of
 so much of the soft parts below the point of division  of the  bone, and lastly
 permits the not less  complete  and exact union of the flesh on  the  surface
 of the stump, than if ample flaps had been preserved.
   4th. Of the  fore-arm  at  the elbow joint.  This operation formerly per-
 formed, has been for a long  time  neglected by  surgeons, and many of them
 prefer amputation of the  arm  above.  In order to  execute  it, Brasdor had
 invented a difficult operation, which consisted in opening  the  joint at  its
 posterior part and  terminating by a flap made  from the flesh of the upper
 anterior  part  of the  fore-arm.  I think this plan  may be  advantageously
 replaced by the disarticulation  of the elbow whenever the  condition of the
joint and the flesh will allow it.  It is done in the  following manner:
   The fore-arm being one third flexed, a straight double-edged knife is intro-
 duced transversely in front of the joint  from one tuberosity of the humeras
 to the  other, and serves to make a flap of the flesh of the upper anterior parts
 of the fore-arm.  This flap  being turned back,  the articular capsule and
 lateral ligaments are divided  at  the  second cut, and the  operation is ter-
 minated by sawing the olecranon from in front backwards.
   The brachial artery is  not divided in  this  amputation  but only its radial
and ulnar  divisions.   These are  soon tied  as well  as some muscular and
recurrent branches which pour  out blood.  The flap should  then be folded
 from before backwards over the lower extremity of the humerus, and kept in
this situation by long adhesive strips.
   I have performed this operation  ten or twelve times  and always success-
fully.  It has the advantage of preserving more  of the  limb, and we  gain
much by dividing the  olecranon with the saw, because,  fixed  to the cicatrix,
this process continues to furnish a solid  insertion  for the triceps brachialis 
CLINICAL SURGERY.
369
 muscle.   I always  perform this operation except when too little  of the soft
 parts are left to form an anterior flap to cover  the  condyles  of the humerus.
 In this case, it is performed as follows :
   The fore-arm should be demi-flexed and the surgeon place himself on the
 outside of the limb.  The first incision is made at three fingers' breadth below
 the condyles of the humerus, and comprises the integuments as well as the
 aponeuroses.  The parts are then held up by an assistant, and at a second cut
 the surgeon divides level with their edges the  muscular  fibres down to the
 bones.  Ascending slightly along the latter by detaching the soft  parts from
 their surface we reach  the joint which should be opened by the section of the
 lateral ligaments and anterior part of the capsule.   The knife then penetrates
 easily between the bones, and the operation is finished, as in the preceding
 case, by the section of  the olecranon.
   5th. Of the arm and thigh.   We shall treat under the  same head both  of
 these subjects, in order to  subsequently avoid repetition, inasmuch  as 1st.
 Their structure is  very analogous ;  and 2d. Because the operation, whether
 circular or flap, is the same in both cases.
   The amputation may be performed at any point of the arm or thigh, there is
 no choice, the disease alone requiring the operation must  determine.  But  as
 a general  rule, we  should  amputate as low down as possible, in order  to
 preserve  a long fragment, which  may be useful.  Even when  the  disease
 requires amputation of the arm at the upper part, it is very easily performed
 with making two longitudinal  incisions to  form a trapezium shaped flap,  as
 has been  recommended, but by simply following the rules we have laid down
 for the circular operation.
   The amputation  is well  performed when the wound representing a hollow
 cone  of at least two inches in depth, at the apex of which is seen the bone,
 there remains enough  skin to cover the stump easily and meet on  both sides,
 forming a longitudinal wound directed from before backwards.   It is badly
 donewhen the bone projects, or the skin is too  short to cover the whole stump,
 or when,  too large, it folds on itself, forming a kind of pouch behind which a
 vacuum exists which may  serve as a receptacle for any discharge from the
 wounded surface.   When about to dress it, after the operation, it is most ad-
 visable to let the ends of the ligatures hang from the posterior angle of the
junction;  this is more easily done in the arm than in  the thigh, and with
 more certainty.
   Thus, in the arm and thigh, as also wherever the circular operation can be
 performed, there are two  stages in the division of the soft parts, one  com-
 prising the  integuments  and  superficial muscles,  the other the deep seated
 muscles adhering to the bone, a stage in  which these adhesions are broken up,
 and by the successive  retractions of the flesh, the  bone is denuded to a con-
 siderable distance, even five or six inches.
   6th. Of the arm at the shoulder joint.  Four general methods are now in use
 for the disarticulation of the shoulder.   In the first, an  external and internal
 flap is made; in the second, an anterior and posterior flap.  These two plans
 are generally adopted.   Still some distinguished  men have proposed and per-
 formed two others; the circular (ofSauson),  and  the  oval (of Scontetten).
 It must be here remarked, that it is scarcely possible, in the ablation of
 the arm, to lay down any invariable and determinate plan for all cases, because
           47 
370
LECTURES ON
the majority of injuries requiring the operations have altered, or even de
stroyed, more or less, the soft parts surrounding the articulation, so that the
surgeon is frequently obliged to suit his operation to existing circumstances.
Therefore I have devised  two principal methods, giving to cither the prefer-
ence, according to the indications of the disease.   The first is as follows:
   The limb  being raised from the trunk, the operator lifts with one hand the
deltoid muscle and the parts covering the  shoulder externally, and  passing
with the other an amputating knife under these parts, grazing the bone imme-
diately below the acromion, I make at one cut the external flap, which is done
by Lafaye by three incisions and  a painful  dissection.   This flap being held
up by an  assistant, and the joint exposed, I divide the tendons and articular
capsule.  The  edge of the  knife  is then carried in front of the head of the
humerus,  between  it and  the flesh which it separates from above downwards
as far as the insertion of the latissimus dorsi, teres major and  pectoralis major
muscles.  At this  stage Lafaye  tied the artery;  I prefer, however, to com-
press it by the hand of an  assistant grasping the whole flap, and without stop-
ping terminate the operation by dividing near their insertions the tendons of
the muscles forming the folds of the axilla and the skin.
   The operation thus performed  lasts but  a few seconds,  makes a much
cleaner wound and more  exact union, and is more rapidly cured than by any
other plan with which  I am acquainted.  Nevertheless, it must be observed,
that  in this  manner one  of the flaps  is outside and the other on the inside
This  possesses some inconveniences, and therefore I only employ it in cases
in which the  alteration of the tissues does not permit that which we will now
describe.
   In  the second place, I make a flap from the soft parts of the anterior and
posterior regions of the shoulder.  The arm is elevated to a right angle with
the body, a catling is introduced below and slightly in front of the summit of
the acromion.  The operator then  divides at a single cut all the flesh forming
the posterior  part of the shoulder,  as far as the posterior edge  of  the  axilla.
This first section forms a flap, which being raised up, exposes the posterior part
of the joint.   The elbow is then inclined forwards against the thorax, the head
of the humerus thus rendered more saliant,  the tendons and articular capsule
are divided ; the bone is luxated;  the instrument after having passed around
the head from behind forwards, is.  carried from above  downwards, along its
anterior side, to form the  second flap, which  the operator detaches after the
assistant, having grasped it at its base, has arrested the flow of blood by com-
pressing the artery which  it  contains.   In order to perform this operation, the
surgeon, standing behind the patient, should hold the knife in his right hand
to operate on the left shoulder, and vice-versa.   If  he be not ambidexter, he
stands before the patient, to  operate on the  right side, and commences with
the anterior flap.
   This plan is undoubtedly  the most simple and easily performed  of  any in
use, and as such considered  by all  surgeons who are not led away by the inter-
ests of self-love.  The two flaps in fact  extend in the direction of the longest
diameter of  the wound, and their mutual appo.ition is as exact as simple and
easy.   Collected in one bundle below, the ligatures form a kind of  conductor
or gutter, which assists the escape  of the pus.  The cicatrix resulting from the
operation is linear, of small  extent, and always soon  formed.  The axillary
abscesses so frequently occurring in the other method are unknown in this 
CLINICAL SURGERY.
371
 Lastly, although very analagous in its  results to the  plan of M. Larrey,
 it possesses the advantage of more rapid performance.
   Amputations and Disarticulations of the Inferior Extremities.  1st. Of the
 great and other toes, in the continuity of  the first, and of the five  metatarsal
 bones.  The amputation of the great toe was generally performed at its meta-
 tarso-phalangial articulation.  This plan is liable to many serious objections :
 the head  of the first metatarsal bone forms, after the operation on the inter-
 nal part of the foot, a very saliant angle which renders the union of the flaps
 very difficult, and consequently the cicatrization tedious.  Besides after the
 cure the shoe, being no longer supported by the toe, presses  strongly against
 the head of this bone, or the latter strikes every now and  then against  any
 projecting object; hence a constant source of irritation, and often inconvenient
 permanent excoriations which may produce disorganization of the -soft parts
 and caries of the bone.   For these reasons I prefer amputation in the continu-
 ity of the first metatarsal bone.   There is, I grant, an objection, and  not an
 unreasonable one to this, namely, the utility of the head of this bone, which,
 after the removal of the toe, affords to the metatarsus  and the whole foot a
 large point of support inside and in front, and it has even been said that its
 removal always causes the turning of the foot inwards.  This is indeed a seri-
 ous inconvenience, and were it constant, as has been alleged, I should reject
 at once this plan of operating.   Such, however, is  not the case, and  I  have
 never seen it after all the operations of this kind that I have performed.  Should
 it occur, it may be remedied by wearing a shoe of which the  sole was thicker
 at that point than any other.  The operation is done in the following manner:
  The patient being laid on a bed and held by assistants, an inner flap is made
 from the flesh situated on the inside of the first metatarsal bone, by a superior
 internal incision, commencing behind the  head  of  the  metatarsal bone, and
 terminating near the articulation of the great toe, by a second incision precisely
 similar, and lastly, by a third  incision perpendicular to  the  two first, made
 at their anterior extremity and uniting them.   The external flap is  made  bv
 two other incisions, dorsal and plantar, between the first and  second metatar-
 sal bones.   The flaps are elevated, the bone isolated and denuded at its ante-
 rior part to some distance behind its head.  A thin  piece of wood  is slipped
 into the interosseous space, in order to protect the  parts from the saw,  and
 the first metatarsal bone is divided obliquely from within outwards and from
 behind forwards.
   The same operation is applicable to the fifth  bone of the metatarsus, if its
 anterior portion were carious, or any disease existed requiring the extirpation
 of the whole of the toe.
  The affection most frequently demanding the amputation  of the great toe
 is white swelling with  caries of its metatarso-phalangial articulation.  Some-
 times the disease is confined to the phalanx of the toe or its articular surface,
 and sometimes extends over the articular surface, and even to the body of the
 metatarsus,  whose cartilages are often destroyed.   I think therefore, that the
 plan I have adopted from choice and from physiological reasons, may some-
 times  become indispensable from the nature of the disease.
  2d. Of the four remaining toes. I shall merely observe here,  that when these
toes are affected with a disease extending to their metatarso-phalangial articula •
tion, I perform the operation by which  I remove the middle and ring fingers,
when it is desired to remove at the same time the heads of the metacarpal bones 
372
LECTURES ON
 supporting them.   But it has been established as a principle, that as regards
 these toes, it is always better to amputate them at their metatarso-phalangial
 articulation, than  at the articulation of their phalanges.   1 differ from this
 opinion, at least in  a majority of  cases; having  seen this operation followed
 by very severe symptoms, which sometimes  are  even fatal.  Therefore, ac-
 cording to circumstances, I either remove the anterior portion of the meta-
 tarsal bone, or perform  the  simple  ablation  of  one or two  of  the last
 phalanges.   The operation is thus rendered  much less  dangerous, and as the
 disease  is generally situated in the two  last phalanges, the end proposed is
 fulfilled.  In the same manner, I  have modified the treatment of curvature
 or  permanent  contraction of the  second  toe, when it  depends on  a vicious
 direction of the two last phalanges, and  not on an  affection of the plantar
 aponeurosis.  When this affection  is not  congenital, it appears to arise prin-
 cipally from the use of shoes which are too  short and  narrow, especially in
 persons whose second toe is immoderately long, as is frequently the case.
   The manual part of the operation is the same as for amputation of the fingers
 at their phalangial articulations, that-is, instead of making lateral flaps, as in
 a  metatarso or metacarpo-phalangial amputation,  we make, an inferior flap
 from the plantar face of  the toe, and a superior from the dorsal face; but in
 such a manner, that the  inferior  flap may  be longer and  cover nearly the
 whole of the wound.   The intention of this disposition is to avoid the pressure
 of the cicatrix by the sole of the shoe on  the ground, in walking or standing.
   3rd.  Of the five  metatarsal bones,  at  their tarso-metatarsal  articulation
 (called partial amputation  of  the foot),    Chopart devised  the  partial
 amputation of the foot at the second row of  the tarsus, that is, at the line of arti-
 culation of the os  calcis and astragalus with the caboides  and  scaphoide-.
 But neither he nor  his imitators  had calculated the serious inconveniences
 and  dangers of the  operation.  Every one feels the importance of preserving
 as much as possible an organ so useful and so necessary as the foot.   On the
 posterior part, as is well  known, rests  the  principal  part of the weight of the
 body.  Now by Chopart's plan, that is, by the removal of a part of the  tarsus,
 we deprive  the patient of the support which he  requires  to walk or  stand;
 so that the whole limb becomes very inconvenient and  nearly useless.  But,
 again, the insertion of the  posterior and anterior muscles of the leg, which
 are the antagonists of the gastrocnemius and  soleus, being divided, the foot is
 necessarily turned considerably backwards.  Lastly, I  have often seen very
 serious inflammatory and nervous symptoms follow this amputation performed
on the articulations of a very complicated and uneven mechanism.  Such are
the principal reasons for which I have entirely rejected this method, and admitted
as a general rule, 1st., that partial amputation  of the foot at the tarso-metatarsal
articulations  is infinitely preferable ; 2d.,  that the knife  should be applied
nearer to the heel only when the nature  of  the disease imperiously requires it.
  Moreover the importance of preserving as much of the foot as possible, and
the inconveniences of a contrary course, appear to have been evident  to the
ancient surgeons; those of the middle ages already conceived the idea of
merely removing the anterior  portion; but  the barbarous means used were
deservedly rejected.  The amputation at the tarso-metatarsal articulation is
said to have been first performed in 1720.  It  is certain that it was done by
 Percy in 1789, by Hey in  1799, and M.  Sauson, one of the surgeons of the
 Hotel-Dieu of Paris, who saw it performed in  1813 by a  military surgeon who 
CLINICAL SURGERY.                        373
wished to perforin, and thought he did, Chopart's operation-.  In 1815 only,
it was  properly  described, and  established on  fixed principles, which  are
generally known.
  4th.  Of the leg.  Here, as in the fore-arm I prefer the circular  operation.
The  point at which it  is proper to perform it  is not left  to the arbitrary
choice  of the operator, the shape, structure, and  functions of the parts impe-
riously indicate  it.  It  should be always  performed at  the junction of the
upper third of the leg with the inferior two thirds, if we wish to preserve to
the st.T.np the action of the tendons of the  flexor muscles which descend
thus  far.   We are speaking now of the point at which the bone is to be divided,
and not. at which the knife is to be applied  to  divide the soft parts; this dis-
tinction is applicable, moreover, to all  amputations.   In  the leg, as in  the
arm, fore-arm, and  thigh, the point of incision of the  integuments must  be
proportioned to  the thickness of the  soft, parts.   Generally,  it is about
two  inches  below  the  spot  at which the  bone  is divided. . But, all other
things  being  equal,  we  should preserve more skin  in  an amputation  of
the leg than in that of the thigh, because the muscles  contract less, and  the
flesh, supported by  two bones, is less readily removed from  the centre of the
slump.
   The rule just laid down is founded on diverse reasons; we have  already
spoken of the necessity of preserving the mobility of the stump.  Again, if we
amputate above the  spot indicated, we meet with the popliteal .vessels and the
superior fibulp-tibial  articulation: below, we leave a  stump uselessly  long
and  embarrassing in walking.  Sometimes  injuries of the  leg are very high
up, and then we must amputate above this spot, or at the inferior part of the
thigh.  This latter  plan is liable to many objections;  in order to avoid them
we carry  the saw,  according to M. Larrey's  method, even through the con-'
dyles of the tibia,'and then remove the remaining portion of the fibula.  We
should carefully avoid  the ligament of the patella, in order  that the patient
may flex the knee and use a wooden leg.
   The operation which  I perform consists of the following stages.  1st.  The
circular incision of  the integuments.  2d. The circular section of the muscles
and  other parts down  to the bone.   3d.  The division of the muscles and
adherent fibrous and  interosseous organs.  4th. The use of  the three tailed
retractor.   5th.  The  incision of the periosteum.  6th. Lastly,  the division
of the bones by  the saw.
   Surgeons have for a long time endeavored to devise a flap operation appli-
cable to the leg.   Since its invention in 1679, by an English surgeon  named
Lowdham, and described by Verdinn, it has been successively corrected and
modified by Garengeot, Lafaye,  and O'Halloran.  It  had, for  a long time,
been banished from practice, when  a professor of the faculty of Paris, a few
vears a"-o, vainly endeavored to  revive  it.  I have never performed it, but
have imagined an operation  which should consist, 1st.  In a vertical incision
upon the tibia, commencing a little below the point at which- the bone is to
be divided, and three  inches in length.  2d. Another incision parallel to the
latter  and dividing deeply the whole thickness  of the calf of the leg.  3d.
Lastly, a  third  circular incision meeting  the two preceding ones at their
inferior extremity; the flap should  then  be raised up,  and after the section
of the bone, brought down and closed over the stump.
   Differing from many distinguished  surgeons, at the  same time  and same 
374
LECTURES  ON
stroke I divide the integuments and all the soft parts as far  as the bone, and
thus avoid a long and difficult dissection of the skin, spare the patient  pain,
and shorten the operation.   To these advantages may be added one still greater,
perhaps, that of not destroying the natural adhesions of the skin, and conse-
quently preserving unhurt its nutritive cellular membrane.   This may be done
where there is but a single bone, as in the arm  or thigh : but the rule cannot
apply to the case of  two parallel bones.  Thus you may observe in the direc-
tions given for the fore-arm and leg, that there is one stage more,  that is the
previous circular section  of the  integuments, and their subsequent dissec-
tion to a greater or less extent.   Moreover, the blade of the knife is directed
very obliquely in the second  stage of the operation, a circumstance which  is
not observed in amputation of the arm and thigh.  It is, because the muscles
of the fore-arm and  leg possess but little contractility, with difficulty isolated
and  removed  from the centre of the wound; and lastly because it is highly
important to preserve integuments sufficient to cover the wound exactly.
  In order to accomplish this end, that is, to have a cone of integuments and
flesh sufficient to cover the wound exactly, we must here, as  in the amputation
of the fore-arm, demi-flex the leg on the thigh, and the latter on the pelvis. We
shall hereafter see the inconvenience resulting from a neglect of this rule.
  5th. Of the leg, at the knee-joint.  The horror formerly entertained  by the
idea of amputation at the elbow and knee joint, seems to be passing  away.  I
have for a long time, and with much success,.performed the  former, and it  is
now generally admitted.  As to the latter, it has as yet no partisan among
surgeons.  M. Larrey formally rejects it. From considerations drawn from the
structure of the joint and the organization of the soft parts  surrounding  it, I
am of the same opinion, and prefer, when it is impossible to choose  the  spot
for amputation, to divide the condyles of the tibia, or the lower  part of the
thigh.   Of thirteen cases of this disarticulation, twelve appear to have  been
successful; but their history is not sufficiently circumstantial to carry credit
with it.   We must therefore wait for a more extensive and perfect experience.
   6th.  Of the thigh  at the  hip-joint.  Circumstances may exist, in which the
only alternative left to the patient is  the frightful and always uncertain opera-
tion of disarticulation of the  hip-joint.  It is always  with  repugnance, and
after having abandoned all hope of success by any other means, that the sur-
geon decides on this mutilation, the greatest that the  man  can undergo. 'It
had only been done  a few times, and  then merely when  some injury,  or
gangrene or suppuration had destroyed nearly all  the parts surrounding the
articulation,  when M. Larrey had the boldness to perform it immediately, (in
cases of soldiers,) where the thigh had been disorganized by gun-shot wounds,
 as far as its  superior articulation.   His plan consists now in the formation of
two flaps, one external and the other internal, and the ligature of the femoral
artery in the groin,  previous to commencing  the operation.  M. Larrey has
laid down this  precaution as  a rule, inasmuch, says he, as it  permits the
surgeon to operate  with  more  safety, and exposes the patient to less risk.
He performs it as follows:
   The patient being laid on his back, the pelvis  entirely resting on the  edge
of the bed or table, the operator standing on the outside of the limb, makes an
incision parallel  to the femoral artery, commencing under the crural arch, ex-
poses this  artery, and secures it by ligature.  Armed with  a long knife, he
plunges it perpendicularly to the lower part of  the incision  previously made 
CLINICAL SURGERY.
375
 for securing the artery; he grazes the internal part of the femur on  a level
 with the trochanter minor, and brings the instrument out  at a point  diametri-
 cally opposite to that of its introduction.  Directing then its edge downwards
 and outwards, he makes from the internal and upper fleshy parts of the thigh
 a flap about six inches in length, but which of course  varies with the size of
 the limb.   An assistant draws this flap inwards.  The anterior portion of the
 fibrous capsule is then divided, the bone  luxated;  then the knife  passed
, between the articular surfaces,  serves to  divide the external  part of the
 capsule  and terminates by  making  from the flesh of'the thigh a flap of the
 same length as the preceding, in the formation of which we  must be  careful
 to graze the great trochanter, turning the knife slightly in order to avoid  this
 process.  The arteries are then tied, and the flaps brought together.
   Mr. Guthrie  has performed this operation, but in another way, which has
 succeeded, and  which consists, after having made pressure on the  crural
 artery, in dividing  the skin  by two semicircular incisions which commence
 four inches below the anterior superior spinous process of the ilium, pass
 obliquely on either side of the limb, and meet on its posterior surface.  The
 muscles are then divided on each side in the same direction, and the  operation
 terminated by the disarticulation of the femur.  The femoral artery is then
 first secured, and the others  successively in proportion to  their size.
   Beclard, after having made pressure on the artery, commenced by making
 an external posterior flap, by plunging his knife obliquely from without inwards
 and from before backwards,  from the vicinity of the tuberosity  of the ilium to
 the  internal extremity of the ischiatic notch,  grazing the posterior face of the
 neck of the femur.   A second flap was  formed in the same  manner in front,
 and the operator ended by the section of the capsule and the disarticulation.
   The methods consisting in two flaps are in some measure necessary when-
 ever it is possible to make two similar flaps.  But it is very difficult to attain
 this end by the method with  internal and external flaps, for a great part of the
 latter is formed merely^by the skin covering the. great trochanter, whilst  the
 former contains nearly all   the flesh forming  the upper part of the thigh.
 Again, by this method there remains on a  level with the  cotyloid cavity  a
 considerable vacuum, which  does not allow so prompt an union of the wound.
 These objections joined to the extent of the wound explain why patients who
 have undergone this operation have  nearly  all fallen victims to the primary
 symptoms, occasioned by the violence of the local irritation.
   The following operation is the one which  I prefer in disarticulation of the
 thigh : the  surgeon stands on the inside of  the limb and uses,  if he be ambi-
 dexter, the right hand for the right leg, and the left hand for the left  leg.  The
 crural artery is compressed upon the ramus of the pubis by an assistant.  The
 operator  himself sustains the thigh  and inclines it  more or less  in flexion,
 extension or abduction.   He makes on  the  inside a semilunar incision, with
 its  convexity downwards, commencing near  the anterior superior  spinous
 process  of the  ilium and ending at the tuberosity of the  ischium ;  at first
 mere! v divides  the  skin which is retracted by  an assistant, cuts immediately
 the muscles in  the same  direction, thus making an internal flap, four or five
 inches lono-, raises it up,  divides the  capsule, traverses the articulation, and
 ends by forming the external flap.
   Having  thus sketched the operations I have devised, and modifications  I 
376
LECTURES ON
have made, we will now point out the greater or less serious objections attached
to some operations adopted by other surgeons.
   1st.  You  know that  in the partial  amputation of the foot according to
Chopart's method, an incision is made in the line  going from the astragalo-
scaphoid articulation to that of the os calcis with the cuboid, but at abour
half an inch in front of  this line, in order to make a dorsal flap.   In order to
render the operation more rapid and brilliant, it has been proposed to divide
the skin  and astragalo-scaphoid articulation at the same  time.  Nothing
certainly is  more easy, but the integuments would retract over the dorsal face
of the foot, and expose  the bones, from which very serious accidents might
arise.
  2d. In disarticulation of the two last phalanges of the fingers, many surgeons
have thought that in  certain cases it  might be useful to commence on the
palmar face, and to do this they pierce the integuments placed before the ar-
ticulation with the bistoury laid flat to make an anterior  flap.   This plan i*
exposed to the  danger of striking against the projections  of the bone, break-
ing the point of the instrument and causing unnecessary pain.   We have al-
ready said what must be thought of the previous incision  proposed to be per-
formed on the first phalanx some time before the disarticulation of the second,
in order  to procure the adhesion of the  flexor tendons.
   3rd. In individual amputation of the fingers at their metacarpo-phalangial ar-
ticulations, some surgeons plunge the point of the bistoury perpendicularly from
the dorsal to the palmar face of the hand, twice, on the right and left of the
articulation, to make two flaps.  This  plan is more inconvenient and painful
than that I have proposed.                                         .
   4th. In extirpation of the hand, or disarticulation of the wfist, the circular
or the flap operation is now generally performed.   In the latter case some
suro-eons  prefer a single flap, others  a double one.  Lastly the double  flap
ooeration is performed in two  ways.  In that  with a single flap, we attack
the articulation on its posterior or dorsal surface, cutting at one stroke the in-
teguments and tendons, and finishing, after having passed the knife through the
joint  by an anterior  single  flap, about three fingers in breadth, and rounded
from  within  outwards.  In the first  operation with two flaps we begin also
on the posterior face of the joint, taking  care to make a  convex flap which
should be longer, and finish by an anterior shorter flap, or rather by two flaps
of the same length approximating to each  other.  Lastly,  an operation, winch
belongs to one of  the surgeons of a Paris hospital  consists in supinating the
hand,aattackingthe joint at its anterior surface, plunging a catling transverse-
ly from one apophysis to the other, the edge turned towards the palm of the
hand, and making a flap from the flesh of this part, then opening the joint and
finishing by the posterior flap.                                 .
   In these three  methods, it is always difficult to  form an anterior flap and
oive it the desired shape and length, on  account of the density of the tissues
and the projections of the scaphoid, trapezium, pisiform, and unciform bones.
The single flap and first of the double flap operations present  the fewest ob-
iectionsrbecause the  knife, having once traversed the  articulation, can easily
divide the tendons near the latter before cutting the  integuments and form-
;lMr the  anterior flap.  The last we have pointed  out is unquestionably the
most simple, easily executed, and advantageous  in its resul ts. For my own part,
 I prefer the circular operation  as described by Sabatier  as the most certain, 
CLINICAL SURGERY.
377
rapid, and unequalled as regards the ease with which the opposite parts of the
wound can be brought together.
  5th.  The greater part of the operations relative to the disarticulation of the
humerus, may be referred to two general methods, one consisting in a single,
the other in a double flap.   The first, belonging to  Ledran, has fallen  into
disuse.  The second is performed in two ways': some make a superior  exter-
nal and an inferior internal flap.  I have simplified this, by making at one cut
the upper flap, which formerly required three incisions; but it still is liable to
many inconveniences,  and  1 never employ it but  under peculiar circum-
stances.
  The best method  consists in making an anterior and posterior flap.  Desault
adopted it, but he began by the anterior flap ; and the danger of isolating first
the parts in which the most important vessels are found may be easily conceived.
  One of our most distinguished  surgeons performs  this operation in the fol-
lowing manner": the arm being nearly pendent on the side of the body, with
one hand he raises  the posterior fold of the axilla, upon which he applies the
knife perpendicularly  from  belo-.y  upwanls.  The point of  the instrument
soon meets  with the inferior surface  of  the acromion.  Then  at the same
time elevating the flesh still more, he gives the instrument an oblique direction
from below upwards and from behind forwards, so that the point may pierce
the skin in the space which separates the acromion from the coracoid process,
and the joint is  thus separated ; he then makes the first, the posterior flap.  I
think that the difficulties presented  by this plan are very great, and that  few
persons can familiarise  themselves  sufficiently with this mode of extirpation
of the arm to perform it with  the only advantage it possesses, celerity, with-
out any fear of accidents.
  6th.  Abernethy and Graefe have proposed the circular operation in  extir-
pation  of  the thigh ; but that with two  flaps is generally preferred.   M.
Larrey makes first  an incision parallel to the crural artery, ties that vessel,
and then starting from that incision makes two flaps, one external, the other
internal.   This distinguished surgeon lays it down as a.rule, to tie the artery
before  commencing the operation, as it  gives the surgeon more  time, and is
less dangerous  to the  patient.  This is certainly ah  excellent  reason,  but
experience has proved that compression of the artery on the horizontal ramus
of .the pubis fulfils the same end, and it seems  superfluous to complicate an
operation, already so serious, by a secondary operation which  necessarily in-
creases its duration. After a patient investigation of all  the different plans
proposed and adopted,  I have been led  to prefer that consisting in the forma-
tion of anterior and  posterior flaps, which independently of many advantages
already enumerated in  another part of this chapter, makes these flaps more
equal and symmetrical.
  We have now arrived at an essential consideration in amputations, namely,
the means of suspending temporarily the flow of blood during the operation ;
and secondly, the means of preventing all haemorrhage after the amputation.
  1st. We may  easily  conceive the fear of the  ancient surgeons, when we
remember that they possessed no means of suspending the flow of blood during
an operation.  Archigenus of Apamea is said to have  been the first to propose
a circular ligature around the limb  ; to sprinkle it with cold water; and even
                48 
378
LECTURES  ON
he had the idea, bold in his day, to previously secure the vessel.  A. Pare in
later days used the ligature of the limb, a  faithless and painful method, to
which  this father of French surgery  attributed the advantages of  not only
arresting the course of the blood, but  also of diminishing the pain by benumb-
ing the limb.  During the siege of Besancon, Morel devised the field tourni-
quet, by adding to the ligature of Pare a plate and  two short sticks, by which
it could be  twisted.  Lastly, J.  L. Petit made a great improvement by the
invention of the tourniquet, which merely compresses two opposite points  of
the limb.  Therefore the means  of suspending  temporarily the course of the
blood are now reduced to two, and we employ, either compression, or a. pre-
vious ligature. Compression is effected either by mechanical instruments, or the
hand.  Two indispensable conditions are required for the use of compression
by either means;  the superficial position of the artery, and its super position
on a bone or some solid part which may furnish a firm support.
  This being granted, which is preferable, the  mechanical or manual com-
pression ? Experience and facts must answer this question.  Wherever, and
in whatever way I may perform  an amputation, I always require an assistant
to compress previously the arterial trunk of the limb, and never have regretted
the proceeding, nor seen haemorrhage from the principal vessel.  This com-
pression should always be entrusted to an intelligent  assistant and one who
possesses great  coolness.  Great strength is unnecessary.    The essential
part is to  compress  firmly and perpendicularly  to  the  resisting  surface.
Therefore should he be perfectly acquainted with the inclination of the bony
planes on which the vessels rest.  For example, that of the upper surface of
the horizontal ramus of the pubis look upwards and forwards, that of the first
rib upwards and slightly outwards ;  so that in the groin, compression should
be made from above  downwards, and from before backwards, and the sub-
clavian depression from above downwards, and from without inwards.   If
compression sometimes fail, it is because it is not practised according to those
principles which are equally requisite for mechanical instruments.
  Some amputations may be performed without employing compression, even
when large vessels are to be  divided.  Such are those in which the division
of the vessel is in the last stage of the  operation,  and when intelligent
assistants by firmly grasping the parts  can compress  them and prevent the
effusion of blood  before the completion of the flap.   But as a general rule,
and  applicable to all  operations, we should only undertake, without having
previously interrupted the circulation, amputations in which small  arteries
may be divided, and which can be instantly secured.
  However, in many cases we must have recourse to previous ligature and
compression by instruments.  I know but one case  in which the previous liga-
ture may be necessary: namely, when from the disorganization of the r>arts.
and the artery particularly, we may not be able, after amputation, to place a lig-
ature firmly on the surface of the stump.  We must then commence by tying
the arterial trunk above the spot which has been selected as proper for the am-
putation. As to the mechanical means of compression, the tourniquet of Petit
is far preferable to all others in use.   In whatever manner compression may be
effected, it should be continued until all the arteries are secured.  Then, in-
stead of suddenly removing it,  it is to be gradually diminished, so as to be
immediately reapplied in case of any loss of blood. 
CLINICAL SURGERY.
379
  In all amputations of the thoracic and abdominal extremities, manual com-
pression is performed on two principal points:  the axillary and brachial arte-
ries in the former case, and on the crural artery in the latter.   Compression
of the axillary artery behind the clavicle, on the first rib, or in front of the
clavicle, between the  deltoid and  great pectoral muscles, on the 2d and 3d
rib, is not always sufficiently secure; and therefore, in disarticulation of the
humerus I always charge an assistant to grasp with his hand  the anterior flap
at the moment of dividing it, and to compress the. artery with his thumb  in
the thickness of the flap.  Behind the clavicle on  the first rib, compression is
more painful to the patient, more difficult and tiresome to the assistant.   It
is better, unless for particular reasons, to effect it in front of the clavicle.
Garengeot and  Ledran tied the principal artery previous to extirpating the
arm.   This practice is no longer in use.  When compressing  the crural artery
on the horizontal ramus of the pubis, we should be careful to  not press on any
inguinal ganglion in order to spare unnecessary  pain to the patient.  In fat
people, it is very difficult  to obliterate completely the femoral  artery, and
mechanical means must be employed.  The assistant to whom the compression
is entrusted should not apply his fingers longitudinally or parallel to its dia-
meter, but at a right or obtuse angle.  We will not here treat of the arterial
haemorrhage which  may occur during an  operation;  it cannot take place  in
amputation, unless the  compression has been improperly or ineffectually made.
For many years,  also, surgeons have adopted the plan of  tying the vessels  as
they were divided in the course of an operation.   But writers, whilst treating
of arterial haemorrhage, have entirely overlooked that which is furnished by
the veins.   They have, therefore, neither  indicated its mechanism, nor the
most simple, and effectual means of arresting it.
  It sometimes happens,  that  at  the moment of dividing the parts in which
the flow of  the blood has been arrested by compression, a considerable gush
of blood takes place.   The inexperienced  surgeon may be  alarmed, and by
his agitation increase  the very disaster he so much fears.  The color of the
blood should guide  the operator; if it be black, it proceeds from the lower
part of the limb, and is a matter of  small importance; but when we operate
on parts abundantly furnished with veins, and in which the circulation has not
been arrested,  the  blood  sometimes continues to flow ; it covers the whole
surface of the wound and arrests the progress of the operation.  This fre-
quently happens  in  laryngotomy or tracheotomy. Again, when large veins
are divided, the blood  gushes forth in torrents, the patient becomes  pale and
appears about to expire in  the hands of the surgeon.  This is often seen  in
amputations of the  upper part of the limbs, during the extirpation of fungous
tumors, of the maxillary sinus, cancer of the neck, of the breast, &c.
  Now it is in  the patient  himself  that we  must seek for the cause of this
venous haemorrhage ; the flow of blood  depends more on his exertions than
on the size of the divided veins.   In  fact  in a  majority of operations, the
patient suspends the respiratory movements, fortifies himself against pain, and
the blood, unable to pass  through the lungs, is arrested in the vena  cava,
and distending these vessels as well as those which empty into them, it regurgi-
tates and finds no exit but in the divided veins.   The most rational and certain
plan of arresting it,  is to desire the patient to breathe, in order to restore the
nervous circulation.  The lungs are hardly dilated once or  twice, when the 
380
LECTURES ON
bleeding ceases, but is again renewed on a renewal of the exertions.  It  is
therefore an important rule, to make the patient breathe with his mouth widely
open, during an operation, and desire him to amply inflate his lungs, without
making any effort to arrest free inspiration and expiration.
   Qd.  Of the means of permanently arresting haemorrhage.—The surgeon's
first care after an operation is to  obliterate the divided vessels,  which might
furnish a dreadful loss of blood.  Many hemostatic  means  have been pro-
posed  during the different ages of surgery.  Such are refrigerants, absorbent.-,.
astringents, escharotics, the actual cautery, compression, ligature, torsion of
the arteries, &c.
   Hippocrates proposed merely a mild regimen and the elevation  of the
stump.  Celsus used a sponge wetted with vinegar.   It  is said that Archi-
genus  of Apamea previously tied  the  vessels; this  fact is  doubtful, for  it
supposes an  anatomical knowledge of the circulation,  foreign to his day.
Paulus of ^Bgina applied a red-hot iron ; this may have arrested  even the
flow of blood from large arteries, but it must  have recurred on the separation
of. the slough; The Arabian  surgeons  employed  knives heated to redness.
Theodric of  Cervia applied opiate  preparations  to the stump.  Guy  de
Chauliac desired to remove the limb by gangrene; for this purpose  he en-
veloped the whole extremity with a plaster of pitch  and applied a ligature
very tightly at the point of separation,  so that the limb was entirely strangu-
lated.   Lastly, our celebrated countryman Ambrose Pare completely revolu-
tionized this important branch of our art.  Although in his day the circulation
of the blood was  but imperfectly understood, he proposed the ligature  of the
vessels at the surface of the stump; a  method considered even now  as the
most simple  and certain  that can be  used. The  manner  of performing
requires no  explanation from me.  Ligatures  of  different  materials and,
various sizes serve generally to secure the vessel and  arrest the  hemorrhage.
It has  been supposed, in latter times, that animal ligatures on account of their
analogy with our tissues might be easily absorbed, and that by cutting them
very near to the arteries, union by the first .intention might be effected.
Experience and observation have not,confirmed this idea.
   Much importance is attached to the  shape of ligatures: many surgeon?
making them  of. thread, placed in  parallel  lines on  the same  plane  like  a
riband, so that they may be flat, and not divide the vessel  too  suddenly;
others  pretend that they should be round, in  order to divide the internal and
middle coats of the  artery, and  hasten their  separation.   It is of very little
importance, as the act of tying them  always, whatever  may be their  shape,
reduces them  to a rounded form.
   The  surgeon should be careful  not  to include in  the ligature any large
nerves or veins, as from the first intolerable pain and very serious symptoms
may follow;  and that of the latter is often productive  of phlebitis and  acci-
dents which may  be fatal.  Lastly, we must be careful not to seize an  artery
by merely one side, with one branch of the forceps alone in its canal.   It has
happened that a portion only of the circumference of the artery having been
included in the ligature, bleeding takes  place  immediately after the dressing
of the  wound.
   If, after securing  the principal arteries of a limb, blood be  still poured
from some small branches  beyond our reach,  we must have  recourse  to the 
CLINICAL SURGERY.
381
actual cautery, as the only means of arresting the haemorrhage.  The ligature
of an artery is sometimes very difficult after an operation, in consequence of
some condition inherent in the artery itself.  A tense aponeurosis may pre-
vent it, and require division to disengage the vessel.  Thus I frequently divide
the interosseous ligaments of the  leg  and fore-arm, in order to isolate the
anterior and posterior tibial arteries, and  even the interosseous arteries which
sometimes are closely applied to them.
   Let us now consider an important part of ligatures, namely, the parts they
are to embrace, and the degree of tightness necessary.   We know that the
obliteration of a vessel takes place by the formation of a coagulum extending
as hio-h as the first collateral branch.  When  the  artery has been tied too
tightly, or too exactly separated from the surrounding elastic cellular tissue,
its outer  coat is too  easily divided, the coagulum as yet fluid escapes, and
the haemorrhage returns.  If,  on the contrary, the artery be  not sufficiently
compressed, its outer coat and  the  cellular tissue included in the ligature
diminish in size, become more dense,  and the blood establishes in the centre
of the vessel  and the ligature a canal through which  it flows in greater  or
less quantity.   If we include in  the ligature muscular fibres, they are too
easily divided.  The  adipose cellular tissue is subject to the  same incon-
venience.  Should  any portions of fibrous tissue be comprised, it  does not
indeed affect the success of the  operation, but is too  slowly divided and
generally retains the ligature for weeks or even months in the parts.
   It now remains,merely to say a few words concerning a hemostatic  measure
lastly proposed, namely, the torsion of arteries.
   It  has  been observed that lacerated wounds seldom pour out much blood ;
this depends undoubtedly on some new character being given to the  coats of
the vessels by the peculiar nature of the accident.   Starting with this fact, a
surgeon  of modern days  has tried to prove that, by a similar action  on these
oro-ans, analogous results must be obtained.   Arteries were lacerated, torn,
crushed,  cauterised on animals, without any  effect more than  a temporary
suspension of the haemorrhage.  After numerous experiments of this nature
he conceived the idea of twisting the vessel carefully:  the first case succeed-
ed, and since that time an immense number of experiments have been made
on animals.  It is done in the following manner:
   The free extremity of the artery being held by a pair of artery forceps, of
which the two branches are held together by a slide, it is gently drawn out to
the extent of five or six lines, more or less.  The surrounding tissues are
separated by ordinary forceps ; then holding the  artery near the wound with
the latter forceps in one hand, the artery forceps are twisted six, ten, fifteen,
or twenty times on their axis, more or less, according to the size of the artery,
that is, until that  portion of the vessel  included between the instruments is
ruptured; the operation is then terminated. It  is not absolutely necessary
to rupture the artery when its calibre  is  small, butit is a more certain method
in those  of some size.                                .   ,  ,  .,     c  .
   In performing this torsion, we should  be careful  to seize both sides ot the
artery with the°forceps, and also, to leave no blood between the two instru-
ments, as it  is  incompressible, and by pressure would cause the bursting of
the membranes.  That portion  should therefore be emptied of blood.  The
second forceps are  not used by some  surgeons; this is objectionable,  as the 
382
LECTURES ON
torsion extends beyond the surface of the wound, the nervous filaments and
cellular  tissue in contact with the vessel are lacerated, the operation  is
more painful, and may be followed by inflammation.   If a collateral branch
be near, it may be ruptured, as has frequently happened in experiments on
animals.  It is therefore much better in all cases to make use of the forceps,
as the most effectual means of performing the torsion.
   Let us now inquire the real value of this method in arresting hsemorrhagc.
When M. Amussat proposed it in 1829, he had made numberless experiments
on different animals, such as dogs, horses, rabbits, &c; experiments which he
has since continued,  and  had always succeeded in arresting haemorrhage from
the largest arteries, as the crural, brachial,  carotids, &c.  Since  then he has
applied  it  to  man in several  amputations performed in the presence of dif-
ferent surgeons, amongst others, in an extirpation of  the testicle, four ampu-
tations of the thigh, one disarticulation of the arm, several extirpations  Of the
mammae, &c.  No secondary haemorrhage occurred in any of these operations;
union by the first intention was effected (in seven days) only in the  youngest
of the children.  The four were perfectly cured, and  exhibited to the National
Institute on the 21st January, 1831. When this plan was known abroad,  it was
soon tried by several distinguished surgeons.   M. Lieber, surgeon in chief of
the New Hospital  of Berlin, repeated the experiments of M. Amussat with the
same results.   At the same period M. Fricke at Hamburg, MM. Waustand
Ansieaux a Liege, MM.  Rust  and Dieffenback at Berlin, applied it to man
with varied  success.   In October of the same year, (1829-), M.  Schrader  of
Dresden performed  torsion of the temporal  arteries, the mammary, and in
November of the brachial arteries.  In no  case was there secondary haemor-
rhage. In France, M. Delpech was unsuccessful in two cases in which he tried
this plan. But here the failure was no argument against the operation ; for one
of the patients exhausted by disease and a cancerous ulcer, covered  with me-
lanotic tumors which occupied the whole surface of the fractured limb, died
on the 44th day after the operation ; the other who suffered amputation for a
comminuted fracture of the leg, died on the 18th day;  and in neither case
was there any  secondary haemorrhage.   Towards the close of  1831, in six
amputations performed at the Hospital St. Louis, torsion only succeeded
once, and could not be performed or failed in the other  five.   Ordered by the
Institute to  make a report on this plan, I made a number of experiments at
the Hotel-Dieu, and  arrived at this conclusion : that in man it  may  be safely
applied to arteries of small calibre, but is unworthy of confidence in  those
of larger size.  In  three  or  four amputations at the Hospital St.  Antoine,
no haemorrhage occurred ; many  other  surgeons have given  it a trial, as
MM. Guerin, at Paris, Bedor and  Fourcade, at Troyes, Lallemand,at Mont-
pellier, Key at Guy's Hospital, &c.
  In amputations, and indeed in all large  and  bloody operations, instead  of
dressing the wound immediately after the arteries are secured, I prefer  wait-
ing one or several hours, for the following reasons:
  It  frequently happens that notwithstanding all the care taken by the opera-
tor to secure every bleeding vessel, secondary haemorrhage occurs after  some
time;  this is always  distressing to the patient, as all the dressings  must be
removed in order to arrest it.   We can never be certain that  this  will not
happen.  Now when the  limb is dressed, the haemorrhage can  only be ascer- 
CLINICAL SURGERY.
383
tained when all the apparatus is soaked with blood, that is when this loss of
blood has produced a serious and perchance fatal effect on the  patient.  The
secondary haemorrhage may be explained in this way.  Sometimes an artery
has not been tied, and yet pours out no blood; the surgeon does not discover
its extremity on the surface of the stump: having retired deeply in the flesh,
it allows no blood to escape.  We then  wait in vain for several minutes, no
new discharge takes place ; but in one or two hours, or even in less time, the
irritation attracts the fluids towards the wound and haemorrhage takes place.
This stoppage of the flow of blood from a divided artery often depends  on a
deep moral impression  produced by the idea of the operation on the patient,
or more or less violent spasms which he  may suffer during its  continuance.
Some persons fall into syncope from fear, or at the sight of the blood.  Under
such circumstances we should wait for two or three hours before dressing the
wound.  Haemorrhage may occur from a considerable afflux of  blood to the
part, and the dilatation of vessels hitherto unperceived.  It may also happen
from the ineffectual application of the ligature, &c.   By taking the precaution
here recommended, secondary haemorrhage  may be  nearly in every  case
prevented.
   Of the dressing.—Formerly, with the double intention of more certainly
arresting the haemorrhage and exciting what was considered a useful suppura-
tion, especially in amputations required by long standing disease, the wound
was filled with pellets of charpie^ kept in by a bandage.  Acute pain, vio-
lent inflammation, accompanied  by  serious  sympathetic symptoms, the ex-
posure of the bone, and the conical shape of the stump, were  the frequent
consequences of this mode of dressing.   Since a few years some surgeons have
fallen into  the opposite extreme, by praising a plan  which has for its object to
avoid all suppuration and effect the  immediate union of  the divided parts.
Many practitioners have been deceived by such seductive expectations, but the
delusion  has given way to experience, and a happy medium is now generally
adopted.  The proper plan is to combine the advantages of both plans; in
order to do this, the ligatures are to be collected in  one bundle and placed in
the most depending angle of the wound ; if this bundle be not sufficiently large,
we add, but rarely, however, a small cylinder of lint or muslin; the integuments
are then brought over the stump and there fastened by adhesive plaister.  The
fluids then  are discharged by means  of the ligatures which serve  as a spout,
and no effusion nor  infiltration takes place, neither do abscesses form in the
stump.   Immediate  reunion takes place  throughout  a great  extent  of the
wound ; suppuration occurs merely in the course of the ligatures,  and gener-
ally ceases  when the latter come away.
  Former surgeons were unacquainted with the difficulties which make opera-
tors in our days hesitate between union, by the first and second intention, of
wounds after amputations. Their operations could have no reference to the
former plan, as they frequently did not leave flesh enough to cover the bones.
They merely expected the formation of  a cicatrix  after  suppuration, which
cicatrix was always weak arid easily destroyed.   In later times  this  cicatrix
was more skilfully obtained, but always after a more or less copious suppura-
tion, and the interposition between the lips of the wound of various foreign
bodies.  The plan of bringing the flaps together in order to procure immediate
adhesion, is due to B. Bell, who proposed it in 1772, and it was since laid down 
384
LECTURES  ON
as a general rule by Alanson in 1779.   Since that time it has been constantly
followed in England.   Introduced into Germany by Graefe, it was there  re-
ceived with enthusiasm.  In France we were  slower in adopting it.  But
being successfully employed in several cases by the celebrated Desault, and
then by several military surgeons, it soon had numerous partisans. The idea nf
sparing pain, of avoiding a tedious and abundant suppuration, and removing in
a few days a large wound, carried away many men and soon  more than one
voice proclaimed its advantages.  Cases of brilliant and rapid success poured
in from all quarters.  I confess that, for a long time, this  plausible doctrine
guided my conduct; but experience, and the observation and comparison of
a large mass of facts, have proved to me how ill founded  are the  advantages
■which this plan is supposed to possess ; and I am convinced that more patients
are lost by its exclusive adoption, than by following the method we have de-
vised.    Of thirty operations according to our method, six have died ; whilst
nine have perished of twenty-nine,  one whom immediate  union had been  at-
tempted.   This disproportion is great.
  Nevertheless immediate union may be advantageous in amputations for an
injury, on the field of battle, for instance, because in  these cases things are
in a very different condition ;  the individual is healthy and vigorous,  his
constitution has  not been worn out by former disease, Or a suppuration of
more or less standing, which has become, as it were, a necessary habit to the
economy.  In the civil hospitals, a  great majority of the patients are affected
with organic lesions, or have been weakened by suppuration and pain for several
months.  By amputation we suddenly suppress a cause of irritation which had
modified the whole organism; the economy can  seldom accustom itself to so
sudden a change, and almost  immediately some visceral inflammation takes
place.  It  is often difficult to recognize these inflammations, for they preserve
of their peculiar character only the  phenomena of suppuration and especially
intermittent  chills.  We may, indeed, establish an artificial discharge, some
days previously to the  operation, but this generally fails and cannot replace
the powerful influence of a disease  requiring the sacrifice of a limb.
   Can  it  be  supposed, also,  that  because the lips  of  a wound  have been
accurately brought together either by simple dressing or a suture, that no fluid
can escape, that no secretion  can take place?  Certainly not.   The lips of
the wound unite more  readily than the interior, the  matter of an inevitable
distillation from the capillaries of the muscles accumulates beneath the skin,
penetrates into  the interstices of the tissues, and acting like a foreign body,
frequently gives  rise to large  abscesses which endanger the success of the
operation; or the resulting irritation  occasions a number of small ulcers on
the internal surface of the  flesh; or,  again,  a small artery pours  out blood,
which finding no exit is infiltrated in the limb, and accumulates in greater or
less quantity under the skin.   In all cases, the fluid at last destroys the adhe-
sion of the edges of the wound, or it must be destroyed by an instrument.   If
there be any circumstances favorable to this method, it is certainly when torsion
has been employed,  and in which no foreign  body remains ; this, in  the
numerous  experiments made  by surgeons of divers  nations, has  succeeded
but in a very small number of cases.
  Amputations  may be followed by many different affections, known umW
the name of consecutive or secondary affections.   Such are haemorrhage, ex- 
CLINICAL SURGERY.
385
cesssive inflammation of the stump, fistulous sinuses, abscesses in the extremity
of the amputated limb, necrosis, exfoliation, the projection of  the bone, phle-
bitis, inflammation of the internal organs, collections of pus in different parts
of the body, hospital gangrene, &c.  Of all the complications which can inter-
rupt the progress of cicatrization and constitute too frequently causes of death,
some  are  common to many operations, others peculiar to amputations ; some
are occasioned by external, some by internal  causes, inherent to the idiosyn-
crasy and constitution of the patients; some are physical, others moral.  Upon
many points we cannot add much to what we have already said when treating
of burns, gun-shot wounds, &c, and upon others, our limits do not allow us to
enter into much detail.   We shall, therefore, terminate this chapter by some
short  remarks on secondary haemorrhage, and some accidents  peculiar to
certain amputations.
  Secondary haemorrhage is one of the most grievous  occurrences which can
tend to mar the  success of an operation/   It generally occurs  when we least
expect it,  and when the surgeon and patient are anxiously expecting a rapid
cure.   It appears at divers periods, which cannot be foreseen, sometimes in a
few moments, or a few hours after the operation, as has been remarked, some-
times after many days or weeks, and even months.   T. L. Petit  observed it
twenty days after an amputation of the thigh,  which had been performed very
high up.  A few years  ago, in the hospital of La  Charite, it appeared  two
months after an amputation of the leg, at the bottom of a fistulous sinus, which
had not completely closed and which had ulcerated one side of the  popliteal
artery.
  Besides the causes of which we have already spoken elsewhere, secondary
haemorrhage  recognizes  many others,  such as  too deep a moral impression,
exciting drinks, the  irritation of the wound from too  great compression.  I
have called this last variety active haemorrhage from lesion of the tissues.  It
generally manifests itself during the first hours after an operation, sometimes
later, but especially at the period of invasion and during the traumatic fever.
This  accident  may also  proceed from the insufficiency  of  the  hemortatic
measures  previously employed; thus after cauterizing a vessel, it frequently
manifests itself on the separation of the eschar.  The inflammation  and suppu-
ration of the interior of the arteries of the stump tend especially to the expulsion
of the contained coagulum and consequently to secondary haemorrhage.   An
inflammation which continues and keeps up suppuration in the vicinity of an
artery will suffice to ulcerate it and give a passage for the blood.  The period
of the separation of the ligatures requires double  attention; the coagulum
frequently has  not acquired sufficient firmness, the  end of the artery is  not
solidly closed, or else the ligature around this end has softened its parietes, it
yields to the impulsion of the blood and haemorrhage takes place.
   Secondary haemorrhage is more difficult to arrest than that which occurs
immediately after an amputation, because the tissues which have commenced
to inflame or are already inflamed,  have acquired new  characters.  The
cellular tissue  has lost its natural elasticity and flexibility; it has become
thick, dense, sometimes  lardaceous from inflammation, and  is very easily
divided by the ligature.  Thus haemorrhage recurs whenever these means  are
used.  Immediate ligature is in such  cases generally impracticable, and  the
most advisable plan is to tie the principal artery of the limb at some  distance
                49 
586
LECTURES  ON
from the stump.   This I have been obliged to do several times, and  it has
been very generally successful.  Again, it  must not be  forgotten that this
secondary haemorrhage depends on numerous and various causes, which  it
vs important to ascertain in order to apply the most effectual remedial agents.
  We have spoken, when treating of the amputation of the leg, of the necessity
of preserving more integuments there than elsewhere, and of keeping the limb
during the operation  in a demiflexed position.  We think it proper to point
out here the consequences of a neglect of this caution.  If the skin does not
extend sufficiently far over the flesh,  (and this remark applies to other ampu-
tations) the  muscles become inflamed, swollen, and project beyond it, whilst
the inflamed integuments lose their elasticity and contract upon themselves.
It follows thence, that the muscles are compressed in their passage  through
the wound, and we soon observe in the stump all  the  effects of an inflamma-
tion accompanied by strangulation.   When  amputation has been performed
with the limb extended, and that after the operation it is demiflexed, the flesh
of the posterior part of the stump, which retracts but little, slide  from above
downwards  along the bones, become  relatively too  long, and passing beyond
the skin when inflammation comes on, present a most  favorable condition for
the  development of the symptoms just pointed out.  This may be remedied
by applying a sufficient number of leeches  around  the stump, and incising on
the sides  the  skin and  aponeurotic  envelope.   Another  frequent  accident
following amputation of the leg, is an acute  inflammation, sometimes gangrene
and perforation of the skin at the,point at which it rests on the  acute angle
formed by the tibia.   It  is to obviate this inconvenience that it is advised  to
close the  wound towards the fibula;  but this does not always succeed.  For
this reason, M. Larrey divides the bone as  high as possible, in order to dimi-
nish the bony projection, and avoid necrosis of the tibia, which  occurs much
more frequently than that of the fibula.   Some surgeons with the same inten-
tion remove at the time of the operation, a portion  of the anterior angle of the
bone.   In all cases whenever the accident  occurs, we  should unhesitatingly,
incise the skin opposite the  projection of the tibia, in order to prevent its
becoming gangrenous from pressure.
                        CHAPTER XLV.

              ON  HYDROCELE  AND ITS PRINCIPAL VARIETIES.

  Nothing  is more simple  than the diagnosis of simple hydrocele, nothing
more firmly established  than its treatment: for these  reasons we should say
but little concerning it if the varieties and complications which it frequently
presents were not deserving of your  attention.   The name of hydrocele is
given to watery tumors  of the scrotum; in one case, it is efftised into the
cellules of the cellular tissue,  this  is hydrocele  from infiltration; in another,
it  is collected  in  a sac, this  is hydrocele from effusion.  We also meet in
practice with a  third species of hydrocele distinguished from the others by
the accumulation of serum in  serous or accidental cavities, developed  either 
CLINICAL SURGERY.
387
in the middle of the spermatic chord, or in the testicle or the  epididymis.
Let me  here remark that each of the species  here spoken of, may present
many varieties, of which the characteristic marks will be pointed  out.
  Previously to making any remarks on hydrocele from infiltration,  let us
designate the characters of the'principal  varieties  which we have established
in the cellular  tissue which plays so important a part in this hydrocele.  I
have observed  in the general cellular tissue four  varieties, which are,  1st,
the adipose cellular tissue, existing nearly isolated in some animals, as the
sheej),  developed in the omentum, strongly  marked  in  some  individuals.
W^hen inflammation attacks this  tissue, it generally terminates by a kind of
wasting and putrefaction of the inflamed  parts.  This is observed in strangu-
lated hernia when the omentum is left outside, and in  sheep which have been
inoculated or vaccinated  in order to  prevent them from  being  attacked by
certain  diseases.
  2d. The fibrous cellular tissue containing neither adeps nor serum.  This
tissue in man is principally found around the .articulations.  When inflamed
it is generally accompanied by strangulation.   In the dog and  some carnivo-
rous animals the cellular tissue is nearly every where fibrous.
   3rd.  The elastic cellular tissue  containing none of the elements of which
we have spoken.  It is  seen around the tendons which are unprovided with
synovial burse.  Inflammations affecting it have a great tendency to spread, as
may be seen in the palm of the hand, when inflammation of the  tendons readily
extends to the fore-arm, &c.
   4th.  The serous cellular tissue, always free from adeps, inelastic and con-
tinually moistened by  serum.  It  is found in the eyelids, the  genitals, the
scrotum, &c. Inflammation of this tissue often terminates by suppuration.  In
 it is seated hydrocele from infiltration whether idiopathic or symptomatic.
   Considered as regards its situation this hydrocele  occupies the spermatic
chord, or the middle septum of cellular  tissue, or  lastly in the sub-cutaneous
serous areolae.   In the  first case, the  tumor is circumscribed, fluctuating and
 confined to one chord ; in the second, it  is elongated, extended  from the ring
 to  the base  of the scrotum, preserving  the impression made by the finger,
 only occupying one testicle; lastly in the  third, the  tumor isvolummous,doughy,
 extends rapidly to the whole scrotum without being arrested by the median
 line.  The knowledge of these different cases is  important in the  treatment,
 for supposing we wish to give exit to some infiltrated fluid, we must make, m
 the two first varieties, an incision of greater or less extent, whilst in the third
 a simple puncture will  frequently evacuate all the fluid contained in the sub-
 cutaneous  areolae, on  account  of the  free communication  between  them.
 Hydrocele, from  idiopathic infiltration,generally occurs only in newly-born
 children and in old men.   The disease may be confined to one side or attach
 the whole of the scrotum.                                       ,  a
   Hydrocele from effusion, of which we shall treat particuarly  is fluctua-
 ting^ it ascends from the most dependent portion  of ^ scrotum towards the
  Z nal canal, is almost always developed in  front of the  testicle, and offers
 resistJ only when the serous sac and other coats being ^ndjd «nd r»-
 dered thin, resist the effort of the fluid and reactupon it.   These dispositions
 however, may vary, as will be seen by the following case. 
388
LECTURES  ON
  Case I.—A man came to the Hotel-Dieu, after having been treated in ano-
ther hospital for hydrocele, which had been punctured.   He said the operation
was very painful.  Blood alone, and no serum, passed through the canula;
the scrotum, instead of decreasing in  size,  had immediately grown  much
larger.  It had become hot, painful and tense, and required a severe antiphlo-
gistic treatment to restore it to its state previous to the operation.
  Placing a lighted  candle behind the tumor, I saw that it was transparent,
and presented in front, about the situation of the former puncture, an opacity
formed, as I supposed, by  the testicle.   Holding this substance  between
two fingers, the tunica vaginalis was easily  emptied by a puncture made more
posteriorly.
  We have stated  in the commencement of this  chapter, that the disease
under consideration presents complications  and varieties worthy of attention;
for  example, hydrocele from effusion of the tunica vaginalis may be compli-
cated with encysted hydrocele of the spermatic chord.  This has been a fre-
quent source of erroneous diagnosis; frequently situated opposite to the in-
guinal ring, and sometimes extending to the canal, it has often been mistaken
for  inguinal hernia.
  As long as these  diseases are separate,  they are easily distinguished ; the
tumor of  the  chord is  above,  that of the  serous coat of  the testicle below.
When they approach and mingle with each other, the hydrocele of the tunica
vaginalis passes in  front of the other.   Sometimes great  care is requisite to
ascertain  the disease.  By placing the individual  on his back,  the tumor,
generally  rounded, circumscribed,  may be perceived,  isolated and distinct
from  the intestine  or omentum; add to these symptoms the transparency and
fluctuation presented by this kind of tumor.   Such are the principal charac-
teristics of the disease.   The diagnosis is sometimes exceedingly difficult, as
the following case will show.
  Case II.—Encysted Hydrocele of the Spermatic Chord.—A child, of twelve
years of age, was operated on in the Hotel-Dieu in 1828, for hydrocele of
the tunica vaginalis  of the leftside.  He  was treated by injection, and dis-
charged cured.  Some  months after, there appeared in  the groin, opposite to
the inguinal ring, a small, soft, fluctuating tumor;  the  color of the skin wa9
unchanged.  The  disease was  mistaken for  hernia, for a truss was recom-
mended.  Notwithstanding its use, the tumor increased, and the patient en-
tered the Hotel-Dieu in October, 1829, in the following condition:
   There was a round and  yet slightly elongated tumor about the size of a
large pigeon's egg, opposite to the inguinal  ring;, it commenced at about half
an  inch from this point, and terminated near the epididymis.  Notwithstand-
ing its tension, it was fluctuating,  and  the color of the skin was unchanged.
Coughing produced no effect on the tumor.  It could not be pushed into the
inguinal canal, but  it could be felt  to  be isolated; and lastly, it was very
transparent.  Feeling confident that it was  encysted hydrocele, I determined
to treat it by incision.  The operation was  performed on the 13fh of October.
An incision was very carefully made, as in hernia, in the skin covering the
tumor.  We were exposed to two dangers; an error of diagnosis, and injury
of  the  constituent parts  of the chord,  whose relation with the sac could not
be  ascertained. The subjacent layers were successively divided, and the sac
was  at last reached. A jet of yellow serum indicated arrival at its interior. 
CLINICAL SURGERY.
389
 The aperture was enlarged, the finger introduced into the cyst discovered no
 communication.  The serum was completely evacuated, and the sac  filled
 with charpie to excite inflammation and consequent adhesion of its parietes.
 No bad symptom ensued. The charpie was renewed.  In a few days a mode-
 rate inflammation attacked the  cyst,  and copious suppuration took place.
 Twelve days after, it had cicatrized.  (Dr. Paillard.)
   The uncertainty as to the nature of the tumor, whatever signs we may pos-
 sess to ascertain it,  should in a measure indicate the treatment;  in fact, in-
 jection is one of the best, most simple and prompt in encysted hydrocele.  But
 if we have erred in our diagnosis, and thrown an irritating fluid  into a her-
 nial sac;  dreadful accidents may arise ; this is no supposition ; an irritating-
 fluid has  been frequently thrown into  a hydrocele of the  tunica vaginalis
 which had preserved its communication with the peritoneum.  Extreme cau-
 tion must therefore be used not to endanger the life  of the patient; if we are
 obliged to inject, the fingers should be applied to the inguinal ring in order to
 interrupt  the anormal communication.
   When the least doubt exists we must  have  recourse  to  some  other plan.
 The incision of the  cyst removes all uneasiness in this respect, and deserves
 on that accountj the preference in a majority of cases.
   It is useful to observe the difficulty, if not the impossibility of determining
 precisely  the relations of the vessels of the spermatic  chord with encysted
 hydrocele of the chord.  Hence in the operation by incision, the parts should
 be divided very slowly and Carefully.
   Hydrocele presents many important varieties in  form.   Thus the tumor,
 generally single and regular, is sometimes  strangulated at its middle like a
 wallet, the two portions communicating with each other.
   We sometimes find in the interior of simple hydrocele cells, in greater  or
 less  abundance, and a kind of cellular structure containing serum, so that
 when wc make a puncture, only a portion of the effused matter escapes, and
 in order to evacuate the tumor completely, every successive division would
 require a puncture.   In cases of this kind  presenting a disposition analogous
 to that ppinted oat in hernial sac, and there called multilocular incision, as in
 the preceding case, should be preferred to all other plans, as is proved by this
 case.
   Case III.—A man was admitted into the Hotel-Dieu, with a tumor on the
 left side of the scrotum.  Eighteen months previously he had received a blow
 on the testicle.  From that period the organ became unequally swollen.  On
 examination I found  an uneven, fluid, fluctuating, transparent tumor.  Attri-
 buting this inequality to the resistance of  the  tunica Vaginalis, I  plunged a
 trocar into the  most voluminous part of the tumor;  a yellowish pus escaped,
 but the tumor was only half emptied.   By  touching the most projecting part,
 1  found a  distinct fluctuation, I made a second puncture.  A turbid  fluid
 escaped, the leftside of the scrotum returned to its natural size.  The former
 fluid easily coagulated by heat; the latter  remained unchanged, and on
 analysis proved to be entirely albumen.   The chord was in the same state  as
 that of the opposite side and presented no symptom of effusion.
   This is a highly important case,  for  it  has frequently happened that
hydroceles considered  as  multilocular, were merely hydroceles of the tunica
vaginalis, complicated with encysted hydrocele of the chord.  Experience has 
390
LECTURES ON
also shown me that there are hydroceles of which the sac cannot be completely
emptied by one puncture, and that this is owing to the multiplicity of cells and
a kind of cellular tissue retaining the fluid.
   Hydrocele of the tunica vaginalis  presents  remarkable  differences as it
occurs in adults oris congenital.  Before the fcetus has arrived  at maturity
the testicle is in the abdomen, whence it descends after birth.  The extension
of peritoneum by which it is  accompanied, and which constitutes the tunica
vaginalis, generally closes soon after the descent.  But some fluid may also
pass into it  from the "abdomen.   Hydrocele  then  occurs, called congenital,
disappearing under pressure because the water is thrown into the belly.
   I have said that this hydrocele  may appear while the testicle is still in the
abdomen, and is  found  behind the superior orifice of  the inguinal,  canal.
This is easily understood.   The peritoneal covering of the  testicle, which
corresponds to the abdominal aperture of the inguinal  canal is pressed upon,
either by the fluid contained in the belly, by the intestines or omentum, gradu-
ally yields to this pressure, elongates, is engaged in the canal  through  which
the testicle passes, and finally reaches  the bottom of the scrotum.  We then
see a fluctuating, translucent, soft pyriform tumor, which entirely  disappears
under pressure, or the horizontal position, but which when  left  to itself and
the individual stands erect, soon reappears.,
   I have also seen another variety of congenital hydrocele of which the charac-
ter is the same enlongation of the  peritoneum  which  constitutes the tunica
vaginalis, whilst the testicle yet in the  inguinal canal, is about descending.
   The tumor in these two varieties of hydrocele is only covered  by the in-
teguments  of the scrotum, the  subjacent  cellular tissue,  and  the cellulo-
fibrous layer of the fascia superficialis.  The upper portion is engaged in the
inguinal ring, and the  testicle adheres to the posterior part of its  neck, as it
would at the bottom of the  tunica vaginalis.  Lastly, the  abdominal orifice
of the hydrocele communicates with the1 cavity of  the peritoneum  by a small
aperture.
   These two varieties require a careful examination,  as they may easily be
confounded with hernia.
   Among the complications  of hydrocele, hernia must not.be  forgotten; it
occurs chiefly in  old  men.   The hydrocele generally passes in  front of the
hernia; and sometimes, but rarely,  behind it.  Some surgeons have proposed
to leave the, tunica vaginalis in such cases untouched and to open merely the
hernial sac.   I have found that we'only spare the  hydrocele at the expense
of the extent of the incision in the sac, at the bottom of wliich the fluid after-
wards collects.  Severe inflammation and other symptoms ensue which might
have been avoided by opening at the same time the serous coat of the testicle.
By these means, the destruction of the strangulation and the radical cure of
the hernia are effected.
   It.sometimes happens, when the hydrocele is in front of the hernia, that a
portion of the omentum or intestine passes through the openings in the tissue
enveloping the tunica vaginalis, and  projects into the fluid constituting the
hydrocele.   The secondary tumors are covered by the hernial sac and serous
layer of the coat Of the testicle.
   As the hydrocele may be partly or entirely covered  by a hernial sac more
or less filled with  omentum,  in puncturing it we must be careful not topunc- 
CLINICAL SURGERY.                        591
ture the sac, nor the testicle.  The relations of the two sacs, in this case, are
highly important  to be ascertained.  Indeed, these relations are not  always
the same; thus sometimes,  although the hydrocele forms the most posterior
and inferior portion of the whole tumor, the watery tumor is often found i:s
front and  outside  of the hernia.  In other  cases, the turtica vaginalis pene-
trates into the hydrocele, and forms a trueaqueous hernia in its cavity.  The
contrary may take place, and the tunica vaginalis then yields at one of its
points corresponding to the hernia, and  makes a laceration through which a
portion of the latter passes.   Frequently then, the hardness and elasticity of
the edges  of this rupture as well as its  narrowness are such, that the parts
constituting this  species of hernia by  prolongation are often irritated, con-
tused, and constricted in their passage; symptoms of strangulations occur,
vvhichare erroneously attributed to the constriction of the rin<>-.
   I have met' with  many of these cases.  It is important, to distinguish them
and remember them when we perform the operations for hydrocele and stran-
gulated hernia ; we thus avoid plunging the trocar into a hernial  sac, cutting
the coats of a  hydrocele  for those of a hernia, and enlarging the ring when
the strangulation is  produced  by the contraction of  the laceration of the
tunica vaginalis upon the parts which have penetrated  into its cavity.
   Among the compli-cations of hydrocele, we shall merely mention sarcocele,
of which a  remarkable case was given in the first volume.   But several less
frequent and less understood causes demand more attention.   Serous cysts
may be. developed  in one  side of-the'scrotum, enlarging  it considerably.
Scirrhus of the testicle has been supposed to exist in similar cases, and the tes-
ticle been extirpated.  Sometimes these cysts appear  in  the  midst of  the
organ itself.. This is what Morgagni-calls hydatids of the testicle.  Heat-
tributes the formation of hydrocele to the rupture of these cysts; having ob-
served, says he,  in all cases of this disease hydatids of the testicle entire or
torn,  or else remains of  old hydatids  of white tubercles, he concluded  that
the rupture of these hydatids was  the most general, if not the only cause of
hydrocele.  The value of this explanation  is not worthy of discussion in the
present state of science; we shall merely observe that a hydatid cyst developed
in the substance of the chord or of one of the testicles, may, by its softness, re-
sistance, more or less marked transparency, the inequalities and other charac-
ters it may present, give rise to the supposition of the existence of a hydrocele
of the chord or  tunica vaginalis.   They may be easily  confounded with  hy-
droceles of which  the cavity is  divided by'septa into several cells.  I have
seen  several members of the same family affected with this singular disease;
treated them by incision of the cyst, and they were, all cured.
   Purulent or miticerous cysts, scrofulous testicles  and other products  of
chronic inflammation of the testis, wliich have sometimes been called encysted
hydrocele of that organ, constitute changes totally different from that of which
we are treating.   These purulent cysts require either  the incision of  the  pa-
rietes, or the extirpation-of the  cyst.
   The  state of the tunica vaginalispresentsdegrees of, disorganization .which
it is important to study.  ' In the commencement of the disease it is thin, trans-
parent, and easily  pierced.   At a later period,  this envelope or rather the cel-
lular  tissue of the  external surface frequently is much  thickened, and nearly
as dense as cartilage.  In that case transparency no  longer is present, and 
392
LECTURKS  ON
after the puncture, the coat instead of collapsing, remains like a shell around
the organ.  Sometimes I have seen these serous cysts become the seat of more
or less copious sanguine effusion, or present  plates of ossification of various
extent.
   Case IV.—During the year 1820, Mr. Ch.de Lille, about 40 years of age,
came tome for advice.   He had in one side of the scrotum  a round, uneven,
hard, resisting, opaque tumor, about as large as the fist of a child  of twelve
years of age,and which.united to the testicle, was, as well as this organ,  in a
morbid condition and suspended by a chord.   From these symptoms we might
suppose either the existence of hydrocele complicated yvith cartilaginous dege-
neration of the tunica vaginalis, or sarcocele or hydro-sarcocele. They were the
only  ones indicated by. the disease itself,  and the diagnosis might have been
very obscure, but in this  case the history given by  the patient served to
remove all doubts.
   The disease had commenced at the age of two and twenty, that is at an age
in which carcinomatous degeneration seldom occurs; it was not painful,  but
merely inconvenient from  its weight;  lastly, its cure by puncture, had  been
several times attempted, either followed or not by injection, and whenever it
had been  emptied, it was ascertained that the testicle was sound, but that its
covering became more and more thickened.
   From these data no mistake could be committed ; the patient had hydrocele
accompanied by cartilaginous degeneration of the tunica vaginalis.  I  per-
formed the operation of incision; a small quantity of yellowish transparent
serum escaped.  The cavity of the cartilaginous shell into which the membrane
was transformed, and of which the parietes were not more  than four or five
lines in thickness, was divided by sword-like prolongations, rudiments of septa
which would have become organized,  and separated the principal into several
secondary cavities.  In less than a month the patient was cured.
   Of the different plans proposed for the radical cure of  hydrocele, that most
generally in use is by injection.  I have sometimes succeeded by a blister to
the scrotum.  This  produces an irritation extending to the  tunica  vaginalis,
causes the absorption of the fluid, and the consequent adhesion of the oppo-
site sides.  It is not a matter of indifference what is used  for injection.  I have
derived most advantage from the following: in a pint of  strong wine of Ilou-
sillon, boil two ounces of Province roses, and sometimes increase the strength
by the addition  of a little brandy.  I make three injections, each one.  lasting
three minutes.   The only precaution,which I never omit, is to be certain that
the point of the canula is in the cavity of the tunica vaginalis; should it have
slipped out, it may have entered the cellular tissue, and no injection must be
performed under those circumstances.  From a neglect of this caution,  gan-
grene has sometimes followed the operation, as will be seen  in the  following
case.
   Case.—A man was admitted into the. hospital with hydrocele.  It was
punctured, but the injection was thrown not into the tunica vaginalis but into
the cellular tissue ;  an intense inflammation supervened which was with  great
difficulty arrested.  The effusion having returned, the man came again to the
Hotel-Dieu, in 1833.  I performed the operation by incision ; at the end of
twenty-four  hours  the patient  was  seized  with vomiting, and scon  after
haemorrhage appeared.  I removed the dressing, washed the wound and placed 
CLINICAL SURGERY.
393
on it compresses wetted with cold water; I used no tampon as the blood came
from the inguinal ring.'  This is a plan very common in Germany, to expose
the limb to the air, and wet it with cold water, in haemorrhage.  It is inappli-
cable to  haemorrhage from large vessels ; but in that from small vessels
combined  with symptoms of inflammation it is useful.   Our patient was  atthe
stage of inflammation ; the bleeding did not return.   It woujd  have been
otherwise  had we used  a  tampon.   A  man whose  thigh  was amputated,
received a blow on the  stump, blood immediately flowed from it; I undressed
the limb, but could not discover the  bleeding vessel.   I applied a tampon, the
pain and haemorrhage returned ;  I removed it, they ceased.  Twice this was
done with the same consequences.   It was  then very evident, that the dress-
ing kept up the tension of the parts and consequently the haemorrhage (which
I have named haemorrhage  from irritation); therefore  it was not  re-applied.
This is a haemorrhage which must be treated medically by emollient means,
venesection, the application of cold water, and the removal of all irritating
measures.
                      CHAPTER  XLVI.

               ON THE TREATMENT OF GOITRE BY THE SETON.

  Individuals of a lymphatic constitution, marked by the softness and white-
ness of their skin,, a well rounded form* by indolent and relaxed habits are
subject to goitre.  WTomen are more liable to the disease than men, and
children than adults.  The gland, which in the healthy state weighs from one
to two ounces,  frequently in the morbid state reaches the weight of one or
two pounds.  In the vallies of Savoy and the Valais where goitre is endemic,
it spares no sex, nor age ;  and  so great is the influence of climate in  its pro-
duction, that an adult who might settle in that country, would be liable to the
disease.  Several causes have been assigned for this disease.   Fodere, in his
curious details of  the  countries in which this affection  is prevalent, admits
perhaps too exclusively, the humidity of the atmosphere added to the humidity
of the temperature ;  the inhabitants  of these countries, says he, are almost
continually in a vapor bath.  A warm moist temperature during a great part
of the year may  certainly affect our organs,  but goitre  occurs  in  persons
under different circumstances.
  In the month of March,  1833, two women  came to the Hotel-Dieu ; one,
26  vears of age,  had labored under goitre for several years.   The gland
presented the form of a large, elastic, round and uneven tumor.  The base
appeared large.   The tumor at first was small, but rapidly increased  to the
size of both fists.  The  voice  was rendered  hoarse and  rough from the
mechanical pressure.  The return of the venous  blood was embarrassed
whilst the course  of the arterial blood was  unimpeded, hence the woman was
subject to head-ache, vertigo and fainting.
  the other woman had had the sanie disease for twelve or fifteen months.
Both sides of the  thyroid gland were affected.   A seton was passed through
           50 
394
LECTURES  ON
each  tumor and after a prolonged suppuration  of several months  she was
entirely cured.
   The first patient was treated in the  same manner, with a similar  success.
   I will now enter into some details concerning the operation, and my opinion
of this remedy, and some other therapeutic agents which have been celebrated
in goitre.  Latterly, iodine has been lauded with a kind of enthusiasm, and
it would seem that no goitre can resist its energetic effects; in many cases it
fails,  and the slightest reflection might foretel this result.  Goitre depends on
various  causes:  sometimes, it is a simple hypertrophy of the  thyroid gland;
sometimes, a scirrhous degeneration ; and again, it  may be a cyst filled with
divers contents.   Iodine cannot act similarly in diseases so different, there-
fore, as  we have  said, it does not succeed in many cases, any better than the
powder  of  Sancy, calcined sponge, mercurial frictions, camphorated, ammoni-
ated and opiate liniments, plaisters of cicuta, and a host of other pharmaceutic
means equally celebrated.   It  is  just to declare that iodine has  effected
cures.
  Of all the remedies I have ever used, that from which I have derived  most
advantage, is decidedly the seton. It has lately been  published as new by
professor Quadri of Naples.  This gentleman has undoubtedly committed an
involuntary error; for he has/ used it  many years since, in a patient whose
case w'e have detailed.
  Some time after the application  of "the seton the goitre diminishes, and the
resolution which is gradually effected,  is complete in a few months ; it may
even  take  place after the removal of the seton. and the cicatrization of the
wounds.  How  does the  seton act  ?  This is difficult to determine.   Is  it by
inflammation of  the tissue of the thyroid gland ?  Is it by the discharge of the
organ from suppuration ?  This is  a matter of little importance; the essential
point is  to cure the disease.
  When the seton is  passed through the thyroid gland,  a copious flow of
venous blood follows.  This  circumstance is  at first  alarming, but  the dis-
charge soon ceases.  It resembles  that from the nose  after the extirpation of
polypi of the nasal fossae.  By desiring the patient to breathe freely,  in, order
to restore the venous irritation, a cold application, or slight compression, this
haemorrhage, caused by the lesion  of the venous plexus in front of the  thy-
roid gland, is arrested.   The seton should remain  several months ; but its
duration depends on the progress of  the  disease towards a cure.   In the
application of the seton  we  should carefully remember the  position of the
thyroid arteries.
  Now shall we  say what has been said of iodine and other specifics, that it
will always cure  goitre ?  By no means.  The scirrhous state in which this
gland is sometimes found can never be remedied by its use; but hypertrophy,
cysts, and hydatids, in which iodine  and its  preparations, as well as other
pretended specifics so often fail, are the forms of the disease in which the seton
may be very frequently employed with great advantage. 
CLINICAL SURGERY.
395
                       CHAPTER  XLVII.

   ON  THE ARSENICAL PREPARATIONS IN CANCEROUS AND OTHER CORRODING
                              ULCERATIONS.

  We  frequently see in the Hotel-Dieu patients who seek advice for corrod-
ing ulcers of  the nose, lips, cheeks and other parts of the body.  These ulcer-
ations produced by venereal, scrofulous and hepatic affections, either alone or
so combined as to constitute a simple or compound disease, are frequently the
horror  of the  practitioner on account of the inefficiency of remedial agent?.
Hence from their numerous  relapses, and especially those of a cancerous na-
ture, even after their total removal by the knife, surgeons have had recourse to
remedies of a very dangerous, or extremely active nature.
  In the list of the remedies, arsenic enjoys undoubtedly the first place.   It is
employed both internally and externally, but always with  fear, so dangerous
is the least error, the slightest modification of the mode of administration, or
the slightest imprudence on  the part of the patient.  Notwithstanding, there-
fore, its great value,  physicians have generally used it with great reluctance.
It is, nevertheless, important to determine the therapeutic effects of this heroic
remedy, to point out  thecasesin which it may be injurious.  Such  a  work de-
mands  a host of experiments which we may one day  make ;  we shall  now
merely treat of its external use which has been for a long time known to science.
Most of the prescriptions bequeathed to us by former physicians  are bad, or
their application is liable to serious objections, or their usefulness  does not
counterbalance their danger.   Such are the powder of Rousselot,* that of
Pere Come, modified by several surgeons, and  particularly by M. Patrix, who
has described the_best manner of employing the  arsenical paste; the powder
of Justamond,t of Pierre Alliot, of Plukket, the cerate of Hellmund, &c. &c,
preparations of which arsenious acid is generally the base.
  This poison has  been mixed  with divers other substances, of which  some
injure  its action and others constitute a remedy  of disagreeable or difficult
application.
  One  of  the first effects, and often one of the first inconveniences of arseni-
cal preparations, is to act as an escharotic, or caustic, to destroy the parts to
a greater or less depth, and sometimes produce deformity.  The preparations
which we employ have not that effect.  They act by modifying the diseased
surfaces, not  by producing a slough.  This is one of. their chief advantages.
  The  preparations I use are either in powder or liquid ; the arsenious acid is
the base of all.  The calomel may be counted as something; but still it  should
never be omitted.  These  two remedies, arsenic and calomel, are necessary to

       •Powder of  Rousselot.
           Hfr White Arsenic powdered
                  Cinnabar
                  Dragons blood
        |P0WDEH OF JUSTAMOND.
                p  White oxide of arsenic powdered
                  Sulphuret of antimony
1 part
16 parts
8 "     Mix.

2 parts
4 "     Mix.
      Translator. 
396
LECTURES ON
the preparation, without our being able to assign precisely to either the part
which it plays.  The powder is prepared as follows :
         Of arsenic or arsenious acid .       .              4 parts
         Of calomel   ....             96—100 parts.
  The arsenic may be increased to five or six per cent.
  The liquid is merely the solution  of these remedies  in distilled water; it is
mixed with powdered gum arabic so as to give  the  preparation the form of  a
paste.   In the liquid form, I generally employ a larger proportion of arsenic ;
thus into a hundred parts, I introduce, 6, 8, 10, or 12  parts of arsenious acid,
the rest is calomel, and I have even  used larger proportions.
  Case.—A girl of 15 years of age was admitted into the Hotel-Dieu in March
1833, for a suspicious looking ulcer on the left  side of  the  lower  lip.  The
ulcer extended about an inch, its edges  were jagged and inverted, its surface
uneven and grayish ; it was formed at the expense  of the skin and subjacent
cellular tissue, and extended  as far as the mucous membrane of the lip, rest-
ing on  an indurated base.  The disease had existed for  seven years.   A por-
tion  of the ulcer was covered by a yellow crust formed  by the dessication of
the discharge.   A poultice was  applied to loosen this  crust.  In a  few days
after the first application of  the arsenical powder, a slight  inflammation took
place.   The surface of the ulcer was advantageously modified.  A second
application was followed by some symptoms of poisoning*; the patient had
nausea and vomiting.   Every one is  familiar with the  dangers of the use of
arsenic, and in order to guard against them  as  much  as possible, I had put
the patient exclusively on a milk diet for some time  previously.  The  symp-
toms disappeared and on the separation of the  preparation the wound was
nearly healed.
  In these cases I prescribe the free use of milk; and also the application of
a piece of linen  on the wound on account of the vicinity of the mouth, which
is not to be removed until the separation of the powder.  The patient is nour-
ished by a sucking bottle.
  The mode of  application of these preparations is  very simple.  A poultice
is first applied to separate the crust  covering the ulcer;  then a small piece of
charpie dusted with the powder is laid on the ulcerated surface.  Should this
surface be not very large, it  is wholly covered: in  other cases, we cover one
third, one fourth, one half, and  so on gradually, until the whole is covered.
  The solution,  or rather the paste,  is applied in the same  manner.
  This application, after considerable pain, inflammation, &c, ordinarily falls
off spontaneously in eight to  ten days.   It is to be renewed according to cir-
cumstances.   Generally  five or six applications  are  required, often  two or
three are sufficient.
                         CHAPTERXLVIII.

         ON SYMPTOMATIC GANGRENE CONSEQUENT TO ARTERITIS.

  That variety of gangrene which has been alternately named spontaneous,
senile, dry gangrene, without any known cause, had been, until recently ex-
clusively considered under the  relation of its external appearance.  Hence 
CLINICAL SURGERY.
3S7
we were generally limited to two therapeutic indications ; to arrest the gan-
grene by topical applications, and remove the diseased parts, without suspect-
ing that there might be different ways of effecting the same object.  Struck
by the  obscurity presented by this disease, we have endeavored to enlighten
it by pathological anatomy, and were soon convinced that its cause, although
unperceived and  for a long time concealed, existed,  and was to be found in
the inflammation  of the principal arteries  of the limb affected, which were
seen inflamed, red, the blood coagulated, the artery obliterated, and the cir-
culation completely interrupted.  The coagulation of the blood may occur in
different ways,  either by its contact with the inflamed artery, or by its mix
ture with  the concrete lymph, or by an ulceration of the artery.   Autopsy
has shown all these circumstances. . When amputation  is performed for this
affection, the vessels filled by coagula of fibrin, or a mixture of pus and fibrin,
pour out no blood, and the ligatures are perfectly useless.
  The etiology of symptomatic gangrene was unknown until modern days.
Old  age and debility were regarded  as the principal causes of the disease;
but this opinion cannot be maintained,  since children are sometimes attacked
with it.  The ossification of the arteries has been supposed to cause it; but
observation shows this to be merely a coincidence.  In fact, the mere ossifica-
tion  of the arteries is not sufficient to sensibly interrupt  the course of the
blood,  and it frequently occurs without any appreciable change in the circu-
lation.   How often do we  dissect bodies in which all the arteries of a limb
may be ossified and no gangrene exist.   The true cause of the disease consists
in the  obliteration of the arteries and the suspension  of the course of the
blood in its vessels.  How does this occur ?   Let us now enquire.  Exa-
mine individuals  affected with symptomatic gangrene,  you will find nearly
always that they have abused  the use of alcoholic liquors, stimulating food,
or have labored under chronic diseases of the heart, the valves of the aorta
and  large vessels; causes most frequently exciting the irritation and inflam-
mation of the arterial system.  In a  majority of cases, the gangrene is pre-
ceded by pain, sometimes very severe, fever and other inflammatory symptoms.
Lastly, inspection always shows the existence of inflammation of the arterial
coats.   This  may undoubtedly  occur in arteries which   are already dis-
eased,  indurated,  ossified, as is often met with  in old persons ;  but it fre-
quently occurs in the arteries of young subjects, without any traces of disor-
ganization.  In  short, it may coincide with a calcareous incrustation of the
vessels and old age, or be independent of these conditions.
   Lastly, experiments made on  living animals produce the same effects,
cause artificially symptomatic gangrene, like that which occurs spontaneously.
M. Cruvelheir has proved that by injecting irritating  substances into  the
arteries of an animal, inflammation of the internal  coat is produced, and
the consequent mortification of the parts to which they are distributed.
   Case.__Arteritis;  Coagulation  of the  Blood; Symptomatic Gangrene;
Death.__Rigolet, 40 years of age, was admitted into the hospital on the 15th
of July 1832, with incipient gangrene of the leg.  She was  a.woman of deli-
cate constitution  but had always enjoyed good health.  She  said that she re-
cently had cholera; but on being questioned as to the symptoms, stated that
she  merely had  had violent cramps in the right leg.   A heavy, dull pain had
been previously felt in the fossa iliaca of the same side : thence it descended 
398
LECTURES  ON
along the inner part of the thigh, to the posterior part of the leg, and lastly
reached  the  sole of the foot and toes.  These parts had been tormented by
formication, lancinating pains, and lastly by a burning pain.  At that period,
eight or ten days previous to her entrance into the hospital, the foot had be-
come cold;  violet spots had appeared; the pain  was  so  severe that  she
could not sleep; the symptoms  had increased so much that she decided on
entering the  Hotel-Dieu.
   On the 16th  the right foot and leg were swelled as far up as the knee, to
double the size of the other ; the skin was tense,  and shining as in phlegmo-
nous erysipelas.   It was of a violet color, very dark towards the toes, less in-
tense higher up, and scattered in  plates over the limb-  The epidermis in
some spots was raised ; the leg  was intensely cold, the sensibility diminishing
in the direct ratio of the temperature.  The femoral artery of the right, side
could scarcely be felt, and seemed converted throughout its  whole course in-
to a hard and scarcely compressible cord.   I pronounced  the disease to be
arteritis of which the gangrene was merely a symptom.
   (Venesection to twelve ounces, gum water, emollient poultice to the whole
limb.)
   The bleeding quieted the pains  and restored  sleep.  It was repeated the
next day;  on the 18th the effect was more evident;  the pain had nearly dis-
appeared ; the swelling had diminished ; the  heat and sensibility had returned
in several spots.  But  upon the mortified parts  had appeared some  vesicles
filled with  a dark fluid, which when ruptured, exposed the skin black, gan-
grenous, exhaling a  fcetid odor.  In order  to arrest the decomposition and
mark the fetor,  the  parts  were bathed with camphorated spirits.  22d, she
was again bled.
   On the following days, the gangrene seemed arrested at about four fingers'
breadth below the  knee.   All below this point was probably mortified.  The
movements of the foot were gone ; the leg alone could be flexed and extended
on the thigh.  Still,  whether  the nerves were yet untouched, or that there
existed a feeling similar to that  after amputation, thepatient at intervals com-
plained of acute pain in the foot.
   Until  that time the treatment had not caused the gangrene to recede; but
at least it appeared to be arrested.  Towards  the close of July,' notwithstand-
ing repeated bleedings, the icy coldness, the fore-runner of gangrene, attacked
the knee and gradually ascended.   On the  11th  of August the mortification
occupied the patella;  the cold was felt two inches above it; the pulsations of
the femoral  artery were imperceptible.  16th, the inferior third of the thigh
was attacked; her strength  rapidly gave way; diarrhea supervened, and death
finally released her on the  19th day of August.
   Necropsy.,<—Corpse dry and  emaciated; the leg gangrenous, although less
swollen than in the commencement, is yet one third larger than the other; the
epidermis nearly totally removed; the derma is black, dry, hard, very compact,
exhaling  no odor but that of camphor.  Three sloughs, of which the patient
scarely complained, were situated on the right side of the pelvis ; the first
near the  tuberosity of the ischium; the second near the coccyx; the third, as
large as one's hand, extended obliquely towards the crista of the ilium.scarcely
passing beyond the median line of the left side.  The vessels of the sound
limb were first examined.  In the middle of the thigh the artery although  of 
CLINICAL SURGERY.
399
 normal appearance was contracted, occupied by a filiform, roseate coagulum,
 apparently formed after death.  Towards the crural arch the artery recovered
 its calibre; it was hard, incompressible, filled by a  red coagulum, slightly
 adhering to its inner coat, but grayish in the centre.   This extended upwards
 as far as the origin of the primitive iliac, and slightly projected into  the left
 iliac, but did not obliterate it.  The right internal iliac was also closed by a
 similar coagulum.   The crural veins of that side was filled with a reddish coa-
 gulum. The  vessels of the left limb, the aorta and heart were nearly empty.
   Between the sound and gangrenous parts was a space of two to three inches,
 in which cold  had been felt during life ;  there the cellular tissue was marbled
 with a grayish red color, and the capillaries were highly injected.   Below this,
 on the verge of the gangrene, this injection disappeared.  The epidermis of the
 leg was totally removed ; the derma black, hard, dry as parchment, the subcu-
 taneous cellular tissue of a  grayish yellow, the aponeuroses paler, slightly
 softened ;the  muscles of a lively red, moist, furrowed by cellular layers of a
 more than ordinary white appearance ; the nerves roseate ; the vessels  about
 the popliteal space  containing, first, a coagulum, analogous to the upper gray
 coagulum, and a little lower down a reddish  sanies.   The deep seated cel-
 lular tissue was gorged in some places with this sanies; in others, changed into
 brown  spongy sloughs; but generally it presented a yellow grayish and nearly
 normal appearance ; the bones of a pale gray color adhered firmly to the peri-
 osteum ;  the marrow of the same color; nothing morbid was  observed  in the
 viscera, but ,some  redness of the small intestines.
   It may be conceived that in this gangrene, following  the suspension of the
 course of the blood, the parts deprived of their vitality, in consequence  of the
 absence of this  nutritious fluid, are generally  deprived  of a great  part of
 their moisture, that they shrink and dessicate, and form  at the extremity of
 the remaining living parts, species of carbonized appendages, which are some-
 times so hard as  to sound on percussion.  It is, therefore, not surprising that
 the odor from  this kind of gangrene should not resemble that resulting from
 the excess of inflammation of the parts.
  The  symptoms of symptomatic gangrene are very remarkable.  In the com-
 mencement it is a purely  local affection, and  we may easily understand the
 perplexity of surgeons deprived of  the lights of pathology, and who  could
 find no external  lesion  nor disease  of the viscera sufficient to  explain the
 result.   The respiration and circulation preserve their  regularity; the brain
 and digestive organs perform  their functions as  in health.  It is only  as the
 disease advances, and as absorption takes place, that the whole economy  is
 affected and death occurs.
  The  progress of the gangrene is heralded by remarkable uneasiness, numb-
 ness, a sensation  of cold and  paleness  of the parts.   It is not a corpse-
 like coldness,  and  one which only takes place because the  mortified part
 assumes the temperature  of  the  surrounding air;  it is colder than this,
and lower than the temperature indicated by the thermometer placed in run-
ning water.  The thermometer applied to the limb, falls as we approach the
gangrene.   Again, when the heat is  wanting, the sensibility is lost,  and  gan-
grene is about  to  commence.   Pain, sometimes acute, intolerable, lacerating,
accompanied by  very inconvenient formication, often  exists in this disease. 
400
LECTURES  ON
These phenomena are soon followed by slight swelling, wales, a violet color of
the parts ; at other times there  is  no  swelling, and the parts  are pale and
shrunken.  Vesicles make their appearance ; beneath them is found a slough ;
sometimes they are not seen, and then black spots  appear at the  onset, and
change  into  eschars;  the sensibility  of the  parts is destroyed;  there is
withering,  dessication, mummification, as the disease attacks the fingers,
toes, &c.
  But the most important symptoms are  those which  occur in the  arteries.
The pulse is imperceptible or even entirely gone.   In the  direction of the ar-
tery we feel a hard round  cord,  and as  the  pulsation ceases and this  cord
extends, we may calculate on the certain progress  of the disease.  However,
it should be remarked that the hard cord felt over the track of the crural artery
and referred  to this  vessel, is sometimes owing to  the engorgement of the
vein.  This fact was observed in the foregoing case, and should not be for-
gotten.   The sloughs on the pelvis, in that  case, also presented  a  singular
feature, that  they were confined  to  one side; the obliteration of  the cor'
responding arteries accounts for this disposition.   Women  are less subject
to gangrene than  men.  It was formerly supposed  to be more frequent in
winter; as it was thought to resemble that produced by  congelation.   This
theory and its consequences are equally false ;  for it occurs  by  far more fre-
quently in summer.   Indeed this very fact induced me to conclude, apriori,
that there was something more than a mere embarrassment in the circulation.
  , The treatment has changed  with  the etiology of  the disease.   Pott, who
wrote some valuable observations on senile gangrene, treated  it by a combina-
tion of bark and opium.  Finding the former of these remedies injurious, he
used the opium alone, with success in several cases.  Notwithstanding l\>
distinguished skill, fatal terminations were frequent.
   For fifteen years, I have tried  every kind of stimulant,  both externally and
internally, and whether there was arteritis or ossification ; the disease always
was aggravated by their exhibition.  I had determined on a different course,
when an old woman of sixty odd years of age  was admitted into  the Hotel-
Dieu with senile gangrene of the toes of the left  foot.   For several months
the bark and opiates, both externally and internally, were administered with-
out any improvement.   The toes were mortified at their extremities  and des-
sicated; the adjoining were swollen and of a violet color, and a pungent and
disagreeable  smell proceeded from the gangrene.   The remaining parts  of
the toes, the back and sole of  the foot were successively attacked, first  by
swelling and then by gangrene.  There was nothing particular in the state of
the heart, lungs, and large vessels.   Still the pains continued ;  the anodynes,
antispasmodics, tonics, and antiseptics,  recommended by writers, could not
arrest the progress of the mortification.   The  pulse was full  and hard, the
countenance flushed and animated; I ordered her  bled to eight ounces.  By
this operation, the pain was soothed, sleep restored,  the progress of the gan-
grene suspended, and  the improvement so great, that the patient had never
felt so well since the commencement  of the disease.   This state lasted  for
about two weeks, when all  the symptoms reappeared.  A  second  bleeding
was then performed with a like success.  From that period it  was  repeated
 whenever the disease threatened a relapse.  By this plan the progress of the 
CLINICAL  SURGERY.
401
gangrene was definitely arrested; the mortified parts separated, the wound
healed, and the patient left the hospital, with the advice to recur to  bleeding
whenever symptoms of her old disease threatened  a return of it.
  Since then we have used repeated  venesection, and by this  treatment re-
lieved and cured two thirds and even three fourths of our patients.
  The following case is a proof of the efficacy of this plan, which fails but in
few cases.
  Case II.—M.....(Pierre Esprit) 71 years of age, was admitted in March
1833.  For some days previously he had experienced a sensation of great cold
in the left great toe, soon followed by pain which rapidly increased.  The toe
was at the same time swollen, and of a violet color.  The pain increased daily.
A vesicle containing a fluid of deep brown color soon appeared on the internal
middle part of the great toe ; it burst, and beneath was seen an eschar which
gradually attacked the whole of the  inner  surface of the toe.   This eschar
was hard and dry ;  the pain extremely acute  throughout the whole toe and
foot, deprived the patient of sleep  and appetite, and  excited some fever.
There was no symptom of disease of the heart or large vessels ;  the  crural
artery of the diseased side was hard and evidently ossified.
  M .... said that he had never been sick in his life ; has had no contusion, no
violence offered to the toe, and can attribute the disease  to no cause.  Per-
suaded that this  was a case of senile gangrene, produced by an arteritis fol-
lowed by an obliteration of the  coagula formed in the principal arteries of the
lower extremity, I prescribed a  large bleeding, and emollient poultices to the
affected parts.  He was much relieved by the loss of blood.   He slept  well
that night and his appetite, which had been gone for fifteen days, immediately
returned.
  This condition suffered no  change.  The pain returned no more.   The gan-
grene progressed no  further and a red   circle  or  line indicated  its arrest.
Emollient and refreshing drinks, poultices,  and moderate regimen, were  con-
tinued without interruption until the separation of the slough, which  occupied
the  whole of the skin of the inner face of  the great  toe  as  well as the  sub-
cutaneous cellular  tissue; and at the close of the month of April M......
was discharged cured.
  Opium is not a remedy to be  despised, and it may even be stated that anti-
phiogistics and anodynes combined according to the situation and strength of
the patient, constitute the best treatment of senile gangrene, whatever period
it may have attained.  Refreshing acidulated drinks, emollient topical appli-
cations, in short, the whole series of general and local anti-phlogistic remedies
should be used to second the effect of the principal means  of which  we have
spoken ;  namely general bleeding and opium.
  A very interesting question is here presented ;  if the gangrene be not ar-
rested, is it not proper to amputate all the parts affected, or even threatened,
in order to preserve the rest ?  This has been done several times by  a distin-
guished surgeon; why is not his example  followed ?  We  answer,  because,
in the first case, by acting  on gangrene from an external cause, we at once re-
move the disease and its cause; in senile gangrene, the cause  is beyond the
reach of the knife.
  It need not be asked, indeed  if amputation can  arrest the gangrene, when
the latter is merely a symptom, but if amputation  is  of any avail  in arteritis
              51 
402
LECTURES  ON
the question thus proposed is answered beforehand.  Amputation should never
be performed unless the disease is exactly limited and the cause producing it
entirely removed.
                        CHAPTER XLIX.

           ON LUXATIONS OF THE LOWER EXTREMITY OF THE ULNA.

   Luxations of the ulna in front of the radius are very rare.  In the course
 of many years practice I have never seen but two cases.
   Case.—M. Blot, quarter master of the gendarmerie, of Gisors, 32 years of
 age, of a sanguine temperament and  athletic frame, was leading a patrol, at
 midnight on a very dark night, when meeting a stage coach, and the horse, being
 frightened by the lamp reared and fell backwards  with his rider.  Accustom-
 ed, as he said, to  this kind  of accidents, he extricated himself from beneath
 the horse immediately; but his right arm remained between  the head  of the
 horse and the ground, and  was severely contused.  The  pain, at the moment
 was so acute that M. Blot thought his arm was broken.  He got up, placed his
 arm in a sling, and thus returned to Gisors, a distance of three leagues. Dr.
 Fournier, a distinguished practitioner, first saw the patient, four hours after the
 accident.  He found a  luxation of the ulna.  He  attempted its reduction
 assisted by two friends, making counter extension on the elbow flexed to a
 right angle, and extension by the hand.  This was continued for  twenty or
 thirty minutes, without success.  M. Fournier then ordered a bread poultice,
 to diminish the irritation and swelling already considerable, and retired.  M.
 Dufay, (who  had been previously called,) came in an hour, examined the wrist,
 made a second attempt, but soon desisted.  The surgeons  met at nine the next
 morning.  The poultice had given some relief.  The attempts at reduction
 were again unsuccessfully made, and it was determined to send the patientto
 Paris.
   Blot  made the journey in a carriage at night, and he assured me, although
 it appears singular, that he suffered less from the motion of the vehicle than
 when tranquil in bed.   He arrived at the Hotel-Dieu in  the morning, thirty-
 four hours after the accident.
   He then presented the following symptoms: the fore-arm was much swol-
 len ; the hand in a position between pronation and  supination ; the lower part
of the fore-arm was deformed, rounded, and its greater diameter consequently
diminished; an anormal projection elevated the skin beneath the anterior mid-
dle part of the wrist; the internal malleolus could not be felt; its place was
occupied by a deep  depression.   By following the ulna  with the finger from
the elbow to the hand, it could be perceived to be directed obliquely forwards
and  outwards, crossing and passing over the lower part of the radius.   The
luxation of the ulna forwards was evident.
  The radius remained in situ, and the relations of the hand to this bone were
perfectly natural.  The carpus  projected neither forwards nor backwards.
The movements of pronation and supination were completely lost.   Lastly, 
CLINICAL SURGERY.                       403
we remarked two contusions with ecchymosis; one corresponding to the infe-
rior  third and internal face of the ulna; the  other to the union of the radius
with the hand, and the external surface.
   This being ascertained, we proceeded to the reduction.  The patient was
seated in the angle of the wall, to which is fastened the iron ring used in simi-
lar cases; a cloth passed  under the right axilla through this ring made an
immovable counter extension ; another cloth was applied to the bend of the
elbow and given to assistants, in order that the fore-arm should remain flexed
at a right angle on the arm ; a napkin was attached to the wrist and three or
four assistants  made extension.   The reduction could not be effected.  The
idea then occurred to me, of making extension myself on the hand by inclin-
ing it forcibly towards the radial side, whilst with my two thumbs I would en-
deavor  to push the ulna inwards and backwards.  In fact, by this plan the
reduction was effected, the snapping of the bones was heard; the patient cried
out, I am cured.  The bandage was then removed from the wrist, the deform-
ity had disappeared, he could pronate and supinate the hand.  The apparatus
for fracture of the fore-arm was applied, in order to preserve the reduction
and prevent the swelling.   On the third day he left Paris for Gisors.
  This is a case which must be studied, and its nature ascertained when it
presents itself to our observation, on account of its importance and rarity.
I have sought in numerous registers for an analogous case, and found but one.
A ship builder opposing his hand to a wall  about to fall upon him, had the
ulnar articulation forced, and came to the Hotel-Dieu  with all the symptoms
enumerated in the preceding case.  The reduction was made in the same man-
ner and with equal success.  Thus, during twenty-four years that I have been
a surgeon in this hospital, I have seen but two cases.  Sir A. Cooper and M.
Breschet cite but few examples.  It is important that they should not be lost;
for it is in luxations particularly that surgery is wanting.
  The skin was not torn.  In luxation  of the ulna forwards, this accident
must be very rare ; great external violence is necessary; the radius must be
fractured.  The strength of  the  ligaments, the thickness of the flesh, and
even of the  skin in front, must present almost  insurmountable obstacles.
Such is not  the case in luxations backwards. There, indeed, the ligaments
are not so strong, the skin covers the bone almost immediately, and moreover
it is more easily  divided  by the sharp  projection of the styloid process.
Should we in these cases of luxation with rupture of the integuments, reduce,
resect, or amputate ?   I should prefer immediate reduction, free enlargement
of the  wound, for the  most serious  consequences are the inflammation and
strangulation of the sub-aponeurotic tissues; I would have recourse to resec-
tion only in indispensable and well-marked cases ;and never would perform
amputation. 
404
LECTURES  ON
                              CHAPTER  L.

                  ON LIGATURE  OF THE PRINCIPAL ARTERIES.

    The ligature of the principal arterial trunks is one  of the  most brilPant
 achievements of  modern  surgery.  Formerly the unhappy patient laboring
 under aneurism of these parts were devoted to an almost inevitable death, for
 a spontaneous cure was of very rare occurrence.  Grant that aneurisms had
 been known  to terminate  by inflammation, abscess, gangrene  of the aneuris-
 mal sac, or even by the compression exerted by this same  sac, on the artery
 through the medium of a coagulum, these cases  badly observed  were lost  to
 science.
    A great difficulty, which must for a long time have arrested surgeons, was
 the restoration of the circulation ; how could it  be  conceived  that vitality
 could exist in a limb of which the brachial or femoral artery  had been tied.
 The collateral arteries did not appear sufficient to supply their place.  These
 fears were dispelled when  Anel made known his method, and  the mechanism
> of anastomosis was better understood.  The brachial  and femoral arteries
 were then successfully tied for aneurisms at the bend of the arm and  in the
 popliteal space.   But for many years the crural arch for the inferior, and the
 clavicle for the superior extremity, appeared to surgeons limits beyond which
 it  was dangerous  to pass.   Bolder attempts soon dissipated  these idle fears,
 and the ligature of the external iliac and the primitive iliac  in the pelvis, that
 of the subclavian  between  or outside of the scalein muscles, attested the march
 of science.   Anel's method was inapplicable to all cases.   Thus,  for exam-
 ple, aneurisms of the primitive iliac, the origin of the carotid or subclavian were
 amongst those in which a ligature between them and the centre of the circula-
 tion was inapplicable.  The method applied successfully to the former was
 useless in the latter cases.   Hence two important divisions, which will be the
 subject of this chapter.  1st. Of ligatures between the  heart and the aneuris-
 mal tumors.   2d. Of ligatures  between the tumor and  the capillaries.
    1st Division.   Ligatures between the heart and aneurismal tumors.—We
 shall not treat of  the general and local debilitating plan, (Valsalva's method,)
 but only remark, that when rigorously followed, it affects  the  action of the
 centre of the circulation less than that of the parietes of the aneurism.   Thus
 I have observed, that when at the proper period, or when tired of its fruitless
 application, the surgeon wishes to commence to strengthen the patient, in order
 that he may undergo the operation, the tumor surrounded by parts of which the
 elasticity is lost suddenly, from the impetus of the blood filling the vessels,
 takes on a  rapid  increase, which may become fatal when situated in the sub-
 clavian and iliac regions.   Pounded ice, ice water, and snow are sometimes
 useful applications in aneurism.   This is not the case with  adhesive prepara-
 tions, astringent powders and the actual  cautery, which are now generally
 abandoned.
    Of later days, compression solely on the arteries above the tumor has been
 frequently practised.
    Of the different instruments by which it may be  effected, our compressor
 is  that most usually used,  and which fulfils best all the  indications.  Isolated 
CLINICAL  SURGERY.
405
and free around the limb,  it only touches the latter at two  opposite points.
Therefore it is particularly suited to cases in which we merely wish to mode-
rate or suspend entirely the course of the blood in a principal trunk, leaving
the collateral circulation free, in treating aneurism by compression.  It is less
certain when we desire to  arrest the entire circulation of a limb.   Some  per-
sons cannot endure the application of this instrument, and in  a great number
of cases we are obliged to  have recourse to the ligatures, which is in fact, the
most effectual of  all  the means hitherto proposed.
   Anel's or Hunter's method is now generally followed.  When an artery is
tied according to  this method, the ligature should be  placed  moderately  dis-
tant from the aneurism, in  order to find it perfectly healthy, and where it  is as
superficial as possible, in order to separate it  more easily from the veins  and
adjacent nerves and give to the ligature a sufficient degree of tightness.
   Another not less important precept is to preserve above the wound, enough
collateral branches to maintain  the circulation  in  the  lower  part of the limb
after the operation, and to make'the incisions so that the ligatures shall not be
too near the large collateral branches, especially the upper ones, because their
too immediate vicinity is one of the most  frequent causes of secondary haemor-
rhage.  The external incision should be  long enough to enable us to act freely
on the vessel, and the aponeurosis should be divided to a greater extent than
the skin.
   The diagnosis  of  aneurism is  easy when the disease is recent; but very
difficult when it  is of long standing, large  and irregular.   But if an artery
is partly or completely surrounded by  a cyst, an abscess,  by a  cellular or
glandular engorgement, we must be particularly careful, for there is no region
of the body in which the mistake has  not occurred.  Lastly, a small rupture
may take place in the aneurismal sac;  the blood is then gradually infiltrated,
and extendsinto the cellular tissue, forming bloody tumors, free from pulsations
and all the other  phenomena of aneurism. I saw  a curious case of this kind ;
the blood after having escaped  from an opening in the aorta, was infiltrated in
the cellular tissue of the neck, and had formed several tumors which discharged
on bursting but little blood; this, however, frequently repeated, caused the death
of the patient.
   In April, 1810, a woman 66  years of age, remarkable for the flaccidity of
her muscles, entered the Hotel-Dieu, to be treated for a gangrenous eschar on
the inside of the left elbow, attended by  oedematous infiltration and consider-
able debility of the arm of the same  side, with absence of the pulse, which was
attributed to the  swelling  of the limb, the ossification or the narrowness of the
artery.   She stated  that two months previously she  had fallen  down, after
which she felt some pain in the shoulder; but a surgeon whom she consulted
said there was neither fracture nor luxation; the pain continuing six weeks
afterwards she went to a bone setter, who  pronounced her arm to be dislocated;
performed violent movements with it, and then assured her that she was cured;
lastly, that from that period her arm was  swollen, and the slough on the elbow
formed where one of the bandages had been  applied.
  The eschar was dressed ; the arm  covered with  tonic fomentations and
placed on an elevated pillow.  The slough soon separated, and things remained
in this state for some time.  On the 21st day after her  admission, she  com- 
406
LECTURES ON
 plained for the first time of the inconvenience of a tumor which had formed in
 the axilla of the same side, she did not know at what period.
   This voluminous tumor raised up the clavicle and great pectoral muscle,
 and kept the arm from the body; it was slightly painful, free from pulsation,
 and communicated the sensation of deep-seated fluctuation.  I thought it might
 be a chronic abscess, but being warned by its locality, determined, before open-
 ing it,  to make a puncture in order to ascertain its true nature.   This I did
 with a  very narrow, sharp bistoury, at  the most projecting point of the tumor,
 where  the fluctuation was most  apparent.  But instead of pus, arterial blood
 flowed  along the blade of the bistoury.  This  was therefore very carefully
 withdrawn, an adhesive strip applied, and over that, a compress and bandage;
 the  resolution of tying the subclavian artery was then  adopted, and its per-
 formance postponed until the arrival of the surgeon in chief.   (I was at that
 iime only chirurgien en second or  second  surgeon.)  He placed one hand
 beneath the anterior superior part of the dressing, and said that he distinctly
 felt the pulsations of an aneurismal tumor.   The bandage was removed, no
 one could perceive the pulsations, not even  the surgeon himself.  We then
 began to doubt its being an aneurism, and to believe that I had merely opened
 a small artery, situated in the parietes of an abscess.  Continuing, however,
 the examination, we discovered in that portion of the tumor which raised up
 the clavicle, slightly distinct pulsations, accompanied by a movement of dilata-
 tion, and nearer to the axilla, an obscure hissing noise, similar to that produced
 by the  passage of the blood from an artery into an  aneurismal tumor.  W"e
 soon  found two tumors ; one  small, situated beneath and along the clavicle,
 pulsating; the  other  large, fluctuating,  and  in  which was with difficulty
 discovered and  that only upon  the line of  separation from  the  other  the
 hissing  noise already  spoken of;  no  doubt then  existed, it was an aneu-
 rism.
  I proposed the ligature of the  subclavian between the scaleni  muscles; the
 surgeon in chief withheld his consent,  and thus deprived French surgery of
 the honor of having first performed this brilliant operation.  Valsalva's method
 was adopted, and the patient immediately bled.  For the space of four days
 she was so weak as to be unable to bear a second bleeding.  At the end of
 this time, feeling some lancinating pain in the tumor, the dressing was removed,
 and found slightly tinged with fluid  blood; an eschar of at least an inch in
 diameter  had formed.  I again  urged the operation, it was again rejected.
 During  the night two gentlemen who were watching the patient, perceiving
 that the  dressing  was becoming saturated with blood,  they  removed it;
 supplied  another piece of adhesive plaister much  larger than the former one,
 directly over it, in order to supply the place of the eschar, which had separated
 at one point of its circumference, and the haemorrhage was arrested without
 losing eight ounces  of blood.  She expired the next morning.
  The examination of the body proved the existence of  two tumors; one of
them was formed by a dilatation of the  subclavian artery to an extent of  two
inches;  the other was the principal tumor, communicating with the former by
a rupture of the artery.
 Case I.—Consecutive false aneurism of the left axillary artery; the subcla-
vian successfully tied.—C. Chevalier, 37 years of age, by trade a joiner, was 
CLINICAL SURGERY.
407
adntittedinto the Hotel-Dieu on the 27th of February, 1819, with consecutive
false aneurism of the left axillary artery.
  Taken prisoner in Spain in 1811, he endeavored to escape, and in his flight
received a sword  cut on the posterior part of the shoulder.  A great quantity
of blood was lost, and  he  fainted.  The haemorrhage ceased, and a simple
dressing was applied sometime afterwards,  and in three weeks it had entirely
healed, without any further loss of blood. Two months after the wound, Cheva-
lier felt in the arm-pita smalltumorof the size of a walnut, without any change
in the color  of the skin, and pulsating.   After the lapse of two years the tumor
had attained the size of a hen's egg, and the pulsations were much stronger.
  From the  great exertions required by him to reach France, being obliged to
walk 300 leagues on foot, the tumor increased rapidly.   It became as large
as a child's  head; and he could no longer  follow his  trade; he determined
therefore, to come  to the  Hotel-Dieu for advice, and was admitted on the
27th of February 1819, presenting the following symptoms.
  On the posterior superior part of the left shoulder in the groove separating
the teres  major from the teres minor and supra  spinatus, there was  a small
cicatrix ;  that of the wound many years previously.  The tumor, however, did
not incline to this side; but was developed in the arm pit, between the chest
and the arm ; it was as large as the head of a child one year  old, unequally
rounded, uneven on its lower and anterior part, covered by bluish and dilated
veins;  it  was hard, and presented at every point of  its surface strong pul-
sations, isochronous with those of the heart.
   Anteriorly and lower down it was covered by the skin, anteriorly and above
by the  great pectoral muscle; it was supported  internally by the chest, and
covered outwardly by the arm, it ascended  as  high  as  the  clavicle  without
leaving any  sensible interval between it and the  bone.  The scapula clavicle
and the whole shoulder were elevated by the tumor, and  the  depression  be-
hind the clavicle was considerably increased.
  The  limb  of that side was somewhat  niore  emaciated  and weak than  the
other ;  there was a sensation  of uneasiness in  the axilla, numbness  in  the
ends of the  fingers, difficulty of motion on  account of the development of the
tumor ; the  heat and sensibility were  natural, but the pulsations of the radial
brachial arteries,  &c, could not be felt.
  On the  contrary the pulsations of the subclavian were  very strong, and by
compressing this artery the pulsations  in the  tumor could be arrested.   An
attentive examination of  the tumor convinced us that the  only chance of suc-
cess was  to tie the subclavian artery.
   This artery, throughout  its  course on the left side, presents three different
parts;  the first from its origin  from the  aorta, to its  entrance  between  the
scaleni muscles ; the second from its entrance to its departure from these mus-
cles ; the third from this point of departure as far as the  upper face  of  the
first'rib; an  important distinction and almost unnoticed by writers.
  This third part of the passage of the  subclavian artery is  near the skin in
persons with a small and long neck, drooping and thin shoulders, deep seated
in the contrary cases, and principally in those  where the  shoulders are ele-
vated by a tumor in the axilla, as in the case of our patient.  To this diffi-
culty is added another common to all, namely, that the artery at this point is
so surrounded  by the nerves of the brachial plexus that it is  difficult  to iso- 
408                            LECTURES ON
 late it.  The second part of its course presents this advantage, that the sub-
 clavian penetrating alone the internal of the scalein, and  being completely
 separated from the subclavian vein which passes in front of the  scalenus  an-
 ticus, and from the plexus of the nerves of the  arm  which are situated out-
 wardly and backwardly, we can easily reach the artery by taking the scalenus
 anticus for our guide, and it may be tied without the danger of including any
 nerves.
   The first division of the artery is so deeply hidden in the  apex of the
 inverted cone forming the chest, so near the pleura and lungs, that it would
 be difficult to reach it without wounding those parts, and we should avoid, as
 far as possible, the attempt to tie this portion of the subclavian.  From all
 these considerations I determined to tie the artery, in the present case, between
 the scaleni; and the patient having joyfully consented to the operation, it was
 done as follows:—The man lying on the bed, I made a slightly oblique incision
 from above  downwards, and from within outwards, on the left side and lower
 part of the neck, at the distance of one inch above the clavicle.  This incision
 divided the  skin, the platisma myoides, the subcutaneous cellular tissue and
 three small  vessels, which were immediately secured ; the ligaments of which
 caused some pain  at the base of the neck.   Continuing the operation,  I
 reached  the cellular  tissue and glands surrounding the artery and nerves of
 the brachial plexus.  I then sought for the external edge of the scalenus anti-
 cus, and divided this  muscle completely near its insertion, by means  of  a
 probe  pointed  bistoury; the artery was then exposed, could be  felt, and its
 pulsations easily arrested by the  finger.
   A curved  silver  director was  then passed under the artery, a probe armed
 with a triple silk ligature passed along the groove'of the director and with-
 drawn on the opposite side.  The ligature was then tightened  and instantly
 the pulsations  in the  tumor ceased.  The wound was dressed simply;  the
 tumor covered with resolvent applications; the  limb placed on a  pillow sur-
 rounded by bags filled with hot sand.
   During the day the patient complained only of slight pain in  the  throat.
 As a precautionary measure,  some blood was taken from him; there is no
 pulsation in the tumor.  He passed a good night.  The limb preserved its heat,
 myotility  and sensibility; some slight lancinating pains were felt in the tumor.
 For ten days after the operation, every thing  went on well.  On the 11th.
 the ligature was removed, without any loss of blood.   On the 30th, the  wound
 was nearly healed;  he  had begun to  use his  arm.   The tumor was sensibly
 diminishing, but it presented a softness and fluctuation which made me dread
 suppuration and a spontaneous opening.   It was therefore covered with com-
 presses dipped in Goulard's solution, renewed every two hours.
   On the  78th  day the tumor was reduced to  one fifth of its original size,
 the softness  and  fluctuation had disappeared.   The warmth, myotility, and
sensibilty are the same as in the opposite side.   The circulation of the arm,
as of all limbs in which the principal artery has been  tied, presents a peculiar
character, the arteries  do not evince the least pulsation, they feel however
distended with blood.  By passing through the  numerous  and small  anasto-
moses  which bring it from the upper to the lower parts of the limb, this fluid
is no longer influenced by the heart's action.
   After leaving the hospital, Chevalier again took  up  his trade of a  joiner. 
                           CLINICAL SURGERY.                        409

For three years he enjoyed good health; but at that period he was attacked,
from severe labor, with inflammation and swelling in the arm pit.   Uncertain
as  to the nature of his disease he came again to the Hotel Dieu on the 14th
of July, 1822.  The  axilla was filled by a tumor as  large as the fist; the
skin  covering it was red,  and thin,  the  apex of a violet color threatened
immediate bursting.  There was no pulsation in this tumor; the patient has
had chills,  fever,  want  of appetite, &c.   Persuaded  that the tumor was
unconnected with the circulation, I wished to open it; but the patient preferred
leaving this  to the efforts of nature.  An emollient poultice was therefore
applied  to the whole surface of the axilla.  In two weeks it  opened spon-
taneously, and discharged a large quantity of pus and matter, very analogous
in  color and consistence to inspissated grape juice, evidently formed from
the old blood, uninfluenced by the  circulation and changed by the  process of
suppuration around it.  The opening was enlarged and barley water injected
into the abscess.  The fever and suppuration  soon diminished, the appetite
and sleep returned, the abscess healed, and the patient left the hospital  on the
21st of October, 1822, in perfect health.
   When an aneurism proceeds from the axillary artery, not far from the ori-
 gin of the brachial, while the disease is  still recent, the artery may be tied
 between the tumor and the clavicle; but when the disease is of long standing,
 or it arises from the axillary artery near the origin of this vessel, the subclavian
 artery must be tied.  M. Pelletau attempted to tie the axillary artery  imme-
 diately below the clavicle, for a large aneurism filling the axilla; in his patient
 a considerable space  still  existed between the tumor and the clavicle.  M.
 Pelletau, having reached  the artery, introduced his needle several times with-
 out being able to pass it around the vessel on account of its  great depth.  The
 operation was abandoned.  The sufferings of the patient increased, the inflam-
 mation  of the  chest supervened,  and he died on the 20th day.  It must be
 confessed that it is sometimes impossible to tie the  subclavian  artery on
 account of  the enormous development of the disease and the displacement of
 the clavicle.  The celebrated Astley Cooper was once obliged to abandon a
  similar attempt.
    More than twenty patients laboring under aneurism of the carotid, sub-
  clavian, brachial, external iliac, femoral, &c, have undergone the operation at
  the Hotel-Dieu, and gangrene has followed in only one case.
    The  compression and ligature of the nerves is the most frequent cause of
  this accident.  Dr. Orpen relates a case of  subclavian aneurism, in which the
  tumor, after having rapidly increased and beaten violently, had entirely lost
|  its pulsations, and so greatly diminished in size as to be reduced to that of a
  small nut.   The pulsation in the arteries of the  limbs became imperceptible,
I  the arm useless and extremely emaciated.   Dr. Orpen supposed, and correct-
I  lv, that in  this patient, the diminution of the arm and loss of voluntary
k  motion were owing to the pressure of  the  tumor on the cervical  nerves, and
I  not to the  absence of a sufficient quantity of blood in consequence of the
I  obliteration of the artery.  Van Swieten relates a similar case.
I   Chevalier's case confirms the point established so positively by the beauti-
I ful dissections of Scarpe, namely, that the parts of the arterial system near-
I est  the trunk  have not less numerous and effectual communications between
I each other than more remote parts.  Nature herself, always so fertile in
I                   52 
410
LECTURES  ON
resources, had already proved that the obliteration of a main trunk was com-
patible  with circulation and life of the  limb.   In M.  Breschet's notes to
Hodgson's work, is related a case in which the left subclavian and several of its
most important branches had been obliterated by an aneurism of the aorta; a
small aneurismal tumor was situated at the commencement of the subclavian,
of which  the cavity, from  the place at which it left the small  sac, was com-
pletely filled by a compact ligamentous substance, which extended into the
vertebral, internal mammary, and superior intercostal arteries.   The inferior
thyroid was the  first branch which remained open, and through it the blood
passed through the superior thyroid  into the subclavian,  which although con-
tracted  was permeable  at this spot.   The limb was of ordinary strength and
size, notwithstanding the obliteration from its commencement of its principal
artery and most important branches.
  Case II.—Ligature of the External Iliac Artery, read before the Academy
of  Sciences.—At first sight,  ligature of  the external iliac seems  more
difficult and dangerous than  that  of the  subclavian artery; but in per-
forming it, it is found generally difficult and not more dangerous.  The pari-
etes of the abdomen  are opened in the high operation for  stone; in almost all
the operations  for hernia the peritoneum itself is divided ; why should we
not follow the  same course to cure a disease  as serious as either of these?
The spot at which  the incision  should be  made, and the disposition of the
peritoneum  enable us to expose easily the artery and avoid that membrane.
  Many different operations have been adopted ; the first consists in making
in the abdominal parietes  an incision parallel  to the direction  of the artery,
starting from the point at which it passes under the crural arch, and ascend-
ing parallel to the  external edge  of the rectus muscle towards the umbi-
licus.
   In the second we divide  the abdominal parietes in the direction of the iliac
artery parallel to the crural arch, and at the distance of half an inch from the
latter; this  is  Abernethy's  method.  The third plan, says Astley Cooper,
consists in making in the parietes of  the  abdomen  above  the  crural arch  a
crescentic incision, commencing above the anterior superior spinous process
of the ilium and terminating above the inguinal ring.
  Bogros  has proposed to make in the parietes  of the  abdomen, immediately
above the  crural arch, an incision of two inches in length, of which the exter-
nal incision  is at the  same distance from the spine of the ilium that the inter-
nal incison is from the symphysis pubis.   The  tendon of  the  great oblique
being divided parallel  to Poupart's ligament, the operator pushes aside the
vessels of the testicle, and  reaches the artery which may be readily tied.1  But
it must be confessed, that this incision, exactly  perpendicular to the direction
of the vessel allows us to place the ligature at the distance only of one inch from
the crural arch.
  The incision according to the  first plan gives  an opening parallel to the
iliac artery, but which can  have merely the width produced by the separation
of the edges of the wound, rendering it difficult to find the artery, to separate it
from the adjacent parts, as  well as to apply the ligature.   It presents also  the
danger of opening the peritoneum, which as it departs from the  crural arch to-
wards the umbilicus, adheres more intimately to the abdominal parietes.
  The incision parallel to the crural  arch  being perpendicular  to  the  iliac 
CLINICAL SURGERY.
411
artery,  gives  greater facility to all  the  stages of the operation, moreover it
strikes precisely the line at which the peritoneum leaves the abdominal parie-
tes to be reflected over the pelvis,in the midst of a soft and adipose cellular
tissue, which occupies the triangular space formed by the parts attheir separ-
ation.  It gives a greater facility to turn aside the peritoneum, and is less lia-
ble to open this membrane; it may,however, when the incision is carried too
much beyond the inguinal ring, wound the epigastric artery.
   The ligature of the artery may be performed higher up, but we run  a risk
of wounding the peritoneum; by performing it lower down, we  avoid this
danger ; but the ligature is so near the tumor, and the origin of the epigastric
artery, that the  aneurismal sac may be secondarily affected by  inflammation
and open into the wound, and the inferior portion being traversed by the blood
from the epigastric artery,  may preserve its calibre and maintain or even re-
store the circulation  and pulsation in the aneurismal tumor.
  In all these  operations we separate the artery from the corpus pampiniforme
on its outside;  the vein and lumbar plexus on the inside, by means  of the
finger rather than the bistoury; the laxity of the cellular tissue  renders this
separation easy,  which might be dangerous if we used  a cutting instrument.
  The termination of the external iliac artery is more easily found  in the female
than in the male; it is not so deep in the former;  which must be  attributed
to the larger dimensions and smaller depth of the female pelvis.  The opera-
tion is performed with less difficulty in thin than in corpulent individuals.
   Berger (Francois), formerly a soldier,'but now a stone cutter and saltpetre
manufacturer,  according to circumstances, 45 years of age, of a strong consti-
tution, sanguine and nervous temperament,  impatient and irascible disposition,
having always enjoyed uninterrupted good health, in the month of June, 1815,
exerted himself in raising a plank, of which the end was leaning against  his
left groin.   He  felt  at this part an acute but momentary pain, which did not
prevent  his continuing to work.  However,  after the lapse of  two months,
Berger felt in the left groin, about two inches below the crural arch, a tumor
as large as a filbert, perfectly indolent, on which account he paid no attention
to it.
   This tumor increased almost imperceptibly until the month of June, 1816.
  At that period, the patient having made a severe exertion in lifting a beam,
the tumor suddenly became as large as a hen's  egg; lastly, three  weeks pre-
vious to his admission into the hospital, he  fell on the  edge of a large  copper
kettle used in the  crystalization of  saltpetre,  and  by a kind of fatality,
struck on the tumor.  This caused a development of the tumor so great as  to
alarm the patient and induce him  to ask the advice of  a surgeon, who after
bavin"- ascertained the nature  of the disease, sent him  to the Hotel-Dieu, on
the 23rd of August,  1816.
  The tumor situated, as has been said, in the left groin and over the femoral
artery, had  then  the  size and shape  of a large pear, of which the base was
upwards;  it commenced.a little above the crural arch, and extended four
inches below it;  it was two inches and a half in width; and projected two
inches above the level of the adjacent parts; it presented dilatations and
contractions perfectly isochronous with the movements of  the, heart.  By
pressing on the termination of the abdominal aorta or on that  part  of the
external iliac corresponding to the horizontal ramus of the pubis, all movement 
412
LECTURES ON
 in the tumor was suspended, which, at the same time, diminished in volume
 and tension; by compressing the femoral artery below it, the pulsations became
 stronger, the tumor larger and more tense.
   By compressing the tumor, it partly disappeared, and we then felt that its
 parietes were unequal and nearly of cartilaginous hardness ; on removino- the
 pressure, it rapidly regained its original size; it was moreover perfectly indo-
 lent and had not changed the color of the skin.
   There then  existed no doubt as to  its being  an aneurism of the femoral
 artery;  and as it had for  some months past  made very rapid progress, there
 could be no doubt as to the danger of leaving  it to itself, and of the necessity
 of doing something.
   Two methods could be adopted, compression and ligature.  If compression
 did not succeed, it might at least prepare the  way for the success of the liga-
 ture ; it was therefore determined to  try it  and assist  its operation by the
 application of ice to the tumor.  Convinced by many attempts of the ease with
 which we can compress, with the fingers, the external iliac artery, above the
 crual arch, on the horizontal ramus of  the pubis, at my suggestion, Sirheurv,
 one  of our most ingenious  cuttlers, made an  instrument by means of which.
 one  end being supported by the sacrum, the termination of the external iliac
 was compressed by a pad, at the other  regulated by a screw.  This was then
 applied, the circulation entirely arrested in the limb below it as well as in the
 tumor, upon which was applied, in a bladder, some  pounded ice.  Such was
 the first apparatus used in Berger's case; its imperfection soon became manifest.
 The pulsations in  the aneurismal tumor which had been arrested on the first
 application of theinstrument, reappeared whenever the patient spoke, coughed,
 or used  the  slightest exertion.  H'13  body, although on a horizontal plane
 slipped towards the foot of the bed, impelled to this movement by the com-
 pression, from  the pain of  which, by this means, he endeavored to escape.
 Lastly, when the, compression was perfect it became so fatiguing that it could
 scarcely be endured for fifteen or twenty minutes during the application of the
 ice, whilst he.could bear it for half an hour if  the ice was not applied.
  The pain  produced by the compression was felt for some minutes after its
 removal; and  even  was then greater.  This pain, evidently owing to the
 compression of the crural nerves, ceased entirely in five or six minutes.  This
 intermittent compression was continued until the 18th of September, when it
 became so painful that we were obliged to abandon its use.  At that time the
 tumor had sensibly decreased.  The patient was permitted to rise from bed
 during several days.   He then experienced in the knee joint and left side a
 sensation of uneasiness and stiffness which disappeared in 48 hours.
  These difficulties did not make me abandon the hope of effecting a cure by
 pressure.  A new machine, more simple than the first, analogous to the
 bandage of Camper, and made on  the same principles by M. Verdier, a very
 skilful truss-maker, was used on Berger.  It consisted of an elastic steel band,
 forming the five sixths of an oval.   The right extremity enlarged and flattened
 rested on the hip of the same side, the left  extremity narrower and turned
downwards was furnished with a pad exactly answering to the spot at which
the external iliac artery passes over the body of the pubis.   The whole action
of the instrument  consisted in its  elasticity.   It was applied on the 20th of
September. 
CLINICAL SURGERY.
413
  It was easily seen that it had the advantage over the first instrument of
following all the movements of the body; an advantage which gave the  com-
pression an  exactness  and fixedness which would have attained the desired
end had Berger been more resolute and less impatient.
  The  application of pounded ice was recommenced, and renewed as often
as was requisite.
  The  patient could  not bear the  application of this second machine with
more ease than the first;  he even complained more of it, and from the 9th of
October, that is, ten days after its first use, Berger frequently demanded the
operation.  In vain I represented to him the advantages of a plan which would
cure him without  any operation;  he refused  to  submit  to  the  compres-
sion, and incessantly solicited  the operation.  At last, yielding to his entrea
ties, I  determined to perform it, and for this purpose, permitted him to rest
for several days.  This time I  wished to employ in the restoration of the tone
of his nervous  system, prepare him for the operation and make some experi-
ments on the dead body previous to operating on the living.
  The  aneurismal tumor was  then reduced  to two thirds of its size, and the
force of the  pulsations sensibly diminished.
  On the 9th and 10th of October he had some pain in the tumor extending
to the middle of the thigh, occurring at intervals and severe enough to awake
him suddenly; it  ceased on the 13th, but on the back part of the thigh and
along the course of the sciatic nerve, the pain, although less severe,  presented
the same character.  The patient was habitually constipated; on the 14th
and 15th two enemata were administered, which brought away only some dry
and black matter.
  As the operation was  to be  performed on  the next day, he was ordered an
 ounce of syrup of diacodium, which procured him a tranquil sleep of  six hours.
  The patient was laid  in a horizontal position, an assistant placed so as to
 be able to suspend, at least momentarily,  the circulation of the lower limb by
 compression on the termination of the abdominal aorta.   I then commenced
 atone inch below and in  front of the anterior superior spinous process of the
 ilium,  an incision parallel to the crural arch, which was carried as far as the
 outer extremity of the inguinal ring.  The skin, aponeurosis, and muscles
 were successively divided with great caution ;  I soon reached the cellular tis-
 sue, which was yellowish, slightly injected, remarkably dense, and containing
 a large number of lymphatic ganglia with which it formed a thick layer adher-
 ing closely to the external iliac artery, from which circumstance there was
  some difficulty in exposing the  artery. The cellular tissue was removed layer
  by layer ; but in order to assist this very delicate dissection several small in-
  cisions  of the crural arch, which  was extremely  tense,  became necessary.
  The artery being then disengaged externally from the cellular tissue and cor-
  pus pampiniforme, separated  internally from the iliac vein by means of the
  index finger, it was raised by the two index fingers whilst an assistant passed
   grooved director beneath it.   By pressing the  artery on the director al
  mlsation was suspended in the tumor.   A  ligature was then placed at about
  In inch from the diseased spot.  A precautionary ligature (ligature dattente)
   as then placed in the same manner at the  distance of half an inch from the
  ormer  When the first  ligature  was secured, all  pulsation  immediately 
414                          LECTURES ON
   One thing remarkable occurred during the operation ; that when the patient
 forcibly contracted the muscles of the abdomen, the edges of the wound were
 brought nearly into contact, and the peritoneum protruded.   This required
 the  fingers of an assistant  to thrust back the peritoneum, and to keep the
 wound open.  The first ligature was placed in the inferior angle of the wound,
 the second in  the superior.  Both were enveloped  in a small compress.  The
 wound was covered with  muslin  spread with simple cerate, over that some
 fine charpie, and the dressing finished by triangular compresses and a bandage.
   The  first symptoms  experienced  by the patient were evidently nervous;
 they had occurred  during the course of the disease, and had complicated all
 the other symptoms of the case.
   Berger bore the operation with great fortitude; but after the dressing com-
 plained of  some sickness of stomach, a slight tendency to syncope.
   He was carried to bed, his head raised by pillows, the thighs and legs flexed
 on the pelvis, the left limb surrounded by bags filled with hot ashes and cloths.
 He was ordered  mucilaginous drinks and light soup.
   During the whole of the day he felt no numbness in the limb.  The sensi-
 bility and myotility were perfect.   The heat did not abate for a moment, and
 even seemed  greater than that of the  opposite side to the patient; but the
 hand could discover no difference.   His countenance, however, was changed;
 he had pain in the abdomen, and principally in the epigastric region.  There
 was continual eructation of gas.  In the middle of the day he felt a general
 heat, some  thirst, his face became very flushed ; pulse frequent and hard.  In
 the evening, the epigastric region was tumefied, and resonant on percussion;
 he was very uneasy.
   He was  ordered  an infusion of chamomile flowers and anise seed  sweet-
 ened, dry friction over the epigastrium, and to be bled during the night should
 any symptoms of congestion of the brain or any other part supervene.
   During the night pain in the epigastrium with copious discharge of gas, no
 sleep.
   2d day.  The limb still possessed its sensibility  and mobility.   It appeared
 warmer than the opposite one; the sand bags were removed, and hot flannels
 alone applied.   Pain in the epigastrium still  severe.  The stomach was so
 much distended with gas that it appeared through the parietes of the abdomen;
 he had eructations.   Pulse not so  full as on  the preceding  evening, face
shrunken, tongue dry, covered with a black coating, as also  were the lips and
teeth.
   An enema of two ounces of tamarinds infused in eight ounces of water was
prescribed : as it produced no effect, a second was given.  This was soon dis-
charged colored by  the faeces; causing also some discharge of flatus which re-
lieved the  patient  and  procured  him a little sleep.  The pain in the epigas-
trium soon returned accompanied by free eructation of flatus. In the middle of
the day, the face became very red, the pulse hard and frequent, the pain of
the epigastrium extended  to the hypochondriac regions.  He  was  bled ten
 ounces,  ordered emollient enemata, and vegetable lemonade.   These remedies
 calmed the  pain slightly and he slept for a few hours.
   In the evening he was slightly delirious; epigastrium still painful, tense and
 sonorous on percussion; he discharged gas almost continually from the mouth;
 tongue red, and dry, pulse hard and  frequent.  He was  bled   eight ounce* 
CLINICAL SURGERY.
415
more in the middle of the night;  the enemata, and  repeated introduction of
a gum elastic tube into the anus, caused the discharge of a great deal of gas,
but no stercoral matter.   He slept for a few hours.
  3rd day. His countenance expressed  less anxiety; he was  more tranquil,
pulse less frequent and hard ; tongue not so dry;  skin slightly moist; region
of  the stomach less tense and painful.   Continue the lemonade; two enemata
each containing half an ounce of castor oil were administered ; they were re-
tained, but a copious discharge of urine took place.   During the evening he
was much better, and that night slept for three  hours.
  4th day. Pulse nearly natural; tongue moist; pain in the epigastrium less
severe ; a good deal of flatus discharged  by the mouth.  The limb had lost
none of its ordinary sensibility, contractility and warmth.  He took some soup
during the day, the lemonade and emollient  enemata were continued, and  a
sound repeatedly introduced into the  anus.  Evening same  state ; he  slept
for several hours during the night, but was interrupted several times  by fear-
ful dreams.
   5th day. The dressings being completely saturated with the suppuration,
were removed  \vithout the least pain to the patient.  At three  lines from the
upper angle of the wound, a  small black spot of  two lines in diameter was
seen, probably resulting from  the pressure of the bandage.
  The aneurismal was reduced to one third of  its  original size, and was free
from pulsations.   The popliteal posterior tibial and the dorsal  artery of the
foot did not pulsate, but they could be felt full of blood.  The  limb preserved
its sensibilty and warmth.  The pain in the  epigastrium had  entirely disap-
peared but the eructation continued; the tongue  was red and dry, and the  pulse
still frequent.   He had some cough, and at each effort experienced pain in the
 wound ;  the latter was dressed with cerate and fine lint, kept on by  com-
 presses and a triangular bandage.  The lemonade and bouillon continued.
   During the day he had slight delirium.  Much  agitated  during the night.
 Two emollient enemata brought away a copious discharge of black hard foeces
 After this evacuation, the delirium ceased.
   6th day  In  the morning, great dejection of  countenance, tongue dry and
 brown; pulse frequent;  lips and teeth covered with a fuliginous crust.   The
 wound was dressed as before.   The tumor presented for  the first time a slight
 trembling.  He was ordered for that day, small beer alternately with seltzer
 water.  Evening, more tranquil.  Night following slept several hours.
   7th day. Tongue dry and red; pulse less frequent; voice somewhat changed.
 He had no difficulty of respiration;  no pain in  the thorax or abdomen, except
 at each attack  of coughing there was some in the wound.  The limb was warm
 and preserved its  sensibility.   Suppuration copious but of good appearance.
 The tumor presented a slight trembling as previously.  Continue the seltzer
 water and beer; he  took some  soup.  Two enemata  occasioned at first a
 slight colic, soon followed two copious evacuations of yellow  liquid matter ;
 he had three more stools during the day;  a  little appetite was felt; he was
 allowed more soup;  towards morning he had some sleep.
   8th day. There was a general moistness;  countenance good ; pulse calm ;
 tongue  red and  moist; suppuration although copious was  healthy.   The
 almost continual eructation which had tormented him had entirely ceased.
   9th day. We observed on the left side of the abdomen, a few lines above 
416
LECTURES ON
the wound, some extremely strong pulsations which appeared to proceed from
the external iliac artery.  The aneurismal tumor presented pulsations more
distinct than usual, but we could perceive a daily diminution  in  its  size.
The small eschar which had formed at a few lines from the external  angle of
the wound had entirely separated.  In order to restore his strength weakened
by dieting, he  was ordered  two table spoonsfuls of Bordeaux wine (claret)
morning and evening.   From the 10th to the  12th  day, the patient had at
intervals hiccough, accompanied by no other unpleasant symptom, but recur-
ring so often as to disturb his sleep.   During  the night of the 12th day, he
felt  some pain in the  lower extremities, and although  evanescent  they
occupied his imagination  sufficiently to  cause the  hiccough  to disappear
entirely.
   13th day. The quantity of pus furnished by  the wound was  observed to
proceed from a small abscess, seated above its  superior angle, on  the inside
of the crista of the ilium.  By very slight pressure this was emptied.  As the
patient's appetite increased  he was allowed more. food.  He passed a good
night.
  14th day. The pulsations which had been observed in the direction of the
iliac artery had ceased.  These pulsations were very evident on the  opposite
side.  It was observed also that those of the tumor were irregular and inter-
mittent,  the intermissions lasting often for  several seconds, and  during  this
time, the arteries of the rest  of the body presented  no analogous symptom,*
which proved  sufficiently that the intermission was  owing to some  entirely
local embarrassment of the circulation.
   15th day. The ligatures being gently raised up, came out of the wound for
several lines;  they were not however entirely removed.  During the evening
he had violent  cephalalgia; having'had no  evacuation for  several days, an
emollient enema was prescribed as also a sinapism to the right arm.   In a few
hours he had two copious stools, the head-ache was removed and he slept well
for the rest of the night.
   16th  day. The two ligatures  came  away spontaneously and at the same
moment.*  The patient's appetite increasing he was allowed two cutlets and
some soup; the claret wine, beer, and  seltzer water were continued.
  20th  day. The pulsations in  the tumor were  perceptible to the sight and
touch, suppuration very copious, it was dressed twice daily.   Every two or
three days emmollient injection  were administered in order to overcome the
habitual constipation of the patient.
  23rd day. The angles of  the wound had  begun to cicatrize; some, too,
luxuriant granulations were touched with nitrate of silver.  On the  morning
and evening of that day a little blood was found mixed with the pus.  The
patient had not slept any during the night, and had been exceedingly  agitated.
About nine o'clock P.  M. haemorrhage took  place soaking the whole dressing.
About two  ounces of  blood  were supposed to have  been lost, but on a very

  * Practitioners have for a long time attached great importance to the temporary
ligature (ligature d'attente).   From this period I have never again employed it, being
convinced that it is more likely to occasion than to prevent haemorrhage ; that it frequently
divides the artery before  the other ligature; lastly that it cannot arrest haemorrhage,
since it acts upon an inflamed part of the vessel, which has become sciss'.ble, and wliich
may be easily divided by very slight constriction. 
CLINICAL SURGERY.
417
attentive examination, the point from which the blood proceeded could not be
ascertained;  the wound was dressed as on the preceding days.
  24t!i day. In the morning a second bleeding more copious than the first took
place ; accompanied by pain in the wound.   The blood appeared to come from
the lower part of the wound, and was evidently arterial.  Compression with
the middle and index fingers of the right hand produced no effect, at an inch
above the wound; below it, it arrested the flow of blood, and gave time to
clean away the  coagulated blood.   The compression by a graduated compress
and the elastic instrument of which we have spoken was substituted for that
of the fingers;  the wound was covered with a little charpie.   The patient's
countenance was changed, and the eructation had again appeared.
  By raising the iliac artery on a sound, it could be distinctly seen and com-
pressed by the finger.  By pressure the pulsations in the  tumor ceased.  The
artery was tied, and from that moment and during six days, the pulsations did
not return.  Again, compression on this  artery above the ligature did not
lessen the pulsations in the tumor; the blood producing them came from a
more remote source; in fact,  by compressing  the abdominal aorta, they
ceased; the blood therefore did not  come from the end of the artery which
had been tied, but from arteries between the ligature and the abdominal aorta.
Now, what artery could thus have re-established the  circulation of the blood,
unless it were the internal iliac, with which anastomosed perhaps the internal
mammary ?
  But by what vessel  was  the  blood again  carried  into  the aneurismal
tumor ?
  The femoral  artery did not pulsate below the tumor,  and press-ire upon it
appeared to augment instead of diminishing the pulsations in the tumor.
   Was the blood returned by the profunda femoris ? The  situation of this
artery behind the tumor prevented the solution of this question.  Lastly, was
it by the  epigastric  artery ?  We know the double communication of this
vessel with the internal mammary and obturator arteries; and even that a
considerable branch sometimes extends from  one to the other of these last
arteries.  This idea led us to. examine attentively the course of the epigastric
artery, and we felt, with astonishment, strong pulsations in this artery, through
the parietes of the abdomen, and especially in the vicinity of the tumor.  It
therefore  appeared that the  epigastric artery was  the principal agent of the
return of the blood into the tumor, and that here, as sometimes happens in
ligature of the primitive carotid, the great  freedom of anastomosis, instead of
facilitating, reproduced the, disease.   In  the present case, this anastomosis
might occasion a haemorrhage eventually perhaps fatal.
   Every one knows  the secondary haemorrhage, and that the loss of an equal
or even less quantity of blood, is more serious than in a primitive haemorrhage.
I knew that a haemorrhage, much less severe it is true, had ceased spontane-
ously in a patient of M. Moulland; but  I also knew that a fatal case had
occurred in the hands of the illustrious A.  Cooper himself.
   I wished to abandon my patient neither to the chance which had saved the
former, nor to the fate of the latter.  Here difficulties crowded upon me; did
the blood proceed from  the  superior or inferior end of the artery ?  In the
former case the temporary ligature having fallen off long  since, and the artery
having  necessarily retracted after the division  of its coats, it appeared almost
                    53 
418
LECTURES ON
 impossible to tie it again.  It was much  more probable that the haemorrhage
 came from the inferior end ;  but admitting this, we had yet to find the means
 of arresting it.
   Ought we to  tie the inferior end of the artery above  the tumor ? But in ad-
 dition to this end being very short, which would make it almost impossible to
 place the ligature without injuring the tumor, the end  of the artery must be
 embedded  in  an inflamed cellular tissue, partaking also  of this  inflamma-
 tion ;  it must be so easily divisible, that a ligature most  carefully  applied,
 would almost immediately cut its coats, and the haemorrhage return in a  few
 hours.  Again, if this ligature were placed below the origin of the epigastric
 artery, the latter might  maintain the bleeding, by  continuing to pour into the
 wound the blood which it received apparently from the  internal mammary or
 obturator arteries.  Ought we to tie the femoral artery below the tumor in or-
 der to prevent the reflux of the blood into the tumor ? But in the first place, it
 was  doubtful if the source of the haemorrhage was there ; again, this ligature
 would fall far  below the  origin  of  the profunda.  Far from arresting the
 haemorrhage, it seemed likely to increase it.  Ought we to open the aneuris-
 mal tumor longitudinally as in the operations for  aneurism by incision ?   To
 perform this an essential condition was wanting;  that  of being able to  sus-
 pend the course of the blood in the limb during the operation ; also, the blood
 which certainly passed into the aneurismal tumor, from   the epigastric artery
 and the femoral itself, would render the operation dangerous.  Former experi-
 ments had shown that we could temporarily arrest the blood in the lovver parts
 of the body by pressure on the abdominal aorta ;  but in addition to the con-
 traction of the  muscles  occasioning pain, the slightest  motion  of the patient,
 the least hesitation on the part of the assistant, might deprive us of this resource;
 it appeared very difficult to tie the epigastric artery, the profunda femoris, and
 the femoral itself in the aneurismal  tumor, without the danger of dividing
 them or some of their branches.   These considerations  led me to abandon the
 ligature, and trust to compression, which although generally less perfect than
 ligature, was at least free from the dangers accompanying the latter.
   In order to be effectual, the compression  should bear upon the precise point
 furnishing the blood.  The difficulty was to find that point.  In order to do
 this I again tried the compression above and below the wound ; the first allow-
 ed the blood to flow, the latter arrested it completely.   The blood therefore
 came from the inferior end of the artery ;  upon  which compression  was to
 be applied; and this compression finding only  opposed  to  it an impetus
 diminished by the resistance of the anastomosis presented much better chances
 of success.
  An hour and a half had scarcely elapsed when the blood appeared for the
 third time ; the compression was increased and the blood again arrested.   An
 hour afterwards, the pressure being relaxed, a fourth haemorrhage took place;
the compression was increased and the blood suspended ; but  carried to  the
 degree necessary, the compression became  extremely painful.  Did not  the
 same cause produce the  extraordinary and unexpected return of the pulsation
in the tumor and the haemorrhage?   From  what other cause  in fact, could
arise the return of the pulsations from the 6th day, and the haemorrhage occur-
ing eight days after the separation of the ligatures, and twenty three days
after the operation!  The bandage was then  removed and the wound cleansed; 
CLINICAL SURGERY.
419
three coagula of blood were extracted, hard, dense, round, and apparently en-
cysted, about the size of an ordinary musket ball; one was entirely composed
of fibrin;  at the moment of their extraction a gush of blood took place; the
fore finger being carried to the bottom of the hand arrested the hemorrhage.
Immediately some plugs dusted with powdered colophony were made and
thrust to the bottom of the wound on withdrawing the finger; and thus not an
additional drop of blood was lost. Other tampons were placed over these; the
wound exactly filled and over the whole compresses and a bandage applied. The
leg and thigh were flexed upon the pelvis and kept in this position by means
of a pillow under  the ham.  He was ordered some weak  punch and soup.
Evening, things were in a good condition; no blood had been lost.  His coun-
tenance was good, his mind tranquil,  and pulse natural.
  25th day.  There was on the inner side of the bandage a quantity of  blood
which however had not as yet soaked through the dressing; plugs of lint were
re-applied at this point and kept on by a new bandage.  There was no numb-
ness  in  the limb;  it preserved its heat,  sensibility and myotility;  but the
morale of the patient became again  affected, his countenance  changed, had
slight pain in the epigastrium, great eructation of gas; the punch and soup
continued.
  Evening,  he  was more tranquil, but  complained of uneasiness from the
position he was obliged to maintain; felt some pain in the heel, which ceased
on changing his posture.  Epigastric pains and eructation had ceased.  Night
was calm and had some sleep.
  26th day. Copious oozing of pus and blood had taken place between the
skin and upper part of the dressing, the abdomen was slightly  painful for
some inches around the bandage.  The  patient was pretty well, had a little
appetite; the soup was continued.
   27th to 29th day, same state.  30th. Evening, the patient uneasy in every
position, had suddenly moved about  several times; a fifth haemorrhage occur-
ed.  About two ounces were supposed to have been lost, but it was corrected
by the tampon.  The patient seemed  not  to mind it, he appeared  fortified
ao-ainst  accidents, and although much emaciated, his strength  remained ; he
was  ordered a glass of claret, and soup containing a potato.  From this
period the haemorrhage never returned.
   The patient complained on the following days of pain in the upper part of
the left thigh, caused undoubtedly by the compression of the bandage, never-
theless the apparatus was kept on until  the 32d day, and then only carefully
 and gradually removed.  There was no  appearance of blood in the pus.
   The next morning several additional  pieces of the  dressing were removed,
 and merely the tampons contained in the wound left; the edges of the latter were
 red and excoriated at some points ; these excoriations were covered  with ce-
 rate; some lint, compresses and a triangular bandage completed the dressing.
   33rd.  The upper part of the left thigh was red, swollen, and slightly pain-
 ful, the patient had no appetite, great thirst, tongue red and dry, pulse fre-
 quent ; compresses wetted with Goulard's solution were applied to the thigh.
   34th. Five days after the last haemorrhage, and ten after the first, the re-
 mainder of the charpie was very carefully withdrawn from the wound, which
 was dressed with plugs of soft lint, kept in by some compresses and a bandage.
   The removal of the dressing then  allowed us  to perceive, that not  only the 
420
LECTURES ON
aneurismal tumor no longer pulsated, but thatit was empty and reduced to its
parietes which presented a cartilaginous consistence.  35th. The state of the
patient had improved ;  the pain and swelling of the thigh greatly diminished ;
the tongue was red but moist, the pulse less frequent, wound of  healthy look,
suppuration less abundant and natural, limb warm.  36th. The tumor in the
thigh had become soft and flaccid; it could be touched without giving pain, and
presented some fluctation at its middle and upper part.  Did this fluctuation
depend on the formation of an abscess, or from some effusion of blood  follow-
ing the rupture of the aneurismal sac ?  This question was to be solved be-
fore proceeding to any active measures.  If it were an  abscess, it required
opening;  if caused by a collection of blood, would not this proceeding ex-
pose us to more haemorrhage.
   The inflammatory symptoms preceding this collection ; the  remission of
these symptoms at the moment in which it appeared formed, led us to try the
effect of a slight puncture in the upper part of the thigh, two  inches  below
the aneurismal tumor.   At first only afew drops of true sanies were  discharg-
ed, of an extremely offensive smell; but a slight pressure below the opening
gave exit to a great quantity of the same matter mixed with a very thick pus.
The opening into the abscess was then enlarged.  Moderate  pressure caused
the discharge of a quantity of pus mixed with some blood.  The whole  thigh
was covered with an emollient poultice.   He was ordered a decoction of bark
and wine and water.  The wound was dressed twice daily, and at each dress-
ing moderate pressure gave exit to a large quantity of pus.
   40th day. The pressure  appearing insufficient to evacuate the pus  com-
pletely, the opening was enlarged, the limb demi-flexed,  the knee elevated on
pillows, so that the upper portion of the thigh  became the most depending
part. At this period  the patient began to feel in the external part of the
thigh very acute pain, intermittent and sometimes extending from  the  head
of the fibula to the external malleolus.  This pain was particularly severe at
the time of dressing.  The limb was wrapped in flannel, and the pain seemed
to have disappeared for a few days.
   On the 40th day of the operation the bottom of the wound was  filled up,
its aperture contracted.  Its edges were in immediate contact; suppuration
not very abundant, the  granulations grayish and  pale; it was  dressed with
honeyed  wine.  Patient has little appetite; the pain in the  knee and leg
deprived him of sleep.   Ordered an ounce of syrup  of  diacodium.  On the
following  day the suppuration  sensibly diminished, the appetite  improved
daily.  From the 42d  to the  48th day, the progress of the convalescence
seemed arrested, the patient was morose and apparently despairing of his life.
Several  nervous symptoms were manifested and gave reason  to fear a malig-
nant fever.  A change of air and scene seemed  necessary, he was  therefore
removed to a more lively part of the city.   This change and the food allowed
him influenced so greatly his convalescence, that the suppuration had entirely
ceased,  and the wound cicatrized  in eight days.  He was then  permitted to
sit up  every day for a  few hours.  60th  day, he rose from his bed without
assistance.  64th day, the opening in the abscess being also nearly cicatrized,
an oedematous engorgement took place around it, which  was discussed by the
use of alcoholic applications.
.   68th day*  He walked alone, to his meals at some distance from the house, 
CLINICAL SURGERY
421
 feeling only a  slight stiffness of the thigh.  Thus after surmounting innu-
 merable difficulties and dangers Berger at last was effectually cured.
   On the 7th of July, 1819, three years after the operation, the patient was in
 the following state:
   The  limb preserved the same size, shape, and nearly the same strength as
 the  opposite one.   The heat,  sensibility and myotility had undergone no
 change; the circulation was carried  on, but without being made  manifest by
 any sensible pulsations, although  the arteries were full and resisting.
   He  frequently walked  several leagues, and followed his trade without
 fatigue.  He labored still under one inconvenience, namely a weakness of the
 parietes of the abdomen, at  the  cicatrix, for which he was obliged to wear a
 truss.
   On the 15th of January 1827,  eleven years after the operation, Berger was
 in a most satisfactory state and occupied at the laborious trade of a mason.
   II. Ligatures.—Of Ligature of the Arteries between the  Aneurismal
 Tumor and the Capillary Vessels, or beyond the Aneurism.—Under certain
 circumstances, a ligature cannot  be applied between the tumor and the heart,
 on account of the too great proximity of the aneurism  to the centre of the
 circulation.  No resource is then left to the surgeon but the application of a
 ligature between the tumor and the capillaries.   The idea of this  plan belongs
 to Brasdor, but Deschamps first  performed on the living body.   He tied the
 femoral  artery below the tumor for  an inguinal aneurism.   The  disease
 rapidly  increased, and to prevent its rupture, and the death  of  the patient,
 Deschamps was obliged to open the  aneurismal sac, and tie the artery above.
 This attempt, and that of Astley Cooper equally unsuccessful, had brought
 the operation into discredit, when some successful cases have again attracted
 public attention.
   It appears beyond a doubt that the unfavorable results in these two cases
 was  owing to the origin of some important branch frofm the diseased artery
 between the ligature and aneurismal sac.  Therefore, we are  now of opinion
 that  the chances of cure are as numerous as  possible, when no branch capable
 of maintaining the circulation  in the sac  exists  between the latter and the
 tumor.   This  successful termination may even take place,  although small
 branches may arise from the vicinity of the  aneurism, by the extension of the
 coagulum,  filling successively the latter and the  trunk itself.   The  presence
 of considerable ramifications, capable of preventing the solidification of the
 blood in the tumor evidently render the operation useless.  On the other hand
 it may be injurious and accelerate the march of the disease.   It  will be seen,
 that if the fluid impelled by the heart finds  beyond the aneurism a narrow
 opening, although sufficient to admit it  in  a certain stream, it will make a
 continual effort, in which the  tumor plays its part, to dilate this opening, and
 the result will be the dilatation  of the parietes of the sac.
  The plan of  which we  now  treat does  not apply to reCent  and  diffuse
 traumatic aneurisms, or to varicose aneurisms, whilst  it should be applied to
 spontaneous or circumscribed traumatic aneurisms,  with solid cysts.   The
presence of the epigastric artery above and below the tumor is an obstacle to
its application to the  thigh.
  By recapitulating the facts favorable  to this plan, it will be found that of
five cases no arterial  branch arising between the ligature and the aneurismal 
422
LECTURES ON
sac, three have been successful; that in the opposite case, especially those of
the iliac fossa and groin, have not been arrested in their progress.   In some
others, and particularly in the inferior region of the neck, the progress of the
disease has not only been slackened, but modified for eight montlis. and even
for two years.
   The following  case, although  unsuccessful, is  interesting,  since death
could  not be attributed to the plan, but rather fear, which suggested a most
energetic antiphlogistic treatment (six bleedings in four days).  Those also
who assisted  at the operation will remember it, as  a  rare example of the
patience, sang-froid, and skill of the illustrious operator.
   Case.—Subclavian Aneurism; Ligature of the Axillary Artery; Death; Au-
topsy.—Ch. Paris, 40  years  of age, a day laborer living in the country, of
robust constitution, felt five months ago, after violent  exertion, pain above
the right shoulder; he  ceased working, and on the third day a pulsating tumor
of the size of the thumb, formed above  the  clavicle.  During two  months,
his surgeon, who understood  its nature, covered it with pounded ice; the
man was bled three times and kept on strict diet; the tumor was reduced to
the size of a French bean, when he again began to labor; it made no progress
for three weeks, but then  rapidly increased, rendering the movements of the
arm very difficult.  Paris  remained quiet,  and underwent no  treatment
until his admission into the Hotel-Dieu, on the 28th of May, 1829.
   He was then in  the following state :  a large saliant tumor, without any
change of color in the skin,  occupied  the lower  part of the neck,  resting  on
the  clavicle, which it slightly covered  in front, without appearing to pass
beyond  it,  below and behind,  it ascended as  far as the middle third of the
neck.  The tumor commenced aiabout half  an inch from the right sterno-
clavicular articulation and the trachea, and extended to the internal edge of
the trapezius muscle,  thus occupying the whole  of the  subclavicular space;
its vertical diameter was two inches and five lines; the transverse three inches
five lines; it raised  up  the sterno-mastoid muscle.  A species of hard and
 thick membrane resisting the sac, could be distinctly felt; the circumference
 was  irregular; it  extended further upwards and inwards than downwards
 and  outwards, and approximated very closely to the cricoid cartilage.  The
 finder could distinguish  in every part of the tumor strong superficial pulsa-
 tions isochronous with the pulse.   Moderate pressure gave no pain, but dimin-
 ished the size of the tumor,  which  presented some resistance to  the fingers.
 The following was the state of the circumjacent parts  : by seeking the caro-
 tid in the tumor, and nearly where this artery divides, it was easily found;  but
 then, by tracing it towards its origin, the position and pulsations of the tumor
 prevented its discovery; by depressing forcibly the integuments of the neck over
 the track of the artery, and pushing the tumor slightly outwards, the carotid
 could be distinctly felt, because the artery presented a remarkable trembling,
 strongly contrasted with the  pulsations of  the  sac.  Carrying the examina-
 tion towards the upper part of the sternum, the fingers felt, and the eye per-
 ceived  the  pulsations furnished by a large arterial trunk, situated partly in
 front and to the right of the trachea.  This was probably the arteria innomi-
 nata.                                                          .     .,
    The pulsations of the  axillary artery and the branches of the right side,
 were not  different from those of the  opposite side.    The right arm  wa3 
CLINICAL SURGERY.
423
swollen, especially the hand ; benumbed, without change of temperature ; the
right  hand demi-flexed, and its  motions nearly  lost.   Auscultation and
percussion announced a sound state of the lungs.  The pulsations of the heart
were simple, but strong and sonorous; the patient stated that he had never had
palpitation nor any other symptom characteristic  of disease of that organ.
The digestive and cerebral  functions were naturally performed.  During the
first fifteen days, he was twice bled, at each time twelve ounces, which seemed
to weaken him greatly.   He  took but  little nourishment;  saturnine lotions
and ice were constantly applied to the tumor.  The tumor, however, sensibly
increased, and prompt recourse to a surgical operation was evidently required
in order to save the man's life.
   Valsalva's method offered no better  hopes of success.  There remained,
therefore, only the ligature of the artery; where was it to  be applied ? be-
tween the tumor and the heart ?   It would have been difficult, if not impossi-
ble to determine precisely the point of the subclavian, from which the tumor
originated.  The innominata itself was  perhaps affected ; the strong pulsations
felt behind the sterno clavicular articulation caused this to be feared.   Were
we even certain of its integrity would  it be safe to attempt  to tie it?  This
bold operation performed by Mott of New York,  and Graefe of Berlin, has
not been sufficiently successful to inspire much confidence.   We were there-
fore reduced to the last alternative of tying the axillary artery, between the
tumor and the capillaries.
   After having maturely examined this method, again dissected this region,
and minutely studied the important relations of the axillary artery, the opera-
tion was performed on the  12th of June, 1829.  An incision was njade com-
mencing near the internal extremity of the clavicle, two fingers'breadth below
it, extending outwards  nearly parallel to the bone; this incision was three
inches in length.  The operator  divided successively the  fibres of the great
pectoral muscles, the venous and  arterial branches, and then the upper third of
the lesser pectoral muscle;  on reaching the artery, it was found, as supposed by
M. Sanson before the operation,  that the aneurismal sac extended somewhat
beyond the clavicle ; lastly, the axillary artery was separated from its vein and
the nerves of the brachial plexus. By means of a curved needle a  ligature
was passed around it; the patient felt no pain  when the ligature  was tied.
Immediately after the securing of the ligature the  pulsations  m the tumor
o-reatly increased, and  the first twenty were very irregular, as remarked by
M Sanson, who kept his  hand on the tumor;  but they afterwards  regained
their natural force.  The wound  was simply dressed ; the application of ice
 was continued and compresses soaked  in a solution  of acetate  of lead.  He
was ordered at night a grain of extract of opium.  Ten hours after the Opera-
 tion, his pulse was strong and amounted, as  on the evening  preceding, to  84
 strokes per minute.   He was bled four ounces.
    13th of June.  The patient was weak, complained of insomnia, uneasiness;
 the pulsations of the tumor had not sensibly  diminished,  but the tension was
 less;  pulse beats 66 times per minute; the arm  preserved  its natural heat,
 but without any perceptible circulation.  Evening, pulse 96; the nausea,
 insomnia, have disappeared ; limb in the same  state ; a pricking sensation  is
 (eUin +he fino-ers;  tumor evidently  diminished, pulsating although not so
 ^.'onMy as before.   15th. No change; remedies  continued; some soup was 
424
LECTURES ON
allowed.  16th, sleep; pulse 80; tumor and pulsations diminished ; resp'ration
free; great thirst; has had no alvine evacuation  since  the operation;  except
that, is doing well.  17th, morning, tumor and arm in the same state ;  wound
dressed for the first time ; eight ounces  of blood  were drawn from h arm
(acetate of lead continued) ; two o'clock, P.M., dressing saturated w !i Ver-
million colored blood,  easily  coagulating ;  pulse quickened, face p; le and
haggard;  (athalf past six o'clock twelve ounces of blood were  taker., refri-
gerants  applied to the wound itself);  10 P.M., some blood oozed ft■ m the
wound, at half past eleven P.M. eight ounces ot blood withdrawn from <  -vein;
18th, four o'clock A. M., another slight  oozing was soon arrested by c< ipres-
sion ; general paleness ; icterose hue;  great debility ; respiration emba; as9ed
cough dry and frequent, thirst, nausea; pulsations do not diminish in strength;
no evacuation per anum; the acetate of lead discontinued ; wound dres-^-d and
covered with ice ;  evening, no bad symptom, arm preserves its natur '. heat.
  19th, Patient is  very pale,  pulse frequent, debility great, pulsatios less
strong in the  external part  of the  tumor.   Again bled four  oui-.es.—
Evening, cough less frequent;  some sleep, felt pretty well, took a little soup.
20th, debility increases; evening, his extremities were cold, he was agitated,
insomnia, slight delirium.   At one o'clock,  Paris felt his end appro ching,
and at half past two A. M. he expired.
  Autopsy.—Thirty hours after death ; great emaciation ;  the right ar.'i was
livid, oedematous ; the  epidermis detached at several points; the end-  of the
fingers black.   The cavity of the pleurae contained a little sanguinolent fluid;
the anterior part of the lungs sound ;  the posterior red in patches, was hepa-
tized in the right lung and also covered by some recent false membran es.
  The heart, extremely large was flabby; the ventricles much dilated ; its pa-
rietes soft and thin contained no coagula; on  the  outside  there was  a white
patch attributed to a former pericarditis.
  The aorta was greatly dilated at its origin;  this dilatation extended, but
diminished gradually, as far as the diaphragm, where the vessel was of its or-
dinary size.  Its internal surface red and granulated,presented cartilaginous
patches of a deep red color; patches of ossification were also seen he-e and
there ; some erosions were found on the inner membrane.  The innominata
presented similar lesions, also much dilated, passing  in front of the  (r ichea,
where it gave off the carotid which was sound.  The subclavian  dilated im-
mediately at its origin formed the aneurismal sac.  The tumor occupied the
subclavicular space; it   had partly destroyed the  first rib, and as we have al-
ready said extended beyond the clavicle; outwardly it Covered the ne- ves of
the brachial plexus ; inwardly it was covered by the clavicular portion of the
sterno-mastoid muscle, theomo-hyoiedeus and scalenus anticus, which ai hered
intimately to the anterior parietes of the sac.  But the last muscle pre ented
an efficient obstacle to the  development of  the tumor towards  the  heart; for
by passing the finger into the  aneurismal  sac, and then under the sc lenus
anticus, a marked contraction  in the subclavian was felt.   The pariete* >f the
sac were thick and resisting inwardly, but  at some  points   belov  the
pleura formed its only  covering.   The cavity of the  aneurism con ained
merely  a  clot  of  recent blood;  it  was  lined in   front by lay -s  of
fibrin.     The  coats  of the  artery forming the  dilatation  could   i  no
wise be  distinguished.  The  vertebral internal mammary, and  i f'erior 
CLINICAL SURGERY.
425
thyroidal arteries were entirely obliterated.  The axillary artery was sound at
the point of the application of the ligature; an opening in the artery was per-
ceived at this point, probably made during the dissection.  Several students
had also pulled at the ligature before commencing the autopsy, and this might
have lacerated it.   The remainder of the arterial  system was  sound.   The
digestive and urinary organs presented no marks of disorder; head was not
examined.
  Let us now examine the cause of the death of Paris with all  the attention
and impartiality  which  the case demands,  We  have  seen that the pulsa-
tions immediately after tying the artery were extremely strong; still the  sac
was not ruptured, although  its. parietes were thinned in  some places, and two
days after the operation the pulsations sensibly  diminished.  Thus the tumor
presented no alarming symptom.  The patient did well until the fifth day ; a
slight haemorrhage then occurred.  The cause of this accident was unknown;
the blood was supposed to come from the  sac or  the axillary artery ;  but it is
more probable that  it proceeded from small sized vessels; the autopsy did not
decide this question positively.
  Paris, weakened  by bleeding and dieting, was still more so after the haemor-
rhage ; however, as a recurrence of the bleeding was feared, the ice and com-
presses were applied to the wound ;  twenty ounces of blood were withdrawn
at three bleedings in the same day.   Now it is very probable that these bleed-
ings opposed the cure of the aueurismal tumor ; for the plastic quality of the
blood is necessary to its coagulation, and the more  the  patient is  bled, the
more this quality is lessened  and consequently also the chance of cure.  This
same circumstance caused a greater  liability  to haemorrhage.   The greatest
inconvenience of these repeated bleedings, was to reduce so much the strength
of the patient as to render him unable to  support any further loss of blood.
  It might  have  been feared that  the success  of the operation was compro-
mised by the existence of large branches  furnished by the subclavian in front
of the tumor, or by  the tumor itself.  The autopsy showed the obliteration of
all these branches, as is  frequently the case when the aneurism has attained a
certain size, and situated so that compression can act on the arteries.   Gen-
erally, as we cannot ascertain whether-the branches furnished by an artery at
the spot where it is  aneurismal, are not obliterated, their existence should not
contra-indicate the  ligature between the tumor and the capillaries.
   If,  in detailing this curious case, we have pointed out the objections to the re-
peated bleedings,  we should  also mention that the great changes in the  aorta
and lungs must have greatly influenced the death of Paris.
   Be it as it may'his loss is to be.lamented.  Had the case been successful,
others might have imitated it and many valuable lives been  saved.  The re-
sult, however, should not deter surgeons from renewing the operation of Bras-
dor.  Were we  always to judge of the value  of  an  operation by one case,
many of our surgical resources would be cut off.  Astley Cooper failed  in
his first operation for tying the primitive carotid in a case of aneurism of that
artery   This did not prevent Mr. Cline from attempting it, as well as Astley
Cooper  and other surgeons.   They succeeded.  Since that period they have
been  imitated by other  surgeons, and ligature  of  the primitive carotid is no
longer considered so serious an undertaking.
           54 
426
LECTURES ON
  The first case of artificial anus operated upon by the method which has
since been so often successful I lost.
  We have seen in the account of the post-mortem examination of the above
patient that the arteria innominata, although very large, was sound ; it might
have been tied; but we have already observed that two similar operations by
Mott, of  America, and Graefe, of Prussia, have failed.  A third lately per-
formed in Paris was not successful; the patient died of haemorrhage.  These
failures are not encouraging.  Still, instead of condemning we should rather
praise those, who in desperate cases, would have recourse to so bold an opera-
tion.  Additional cases of ligature of  the innominata are required to give it
weight.
                         CHAPTER  LI.

                               ON  BURNS.

  On the means of conducting the Healing of Burns, with a view to their
favorable Cicatrization.—-It is proved  by observation that nature has two
modes of effecting the consolidation of solutions of continuity.  Whatever
be the extent of the wound and the nature of the textures in which it has been
made, provided the process of reparation does not exceed the powers of the
individual, there takes  place over the whole surface an inflammatory action,
which constantly tends  to approximate the bodies, and bring them into con-
tact,  intimately agglutinating  them by a layer of lymph, by the organization
of which the continuity is restored.   This interposed structure itself at length
disappears, and then there remains no other trace of the lesion than a. mere
line, which at last becomes imperceptible.   This is immediate reunion, or
union by the first intention.
  But where there is a considerable loss of substance, or-where, for various
reasons,  the  first  mode  of union  is designedly prevented, other phenomena
present themselves; a new tissue is formed to supply the place of that which
has been destroyed.  This is fibro-cellular in its nature, and I have called it
the tissue of  cicatrix.   If the work of reproduction go on regularly, and the
loss of substance be nearly or altogether repaired,  we then have a production
to which I have given the name of patulous tissue (tissu dVtale) of the cica-
trix.  But where this is not the case, it causes deformities, bridles or bands
between  parts, in a word, bad cicatrices with the partial  or total loss of the
mobility  of the part.
  The result of cicatrization  may occur in  every case  where a  burn has
caused loss of substance, but in different forms and degrees; these we will
now proceed  to examine.
  Burn  of the 1st Degree.—Heat acts in two ways in producing this,degree
of burn; either its action, more  or less intense,  is instantaneous,  and gives
rise to a true erysipelas, marked by sanguineous  conjestion of  the  skin,
redness and sharp pain, constituting the acute stage of a burn; but this causes 
CLINICAL SURGERY.
427
neither solution of continuity nor loss of substance, and consequently requires
no cicatrization to cure it.  In other cases the heat,  exercising a gentle  but
prolonged influence, as in women who make habitual use of chafing dishes, in
old people and convalescents who sit much by the fire, in artisans of  certain
trades, in such persons I say, the heat produces different lesions of the skin,
which ought rather to be regarded as deformities, and of which we will speak,
hereafter.  These results constitute what I call the chronic form of burns of
the first degree.
  2nd degree. This consists in vesication more or less  extensive.   The  epi-
dermis is  detached from the rete mucosum and must perish.  There is  here
loss of substance and there will be consequently a process of reproduction.
But this is carried on in three different modes, that is to say, 1st, without sup-
puration,  2nd, with slight suppuration, or 3rd, with suppuration which is long
and copious.   It is very important to  discriminate between these ; for  each
presents different results, from which arise as many different indications.
  In many cases while the epidermis which forms the vesication, though  de-
tached, has  not been removed, but rests on the mucous surface after the eva-
cuation of the fluid, there being no suppuration, a new  epidermis  is  formed,
the period varying from 24 hours to five or six days or even more.   There re-
mains then no trace of the burn,  but  redness, more or less  marked, which
usually disappears from the 12th to the 30th day.   This termination is in all
respects like that of a flying blister, and the  rete mucosum  being unaltered
by suppuration,  the color of the skin is preserved.  In fact, in a negro,  who
suffers from a burn in tins degree,  the surface still remains black.  But  it is
different in those burns of which I shall next speak.
   When the action of the heat has been more intense,  or being in other res-
pects the same as if the epidermis had been removed by accident or ignorance
and thus  left the rete mucosum naked, inflammation more or  less acute takes
place, and we observe two orders of phenomena;  or after an effusion of serum
for some  days, a suppuration follows, small in quantity and of short duration,
and then the result is little different from that pointed  out as  accompanying
the preceding degree; the wound becomes dry, a delicate pellicle, the  element
 of the new  epidermis extends itself over it, and all traces of the lesion are
 effaced ;  or secondly, under other circumstances, a copious suppuration takes
 place, which in many cases continues notwithstanding the utmost care for seve-
 ral months.  Let us now examine in detail the phenomena of this latter  case.
 The effect of this long and abundant suppuration differs in nothing from what
 takes place when a blister has been very long applied ; either the rete muco-
 sum is completely destroyed or deeply impaired in  its organization; whilst
 at other times, it is destroyed in some parts, and preserved in an  unimpaired
 state in others.   In the first case the disorder has penetrated  to the  chorion,
 the burn has passed into the third degree, and the progress of cicatrization  is
 the same as in this last, of which I shall soon speak.   In the second  case the
 coloring  matter generally becomes of much deeper color than natural; hence
 those yellow or brown stains which  remain after  the  cicatrization, stains,
 which are never removed, nor even modified, except to a very trifling extent.
 In the neoro also, the skin become much deeper colored than natural. Lastly,
 in this thud case, the surfaced the  chorion granulates  unequally  at every
 point where the rete mucosum has been completely destroyed.  The cicatrix, 
428
LECTUDES ON
then presents a mottled appearance, being prominent and white at some points
while at others it is depressed, and more or less brown.
  A knowledge of these facts forms not only the basis of the indications to be
fulfilled, and of the prognosis to be given, but also furnishes useful  hints for
general practice.   Thus, for example, when we are obliged to apply a perma-
nent blister on a  part of the body which is exposed, especially in a female,
it teaches us not to continue the suppuration long enough to  leave  a mark ;
and if the disease requires its longer  presence, care must be taken to shift it
from one place to another.  I have thus kept blisters open in different  parts
of the body in young  person , in diseases  imperatively requiring their  use
for a long period,  without causing any scar.
  After what  I have  said, you will comprehend what ought to be the treat-
ment of this species of burn.  It is  evident that  it ought to consist in emol-
lients  and antiphiogistics, even venesection,  if it be rendered necessary by
more than usual inflammation ; great  care being taken to avoid the  application
of irritants, or the removal of the detached epidermis, while we strive to  sup-
press suppuration.  For if we are only called in at a period when suppuration
has already existed for some time,  and the rete mucosum  is completely disor-
ganized or destroyed, other means become necessary.  The granulations are to
be repressed with nitrate of silver,  and afterwards covered  with linen  with
numerous holes in it, and spread with cerate; dessicating substances such
as tend to accelerate cicatrization should  be used ; plates  of sheet lead, by
their  equal pressure, may also be of great use.   By these means we shall
obtain an equal,  flat cicatrix, free from deformity ; but generally, time alone
can remove the yellow and brown spots resulting from the great alteration of
the rete mucosum, which has not been destroyed.
  3d degree. This degree of burn is characterized by the total destruction
of the epidermis, of the rete mucosum  and a greater or less portion of the
chorion ; but this last,is not  destroyed through its whole extent.   Mark  well
(said  M.  Dupuytren) the limit of the disorganization ;  it is by that we are
enabled to explain the manner in which the cicatrix is formed, and the differ-
ence between this and what takes place in the cicatrices of the following de-
grees.   In this case, in fact, the whole thickness of the true skin is  not
destroyed, nor, consequently, is  a  complete  reproduction of the cutaneous
tissue required, as in the fourth degree; there remains of this a  layer of greater
or less thickness, from which the new surface is produced.  When the eschar
which comprises the rete mucosum and a portion of the thickness  of the true
skin has separated, the surface of the wound presents a number of small red
points on a white ground.  This  is  the portion of the chorion which has not
been destroyed.  Soon these red points increase more and more, and at length
altogether occupy the surface, which  thus becomes uniformly red.   The cica-
trix, then, is  made up of granulations, which are of cellular, vascular,  and
nervous texture,  and by their progressive development they fill the cavity
which the eschar  had left.
  But however instantaneous may have been the action of the heat, it never
implicates all the  tissues to a perfectly equal depth.  It happens then, in this
third degree, that at certain points the rete mucosum alone has  been destroyed,
and  the chorion  slightly affected; while in others this last  is deeply impli-
cated but not completely perforated.  The inequalities thus produced in the 
CLINICAL SURGERY.
429
cellulo-vascular granulations of which I have spoken, are perceptible through-
out the whole progress of the cure, and if left to themselves, produce a cica-
trix more or less uneven.
  It may be imagined that all the methods of cure recommended for the se-
cond degree apply equally here.  It further, however, becomes necessary to
take care that no preternatural  adhesions are formed, and that none of the
natural  apertures become closed, by preventing the contact of the former by
the interposition  of some substance, as  lint spread with cerate, and intro-
ducing into the latter, tents, canulas of gum elastic, or any other appropriate
instrument.
  For the last fifteen years, I have used  with great advantage, an ivory tube
introduced into the nostrils when the nose has been more or less burnt, or re-
moved on account of a cancerous disease.  It prevents the contact and adhe-
sion of the parietes of the cavity, and  thus renders the deformity less dis-
gusting.
   In order to correct the excessive growth of  the granulations, the nitrate of
silver is to be used as  before, and very particular attention given to the mode
of  applying the dressings ; these ought to be so arranged that the matter may
be  absorbed by them and remain the shortest possible time in contact with the
wound.  To accomplish this, I am  in the habit of covering the surface with
compresses pierced by numerous little holes very close to each other and spread
with cerate; above this  I apply a layer  of dry charpie, and retain the whole
in situ, not with a roller, but by means of bandages separate from each other.
The pus thus passes through the apertures in the first compresses, is absorbed
bv the  charpie, and may even escape between the interstices  of the  outer
bandages.   After a time the granulations become firmer, particularly at the
base,' and  assume  a fibrous structure.   An epidermis next forms atthe sum-
 mit; at first very thin, and  beneath which is  generated a rete mucosum of
 bright  red color, irritable, very liable to congestion, and the frequent seat of
 erysipelas.  This rete mucosum is imperfectly formed, and for the most part
 wants the pigmentum or coloring matter; so that  in the negro the cicatrix be-
 comes  white, and in the white of a  paler color than the rest  of the skm.  In
 some cases, however,  the pigmentum is found in superabundant quantity, giv-
 ing to the skin a discoloration more or less deep.  An entirely new formed
 rete mucosum often remains imperfect and constitutes an irremediable deform-
 ity  Lastly, the epidermis, at first very thin and liable to scale off, after a
 period, sometimes very short, acquires all the properties except the color of
 the original epidermis.                                                .
    4th  degree.   This  is characterized by complete destruction  ot the  skin,
  through its whole thickness, the subjacent cellular tissue being laid bare, but
  remaining itself uninjured, or but very slightly affected.
    The cicatrization in this  degree takes place in various ways. 1st, after the
  separation of the eschar, the edges of the wound gradually approximate and
  so unite   2ndly, the edges remaining apart, a new cutaneous texture is form-
  ed at the expend of  the cellular membrane beneath, which  replaces the por-
  tion which had  been  lost.   3rdly,  both the above processes simultaneously

  ^ After the fall of the eschar, the bottom of the wound is formed by the cel-
  lular tissue ; the edges exhibit a red circle, (the rete mucosum) which  gradu- 
430
LECTURES  ON
ally diminishes, the  skin  of the  surrounding parts yielding proportionally.
After being dragged to a certain extent, however, they can be stretched no fur-
ther, and then new texture is formed to fill up the void which  still remains.
Of course the looser the skin and cellular membrane adjoining  the burn  are
the smaller is the cicatrix which is ultimately  formed ; while in parts which do
not admit of  the adjacent skin yielding, the gap left and the new tissue  re-
quired must  be proportionally larger.  The cellular membrane which is situ-
ated at the bottom of the wound and which is in a state of granulation, under-
goes a peculiar change and constitutes the chorion; when once this is formed
the rest of the cicatrization goes on rapidly ; a rete mucosum though imperfect,
is formed, and this again is covered by an epidermis differing but little from
the natural one.  The  production of this accidental chorion, however, costs
much to nature ; she is very long in effecting  its organization, particularly in
large wounds  ; but after this, all is rapid,  and  it is astonishing to see a wound
which  has lasted  one, two, or more months, almost  without  any apparent
change, all at once heal  up in a few days.  Much care however is required in
directing the process, so great is the liability to deformity from the adhesions
and contractions which occur.
  The first thing to be attended to, is the position of the limb or of the part;
and as a general rule, this  must be laid in such a posture as diametrically to
oppose the approximation of the edges of  the wound, in order to obtain a cica-
trix  corresponding in size to the extent of skin destroyed, or even of greater
extent; and thus to allow  for the contractile power of the new  tissue.  It is
unnecessary to give examples, the rule is too conspicuous to require them, and it
must be put in force  by different means in each different region of the  body.
  There are circumstances, however, under which it is impossible or very diffi-
cult to observe the requisite position; such, for instance, is the case where the
skin is destroyed through the whole circumference and over a certain extent of
a limb.   Here in adopting any one position we lose the advantage of others; the
only thing to be  done in such circumstances, is to place the limb in such a man-
ner that the cicatrix shall be, when forming, under the least  possible restraint.
Thus, if the  burn  occupy the  whole circumference of the wrist, the limb
ought to be kept extended rather than bent, because the former position will
prove less inconvenient when the cicatrix is completed than the latter would.
Occasionally the position  may be varied and the limb kept for a time in  one
position and  then in another.   Cases  are often to be met with in which the
means necessary to produce a good cicatrix cannot be  adopted, or  at least
persevered in, without great inconvenience,  or even without  danger  to the
life of the patient.  This happens, for instance, when there is risk of his being
worn out by  long continued suppuration.  So far  from preventing the cicatri-
zation we are then glad to accelerate it  by facilitating an approximation of
the edges; but it is right that  the practitioner should  take the  precaution of
explaining to the patient or his friends the reason which induces him to adopt
this course, as well as the evil which must result  from it.
   There  are some regions of the bodj where we  cannot make use of position,
and where it is always very difficult, and sometimes impossible to prevent de-
formity, such particularly is the face.  If a burn of the fourth degree, for ex-
 ample, destroy a portion of the lower eyelid  and cheek, it  would be impossi
 ble to prevent the edges of the wound from approaching, and the eyelid may 
CLINICAL SURGERY.
431
be seen cicatrized in such a manner as to bring it almost into contact with the
upper lip.  Such was the case in a girl lately brought to me, and I had great
difficulty in persuading the parents that the surgeon was not in fault.
  However slender may be our resources, when we are deprived of position,
to prevent vicious cicatrices and deformities, as people are prone to impute
them to unskilfulness and ignorance, they should never be neglected.  Thus
1st, it is necessary to retard as long as possible the  separation of the eschar,
for this, as long as it remains,  keeps the borders  of the wound apart.  The
process of  cicatrization commences beneath  it, while the inflammation of the
edges of the wound extends  into the adjacent tissues, by which they are  less
easily approximated when the eschar falls.  This resource then, merits atten-
tion, but without being of very great importance.
  2d.  When the eschar has  dropped off,  the cicatrization  must be hastened
by frequent  cauterization,  by means of nitrate of  silver.  This  speedily
determines the formation of  the new cellular tissue, and I  have obtained great
advantages from it in  many cases.  Far from increasing the deformity, as
many have said, it tends to produce an equal smooth cicatrix; but care must
be taken that the healing is not retarded  by  the contact of purulent  matter,
and this must therefore be carefully removed from the surface and the wound
frequently dressed.
  The position which has been adopted as proper for the cicatrization must be
persevered in for a considerable time, a month, six weeks, or longer, after the
entire healing of the wound.   The force  of retraction possessed by the cica-
trix (a force, by the way, which has been much exaggerated) may produce such
contraction of the wound as would lose the advantage previously gained; and
the parts must therefore  be very gradually suffered to return to their former
freedom.   In burns of the fourth degree, the adequate position of the parts
must be maintained by bandages, varied  according  to circumstances, but so
contrived as to counteract the  contraction of the  muscles.   In burns of the
second and third degrees, the adhesion of the neighbouring parts is prevented
by merely keeping  them separated by  the interposition of dressings, and
moving them from time to time; but in those of the fourth degree, such simple
means will not suffice.
  It will be perceived, continued M. Dupuytren, that if a burn of the fourth
degree affect the circumference,of any of the natural orifices, such as of the
nostrils, or vagina, or the mouth, &c. it is not compression, such as that em-
ployed in other cases, that will suffice; but compression exercised from within
outwards, and by the separation of the parietes of the openings by means of
charpie, tents, sounds, sponges, ivory  tubes, &c.   These contrivances are the
same as in  burns  of the  third  degree, but with these differences, that their
necessity is much  more  urgent; that the diameter  of the foreign body must
always exceed that of the aperture into which it is introduced, and that their
use must be continued long after the apparent cure, in order to overcome the
force of contraction of the new textures.
  Strips of adhesive plaisters have been employed as  one of the means destined
to fulfil the indications of which we are treating.   But however useful they
may be in approximating the edges of a  wound, they are  useless when used
with the contrary intention. In the former case they resist any effort which tends 
432
LECTURES ON
 to lengthen  them; but in the second they slip, and follow the integuments
 upon which they are applied.
   5th and 6th degrees.   When the burn is so deep as to implicate the muscles
 and tendons, most  of  the means I have  pointed  out  become superfluous.
 The  treatment in this case  consists almost entirely in giving to the limb or
 part such position as shall be least inconvenient when the parts are cicatrized.
 Most frequently  the disorganization is carried (o such an extent that we have
 only to occupy ourselves in endeavoring to save  the life of the sufferer by
 promoting the healing process in every way, without reference to what defor-
 mity may arise or the loss of function which may ensue.  The treatment doe-,
 not materially differ from that applicable to the  cicatrization of stumps after
 amputation.
   2c?.  On  the Physical,  Anatomical and  Pathological Characters of the
 Cicatrices following Burns.—It  is  of great importance  that we should
 obtain an accurate knowledge of  the physical characters of cicatrices, in order
 to be able to calculate the effects which may result under particular circum-
 stances.  The cicatrix, then, is  formed by the  exudation of plastic lymph,
 which, becoming organized, exhibits the appearance  of a thin pellicle of a
 reddish  color and very fragile;  beneath this is the cellulo-vascular tissue,
 which it covers.   During several  weeks, and sometimes during several months
 after its formation, the organization of the cicatrix goes on, becoming pro-
 gressively more  perfect;  and it  is only by a secondary organic  action that it
 acquires the density necessary to  qualify it to supply the place of the lost skin.
 The consecutive retraction  only ceases when the  cicatrix has become white
 and solid, such as it is to remain during the remainder of life.  The cicatrices
 are covered  by a slight epidermis, which is very adherent  and  shining, the
 existence of  which may be demonstrated by maceration, or the application of
 a blister.  Beneath this is  that  fibrous layer which I have called tissue of
 the cicatrix, on which the phenomena of the  retraction  depend.   The cicatrix
 is  pierced by only a small number of exhalant or absorbent pores; hence its
 surface is almost always dry, even when perspiration  bedews the rest of the
 body.  Neither do we find on the inner surfaces of the cicatrices those fibro-
 cellular apertures, which, in the natural  state,  exist under the skin, and be-
 neath which are lodged the separate  little nodules of fat.  A tissue composed
 of laminae more or less close, and destitute of adipose  matter, unites the new
 skin to the subjacent parts, and a depression exists, which is in proportion to
 the loss of substance, and to the extent to which the adjacent parts were pre-
 viously furnished with fat.   When  the lesion has penetrated to the muscles,
 tendons or bones, the cicatrix usually adheres intimately to these organs, and
is dragged out of  its place when they move,  thus constraining their functions.
  It is a remarkable fact, that, whenever parts of different organization run in-
to a common  cicatrix, they lose before passing into it their own proper texture,
and degenerate into a homogeneous fibrous structure, which becomes blended
with the new formation, to the inner  surface  of which they adhere.  This dis-
position is especially remarkable in muscles, tendons, and other organs impli-
cated in a burn of the fifth degree, or which contribute to form the stump of
a limb destroyed  by a burn of the sixth degree.
  The causes of  the indelible nature of certain  cicatrices have  already been 
CLINICAL SURGERY.
433
explained, as well as why they preserve during the rest of life the form as
well as the organic characters which are proper to them.   But a fact which
ought to  be particularly attended  to, because  a knowledge of it is of great
importance under different circumstances, is,  that they vary in appearance,
and  to  a  certain degree even in texture, according to the causes which pro-
duced the solution of continuity from which they have resulted.  In spite of
years, and notwithstanding the changes which take place in their organization,
the eye of the  practised surgeon  can  readily distinguish  the cicatrices  of
burns from those of incised wounds, and  those following cancerous ulcera-
tions, syphilitic or scrofulous abscesses.  You will easily understand of what
importance it is, in legal medicine, to be able to make such distinctions, as
well  in determining the identity of individuals, as also in order to ascertain
the cause  which had produced the breach of surface.
  The  development of vascularity in cicatrices is very variable.  In most
instances  they only exhibit very minute capillary ramifications, which are
with much difficulty traversed by  the  finest injections; and in persons who
have  scars on the face it may be seen that they do not participate in the color
produced  on the surrounding skin by heat or by emotion.  It is probable that
cicatrices  receive  nerves but in a small number.  They are not insensible to
the impression of foreign bodies,  and when inflamed become very painful.
It is also  well known that their susceptibility  is very great  to atmospheric
impressions, and that they accurately announce by painful sensations the vari-
ations which occur in the thermometrical and hydrometrical states of the air.
  Like  all other anormal textures, cicatrices are easily irritated, and are even
destroyed, particularly by inflammation, with prodigious rapidity.  In most
cases it requires only a few days, or even hours, to destroy the process of re-
paration of many months,  and to restore to the solution of  continuity its ori-
ginal dimensions.   But this destruction is often superficial;  it does not impli-
cate  the whole  thickness of the texture which  forms the  cicatrix, and  its
reproduction is effected with great rapidity.   As to the rest, cicatrices are
usually  exempt  from exanthematous affections, such as small pox, measles,
and scarlatina; remaining pale amid the general redness of these diseases;
the reverse of this is only seen where the  solution has been very superficial,
the skin having been partly preserved.  The intimate adherence of cicatrices
to the subjacent parts, and their defective power of supporting inflammation,
have led  to the general rule in surgery, of avoiding to carry incisions either
through them or into their immediate vicinity.
  Cicatrices become causes of exemption from  military service when they
adhere to  muscles, tendons, or bones, so as to impede the execution  of move-
ments which ought to be perfectly free.  So likewise extensive cicatrices, such
as those which occupy considerable portions of a limb, ought to be regarded
as disqualifying from active service, even although the  movements remain
unimpaired, for such large surfaces of new tissue could not be exposed without
danger to  prolonged friction, nor even to considerable perspiration, and other
sources of fatigue connected with military life.
  The cutaneous adhesions which unite together parts which have been burnt
are at first soft, large and reddish;  the successive  changes of texture which
the cicatrices, whence they are produced, undergo, gradually renders thenv
more dense and solid.
           55 
434
LECTURES ON
   They are more or less stretched by the movements of the parts; and by this
 kind of dragging they become elongated to a certain point, beyond  which it is
 impossible to carry their extension  farther.   These adventitious  bands are
 then completely organized and analogous to the membranes of the palmipedes.
 It  is only when they have,  attained this  definitive state that  they can with
 propriety become the objects of surgical operations, with a view to their removal.
 There  is not a season that I have not practised a certain number of such
 operations  in  this  hospital,  and taken  occasion to  illustrate  the  above
 principles.
   3rd.  On  the means of correcting  deformities, and remedying the loss of
 function, resulting from vicious cicatrices, following burns.—The cicatriza
 tion of burns, with loss of substance, left to  itself, gives rise to a  prodigious
 number of deformities, more or less severe, and to loss  of function of corres-
 ponding extent, the consequence of inequalities, columns, bridles,  adhesions,
 depressions, &c.  But before speaking of the operations required for these, I
 shall briefly advert to the effect on the tissue  of the integument, produced by
 the slow and gentle but long continued action of heat;  or in other words, the
 effects of burns of the first degree in the chronic state.
  The first effect of this is  a sanguineous congestion of the skin, and this is
 followed after  a longer or  shorter time, by  a withering of the parts which
 become soft  and wrinkled.   At a more  advanced period wales  (vergetures)
 manifest themselves, which are permanent, and at first become  livid, yellow,
 copper colored or brown.  They are the consequence of an  unequal develop-
 ment of different points of the cutaneous capillary system.  If the parts be
 removed from the action of heat, they may be dissipated either spontaneously
 or by the use of baths and discutient or astringent lotions.  But if the exposure
 to heat be continued, they increase in number, extend in various directions,
 and form lines of a greater or less breadth, which cross each other, and leave
 spaces of various shapes and sizes between them, on which the skin is healthy
 and white; these lines become of a deep hue, and sometimes even black.  In
 this state they form mottled spots, which are  not only difficult to remove, but
 are sometimes not to be effaced when of long standing and dark colored.   In
 this variety of the first degree of  burn, in its  chronic  form, the  epidermis is
 scarcely altered in its composition or color.  If boiling water be poured on the
 part in  the dead body, the epidermis becomes separated, and the mottling is
 seen to  exist in the rete mucosum, in which texture therefore this degeneration
 has its seat.
  The treatment of these mottled spots consists in the  removal of the cause
 which has produced them, and in the long continued use of astringent lotions,
 particularly the acetate of lead.  In general, however these  means are insuffi-
 cient, and we must  then  try the  effect  of combining them with methodical
 pressure.
  It is not uncommon to see varices produced by this gradual but  continued
 application of heat.  When this happens, the same treatment only is required
 as when they arise from other causes.
  Let us now pass  on to burns with loss of substance, of the number and
 variety of which you may form some idea from the following resume of those
 which I have myself witnessed.
i  I  have in some cases seen all the integuments of the  base of the cranium. 
CLINICAL SURGERY.
435
and with them both ears and eyebrows forcibly dragged up by a cicatrix,
attracting them towards the crown of the  head;" in  others the  upper eyelid
and eyebrow  immovably fixed on the forehead, the eyelids  turned inside
out, and bound down in that situation by adventitious adhesions; the com-
missures of the eyelids forcibly dragged from their place by cicatrices on the
temple or nose;  the ala of the nose pulled upwards, and  the aperture of the
nostril obliterated ; the  commissures  of the  mouth pulled upwards or down-
wards, or to one  side; the upper lip united to the columna  nasi; the same
joined to the lower  eyelid ; the lower lip adherent to  the chin; the ears °rued
to the temples; the aperture of the ear closed; the head bent forward upon
the neck, and  the chin adherent to the upper part of the chest;  the head and
shoulder brought together; the  mammae horribly deformed; the adhesions
preventing their development; trunk bent forwards by bands extending from
the thorax to the abdomen ; the shoulder depressed towards the  hip, and thus
dragged up by a cicatrix occupying the side of the trunk; the elbow applied
to the trunk by a cicatrix in the  axilla; the  fore-arm bent on the arm ; the
hand  on the fore-arm, the fingers variously bent and united ;  the penis united
to the integuments  over the linea alba, and having  a kind  of adventitious
sheath, like that of  some quadrupeds ; the thigh kept in a state of flexion hy
a cicatrix in the  groin;  the inguinal  ring weakened so as to occasion hernia,
the cicatrix acting in such a manner as to prevent the necessary support by
bandaging;  the leg bent on the thigh ; the feet turned completely upwards or
downwards by burns  in childhood, on either surface  of the limbs; the great
toe pulled in upon the sole of the foot, so as to prevent the individual from
walking.  Such are the  most striking deformities  which I have seen, several
of which I have sometimes witnessed in the same person.  Most of them I
have seen several times ; but some are much more common than others, burns
of the hands for instance, owing to the mechanical instinct which leads us to
extend these parts when any danger is threatened; next in succession come
the lower extremities, and  then the upper.
   Numerous and varied as are the deformities which result from burns, they
are nevertheless resolvable into a small number of heads; all, in fact, consist
either in cicatrices  which are too short, too saliant or which produce praeter-
nalural adhesions or obliterations of apertures, or lastly, which cause the loss
of parts.  These last are irremediable, and  I have therefore nothing further
to say with respect to them.  As to  the  others, I have already pointed out
their  mechanism, and the means best adapted to prevent their formation; and
I have now to consider what is to be done when they are already present.
   The treatment most applicable to them  consists in  general in bringing back
the parts to the condition  which they previously possessed,  by means  of an
operation.   But  the success of this proceeding does  not  depend exclusively
on the manner of its performance, or on  the  exact observation of the esta-
blished rules of art; it  also depends on the  disposition of the cicatrix which
is the subject  of our interference. As a  general rule, the more superficial
the adhesion,  the easier  and more effectual is the  operation;  while on  the
contrary, it is more difficult and uncertain in  proportion to the depth of the
burn. In this last  case, indeed, the  mere displacement may be  obviated, but
the movement of parts seriously injured or destroyed, it is nearly or altogether
impossible to restore. 
436
LECTURES ON
   We have seen above at what epoch the cicatrix  may with propriety become
the subject of surgical interference;  for instance, 1st, we must not attempt to
correct the deformities of which we speak until some months, or even  some
years have elapsed after the  formation of the cicatrix.   This rule cannot be
deviated from, without the risk of seeing the loss of substance recur, in con-
sequence of the new textures  being  again destroyed ;  their  organization
remaining so incomplete  as to lead to this result from very slight causes, and
sometimes even spontaneously;   2dly, we must never operate unless we are
sure of obtaining, by means of position and bandaging, a cicatrix which is
larger and less deformed than the one we desire to correct.  This precept
applies particularly to the face, which, indeed, it is generally most prudent not
to touch; in truth, art here presents but  feeble  prospects of assistance, and
an attempt to  form a cicatrix by new cutaneous  tissues  often  leads  to  an
increased deformity, by the addition of a cicatrix to the one already existing;
3dly, we ought  not to perform an operation except where it is calculated to
restore to the parts their form and functions; and we are therefore to abstain
when joints are anchylosed, or muscles and tendons destroyed ; at all events,
we must under such circumstances, explain to  the patient  that  though the
deformity may perhaps be reduced, the use of the parts cannot be restored by
any operation.
  When the operation is deemed both necessary and practicable, the manner
of conducting it  varies according to circumstances.  Some surgeons of the
present day of great eminence, are of opinion that the tissue of cicatrix pos-
sesses in an extraordinary degree the power of contraction ; which  it always re-
tains, whatever be the time which has elapsed since its formation, and which the
resources  of art are unable to vanquish.   Hence they infer that any operation
which allows the cicatrix to remain is illusory, and will be followed by the same
retraction as before;  and  consequently, that in order to accomplish the end in
view the whole of the original cicatrix must be entirely removed, and the
edges of the wound brought together so as to be united by the first intention. The
principle on which this opinion rests is very much exaggerated. It is true, how-
ever, that the new tissue is endowed with a power of retraction, but it is neither
so great nor so durable as  has been imagined.  I have pointed out above the
changes  which  the  cicatrices  undergo from their commencement  to their
complete organization.   These changes require a long time, and it is during
this period that the contraction is observed to take place. But when  the cica-
trices have acquired  their full  degree  of solidity,  when the adhesions,  or
bands, are definitively formed,  their degree of contractile power scarcely
differs from that of the  natural textures; and it  is partly on this  account
that I delay the operation till the organization of the cicatrix is completed.
  The result of the doctrine which I am now combating would be,  that,  in
a very large majority of cases, nothing could be done.   In fact, if the cicatrix
be very extensive (just the  circumstances in which an  operation is most re-
quired) it would be impossible to approximate the edges of the wound as di-
rected ; or if this end were accomplished, we should have a second cicatrix,
with all the inconveniences of being too tight, thus  occasioning dragging and
constraint in the movements.  Should we, then, on the other hand, leave the
edges of the wound apart, that new cutaneous tissue may be formed ?   In most
cases we should subject the patient to the most serious evils; by thus exposing 
CLINICAL SURGERY.                        437
the subcutaneous cellular membrane, the muscles, tendons, aponeuroses, and
even bones, such inflammation might be produced as would destroy the patient;
neither, in many cases, would it be possible  to procure a more extensive
cicatrix  than nature had previously formed, to repair the first loss.  These
considerations have led me to adopt the following mode of proceeding in these
cases.   If the cicatrix be too small:
  1st.  I make incisions across it at various points, and carried deep enough
to divide it through the whole of the width and depth of the new structure ;
so that it may be readily extensible, but without any portion of it being re-
moved.
  2d. I stretch the parts in a direction opposite to that in which the disease had
carried them, and thus cause cicatrization with the production of new cutaneous
tissue. After the destruction of the contracted bands, the extension is effected
by the application of the hand; while the parts are subsequently retained in their
proper situation  by apparatus  and bandages.  If the limb is found to possess
its natural  suppleness,and yields without much effort and without much pain,
it may at once be placed in the position which it is intended to preserve; but
if the parts be stiff, and the joints but little movable, they are only to be car-
ried into their natural posture by slow and gradual extension.   By not at-
tending to  this,  very serious mischief  may result; particularly horrible pain
to the patient, violent inflammation, and even gangrene.  Apparatus so con-
trived  as (such as is used in club-foot), by being elastic, to keep up a gentle
but permanent action, affords great assistance in this branch of surgery.
  3d. The operation being completed, both surgeon and patient find them-
selves in the same circumstances as after the separation of the eschar in burns ;
that is to say, that the former ought to direct every effort towards the forma-
tion of a  cicatrix by the means already pointed out, and to oppose by every
means the approximation of  the edges  of the wound.   It is not uncommon
after the division of the principal bands, and when two or three incisions  have
sufficed for this, to  see secondary bands manifest themselves ; in which case
we  must not  hesitate to divide  them also, not leaving one.  It is in conse-
quence  of  this necessary precept that we frequently see practitioners unsuc-
cessful, even though the operations have, in the first instance, been apparently-
well conducted  ; and thus  have the patients failed to derive any advantage,
after all their  sufferings and courage.
  If the object be to remedy saliant cicatrices, it is to be effected  by removing
all the projecting parts; not, however, by transverse incisions, but by means
of a thin  double-edged bistoury, which is  to be introduced flat beneath the
middle of the cicatrix,  and then carried first to one end of it and then to the
other horizontally, so as completely to shave off the part.  This being done,
the edges of the wound are to be kept apart, and the surface frequently rubbed
with caustic,  so as to keep it always a little beneath the level of the integu-
ments.
  If there  be merely unnatural  adhesions, after having incised them,  they
are to be dissected out freely, and, in fact, beyond their origin, the parts are
then to be kept separated, and pressure systematically kept up at the point
whence the new  cicatrix proceeds, viz.: at the angle where the parts join.
  If we have to remedy the narrowing or obliteration of some natural aper-
ture, this is to be done in the former case, by the introduction of tents or of 
438
LECTURES ON
ivory tubes, variously contrived, but of a calibre much exceeding that of the
natural opening, and which are to be left in long after the cicatrization is com-
pleted, on account of the great tendency of such orifices to contract.  In the
latter case, the canal is first to be restored by a cutting instrument or trochar,
after which the means above mentioned are to be used.
  The cicatrices formed by these various operations possess (like the original
ones, produced by the burn) a strong tendency to contract, which continues
until  the organization be  definitively completed, just  as with respect to the
former.  Hence it becomes necessary that all the means of retaining the pro-
per position be continued long after the healing of the new wound.   It is also
proper to employ baths,  fomentations, emollient, oily embrocations, &c.;
at first constantly, and afterwards only during the night; gradually discon-
tinuing them  as the patient is  able to return to the proper exercise of the
parts.
  In burns of the second degree, the cicatrices are always without puckering
and without approximation of the edges towards the centre, and consequently
without the great deformities which follow the severer kinds of burn.  They
sometimes exhibit projecting inequalities, bands or adhesions, partial or com-
plete occlusions of natural openings; but as these are always superficial, the
operations are very simple and without the risk of implicating important or-
gans.  The first of these deformities is removed by shaYing off the eminences
with a sharp bistoury, and taking care by means of caustic and pressure, that
the blemish does not recur.  In the second, the parts are separated by cutting
the tissue which joins them with a  bistoury alone, or guided by a grooved
director; or if the adhesion be loose and membranous, it may be divided with
a pair  of scissors, the only care requisite being not to involve any thing in the
operation but the  adventitious texture.  The deformities resulting from the
third degree of burn do not require to be treated differently from those of the
second ;  but much more  care is required in the division  of the contiguous
parts,  because the  cicatrix  is much thinner,  and more risk is incurred of
wounding a  nerve, artery, vein, or other subjacent part.  A precept which ap-
plies  to  cicatrices of every degree,  is, that when the adhesion is very exten-
sive, (as  when the arm is tied to the trunk, or the two thighs together,) it ought
not to be separated at one operation, as a wound of such magnitude might
lead to formidable consequences ; we must here proceed by portions, waiting
for the healing of the first wound before we proceed.
  Such are the rules by which I am guided ;  and those who have attended my
clinique  during many years back have had abundant opportunities of witness-
in^ the results.  At present I shall content myself with detailing two recent
cases in  illustration.
  Case I.—Retraction of the fingers in consequence of a Bum; Adhesion to
the palm of  the hand ; Operation; Cure.—An infant, two and a half years old
in good  health,  fell upon the fire  with its  hand  resting  on the hot  coals.
Notwithstanding the immediate assistance of the parents, the burn implicated
the entire thickness of the dermis (4th  degree of burns).   The wound occu-
pied three fourths of the inner surface of the hand; suppuration soon came on
and it was dressed with a liniment of lime water and oil.  By the advice of
a practitioner, the fingers were maintained extended by a wooden splint.  At
the end of five weeks the wound had entirely  cicatrized ; the apparatus was 
CLINICAL SURGERY.                        439
 removed, and some days after the parents saw with surprise the cicatrix begin
 to contract, the little finger semi-flexed, and the ring-finger commencing to be
 so.  No attempt was made to arrest the deformity, which at the end of eighteen
 months presented the  following appearance.  The little finger  forcibly bent
 in such a manner that its dorsal surface turned  inwards; the  first phalanx
 partly adherent to the palm of the hand; the ring finger rather less flexed,
 the middle  still less, and the fore finger nearly free.  The skin of the palm
 of the hand was covered by an inextensible  band.
   The operation was thus performed :  The fore-arm being held firmly by as-
 sistants the whole thickness of the cicatrix was cut across with a straight bis-
 toury: after  which the preternatural adhesions of the fingers were destroyed.
 That the  extension might be easier and the success more certain, three other
 incisions were directed perpendicularly to the interdigital  spaces, and meet-
 ing the  great transverse  incision.  But little  blood was lost, and in an hour
 after the operation the dressing was  applied.  A wooden palette, terminated
 by four divisions in the form of fingers, was fixed by a bandage on  the dorsal
 face of the fore-arm and hand ; each finger was separately extended,  and main-
 tained in situ by  strips  of bandage, the thumb  alone  remaining  free.   The
 wound was covered with linen, spread with cerate.   Towards the end of the
 fourth month the child was presented at the public consultation, all the parts
 having recovered their  natural situation and movements.
  Case II. The handbound to the fore-arm ; Operalionby transverse incision;
 Description of apparatus for  effecting  gradual extension;  Complete cure.
 —A child, ten years of age, was  brought to the Hotel-Dieu in  October 1831;
 The father stated that, when two years old, the infant fell near a pan contain-
 ing boiling soup; the left arm  was  immersed in the fluid and much burnt.
 Six months after the wound  had cicatrized ; but the necessary precautions not
 having been taken, a band, which was formed by the cicatrix, retained the hand
 in a state of flexion, so that it formed nearly a right angle  with  the fore-arm.
 This adhesion continued undiminished.   M. Dupuytren, before operating, re-
 marked that many surgeons, both in France and  England, think that such a
 deformity cannot be remedied without removing the adventitious band through-
 oat its whole extent, and that transverse incisions are insufficient.   The lat-
 ter mode, however, was here adopted.   The arm was  extended, held by an
 assistant,  and the band  divided  transversly, at three different points, by
 means of a bistoury; it extended from the middle of the fore-arm to the palm
 of the. hand.   Had the proceeding ceased here, it would, indeed, have been
 imperfect; but after the incisions had been  made, a mode of dressing  was
 adopted, consisting of a sort of inflexible apparatus which accomodated itself to
 the rotundity of the limb, and long enough to reach to  the extremities of the
 fingers, supposing  them to be fully extended.  This apparel was kept in its
 place by numerous turns of bandage; a strap passing before the fingers, and
 attached  at the other extremity to the apparatus in such  manner  that by a
 very slight effort the fingers and  wrist could be extended  as gently as might
 be desired and there maintained by the strap.  The pain caused by this pro-
ceeding was  not very  intolerable.   The next and following days  the strap
was  tightened by one degree; then by two,  three, and  so on, until  the wrist
was fully extended, which was the case  at the end of two months and a half,
when the child was discharged  completely  cured, and using the  left hand 
440
LECTURES ON
almost as well as the right; I say almost, because the want of habit had rendered
it a little awkw ard.
  A month  ago  the same operation was  performed on a patient laboring un
der contraction (from a burn) of the thumb of the left hand, with equal success ;
and another patient, aged 15, is now in the Hospital, presenting a  deformity
of the same  kind.  A similar method was adopted three  weeks  ago, with
every prospect of the like success.
                        CHAPTER  LII.

    ON FRACTURES OF THE NECK OF THE THIGH BONE,  THEIR CAUSES AND
                              TREATMENT.

   Fractures of  the neck of the femur have attracted  so much attention of
late years that we are told in most ex professo treatises on such subjects, that
they are as well understood as those of other parts of the thigh-bone.  Those,
however, who have witnessed the practice of  the  Hotel-Dieu during the past
winter, must be aware that much additional light has lately been thrown upon
the subject.   If you examine, said M. Dupuytren,  the age of different
individuals who are at  this moment in our wards with  fractures of this part,
you will perceive that they are all past 50 years of age; and  among those to
be hereafter pointed out to you, you will remark that there are no children,
and in general very few adults.  But in both sexes you  will find this accident
more  common after 60 years of age.  Never in any instance were the  pre-
disposing and exciting  causes  more conspicuous than here.  I have never
seen fracture of the neck of the thigh in an infant, and very rarely in a young
person.  Sabatier, however, in  his  interesting memoir in the transactions of
the old Academy of Medicine, mentions  the  case of a youth of 15, who had
a fracture of this kind.  These lesions, on the  contrary,  become more frequen*
as life advances, and are most common between 70 and 80 years of age.  It
is impossible but that there must  be some cause for  this difference in the
period of fracture of the neck of the femur at different epochs of life.
   This cause is well ascertained, and resides in the anatomical disposition of
the parts, which is not the same at different  ages.  The neck of the femur
in fact has not at all periods of  life the same direction ; and  this disposition
of the parts  is important to  be known.  In  early life  the axis of the neck
approaches to that of the body  of the bone; the angle  which it forms being
the most open  possible. The great trochanter makes but a very small pro-
jection ; and we shall see, by and by, that falls upon this part are the most
frequent causes of fracture of the neck of the  femur; that the frequency of
the accident is in direct  proportion to the extent to which the trochanter pro-
jects ; and that such projection is in direct proportion to the length of the
neck of the bone, and the greater or smaller angle which it forms with it.
Now we know that the  trochanter lies  deep  in children, and that it hides
itself, so to speak, behind the prominence of the-os coxae; the result  of this
is, that in falls on the side, the blow does not come upon it, and consequently
the risk of  the fracture is  diminished.   Another  anatomical  disposition 
CLINICAL SURGERY.
441
 renders  fracture  of the%neck  still  more  difficult.  The shorter the bone
 is, the  less of a  right angle it makes with the  body,  and consequently,
 the more it approaches the direction of the axis of the femur, and the causes of
 fracture have therefore less influence on the neck.  There is also another reason
 why fractures of the neck are rare at an  early age, namely, the great flexibility
 of the bony tissue, in consequence of the abundance of organic matter in the
 bone.  In  adult age, fracture of the  neck of the femur is rare, but  less so
 than in infancy, the earthy matters are more abundant than at an earlier ao-e, but
 less so than they subsequently beconie.  The neck also presents  a different
 disposition; it is larger, and the angle which it forms with the body is much
 more marked than in the child.  There results from this more projection  of
 the great trochanter, and  consequently  more purchase for  the causes  tending
 to produce fracture to act upon.  This greater length of the neck of  the femur,
 however, and this  projection of the trochanter vary further according to sex
 and individual peculiarities.   Women have  the neck of the femur longer, and
 consequently, a more  projecting trochanter than men.  The nearer in the
 male sex the formation approaches to that proper to the female, the more risk
 is there of fracture.  If the relief of the muscles of the haunch in men presents
 an obstacle to the production of fracture, by diminishing the  effect of falls
 upon the great trochanter, the thickness of the layer of fat in women  fulfils
 the same indication; but when there is much emaciation present, women become
 more liable than men to the  accident.  Let us next inquire how it happens
 that old men are so much  exposed to this kind of fracture.  At this period of
 life the pelvis has acquired  all its  breadth; the  trochanter major is more
 projecting; the neck  of  the femur longer,  and inclined to a  right  angle.
 Besides, the skeleton of an old  man  weighs much  less  than that of a young
 adult, which depends  upon the bones having lost much of their organic sub-
 stance,  having a greater  quantity  of earthy matters, and thus being more
 friable.   In aged women,  while  the  anatomical disposition retains the pecu-
 liarities formerly mentioned,  the friability is even more marked than in m»n.
 Accordingly at the Salpetriere, which is an  asylum for old women, there are
 more  cases of this nature  than at the  Bicetre, which is a  receptacle  for  old
 men.   These considerations are of importance in reference to the  theory of
 fractures.  Thus in the child the cure may be effected in three weeks or a month,
 while in the adult it will require a much longer period ; and in those advanced
 in life, a hundred or a hundred and twenty days, and even more, are required.
  If we recapitulate briefly what we have said with respect to the predisposing
 causes of this fracture, we shall see that shortness of the neck of the femur,
 very considerable  openness of  the  angle which  it makes with  the  body,
 deficiency in the projection of the great trochanter, flexibility of the osseous tis-
 sue, abundance of adipose matter, render it almost impossible that fracture of the
 neck of the  femur should take place in children. In women the less considera-
 ble obliquity of the  neck, relatively to the axis of the body of the bone,  the length
 and prominence of the great trochanter, explain the greater frequency of this
 accident in them than in men. Sir Astley Cooper  has said that fracture of the
 neck of the femur  rarely took place before the age of fifty;  but there are many
exceptions to this rule.  There are also some other  particular circumstances
which predispose to fracture of the neck of the  femur, such as rachitis and
cancerous diathesis ; but as these are common to all parts of the osseous sys-
tem, it is unnecessary to dwell upon them here.
            56 
442
LECTURES  ON
  What then are the existing causes of this fracture ?  Almost all the patients
whom we interrogate reply, that they have fallen on the great trochanter, and
in such  manner that they have been unable to protect themselves with the arm,
as is  usually  done instinctively.    The  frequency of this cause has been
recognised by all authors.  Thus of 36 cases observed by Desault, 24 were
produced  by falls of this kind.   In infants and young persons who have fallen
on this part, and who have been preserved from fracture, we meet with decol-
lation of  the epiphysis.  Falls upon the trochanter are, however, far from
being the  sole  cause of fracture of the neck of the femur; I  shall point out
others which play an important part;  but I must first make a remark which
has excited little attention ;  namely, that at the time the patients fracture the
bone, they bruise the external parts.   I this morning examined a woman who
stuttered and answered  badly the questions put to her; but on touching the
great trochanter  it gave her much pain, although the limb was not moved; and
this led  me to examine  the  part,  when I found a large ecchymosis upon it.
This fact is of some importance in  directing us to the part which the patient
has struck, when he is himself unable  to give an account of his fall.
  I have said that other causes might produce fracture of  the neck.  This is,
in fact,  what happens in a fall on the soles of the feet, or  still more upon the
knees;  but  in both cases it  is necessary that the muscles be  stretched and
inflexible.  Sir Astley Cooper observed that in London, fracture of  the neck
of the femur often arises from a false step off the edge of the pavement. Under
such circumstances the head of the femur impinges strongly against the coty-
loid cavity; from this there  results  an effort tending  to diminish the  angle
which the neck makes with  the body of the femur; I have also  frequently
observed a depression of the cotyloid cavity  produced by the head of the femur
in consequence of a fall  on the feet or knees.
  It is not from this cause, however, but from a fall on the haunch,  that this
accident generally happens.  In  this case  the neck is placed between two
opposite forces ;  the head of the  bone being pressed on  the one side by the
weight  of the  body, while the  great  trochanter is opposed by that against
which it strikes,  and the point  which most usually gives way is that  immedi-
ately under the head of the bone, at the upper and internal part of its neck.
  It has also been thought that this fracture may arise simply from a muscu-
lar exertion, and a case is quoted in which this is said to have taken  place in
a ne°ro  affected with tetanus.   This fracture may likewise arise from  causes
directly applied.  These are  usually projectiles,and particularly cannon balls,
several  instances of which I  saw after the days of July.
  The diagnosis of fracture of the neck of the thigh bone is  not free from
difficulty.  It  sometimes happens that a  fall on the haunch, accompanied by
bruising of the muscles and  joints, imitate  this fracture,  while on the other
hand, the  same cause may produce an actual  solution of  continuity and yet
the  patient be able to run and walk.   It is thus that persons have been known,
after they had  fractured the  neck of the femur, to be able to reach home with-
out presenting any shortening;  it  is thus that displacement of the fragments
does not take place till after  some hours, or even many days, either in  conse-
quence  of some movement on the part of the  patient, or  of the examination
made with a view of ascertaining the nature of the malady.
  What  is  the  cause  of  the peculiarity  mentioned by authors,  which  I
have  myself frequently  seen,  and of which  Sabatier, in  a  memoir  to the 
CLINICAL SURGERY.
443
  Academy of Surgery, has given numerous examples ? It is because the frac-
  ture takes place within the capsule, and the fragments remain in exact appo-
  sition.  But it will be asked how does it happen that after some time they
  leave each other, and  the fracture becomes evident ? It is because the relations
  of the fragments are changed, either by the weight of the body or muscular
  action, or by the wearing away of some part of the fragments.  The shorten-
  ing and twisting of the limb leave then no doubt as to the fracture.  The two
  preceding signs appear sometimes  only after 50, 60, or 80 days of treatment
  by rest and  extension, and are caused by the yielding of the callus to the
  contraction of the muscles or  the weight of the body.   Before we proceed let
  us say a few words with regard to the cause of this consecutive displacement.
   It is  known, that at the first period of its formation, the callus of long
  bones often  yields, and produces deformities, when a perfect cure has been
  expected.   Who has not  seen oblique  fractures of the femur give way under
  the weight imposed upon it when  a patient began to walk again, at a time
  when  all risk seemed to be  at an end  ?  The same thing happens in fracture
  of the neck of the femur.  At the  end of two  or three months, the provi-
  sional callus yields beneath the weight, when the patient  rests upon  it, and
  shortening is the result.   I have seen this at the end of two, three, or four
  months.  It  is therefore  necessary that  patients should be controlled by the
  proper apparatus, during  100,  120, or  140 days, or even more.
   The weight of the limb, and still more that of the body on the broken part,
 is to be regarded as  the great cause  of displacement whether primitive or
 consecutive.   But another active power in producing displacement consists
 in the prolonged action of the cause which  has given rise to the fracture.  It
 sometimes happens that it buries the upper fragment in the thickness of  the
 spongy tissue of the superior extremity of the lower fragment, and consolida-
 tion takes place in this  situation  rather  quickly.   Numerous anatomical
 preparations in the museum of the Hotel-Dieu  exhibit this phenomenon, and
 sufficiently demonstrate the reality of its existence.   Lastly, there exists
 another cause of displacement in fractures of the neck of the femur,  namely
 muscular action.
  The primitive symptoms take place when in a fall  upon the heel or knee;
 the shortening and displacement take place at  the moment.  In this case it
 is clear that, the upper fragment remaining  in its plaoe, the lower one is
 pushed up by the weight of the  body.  But a vertical fall is the least common
 cause of a fracture of the  neck of the  femur, and when, as is most common,
 the blow is received on the trochanter,  the cause tends not to shorten but to
 lengthen the limb.  There exists then, another cause of this shortening, which
 until now has been  but little  understood.  It depends upon the  adductor
 muscles, which, being designed to carry the limb outwards when it is rotated,
 are inserted on one side in the  ischium, and on  the other terminate  behind
 and along the linea aspera  of the femur.  It is on them that the displacement,
 and in part at  least the shortening depends.   These two symptoms appear
 when the. patient endeavors to  rise, or else they depend on a slow tonic con-
 traction of the muscles  which no longer meet with any resistance in the lower
fragment.  It is thus that the shortening takes place, when after the formation
of th.3  callus, the patient  executes movements, or attempts prematurely to 
444
LECTURES  ON
walk.  Muscular action and the weight of the  body are therefore the tin,'
causes of this occurrence.
  When there is displacement, the fracture is always easily known ; but when
this does not take place, it may be suspected without being positively ascer-
tained.  Suppose the symptoms to be well marked, that there is  shortening,
outward deviation of the limb, inability to raise it, we must further ascertain
whether the limb preserves the shortening or loses it on extension, if the great
trochanter  rotates on the axis of the femur or the extremity of the lever.
  If the shortening is only some lines; it is difficult to distinguish it from that
which is produced by an upward movement of the pelvis, caused by the contu-
sion ; the diagnosis becomes more evident if it extends to half an inch or more.
However when the displacement is recent, it may depend on luxation of the
head of the femur, or upon an ascent of the pelvis.
  In luxation forwards, the head of the femur passes on the horizontal branch
of the os pubis, then there  is shortening ; but the cause is detected  by the hard
tumor which may be felt to  roll when, the femur  is  moved.   In luxation
into  the sub-pubic region  the member is also turned outwards but it  is  elon-
gated, and  there is in this situation an enlargement and unusual tension of the
muscles ; the hip is hollow, while in the case of fracture it projects.
  In luxation upwards and outwards, the head of the femur is in the external
iliac fossa; the limb is shortened, but the point of the foot and the patella are
turned inwards, the heel being  thrown out.
  It is true, that sometimes in the case of fracture the limb turns inwards.
Ambrose Pare, who first gave an account of this accident, states that he found,
in the case of a lady, the leg shorter and the great trochanter mounted on the
ossailia; he thought it was a luxation, attempted its reduction, and  applied
a bandage.   But after some days, violent pain came on, the limb was  again
shortened,  and he found the foot turned inwards.  J. L. Petit relates a similar
case in his  Treatise on the Diseases of Bones.  Bichat makes Desault  say that
this  variety is common.   In the course of a long practice, having seen  it but
once or twice, I am  inclined to think that.Bichat was  mistaken.   But since
this  inward deviation has been observed, how is this fracture to be distinguished
from luxation upwards and outwards?  In luxation, the round  head of the
bone can be felt in the external iliac fossa.  In fracture the thigh can be easily
rotated ; not so in luxation.  In luxation the limb  cannot be extended with-
out great exertion, and when once reduced the displacement disappears.  In
fracture, its ordinary length may be soon obtained,  but the shortening recurs
on a suspension of the extension.  These two diseases cannot then be mistaken
for each other.
   There is, finally, a luxation downwards and backwards, which  I have only
observed two or three times ; the limb is then turned inwards, and sometime:*
a little elongated, and it cannot be brought into its ordinary state except by the
effort of reduction, and once reduced the displacement does not  again recur.
Thus, the  distinctive character is as follows : shortening produced by a frac-
ture yields to  the  smallest  effort at elongation;  shortening produced by a
luxation is more difficult to remove, but once  reduced  the deformity dis-
appears.
   After having detailed  the symptoms, it is my duty to speak of the  conse- 
CLINICAL SURGERY.                        445
quences of fractures left to themselves, in prder that you may understand the
mechanism of the treatment.  I have always seen persons affected with fracture
jf the neck of the femur which has not been treated labor under a shortening
of one, two, three or four inches, and the turning of the foot outwards rendered
progression very difficult;  the great trochanter was elevated, approached the
crest of the bone, and was carried backwards.   But it is above all worthy of
remark, that in these  cases a false articulation is formed in the external iliac
fossa.
  Let us now inquire what are the material effects of these fractures upon
the bones,  beginning with the cotyloid cavity.   I have  found this cavity
driven in several times by the head of the femur; this accident was produced
by a fall on  the knees.   In this  case  the head of the femur impinges with
violence against the bottom of the cavity, and being the more resistant, breaks
it.  The  most  remarkable case which  I have observed was this ; the bottom
of the cotyloid cavity had been driven in, and the head of the femur, which
remained entire, had passed completely into the pelvis; the neck, which had
not experienced any injury, was so firmly retained in this accidental opening,
that it was very difficult in the preparation to disengage it, and thus reduce
this new kind of dislocation.  In early  youth, the violence might separate the
pieces of which the os innominatum is composed, and whose point of union cor-
responds to the centre of the acetabulum.
  In other  cases the cotyloid cavity is broken without the head of the bone
being displaced; but the most common effect of the fracture is to be seen at
the upper extremity of the femur in the radiated comminution of the head of
the bone, the neck remaining entire.  The most common cause producing this
accident is a gun-shot  wound acting  directly on the  part;  though it also
arises from falls on the great trochanter, and even on the soles of the feet.
  The neck, however, is much more frequently the seat of fracture because
it forms a  curved lever.  Its diminished size towards its middle part also
contributes to the production of the  fracture.  This may take place from be-
low upwards, or from above downwards, depending upon the manner in which
the fall occurs; but usually it is at the base of the neck that the  fracture takes
place: there are, however, infinite varieties in this respect.  I request you to
observe, that according to the seat of  these fractures they are called intra-
capsular or extra  capsular: and it is a distinction which has been much dwelt
on, because many practitioners  think that  it is difficult  or impossible that
consolidation of the fracture can be effected when it has  taken place within
the capsule ; while they admit that it is possible  and even easy  when it has
taken place without the capsule.
  Astley Cooper, whose authority is so imposing in surgery, says expressly, that
in all cases of transverse  fracture of the neck of the femur within the capsular
ligament  which he has had occasion to examine,  he  has never found  bony
callus:  "The dissections that I have been  enabled to  make, adds this  dis-
tinguished  surgeon, have  convinced me that the fragments  of the  neck
of the femur, when the fracture is intra-capsular,  never  unite by bony  cal-
lus- the union takes place by a ligamentous  substance, as in fracture of the
patella."
  Persuaded of its impossibility, he has also made  experiments on living ani-
mals which have confirmed his opinion : and the English  surgeons have also
adopted the opinion of their countrymen. 
446                            LECTURES ON
    But to the  facts which they adduce in support of. this non-consolidation,
 numerous  facts of an opposite nature may be  advanced.  A considerable
 number of anatomical preparations show intra-capsular fractures exceedingly
 well united ; and those which exi§t in the cabinets of the faculty at Paris, and
 the museum of the Hotel-Dieu, prove that this  consolidation with or without
 deformity is real.  Sir Astley Cooper has probably only seen fractures of the
 neck of the femur which  have not been cured, which have  been treated ill,
 or not treated at all.  This  is the only way of explaining the opinion of the
 English surgeon, which is  evidently erroneous.
   An examination, however, of these  anatomical preparations, though emi-
 nently calculated to convince us of the reality of this union of fracture within
 the  capsule, does not appear to have  produced  this effect  on  the other
 English surgeons who have visited our museum.  Mr. Cross says he has atten-
 tively examined the preparations in the School of Medicine at Paris,  and that
 none of them appear to him to prove that bony  union ever takes place where
 the head has been completely separated from the capsular ligament.  When
 one has seen the preparations  at the Hotel-Dieu, which  every person may
 examine at leisure, if he then denies the possibility of consolidation within
 the capsule, I  know not  what proofs are  required to  produce conviction.
 For myself, 1 regard this consolidation as demonstrated, notwithstanding the
 contrary opinion of the English surgeons.
   Theoretical and  practical  reasons having been brought forward  in  favor
 of and against  the  possibility of'consolidation of  the intra-capsular fracture
 of the neck of the femur, it will be proper to consider this point.
   It has been said  that the upper fragment  contains few or no vessels, and
 that it then becomes a foreign body in the articulation.   This assertion  is in-
 correct; the head of the bone receives vessels from the bottom of the  acetabu-
 lum by means of the round ligament. These, without being very numerous or
 large, may nevertheless be sufficient for the nutrition of the upper fragment: be-
 sides the synovial membrane embraces the cartilage, and forms at its base a small
 cul-de-sac which covers distinct lumps of red cellular membrane, well sup-
 plied  by blood-vessels.   The inferior fragment is well  supplied by  the nu-
tritious artery  of the bone, and the different vessels spread throughout its
 spongy texture.
   It is therefore evident, that the lower fragment receives more blood-vessels
 than the upper, whose vitality is  less active, more  languishing, and that, in
 order to effect  the consolidation, the inferior fragment, enjoying the free ex-
ercise of its vital functions, plays the most  important part: but it is not les-
true that there is in the upper  fragment  sufficient nutrition not only for its
life, but also for its share in the process of union.
 The want of periosteum around this portion of the  bone has also been assigned
as  another cause.  This is  a very great error: the neck of the femur possesses
 a periosteum, undoubtedly thin, but yet very evident, and which, though not
enjoying a vitality equal to  that of other bones, nevertheless has its full share.
 This  thinness and isolation of the periosteum of the bone is therefore only
 a difficulty, but not an insurmountable obstacle to consolidation.
   Others have said that the synovia constantly bathing the fragments rendered
consolidation impossible.   This might be a good reason if the same anatomi-
cal disposition in other parts were found to influence the  formation of  callus
Now, it is well  known that fractures penetrating the joints unite perfectly 
CLINICAL SURGERY.
447
and that the same thing takes place in the olecranon and patella, where the
synovia constantly bathes the parts.  It is not therefore the  presence  of the
synovia which opposes the  bony union  of the intra-scapular fracture.  The
true causes preventing or rendering difficult the exact solid union, and  espe-
cially one free from deformity, are the displacement of the fragments,  their
want  of relation and contact, whether the fracture be intra or extra-capsular.
   On the indications of Cure in Fractures of the Neck of the Femur.—The cele-
brated Louis has said in the most eloquent manner, " Diagnosis holds the first
rank in our science, and is the most useful and difficult part of it; without an ex-
act and precise diagnosis theory is always faulty, and practice often incorrect.'"
This  remark, made  by Louis  in his memoir on fungus of the dura mater, is
equally applicable to the present subject.  All treatment which is not  based
on correct indications of cure, is purely empirical, and only becomes rational
when it is founded on these indications.
   At first sight one  might suppose that  it was the same in fractures of the
neck of  the thigh bone  as in other solutions of continuity, that it was suffi-
cient to replace the fragments, and maintain them in contact.  But how many
difficulties present themselves !  How are fractures of this kind to be reduced?
 Are we to use powerful extension and  counter extension ?  Certainly not;
 because we should  thus increase the tension of the muscles, which is already
 very  great.  In luxations this may be effected by diverting the attention of
 the patient and seizing that moment to  perform the reduction.  But in frac-
 tures this cannot be done,  because the attention of the patient is concentrated
 on the injury.   Another method of overcoming muscular action is to place the
 limb in a state of flexion, as recommended by Pott in fractures generally.  I
 believe I am the first who applied these rules to fracture of the neck of the
 femur ;  and am surprised  that it should have escaped the  sagacious mind of
 that  celebrated surgeon.
    I suppose that in a case of this kind extension and counter extension have
 been used. It is evident that if the limb be placed in a state of flexion, no diffi-
 culty is experienced in overcoming the displacement as to circumference and
 leno-th, and consequently  the outward  turning of the foot, and the shortening.
 But how are the fragments to be kept in contact ?  Generally after the reduc-
 tion of  the fractures, splints and bandages are used, which tend to prevent a
 consecutive displacement.
    This'apparatus is applicable perfectly to fractures of the arm, leg, and even
  of the thigh; but is it equally sj to fractures of  the neck of the femur ?  To
  understand this, an examination of the parts is sufficient.  The  neck of the
  femur, situated in  the centre of very thick soft parts, is inevitably beyond the
  action'of all kinds of  bandages and apparatus; and we may well be surprised
  that surgeons are daily taxing their ingenuity with some new invention.  De-
  saultsaw that all of the machines used  were almost or entirely useless; he says,
  that we must first  act upon the pelvis  by counter extension in order to  raise
  the  upper  fra-ment, and then on the foot, to  bring  the lower fragment from
  above downwards; such is the origin of the apparatus for continual extension,
  which has since undergone many changes, but in principle has always been the
same.
  We are here brought back to the consideration of a question  already  dis-
cussed that of the length of time necessary to establish the solidity of the 
448
LECTURES  ON
 callus, sufficient to resist the weight of the body and muscular action.   It can
 not be uniformly answered, for many distinctions exist; if the  fracture of the
 thigh bone be transverse, the fragments must be brought together and kept in
 contact: after 40 days reunion has taken place.  The same is  true as regards
the tibia and the bones of the fore-arm ; but if the fracture be oblique in these
 different places, 40, 50, 60 days will not suffice for the production of callus.
   Whjr ? Because in fractures of this  nature there is no  solid support.   If
therefore you do not keep the fragments in contact, long after forty days di«
placement will take place.   This may be easily conceived ; the bones touch
each other by inclined planes ; the weight of the body and muscular action
tend to this displacement, because at the end  of 40  days only a provisorv
callus will have been formed.   If you then remove the apparatus,  shortening
will again occur,  and it must be reapplied.   Thus therefore 40 days are suffi
cient  for ordinary fractures, and 70 and 80 for oblique fractures.
   What has been  said with respect to  these fractures applies also to trans
verse  fractures of the patella and olecranon.  At the end of 40 days the limb
is found in a good condition, but should the patient walk, the fragments sepa
rate, because the  callus is not yet sufficiently strong.
   I suppose that  the fracture of the neck of the femur is transvere, and that
this part is divided into two halves; it  may then be  easily reduced ;  but the
difficulty is to retain it so, because the fragments are not placed fronting each
other.   Suppose, now, that the fracture is oblique ; if the patient attempts to
walk the lower fragment impinges slightly upon the upper one; this fragment
then will offer some obstacle to its displacement; so that this is less easy than
in a perpendicular  fracture.   Can' the nature of the fracture be ascertained
from mere  inspection ? No.   So that we must act as if the fracture had the
strongest tendency  to  consecutive displacement.   Fractures theref re of the
neck of the femur should be kept as long as possible in the apparatus
   What is the length of time necessary ?  This evidently depends  on age
and constitution.  As  a general rule, they require double the length of time
requisite for fractures of the bodies of the long bones; even aftt/ this time
I  have  seen displacement occur.  The  period  should therefore be extended
beyond 100 days, which is  about the time the callus is perfectly formed ; and
in advanced age  we may even extend it farther.   With this intention I some-
times leave  the  limb 120 days and even more in the apparatus.  The
general indication  is,  then, to reduce the fragments and  maintain them in
contact.  Pott fulfils this purpose by preventing the muscles from contracting.
We must therefore not only reduce them, but keep them in contact.   This is
difficult in  proportion as the fracture is perpendicular.  When it is oblique
there  is less tendency to displacement; but as we cannot know its nature, we
should employ double the time usual for oblique fractures of the bodies of the
long bones; even more, we should add 20, 30, or 40 days, in order to obviate
any consecutive  displacement.  When individuals  have  been thus treated,
 they have scarcely ever any shortening, consecutive displacement rarely takes
 place, and when  it  does it is very slight.
   Two methods to which I now call your attention  are used  by surgeons to
effect reduction  of fracture of the neck of the  femur.  One generally em-
 ployed is extension, the other, due to me, is demi-flexion.  I have said above,
 that the most important indication is to reduce and keep the fragments in cob- 
CLINICAL SURGERY.                       449
tact;  but two circumstances may occur, on which  it is proper to dwell for a
few moments ;  sometimes  and generally there is  great displacement, some-
times  little or none.  In the latter case the fracture is intra-capsular, and the
fragments are but  little separated or caught (engrenes) in each other: exten-
sion is then useless, but we should not be  misled by  this pretended fixedness
of the parts ; but  apply the proper apparatus.  Generally, however, there  is
displacement, perhaps only of a few lines, half an inch, an inch, or more; there
can then be  no doubt; and such are the cases in which the plan of which I
have spoken becomes necessary.
  In extension  the patient is placed on  his back, the pelvis firmly fixed, one
or several assistants take hold of the lower extremity, and extend the limb,
and at the same time rotate it inwardly  ; but during these attempts the mus-
cles may contract, and resist the efforts of one, two, or several assistants: this
plan is therefore defective.  Traction moreover tends to  produce displace-
ment, and on its cessation the shortening immediately returns.
  The best method of effecting the  reduction of fractures in general and  of
that of the neck of the femur in particular, is  to diminish the resistance of the
muscles  by placing them  in a state of demi-flexion; which is  done in the
following manner.
  The patient  being in the same position, the pelvis fixed by assistants, the
thigh is flexed on the abdomen by raising it, and exerting gentle extension, the
leg is  also flexed on the thigh.   This is scarcely done when without difficulty
the lower extremity regains its usual length, and the  foot its natural  position.
If the demi-flexed position is best for reducing the fragments and maintaining
them  reduced,  it follows  that the best  apparatus for fractures  is that which
keeps the muscles in the demi-flexed  position.  This is the principle laid down
by Pott, but which he has singularly  overlooked in the treatment of fractures
of the neck of  the femur.
  Thus two  methods are  used, continual extension  or continual relaxation.
I use  these words  designedly..  It is impossible  to  find two methods more
diametrically opposite; the former is the basis of  the treatment of  Desault,
the latter that of the treatment I have generally pursued.
  In the former method, one power is applied to the pelvis, another to the foot,
acting in opposite directions, in order to prevent any  overlapping of the parts.
With this intention has the immense variety of apparatus been invented, which
have  since become little  more  than  objects of curiosity;  such as the bed  of
Hippocrates; the glossoconeum,  described by Ambrose Pare; the gutter  of
Fabricius Hildanus; the plan  of  Guy de Chauliac ; the  machine of Bellocq,
Gooch, Aitken, Bruninghawsen, Vermandois, Heister, Petit, &c. and a host  of
others.
  Desault  thought that muscular action  could be overcome by mechanical
power.   He first  instituted this plan of  treatment at La Charite, then at the
Hotel-Dieu, and it was adopted  by  his  numerous pupils.  However, it was
soon seen that it did not invariably succeed.  I have before said that extension
was wrong, and it may also be the cause of serious injury to the patient, from
the action necessarily exerted  on  the integuments of the pelvis and the leg.
  What  is the  consequence ?  Acute, insupportable pain sometimes followed
by inflammation, suppuration,  and gangrene, to which the  patient often falls
a victim.
           57 
450
LECTURES  ON
   Can these accidents be prevented ?  I have endeavored by all possible means
 to neutralize the effects of the compression, by padding the apparatus with
 cotton, and have  not  succeeded;  I  have therefore abandoned  it, as  an
 unnatural method.  I may add that, however exactly it  may be applied, it
 frequently leaves a shortened limb.
   On reading  the  works of Pott, I was  surprised to find  that he had  not
 applied his  method of relaxation to fracture of  the neck  of the femur and
 thought he had forgotten it, determining myself to use it in this kind of frac-
 ture.  The first apparatus I used consisted of two inclined planes  of wood,
 covered by a cushion, and united by a hinge so as to vary the inclination to
 suit the case ; but the pain caused by the hollow of the ham resting on its apex
 was too acute; and in one case the long and constant compression occasioned
 gangrene  of the upper part of the calf of the leg.
   I placed the  patient on the injured side ; but the weight of the body acting
 on the great trochanter, caused inflammation and gangrene; and as it thrust
 the lower fragment inwardly, the effect of position was destroyed.  The other
 side was equally objectionable.   At last I returned to the position on  the back,
 notwithstanding the inconveniences  resulting from the  constant pressure of
 the soft parts covering the sacrum and coccyx ;  but these  are common to all
 plans and far from being peculiar to this.   The tonic action of the  muscles
 was to be opposed, and  at the same  time the contraction  prevented; the
 double inclined plane I now use combines  these advantages; in it the thigh
 is flexed  upon  the  pelvis and the leg on  the  thigh, nearly at  aright angle.
 This position is certainly that in which the muscles are most relaxed ; and it
 is remarkable that the outward deviation ceases, as soon  as the limb is placed
 in it.  Our  apparatus is therefore formed in the following  manner;  a pillow
 doubled on itself, rounded like a bolster, is placed atthe apex of two inclined
 planes composed of pillows placed above each  other; and upon whose summit
 reposes the hollow of the ham.   The leg is fixed by a cravat of which the ends
 are fastened to the bed frame, and another across the middle of the thigh.
 During the first month the thigh is  to be raised daily  or nearly so, by gently
 drawing down the lower fragment, so that it may preserve a perfect relation
 to the upper.   When consolidation  is supposed to be effected, the  inclined
 plane is gradually diminished by taking away a pillow now and then, until it
 is entirely removed.  The  patient should  remain in bed some days,  and then
 only should  be permitted to walk with exevy precaution.   This plan of treat-
 ment generally leads to  easy cures, free from inconvenience during its appli-
 cation, and generally the consolidation is without shortening, or with a short-
 ening so slight as  to be easily concealed by wearing a high  heeled shoe.  Let
 us now detail some cases in support of the  principles advanced.
   Case I.—Fracture of the Neck of the Femur ;  Cure, without shortening
 or deviation.—M....., 58 years of age,  of small stature, but of good con-
 stitution, being  thrown down, fell on the left trochanter.   She endeavored in
 vain to rise, and was immediately carried to the Hotel-Dieu.
   On admission,  she complained of acute pain in the right  groin and thigh.
Being placed on  the bed, the left lower  extremity rested on its outer side;
the knee  carried  forcibly outwards, was an inch above that on the  opposite
 side ; the  toes were turned outwards, and the heel corresponded to the space
 between the internal malleolus and tendon Achillis of the  opposite side. 
CLINICAL SURGE RY.
451
    The pain in the groin was increased by the rotation given to the limb in or-
 der to determine the extent of the arc described by the great trochanter, an
 extent which  was sensibly diminished; there was also  considerable swelling
 at the upper part of the thigh, and inability to raise the left foot.  As there
 were  present sufficient symptoms of the nature of the fracture, we had not
 recourse to any other means of determining crepitation; this sign, besides
 being useless in  this  case, is  always very difficult in this  kind of fractures,
 where the  bone is  so thickly  covered by the soft parts, and attempts to dis-
 tinguish it often produce new injuries, either to the surrounding parts or to the
 capsule of  the joint.
   The patient was  put in  a bath, and then placed on the  double inclined
 plane of pillows.  A  handkerchief folded like a cravat, and intended to fix
 both the pillows and the limb,  was placed across the middle of the thigh, and
 its ends  fastened obliquely to the frame of the bed ; another around the in-
 step, and fastened in the same  manner as  the preceding to the foot of the bed.
 (Orangeade and light soups were directed).
   On  the 11th  of July the  patient complained of slight pain in the knee,
 which was to be attributed to the situation to which it was not yet accustomed.
 There was  no pain  in  the groin ;  the limb has lost its tendency to turn out-
 wards, and  by approximating  the knees the patellae were  found to be even.
 On the following days, being habituated to the constraint caused by the fixed
 position  of  the limb, the woman complained of no pain ; the apparatus was
 examined daily, and the limb kept in its proper situation.   On the 9th of Oc-
 tober (89th day of treatment),  the bandages over the leg and  instep were re-
 moved and the limb set at liberty.  The patient could slightly raise the foot.
 By placing the legs alongside of each  other, it was easily seen that the patellae
 were on  the same level.
   On  the 12th of  October, the plane of pillows was gradually lowered ; and
 on the 25th the woman could raise the limb with great ease. She was per-
 mitted  to set in an arm chair without leaning at all on  the fractured leg.
 On the 25th M. walked on crutches.  There was no shortening nor twisting, and
 in a few days it will  be impossible to distinguish which is the injured member.
   This case is an incontestable argument against the  opinion of those who
 have thought  and written that union of fractures of the neck of the femur
 never took place without shortening; and the apparatus employed is decided-
 ly the most simple and efficacious now in use.  Its great advantage is in being
 free from pain or constraint;  and patients wait patiently  100, 120 days, or
 even more, without complaining; a period of time apparently long, but never-
 theless indispensable, as the accident mostly occurs in persons advanced in
 age, in whom the powers of restoration are less energetic than in youth.
   Case II,-—Fracture  of the Neck of the  Femur; Fall on the Great Tro-
 chanter ;  Evident Symptoms; Treatment by the Double  Inclined Plane;
 Perfect Union;  Cure on the 85th day.—Bequend (P. T.), 67 years of age,
 of a strong  constitution, and generally enjoying good  health, was admitted
 into the Hotel-Dieu on the 9th of January 1831, for a fracture of the neck of
the right femur.   It had  been  caused by a fall on the great trochanter.  At
the moment of the accident, there was acute pain in the joint, inability to
elevate the limb or to rise from  the ground. 
452
LECTURES  ON
   She was brought on the next morning to the hospital, the limb carefully ex-
amined and found in the following state :
   It was shortened by  at least two inches, rotated outwardly, demi-flexed,
the heel placed above the malleolus of the opposite side, the great trochanter
less projecting and drawn near the crest of the ilium.   On applying one hand
to the trochanter and rotating the limb, it was seen not to describe an arc of
a  circle, but to  turn as if on a pivot.  This sign, to which Desault attached
so  much  importance, I do not think deserving of the value attributed to it,
for it is difficult, on the  one hand, to impart this circular motion to the thigh;
and on the other, it varies as regards the seat of fracture ;  it is  not very evi-
dent  if it be near the  great trochanter; and extremely so, on the contrary,
if the lesion exist near the head of the bone.
   The natural length  and position could be easily given to the limb ; but on
ceasing the extension, the shortening returned : this  circumstance alone was
sufficient to distinguish  the  accident from a contusion, luxation or disease of
the hip joint.  The patient complained moreover of lively pain in the articu-
lation : she was unable to elevate the whole leg, that is to say, to flex the thigh
on the pelvis, the leg being extended on the thigh.  A severe contusion existed
in the region of the great trochanter.
   The fracture being thus ascertained, was reduced by extension and counter
extension, and  the limb placed upon the double inclined plane already describ-
ed : it  recovered  its natural direction from position alone, and was no longer
rotated outwardly. The handkerchiefs were applied as in the previous case.
   This apparatus possesses many advantages, among which the following are
the most striking; it maybe  constructed and renewed with the greatest ease,
it  places the parts in their normal position, causes neither contusions nor
eschars; it restores to the limb  its natural shape, and preserves it by a con-
stant, gentle, and gradual extension.  After 75 days, the apparatus was gradu-
ally removed.  It was  soon  perceived that the union was perfect, and by
comparing the limbs, that they were of  the  same length..  No  unpleasant
symptom occurred during the whole period of treatment.  On the 4th of the
following  April, 85 days after  her admission, she left the  Hospital entirely
cured.  Let us  now  compare these results with  those of fractures left to
themselves.  There is either no cure at all, or a  cure  with deformities ren-
dering the limb incapable of performing its functions; such are the inevitable
consequences  of abandoning nature to her own  resources.  Indeed a bone
once dislocated,  is never spontaneously reduced.   Some examples of sponta-
neous reduction  of the lower jaw, the head of the  humerus, the  base of  the
phalanges, &c. only confirm this principle ; they establish rather an inferiority
than  a  capability, for they  result from  a weakening  of the ligaments and
muscles, which allows luxation to be effected with the same ease with  which
it  is  reduced.  Muscles atttached to a bone  in its  proper situation have a
different action when that bone is luxated; and this action, far from  restoring
it  to its natural position, generally tends to remove it still  farther.  Nature,
which under  other circumstances triumphs over difficulties and  obstacles
opposed to her  laws, in these  cases displays but feeble efforts to restore her
functions.  They always remain  impossible or very limited.  In vain new
cavities are formed in order to replace the former ones; always imperfect, they 
CLINICAL SURGERY.
453
perform but illy their duty, and the muscles compressed, turned aside, removed
or approximated to their insertions, cannot play their wonted part.  This is
not all; the upper extremity of the inferior  fragment, by pressing on a part
of the bone not originally destined to receive it, may cause irritation ; tume-
faction, abscesses, suppuration and  caries may result, and death at last close
the scene.
  In the plan which I have adopted, on the contrary, all these accidents are
prevented, the  patient suffers but little, and at the end of a longer or shorter
time, which varies only according to age and constitution, he recovers the use
of his limb with so slight a deformity, that a stranger cannot always detect.
CHAPTER LIII
     ON  ARTIFICIAL  ANUS : ITS ANATOMICAL CHARACTERS, EFFECTS, SEAT,
                  PROGNOSIS, DIAGNOSIS, AND TREATMENT.

  Of all the diseases to which man is liable, there is no one so inconvenient
and disgusting as the artificial anus.  How wretched is the patient from whom,
despite of his will, the alimentary, bilious,  and  fecal matter contained  in  his
intestines are constantly escaping.   He  endeavors in vain  to  palliate  his
horrible  disease, by  pockets, reservoirs,  boxes, &c; he must forego society,
and be condemned to lead a solitary and miserable life.
  But before giving  an account of the^ manner in which I have generally suc-
ceeded in curing this disease, always disgusting,  often dangerous, and in
some cases  inevitably fatal, it will be indispensable to explain the morbid
anatomy of  the  intestine, and review the causes,  prognosis,  diagnosis, and
remedies of other surgeons.
 -In health, the food in a given time passes through the whole length of  the
alimentary canal, and undergoes in each of its portions different but necessary
changes, which furnish to the  absorbing vessels the elements of nutrition :  the
residuum is  then directed towards the anus, whence it  is expelled by means
of a power subject to the  will. The length of time, the space passed over, the
successive changes of  the food, the absorption of  the  chyle, and lastly  the
expulsion of the mass, constitute a series  of operations indispensable to  the
regular mechanism of the intestines.
  It follows,  that if on  account of disease  these  numerous  conditions  are
changed, reduced or disturbed, there will  be  imperfection and  disorder in
the digestion,  and injury more or less serious to the  nutrition, resulting from
it; such is in  fact what happens in artificial anus.
  This disease consists in an  original or  accidental opening somewhere in  the
abdomen, communicating with the intestine, and giving exit to a part or  the
whole of the fecal matter. This anormal  anus is rarely congenital. It mostly
results from wounds with or without loss of substance, inflammation, abscesses,
and especially by strangulations, which end in the destruction of a more or less
extensive portion of the gut.
  The artificial anus of which we are now treating  is not so easily produced 
454
LECTURES ON
  as  it may be imagined.  Its  production, indeed, demands the presence of
  many different circumstances ; thus, it is necessary that  the intestine which
  is to form it should be opposite the point in  the  abdominal parietes  through
  which the stercoral matter is to issue.  It must, moreover, be retained in the
  vicinity, ot engaged and fixed in an aperture of the abdominal parietes, and a
  communication must exist between this aperture and that of  the intestine.
  Lastly the edges of these two apertures must adhere to each other, or to the
  adjoining parts, conditions which  very rarely happen simultaneously, as is
  proved by experience.
   Anatomy of artificial Anus.'—When once formed, an artificial  anus presents
  a solution of  continuity established at the expense of  the intestines and the
  parieties of the abdomen, united and completely adherent to each other.  This
  opening, by whatever  cause it may  have  been produced,  is almost always
  round, sometimes irregular; varying from a few lines to  an inch or more in
  diameter.  Generally, its edges are thick, depressed, adherent  to the subja-
  cent parts, turned towards the abdominal  cavity, and continuous with the
  mucous  membrane of the intestine.  A reddish circle indicates  the point of
  this union.   The adjoining integuments are furrowed  by radiating folds
  analogous to those found around cicatrices, which take their name from their
  resemblance  to the vent of  alien; and almost always, notwithstanding the
 most scrupulous care, the fecal matter irritates them by contact,  renders them
 erysipelatous, or excoriates them to different depths.
   The adhesions indispensable to artificial anus are found  at the  edges of the
 opening, between the intestine and abdominal parietes.  They are  produced
 by an adhesive inflammation, which takes place immediately on the protrusion
 of the intestine.  A few hours are sufficient to establish them, but many days
 are necessaryr for their solidity.  They always commence  on the serous  sur-
 face of the intestine and abdomen, and gradually extend to the other divided
 tissues, and soon to the skin and mucous membrane.   In  hernia these adhe-
 sions precede the destruction of the  parts, and  frequently prevent effusion
. into the  abdomen ; in  wounds, on the contrary, they  occur only after the
 division of  the intestine ; but this solution of continuity is often followed by
 fatal effusions.  In the majority of cases their extent varies from  half a line to
 aline; in others, it is  of  some lines;  and sometimes, but rarely, of half an
 inch.  These adhesions are formed by a substance which passes  successively
 from the glutinous  to the cellular, and lastly to the fibrous state.  Having
 attained this last degree of organization they are sufficiently strong to re-ist
 efficiently the majority of causes which  might tend to separate the ends of the
 intestine from the parietes of the abdomen.
   These adhesions never extend far from  the ends of the intestine, whence
 it follows, that these ends being only contiguous and enveloped by a smooth
 membrane,  as throughout the remainder of their extent, leave, between them
 a kind of cul-de-sac, of which the opening looks-towards the belly, and the
 fundus towards the skin.  In certain  subjects, it is in this  cul-de-sac that the
 abdominal organs are implicated in the formation of hernia?,  which raise,
 compress, thrust aside, and complicate more or less the accidental anus.
   The abnormal anus, especially that  formed  by the destruction  of the whole
 calibre of the  intestine,  whose opening  appears immediately external,  rarely
 remains in the state of a simple fistula.   A tumor produced  by the  reversing of 
CLINICAL SURGERY.                         455
the intestine is almost always formed at the  accidental opening.   It takes
place the more easily, as this organ ns loose in  the abdominal cavity, large in
proportion to the  efforts at stool, and serious in the ratio of duration.  There
are sometimes two tumors, one produced by the reversing of the superior por-
tion of the gut, and the other by that of the inferior portion.  The latter is
more rare than the former; it is less voluminous, and appears to be produced
by the antiperistaltic movements which expel through the unnatural aperture
the mucus of the lower part of the intestinal canal.
  These tumors mostly appear under the form of cones more or less elongated,
with the apex at the integuments, and at the base having a depressed opening,
whence the fecal  matter  escapes, if they belong to the upper portion ; mucus
and even enemata if they are produced by the  lower  part.  The length of
these inversions  is sometimes considerable; they have  been seen of 16 to 18
inches and even  two feet.  Their surface is red  like the internal surface of
the gut, but colored by the irritation produced by  the atmospheric air. When
they are of long standing the mucous membrane covering them becomes dense
and solid ; covered by a light and dry epidermis, arid assuming the characters
of  the cutaneous tissue.  The volume of these tumors is  seldom great, and
varies according  as their root is more or less compressed by the opening through
which they have issued.   When  this-compression is great,  their vessels
become engorged, and their size rapidly increased.
   Desault has observed in many  of  these tumors  a  peristaltic movement
similar to that   of the  intestines.    The reversion of the gut in anormal
anus is  rather inconvenient and  painful than dangerous.  However when
the opening in  the abdominal muscles is too  narrow, the issue to  the fecal
matter is constrained, and tenesmus and colic  ensue.
   On examining  the opening of the skin  and the fundus of the artificial anus,
a soecies of funnel may be perceived, which has been accurately described by
the' celebrated Scarpa.   It is formed of parts reduced to a homogeneous nature
by inflammation  and .the contact of  faeces.  Its apex is  at the skin, its base at
th- gut.  Its length, direction,  form, and dimensions,  vary ad infinitum, and
 influence neatly the  cure of artificial anus.   In proportion as it is extended
 and capacious, nature tends to  its cure, and  to  the assistance of  art m re-

  "Tt"SthV bottom of this infundibulum are found  the  most remarkable  and
 important characters of artificial anus.   There exist  the  orifices of the  two
 ends of the  intestinal  canal,  and  the  septum  separating them.   Ot these
 orifices one belongs to the upper end of the intestine;  and which being con-
 stantly tr -versed by the food and faecal matter, is larger and more free than the
 other   The second opening is in the lower portion of the gut, and receiving no
 alimentary or stercoral matter, or at least in very small quantity, it is generally
 nirrow, contracted, and difficult to find.                        _
    To these orifices succeed the  ends of the intestine which terminate them.
 Those ends villous  and coated internally with mucus, thin, covered by tne
 pe-itoneum/aml outwardly lubricated  by its serum,  sometimes  cross  each
 oTl ein the abdomen, are sometimes convoluted, sometimes  parallel, but
 generally recede at an angle more or less acute ; and  at last are lost in the
 folds of the intestinal canal.
    Br continuing the examination there may be seen between the  two orifices, 
456
LECTURES ON
and on the same level, an angular projection more or less evident and near
the entrance of the funnel of which we have  spoken; this projection, called
also a spur (eperon), and which has been described by Saviard and Moraud,
results from the union at an acute angle of the corresponding parietes of
the two  parts of the intestinal canal which terminate at the artificial anus.
Being formed by that part of the  gut which either gangrene or wounds have
spared on the mesenteric portion,  this spur advances more or less towards the
skin, according as the intestine has undergone more or less loss of  substance
and change in  its direction.  It  is almost imperceptible and hidden in
the bottom  of the  funnel when  the  gut has suffered  but  slightly  from  a
wound or eschar, and when it coasts along  the posterior face of the parietes
of the abdomen preserving its natural curvature.   It is very large,  and reaches
the level of  the skin, when  the intestine has been destroyed throughout its
whole circumference, and when in consequence of this loss of substance its
two ends meet at an acute angle, and become parallel.  In the first case there
is, across the two orifices of the intestine, a cylindroid groove, which may still
direct any matter  from the upper towards the lower end :  this species of
artificial anus is the most easily cured.  In the second case, no vestige of this
groove appears, and the spur situated between the two orifices of the intestine,
becomes a barrier over which no  matter can pass; thus the difficulties are
increased, and the resources of artless certain.  Whatever may have originally
been the  projection of the spur, after some time it ceases to divide into equal
portions  the bottom of the funnel into which the ends of the gut open.  It
gradually descends  towards the lower portion, and at last hermetically closes
its entrance.
  On the side of the cavity of the  gut, this spur presents always the form of a
crescent, of which the angles directed towards the convexity of the new curve of
the intestine are lost, either in the parietes of this organ or the edges of the
deepest part of the wound in the abdomen.  Examined on  the  side of the
abdomen, it  is seen  to divide, and the two equal portions of which  it is com-
posed receive the mesentery between them.   This division is the result, of the
mechanism of its formation.   Produced by the contact, at a more or less acute
angle, of  the two   halves of a fold  of  intestine, it is  formed of one wall
only on its  cutting edge; everywhere  else it is composed  of two parietes
which leave  between  them a triangular  space.  A fact of great  importance
follows from this last circumstance, namely, that the cavity of each of the ends
is  separated from  the other by a  double septum, whose abdominal surfaces
are smooth and free from all adhesion.   In order to pass from one cavity to
the other, by traversing their parietes, we  must also  traverse the cavity of
the peritoneum; thence arise the difficulties and dangers of the communication
to be established between the ends of the gut, by dividing the septum which
separates  them.  This spur and  the double septum resulting from it are not
so unchangeably fixed as to be unable to advance or recede.  United to the
mesentery they follow to a certain point the movements communicated by this
ligament of which the arrangement demands particular attention.  This mem-
branous fold, extended from the anterior portion of the vertebral column to the
curvature of the intestine, possesses, in  its  ordinary state, merely the length
comprised between  these two points.  Notwithstanding its extensibility, it is
always in a state of more  or less tension, when  the gut removed from its 
CLINICAL SURGERY.
457
ordinary situation escapes through  the abdomen, as happens in the generality
of herniae and penetrating wounds of the abdomen with protrusion.  Forced to
follow the displaced intestine, the mesentery forms, from the vertebral column
and the most remote point of the intestine, a cord, which, by its tension, keeps
the body inclined forward, prevents its erect position, and still more any incli-
nation backward.
  In  artificial anus, the end of this  cord  corresponding  to the intestine  is
attached to the bottom of the re-entering angle which it forms on the abdominal
side, precisely at the base of the spur separating the two apertures.  In con-
sequence of this arrangement the spur and intestine are continually drawn by
the mesentery, and their tension must be in proportion to  that of this mem-
brane.  We may thus readily perceive the beneficial influence that movements
and position of the body backwards must exercise in the spontaneous cure of
artificial anus.
  The  consequences of this tension, however, are sometimes less favorable.
I have  twice seen it rupture the adhesion of the intestine  to the abdominal
parietes, and give  rise to fatal effusion of stercoraceous matter.
  For a long time  after the cure, this action of the mesentery continues and
causes a singular phenomenon, which I will briefly describe.  In  many indi-
viduals cured spontaneously of artificial anus, who  afterwards returned to the
Hotel Dieu, and died of other diseases, I examined with curiosity the situa-
tion of the  parts ; but what was my astonishment, on finding the  intestine free
and floating in the abdominal cavity, instead of being adherent to its parietes.
I should have thought myself mistaken, if the identity of the persons had not
been  well ascertained, and I had not discovered a fibrous cord extended from
the point in the abdomen, corresponding to the artificial anus, to the intestine.
   This cord, a few lines in diameter and some inches in length, larger at its
extremities than in its central portion,  covered by the peritoneum and formed
entirely of a cellular and fibrous tissue, without  any cavity, was evidently
formed by the progressive elongation of the cellular tissue which had united the
intestine to the parietes of the abdomen, and this elongation had been caused
by the continual  traction  exercised upon fhe gut by the mesentery in the
different movements which had taken place during life.
   The changes of which we have just spoken are not the only ones which take
place.  The ends  of the intestinal canal, perfectly similar to each other in the
early stage of the disease, soon take on very different characters.  The upper
portion continuing to receive alimentary matter, not only preserves its calibre,
appearance, and movements, but obliged to perform alone a function formerly
executed by the whole canal, is rendered larger ; its parietes being thicker and
stronger become the seat of a more energetic circulation, as well as  of a more
active secretion and absorption.  This excess of vitality extends  even to the
lymphatic  ganglia and portions of  the mesentery appertaining to  it.  The
lower portion, on  the  contrary, more or less deprived of its  functions, no
longer exerted by alimentary or fecal matter, having nothing to contain or ela-
borate, collapses, or as it were withers,  loses its thickness and solidity, and be-
comes the seat of  an atrophy extending to the mesentery and lymphatic.
   It must be nevertheless  observed, that however reduced and  atrophied the
lower portion of  the intestine may become, it is  never entirely obliterated.
The internal membrane.in contact with itself, secretes a whitish ropy mucus,
            58 
458
LECTURES  ON
of an albuminous appearance, capable of remaining months and years in the
place of its formation, without contracting any fecal odour, and which is ex-
pelled in the shape of long  cylinders, either spontaneously or by a stimulant
enema.  M. Begin, however, a few years ago, observed at the Hospital of
Val-de-Grace  a fact which would seem to indicate that the  complete disap-
pearance of the intestinal cavity is not impossible.  In a man 80 years of age,
who had for more than 40 years labored  under an artificial anus in the  right
groin, formed at the expense of the  transverse colon, which was depressed to
the level of the corresponding ring, this surgeon found the upper portion alone
adherent to the wound.  It was impossible to discover, either at the  cicatrix
or adjoining parts, any entrance into the lower portion.   The latter, under the
form of a  white cord, of about the size of a writing quill and very solid,
ascended towards the left kidney, and then descended after some convolutions
to the anus. As it approached this  opening its size increased, and its resist-
ance was less.   At its lower portion it was still open and contained a whitish
mucus; but above it could not admit  a very delicate probe, and along its
ascending portion for the extent of six or eight inches, in the vicinity of the
artificial anus,  it was so completely obliterated as not to evince the least sign
of an internal  canal.
  Effects and consequences of artificial Anus.—In health the intestine, loose
and floating, although  attached to the mesentery, describes in  the abdomen a
series of uniform  curvatures, through which the food passes freely ; on the
occurrence of artificial anus,  this series is immediately altered.  A  fold of
intestine is elongated, and  directed towards some open  point in the abdominal
parietes ; it assumes the form of a triangle of which the base is formed by the
mesentery, and the sides are measured, one by the stomachic, the other by the
anal portion.  It is well known that, in the most simple herniae, this angular
direction substituted for the uniform and regular curve of the gut causes much
embarrassment in the circulation of the  alimentary and fecal matter.
   In the case of which we are now treating, the intestine, on account of the
adhesions which it has contracted with some  part of the abdominal parietes,
is turned from  its natural direction, and  rendered immovable throughout a
greater or  less portion of its length.  This immobility not only opposes the
movements of  the digestive tube, but has another effect not  less remarkable,
namely, that the portion of  intestine engaged  in the parietes of the abdomen
becomes a fixed point on wliich the efforts of the intestinal canal are spent,
and towards which they constantly propel all substances, whence there results
a real  acceleration of their passage from the stomach  to the artificial anus.
The most  serious of these  inconveniences is the shortening of the surface
over which the  alimentary matter must pass.  They remain  a shorter space
of time in the intestinal cavity, are less completely digested, and their nutri-
tive principles are absorbed  less perfectly.  Nutrition then becomes changed,
and exhaustion seems to threaten a cessation of the organic functions.   Who
has not been  struck with the mass of heterogeneous substances entirely di-
gested, matter which may still be recognised, and food of which the original
characters have undergone no change, which are discharged from the majority
of cases of artificial anus ?   Add to  these serious inconveniences and real
dangers, the constant and involuntary discharges of bilious, mucous, alimen-
tary and faecal  matter which  follow each other uninterruptedly, according; to 
CLINICAL SURGERY.
459
the state of repletion or vacuity of the canal, and the variable height at which
the accidental  anus is situated.  From this flow of acrid and irritating sub-
stances result excoriations, fissures,  erysipelas,  an insupportable  pruritus,
various eruptions, which annoy the patient and increase the effluvium arisin°-
from his body and clothing.  Ointments, washes, metallic or other reservoirs
are- but imperfect remedies;  and compression, which may in some degree
prevent the discharge and supply the place of a sphincter, becomes very dan-
gerous in  many cases.
  Let us  now inquire into the causes of this disease.  Hippocrates, in his
book on epidermis, gives a case produced by a penetrating wound of the abdo-
men,  with  lesion of the intestine ; this is a frequent cause, especially in sol-
diers.   When  the gut is wounded and retained without the cavity of the
abdomen, the alimentary or faecal matter which it contains continues to'flow
through the opening;  adhesions fasten it to the parietes of the belly:  this is
the most  simple form of artificial anus.   In rarer cases, where the  wounded
intestine remains in  the  abdominal cavity, it sometimes happens  that  the
effused matter traverses a  long passage before arriving at the external wound.
But generally they are fatal, by producing an inflammation of the peritoneum.
  Foreign  bodies, inadvertently swallowed, sometimes jrritate the  coats of
the intestine, and cause their adhesion to the peritoneum lining the abdomen,
so as afterwards to give rise to stercoraceous abscesses whose aperture gradu-
ally becomes fistulous.  In some very rare cases it has been observed that-
tumbrici contained in the lower portion of  the  small intestine have opened
unnatural passages in order to reach the surface.  The abscesses which occur
in those cases  are remarkable  for the slowness with which the phenomena
preceding their formation  are developed.
  But in  the first rank of all the causes of artificial  anus are to be placed,
strangulated, inguinal, crural, obstructed, irreduced herniae, and those whose
inflammation terminates in gangrene.  If the assistance of art be not inter-
posed, to the phenomena  of strangulation and intensity of the local inflam-
mation there  succeed gradually the diminution of the frequency and force of
the pulse, the disappearance  of general agitation and anxiety, and at  the
same time the surface of the tumor acquires a livid hue, its size increases as
its resistance and sensibility diminish.  The abscess then becomes more evi-
dent,  and sloughs formed at some point of its extent-give exit to fetid, ster-
coraceous matter, mixed with pus and intestinal gas.  If the gangrenous her-
nia be  opened  with an instrument, the  intestine is sometimes  found dead,
although as yet unbroken ; sometimes its contents are  effused into the hernial
sac, and sometimes the hernia and its coverings constitutes a  common mass,
in a state of complete mortification.
  In  proportion as the evacuations find a free passage through the spontane-
ous opening in the intestine, or by the removal of the strangulation, tranqui-
lity returns" the sloughs cease to fall, the wound assumes  a  :red color, the
adjoinin°- tissues approximate each other, and  the artificial anus is established
either  definitively or  temporarily, according  to the loss of  substance which
the alimentary canal has experienced.
  Artificial anus may sometimes result  from an  operation performed,  when
the surgeon is reduced to this last and deplorable extremity, in order to pre-
vent the fatal issue of injuries of the intestines.   It is thus that in wounds 
460
LECTURES ON
 with entire division of the gut, the establishment of accidental anus are justly
 considered by the majority of surgeons as offering a greater  chance of cure
 than when sutures are used.   After gangrene  has taken place in hernia, the
 incision of the intestine, the removal of its strangulation, and  the formation of
 an artificial anus, is an operation more advantageous  and certain  than the
 excision of the diseased parts, the destruction of adhesions formed by nature
 with the abdominal  openings, and the practice of invaginations.  The forma-
 tion of an artificial anus is the only operation which the surgeon can propose
 with any advantage, in the case of children born with imperforate anus, when
 the obliteration of the lower part of the rectum does not permit the  faeces to
 descend low enough to guide the  bistoury  or trochar, in order to give them
 issue.
   Lastly, from analogy, artificial anus offers a resource, perhaps too much
 neglected, in many  cases  of organic changes in the parietes  of the  large in-
 testines, of  which the effect is  to arrest the Course of the faecal matter and
 threaten inevitably the life of the patient.   If  the rectum, for example, were
 obliterated, and all endeavors to re-establish its continuity were to fail, would
 we not be  authorized in making an incision into the left groin, drawing out
 the descending portion of the colon, and establishing an artificial anus ?
   Seat.—Artificial anus  may be  seated in  any part of the abdominal surface.
 It is mostly found,  however, near the openings through which the vessels or
 nerves  pass out, for  this simple reason, that herniae, whence the disease gene-
 rally arises, are more frequent  at these points than elsewhere.  Thus, it is
 most frequently to be met with  in the groins, or the iliac and umbilical re-
 gions.
   Diagnosis.—The  existence of artificial anus  scarcely ever  gives rise to
 the least uncertainty.  It suffices to remember the characters belonging to the
 apertures which constitute it, and  to examine the nature  of the fluids dis-
 charged, in order to recognise it.   The disease  is generally found in the spots
 which we have mentioned ; and when elsewhere,  it has been preceded, either
 by the protrusion and strangulation of the intestines, penetrating wounds of
 the belly, or abscesses which on bursting have given exit to these fluids.   In
 less  apparent cases  when  there  exist  only  long and  sinuous fistulae,  from
 which there issues  nothing  but pus  colored  by the  intestinal fluids, the
 true nature of the disease may be easily recognised by  going back to its
 origin, and the symptoms which preceded and accompanied  its development;
 and  lastly,  by exploring carefully the track of the fistula and attentively
 examining the fluids which are expelled.
   Prognosis.—Artificial anus is always a serious disease, and  its issue some-
 times fatal.  The prognosis is always unfavorable, other things being equal,
 when the unnatural opening  in  the Intestine results from an  injury near the
 stomach.  Absorption and assimilation will be then imperfectly executed, and
 insufficient for the wants of the organism in proportion to the briefness of the
 passage which the food must traverse in the  canal destined for their elabora-
tion.   An opening in  the rectum, colon, and caecum has but  little influence
on assimilation ; an  injury to the ileum has more marked effects : lastly, the
opening of the jejunum, and especially of its upper portions, into an  artificial
anus, is  followed by rapid exhaustion and  marasmus.  We may discover
 which is the wounded intestine, bv the consistence, odor, and degree of altera-
 tion of the matter discharged. 
CLINICAL SURGERY.
461
  In another point of view, artificial anus, wherever it may be seated, is seri-
ous in proportion to the quantity of alimentary or faecal matter which flows
through the wound.
  When both ends  of the intestine are easily found, the prognosis is more
favorable than when one end alone can be discovered.
  The more simple the disease is, the freer is it from danger. Artificial anus,
when seated in parts which may be easily cleansed, and which are fitted to
receive exactly the apparatus intended to receive the discharges, are always
less inconvenient than others.
  In  general, the effect upon the nutrition  should serve as the basis of  our
prognosis ; other circumstances are but secondary.
  Treatment of artificial Anus.—If my propositions be true, and the facts on
which they are established constant, I think I have demonstrated that the dis-
charges of stercoraceous matter, and the obstacles in the way of their return
to a natural  passage, are caused : 1st.  by the adhesion, the angular direction -
and  immobility of the intestine being substituted for its  regular and gentle
curve, and its mobility in  every direction : 2d. by the loss of substance which
it has experienced, and the contraction which is the result: 3rd and lastly, by
the spur and double septum which  separates its two ends.  These obstacles,
however great, are not always insurmountable, and have more than once been
conquered by both nature and art.
  The loss of substance is undoubtedly  irreparable; but in some cases  it is
supplied by the extension  of the tissues, and the dilatation of the calibre of the
gut.   The adhesion to the abdominal  parietes  may so far relax as to permit
the most favorable position for the restoration of the course of the fluid.
  The projection,of the spur and, double septum may also be diminished by
the traction of the mesentery, and the efforts of  the contents  of the canal in
passing from the superior  to the inferior portion.
  A generous diet, such as has been recommended by Louis, in the intention
of gradually increasing the communication between the ends of the intestine,
purgatives administered by others, in order to  overcome the obstacles to the
freedom of this communication; the introduction of dossets of lint, gradually
augmenting in size, after the manner of  Desault, in order to dilate, the con-
traction separating them ;  motion and positionof the body backwards practised
bv us, in  order to put the mesentery on the stretch and obliterate the  spur
and  septum resulting from it: compression on the external orifice  of the arti-
ficial anus;  have all either separately or conjointly effected cures.  Far from
denying this fact we are among the first to  proclaim it; but under what cir-
cumstances have they succeeded ?   This point must  be established, in order
to distinguish the cases in which the efforts of nature and those of art are suffi-
cient to cure artificial anus, from those in which these efforts fail and more
efficacious means are required.
  Before attacking the principal disease, the complications sometimes accom-
panying it are to be removed.  Thus for example, if the tissues be indurated
and  the external orifice contracted by callosities, they must  be  restored to
their natural state by means of rest, a strict  attention to propriety, emollient
fomentations, wool, and similar remedies.   If the  integuments be irritated,
painful, affected with inflammation or erysipelas, the continued  use of the 
462
LECTURES  ON
above means will generally dispel this irritation.  Vv'hen fistulas of any length
exist, they must be divided and the abscesses opened.
  But the most frequent complication and  the most important to  remove,  is
the reversion of the gut across the wound.   This, however, may be  effected by
a horizontal position for some days, the taxis, or a gentle and continued  com-
pression.  When we cannot succeed in reducing  the intestine,  the  tumor
may, as was done by Desault, be surrounded by a roller, moderately tight.
  The greater number of cases of artificial anus, which  consist merely in a
simple perforation of some  point  of the circumference and length  of the
intestinal canal, are  curable : these cases, indeed, only give rise to stercoral
fistulas, behind  which the gut remains  nearly  healthy, without having ex-
perienced any appreciable loss of substance,  manifest contraction, or evi-
dent change in  its direction.  The efforts of nature  alone, and a slight com-
pression on the external wound, will generally obliterate these fistulas.
  Such simple means will not suffice when the anormal anus is produced by
the destruction or removal of a third or half of the  circumference of  the in-
testine, throughout a surface varying from several lines to an inch.   The loss
of substance  and change of direction of the alimentary canal, as well as the
projection of the spur separating the two  portions of this organ, may still, by
a proper course of treatment,  be.  remedied, aPd the alimentary substances
caused to return to their proper channel.
  But such is not  the  case when there is loss or  destruction of  substance
throughout four fifths, and, a fortiori, the whole circumference of the gut, with
or without implicating the mesentery.  Here, the loss of substance, the con-
traction, change of direction of the canal, and above all the projection of the
spur and the septum present insurmountable obstacles to the establishment of
the natural  course of the alimentary  substances.   Compression, the most
efficacious of all curative means proposed^whenexact enough to close all exit,
produces immediately all the symptoms of strangulation.
  Thus, from the examination of  cases observed at the Hotel-Dieu or col-
lected from authors, I have concluded, that the number cured spontaneously,
or by the means above  mentioned, are to those which  obstinately  resist all
treatment, as 3 :  1.  It must be remarked that this last fourth of the patients
consists of those who, on account of the discharge of the whole of the resi-
duum  of digestion through  the abominal  aperture  are  the  most  seriously
affected, and most imperiously require our  aid.   To this species of artificial
anus, therefore, our attention should be  directed ; but, in order to proceed
with certainty and utility, we must understand  exactly  the difficulties and
obstacles to be surmounted.  These are, the loss of substance and contraction
of the intestine, the adhesion of its extremities to the parietes of the abdomen,
the changes in its direction and mobility ; and above all the spur and double
septum between its ends.
  At first sight it is evident  that the loss of substance cannot be  restored ;
and any attempt to produce adhesions between their extremities, so as to re-
establish the continuity  of the canal, not only compromises the cure but also
the life of the patient
   The adhesions of the gut to the abdominal  parietes should also remain undis-
turbed ;  our only resource is then to opearte on the spur and septum. 
CLINICAL SURGERY.
463
  The simple division of these parts  would at first appear a prompt and
easy  method of restoring the communication of the  two ends.   It  would,
most assuredly, be by far preferable to any other, if these  ends  adhered to
each other to a certain height.  But on reflection, we will  soon  see that the
patient would be  exposed  to immediate death from effusion of faecal matter
into the abdomen.
  Reason and  prudence therefore teach us to remove this spur and septum,
by thrusting  them  into the  abdomen, and imitating  as  far as possible the
effects of the traction of the mesentery.  If these attempts  be unsuccessful,
at least, in my  opinion, they can be of  no harm.
  Impressed with this idea, I had an instrument constructed, of which I
give here  merely an idea since it is  not proper to judge it from one case
alone in  which I have used it.  It  is composed of an  ivory crescent* pointed
and with very blunt edges, having an  opening of three  quarters of an inch,
protected by linen and fastened to  a handle two or three inches long terminat-
ing in an elongated plate, a  little curved, and furnished at the end with some
holes in  order to  receive tapes which pass around the pelvis.
  Case I.—In 1809 a man  was admitted into the Hotel-Dieu, for a strangu-
lated hernia which had resulted in artificial anus.  I thought that the removal
of the spur, after the manner of Desault, would be the  most certain, energetic,
and efficacious measure.  With this  idea, I used the instrument above de-
scribed.   The  concavity of  the  crescent was applied to the spur, which was
thus pressed from  before backward by the tapes passed around the pelvis.
 But either its application or some other cause, excited pain, colic, and nausea.
Obliged,  therefore,  to abandon the hope of removing  the projection which
separated the ends of the gut, its division or perforation alone remained.  How
was this to be  done ?  By means of a punch which would open  at the same
 time the intestine and the peritoneum ?  Its result would be a  solution of
 continuity through which  an inevitable  effusion into the peritoneum would
 take place.  This  effusion  must  therefore  be prevented.   The ends of the
 intestine are covered on all sides by  peritoneum, and this membrane forms
 around them an uninterrupted cavity.  This circumstance presenting an in-
 surmountable objection to all idea of instantaneous  division or  perforation,
 should teach us,  as will be hereafter seen, to divide the double septum, separat-
 ing the intestines without opening the peritoneal cavity.
    The well  known facility with which  serous membranes take  on  adhesive
 inflammation and unite on their free surfaces, appeared to offer the long desired
 means of curing the most complete, and consequently the most inconvenient
 and dangerous species of artificial anus.  The first step consisted in passing
 a needle through the parietes of both  ends of the intestine as far as possible
 from the projection of the  spur.   This needle was to leave behind it in the
 parts a thread, which might be gradually increased, so as to afterwards admit
 a  piece of braid.  An opening capable of enlargement could then be made
 behind the projection, in the midst of new adhesions, by a perforating instru-
 ment so as to  establish between the ends of the gut such a communication
 that nothing could be discharged from the external wound.
    After many experiments  on  animals, and particularly on dogs, this opera-
 tion  was, some  years subsequently,  practised  on the patient whose case we
 will now relate. 
464
LECTURES ON
   Case II.—Aucler (F.), 36 years of age, of an excellent constitution, had
been  affected since childhood with an inguinal hernia, but which had never
been  of any inconvenience to him.  On the 13th of May 1813, having de-
scended  into  a privy-sink to measure it, the stench made him vomit, he im-
mediately felt a lively pain in the left groin, found his hernia much increased,
and at the  same time was seized with colic, hiccup, and the ordinary symp-
toms of strangulation.  He had no sleep that night; the next day, a physician
was called, who, disregarding the tumor, prescribed purgatives and antispas-
modics, kept the patient in a deceptive security, and thus lost in fruitless and
even dangerous remedies the  most precious moments.   Five days were thus
passed ; when Aucler determined to be carried to the Hotel-Dieu on the 17th
of May 1813, at half past nine o'clock in the evening.
   He had  been scarcely placed in bed, when the symptoms of strangulation
of the neck of the sac were recognised ; and from his extreme prostration, it
was feared  that gangrene had taken place.  The operation was immediately
performed ;  and, as had been foreseen, the neck of the sac was strangulated,
and a circular mortification produced atthe seat of stricture.   The necessary
divisions  having been performed, the organ, too much injured to admit of re-
duction,  was left in  situ.   The  symptoms of strangulation  immediately
ceased.   He was, however, bled  several times in order to avert a threatening
peritonitis.
  At first, only a small quantity  of faecal matter issued from the  wound; the
destruction of nearly the whole of the gut comprised in the hernia soon gave
a freer passage.   An artificial anus was established, through which the whole
of the substances were  discharged.  Things remained in this state  for six
weeks, without the least effort on the part of nature to afford relief.  I then
tried  the effects of compression, but they were so violent as to oblige us to
remove it in a few hours.   The  patient seemed condemned to labor  always
under artificial anus; and this idea tormented him so strongly, that he im-
plored, at all hazards, any means calciliated to remove his disgusting disease.
   An accurate examination  showed the ends  of the intestine to be healthy,
and separated merely  by a  very projecting  spur  and septum.   I resolved
therefore, on perforating this septum, and then pierce it with a needle carried
as high  as possible into the cavity of the upper end, its point being received
in the cavity of the lower end  and drawn out.  A ligature with which the
needle was armed was left in the opening thus made.
   The operation was free from  pain, and quickly performed.  A  few days
after, a larger ligature was  introduced through the  aperture.  From that
time,  gas began  to escape from the natural anus.   The size of the ligature
was increased at each dressing, and in eight days the patient passed his faeces
by the fundament.
   Thus encouraged, I  augmented the  ligature so  much, that  one day the
spur was ruptured.  This  laceration gave rise to no bad symptom; and the
sudden increase of the communication between the ends of the gut  rendered
the passage of the substances more easy, but still did not prevent its partial
discharge from the artificial anus.
   Desirous of removing completely the disease, I thought that the portion of
the septum above the aperture made by the needle  ought also to take on the
adhesive process; and  that  it might be divided with as little danger as the 
CLINICAL SURGERY
465
part below; and therefore determined to make the attempt.  This consisted
in an incision every three or four days at the distance of half a line from the
upper part  of the septum, by means of blunt scissors directed on the index
finger.  These incisions, small in extent, and not passing beyond the limits of
the already established adhesions, increased the aperture  of communication
so much, that the faeces were discharged by the natural anus.
   Compression  exercised upon the artificial opening and carefully watched
by the patient, would probably in time have entirely closed it;  but Aucler,
desirous of hastening his cure, became so importunate that I at last yielded to
his Solicitations.
   Some living fragments around the aperture were first tied, and then removed
without inconvenience.  The division of the septum was then extended higher
up, and a few hours afterwards the patient was attacked with all the symptoms
of acute peritonitis, which resisted all our efforts.  Was this inflammation
produced by one of those fortuitous causes which sometimes unfortunately
coincide with an operation, and throw  upon it all the responsibility of the
event ?  Was it the result of extension, by continuity of tissue, of inflamma-
tion of the incised parts, to the peritoneum; and did it here occur, from the
very cause,  rendering it so frequent in the operation for stone, and the  most
simple hernia; or, lastly, was it produced by an effusion of faecal matter into
the abdomen ?   I was inclined to the latter opinion.
   The autopsy, however, showed no solution of continuity through which the
stercoraceous matter could have escaped into the peritoneum; none was found
in its  cavity, which contained a quantity of purulent serum  and flakes of
albumen, such as are ordinarily produced by an acute peritonitis.
   The communication between the ends of the gut was restored for the space
of nearly two inches;  its two extremities, before  separated, constituted now
but a single cavity, in which could be seen a raphe, caused by the cicatrization
of the incision made in the septum, and every thing indicated that but for this
melancholy occurrence, the artificial anus would have been cured.
   It would be absurd to lay claim to the priority of this operation, if persons,
excited by motives and interests unworthy of investigation, had not pretended
that the operation was not new.  Schmalkalden,  it is true, in 1798 had  con-
ceived and executed the project of perforating the septum separating the ends
of the intestine; but not only, in 1813, no one in France had-spoken of this
attempt, but it seemed also unknown in Germany, since no mention is made
of it by Sprengel, in his excellent history of medicine.  Physick  of Philadel-
phia, attempted the same operation, but the first account of it was given in
1813, by Dorsey in his Elements of  Sjirgery.  It is useless to waste time in
demonstrating, that during the war of that period, and the prohibitions caused
by it  that ideas originating, in Germany or America could serve as a basis to
analogous attempts in France, when in the former country they were unknown,
and in the latter occurred simultaneously with their first announcement in
another hemisphere.  The design of the operation  I  prefer m  not only to
procure the adhesion of the septum, to divide it, but  also to so dispose of the
edees  of this incision as to  prevent their  reunion; however, although the
passage of the  needle through  the  double septum  and the ligature in the
intestine were productive of no injury, and that the want of success in the case
of Aucler was to be entirely attributed to the attempt to  enlarge, by means
           59 
466
LECTURES ON
 of scissors, the  communication between the  ends of the  intestine, this plan
 and all others based on the use of the needle are liable to serious objections.
   In the first place, it maybe easily seen, that the needle and ligature passing
 through the  parts before their adhesion, the communication they establish
 between the intestine and peritoneum  might in some cases give rise to  an
 effusion into the cavity of the latter.   Again, it is very difficult, almost im-
 possible to carry the needle high  enough, in order to open, between the ends
 of the gut, a communication large enough in all patients for the passage  of the
 faecal matter.
  Secondly, the ligature can only cause the adhesion of those portions of the
 intestine which are in contact; and if, instead of being parallel, and touching,
 those  ends  should be separated from  each other, it will be seen, that it will
 produce a perforation without adhesion, and a dangerous communication be-
 tween the intestine and cavity of the peritoneum.  For these reasons I have
 abandoned the use of the needle and ligature.   Moreover, in  the  operation I
 have described, the spur separating the ends of the gut was destroyed only by
 a number  of little operations;  the  parts were  kept  in a continual state of
 irritation,  always dangerous, and  liable to become suddenly fatal from exten-
 sion of inflammation.   Founding my opinion on the adhesive property  of
 serous membranes, when in contact and in a state of inflammation, I  thought
 that an instrument which  would seize a large extent of  both  ends of the
 intestine, approximate, compress, and inflame it, and lastly divide the whole
 of the double septum behind the spur, would completely answer the end pro-
 posed.  The adhesion must, precede the division of the parts, and this division
 affected by pressure, could never extend beyond the adhesions previously
 established.  It was to  be feared indeed, that the inflammation, instead  of
 being confined to the narrow limits of the instrument, might extend to the rest
 of the peritoneum ; but we know, from  the history of foreign bodies, such  as
needles, pins, &c. which perforate slowly the  intestinal canal, and make their
appearance outwardly, after having caused the adhesion and division by  pres-
 sure of the parts included in their passage, that this extension of inflammation
does not take place. Experiments performed on living animals also proved to me,
 very satisfactorily, that  in the proposed operation the patient would run no
 greater risk than in those frequently performed on the abdomen.
  At first I had an instrument  made in the shape  of scissors, of which the
 blades were cylindrical;  but  soon found that they slipped over the  parts
to which they were applied, instead of  remaining in the proper  position.  I
then armed one blade with steel points which were received into corresponding
holes in the other;  but these points were liable to the same objections as the
needles, as they made numerous openings in the gut, through which gases and
irritating fluids might infiltrate the cavity of  the peritoneum.  At last, after
 many attempts, the enterotome, or instrument intended to divide the approxi-
 mated ends of the gut, was constructed.  It is composed of three pieces,  qr
two  lateral branches and a screw with  several threads.   The branches are
about  seven inches in length ;  one of them, which  may be called the  male
 branch, is  formed of a blade about four inches long, three lines wide, and half
 a line  thick on its cutting edge.   This  edge is undulating,  and terminates  in
 a spheroidal enlargement.   At the junction of the blade with the handle there
 is a mortice of some lines in extent, behind which is the handle itself, two  or 
CLINICAL SURGERY.
467
three inches in length and divided throughout nearly its whole length by another
mortice of four lines in width.
  The female branch of the enterotome is slightly shorter than the male.  It
has on one edge a groove intended to receive the male blade.  The bottom of
this  groove  is  furnished with undulations alternating with those of the male
blade, and having at its extremity a cavity destined to receive the button-like
termination  of the latter.  At the union of this blade with the handle, there
is a pivot which is received into the  mortice of the male branch ;  lastly comes
the handle, having at its extremity a perforation to receive the screw.
  The latter, or the third part of the enterotome is  about one inch and a half in
length, terminating in an oval head; it is passed through the long mortice of
the male, and received  into the perforation in the female branch ;  its  action
consists in approximating at will the blades of the instrument.
  The  mechanism  of  this instrument may be  readily understood.   Two
branches which may be separated at pleasure, having blades with very blunt
and undulating edges, are  put in motion by a screw through their handles;
and thus they seize and retain all substances  which may be between them.
The first effect of their pressure is to bring the parts in contact; this pressure
may be carried as far as to deprive  the parts  of  life, but yet not to immedi-
ately divide them, on account of the thickness of the edges.
  Before using the  instrument on man, I made some experiments on living
animals ; its  effects surpassed my hopes.  The parts were always divided in
six or eight days, and whenever serous membranes were included between the
branches of the enterotome, they were found to adhere on the second or third
day, consequently, long before the division which happened only on the seventh
or eighth.
  This highly important adhesive inflammation extends on each side, along
the  whole length of the branches of the enterotome, as well as around  its
point, which  it exactly circumscribes.  It is accompanied by the signs  of
moderate inflammation, at first weak and easily  destroyed ;  at the end of five.
or six days, this  adhesion is pretty strong.   It afterwards becomes cellular,
and is as solid as a natural  union.
  The action of the  enterotome and  the division of the parts are never at-
tended by acute pain; the inflammation is always limited to the vicinity of
the  parts, around which it forms a small areola, but never extends to the tis-
sue of the organs.  It operates by causing mortification  of the included parts,
and  the  solution of continuity resulting proceeds from  the fall of a slough
which is always found between the blades of the instrument.
  The following case was that in which the first trial of the enterotome was
made:                                          .  _        .     .   .   .
  Case III.—Menage, 36 years of age, labored from infancy under an inguinal
hernia on the right side.  It became strangulated on the 2d of January, 1815.
The symptoms were very violent  and continued until the sixth day, notwith-
standing copious bleedings and frequent attempts at reduction.  At this pe-
riod the operation was performed at the hospital of Chateau-Dieu.
  The eut was gangrenous, for on the next day a  large  quantity of stercora-
ceous matter escaped  through the wound.   The gangrene extended and de-
stroyed successively the intestine, hernial sac, the cellular tissue and adjoin-
ing skin  However, the disease  was arrested,  and an artificial anus brmed 
468
LECTURES  ON
 through which  every thing was discharged; the substances appeared at the
 aperture in about an hour and a half after having been swallowed, and were
 expelled not in the order of introduction or digestibility, but rather in pro-
 portion to  the  quantity of nutrition they contained.   Thus, vegetables were
 discharged in an hour, and meats only in two hours, and in a more advanced
 state of digestion.   His appetite was excessive, but as his food escaped nearly
 as soon as it was swallowed, it afforded no nourishment, and he grew rapidly
 weak and emaciated.
   Seven  or eight weeks after  the operation, he had violent  attacks of colic
 and alvine evacuations which occurred at long intervals; this state continu-
 ing for about a year, he determined to enter the Hotel-Dieu.
   The artificial anus was then about half an inch in diameter; its entrance
 bordered by irregular tumors, resulting  from the swelling  of the mucous
membrane  of the intestine; and behind  it there appeared a hernia, which
protruded on the least exertion.  It occasionally gave passage to an invagina-
tion of the  gut; the adjacent skin was highly irritated ; the sufferings of the
patient very great, and the smell from the wound horrible.
   Menage  had  but one wish ;  that was to be cured.  After a few days, I en-
deavored to ascertain the  respective  situations  of the two ends of the gut.
These endeavors were at first fruitless, as they were drawn down by the her-
nia.  However, after some attempts, the ends of the gut, the  spur and septum
 were  found.  Then, without  loss of time, I introduced as far as possible a
branch of  the  enterotome into each  of the ends, locked  them, and gently
 approximated the blades ; the patient felt no pain; the pressure was increased
 the next day; a  slight colic followed. In a few days the forceps were observed
to be slightly movable, and on the sixth day there was a stool.  On the se-
venth or eighth, the enterotome fell  off; its blades being separated  merely by
 a  membranous  band removed from the intestine, and comprising all the tis-
 sues of the two portions.
   This band, as thin and dry as a piece of parchment, was twenty lines long
 and two wide.  By means of these dimensions it was seen exactly how deep
 the enterotome had penetrated, and the consequent loss of  substance of the
 intestinal septum.   From this moment the faecal matter flowed by the natural
 anus.  As  after some time the artificial anus did not heal, we had recourse
 to adhesive s,traps and the cautery of  the edges with a solution of nitrate of
 silver.  In  four months Menage  was  presented to the Medical Faculty, en-
 tirely cured of  his  artificial anus, and the serious inconveniences which had
 resulted from it.
   Case IV.—A woman, about 50 years of age, of a lymphatic constitution,
 fell, about 15 years  since, with the abdomen against a carriage. There was a
 severe contusion followed by a tumor in the inguinal region.  This was soon
 discussed.   Thirteen years elapsed without a bad symptom, when  18  months
 ago a  new tumor appeared.   A bandage was applied in order to reduce it.
 The tumor became painful, but there was no vomiting.  After fifteen days
 had transpired, it increased  in size,  and an operation was performed ; for
 what reason, I know not.  She declared  that  she never had any hiccough,
 nausea, vomiting nor constipation, and it must be confessed that in the absence
 of those symptoms it is difficult to recognise a strangulated hernia.   In thirty
 days, the patient was  cured.  About  a month after this operation, a second 
CLINICAL SURGERY.
469
tumor, but smaller than the first, appeared; it was operated upon, and the
patient cured.  Six months afterwards, a third tumor manifested itself, and
opened  externally, and from  that time  the  patient discharged  constantly
through this  accidental opening stercoraceous  gases and matter.  On the
contrary, but little escaped from the normal anus ; sometimes nothing during
a space of three months.
  In this situation the patient entered the Hotel-Dieu on the 8th of March,
1832.   There was in the crural region  a round wound of which the edges
were slightly fungous; it was not simple, but presented several openings from
which  the matter  escaped ; otherwise there was no engorgement nor tumor.
Nothing could be  felt in the belly.  Had this woman a crural hernia?  It
may he doubted from  the nature of the symptoms and  the two operations,
which  showed  neither omentum nor intestine.   Was there then  a cyst be-
fore the hernial sac ?   But here the symptoms rendered strangulation doubt-
ful, unless we suppose a portion of the  gut pinched up, as sometimes is the
case.   From  these reasons I considered it to be an organic lesion of the coat
of the  intestine, of which the parietes, by wearing out, gave rise to a fistula
and an artificial anus.
  The digestive functions were unaltered; the patient ate and digested well;
and on  this subject a few remarks will be appropriate.  Experience teaches
us that there  is a great difference between artificial  anus of the small and
large intestines.  When seated in the large intestines, it is of slight incon-
venience, and digestion is undisturbed;  but it is otherwise in the small  guts,
and the disease becomes serious in proportion to its proximity  to the stomach.
When  situated at the lowrei- extremity of  the small intestine,  the matter
discharged resembles highly the faeces, and the patient is but little weakened;
when at its middle part, the faecal character is less marked ; and at the upper
part of the small  intestine the food  passes  out scarcely digested, and the
patient soon perishes from exhaustion.
  In the woman of whom we are now speaking, digestion was perfectly per-
formed, and the strength but slightly affected.   As the matter discharged had
undergone nearly all the changes of chylification and chymification, we were
led to think that the artificial  anus was seated at the lower extremity of the
small intestine.
  Eight days since, there were three small apertures which have been divided
and united in one, at which  the ends of the intestine necessarily terminated.
The enterotome appeared to offer the  best chance of success, but there was
some difficulty in finding the lower end of the gut; however, after  several
days,  we were enabled to discover it,  and introduce a sound into it.
  She was carried to the operating theatre, and the branches  of  the entero-
tome successively introduced, and the screw gently tightened.   By twisting
the instrument slightly, it was seen that its movements were very limited, from
which it was  inferred that the septum  had been included.  The operation was
rapid  and gave but little pain.   At first view an enteritis or peritonitis would
seem to be inevitable;  yet it seldom occurs.   It is  very singular that the gut
may be contused for the space of nearly six inches, without a bad symptom,
whilst its division by scissors gives rise to fatal  effusion.   It is on the inflam-
mation preceding the separation of the slough that our success depends.
  For a long time our  patient did well, the natural course of the discharges 
470
LECTURES  ON
  was established;  the  enterotome had  fallen off, when  the  horrible malady
  which devastated Paris  and raged  with so much fury in  the  Hotel-Dieu,
  attacked her and deprived her of the benefit of an operation which from its
  quickness and simplicity promised a most favorable termination.
    The enterotome being now well known, it only remains to give some general
  rules as to its use; they may be reduced to three principal ones.
    1st. To discover both ends of the intestine.
    2d. To perform the division of their parietes which are  in contact
    3d. To effect the cicatrization of the external opening.
    On reading the works of surgeons who have treated of hernia and artificial
  anus, nothing appears more easy than to find in all cases the lower end of the
  intestine.   It would  seem,  from their description,  very evident, and that
  nothing remained but to introduce a sound into it.  On  the contrary, I think
  it a very difficult  matter.  In a great number of cases, when the disease is of
  \cng standing, and the whole of the faeces are  discharged through the abdo-
  minal opening, neither the spur  nor  the lower  end of the intestine can  be
  discovered; there appears to be but one canal opening in the fistula.  The
  other, partly obliterated and concealed in the abdomen, has so small an opening
  that it is impossible to  discover it if chance, rather than any  anatomical
  knowledge of the parts, does not direct the instrument into it.  No fixed rule
  relative to the position of the intestine can be laid down.   According to the
  case the upper end is superior or inferior, internal or external as regards the
  lower end.  Therefore, in order to discover the latter we must examine the
 internal surface of the wound, not be,discouraged by one or several  fruitless
  attempts, and persevere until ive meet with success.
   Amongst the means which facilitate the discovery of the orifice of the lower
 portion of the intestinal canal, enemata  are of the first importance, when the
 artificial anus communicates with the large intestine.   They are also useful,
 but less frequently, when the termination of  the small  intestine is affected.
 In cases in which the difficulty is apparently insurmountable, by means of
 the tampon,  purgative enemata, and generous living, we may  succeed in ren-
 dering more apparent the lower end of  the intestine.  After having discover-
 ed the two ends, we must ascertain that there exists no  acute nor chronic in-
 flammation of the mucous membrane of the  intestines, peritoneum, nor any
 of  the organs contained in the abdomen.  The irritation produced by the in-
 strument might aggravate the disease and be the cause of death. Before per-
. forming the operation, the patient should be restricted to a moderate diet and
 diluent drinks, with the use of baths and other general  remedies  suitable  to
 the state of his constitution.  Having taken these precautions, the instrument
 may be introduced.  In order to do this the patient is laid on his back, the
 surgeon takes one blade of the enterotome with the right hand, and guiding it,
 with or without the index finger of the other, to  one of the  orifices  of the in-
 testine, introduces it according to circumstances one, two,three, or four inches
 in  depth.  It is then given to an assistant, and the second blade introduced in
 the same way and  to the same depth into the other orifice. The blades are then
 brought together and locked after the manner of a pair of forceps.   They are
 secured by giving the pivot in the handle a half turn.  It now remains, in order
 to have ahold on the intestine, to approximate the blades by pressing on the han-
 dles as with scissors, The screw passing through the elongated mortice of the 
CLTNICAL SURGERY.
471
end of the female branch is received into the  hole corresponding to it in the
male branch, and serves to tighten the enterotome to whatever de°ree may be
deemed proper.
  After having brought the parts in contact, in order to accustom  them to
their new situation, we must not be afraid of tightening the instrument  after
the first day so much as to extinguish all vitality in the tunics included by it;
by this means  we avoid prolonged pain and all danger of inflammation.  This
pressure must indeed be increased every other day, by giving a few turns to
the screw, so as to completely  destroy the circulation in the septum.
  At first sight it might be supposed that the action of  the enterotome was
dangerous; however, the patient  seldom  experiences any pain but at the
moment of its application. A few persons  alone  have  experienced colic,
nausea, and vomiting.  Substances in the alimentary canal have followed their
usual route, the inflammation of the peritoneum and intestine has not extended
beyond the vicinity of the instrument, the functions of nutrition have gone on
regularly, and we have never seen any chill, fever, or agitation.
  The  enterotome, which at first is firmly applied to the gut, becomes in a
few  days movable and projecting.   This mobility increases progressively
until it falls  spontaneously, without traction, pain, or loss of blood.  In the
cases in which I have operated this generally happens from the seventh to the
tenth day.
  On examining the instrument we will find between the blades a membranous
band, three or four inches in length, and a quarter of a line in thickness,
flattened  and withered, but which  recovers its  volume by maceration  so as
to display all the elements of the intestine which has been subjected to pressure.
  This division and  loss of substance  destroy the  spur  and double septum
which separate the ends  of the gut, and restore the communication between
them.   Indeed frequently the  first symptoms of this restoration in the inferior
portion precede the fall of the enterotome ;  in  all  cases,  slight colics take
place, and evacuations, at first of the white and albuminous matter contained
in the  inferior, and soon after the  faecal matter transmitted by the superior
intestines.
  These evacuations are, for the few first days, numerous, liquid, and attended
with colic and tenesmus, phenomena caused  undoubtedly by the irritation
of the inferior portion, by the contact of faeces to which it had been so long
unaccustomed.  These gradually cease, the discharges become more consistent
and regular, the  appetite  moderates, and strength  and plumpness  take the
place of weakness and emaciation.
  After the fall of the enterotome, the artificial anus rapidly diminishes in
extent,  until a very small opening  remains ;  but here it sometimes becomes
stationary and resists all our efforts.  Neither recision of the  edges of the
fistulous orifice, their union by suture, nor their repeated  cauterization, nor
instruments invented in  order to keep  them in contact, seem to exert any
influence over their cure.  Compression alone, by  means of a truss or any
hernial  bandao-e under the pad of which are  placed  several compresses, has
succeeded in cases where  all other means have failed. During the application
of the enterotome we should prescribe strict diet, diluent drinks, rest, emollient
fementations and mucilaginous enemata.   Colic, fever, hiccough, nausea, and 
472
LECTURES ON
 vomiting must be combated by general and local bleeding, the strictest diet,
 and even narcotics and antispasmodics.
   Should, the patient after the entire cicatrization or  contraction of the
 anormal opening feel suddenly colic, nausea, vomiting, and all the symptoms
 of retention of faecal matter, we must, if they do not yield to internal remedies,
 divide the cicatrix and give a free exit to the accumulated substances.
   Case V.—Louis  Trubert, a farmer, 42 years of age, married and the father
 of five children, was admitted on the 15th of March, 1824, into  the Hotel-
 Dieu, for an artificial anus.  He was naturally of a melancholy disposition, and
 extremely limited in his intellect.  His  aspect  was yellow, and clayey, and
 his weakness and emaciation very great.
   Some violent exertion, eighteen  years previous to his  admission  into the
 hospital,  had given rise to an inguinal  hernia on the left  side, which  he
 neglected, and which fifteen years afterwards  had acquired the size of a full
 grown foetus, and was nearly entirely irreducible.
   Irritated by its size, and impressed with the idea that he was the object of
 public derision on  account of his disease, he  determined to  remove it by an
 operation.  With  this  intention, he  made a large incision in the scrotum,
 opened the hernial sac, and was only arrested by the appearance of a fold of
 intestine  of about eighteen inches in length.   A physician was called, who
 after enlarging the wound reduced the strangulated intestine. The patient
 recovered, but his hernia and mania persisting, his want of success onlv served
 to fix the idea more strongly in his mind.
   On the 22d. of February, 1824, three years after his first attempt, Trubert,
 to use his own expression, fell to work, and with a common knife which he
 had sharpened he again divided the scrotum, seized the intestine which pro-
 truded and cut off a large portion of it.
   The pain and discharge of blood and faeces again overcame his firmness; he
 threw aside the knife, and cried for a surgeon.   The latter again enlarged the
 wound, sought the ends of the divided gut, and united them by some stitches,
 which succeeded not in  the adhesion  of the parts, but in the establishment
 of an artificial anus.
   On his admission into the hospital, there was on the left  side of the scrotum
 an elongated tumor, as large as the head of a foetus at full term, and  extending
 from the inguinal ring to the bottom of the testicles.   It was  hard, resistant,
 partly reducible, and presented anteriorly and inferiorly a wound  of a deep
 red color, formed below by the scrotum, above by two ends of intestine folded
 on itself and  in such a manner as to form  several contours ; they were placed
 along side of each other, the right discharging semi-fluid faeces mixed with
undigested matter, such as pieces of carrots and  vegetables.  This discharge
was  continual and involuntary, the other  end  being contracted and without
discharge.
  The patient complained of severe pain in the wound and its vicinity, colic,
and besides a permanent pain accompanied with tension in the left iliac region ;
he was moreover in a most disgustingly  filthy condition,  rendered worse by
the habit of kneading his excrement, as is often the case with maniacs.
  After  some days  the  ends of the  gut  were  reduced  and a compressive
bandage applied over the accidental opening; enemata were administered and 
CLINICAL SURGERY.
473
food cautiously given; the compression, however, was insupportable, and was
abandoned.
  Notwithstanding an increase of the quality of his diet, the patient daily
grew thinner and weaker; I then determined to endeavor to ascertain the
relation and situation of the two ends of the  intestine, and found that the
gastric end dipped into the bottom of the scrotum, forming there inextricable
convolutions, and the rectal end was directed towards the inguinal canal.
  At first our endeavors were limited to his nourishment and cleanliness, and
on the 31st of May, being convinced, that notwithstanding his weakness and
emaciation, there was still a chance for  his recovery, I  determined on the
operation, which was performed in the presence of M. M. Larrey, Aumont,
and  Sauson.
  The blades of the enterotome were introduced successively into each end
of the intestinal canal and  as deeply as possible.   The blade placed in the
gastric portion  would enter only about two and a half inches or three inches,
the instrument was therefore fixed at this depth.  On the first day, there was
slight pain in the belly, and  a free discharge from the artificial anus.  Second
day there was slight oedema and redness around the anormal opening; a gleam
of pleasure was evident in the countenance of the patient.  Third, fourth and fifth
days he seemed still better.   Sixth and seventh had slight colic. Eighth day
the instrument fell, and the two cavities of the intestine now formed but one.
  As usual in the  groove  of the female branch, the septum of the intestines,
composed  of eight coats, was found; it was at least three inches long, black
and  dry.  From  this time  enemata  were administered every day.  Some
flatus passed through the inferior portion of the gut, but the  faeces were dis-
charged from the artificial anus, and the patient was still weak and emaciated.
Fifteen days  after the operation Trubert thought there was a  discharge from
the fundament, and the.size of the. tumor began to diminish;  some time after,
he suffered  from  violent attacks  of colic, threatening to exhaust  his little
remaining strength;  but the evacuations were established through the natural
anus, they became regular, and he soon recovered his strength and plumpness.
  The size of the  tumor did not diminish as much as might have  been ex-
pected : the artificial anus  continued to  discharge  some faeces: persuaded
that  in order to oblige them to follow the natural direction it  would be suffi-
cient to close hermetically the  accidental aperture, I applied a compress,
which kept the  edges of the wound  in contact.   The event justified the pro-
ceeding ; nearly the whole of the matter was discharged by the natural anus,
and  afterwards, a  little more  pressure forced that which  still distilled from
the lips of the wound to  follow the  same route.  Then all discharge ceased
from the  artificial anus; and for the first time since his admission into the
hosoital a smile was perceived on the countenance of the  patient, hitherto
stamped with pain and grief.   The  compress,  however,  sometimes fell off,
and sometimes produced excoriations, obliging us to remove it.  The discharge
was  then  renewed through the  artificial anus.  This observation  frequently
repeated convinced  me  of  the necessity of using  some  method sufficiently
"•eiitle to be borne, and firm  enough to oppose the discharge:  with this inten-
tion  I had recourse to a hernial bandage, which  proved entirely satisfactory.
These divers plans for  compression had not only the desired effect, but yet
another, which  was unexpected, namely to reduce the hernia, of which the
                     60 
474
LECTURES ON
size had been so great an inconvenience.  Since final restoration of the course
of the fasces by the natural passage, the patient has recovered his strength
and good looks, and this improvement coincided so exactly with the discharge
from the  rectum, that his countenance served as an index of the state of the
function.
  Thus in less than five months  was cured a patient who had twice  opened
a large hernial sac, and  once removed a large portion of the contained intes-
tines, and who in consequence of this wound had been affected with artificial
anus complicated by a hernia and inversion of the intestine.  Brought to the
last degree of marasmus by want of nutrition,  he only began  to recover his
strength from the date of the restoration of the  natural  passage; and  what is
still more remarkable, he was relieved at the same time of an enormous her-
nia, of which the  existence had suggested to him  the idea  of removing it
himself.
  We might easily multiply the cases of artificial anus cured by this method;
but it will suffice to give the general result of the operations performed during
a certain number of years.
  From 1813 to 1824 forty-one operations of this nature have been performed,
twenty-one by  ourselves, and  twenty by  other  surgeons, amongst whom we
name with pleasure M. Lallemant, of Montpelier. Three fourths of them were
in consequence  of gangrene following strangulated hernia, and the remaining
fourth of wounds with more or less considerable loss of substance of the alimen-
tary canal.  Of these forty-one cases three have died; one from supposed effu-
sion of fgecal matter, one from indigestion, and a third from  acute peritonitis.
Of the thirty-eight  remaining,  the majority had  not  an unpleasant symptom:
some  it is true suffered from colic, nausea, and  even vomiting, but they
were soon relieved by  effervescent draughts and the application of leeches to
the anus, and emollient fomentations to the abdomen.
  The cure has not  been  equally perfect in all these cases.  In nine there
have  remained  fistulas  of various extent, obliging the patient to wear con-
stantly a bandage in order to prevent the escape of  flatus, mucous,  bilious or
faecal matter.   The other twenty-nine were radically  cured  in  from two to
six months.  The fatality has therefore been one in fourteen; and taking away
the one who perished accidentally from indigestion, it is reduced to one twen-
tieth  of the cases operated upon ; a result much more favorable than generally
obtained in great surgical operations. Lastly, it is to be remarked, that the last
fourth of the patients, although  less fortunate and  obliged to wear a bandage
with a pad, were in a situation incomparably preferable to that in which  they
had previously  existed.
                        CHAPTER  LIV.

         ON DIFFUSE PHLEGMON--ITS CHARACTERS AND TREATMENT.

  I have frequently spoken in my clinical lectures, said M. Dupuytren, of a
species  of phlegmon to which I have given the name of diffuse phlegmon, a
designation which has  since  been  generally  adopted here.  This  disease, 
CLINICAL  SURGERY.
475
though very frequent and severe, has been passed over in silence by most au-
thors, while it has been confounded by others with its complications, and de-
scribed by modern  writers under  the  names of phlegmonous erysipelas,
erysipelatous phlegmon,  traumatic  erysipelas.   Many have mistaken it for
phlebitis, inflammation of the lymphatics, and some other affections.
  The expression diffuse phlegmon has been adopted to distinguish this dis-
ease from that in which the phlegmon is  circumscribed.  Whence is this dif-
ference ?   An examination  of the phenomena of each will explain it.   Let
us take as an example of circumscribed phlegmon, a patient whom you have
seen in one of the wards.
  Case I.—Circumscribed  Phlegmon of the Thigh.—This man, after some
violent exertion, experienced pain in the upper and internal part of the thigh.
To this pain soon succeeded redness, swelling and tension of the part, with
local fever.  Still these  circumstances did  not give rise to any general reac-
tion.   The disease increasing, the patient was prevented from working, and
came  into the hospital.  Having often seen slight excoriations on the foot or
leg cause frequently a considerable phlegmon in the groin when seated over
some  of the  lymphatics, we examined   these parts  very attentively.   We
could find nothing  to account  for the  disorder, and were inclined to admit
the  existence of an  idiopathic  phlegmon;  that is, one  developed by some
local cause, either internal or external, but without any effect foreign to or
removed from its situation.
   At this spot  the  skin was red, hot,  swollen and tense, the least pressure
gave acute pain ; and phlegmon, which for ages has been taken as the proto-
type of inflammation, justified  entirely, in this case, the opinion  of the an-
cients upon  this disease.   But I should also add, that, in all inflammations
the  degree of the disease varies; thus, one or  several of the symptoms of
phlegmonous inflammation are often wanting; in internal phlegmasiae, called
latent, there is no pain ; and that tumefaction is absent, or nearly so, in phleg-
masiae of the serous membranes, and  especially of the  arachnoid.  Never-
theless, in this  species  of inflammation we observe a slight swelling and en-
gorgement of the  cellular tissue adjacent to the diseased membranes.
   When the phlegmon is limited to a small space, as in furunculus, anthrax,
 &c,  the fever  is  local and limited, and often gives rise to no general  pheno-
 mena. But if it be large and extensive, if it occupy the arm-pit or hollow of
 the ham, a symptomatic reaction takes place, the fever becomes general.   This
 phenomena,' it  is true, is not absolutely necessary for the diagnosis of an ex-
 ternal phlegmon; but such is not the  case  in internal phlegmasiae.  Here
 reaction instructs us in our opinion;  not that the want of general reaction
 suffices to remove  all idea of their existence, for, as I have  said, in chronic
 phlegmasiae fever frequently does not exist, or is scarcely evident.
   While treating of febrile complication, it may be  useful to recal  to you
 that in suro-ical operations, an amputation of the leg for instance, fever gene-
 rally comes  on about the third  or fourth day ; this is the traumatic j ever, of
 which easily distinguished when simple and isolated, the diagnosis becomes
 very difficult if it be accompanied, as is often the case, by an internal phleg-
 masia such as pneumonia, hepatitis, &c.  If this internal inflammation causes
 no local pain, and be not revealed  by well marked symptoms, this complica- 
476
LECTURES  ON
  tion  is exceedingly embarrassing, and it  is impossible to distinguish if the
  fever be the effect of the operation, of an  internal inflammation, or of both at
  once.  Soon, indeed, other  symptoms appear, and  the  internal affection be-
  comes evident; but the disease is generally then beyond the reach of art.
    What we have just said will serve to give you a just idea of the principal
  characters of circumscribed phlegmon.  In order to  determine those of diffuse
  phlegmon, we  will again  recur to one of the numerous examples offered by
  this hospital, and then  pass to the exposition  of  our notions of this disease,
  taking care to confirm by cases the principal points.
    Case II.—Diffuse Phlegmon of the Left Leg.—Damiens, a washerwoman.
  aged  68, rather fat, met with  a fall  by which she bruised her leg pretty se-
  verely, but without producing any wound.  The pain at first was slight, and
  accompanied by very circumscribed redness; these symptoms, however, went
  on increasing;  the limb became swollen; fever  supervened;  and she  was
  brought to the hospital, but not for twenty days after the  accident   At this
  time the limb was the seat of very  active inflammation, and the epidermis de-
  tached at several points.   At the inner part, between the middle and lower
  third  of the limb, there was a blackish rounded eschar,  about two inches
 in extent.   Around it,  and at other points  in  the  same situation, mani-
 fest fluctuation was  present.  The eschar was divided,  and we then arrived
 at the depot, from which issued a  considerable quantity of very fcetid, sani-
 ous pus.  A counter opening was made higher up,  and this also gave exit to
 fluid of the same  character.  When  the  soft parts were pressed, it did not
 appear that any communication existed between these  two  collections.  The
 limb was then dressed and placed on pillows; a small bleeding was practised,
 and injections administered, in consequence of the  bowels  having been con-
 fined for some days.   On the fourth day the eschar became detached, and left
 a large opening, which gave vent to an immense quantity of foetid pus.  On
 the fifth, the disease  had  made farther progress, and soon extended over
 the greater  part of the  limb, notwithstanding the  repeated application of
 leeches.
   In other situations, continued M. Dupuytren, diffuse erysipelatous phleg-
 mon frequently  terminates in resolution, but in the lower extremities suppura-
 tion always takes place.  The cellular tissue of these parts passes as rapidly
 into suppuration as that about the eye-lids.  This termination is very unfavor-
 able in diffuse  phlegmon, and  brings  with it the destruction of  the cellular
 membrane.   In  fact, the  pus is poured out,  not into one cell, not into a gene-
 ral cavity, but into each little individual cell, forming a numberless collec-
 tion of distinct  depots.  Thus,  where suppuration takes place the cellular
 membrane  is destroyed in large pieces; I have frequently removed portions
 half a  foot  long.  The skin now becomes attenuated, and being deprived of
 nourishment, perishes from this cause, and not from inflammation.
  This consecutive gangrene of  the skin is  very common in the lower extre-
 mities, particularly the leg, where the  arteries of nutrition  (the anterior and
posterior tibial  and peroneal)  are deep-seated, and  do not communicate
with the skin, except  by very minute  anastamoses, and which are destroyed
by the  death of  the subjacent cellular  membrane.  This  gangrene, however,
is extremely rare on the head, where, nevertheless, this kind of phlegmon is 
CLINICAL SURGERY.
477
frequent.  The distribution of the arteries, however, is very different; situa-
ted between the skin and the occipito-frontalis aponeurosis, they are so united
with the skin that it is difficult to separate them even in dissections.
  If a phlegmon takes place in this situation its seat is always between the
pericranium and aponeurosis; if suppuration occurs speedily, and is limited
to the cellular membrane, without implicating the pericranium, the disease is
not mortal; but, on the contrary, it is usually so if this part be destroyed or
denuded.  But  the skin  escapes destruction, because the  arteries continue
to supply it with sufficient nourishment; even if the whole of the cellular
membrane of the cranium were to perish, it would not cut off the arterial sup-
ply to the skin.
  The causes of diffuse phlegmon are numerous.   It frequently results from
bleeding, even when properly performed and with a  clean instrument; so
also the ligature of a vein may produce it; and in  this as  in the preceding
case, the vein itself may or may not be inflamed.  The inflammation in these
instances may occupy  the whole thickness of the limb, or only the course of
the vessel, and then it is only diffuse in a longitudinal direction.
  When diffuse phlegmon  is the result of venesection, sometimes the opening
made by the lancet  closes, as is usually the case; sometimes it closes and after-
wards  opens, but most generally cicatrization does not  take place.  In all
cases great tumefaction ensues, which  is either limited  to the fore-arm, or
extends to the arm, arm-pit, &c,  if its progress be not arrested.   Sometimes
the vein partakes of the inflammation, and again it is sometimes healthy.  The
following is a case  arising from this cause.
  Case III.—Diffuse Phlegmon of the Right Lower Extremity, following
Venesection in the Foot.—A washerwoman, 25 yearsof age, of good constitu-
tion and lymphatic  temperament, was admitted into one of the medical wards
for amenorrhcea.  She was ordered to be bled in the foot; it was done, but in
a very awkward manner.  Three  different attempts were made over the right
external malleollis  without success.  A more skilful pupil came, who opened
immediately the saphena  on the  left side.   The first punctures were very
painful; the pain continued, and ten days after  the operation the right foot
became much tumefied.   The swelling increased and extended to the leg;
the skin was  red,  hot, tense: she suffered from  acute pain, insomnia, and
raging  fever.   Leeches  were applied and  the  foot and leg  covered with
emollient poultices.  Nevertheless the inflammation reached the  knee, the
whole limb was  of  an  enormous size, and fluctuation could be felt in some
places.   The extremity soon became the seat of the most intense phlogosis,
the mind of the patient began to wander, delirium, nausea, vomiting, diarrhoea,
and a morbid sensibility  of the   abdomen  ensued.   In  this  state she was
brought into our wards, about twenty days after the accident.
  She was bled immediately in the arm, and two long incisions made on the
back part of the  foot, giving exit to a quantity of fetid and sanious pus; lastly
a third long and deep  incision at the  upper internal part of the leg, where
was also a large collection of pus.   The  delirium continued all night, the next
day she had vomiting (30 leeches  to the epigastrium).  3rd day. The skin
of the dorsal face of the foot sloughed off, and left the  extensors of the toes
denuded.   The delirium had ceased, but  the patient was exceedingly ex-
hausted ; the diarrhoea continued, and the thigh was highly swollen and 
478
LECTURES  ON
inflamed (40 leeches to this spot).   4th day. The fever has abated, thirst less,
diarrhoea  inconsiderable; but another  purulent  collection has formed on the
external inferior part of the the thigh. It was freely opened, and a prodigious
quantity of pus  discharged.  As had been done  with the other incisions, the
lips  of the  wound were kept  open, and the limb surrounded by a  large
emollient poultice.
  As the sloughing of the skin daily increased, I feared  that  amputation
would be necessary.    Yet the patient  retained  her  strength, despite  the
numerous causes of exhaustion.  Again, where  could the operation be  per-
formed ?  The disease had extended to the  thigh, where purulent abscesses
had formed.  On the other hand, the fever was high, and there was still some
diarrhoea.   All these circumstances contraindicated the operation, and  my
attention was directed to diminish  the intensity of the  symptoms, arrest  the
diarrhoea,  abate  the fever, and support her  strength.  The limb was dressed
twice during the day.
  It was only after six weeks from the commencement of the disease, that the
inflammation appeared to yield freely.  The tendons of the extensors exfoli-
ated  and fell off with the dressings; the  process of reproduction began, the
diarrhoea and fever had ceased.  We were therefore fortunate in having given
nature time to develop her resources, and thus preserved the limb.  At the
end of two months she had  recovered  her  natural color and appetite, and
slept well; the incisions made  in  the leg and thigh were healed, the wound
resulting from the loss of substance filled with healthy granulations.  Simple
dressings and perfect rest were ordered, and  the  granulations to be touched
every three days with nitrate of silver.   About the end of the third month a
small abscess formed behind the right external melleolus ; it was opened, and
the  pus evacuated.  In eight days it  had healed.  Soon after the menses
appeared,  the patient rapidly recovered, and left the hospital about the middle
of the fourth month, unable as yet to execute any but very slight movements
with the diseased limb.
  Diffuse  phlegmon is the most frequent disease  produced by morbid poisons
applied to the skin or cellular membrane, as  in the  opening of bodies.  It is
sometimes unaccompanied by inflammation of the lymphatics, or engorgement
of the axillary glands.   Nevertheless, these are generally the first symptoms
which attract notice.
  Excessive fatigue during forced marches is also  one of the most frequent
causes of diffuse phlegmon, which then presents such intensity, and is accom-
panied by symptoms so severe,  as almost  invariably to prove  fatal.   This
malignity  is owing to two causes, one  local, the other general; namely, the
fatigue of the limb, and the exhaustion of nervous energy by the prolonged
action of the muscles.
  Persons  laboring under  comminuted  fracture, particularly  if produced
by fire arms, are very liable to a consecutive inflammation situated in parts
adjoining  a fractured bone, and this often assumes the character of  diffuse
phlegmon.  It is also frequently seen after capital operations, and as a com-
plication of various injuries, especially burns.   It has  also been known to
follow the application of the linimentum  ammoniaeto leech bites.  Numerous
observations also show that it may arise from very slight punctures and wounds
without any poisonous inoculation, or from a considerable muscular exertion, 
CLINICAL SURGERY.
479
or even from  the friction  of rough clothing.  Lastly, diffuse phlegmon is
sometimes developed spontaneously, or at least without any assignable cause
  I shall illustrate these statements by some examples.
  Case l\ .—Extensive Diffuse Phlegmon of the Left Upper Extremity from
a Bite  on the Little  Finger.—Boyer, aged 27, a  mason, playing with  some
companions, threw one down, who getting angry bit him in the little finger of
the left hind.  The pain was very acute and the part bled freely.  The pain
continued, and the next day it was followed by tumefaction speedily extending
to the hand and fore-arm.
   Ten  days after, the time at which he was brought to the Hotel-Dieu, the
left arm was more than double its natural size; the skin was hot, very tense
and painful; the little finger exhibited  a small transverse wound at its anterior
surface, which implicated the skin, cellular  membrane, sheath of the tendons,
and from which issued a small quantity of whitish pus.  Obscure fluctuation was
perceived in the  palm of the hand. A longitudinal incision was made  there,
from which a considerable quantity  of  pus  flowed.  The  limb was placed
in  a half bent position on  a pillow, and covered with emollient cataplasms.
   Besides these  local symptoms, there was violent fever, with rapid  pulse,
hurried breathing, hot skin, &c.  (A large bleeding was practised in  the arm,
 soothing drinks, and  rigorous diet ordered.)
   The twelfth day of the accident the patient was much better.   1 he general
 symptoms and those of strangulation were partly removed.   During the night
 an opening of considerable size was made on the  cubital edge of the hand ;
 and the upper part of the fore-arm being still tense, thirty leeches were applied.
 (Local baths, cataplasms.)
    On the 15th day there was very marked fluctuation near the head ot the
 radius: a free incision was made in that situation, in which a piece  ot lint
 was placed after the exit of the pus.   The fever had entirely  disappeared.
    On  the 17th day the patient was affected with slight colic and diarrhoea.
  (Emollient enemata with eight  drops of laudanum in each, rice water for his

  d"I^elht days the symptoms of intestinal irritation had ceased  the suppura-
  tion was healthy, but the inflammation still progressing: on the29thday another
  on-nTS hS Jbe made at the front of the fore-arm, after which the health
  wPas speediry re-established, and the cure was perfect in two months from the

  '"CASE 'y-D^ Phlegmon of Right  Arm from  a Thorn in the  Middle
  F^-  Spontaneous Phlegmon of  the Lower Extremity; Death.-Ke^
     g  il 31 47 nresentint the appearance of premature decrepitude, acci-
  a female aged 47 Fesen» =     ^ middle fi Fer.  She couid not give any
  dG    Account o the symptoms which followed?** it appeared by her story
  precise account of the y^ p                 ^^ fe ^ ^
  that the Anger had swelled an            tro.intestinai disturbance.  At the
  and arm and1 Aatrt*^™ -eoedw   ^      ^ ^ ^ ^
  time of ^.^^extrcmily were aboutlhree times their natural size.
  hand  and all the ^e^J^ dry;  the tongue parched, the conjunc-
  The pulse ™J^*6^^tL house surgeon immediately bled her in
  to^'M^^™***™  Next day 40 leeches were 
480
LECTURES ON
 applied to the limb, particularly about the hand.  The cataplasms, fomenta-
 tions and semi-flexed position were continued, and gave great relief.
   On the fifth day, however, the patient complained for the first time of pain
 in the knee.   On  examining  it considerable swelling was perceived, with
 fluctuation, without any discoloration of the skin.  Twenty leeches, fomenta-
 tions, and semi-flexed  position of the limb were  ordered.
   On the seventh  day several  purulent depots were opened in the hand and
 along the inferior edge of the wrist; the bones were denuded. The state of the
 patient now excited great apprehension.   The  tumefaction had much dimi-
 nished in the upper extremity, but that of the lower limb had augmented and
 extended itself to  the thigh.  The gastric disturbance became intense, cere-
 bral symptoms  supervened, and the patient sank on the ninth day after her ad-
 mission into the hospital, notwithstanding the most anxious and active atten-
 tion shown to her case.
   The facts just related, continued M. Dupuytren, give you some idea of the
 character of diffuse phlegmon;  but we must enter more into particulars.
   The onset of diffuse  phlegmon, and especially of that which is spontaneous,
 is announced by a rigor of greater or less severity;  this is followed by heat
 and  fever.   This fever becomes continued, only it has paroxysms and remis-
 sions two or three times a day, and these have often led to such erroneous
 views as to occasion their being treated by means of cinchona, on the idea of
 there being attacks of ague.  It is not unimportant to  keep in  mind the dis-
 tinction between symptomatic and  intermittent fever.
   A slight degree of pain of the skin frequently  comes on 24 or 36 hours be-
fore  the shivering.   More than once where this pain has been the only symp-
tom, I have been able to predict  the disease.   The skin then becomes of a
roseate  hue.  This  color is not uniform;  and one might as readily anticipate
an attack of erysipelas as of erysipelatous phlegmon if a little oedema did not
show itself  in the subjacent cellular tissue, accompanied by perceptible pit-
ting on pressure.   What practitioner not familiar with the affection could,
from such appearances, foretel the  approach of so terrible a disease ?
   The symptoms increase, the fever runs higher, the finger applied, pressed
 strongly upon  the  skin, no longer makes  any depression, but meets with a
marked resistance, the  cellular membrane becomes hard, the color passes in-
to a violet, and phlyctenae make their appearance; the bowels are sluggish,
the urine is diminished  or suppressed, the patient is deprived of sleep, and
his agitation is extreme.
  For  two, three or four days the disease seems  now to be stationary.   If at
this  time an  incision be made  into the  part, a milky serum  escapes; it is
abundant, and with  but little pus.   A few days  later, the serosity is scanty,
while the pus is plentiful; yet a few days more, and there exudes a discharge
as white as milk, and  almost as consistent as lard.   The cellular membrane
is now struck with suppuration (frappe de suppuration), and this is equivalent
to saying it is struck with death.  Experience alone teaches us to distrust this
deceitful stage ; it has  often enabled  me to declare the  existence of suppura-
 tion, contrary to the opinion of surgeons less accustomed to the disease.
   At length, in a day or two, the skin bursts, the phlyctenae pierce the integu-
 ments, a violet colored  serum exudes.  White or black sloughs are perceived 
CLINICAL SURGERY.
481
beneath, which rapidly extend;  the surgeon then only becomes  aware of
these ravages, when they have already run their course.
  The period of the separation of the skin is thatat which fragments of the cel-
lular tissue are detached.  The skin is therefore separated, its adhesions de-
stroyed, so that it can be raised by  blowing under it. Beneath here and there
little projections are seen, the only bond union of which remains, and these are
composed of vessels and nerves which have resisted the destructive process.
Great care must be taken  not to destroy these last adhesions, as  was done
some fifty years ago.
  At this  period  of the disease redness  and sensibility still exist at some
points in the skin ; but here experience teaches us not to rely on these decep-
tive signs, for  these portions of skin are  like the others irrecoverably lost.
After some days they fade, lose their sensibility, become violet colored, and
fall from want  of nourishment without pain.
  The  local ravages  are now arrived at their term, but not so the danger of
the patient.   You  may be satisfied of this from the example of a man in the
hospital who had  fallen upon  his knee.  An erysipelatous phlegmon  super-
vened, and  extended  rapidly over  the  leg and  thigh, notwithstanding the
most active' means.  The aponeurosis of  the thigh was exposed, the tibia
and patella were laid bare to the periosteum, the entire limb  was deprived of
its  cellular  membrane  and  skin.  What  could  the  efforts of nature avail
against such extensive  mischief?   Art was equally powerless.  A suppura-
tion of  enormous extent, amounting sometimes to a pound and a half or even
two pounds in  the day, rapidly exhausted the strength ; and this young man,
though  of the  best possible constitution, unavoidably sunk under it.   If, in-
deed, the suppuration had been the  only bad symptom, something might have
been hoped for from the combined efforts of nature and art;  but copious per-
spirations and  purging to the extent of ten or twenty stools daily, were con-
joinedwith the preceding.  In vain were these also combated, for yet another
set of symptoms came on ; almost always, indeed, towards the,latter stage,
does suppuration in the pleura, lungs, or liver fill up the melancholy picture.
More than one half of such patients sink at last from internal inflammations,
especially of the liver or lungs.  Such is the history of this affection, which
proves more than any other of the phlegmasiae.
  Let us now consider the chief points attending it.  I have particularly
alluded to the fever coming on in paroxysms, which appear two or three times a
day ; it is often mistaken for intermittent, but it is nevertheless a continued fe-
ver, and often accompanied by adynamic symptoms, which necessarily produce
a change in our treatment,  f have long insisted on this period of a deceitful ar-
rest of  the symptoms,  about the fifth or sixth day, which keeps even the most
experienced practitioners in doubt; and so far misleads the inexperienced as
to induce them to think resolution is at hand when suppuration is already de-
clared   I  have also dwelt upon the fact, that while in circumscribed  phleg-
mon the pus is contained in one or two cells, here it fills each particular cel-
lule of the tissue, and, after the manner in which when  the  muscular
structures become involved in the disease, strangulation takes place, which is
speedily followed  by gangrene, unless relieved by free incisions.  These at-
tacks, less dangerous in children, are alwavs alarming m adults, almost con-
               61 
482
LECTURES  ON
stantly fatal in elderly persons; while if the patient escapes, the convalescence
is of the most lingering kind, the cicatrization very difficult to effect, and the
cicatrix always prone to give way again.
  But one of the most important points to be attended to is the state of the
digestive organs which precedes, accompanies, or follows the breaking out of
the disease.   Already, before  it became the doctrine of our schools, had 1
pointed out the changes which are found in the alimentary canal after death ;
I shall therefore pass on to what is most important in  reference to the treat-
ment.
  Treatment.—This form  of  inflammation may depend upon a cause which
is either external  or internal, most  commonly the former, but complicated
with internal symptoms.   If  a contused or  lacerated wound be made in a
person otherwise healthy, and who has no affection  of the prim.x viae, it is
very uncommon to see diffuse phlegmon produced, or at all events it is easilv
combated; but on the contrary, if gastric symptoms precede or follow the
accident, symptoms of this kind of phlegmon come on loo often without our
being able to repress them.   If a wound without internal complication give
rise to it, though it be contused or lacerated, it must  have been irritated bv
exposure, by violence, or by the friction of the clothes; in short, it must have
been envenomed in some way or other.
  In the treatment, then, every thing  calculated  to cause irritation is to b»
sedulously avoided.  If the wound appears to be becoming inflamed, if there
be any engorgement  of its  edges, any tumefaction about it, leeches must be
applied ;  and  if the  patient be  robust, one or two general bleedings will be
required.   It is often useful, to precede the application of leeches by general
bleeding; if  the order be  reversed, the leeches, in place of unloading the
part, frequently cause an increased flow of blood to it, and thus augment the
evil.
  Bleeding, general  and local, in diffuse phlegmon,  ought to be accompanied
by general, or at all  events local bathing.   These must be of an emollient
kind, such as poultices ; or still better, cold, demulcent, and  sedative appli-
cations to the part.  If the cellular inflammation has  commenced, the baths,
leeches, cataplasms, sedatives, &c. must be again had recourse to;  and this
antiphlogistic treatment is that which  is best adapted to  the first  stage or
onset of the disease.
  But  if the wound  be narrow, if the inflammation appear dependent upon
strangulation of the parts, simple or crucial incisions must be practised with-
out delay, and local inflammation is often  then arrested, and its spreading
prevented. Rigorous diet and diluents are also indicated. There is, however,
a third expedient which  I  have been  in the habit of using, namely, a large
blister  to the  wound and skin adjoining it.  The irritation which it produces,
and the suppuration sometimes prevent the development of the diffuse  phleg-
mon.
  But  if before or after its appearance there be gastric disturbance, if the
tongue without being red at the point and edges is covered at  the base with  a
yellowish coating, if there be loss of appetite, nausea, with little or no tender-
ness at the epigastrium, one or even two emetics may,be advantageous;  and
gentle  purgatives, if the intestinal canal be itself affected, by which the course 
CLINICAL SURGERY                        483
of the phlegmon  is either suspended or rendered less troublesome.  It is a
truth  of which you may be well assured, that  emetics and purgatives, form-
erly too much employed, have now fallen into too great neglect.
  If the phlegmon be fully developed, if after a contused or lacerated wound
swelling of the parts comes on, if the cellular membrane adjoining be already
oedematous, one or two small bleedings may still be of service; I say small,
for  by large  abstractions of bldod we run the risk of reducing the patient to
an unpleasant state of depression.  The remedies above mentioned are to be
assiduously put in  force; the parts to be freed by incisions, and maintained
in an  elevated, very elevated position,  to obviate the congestion as much as
possible, and the cold sedatives to be constantly used.   As to the cataplasms,
so much used at other hospitals, I regard them as often injurious by keeping
up the local discharge. If the symptoms continue or increase, 1 cannot venture
to recommend blisters, having seen results so different from them that I  fear
to apply them.  Sometimes they produce a speedy resolution ;  but at others,
though  rarely it is true, they have been evidently the cause of  sloughing.  I
am  indeed  the more anxious to insist on this point, because in various theses
and other works the success I have obtained has been much exaggerated.  It is
not in phlegmon alone, but in almost all cases of erysipelas, that I recom-
mend  these  remedies, and in  fact  use  them with great advantage.  But if
they b6  sometimes hurtful in  diffuse phlegmon, still  more frequently they
exert no influence of  any kind over its  development.
  About the fourth or  fifth day the cellular tissue is almost always struck with
inflammation.  Ought then the  pus to be left in these little cells, or should
we  hasten  to free it by incisions ?  Such  incisions sometimes diminish the
inflammation and suppuration, which ensue;  but on the other hand they often
also increase them.  It is necessary, then, at this stage al$o of the  malady
to insist upon the application of sedatives and refrigerants.  But if the sup-
puration be definitively established, hesitate no longer; cut freely into those
parts whose  dependent situation renders them liable to become receivers of
the pus ; renew the dressings  frequently, and take care at each time to re-
move all the pus by sponges.
  If, notwithstanding all  your efforts, the skin  perishes for want of nourish-
ment, it is  then  above all that we must endeavor to support the strength of
our patient,  for it is then  especially that adynamic symptoms are most apt to
appear.  If you cannot prevent them,  meet the .first symptoms with unirri-
tating tonics, and those which follow with gentle antispasmodics.  Spirituous
preparations and even wines are hurtful; substitute for them an aqueous infu-
sion of cinchona, and apply the bark itself externally to the parts; if onrthe
contrary gangrene  is  imminent from excess of inflammation, we must again
recur to antiphiogistics and cold sedatives.
  It is at  this time that the state of the cellular membrane comes on which
is designated  by the expression "struck  with suppuration."   Sometimes
enormous portions of the  skin are detached ;  assist their removal, but care-
fully avoid  any forcible pulling, and spare the attachments which remain be-
tween the  skin and subjacent parts.  These bands consist, as has been said,
of vessels and nerves, and their laceration gives pain, or causes haemorrhage.
neither of which the patient can bear without injury.   A new treatment now
commences:  it is  here that the art of dressing becomes of importance. 
484
LECTURES  ON
 Wherever the pus  collects  it must be freed by incisions, and evacuated bv
 gentle  compression, while the vitality of the  skin must be stimulated by the
 application of cinchona or spirituous lotions.  By the combined efforts of
 nature  and art the skin, in  successful cases, is seen to  become  as it were
 glued again to the subjacent parts, and we may then know that the danger is
 on the decline ; and everything is to be done to facilitate the cicatrization of
 the  denuded  parts.  Sometimes  the inflammation runs too high for this pro-
 cess, and then leeches and low diet must again be had  recourse to.  The exu-
 berant granulations are to be kept down with nitrate of silver;  and a solution
 of this  is often very serviceable at this time, the strength being four, five, or
 six grains to the ounce.
   The following is the plan of dressing which ought to be adopted : the edges
 and a very small portion of the surface of the wound are to be covered with
 little slips of bandage spread with cerate.   In this way the laceration of inci-
 pient portions of cicatrix is prevented when the dressings  are again removed.
 The rest of the surface of the wound  must be covered with compresses of
 fine  soft linen spread with cerate and pierced with a number of holes, in the
 manner I have been long accustomed to adopt in burns.  The holes allow the
 matter to escape, which is thus prevented  from remaining in contact with the
 wound ; besides which, the greatest advantage is obtained in being able to re-
 move all the dressings in one mass, and with the greatest ease.
   During the whole period of treatment  the  greatest attention is required
 with  regard to the diet of the patient, and prevent  him  from the least ex-
 posure to cold or damp.  I have opened a number of bodies (said M. Dupuy-
 tren) of those who have sunk under this disease, and I have observed that of
 those who died  towards the  end  of this affection, the phlegmon has seemed
 less  the cause of death than some internal inflammation resulting from some
 imprudence.   Pleurisy, pneumonia, and hepatic abscess were the most com-
 mon, and then followed exposure to  cold of the chest  or limbs.
   If the phlegmon be situated on the lower extremities the patient must hot
 be allowed to get up and walk; these movements give rise to determinations
 of blood, and this may prove the immediate cause of a return of the phlegmon,
 or erysipelas, scarcely less troublesome.  Even when the cicatrix is completely
 formed, the degree  of motion permitted  ought  to be very limited.   Large
 cicatrices are apt to be lacerated, and this  occurs in a singular manner: a lit-
 tle phlyctena  filled with  pus opens at one point, and leaves a greyish ulcer,
 like those we see in syphilis;  the ulceration extends rapidly, and makes inch
 progress that  in twenty-four hours,  more or less, the  cicatrix is entirely de-
 stroyed.  It is true that it is renewed with much less difficulty than before;
 and this accident is not always disadvantageous to the patient, for the primary
 cicatrix is  usually very weak and easily torn ; but this weakness and prone-
 ness to laceration diminish every time it is reproduced, and sometimes it only
 acquires sufficient solidity after undergoing the process three or four times.
 It. is then only that the patient can be regarded as completely out of danger.
 Therefore, to  how many risks has he not been  exposed ?  He  might have
 sunk  under the suppuration,  fallen  a victim to internal inflammation, to the
 consecutive effects  of colliquative sweat  and diarrhoea, and even from the
onset, before the suppurative  stage, to gangrene  succeeding  immediately
the primary inflammatory symptoms. 
CLINICAL SURGERY.
485
                           CHAPTER  LV.

                          ON URINARY. CALCULUS.

 Principal  Symptoms—Anatomy of the parts—Preliminary Treatment—
                               Operation.

  Of all surgical operations, said M.  Dupuytren, lithotomy is that which has
most taxed the ingenuity of surgeons.   Various methods, numerous modifica-
tions, and important discoveries constitute its history.  It is not our intentior.
here to  recapitulate all that is known  on this subject; dictionaries and  works
ex professo will give you the necessary information; and therefore in  these
lectures I shall  merely treat of some improvements which I have myself in-
troduced, and of the most interesting cases daily presented in this hospital.
  Four principal methods now  divide the attention of the medical world, the
supra-pubic or hypogastric, the sub-pubic or lateral, the recto-vesical, and
the destruction of the calculus  in the  bladder without any incision.   I have
tried them  all, and am acquainted with their advantages and disadvantages;
but before  explaining them, it  will be proper to  enter into some details con-
cerning the symptoms of the existence of calculus, the anatomy of the parts,
and the precautions necessary previous to performing the operation.
  The principal symptoms of calculus in the bladder are, an habitual sensa-
tion of weight, erratic, dull pain,  deeply seated in  the  lesser pelvis and at
the anus ; difficulty and even impossibility to ride on horseback or in a rough
carriage without great  increase of pain; the frequent  discharge of bloody
urine, or of pure blood from the irritated bladder ; the irregular interruption
of the stream; pain referred to the glans  penis or to the fossa navicularis,
obliging the patient constantly  to press  the part, or to draw it out; lastly, all
the local and general phenomena of chronic cystitis.
  But none of the above symptoms separately, nor even all conjointly, indi-
cate with certainty the existence of stone in the bladder.  Chronic inflamma-
tion, especially when it attacks the fundus or neck of this organ, and  com-
plicated by the presence of fungous tumors, or the varicose  development
of the vesical  veins, may so far simulate this affection as to deceive even the
most skilful physician.
  The examination of the bladder,  or sounding, is then indispensable, and the
information derived from this source is as valuable as it is various.  The sound
does not always reach the foreign body; it frequently fails in touching it, from
being too short, or caught and  retained in  some region of  the bladder little
accessible to the instrument.  Generally we must seek the  stone  in  the most
depending part, and if we fail in finding it, carry successively the end of the
sound over the pubic region, the apex  and sides of the bladder. The examina-
tion should  be repeated, in both the distended and empty state of the organ.
  The end of the catheter is generally closed, in order to prevent the flow of
urine and keep the bladder distended;  but towards the  end of the examina-
tion it is often useful to empty it, holding at the same time the  instrument 
486                          LECTURES ON
nearly immovable, and waiting to feel if the flow of urine does not bring the
calculus against its extremity.
  In obscure cases it is the duty of the enlightened and conscientious surgeon
to repeat the examination at different periods, with solid and hollow sounds,
of different sizes and  curvatures, and never to perform the  operation  unless
the existence of the stone be clearly ascertained.
  Case I.—A child, 18 months of age, was brought to the Hotel-Dieu in the
beginning of January 1827.  The mother stated that it suffered at intervals
from acute pain in the region of  the bladder,  accompanied by great difficulty
in making water.   I sounded it, but could  find no  stone;  some time after it
was brought back and again sounded;  sometimes it was thought that a calculus
could be  perceived, sometimes  not.   Lastly, the mother  brought  it a third
time,  begging me to deliver her child  from its torments, the pain, as she said,
being so great as  sometimes to  throw it into  convulsions.   It was admitted
into the hospital.  Somedays after it was  carried  to the operating room, but
before making a new examination, the following remarks were made : Yester-
day, said M. Dupuytren, I thought I felt the  calculus, and if it really exist  it
is the  first case of so young a child  which has ever come under my notice,
for it has now suffered for more  than six months,: the stone will be found  at
the fundus of the bladder on the right side.   This last remark is  not made
unintentionally, many  of you witnessed  the case which I  now recal to your
memory:  a year ago, a child two and a half years of age was  admitted  into
the house; he had suffered for some time with very acute pain. He was sounded,
and a calculus thought to be detected : I examined and was  convinced that I
felt the stone; this I repeated several times; sometimes I found it, and some-
times did not. The operation was decided upon, and the child brought to the
amphitheatre; there  I again sounded him, and thinking that I felt the stone,
immediatly cut him, but  notwithstanding the most attentive search no stone
was to be found.  The wound was kept open, I continued the search, some-
times the  sound appeared to strike a foreign body,  and sometimes not.
   The patient suffered at intervals excruciating pain : I supposed that the cal-
culus, which I had always found on the right side had slipped into the  right
ureter, and disappeared at the time of the spasm;  I thought that the contrac-
tions of the ureter were the cause of it.  When he was calm the calculus could
generally  be felt; this confirmed my idea.  However, the child  grew thin,
and was  apparently  sinking,  when  the pain suddenly, disappeared.  The
patient recovered his strength and gaiety.  Some time afterwards he fell sick,
and was transferred to the children's hospital, where he died.  On examining
the body there were found in the fundus of the bladder, on the right side and
near  the  orifice  of the ureter,  suppurated scrofulous  tubercles, and aho
several in the lungs.                                . . ■        '
   The present case somewhat resembles that just related.  The calculus ap-
pears to be on the right side and sometimes disappears. We will sound the child
s:s  attentively as possible, and  use  for this purpose along  gunshot probe.
The curvature of the  catheter sometimes prevents it from passing easily over
the different parts of the bladder; a hollow sound labors  under the incon-
venience of admitting  the urine  into  its cavity, and also air, and the sound of
these liquids of such different density, often  leads to the  supposition that the 
CLINICAL SURGERY.
487
metallic instrument  is striking a calculus.  A stylette, which may be curved
at pleasure, and solid, is free from these objections.
   After these remarks,  the operator proceeded  to search for  the  calculus.
He first sounded with the stylette, then with the catheter, and with a hollow
sound ; nothing  however could be discovered.  The operation was delayed.
   Five days afterwards a second attempt was made;  the catheter and sound
were turned in  every direction  without meeting  the calculus; at last, in the
fundus of the bladder, on the left, the sound appeared to strike a hard body.
This was  several times experienced both by myself and M. Sasoun.  As the
end of the instrument seemed to be  retained by this foreign substance, I  sus-
pected  that the  sensation we felt was owing to the sound meeting one of the
fleshy  columns of the bladder;  for without removing  the end from this  spot
I moved it freely about without feeling  any thing ; returning then to the see-
saw  motion  I again  experienced the same  sensation.  My  colleagues  con-
curred in  this opinion, and the child was sent back to its mother.
   This case is interesting not only as  regards the age of the child, but it also
proves  that catherism, generally so  accurate, may nevertheless sometimes
give but confused notions; hence  no means should be neglected which may
lead to the detection of the calculus.  Examination by  the rectum, the patient
being  laid on his back, and the hypogastric region depressed by the hand of
the surgeon, in some cases gives a good  idea of the size, weight, and situation
of the stone, as well  as  of the  healthy or morbid state of the prostate, and
the degree of elasticity or induration  of the bladder.
   Having  ascertained the existence of the foreign body, it must be extracted
per vias naturales, by sheathed forceps,  or others, be broken up and destroyed
in the cavity of the organ, or lastly, the soft parts must be divided, and it
must be extracted through the opening thus effected.
   Let us suppose that the attempts to  break up the stone have been ineffec-
tual, or impossible from causes of which we shall hereafter speak, cystotomy
is the  most  certain  method, and that most generally followed; but here are
two  obstacles which must be avoided, the too  small or too great division of
the parietes of  the  bladder.  In the first case the parts are lacerated, con-
tused, and inflammation  is the  result; in the second, infiltration of urine is
to be apprehended.
   Haemorrhagy  is no less important: as regards concomitant affections, it is
difficult to foresee them ; but we should not forget that an effect of the  trau-
matic  fever  is to augment the morbid disposition which the viscera may con-
ceal, and  cause to burst forth diseases which otherwise would never have ap-
peared.  Thus we must carefully examine the state of all the organs, as well
as also that of their  functions.
   We will  now explain  in. a few words the anatomy  of the parts, a perfect
knowledge of which is  evidently  of the  highest possible importance to the
surgeon.
   The supra-pubic  region, bounded  above by a horizontal line  drawn from
one  spine  of the ilium  to the  other, and below by the almost  semicircular
line  described by Poupart's ligament  inserted into the pubis, is covered by
tile skin,  beneath which we find a cellular tissue varying in  thickness from a
few line''  to two inches and  more, some branches of  the external pubic and
tee-umentary arteries.  Beneath  this  cellular tissue exists the cellulo-fibrous 
488
LECTURES ON
 layer covering the great oblique muscle, then the aponeurosis of this muscle.
 The thick  dense fibres of this aponeurosis cross each other to form the linea
 alba, a species  of ligamentous band which serves as a support to the anterior
 part of the abdomen and unites the sternum to the symphysis pubis.  Behind
 the aponeurosis, and on  the sides of the  linea alba, are seen the pyramidal
 muscles, but which do not exist in all persons.  The outer edges of the recti
 muscles, directed downwards and inwards, are inserted into the spine  of the
 pubes.  Outside of them are seen the muscular fibres of the internal oblique
 and transversalis muscles, of which the aponeurotic expansion passes in front
 of the recti muscles, and join that of the external oblique in order to form
 the linea alba.
   After removing the  abdominal muscles, we next come to a dense cellular
 layer  known by the name of fascia internalis; then to the peritoneum,  which
 descends from the umbilical region.   Having nearly arrived at the pubes, it
 is folded backwards, reaches the upper region of the bladder, and is reflected
 over the uterus and rectum.
   The bladder, when  empty, is  nearly hidden behind the symphysis pubis;
 but when distended.it elevates  the  hypogastric region, and  may reach and
 even extend beyond the umbilicus.   On  account  of its globular  form, it is
 more  immediately in contact with the pubes and lower part of the abdomen,
 at the median line than any where else.  When empty, it is very easy by in-
 troducing an  instrument through the urethra to elevate its point above the
 symphisis pubis.  By an incision into the lower part of the linea alba we
 may turn aside the deflection of the  peritoneum, so as to come immediately
 upon  the anterior surface of the  viscus.
   The perineal or sub-pubic region presents externally the form of a triangle
 of  which the  apex is at the lower part of the symphysis pubis ; the sides are
 formed by the rami Of the pubes and ischium, and  the base rests upon the
 anus.   The skin  of the perineum  is thin, covered with hairs, and possessed of
 elasticity.   Beneath it is found a layer of cellular tissue covering a cellulo-
 fibrous expansion spread over the muscles of the perineum, the bulb and cor-
 pus spongiosum  of the urethra.  This expansion, constituting the inferior or
 superficial  aponeurosis  of the perineum, arises in front of the anus, between
 the sciatic projections  of the anterior surface of the middle aponeurosis, is
 firmly united to the external edge of the arch of the pubis, and is continuous
 in front with the dartos.   This aponeurosis is placed under the skin, in order
 to separate as  it were the genital and urinary organs.
   On removing the parts, we perceive, behind and on the median line, the ex-
 ternal sphincter, which at its anterior extremity divides into two  layers, of
 which the  superficial one adheres to the subcutaneous aponeurosis, and  the
 deep-seated is lost in the acceleratores urinae and transverse muscles.
   On  the median line, and in front of the sphincter, the bulb of the urethra
is seen, situated eight or ten lines from the anus, and covered by the accelera-
tores  urinae,  which furnish  it with  a movable and  very elastic  sheath.
After  having covered  the origin of the spongy portion of the urethra, these
muscles  separate  in front and are inserted into the  corresponding corpus
cavernosum.   Their action  is to  raise and compress the bulb of the urethra.
  The transverse muscles of the perineum are seated a little more deeply,
at  the junction of the acceleratores and external sphincter.  They  consist of 
CLINICAL SURGERY
489
two muscular bands, extended obliquely from without inwards, and from be-
hind forwards, from the tuberosity of the ischium to the median line, where
they are lost in each other and in the preceding muscles.   On the sides of the
perineum, and joined to the ascending rami of the pubes and ischium are found
the roots of the corpora cavernosa, surrounded at their origin by the erectores
penis muscles, in the same manner as the bulb by the acceleratores urinae.
   From the internal edges of the ascending rami of the ischium, and descend-
ing of the pubes, is detached an  aponeurotic layer arising without,and behind
the external surface of the superior aponeurosis, on a level with the upner ed°e
ot  the levator ani muscle : in  front this aponeurotic layer, which has re-
ceived the name of middle aponeurosis of the perineum, perineal ligament of
Carcassonne, is continuous with the inferior pubic ligament; it then is spread
over  the sides of  the bulb of  the urethra, which it fastens to the median line,
towards  the  margin of the anus, extending between  the digestive,  urinary,
and genital organs, so as to form a second fibrous plane, pierced merely, like
the superior aponeurosis, for the passage of the median organs.   Under the
symphisis pubis is always  to be found  a perforation occupied by the dorsal
arteries and veins  of the corpora cavernosa.  This middle aponeurosis is very
strong in front, weak  behind; its upper sui'face corresponds to the levator
ani muscle ; externally, its lower margin  gives origin to a fibrous layer, which
descends perpendicularly over the side of the pelvis, and is inserted into the
inner edge of the great sacro-sciatic ligament, thus enclosing in its thickness
against the ramus  of the ischium, the trunk of the internal pudic artery.
   On the sides of the perineum, between the urethra covered by its muscles
and the corpora cavernosa, there is a cellular triangular space extending from
integuments  to  the prostate gland and  bladder.  This species of canal ex-
tends  posteriorly along  the rectum, having no limit in this direction but the
levator ani and the superior perineal aponeurosis, and in front it is bounded
bv the junction of the corpora cavernosa.   The  transverse  muscles of the
perineum and the artery of the same  name alone interrupt its regularity;  on
its external side  is to be seen the superficial  perineal artery.  Behind we
meet the extremities of the inferior and middle haemorrhoidal arteries, as well
as a considerable plexus of veins.  Above these different planes is found the
prostate  resting on the anterior part of the rectum.  The converging fibres
of the levatores ani descend obliquely around these two organs, fix and sup-
port them, and  form in this  region  an  elastic plane opposing efficiently the
combined action of the diaphragm and parietes of the abdomen.   This mus-
cular layer is strengthened superiorly by the prolongation of  the pelvic apo-
neurosis, which  descends from  all  parts of the cavity of the pelvis upon the
levator ani, is  applied  to  the circumference of the prostate, envelopes the
rectum and' closes the inferior strait.   This layer, called the superior aponeu-
rosis  of the pelvis, fascia pelvica, recto-vesical aponeurosis, is well repre-
sented by a concave surface, pierced for the passsge of the rectum, genital,
and urinary organs.                           #
  The disposition  of the parts  which we have just studied, continued M.
D'inuytren is the more deserving of all your attention, as it explains the dif-
ference  of 'dano-er  in infiltration of urine.  Thus, for example, a rupture of
the corpus spongiosum and bulb of  the urethra, perforating  the  superficial
aponeurosis, give's  rise merely to a subcutaneous effusion because the spongy
           62 
490
LECTURES  ON
portion and  bulb of the  urethra, the external  sphincter ani, the  crcctores
penis, and corpora cavernosa are placed between the middle and superficial
aponeurosis.   Perforations of the membranous portion,  or of  the rectum
above the external sphincter, cause, it is true, deeper abscesses and more ex-
tended over the sides of the perineum and margin of the anus, but still with-
out any communication with the interior of the pelvis; whilst ruptures of the
bladder, above the edge of the prostate, and incisions passing its limits permit
urinary or stercoraceous  effusions to glide beneath  the peritoneum into the
pelvic cellular tissue, and thus become  the cause of death.  The cause of
these two different  results is, that  in the first case the membranous portion
of the urethra, the prostate, and corresponding part of the rectum and levator
ani are comprised between the middle and profound aponeurosis; and  in the
second, because above this latter aponeurosis there exist only the sub-perito-
neal cellular  tissue, and the folds formed  by the peritoneum  around  the blad-
der and rectum.
   A  further  examination of  the parts will show you, on the median line, be-
tween the most  inferior  part of the rectum and the bulb  of the urethra, a
triangular space to  which I now call your attention; its apex  corresponds
to the point  of the prostate, where this body touches the rectum, and conse-
quently about nine lines in depth beneath the skin.   Its base,  resting against
the integuments,  superficial aponeurosis, and external sphincter, extends about
eight or ten  lines from before backwards.  Its anterior edge is  convex, and
described by  the membranous portion of the urethra, directed obliquely down-
wards, and from behind  forwards ;  its posterior edge, also convex and pro-
jecting forward,  is  represented  by the  lower part of the rectum.  This tri-
angle extends  transversely from one  tuberosity of  the ischium to the other,
and  is about two inches  and a few lines in  extent.   The muscular and apo-
neurotic interlacing of which we have spoken occupies its  middle  part, and
its sides are  bounded by the  two transverse muscles.  It is  in this triangular
space that the bilateral operation is performed.
   It is of  the highest importance in  so serious an operation to remember per-
fectly, not only the disposition of the parts, but also their exact dimensions.
The spongy portion of the urethra is  about five, six, or seven inches in extent.
Its membranous portion  is seven to nine lines in length, curved under the
symphysis pubis, and strengthened  internally by muscular  and aponeurotic
fibres, sometimes offering a  serious impediment to  the introduction  of" Ihe
catheter.   The  prostate,  which  comes next, presents on  its perineal  side a
convex surface, flattened posteriorly and perforated for  the passage  of the
urethra.  Its dimensions in middle life are generally thirteen lines  in its an-
terioposterior, and nineteen in its transverse diameter.
   It was formerly supposed that the neck of the bladder was situated imme-
diately behind  the arch  of the  pubes,  but we now know that the prostate is
separated  from it by a distance of nearly nine lines : the effect of this situa-
tion  of the neck of the bladder  is to eh.igate the straight part of the urethra
and render the sub-pubic  curve less marked.
   In the  corresponding point of the anterior part of the prostate, the arch of
the pubes is  generally about twenty to twenty-two lines broad at its middle  ;
the r.'iini of the ischii are  separated by an interval of nearly two inches  ; last-
ly, the posterior or rectal portion corresponds to a separation of the  tubers 
CLINICAL SURGERY.
491
 nearly equal to two inches and three lines.   I must add, however, that their
 dimensions in adult and well formed persons are subject to great variations.
   The posterior or reeled region forms the last division of the parts which we
 have just  studied.  Directed  obliquely from above downwards, and a little
 Irom left to right, the rectum descends from the end of the colon to the height
 of the bladder, where it is nearly situated on the median line.   During this
 passage it  presents  a  long curvature applied to the  concavity of  the sacrum,
 and which embraces the fundus of the bladder as far as the point  of the pros-
 tate. There the rectum is again  curved, changes its direction, and is carried
 downwards and backwards between the  fibres of the sphincters  as far as the
 anus.
   That  portion of the anus extending  from the mesocolon to the sphincters
 is fixed, free from peritoneum, and constantly corresponds posteriorly to the
 inferior  part of the anterior surface of the sacrum, the coccyx and coccy-
 geous muscle ;  in front it winds around the fundus of the bladder, from  which
 it is  separated  by the ureters, vasa deferentia, and vesiculae seminales, and
 lower down  by the prostate, which is  united to  it by a  lamellated cellular
 tissue.   This portion  of the rectum is often  dilated in old men, so as to re-
 ceive, as it were,  the  prostate, and form on its sides two projections liable to
 be injured in the lateral operation for stone.
   The lower part of the rectum extends  from the point of the prostate to the
 anus.  It is surrounded by the sphincters and directed  downwards and back-
 wards ;  forms  the  posterior  edge of the median  triangle of the peritoneum
 which has  been already mentioned,  and  on  account of its obliquity  is about
 ten  lines to an inch or inch and a half in height.
   That part of the bladder  corresponding to the rectum is divided by the
 ureters  and vasa deferentia  into three distinct  regions.  Of these,  two are
 lateral,  convex, larger  in front than behind, and situated outside of the ureters,
 vasa  deferentia,  and vesiculae  seminales.  The third  is on the  median line,
 triangular, comprised between  these parts, having its base directed upwards
 and  backwards,  whilst its apex, resting  on  the prostate, is directed to the
 rectum.
   Separated behind, near the circumference of the prostate, by a  distance of
 two or three lines, the  ejaculatory ducts, whilst passing through the thickness
 of this  gland, converge gradually, insomuch that near  their orifice on  the
 sides of the veramontanum they are in contact and so closely united as to  be
 separated with difficulty.
   If we measure the integuments towards the interior of the pelvis, the space
 comprised  between the external surface of the perineum and the reflection  of
 the peritoneum  will generally be found of the following dimensions : for the tri-
 angle comprised between the anus and membranous portion of the excretory
 canal of the urine, a space of 8 or 10 lines ; for the height of the prostate, from
 its point to the middle and  posterior part of its circumference  between the
 ureters, vasa deferentia, and vesiculae seminales, seven to ten lines ; lastly, be-
 tween the most elevated portion of the prostate and  the vesico-rectal reflec-
 tion of the  peritoneum, 15 to 18 lines. It is in the length of this line, of which
the total height varies from two and a half inches to three inches and two lines,
that  the recto-vesical operation should be performed.
  The different  states of emptiness  or distension of  the bladder and rectum 
492
LECTURES ON
cause but little change in these relations.  The only case in which the recto-
vesical serous reflection descends and approaches the prostate  is that in which
the rectum and bladder are at the same time contracted and reduced to a very
small size.  The peritoneum has then been seen nearly to touch the prostate,
so that it would have been difficult not to wound  it  in exceeding the limits of
this gland.
  We have now explained in a general  way the parts which may be wounded
by the instrument in the operation of lithotomy: we will hereafter make known
the consequences which must be drawn, relative to a choice between the dif-
ferent methods of operating.
  It has  been endeavored, continued M. Dupuytren, to establish by  calcula-
tion  the proportion of deaths ; but general statistical results differ too much to
merit any  confidence.   The following  table exhibits  the results  to which I
have arrived after having collected for ten years 356 cases of cystotomy, both
in iny own practice -and that of the most distinguished men in Paris and its
environs.
Sex.	Ages'.	No. of Opera-tions.	Cured.	Dead.	Ratio of Deaths to Cures.	
Male.	from 3 to 15 yrs. 15 30 SO 50 50 70 70 .90	-. 97 " 59 45 74 37	88 51 35 56 26	9 . 8 10 18 11	1 to 11 1 7 1 to bet. 4 & 5 1 4 1 to bet. 3 & 4	9 100 13 h 23 24 29 h
Female.	from 3 15 15 50 50 70 70 90	i 11 17 9	7 10 15 7	0 1 2 2	0 0 1 3 3-9 1 to bet. 8 & 9 1 to bet. 3 & 4	0 100 10 12 22
Total.	3 90	356	295	61	1 to 6	17 100
Men.	Id.	312	256 1 56		1 to bet. 5 & 6	18 100
Wo m.	Id.	44	39	5	1 to 9	uh 100
   If we take the mean of the ratios expressed in this table, we arrive at the
o-eneral result that the chances of death are to those of cure :: 1 : 5;  or :: 1  :
6.  This proportion, at first sight, seems considerable, but will appear much
less  so if we  remember the importance of the parts, as well as the presence
of local or general affections.
   It will also be seen that the operation is most successful in childhood ;  then
in youth, and middle age ; whilst the favorable chances diminish rapidly with
increase of years.
   We will now  say a few words on  the  preparation to which  the  patient
should be subjected; the season of the year is of but slight importance ; but 
CLINICAL SURGERY.
493
if possible, we  should  avoid performing the operation during the prevalence
of an epidemic, and visceral or other inflammatory diseases.  If the patient
be affected with nephritic pains, they must be subdued by venesection, emol-
lient drinks and baths.   Bleeding is indicated when the pulse is full; the pa-
tient should be purged once or twice, and put upon a mild diet.   The evening
preceding the operation an enema to empty the large intestines should be ad-
ministered ; and the perineum, scrotum, and margin of the anus shaved.
  The prognosis is different in different individuals; more favorable in women
and children than in adults and old men: success is more certain when the ope-
ration has been  rapidly done :  persons of a nervous and irritable temperament
bear it less easily. Patients who have had the disease for a long time, and whose
constitutions are worn out, and, at the same time, labor under extensive affec-
tion of either the urinary or other organs, offer but slight hopes of success.
  It now remains to operate:  this is done differently according to the sex.
  The hypogastric or high operation, to which I shall first call your attention,
cannot be practised indiscriminately in'all cases, and without regard to age,
sex, constitution, volume of the stone, &c.  We should have  recourse to it
only when the approximation of the tuberosities of the ischii, the  presence of
tumors  in  the  inferior strait of the pelvis, or the great size of the calculus
render its extraction below the pubes impossible.  I may quote in support of
my opinion the experience  of Frere Come in this operation, in  84 cases of
individuals of different ages, sex, station, and  health; the result was one
death of four and a half operations.  This result is much less favorable  than
that  now obtained in an equal number of lateral operations performed indis-
criminately, as  in  the  cases  of Frere Come on children, women, adults and
old  men.
  As regards the instruments and method of this surgeon, while granting
them all their real advantages, continued M. Dupuytren, I am far from think-
ing that they have removed all the dangers of the operation ; thus, in a thesis
defended in  1812, for the chair of operative surgery vacated by the death of
Sabatier, on the subject  of  lithotomy, I advanced the opinion that incisions
in the perineum  and  neck of the bladder added to the dangers of the high
operation all those of lateral method.   Since then, I have thought that a cathe-
ter  introduced into the  bladder  either through the urethra or perineum, in-
creased the inconveniences and dangers of the high operation without being
of any utility.
  These two opinions have, for a long time, been the subject of controversy
among  physicians; some maintaining that an incision  in the perineum, re-
duced to small dimensions, added nothing to the danger of the hypogastric
operation ; but  that, as it terminated in the most depending part of the blad-
der, it afforded  a more  ready exit to the urine.
  Among these objections, that which consisted in maintaining that the inci-
sion of the perineum  and  neck of the bladder  did not render the operation
more dangerous gave way to  the results of the lateral  operation, of which
the mortality, under the same circumstances, is  only one in  six.   Therefore,
what is  this opening in perineum in the supra-pubic operation if it be not the
lateral operation ?  It is idle to assert that this incision reduced to smaller
dimensions is less dangerous than the lateral operation ; it is too well known
that the danger of an incision is not measured by its extent.
I 
494
LECTURES ON
   The  objection drawn from  the facility which an incision in the perineum
 gives to  the introduction of the spear-shaped sound is more plausible.   In-
 deed, it cannot be denied, if this sound be indispensable, that it is more easily
 introduced  into the bladder through an  incision in the perineum.   But the
 spear-shaped  sound may be introduced  by the urethra, as I have frequently
 done on  the living subject.   It is sufficient to give a greater curve to its ex-
 tremity, and depress more strongly its handle, aftef having introduced it into
 the bladder;  moreover, the spear-shaped sound  is not indispensable for the
 performance of the high operation, as we  shall presently clearly prove.
   As to the  facility presented by an incision in the perineum for the discharge
 of urine,  it  may be easily understood that a catheter introduced by the ure-
 thra would fulfil the same indication with, much less danger.  But the opinion
 entertained  that an incision in  the perineum and a Sound introduced into the
 bladder divert the urine from the wound above the pubes, is a mere supposi-
 tion contradicted daily.by observation.  Indeed, whatever may be the extent
 of the wound  in  the perineum, the urine is never entirely diverted from the
 supra-pubian wound.  It seems as if whenever the bladder has  been wounded
 in any part, this point becomes  the centre of all the contractions of the organ,
 and thus in consequence of these  contractions the urine is  expelled.   1 have,
 therefore, for a long time, considered as useless the precautions taken to  pre-
 vent the urine from flowing through the wound  made in  the bladder; nay,
 further, I  consider as dangerous any means tending to diminish  the facility of
 the passage of the urine by the wound,  such as approximation, compression
 of its edges, sutures,  or any similar  method.  I believe that they give rise to
 infiltration of urine, and subsequently to inflammation of the peritoneum or
 the cellular  tissue of the pelvis, two of the most serious accidents complica-
 ting the operation for stone.
  I think, in the  high  operation, that the best plan  of  proceeding is to leave
 the wound,to itself, merely to keep its lips separated by a layer of thin linen,
 and relax  them by position.  The following case will explain the plan of ope-
 rating which I prefer.
  Case II.—M. Le R...., aged 62 years, of middle stature, strong constitu-
 tion, sanguineous temperament, of great  activity, and accustomed to  hard
 work, and generous living, had  for a long time experienced frequent desire to
 make water, difficulty in so  doing, and acute pain after the evacuation.   For
 the last ten years to these symptoms  was added hematuria, whenever he took
a long walk  or ride, or was guilty of any excess in eating or drinking.
  For the last'two years the  symptoms have increased, the discharge of urine
is  almost  continual and  involuntary ; he  suffered from constant pain in the
 hypogastrium and perineum.  At this time a surgeon sounded the patient, and
 found no  stone; a year afterwards,  another surgeon pronounced the disease
to be catarrh of the bladder, and prescribed accordingly.
  However, the  affection grew daily worse, the urine  came away by drops,
accompanied by horrible pain.   The  violent suffering he experienced obliged
him to keep in bed, where he was  attacked by a slow fever, and daily became
 worse and more  emaciated.  His urine carefully examined, gave out a most
 pestilential  ammoniacal odor, and was apparently composed of a mixture of
urine, blood, pus, and  vitiated mucus.
  I was then sent for (1824)  to see the patient, at that time living at Chantilly 
CLINICAL SURGERY.                       495
t.ie history of his symptoms, I concluded that there was a calculus in the blad-
der, and that  it was either very large or situated in the neck of this organ.
I sounded  the patient, and the sound struck against the stone, before having
penetrated into the cavity of  the bladder.  After several  attempts, I could
only partly succeed in introducing it.  The sound placed between the foreign
body and the  parietes of the bladder seemed as if it were in a vice; and the
finger introduced into the rectum discovered the fundus  of the bladder filled,
dilated, and hardened by the presence of  the foreign body.  I then examined
the hypogastrium, after bending the body forward,  and found behind the
pubes, at the bottom of the median line, a hard, resistant, voluminous  body.
  The urine  appeared  purulent, but the inflammation, of which it was "the
product, might be an effect or symptom  of the stone which would disappear
on its removal.  The size of the calculus left no doubt as to the propriety of
performing the high operation.
  The patient on learning the existence of a stone in his bladder, seemed re-
joiced that all  uncertainty about his case was at an end, and begged me to free
him immediately from his enemy, by  any  means whatever. A bath and gentle
laxative were prescribed; and the following evening I returned, accompanied
by M. M. Sauson, Lemaire, Marx, and Souze.
  The pubes  were shaved, and the bladder, hypogastrium and rectum again
examined.   This  examination confirming the one made the previous evening,
I introduced a common silver catheter into the urethra, but it was prevented
by the stone, situated opposite to the neck of the bladder, from entering that
viscus.   Standing therefore on the left side, M. Sauson being on the right  of
the patient, his legs were flexed on the thighs, and these on the abdomen.  M.
Sauson  then  introduced  his forefinger  into the rectum, raised the  stone,
and caused it to project as much as possible above the pubes.
  I then made an incision three inches long, extending in the direction of the
median line from the symphysis pubis.  The adipose cellular tissue was next
divided, then  the aponeurosis of the muscles ; the pyramidal  were separated
from the recti muscles, and  divided transversely for several  lines  on each
sine, and between them I could feel the stone.   Applying then the forefinger
of the  left hand  to the  symphysis  pubis, and guiding upon a straight sharp
pointed bistoury, I plunged it into the bladder just behind the symphysis.  A
white, thick, inodorous  pus immediately escaped.   I  thought at first that I
had opened an abscess of the cellular tissue surrounding the bladder; but the
point of the bistoury had  touched  the stone; it had therefore reached the
bladder, in which the incision was  enlarged from  below upwards for five or
six lines; the  index finger being then introduced, I found the parietes of the
organ to be half an inch thick, and its cavity filled with an enormous calcu-
lus, and  also,  to my great satisfaction, that there was a space of two inches
from the  highest point of the incision and the upper part of the bladder,
which is not  generally covered by peritoneum.   The incision was therefore
enlarged by a  probe-pointed bistoury.
  I then proceeded to  the extraction of the  stone.  It seemed  fixed to the
centre  of the  pelvis by its size, shape, and the contractions of the bladder.
In this  situation  I separated the blades of the forceps, and introduced them
successively on each side of the stone, and having joined them together, gave
to the calculus a vibratory motion; then desiring M. Sauson to pull it firmly 
496
LECTURES  ON
 upwards, it was extracted.  Its  shape was precisely that of the  bladder,
 which it entirely filled, and was three and a half inches in height, three inches
 in length, and two and a half in thickness.   M. Lemaire weighed  it immedi-
 ately, and found it to be six ounces and a half  in weight; it consisted of the
 phosphate of magnesia and ammonia.
   The dressing was of the simple kind ; the patient was laid on his back, his
 legs slightly flexed by means of a kind of bolster placed under the  hams;  a
 large pledget  of fine linen introduced through the wound  into the bladder,
 and above that was placed a piece  of perforated linen spread  with cerate.   No
 sound was introduced into the urethra,  nor into  the wound ; no adhesive
 straps nor sutures were  used; the patient was wrapped in cloths to receive
 the urine, and merely ordered  a  simple  decoction of  the root of the dog's
 grass (triticum repens) sweetened with syrup  of gum.   The abdomen was
 covered with flannels soaked in an emollient decoction.
   He immediately expressed himself much relieved, and being free from pain
 slept  for  two  hours.   During the night the abdomen became painful, he had
 a chill followed by fever, without hiccough or nausea.  He  was bled largely
 from the arm,  the urine flowed freely through the wound.
   The next day he was pretty well; however, as the pulse was full and fre-
 quent, and the abdomen slightly tender, he was bled nine ounces ; the lint in
 the wound was renewed frequently.
   Fourth and fifth days, suppuration was established ;  it was abundant and
 healthy; the pledget was  changed, and the dressing renewed morning and
 evening, the urine still flowing by the wound.
   The urine soon began to  pass by the  urethra, the aperture and suppuration
diminished.   He recovered  daily his appetite, strength,  and good spirits.  In
short, at the  end of a month's time he was completely cured.
   The plan pursued by M. Dupuytren  in  the preceding case may easily be
established as  a  general rule.  The two following  precepts have long been
taught by this  surgeon. 1st. If we determine on the high operation, it should
be performed  immediately, and not be  considered as the ultima ratio of any
other method. 2d. W"e should omit the incision in the perineum, and intro-
duce the spear-shaped sound  through  the urethra (when this instrument is
deemed necessary).  In some  cases it is proper to introduce afterwards into
this canal an elastic catheter.
   Lateral Operation.—Every thing has been  already  said concerning the
lateral operation, continued M. Dupuytren, and notwithstanding all its  suc-
cess it is a dangerous operation.  Convinced by my own experience that it
might be advantageously modified, it occurred to me to divide the neck of the
bladder in the direction of  the  symphysis pubis.  In this operation, which I
performed for the first time in 1816, the instruments do not  differ from those
usually used except  in the  substitution of a probe-pointed  bistoury  for the
lithotomy of Frere Come.
   The patient being  tied and placed as in the ordinary operation, a grooved
sound  was introduced  into the bladder, and  given to an assistant who at the
same  time supported the testicles  : the  sound was held in a perfectly vertical
direction.  The operator, holding  in the right hand an ordinary bistoury, and
with the left keeping the skin of  the perineum tense, made in  it, and in the
direction of  the raphe, an incision about 18 lines in length.  It commenced 
CLINICAL SURGERY.
497
at about two and a half inches from the anus, and terminated at nearly  one
inch from it.  A second incision, parallel to and at the bottom  of the first,
divided the accelerator  urinae muscles and the adipose cellular tissue filling
the space between the bulb  of the urethra in front and the rectum  behind:
it exposed the membranous  portion of the urethra.   At the third step of the
operation, the  membranous portion was divided throughout its whole extent.
The lithotome was then introduced on the sound, which was withdrawn, then
the cutting edge of the former was turned upwards towards the symphysis
pubis, and the operator pressing the handle withdrew it, and thus made  an
incision, dividing, 1st, the neck of the bladder, and the lower portion of the
anterior wall of this organ:  2dly, the most remote  part of the superior por-
tion of  the urethra, the part  above the  prostate, the  cellular tissue placed
between the anterior ligaments of the bladder, and the arterial or veirous
branches in its passage.
  There results  from  this operation a wound of a triangular shape, disposed
in the following  manner:  the apex corresponding to the anterior inferior part
of the body of the bladder, and the base to.the skin of the perineum.
  We will find  in its passage, proceeding from below upwards, the skin of
the perineum and the bulbo-cavernosi  muscles, the bulb of the urethra, the
sub-pubic ligament, the symphysis  pubis, the anterior ligaments of the blad-
der, the cellular tissue,  and vascular plexus, corresponding to these  different
parts.   The posterior edge comprises the space between the  posterior angle
of the external incision  and the anterior and inferior part of the bladder.  Be-
tween these points, we find proceeding  from below upwards,  the skin of the
adipose cellular  tissue, the muscular plane resulting from the reunion and in-
terlacing of the fibres of the external sphincter, accelerator urinae and trans-
verse muscles, the lower part of the prostate, with that of the portion of the
urethra embraced by this gland, the posterior part of the meatus urinarius,
the upper part of the neck of the.bladder and prostate, the inferior part  of
the anterior wall of this organ ; all divided by the bistoury or lithotome, ex-
cept the lower part of the  prostate and urethra corresponding to it.   Nearly
in the centre of the wound is found the membranous portion of the urethra, of
which the superior and  inferior parietes are divided at the same time.  The
calculus, when  extracted, must therefore  pass through a first aperture which
is nearly vertical, and answers to part of the neck, and anterior inferior por-
tion of  the bladder: a second slightly oblique upwards and backwards, like
the membranous portion of the urethra  to which it belongs;  a third horizon-
tal, corresponding to the skin of the perineum.
   Such is the method, continued  M. Dupuytren, which I intended to substi-
tute for the lateral operation.  It was  tried for the first time in 1816 on a
patient  18 years of age, with entire success.  In 1824 the double lithotome
was substituted  for the single; here the incision was made transversely from
rio-ht to left.  It was first used on the 24th.  of April, of the same year, at the
Hotel-Dieu.
   Case III.—Alexander Patrii, aged five and a half years, ot a good consti-
tution, had labored under calculusVince the age  of three years.  The opera-
tion just  described was performed with great ease, and a  stone extracted  of
?bont the tize and shape of  a small almond ; but little blood  was lost.  Du- 
498
LECTURES  on
ring the day, the patient  suffered some pain in the epigastrium, which was
relieved  by leeching, emollient poultices, and sweetened drinks.  However,
the pain reappeared, and was seated particularly in the abdomen ;  the ton«me
slightly red at the edges: I prescribed a plaister of mercurial ointment to the
abdomen.  He was bathed twice, and enemata of decoction of poppy heads
administered.   Lastly, twelve leeches were applied to the liypogastrium, and
from that time no  symptoms of gastro-intestinal irritation were perceived.
The urine  had flowed guttative on the third  day of the operation;  on the
fifth, the prepuce was slightly swollen ; on  the tenth, the oedema had attacked
the whole penis and scrotum; resolvents were applied to  the parts; the swell-
ing continued until the 18th day, when it suddenly disappeared, and the urine
passed entirely by the urethra.  On the 19th of May, twenty days after the
operation, he left the hospital perfectly cured.
  Case IV.—On the 21st  of October of the same year, this operation was
performed, for  the  third time, on a child named Denis Cintrat, 11 years of
age, enjoying otherwise good health.  Two  calculi were extracted,  and he
afterwards  left  the hospital cured.
  Thus it may be seen  that in the early cases  the new  method was success-
ful.  I was, however, perfectly aware of the objections to which it was liable.
Indeed, it seemed, that by  means of it we would avoid two of the most seri-
ous complications of the lateral operation ; namely, division of the rectum, or
of some of the arterial branches.  The incision, being parallel to the rectum,
could but seldom  injure it, and only in the extremely rare cases in which this
gut, being enlarged  as it is  often in old men, has left its natural situation;
but again, if it were not exposed to this danger, might it not be frequently
wounded by the first incision, which, being directed from before backwards,
falls perpendicularly at a short distance  from the anus, and consequently
might easily injure the  rectum.  It was evident, also, that the first incision
on the median line would be a safeguard against haemorrhage; but in the st
cond, how greatly the trunk of the internal pudic is exposed, which, not being
protected  by the  ascending rami of the ischium, tends towards the  median
line, and which, during the  operation, approximated  to the bladder  by the
distention of this organ, is closely applied to the ramus of the bone, and can-
not avoid the impending danger.  Lastly, by this method,  the divided sides
of the urethra  might be lacerated  by a rough, or simply a large stone; the
cellular tissue  surrounding the neck  of  the bladder  might be contused,
the wound  heal slowly, and inflammation and ecchymosis of the scrotum
might add to the danger of  the operation.
  Bilateral Operation.—Convinced by reflection and experience of the serious
nature of these objections, I determined to find a method  of avoiding them.
The greatest danger resulting from the longitudinal direction of the first inci-
sion, it struck me that  by  a transverse incision I should avoid wounding the
rectum, inflammation of the  scrotum and prepuce, as well as the more ordi-
nary haemorrhage, namely, from the  branches ot  the transverse and internal
pudic arteries.   Here, however, arose another  difficulty.   The bladder was
not so easy of access, and the  opening would not permit the extraction of  a
large  calculus.   It was therefore necessary to give the  incision another
shape, and, desirous of preserving  its transverse direction, I determined to 
CLINICAL SURGERY.
499
depress its extremities, giving it a semi-elliptic curve.   As this incision might
be extended on the sides of the anus as far as the volume of the Stone would
require, the principal difficulty was thus avoided.
  The instruments used in the lateral  operation required some modification.
I therefore substituted  for the  ordinary staff one made much lighter, sloped
at the end of the groove, enlarged at its middle, that is at its  greatest curva-
ture, for the  extent  of about two inches.   Thus, it presents at the point in
which  the incision should be made in the urethra,  a deep groove, with round-
ed,  separated, and, as it were, inverted edges, which by its length and shape
renders the section of the canal more easy.  The end of the staff was  free
from the usual cul de sac, which frequently renders it difficult to disengage the
lithotome from its groove.  Lastly, the beak of the instrument was furnished
with an  olive-shaped enlargement, by means of which it passed more easily
through the urethra.
  For  the incision into the bladder, I make use of the double lithotome, which
being opened in the bladder, effects when withdrawn a division of the neck
of this  organ, the urethra and prostate,  by a double incision perfectly symme-
trical.
  This instrument was constructed on the same plan as that of Frere Come,
but with two blades slightly curved, as  well as their sheath, on one  surface.
The handle turns on a central screw, by which the degree of expansion of the
blades  is regulated at will.
  Twenty-six patients, on whom I operated soon  after, were all  perfectly
cured.   Such success was very gratifying, especially as I had  used an imper-
fect instrument.   The double  lithotome preserved a  transverse direction,
approximated too nearly to the tuberosities of the ischium, and endangered the
internal pudic.  In vain were the blades bent, or did I depress my hand when
withdrawing the instrument, the same inconvenience still existed.  Numerous
cutlers endeavored  to  effect this  important improvement; but  were all
unsuccessful.  At last M. Charriere, whose skill is well known, succeeded
in making a double lithotome of which the blades when opened gave the long
desired oblique direction to the incision.   The  following is an exact  de-
scription of the instrument.
  Like all the double lithotomes made previously by the same cutler,  this
opens  by means of a single spring.  This spring placed above, has on its
lower surface a steel prong of which the two rounded branches separate  like
the  letter  V.  Each one of these branches enters a hole made in  the end of
the  heel of the  blade, and may be raised or depressed with separating or
approximating the blades themselv >?.   The blade  is divided into two parts of
unequal length, forming  a very obtuse angle.  This angle is the  point of
articulation of the blade with the body of the instrument. The two small
mortices which1  receive  the corresponding part  of the blade are directed
obliquely from above downwards, and from within outwards, so that the blade
when   it leaves  the sheath,  follows an oblique line, and makes a  curved
incision.  The separation  of the blades is graduated  by a very ingenious
contrivance.   The stem of the spring is divided, and in  the division  is  a
small steel slider, held by a screw-button.   By making it slip in the groove
of the  spring, the degree of separation of the blades may be most accurately
determined. 
500
LECTURES ON
   The advantages of the double lithotome may be easily perceived.  Indeed,
we can by one incision make an opening  in  the  sides  of the neck  of  the
bladder, varying from six to twenty lines, beyond which limit it is not prudent
to extend it.  In order to perform the operation the patient must be placed as
in the ordinary position for lithotomy.   The staff is introduced and given in
charge to an assistant who holds  it in a  perfectly vertical direction.   Holding
a double edged knife in the right hand,  and with the other making the integu-
ments of the  perineum tense, the surgeon makes  a semi-circular  incision,
beginning on the right side, between the anus and ischium, and terminating at
a corresponding point on the left, passing five lines in front of the anus.  The
knife divides  successively the subcutaneous  cellular tissue, the superficial
perineal aponeurosis, and the anterior point of  the external sphincter ani.
   The origin  of the membranous portion of the urethra being exposed,  the
index finger of the left hand seeks the groove of the staff, and guides the point
of the bistoury into it.   During this first step  of the operation, care must be
taken to depress with the  finger the  lower  edge of the wound, and  also to
remove and protect the rectum from  the knife.
   An incision is then made in the urethra, and the  lithotome guided by the
nail of the index finger of  the left introduced  into  it, with the  convexity of
the curve corresponding to the anus.   Having  ascertained its proper situation
as regards the groove, the surgeon takes hold of the handle of the staff", and
raising  under the symphysis  pubis, carries the lithotome forward  into  the
bladder.
   The staff is then withdrawn, and the lithotome turned so as to present its
concavity downwards.   The surgeon then depresses the spring until it meets
the handle, and  withdraws it not horizontally, but  gradually inclining it
downwards.   After this last incision the forefinger of the left  hand carried
into the bladder informs us as to  the extent of the   incision, and serves as a
guide to the forceps.
   The operation  just described was successfully performed on several indi-
viduals ; the  following case,  however, was not  so fortunate, and  we will
therefore give it in detail.
   Cask V.—B.... 63 years of age, married, by trade a locksmith, of a good
constitution, and lymphatico-sanguineous temperament, had always enjoyed
good health, although habitually working hard.  Some years since  began to
pass with his urine small calculi, which, however, gave him no pain.  In the
beginning of the year 1827, he felt for the first time, pain in the bladder and
difficulty in making water.  Hae'maturia sometimes came  on after hard work.
The desire of  making water became  more and more urgent, and he could no
longer retain it.  There was pain after  the discharge at the end of the penis.
Me came to Paris for advice, and was admitted into the  Hotel-Dieu on tlv
22d of August, 1829.
   The patient labored under all  the symptoms of  calculus; the sound gave
notice, of a hard, sonorous, resisting  substance in the bladder;  there was in
short no doubt as to the nature of the disease.   He asserted that his urine was
limpid, but some of it being preserved, at the  end of 24 hours deposited a
copious sediment of purulent matter.  This was anunfavorable circumstance,
but did not contra-indicate the operation. The patient's general health being
good, he was prepared for it by baths, diet, and a mild laxative. 
CLINICAL SURGERY.
501
   On the 27th the operation was performed, and a small calculus extracted;
 two others of  the same size were also withdrawn.  The patient was then
 carried to bed.
   About two o'clock in the afternoon of the same day, I visited  the patient,
 and found him in a state of great suffering.  He had had chills and tenesmus ;
 the hypogastrium was tender, and tense ; the perineum also tense and pain-
 ful ; a little blood escaped from the urethra. I suspected internal haemorrhage,
 examined the  wound and found, it closed by  a clot, which was removed, as
 well as some others which were deeper seated.   Tepid yvater was then injected
 into the bladder.   During this operation the pain was very acute, but some
 relief  was experienced from its evacuation.  By this means the  bladder was
 freed of the blood which it  contained.  The patient's linen was changed, and
 he immediately fell asleep.  I did not  consider the bleeding dangerous, and
 the patient did not lose more than twelve ounces.
   28th.  The patient is pretty comfortable, and had slept part of the preceding
 night.   There  had been  no more haemorrhagy.  The belly was tense  and
 slightly painful; twenty leeches were applied to the groins.
   29th.  All the  functions in gQod order, no pain in the abdomen, no febrile
 symptoms.   The body was  covered with perspiration: the pulse weak and
 almost imperceptible.
   30th.  His pulse has improved, he has no pain, nor chilliness, but a tendency
 to sleep; tongue slightly dry.  His mind began to wander during the  night.
 He was  ordered punch, and a bath extending as high as the umbilicus ; if his
 situation permit, immediately after the  bath two blisters are to be applied to
 the legs.  (Broth as his diet.)
   31st. The blisters were not applied as he appeared a little better; he is
 still weak, slow, in answering, but with less disposition to sleep.
   September 3d. The patient does  not complain of  pain.  However, he is
 exhausted, becoming emaciated,  has a slow fever, the urine has commenced
 passing by the  urethra.   The wound  is healthy.   The belly hard  and swollen
 (leeches were applied to the epigastrium, and the baths continued).  I judged
 that there was inflammation of the cellular tissue of-the bladder.
   5th. Nine days after the  operation.  B .. ., although weak, appeared pretty
 well.  He has not yet  had  a stool, he was therefore  ordered  a purgative
 enema.   He also swallowed some old wine, and a little soup.
   During two or three days he appeared to be doing well,but he soon became
 sleepless, and rapidly emaciated.  Diarrhoea came on ; a slough formed on the
 sacrum.   Bark and other tonics were vainly administered ; his pulse became
 more and more weak, delirium supervened, lasting twenty-four hours, and the
 patient expired on the morning of the 17th, 21 days after the operation.
   Autopsy, 32 kours after death.—Corpse free from rigidity, flesh soft; slough
 on the sacrum small and  shallow;  considerable  emaciation.
   Cranium.—Meninges  healthy.  The  cerebral  substance firm, gritty and
 injected.  There was but a small quantity of serosity.
   Chest.__Ancient cellular adhesions at the apex  of the left lung.   The
 bronchiae slightly red.
  Abdomen.__At the greater curvature of the stomach there was a large,
 pale red patch in the mucous membrane, softened and easily detached.  This
ramollissement extended over a surface of at least three square inches.   In 
502
LECTURES  ON
the duodenum small red spots or membranes were observed, becoming more
numerous as we descended.  Soon we found here and there small superficial
ulcerations, very numerous towards the end of the small  intestine ;  the cce-
cum was also filled with ulcers.   The peritoneum was inflamed, thickened in
some places, in  others covered with albuminous flocculi.  The cavity of the
lesser pelvis contained about a pound and a half of purulent serum.
   Genito-urinary Apparatus.—The wound going  from  the  perineum to the
bladder presented no sign of cicatrization; it was as large as on the first day.
The whole of the perineum was infiltrated with blood, and the  cellular tissue
surrounding the rectum with pus.  Putrefaction, which was already far ad-
vanced, prevented the discovery of the wounded vessel.  Pus mixed with
blood existed all around the wound.   The prostate was not entirely divided ;
the opening into the neck of the bladder was about fourteen lines in extent;
the mucous membrane lining this sac was red, thickened and injected, highly
phlogosed, and nearly entirely covered by a false membrane strongly adherent
to it.  The ureters were healthy ; no calculi were found.
   Recapitulating what has  been said  on the bilateral operation, we  will see
that this method presents the following advantages:
   1st. Its  performance is more easy, quick and certain than the majority of
other methods;  in this point it even surpasses the lateral operation.
   2d. The  incision  is made in the widest part of the  perineal strait of the
pelvis, and  therefore at the most favorable point for the extraction of  calculi,
of any size whatsoever.
   3d. It opens into the bladder a shorter and more direct passage  than either
the lateral or vertical incisions, and  through which the instruments can be
more  easily managed.  The urine can flow freely through this opening, and
meets with  no obstacle which might  favor its extravasation into the  cellular
tissue.
   4th. It  has the advantage  over lateral incisions of making in the  neck of
the bladder and  prostate an opening large  enough for the  extraction  of very
voluminous calculi, without going beyond the circumference of this gland, or
those limits beyond which its division becomes dangerous.
   5th. It avoids  more certainly than thejateral operation the ducti ejaculatorii,
of which the lesion is a matter of some importance.
   6th. Lastly, this operation  may be  performed on both sexes, and at all
ages.
   The bilateral operation has been performed 66 times atthe Hotel-Dieu, and
in private practice;  of these 6 have died ;  26 cases were successively happy
in their result.   The proportion of deaths is generally :: 1 : 12.
   This experience is far  from being  extensive: but without pretending that
the bilateral method guarantees  us from haemorrhages, infiltration of urine,
and inflammation?, so liable to occur from similar operations, it is evident that
if it augment even very slightly the chances of success, that it is to be pre-
ferred to  all other operations in the  perineum, and especially to the lateral
operation, at present so much in use.
   In  a subsequent lecture we shall treat of the recto-yesical  operation, and
of the different methods of destroy ing,the stone in the bladder. 
CLINICAL  SURGERY.
503
                        CHAPTER  LVI.

                         ON GUN-SHOT WOUNDS.

  There is not perhaps in the whole domain of surgery a subject so complex,
embracing so many practical questions, and of which the diagnosis and treat-
ment demand more extended knowledge, correct judgment, and skill, than
wounds from warlike weapons  in  general, and from fire-arms particularly.
Thus, notwithstanding the numerous cases which accidents in hunting, public
festivals, duels, suicides, &c, have brought before the notice of M. Dupuytren
for  many years, he could not have  established a practical theory from these
isolated cases, caused mostly by the same weapons, the same projectiles, and
presenting  similar characters or occupying  the same  regions of  the body.
But three periods, celebrated by different names, the misfortunes of the coun-
try  in  1814 and 1815, the  glorious and  bloody combats  of  1830, and  the
unfortunate struggle of 1832, have given  to this distinguished surgeon an
opportunity of exercising his genius upon  this important  subject.  Before
treating of  wounds, said M. Dupuytren, we  will enter into some details con-
cerning the effects of fire-arms in general.   It will be then much easier to
apply fixed rules to the injuries which they occasion.  These effects depend
upon two principal causes;  the manner in  which the gun has been loaded and
the  distance at which  it is discharged.
  If a gun be loaded  with powder  merely, and  not wadded, the explosion is
not very loud, but severe enough to contuse  the skin violently if sufficiently
near to it.  If  it be  loaded with powder  and wadded, the effects will vary
according to the resistance and distance of the body which receives the injury.
This is a fact, which I have  myself seen.  Two persons had a quarrel:  one
of them discharged a gun loaded only with powder at the belly of his adver-
sary, who fell instantly dead.  The  shot was fired at the distance of one or
two feet.   Being questioned before a judiciary tribunal as to the cause of his
death, we found°on examination the clothes torn, the parietes of the abdomen
pierced by a hole of more than an inch in diameter, the intestine opened; the
wad of the gun was in the middle of the belly, and no other aperture existed;
it was certified that the gun contained merely powder.   Similar cases are well
authenticated. It often happens that suicides in their hurry and agitation forget
to put the ball into the pistol.  The parietes of the mouth are then violently
distended by the rarefaction of the air.  Sometimes the wad traverses  the
palatine vault.   If the shot is directed backwards, the vertebral column indeed
is not injured but  the velum pendulum is lacerated ;  and sometimes  also the
lower  jaw  bone is fractured.  You all know that a certain quantity of water
forcibly projected from the barrel of a gun, will stun and even  kill birds.
Even a tallow candle will at a short distance pierce a pretty thick board.  The
extreme  rapidity communicated to the  soft body here supplies its want of
density and  overcomes the  cohesion of the  wood.  A  handful of coarse salt
does not do much  damage if the gun has not been loaded for a long time; but
if the  salt  have had time to concrete, and the shot be near, the load may fly
like a ball and  do serious mischief. 
504
LECTURES  ON
   Small shot of different sizes acts in two ways ; it either strikes in mass, or
 as it is said, makes a ball (fait balle) which depends on the gun and the dis-
 tance, or it scatters and falls separately.  In the former case its effects are
 more severe than those of a ball.   It was by an accident of this nature that a
 son  of Marshal Moncey was killed, and every year we hear of new victims to
 imprudence or awkwardness.  A ball will frequently pass through  the lungs
 without causing death, whilst  a load of shot lacerates these organs and inevi-
 tably destroys the patient.   In the second case, that is, when the discharge i'^
 distant,  accidents but rarely occur,  unless   some  very important part  be
 wounded.   The eye, if struck by a single grain of shot is irrecoverably lost.
 It the heart, stomach, or intestines be wounded, serious injury might  result;
 but  this species of projectile seldom penetrates beyond the subcutaneous
 cellular tissue.
  Buck-shot and small balls  are similar  to ordinary balls,  and do not less
 injury when discharged at.the proper distance;  but, as there  are  generally
 many of them, the same discharge produces a greater number of wounds and
 increases the danger.
  As it is  principally the  effects  of musket-shot we axe to examine in the
 study of gun-shot wounds, it will, be  proper to glance at the modifications
 experienced by projectiles in their course according to their velocity, direction,
 and  the  different points of their track.  The velocity of a ball diminishes
 from the moment of its leaving the  gun, until it falls to the ground.   The
 air presents a certain resistance which tends to deviate it from a straight line
 and  diminish its rapidity.  Every body against which it strikes deprives it of
 a portion of velocity, and even arrests it suddenly if its thickness  and soli-
 dity  surpass the motive power; but this takes place only when the  projectile
 falls perpendicularly on  the plane of the surface which it  meets.  If this
 meeting be oblique, the ball flies off at an -angle more or less obtuse.  These
elementary principles of physics should not be  forgotten, as they explain many
 remarkable  circumstances  in gun-shot wounds, and we shall  frequently apply
 them.  It would be useless to  expatiate here upon the degree  of resistance
 offered by different bodies on account  of their nature, density and form.
  The action of grape shot, biscayans and bullets, does not  differ from that
 of the projectiles of which we  have  spoken  except in size, irregularity of
 shape, and the immense velocity with which they are propelled.
  The second circumstance influencing the effects of gun-shot, is the distance
 at which they are discharged.  When  near, the injured body receives not only
 the projectile at the moment of its greatest impetus,  but also all the force of
 the explosion itself with the wad.  We have therefore at once, burn, lacera-
 tion, and great contusion of the body.   When  at such a distance that the ball
 alone reaches its destination, its action will be severe in proportion to its
 proximity to the commencement of its career.  Lastly, the projectile when
 arrived at the end of its flight produces merely a slight, impression  or contu-
 sion.  Balls are frequently turned from their course by the form of  the  body
 against which they strike. If they meet obliquely a cylindrical surface, they are
 reflected in the same manner as from  a plane.  If on the contrary they meet
 the  extremity of the  diameter of a curved demi-cylinder,  they  follow this
 curve  and  pass oft* at the other extremity.   The head and  chest present a
 very well marked cylindrical form, and it often happens that a ball striking 
CLINICAL SURGERY.
505
one side of the forehead or chest travels between the bones and skin, and
comes out  at the opposite  point  without  doing  any internal injury.  This
phenomenon is owing undoubtedly to the resistance of the  skin, which being
elastic and at the same time very solid, prevents the ball from being reflected
outwardly.  All elastic bodies resist more or less  the action of balls; clothing,
especially when made of wool, protects in a certain degree the parts which it
covers.   It has been observed, that the hole made by the ball  in the clothes,
is smaller than at the corresponding point in the  skin.  The ball often pene-
trates deeply without perforating the clothing.   In 1814, a French soldier
wounded under the walls of Paris was brought to the Hotel-Dieu ; on examin-
ing the  upper part of the leg, we  found a fragment  of cloth buried  amongst
the bones.   It was drawn out, and found to contain a ball  which had driven
before it a  part of  the gaiter of the soldier.  Amongst the wounded received
at La Pitie, in July 1830, one presented a similar case ; a ball had penetrated
the belly carrying before it the shirt, which was not torn, and was of great use
in the extraction of  the projectile.  It was for want of a  knowledge of this
principle that the  death of Charles 12th, king of Sweden, who was killed by
a bullet passing through his head, was attributed to assassination, because there
was a  great difference between the aperture  in his hat and his forehead.
   This difference of elasticity of the organs explains also several other re-
markable phenomena.  A projectile of which  the velocity is diminished strikes
obliquely a round  surface,  as the thigh, and follows its course without leaving
any mark on the pantaloon of the wounded man ; yet the limb becomes numb
and stiff, the man falls, and the thigh-bone is found to be fractured, and the
soft parts reduced to pulp.
   This is  because the muscles, at the moment of receiving the blow, are in
a state  of tension, which renders  them more liable to rupture ; the skin cover-
in"- them  is not so easily broken, whilst the subjacent parts are killed and
lacerated.  Accidents  of this nature have been attributed to the wind  of
the  ball, that is the action of the air  violently impelled  by the  projectile.
This opinion, although firmly believed by soldiers,  is  entirely erroneous.
   The  ball striking a body of more or less density may undergo various modi-
fications, become  flattened, broken into fragments, and thus produce wounds
 which can hardlv  be accounted for.  A man  receives a gun-shot wound : the
 ball striking the lower part of the right leg,  is divided into two portions  by
 the spine  of the tibia.  Each of these portions  passes through the  calf, and
 lodges  in  the  other leg.   Thus  five  openings have  been  made by  one  ball.
 I saw  several citizens wounded by fragments of a ball which had struck  an
 iron bar which was  near  them.   Sometimes also cast-iron balls meet  very
 hard bodies and break into pieces ; they then give rise to very severe wounds.
   Such are  the ordinary effects of fire-arms considered in a general manner.
 Le^tusnow  enquire if there  are any  circumstances which can add to their
 severity   The dangerous  symptoms which sometimes  follow a  gun-shot
 wound  have <riven rise from time immemorial to the belief in the existence
 of noisoned  balls, and  even in our day this  error has its partisans.  These
 foreicm bodies do not act like poisonous  substances; their presence merely
 excites and maintains an inflammation which  is removed only by suppuration
 or the extraction of the body : such are pieces of clothing, wad, or  fragments
 of balls. But the tissue sometimes becomes accustomed to them, it their lorm
             64 
506
LECTURES  ON
be regular, their surface polished, and of small size.  Balls have been found
in the brain, heart, and most of the other organs.  A remarkable process then
takes place.  A sword-like  production is first spread around the ball; it is
afterwards organized into a villous membrane, exuding pus, but which gradu-
ally becomes thinner, smooth, and furnishes from its internal surface only a
little serum.  The foreign body thus isolated from the organism, may remain
an indefinite length of time.  Sometimes, however,  this serous cyst  acci-
dentally inflames,  pus then forms and  dicharges  outwardly.  Fistulous
sinuses are then formed, which remain as long as their cause exists.  Let us
examine this interesting subject.
   I have frequently had an opportunity, said M. Dupuytren, of examining
the state in which these bodies are found in the midst  of our organs.   When-
ever they excite inflammation and  suppuration, they are surrounded  by a
purulent cyst of a mucous  nature, and after some  time a fistulous  com-
munication is established between them and some point of the surface or in-
terior of the body.   Oh the contrary, whenever they excite neither inflamma-
tion nor suppuration,  they  are  surrounded by a  cyst, whose shape corre-
sponds to their own, but of an organization similar to that of serous membranes.
These cysts adhere by one  surface to the soft parts at whose expense they
have been formed; and the internal surface is in contact with the foreign
body.   Their cavity  always contains a limpid serum and the foreign body.
This remark is  not only curious but important in practice.
   Indeed, if in  operations performed with a design of extracting these foreign
bodies, the latter are merely removed after a simple incision into the  cyst,
and the wound be  then closed, a new tumor is almost always reproduced  in
consequence of a collection of  serum on its internal  surface. Therefore,
when these  bodies are extracted  the cyst must be either removed  or  filled
with charpie, in order to excite  inflammation, suppuration, and adhesion of
its parietes.
   But these foreign  bodies do not always remain immoveable in the tissues;
strange to say they become erratic.  Their displacement may be slow or rapid.
When rapid, they leave no trace of their passage.  When slow, they travel
around the serous cysts of which we have Spoken.  This mobility belongs
not only  to pointed, smooth and elongated  bodies,  but also to bodies of
different shapes, spherical for example, but it is in general less as they ap-
proach a spheroidal form.  The surgeon should not lose sight of this property.
As it frequently happens that they become displaced from day to  day, and
that a body felt one day has disappeared on the next, we should never make
incisions or attempt its extraction from the remembrance of a previous ex-
amination, but  from the sensation experienced at "the moment of operating.
This displacement generally takes place from  the  interior towards the sur-
face; sometimes, but rarely, from the periphery towards the centre.
   It was thought that a ball impelled by a body in combustion preserved  a
degree  of heat  which must increase in proportion to its velocity : the wound,
therefore, presented besides its peculiar characters  those of  a  serious  burn.
The celebrated  Ambrose Pare long ago  demonstrated the  absurdity of this
opinion, by showing that balls passed  through a heap of gunpowder without
causing its explosion.
   Let us  now  apply, continued  M. Dupuytren,  the ideas just exposed  to 
CLINICAL SURGERY.
507
wounds probably so called.  We must examine their general and distinct cha-
racters, their degree of danger, their different complications, the special causes
which may influence their termination, and the treatment proper in each case.
  If the part struck by the ball be supported by bone, as the front of the leg
or the cranium, the skin may be, and indeed is, generally destroyed.  In this
case the contused tissue inflames, ulcerates, and cicatrizes.  We have before
spoken  of the  more  serious effect  of a ball which crushes a limb without
breaking the skin.  It is not rare to  find the latter untouched, even when the
muscles, viscera, &c. are reduced to pulp, and the bones  fractured.  It is
contusion carried to its maximum.   In the case of a woman wounded in July
1830, the humerus was fractured  and the skin unhurt.  In  1814 a soldier
was received into this hospital, whose loins had been grazed  by a cannon ball.
There was seen in this region nothing but a considerable  swelling without
lesion of the integuments.   Inflammation soon set in, all the soft parts became
gangrenous, and on inspecting the corpse, that portion of the vertebral column
was'found broken  into  small  pieces.  It will  be seen that in similar cases
the resources of art are useless.
   If the projectile, driven with.great force, strikes the surface of the body
obliquely, it makes a lacerated wound of greater or less extent, and hollowed
like a groove ; less obliquely, or directly, it penetrates its thickness, and if the
impetus be expended, remains imbedded.  The wound then presents but one
orifice, and according to the remark of Percy,  the bottom of it is larger than
the orifice, on account of the continuance of the rotatory motion.  It is well
known that, like all spherical bodies when projected, balls are possessed of a
 double  movement, one of projection describing the curve of a parabola, the
 other of rotation on its axis, which continues some time longer than the former.
 The. combination of these two forces explains several remarkable  phenomena.
 When a ball has nearly reached the end of its career, it rolls slowly over the
 o-round ; but if it meet an  obstacle, it overthrows it violently, or rises itself
 several feet in height.
   If a ball  possess sufficient force to traverse  the  body; its  passage  is
 marked by two apertures.  That of entrance, often pretty regular, presents
 dimensions proportional, to the size of the wounding body.  Its edges are driven
 in and more violently contused than those of the aperture by which it escapes
 The latter is generally less regular, larger, its edges project, are less contused
 and more unequally lacerated.  The skin, at the point of entrance,  is sup-
 ported by the subjacent  parts, which thus renders the solution of continuity
 more easy,  and prevents laceration.  Again, in explaining this phenomenon,
 the loss of- force  experienced  by the projectile  in  its passage  through the
 tissues must  be  remembered; for  observation proves, that balls traversing
 solid parts divide them  more  evenly in proportion to their velocity.  This
 difference of diameter between the two apertures holds good as regards wounds
 of the cranium, and not otherwise, as was supposed from an  incomplete case

  ^Ue^l  stovTyou an interesting specimen proving the correctness of the
  assertion   It  is  the cranium of a young  man who  had shot.himself with a
  asseruo .   ^ ^  ^^ ^ middle anJ Jower part of the os  frontlS(

  nass'ed through the cerebral substance, struck the osoccipitis at the opposite
      t  been repelled by the elasticity of this bone, which although fractured 
508
LECTURES  ON
was not carried away, and was found in front of the tentorium cerebelli.  The
opening made in the external table of the frontal bone is clean and of the di-
ameter  of the projectile, while that in the internal table is much larger and
more irregular.  The fractured part of the occipital presents a still larger ex-
tent, especially outside.  Notwithstanding this serious wound, the young man
lived three hours after its reception.
  The track of the ball is generally more  or less sinuous, on account of the
unequal  retractility of the  tissues, and change of position of  the wounded.
Levacher saw a ball strike the fore part of the thigh and  come  out at a  point
diametrically opposite, without fracturing  the bone!   Balls are often known
to penetrate the integuments of the foreheadand come out in the integuments
of the  occiput without breaking the skull,  &c.  Dr. Hennen, quoted by
Samuel  Cooper, has seen a still more extraordinary circumstance, a wound
made by a ball  entering near the thyroid cartilage, and traversing the whole
circumference of the neck.  It is easy to explain all these facts by the appli-
cation of the. known laws of motion.  A  ball meeting a bone acts upon it in
different ways.   Sometimes it merely produces a contusion, but  this accident,
although apparently slight, is often serious.  The periosteum, if it  has not
been destroyed, inflames and  separates, the  bone becomes necrosed for  a
greater  or less extent; if it be of a spongy texture, the inflammation is pro-
pagated  to the internal vascular tissue, and may extend farther.   In  the cra-
nium  the two  tables are almost always necrosed at the same time; the  dura
mater consecutively inflamed, &c.
  -When projectiles possess sufficient  force to overcome the  resistance of
bones they, produce  very  various accidents.  When  compact, and there-
fore  inelastic, they are easily broken.  The flat  bones are sometimes perfo-
rated as neatly  as though it were done by a  punch; sometimes with fragments,
like a ball striking a frail and thin substance, as a window glass for example.
If it meet only one point of a long and hard bone or a prismatic bone, as for
instance the tibia, it  notches  It,  and this  may happen without breaking it
throughout the whole circumference.  But the middle of the  long  bones i.-
generally broken into fragments of different shapes and sizes.  If the ball be
nearly spent or strike the bone obliquely the latter may be fractured without
scales.  This was the  case with General  Rapp, whose left arm was broken
across at its middle by a ball which remained imbedded in the flesh.  A mason
wounded on the 28th of July, 1830, in the  attack on the Hotel-de-Ville, had
his right thigh fractured nearly in a similar  manner. The spongy tissue form-
in"- the thick bones  and the ends  of the long bones, less appropriate  to resist
a blow,  is also less capable of dividing it over a large surface.  The fragments
are  generally more  numerous and smaller, but the injury almost always ex-
tends to the joint and circumjacent parts.  Sometimes this spongy  tissue is
traversed without a  fragment, presenting an opening like that made by a tre
phine.   Lastly, if the resistance of the bone overcome the force of the projec-
tile, the latter  becomes misshapen in various ways, it is sometimes flattened
or rendered angular, sometimes grooved, and at  last terminates its career at
the opposing point, or turns aside and injures the  neighboring organs.  If it
meet the projecting edge of a bone, it may split.  Balls have been divided
by the spine of the tibia  and come out separately on the opposite  side
of the leg.   Still more, when they fracture the flat bones and strike  then- 
CLINICAL SURGERY.
509
obliquely, they may divide against the fragments.   A soldier was received in
the Hotel-Dieu in 1830, wounded by a ball which had fractured the right pa-
rietal bone, and divided into two parts, one of which escaped through the in-
teguments, whilst the other penetrated the brain as far as the tentorium cere-
belli.  We  had also at the  same time in this hospital a wounded  man, in
whom the ball, after having fractured the occipital  bone, divided into two frag-
ments, which remained united, and as it were astride of the bone.
  When on account of  the resistance  of the parts, or the  almost exhausted
force of the ball, it remains in the wound, it has a great influence on  the con-
sequences of the  injury,  and demands the surgeon's whole  attention.  It
should always  be removed, and  this  is sometimes a difficult business.  But
how can  we ascertain its presence in the parts ?   The existence of two open-
nigs is not always a proof, for these kinds of wounds often conceal bodies of
different  natures ; sometimes it is the projectile itself, alone or accompanied by
a portion of wad or clothing,  fragments of buttons or other bodies.  It may
have escaped through the wound and left these substances behind.  This is to
be  expected when the  clothes  of, the patient, instead of presenting  a simple
rent, have suffered loss of substance.  As to the projectile, it cannot be in the
wound when this presents two apertures, unless the gun  have been loaded
with more than one ball, or that the ball striking a bone has been split.  The
following is a curious case, showing how difficult the diagnosis may sometimes
be.  In  the month of July,  1830, a citizen  was  wounded by a ball  which
entered above the clavicle and Came out near the inferior angle of the scapu-
la.   He picked it up at  some feet from him.  He was cured in  a few months.
Presenting himself before the committee of indemnity he was examined, and
a hard foreign body felt near  the posterior wound ; an incision  was made and
a fragment of a ball extracted.   It was difficult to believe that it belonged to
the ball  picked up by the patient. Such,  however, was our opinion, and on
weighing the fragments they were found to be exactly equal in weight to an
ordinary  ball.
  When the wound has only one opening, we may conclude that the projectile
is contained in  it.  It may, however, happen that the body driving before it a
portion of clothing has  lodged in it as in a  sac, and is withdrawn when the
patient is undressed.
  The smaller projectiles  most  frequently remain imbedded in  the parts ; this
is generally the case with small shot, but rarely with projectiles  larger  than
ordinary balls.   I have  seen one case to the contrary: on the 29th of July, a
child fourteen years of age was. wounded by a biscayan, which after traversing
the chest stopped under the integuments of the back.  He was  brought to the
hospital and the ball  extracted, which was as it were wrapped in a considera-
ble quantity of  wadding.  Again, we should consider as foreign bodies the
fragments of bone separated from, or but feebly united  to the soft  parts.
When of an irregular shape they are more injurious, as  they lacerate and
irritate the tissues.
  There  is nothin°- more  diversified and extraordinary than the passage of
projectiles through our organs.   We have already spoken of balls describing
the whole circumference of the head, neck and breast: here  follows a still
more remarkable case.  In 1830,  a man fighting on the bridge of Areola, was
struck by a ball which entered opposite to the internal angle of the left eye; 
510
LECTURES ON
the wound, directed backwards and slightly to the right, seemed to pass through
the head.  However, this ball after passing below the cranium came out above
the right shoulder ; the cure was rapid.  Another soldier, placed in ambush
behind the parapet of the bridge of Notre-Dame, was struck by a ball in the
head at the moment he  was levelling his gun.  The ball passed through  the
edge of his  hat along the right side of his nose, pierced the upper-lip, broke
four upper teeth and the lower jaw, came out behind the chin, entered  the
base of the neck behind the clavicle, and buried itself in  the left  shoulder.
The man perished  from inflammation of  the  chest.  There are some organs,
continued M. Dupuytren, so  important that we would suppose their injury to
be inevitably followed by sudden death.   However, we sometimes meet with
exceptions.
  The immortal Harvey, in his researches  on  the circulation of the blood,
found a ball buried in the substance of the heart of a  deer.  The wound was
ancient, and the animal when killed appeared in good health.  At the taking
of the Louvre (1830), the young Duvin," 17 years of age, was  struck by a ball
which  passed through  the left side of the chest, immediately below the base
of the  heart.  An  enormous wound was produced ; a rib had been  broken,
the lung perforated, as well  as the scapula.  However, after thre'e or foui-
days of intense agony, he recovered a little strength, and two months after
tiie occurrence of the wound there was a chance of his recovery.
  But  the most extraordinary wound which came under our notice during the
revolution of July was the following.  A pioneer of the royal guard was struck
at the gate of Saint Denis by a ball, which penetrated  from above downwards
the anterior  part of belly.  The neck  of the bladder as well as the rectum
were opened; the ball came out a little above and outside of the anus.  From
the two wounds urine  and faeces were discharged  at the same time ; the ball
had fractured the  os pubis without entering the cavity of the abdomen.   A
series of severe symptoms followed, but they were happily subdued by ener-
getic treatment.  On the 35th day after the wound the patient appeared to be
out of  danger, when inflammation  took place, and he perished on thelOth
of September following.
  A very remarkable circumstance observed in  gun-shot wounds is, that all
the soft parts situated in the track of the projectile are struck with gangrene
from its immediate effect.  A slough some  lines in thickness is formed,  and
it  must be removed by an  inflammatory process  followed  by suppuration.
This result is inevitable, and a knowledge of it of vast practical importance.
It follows, that in this kind of wound union by the first intention is impossible,
and that  often an endeavor to obtain it would endanger the patient.  It was
undoubtedly this peculiar.character of gun-shot wounds which  gave rise to
the belief in the burning effect of projectiles.  Let us now examine, said M.
Dupuytren,  the  progress of gun-shot wounds, and review successively their
degrees and complications.   When there is only contusion without a wound
and disorganization of  the tissues, art sometimes succeeds in preventing or
restraining the inflammation.  The cure is then effected without any solution
of continuity in the skin.  But most generally an acute inflammation ensues;
the parts of which the  organization has already suffered a severe injury be-
come rapidly gangrenous ; suppuration, which is both  abundant and serious, i*
soon changed by contact with the atmospheric air.  If the injury be of great 
CLINICAL SURGERY.
511
extent death is  almost inevitable.  The tissues of which the  structure has
been destroyed by the contusion cannot resist the eliminatory process.  Gan-
grene sometimes extends further than their general state would have indicated,
and then alone can we ascertain the whole extent and danger of the accident.
These wounds, whether they implicate merely the soft parts or  extend  to the
bones, belong to that class which must necessarily suppurate ;  but their cure
is more easily effected  when they are not very deep, contain no foreign body,
and the general condition of the patient is satisfactory.
  Traumatic inflammation at its onset is generally slower than ordinary con-
tused wounds, a circumstance which long ago attracted the attention of  A.
Pare, and which gives to them a fallacious appearance of mildness.  This'in-
flammation, often more severe at the point of entrance  than  at that of the
escape of the ball, becomes very intense.  If the divided parts abound in fibrous
tissues, a  tumefaction  takes  place which may be very serious  in its results.
Thus swollen, the parts meet with an invincible resistance in their ligamentous
envelope; they become strangulated and dead, that is, they are  struck with
gangrene from compression.  Hence the necessity of enlarging promptly this
species of wound, as proved by experience for many ages, in  order to avoid
the dangerous consequences of strangulation.   One of the  most frequent
complications is that kind of gangrene called  improperly hospital gangrene ;
for it is not exclusively confined to public establishments.   The vast number
of patients, natural unhealthiness of the place, want of cleanliness, and damp-
ness especially,  seem to be favorable to its appearance.  In 1814 this disease
raged at the Hotel-Dieu.   This was not the case in 1830; many of the beds
were unoccupied, and the patients were sufficiently far from each other not to
vitiate the air.   But as this gangrene may arise independently of the causes
just  enumerated, there must be  some  peculiar influence resulting from  the
wound  itself, or the mode of  action  of the  cause.  Contused wounds (and
above ail gun-shot  wounds) are most frequently attacked.  When the process
of cicatrization commences the parts are in a  state of weakness proportionate
to the violence of the contusion, and are  thus very liable to be  acted upon by
general causes.   If inflammation supervene,  it soon becomes too violent, and
gangrene attacks the  most superficial  layer of the wound;  there is a  great
deal of pain and swelling; the surface of the wound becomes of  a  grayish
color; an inorganic matter is deposited, a kind of pulp with a serous and
fetid suppuration.  This is accompanied by a sensation of burning, which
induces the patient to expose his wound  to a current of air.   The fever is
high, heat of the skin  violent, insomnia complete.
   Gun-shot wounds, especially of the limbs,  are frequently complicated by
fractures, which add greatly to their  danger.  A  bone is  seldom fractured
simply; it  is generally broken  into  numerous irregular fragments,  often
separated and driven into the flesh by the violence of the shock.  If  we add
to these injuries those which the soft parts have suffered from  the passage of
the  projectile, the  laceration  of muscles, tendons, aponeuroses, nerves and
bloodvessels, we have a specimen of  the most severe compound fracture.
The danger is greatest in the leg and thigh, on account .of the thickness of
the muscles and aponeuroses, and number and size of the bones.  Let us now
examine the primary and secondary effects of the fracture  and presence of
the scales. 
512
LECTURES ON
  A violent inflammation takes place at the seat of fracture, and extends over
the whole limb.   Those parts which have  most suffered  from the contusion
are often killed, and after the fall of the slough, a greater or  less portion of
bone is exposed ; this is frequently seen in fractures of the leg.   Suppuration
becomes very copious, the pus bathes the fragments, which are necrosed; it is
infiltrated ip the fibrous tissue, in the intervals of the muscles.   A still more
serious accident sometimes adds  to the already dangerous situation of the
patient.  If a fragment of bone  be in the<vicinity of an artery, the pressure
kept up against its parietes causes its  erosion, ulceration, and is followed by
secondary haemorrhage.  This  is most frequently seen in the leg and thigh.
This haemorrhage is generally more tardy  than that resulting  from the fall of
the eschar.  M.  Pelletan relates a case in  which it did  not occur until the
70th day.
  The primary scales, that is to say, those  entirely separated by the wounding
cause, left to themselves can  never recover their vitality; they are  foreign
bodies buried in  the flesh or the bones.  In the flesh they give rise to copious
suppuration, less so in the bones; but they then cause dangerous fistula,  if
they be not expelled, which is rarely the  case, nor absorbed, which  is  still
more rare, nor extracted by means of art.  What  happens  in the case of
secondary scales, or those which are still adherent ?  Some lose this adhesion,
and are then primary.  Some are still supplied with vessels and nerves,  are
then almost always amalgamated with the callus, and contribute towards its
formation.   The tertiary scales, or those in consequence of necrosis, remain in
situ  until  the  process of elimination separates  them.  The ends  of the
fractured bone cannot unite until the termination of this process.  However,
consolidation will take place; the periosteum, cellular tissue, all the soft
parts tumefy, inflame, harden, and acquire  at some points at first a fibrous, then
a cartilaginous, and lastly an osseous consistence. These bony nuclea extend,
and a. ferrule unites  the two ends  by their circumference, or  else by their
extremities.  If the necrosi fragments be  too large to be  expelled, they are
inclosed like necrosis surrounded by new bope, and as in that case there is a
sequestrum, and newly formed bone and callus.  This sequestrum occasions
and keeps up fistulous openings; as I have  observed  for many years in the
patients brought to the Hotel-Dieu.
  In this case, the limb is  generally  shortened or deformed ; the callus is
large and unequal; at two or three points of its circumference are fistulous
openings : a probe introduced meets the sequestra, and the sound produced
is that resulting  from the contact of a metallic instrument and a bone deprived
of life.   The indications here are to enlarge  the aperture, apply the trephine,
and extract the dead bone.
  Generally, in gun-shot wounds, suppuration is very abundant, and  the pus
escapes with difficulty, either because  the track of the ball is long and tortu-
ous, or because  the swelling keeps the surfaces too nearly approximated to
each  other.  It then  accumulates in  the  parts, forms abscesses, becomes
effused, and is productive of great mischief.   The patients die in great number
during  this period of suppuration, either  from exhaustion or  some visceral
disease, or lastly from the absorption of  pus or inflammation of the veins.
To these two last causes are to be attributed  the purulent abscesses found in
the lungs,  liver, muscles, &c, the collections of pus  which frequently fill 
                           CLINICAL SURGERY.                       513

the cavities of the serous membranes, and the synovial cavities of the joints.
Many writers have for a long time pointed out these alterations as consequent
to gun-shot wounds ; but modern pathological anatomy has pointed  out their
true  nature and causes.
   Lastly, we must reckon among the  serious complications haemorrhage,
especially when  secondary, tetanus, coma, erysipelas, diffuse phlegmon, in-
flammations of the internal organs, &c.
   When a ball lodges  among living parts,  the  first sensation is not one of
pain, but a kind of numbness, accompanied by heaviness in the wounded part,
a sensation similar to that experienced from a blow with a stick.  Generally,
persons wounded are only aware of the accident from seeing the flow of blood.
Sometimes, when very severe  injury is  inflicted, as by a cannon shot or bis-
cayan, or when large joints are wounded, this state of stupor is not confined
to"the wounded  part, but seizes the  individual, who no longer is conscious
of what is going on, and falls into a state of complete apathy, indifference, and
insensibility.  Such was the case  of the horseman spoken of by Quesnay ;
amputation of his thigh was proposed  to him as the only chance of his life; he
replied, that it was not his business.   Incisions and the most severe opera-
tions do not  draw from the patient a single indication  of pain.  The skin
becomes pale and cold; sometimes of anicteric  and  leaden hue; horripila-
tion, fainting, and syncope supervene; the pulse is small, corded, irregular, and
often intermittent; the respiration is slow, the countenance bewildered, mouth
open, the eyes fixed, and the features shrunken.  This serious injury to the
vital principle should be looked upon  as the index of a fatal termination, if it
be not removed in a few hours.
   Should reaction come  on,  the  patient rouses from this state of general
stupor; the wound, until now pale, wan, or violet colored, becomes inflamed,
pours out sanguineous  and fetid fluids, and  is soon the seat of an emphysema-
tous tumefaction, extending more or less towards the trunk.  There is an
irregular fever, mixed with chills and heat, a delirium sometimes evanescent,
sometimes furious, vomiting, general jaundice, suppression of  urine.   The
patient then perishes  in an ataxic state carried to the highest degree.  The
effects of the stupor seem not to end with life.  The wounded part and its
vicinitv assume  rapidly a livid color, and exhale  an odour of gangrene and
putrefaction  at once.   This cadaverous lividity attacks the whole body, which
appears struck with a general putrefaction far advanced, at a time when a
natient dyino- from any ordinary disease would evince no symptom of it.
   This disorder has been supposed to result from the shock to  the nervous
system- and  in this light this stupor would be likened to cerebral disturbance
of which it would be only a shadow: such however is not the case;  cerebral
disturbance  has  its peculiar characters, so also has stupor   In the former
case there is lesion of the functions of an organ; in the  second, injury done to
die  vital principle.  The latter is  a state analogous to that developed in con-
  eauence of  a severe visceral inflammation, a typhoid fever, gangrene an
Sensive burn, and in general, any deep and severe lesion   A proof that this
stupor is  independent of  all mechanical agitation, is, that  in individuals who
have received he same wounds, under the same circumstances, it may or may
not occur and seems to depend much  more on the mental state of the wounded
Sian tlie 'circumstances of the wound.   Thus it is generally observed, other
              65 
514
LECTURES ON
things being equal,  in patients  possessing but little moral energy; in the
army, it affects principally the young soldiers.
   Gun-shot wounds generally bleed less  than ordinary contused  wounds.
Even when  a large sized artery is opened, the blood does not always  flow;
its parietes partaking of the contusion  or disorganization of the surrounding
tissues form lacerated fragments or eschars which obstruct and close its calibre;
moreover, if the  whole circumference of  the vascular tube be divided,  it
retracts as in lacerated wounds.
  A limb may be  fractured or carried away near the body, with effusion ot
blood; and sometimes the obliteration of the vessel extends so far that ampu-
tation may be performed without a necessity of tying the vessels.  But those
circumstances which prevent loss of blood when the artery is of small or
moderate size, are insufficient when the wounded vessel is of large diameter.
A young man was wounded  in the attack on the Hotel -de-Ville in 1830, by a
ball, which  penetrated the thigh and opened the femoral artery.  He  was in a
dying  state from loss  of blood,  on his arrival at the  Hotel-Dieu.   The
vessel was secured in less than two minutes, but the  patient could not recover
from the profound syncope into which he had fallen, and expired.  After what
has been said on primitive haemorrhage, it must be acknowledged  that Baron
Larrey by inventing flying ambulances, which traverse the field of battle and
afford instant succor to the wounded soldier, has made a vast improvement in
military surgery.
  Unless the projectile has injured a very large vessel, primitive haemorrhage
is rare in this kind of wound.  The greatest  danger consists in secondary
haemorrhage.  This occurs in two different ways, whether the artery  be com-
pletely divided, or only partially  so.  In the former case  the slough, as we
have said, produced immediately by the shot, and  the  coagulum  of blood
formed in the cavity, as far as the first collateral branch, obliterates  the cir-
culation throughout the whole of this extent.  But it sometimes happens that
from certain causes the circulation becomes very active, the coagulum is  ex-
pelled, the slough thrown off, and  haemorrhage ensues.   In  other  cases, the
causes preventing haemorrhage persist until the whole of the internal surface
of the wound, and consequently the lacerated and disorganized portions of the
artery, are  detached  and eliminated by the  suppurative  process.  But  then
if the end of the obliterated artery be too short, its union not sufficiently firm,
or any imprudence on the part of the patient destroy this union, &c, the ar-
tery is opened and the man exposed to more or less danger.
  Secondary haemorrhage generally comes on about the 10th, 15th, and even
the  20th day, without any precursory  symptoms, except sometimes a slight
sanguineous exhalation  from the wound.   Wounds  of arteries therefore re-
quire great attention, in order that efficacious treatment  may be promptly
employed in case  of accident.
  It should  not be forgotten that secondary is  much more dangerous than
primitive haemorrhage, either on account of the weak state of the patient, or
the inflammation of the arteries and neighboring tissues.
  Indeed, as primitive  haemorrhage takes place on  the  surface, the vessel
which pours out the  blood may be easily seen and secured ; the elasticity of
the healthy cellular tissue permits it to be drawn out. The cellular tissue and
coats of the artery being as yet unchanged,  the  ligature  does not fall  until 
CLINICAL  SURGERY.                       515
after six or eight days, when the coagulum is organized and danger no longer
to be dreaded.  Such is not the case in secondary haemorrhage.  The tissues
have retracted, the vessel is therefore discovered with difficulty ; as well  as
the cellular tissue, it has lost  its natural  extensibility; the ligature cuts it
easily, and falls before the obliteration is  perfect; the bleeding often  occurs
at one or more hours after the operation.
  In similar cases the artery must be tied between the injury and the  heart;
as no  other method will be found of the least benefit.  Secondary hemorrhage
sometimes takes place  from small sized vessels.  In 1830, I saw this  occur
in the case of an officer wounded in a branch of the temporal artery; compres-
sion merely served to suspend the flow of blood.  The trunk of the  vessel
was secured, and  all hemorrhage ceased  from that period.  In many  other
cases  balls had passed through the neck, and we were astonished to see how
projectiles could pass between so many vessels and nerves without injuring
any of them.   In one case, a young man  twenty years of age, delighted  at
reaching the 12th day without any accident, was walking about, eating, and
talking to every one, although he had been  told that  the  least  imprudence
might cost him his life.  He was suddenly seized with hemorrhage, which de-
fied our attempts  to arrest it.  He died in a few hours.
  It sometimes happens that an artery and its accompanying vein are wounded
at the same time at contiguous points  of .their circumference ; a communica-
tion is then formed between them, and  the  blood passes directly from the
artery to the vein.   Thence results a  varicose, or arterioso venous aneurism.
Nerves divided by gun-shot wounds partake of the  disorganization of the
other tissues.   To this cause must undoubtedly be attributed the  slight pain
felt by the patient at the moment of receiving the wound, and the sensation
of weight and numbness  properly compared  by Ambrose Pare to that pro-
duced by the fall of  a beam, or blow with a stick, as we have elsewhere re-
marked.
  One of the most dreadful and most generally fatal complications  is tetanus,
of which  it maybe here proper to mention the principal symptoms.  All
wounds may give rise  to it; but it mostly follows punctured, lacerated or
contused wounds, &c, complicated  by the presence of foreign bodies in the
fibrous tissues, those especially which injure  the nerves without completely
destroying them.  The state of the patient's mind has no doubt great influence
over the development of the disease;  highly wrought feelings, lively emotion,
before or after the wound, have a great share in producing it.   A stimulating
and irritating regimen, worms  in the intestines, &c.  are also undoubtedly a
cause of tetanus.   But these causes are only predisposing and  accessory ;
the true and  proximate cause  consists in a change of temperature to a high
deo-ree of heat.   This effect is the more remarkable when that change is sud-
den.  This cause exerts a marked influence in wounds which suppurate copi-
ously and when  the body is in a state of free perspiration.  Thus in warm
countries  the Antilles for instance, where there is so great a variation between
the temperature of the day and night, this disease commits great ravages, and
carries off yearly many patients. This influence is also  observed on battle
fields bivouacs, where, after having  experienced  the heat of the day, the
wounded  are  exposed to  the night air,  which is at  once  cold   and damp,
It is  seen in  the wards of civil and military hospitals, in which when badly 
516
LECTURES ON
ventilated a current of cold air is directed upon the bed of the patient.   It
seldom occurs during uniform temperatures, whether hot or cold.   But these
are not the only physical causes of tetanus ; any sudden, acute or exciting
noise, a sudden cry to arms, discharges of guns, and  especially of cannon,
the ringing of bells during the night, give rise to an agitation which more t!ian
once determine the development of the disease.
  This malady consists in involuntary, permanent, and painful contractions,
alternately stronger and weaker, constituting- exacerbations and remissions,
characterised principally by more or less marked spasm and relaxation of the
muscles of the affected parts.  It is generally preceded by anxiety, horripila-
tion, sudden jerking movements, spasms/rigidity, and evanescent contractions.
It does not affect all at once and simultaneously all parts of the body, but
attacks at first some one part before extending to the others.  It. commences
either in the wounded portion, or else some spot remote from it; in the former
case it is announced by a  sensation.of  rigidity, which hourly increases;  to
this are added, at longer intervals, contractions and painful twitchings; and
the disease attacks gradually all the muscular system.   In the second  case,
which is most frequent, the muscles of the pharynx are first affected, thence
result a violent dysphagio.  It then extends to the muscles which  elevate the
lower jaw, and  we then have locking of  the jaw, or trismus.  The appear-
ance of traumatic tetanus  after the cicatrization  of the wound is rare.   I
have, however, seen some cases of it.
   Strangulation is one of the most frequent complications of wounds, and
especially of the punctured kind.  The degree  of strangulation is propor-
tionate to the increase of volume of the parts, that is, to the intensity of the
inflammation, and this accident is the more to be feared when the parts are so
organized as to become rapidly developed, and  the surrounding  tissues are
resisting.   Thus there is  no  organic structure  more liable to occasion and
render it  very intense than  the  alternate superposition of fibrous, resisting,
inextensible tissues, and cellular and vascular tissues susceptible of great in-
crease of volume from inflammation ;  such a  structure in a word as we find in
the limbs, from the shoulder to the fingers  and from the hip to the toes.  Two
orders of  tissue are then affected in strangulation.  The inflamed parts  by
compression; the neighboring parts by distension.  If the compression and
distension run very high, both become gangrenous on account of the interrup-
tion of the circulation and  nervous influence, resulting from the compression
of the blood-vessels and nerves.  The termination by gangrene is announced
by the cessation  of pain, the remission of the fever, the  appearance of vesicles
containing a violet colored and feted serosity, the insensibility of the  parts,
coldness,  general prostration,  &c.  Sometimes,  however, and even  when
the majority of these symptoms are met with, mortification is  only at hand ;
there is merely suspension of life, and as it were local and temporary asphyxia.
Here it is sufficient to restore the circulation,  to remove all the symptoms, and
this may frequently be effected by enlarging the wound.
  Happily the inflammation accompanying  strangulation is far from always
terminating in  gangrene.    Sometimes,  but  rarely,  it terminates by  reso-
lution, more frequently by suppuration,  and  still more by induration.  The
second mode of  termination is announced by pulsations in the tumor,  by the
remission of pain, and the  general and local  fever.  But this remission is of 
CLINICAL SURGERY.
51"
short  duration; the pus by collecting soon renews the strangulation, which
may become as violent as the former one.   As to induration it always leaves
after it a hard engorgement more  or less  painful, which, either on account
of its nature or the nature of the tissues affected, ends frequently in white
tumors.
  Even after escaping all the danger just detailed, the patient is by no means
safe.   We have already seen with what difficulty the ends of fractured bones
unite, what causes oppose this  union, how fistulous sinuses and deep seated
abscesses of the limbs are formed, by means of which bones are  denuded and
afterwards necrosed.  This is not all; fractures of the bones in which the spongy
tissue abounds, present phenomena which are not observed in those of compact
tissue.   These phenomena are produced by the inflammation of the cellulo-
vascular membrane lining the areolae of this  tissue, and the  numerous veins
which traverse it.  This inflammation, always followed by necrosis of the bone,
sometimes  extends to great distances,  and much more certainly in gun-shot
wounds, where the projectile, by breaking the  bone, communicates to it a vio-
 lent  shock.
   The large joints present all the conditions of structure  calculated to give
 to the wounds under consideration a degree  of danger to be found nowhere
 else.  That of the wrist and foot is more enveloped by numerous tendons
 and synovial sheaths; that of the knee is remarkable from the extent of bone
 and synovial membrane, the number and strength of its means of union ; that
 of the shoulder and hip is enveloped by thick and strong muscles.  Therefore
 should we expect, even when externally and in the soft parts nothing indicates
 serious injury, to find the articulating ends of the bone broken  into a number
 of fragments, the  ligaments and synovial membranes  extensively lacerated
 and torn.  Such are the different degrees, complications consecutive to acci-
 dents, and principal causes of the danger of gun-shot wounds, causes implant-
 ed in their  nature and  peculiar characters.  But besides these causes there
 exist others which, although foreign to the nature of wounds, have over them
 a powerful influence.  Such are temperature, diet, the mental disposition of
 the wounded man, and accidental moral impressions.          _
   Is  a  lri-h decree of heat, as  is generally supposed, prejudicial to wounds,
 and  especially to gun-shot wounds ? It is a generally received opinion  that it
 is favorable to the development of gangrene, and fever, rapidly fatal to the
 patient   Experience, however, formally contradicts these purely  speculative
 ideas and demonstrates to all military surgeons, that these wounds heal much
 more'auickly in summer than in winter, in warm climates than in  cold ones,
  n closed apartments than in the open air.  Cold inflames the wound, opposes
  he process of cicatrization, keeps its edges red swollen and painful, prevents
  he  formation of good  pus, and retards indefinite y the cure.  Heat on the
  con^ary renders  the  tissues  more pliable, determines to them regenerating
  fluW  favors the  exhalation of those which  are to compose the cicatrix, and
  established; a more  speedy cure.  Again, gangrene, so much feared, is not so

  CTt wmabeSe3y° conceived that the state of the patient's mind will have a
  JaHnfluence ovlr his fate.   In the  young soldier the remembrance of his
  S  fn fof the  object of his affections, from  whom he is perhaps forever sepa-
  rated  ith^old warrior, the loss of a battle and its consequences will give 
518
LECTURES ON
rise  to  profound melancholy and  depression which may amount  to despair.
Add to this privations of all kinds, the want of surgical assistance, inclemency
of weather, long and forced marches, in a word, all the disasters of war.  In
civil wars, enthusiasm on the one hand, carried to the  highest degree;  on the
other despondency, gloomy reflections on the present, and  anxiety for  the
future, are equally fatal in their effects upon the conqueror and the conquered.
Thus in  1830, the mortality was  comparatively  much  smaller  among  the
citizens than  the  soldiers; in 1832, it was comparatively greater among  the
citizens wounded on the 5th and 6th of June, than among those  of July 1830.
Here the  only cause of the difference is to be attributed to the  mental situa-
tion  of the wbunded ;  and the joy of triumph is seen to yield to the grief of
having shed a fellow citizen's blood.
   Accidental moral impressions are not less dangerous.  Joy, fear, any sudden
emotion,  &c, often  produces  a fatal result.  Many  examples of this were
seen in 1830 and 1832.   Another fertile cause of  accidents, which too often,
in civil hospitals, paralyze  the efforts of the surgeon, is error in  diet.  It
would be useless to  expatiate here on  abuses which all our exertions have
hitherto been unable to eradicate.
   Let us  now, continued  M. Dupuytren, examine gun-shot wounds, in rela-
tion  to their situation ; they will present many peculiar  phenomena and
special indications in proportion to the regions they may occupy.
   Wounds of the Head affect the different regions of the cranium or of the
face ; in the cranium, the soft parts, the  hard parts and the brain, separately
or collectively; in the face, the base of the cranium, the frontal sinus, the
orbit, and the eye, the upper  and lower jaws.  When affecting  merely the
soft parts, they are in general  not very serious of themselves ; but in the first
place are tedious in healing, and afterwards are frequently complicated by
erysipelas or  diffuse  phlegmon, tetanus, haemorrhage, and different accidents
resulting  from the lesion of nerves, aponeurotic and  cellular membranes,
which are easily inflamed.
   Erysipelas of the Head is a very frequent consequence of gun-shot wounds.
Its  commencement  is announced by chills,  fever, sometimes  delirium;  the
skin soon becomes slightly red, sometimes more oedematous than red; there
is swelling, heat, and tension of the cellular tissue, generally nauseaand  vo-
miting.   How can this be prevented  or remedied?  If the opening of the
wound be narrow, a  crucial incision must be made over it, even after the inva-
sion of the disease.   If any gastric disturbance be present, an emetic will be
proper.   If the patient be young and vigorous and the inflammation intense,
this  must be preceded by one or more  general bleedings.  Mild purgatives
will  be very useful when the intestinal  canal is overloaded.  Flying blisters
should then be applied over the diseased spot; they have sometimes succeeded
in arresting its progress, but are also sometimes insufficient, and then a per-
manent suppuration must be established.
   Diffuse Phlegmon, common after accidents of all kinds, is not seated in
the   head as  in the limbs,  in the sub-cutaneous cellular tissue, but in the
sub-aponeurotic cellular tissue: this is a distinction of high importance.  Its
ordinary  precursors are chills, cephalalgia, nausea, and vomiting.   An acute
 sensibility of the hair is observed, the scalp is swollen, and impressions left
 by  the fino-ers  remain  in it.  The fever is  continued with paroxysms  and 
CLINICAL SURGERY.
519
delirium ; the ears and forehead are attacked ; after two or three days, pus is
infiltrated  into the subcutaneous cellular tissue; in seven  or  eisrht the soft
parts are separated from the  cranium, and there  is a manifest fluctuation.
Large quantities of fetid pus are discharged.  Then the distension diminishes,
the patient is relieved ; but in two, three, or  four days, enormous patches of
gangrenous cellular tissue appear at the openings; when drawn out the sup-
puration becomes very copious, and the patient  perishes from exhaustion,
repeated loss  of blood,, or  acute inflammation of the encephalon.   Dissec-
tion shows pus effused into  the cavity of the arachnoid upon  the  surface of
the brain,the dura mater separated from the internal surface of the cranium ;
externally, the pericranium destroyed, the bones denuded and necrosed, but
the subcutaneous cellular tissue, the vessels  distributed  to it, and the skin
perfectly sound.  From this sketch it will be perceived how important it is,
when the inflammation cannot be arrested, to practise numerous incisions  in
the wound itself, and its vicinity, the temples, mastoid processes, and towards
the occiput.
   When the wounding cause has been sufficient to injure the bone, it is either
limited to the parietes of the cranium,  or penetrates as far as the brain.   The
bony vault of the  cranium is not every where of the same  thickness, and
consequently does not  every  where offer the same  resistance.   A ball may
strike the cranium perpendicularly without fracturing the bone, but this wound
is always serious, on account of the concussion or contusion of the brain which
manifests itself in three or four days, or of the cerebral inflammation which is
frequently developed after 15, 20, or 25 days.  If it follow an oblique course,
it may cause serious injury in a greater or less extent of the  soft parts, and
moreover a primitive or consecutive necrosis; the lesion is therefore compound.
A ball  may penetrate the osseous tissue and lodge there, without  penetrating
the brain.   Lastly, if the projectile enter the cerebral substance, there is either
instantaneous  death, or development of serious symptoms, according to the
depth of the injury or the importance  of the wounded parts.
   We  will now examine the general,  immediate  and consecutive effects  of
 o-un-shot wounds of the head  upon the brain.   These effects are  concussion,
 compression, contusion and inflammation.
   Simple  concussion is not accompanied by any material lesion of the brain,
 and consists in a more or less  prolonged incapacity from  the effects of the
 shock;  it is one of the most  common results of blows, falls, lesions by pointed,
cuttin'o- or contusing weapons, by gun-shot wounds when  the  projectile does
 not traverse  the cranium; falls and blows on other parts  of the  body, as  on
 the feet, knees, sacrum, &c.  Several degrees are remarked in the phenomena
 of commotion.—1st degree. Dimness of vjsion, tinnitus aurium, the almost
 natural closing of the eyelids, and sudden weakness in the lower extremities;
 then lassitude during three or four days, vague pains, inappetancy, a remark-
 able inaptitude to labor, the necessity of keeping  the feet  separated in order
 to increase the base of support, &c, are the principal symptoms.  To combat
 these  we  should use cautiously aromatics, stimulants, &c,  as  their abuse
 mioht lead to  serious consequences, and cause inflammation  of the brain or
 i ts membranes.  The after treatment consists in avoiding all excesses of diet,
 fatigue or coition, and restriction to a moderate  regimen; and this is to be
 persevered in for some time. 
520
LECTURES ON
   2d degree.  Whatever may be here the cause, the  patient suddenly falls
 senseless, and is so  perfectly unconscious of existence, that on returning  to
 sensibility he remembers nothing of what has passed ; there is prostration, the
 muscles are affected not only with quivering, but  also lose the faculty of
 acting:  spasms frequently exist, involuntary evacuations of  faeces and urine
 There is no longer perception of light, sounds, odours, or taste; the voluntary
 movements are gone; the circulation and respiration are however maintained,
 and that is the reason why death does not take place, the principal nerves of
 organic  life arising from the sides of the medulla oblongata,  Atthe moment
 of  concussion, palpitations are experienced ; the respiration at first altered,
 irregular, soon recovers its regularity, and goes  on so gently with  so little
 noise and motion of the thorax, that the patient seems not to breathe.  This  is
 a characteristic  sign.   The eyelids are  generally closed, from loss of action
 of  the levator muscles.   On opening them the eye is found still brilliant, but
 the dilated pupil, insensible to the impression of light.  Sensibility is blunted,
 but not extinguished; if we pinch the skin the patient, by an automatic move-
 ment, will shrink from  the pain produced.  There  is sometimes vomiting.
  The  primitive  symptoms of the first degree last only a  few minutes  or
 seconds; in the second, the effects  continue one, two, three or more days.
 It  is during the duration of these first symptoms that an error may be and
 often has been committed ; namely, on founding concussion and compression,
 and attributing to a pretended absorption of blood the restoration to health
 after a severe simple concussion.
  Let us then recapitulate, for these  signs  are  very characteristic; that  in
 concussion the patient.remains in the position in which he is  placed, appears
 buried in a profound and tranquil sleep; without movement of the thoracic
 parietes ; his countenance pale, eyelids paralyzed ;  pupil insensible to fric-
 tion ; it is sometimes harassed by light but does  not contract.   The patient
 swallows, but only when the  liquid  has  been  introduced into  the pharynx,
 otherwise it  remains in the mouth.   There is scarcely any motion  of the
 heart; the pulse is so slow and soft as to disappear under the slightest pres-
 sure, but it is regular; digestion is suspended, as  also  the excretions; there
 is frequently retention,  and consequently incontinence of urine, retention of
 faecal matter.  If you pinch the patient he  takes  no  notice of the  first or
 second attempt; it must be repeated, and forcibly, in order  to induce  him to
 draw away the limb; rarely he carries his hand to the spot.   These effects, at
 first very remarkable, gradually diminish ; then the limb is quickly  drawn
away if it be pinched; the pulse is  stronger and more  frequent; the pupil is
sensible to light  even through  the eyelids ; the patient  places his hand before
his  eyes ; changes his position; speech  returns;  he asks for food and falls
again asleep for 24 hours, more or less;  after one or two similar attacks, the
intellect begins to be restored; but lie  is incapable of fixed attention ; he
 begins a phrase and does not finish it.   In four, five, or six days he  is con-
 valescent, but the consequences last much longer ; and sometimes months are
 required for his total restoration to  health.
  These slight stimulants are not sufficient; immediate venesection is contra-
 indicated, and would cause death.  After the expiration  of an hour, if the
 functions are somewhat restored,  in  robust and  sanguineous persons this
 measure may remove the danger  of compression  of the  brain from a stasis 
CLINICAL  SURGERY.
521
of the blood ; if the patient be weak, leeches behind the ears and elsewhere,
as revulsives, &c, sinapisms, pediluvia, stimulating  cataplasms, enemata,
purgatives, nauseating drinks, frictions, and excitants  internally and exter-
nally.   Good effects are obtained from blisters to the nape of the neck.  The
patient sometimes loses the recollection of proper names, things, &c, but this
faculty returns after some time.
   Sd degree. In this degree the patient generally perishes quickly; he  falls
instantly, deprived of all  his senses, and voluntary  motions.   Convulsive
movements ensue, involuntary evacuations; the pulse disappears and returns
at intervals,  respiration gradually grows weaker, and in  a few seconds life is
extinct.  Venesection here is inevitable death. Frictions and spirilous lotions
are useless.
   An examination of the body evinces no effusion on the brain, compression,
coptusion nor disorganization.  This organ has merely lost its consistence,
and is very easily lacerated.
   If in patients  who have died of apoplexy, the cranium be opened, not with
a hammer but  with a saw, the brain appears larger than the case containing
it, or at least it preserves its size and shape. In concussion, on the contrary,
the brain is smaller, is collapsed, and occupies  less space ; because  here  it
contains less blood, and being deprived of its  stimulus, falls into debility.
No  appearance  of separation, laceration  or  contusion,  however,   can  be
observed, either  with the microscope or the naked eye.
   In the description just given of concussion, the brain has been taken as an
example, because the effects are there mere evident than in  other organs, and
through the  medium  of the nerves,  extend to all  other parts  of the body.
 But it  is by no  means the only organ  exposed to  the  accident; the spinal
 marrow may be  also affected, but as it presides merely over motion and sen-
 sation its effects are limited to  paralysis of the parts to which its nerves
 extend.  Thus we observe more or less complete debility of the lower limbs,
 the bladder and rectum, in cases  of concussion of  the  lower part of the
 spinal marrow ;  of the parietes of the belly and chest, in  concussion of the
 back;  last,  with paralysis of the parietes of the chest and  belly, concussion
 of the diaphragmatic nerves, when the projectile has  injured the upper part
 of the cervical column;  producing cessation of respiration and consequent
 death   Again, concussion may take place in the nervous plexuses ; its effects
 then are numbness, a diminution of  sensibility  and myotility, &c. which may
 become absolute in mobility and insensibility;  such are, for example,  cases
 of concussion of the brachial and sciatic plexuses, resulting in more or less
 complete impotency of the upper and  lower limb.
   Lastly  the nervous parts are not alone subject to concussion ; the  liver is,
 on account of its size and texture, after the brain, most frequently affected.
 The phenomena are  here undoubtedly very different from  those observed in
 the other organs, but they may be all referred to a weakening of the organ, or
 a suspension, disturbance, or alteration of its functions; there is mappetency
 lan"uor  and feebleness of digestion, nausea or vomiting, sensation of weight
 in tlie hypochondrium, grayish stools, saffron cobred unne   Symptoms of
   action Onetimes supervene; there is then pain hi the right hypochondrium,
  o wlich are added nausea, and pain in the  shoulder; dejections or vomiting
 of  bilious  matter take  place;  the fever  increases; and we have a more
               66 
522
LECTURES ON
 or less acute hepatitis, which is  more or less  dangerous.   The  spleen and
 kidneys may be affected by concussion but much more rarely.  Their symp-
 toms  are  similar to those of concussion  of the preceding organs.  Their
 diagnosis is moreover extremely obscure.
   When compression  of the brain is  slow and gradual it  may reach a con-
 siderable height; when rapid, its effects are  immediate, dangerous, often fatal,
 however slight  may be the  cause.  After a blow, with or without division of
 the flesh and bones, effusion takes place in the  interior of the cranium;  if it
 be limited, there is hemiplegia of the opposite side ; if there exist the  same
 quantity on both sides at once, there  is neither  hemiplegia nor paralysis, but
 rigidity of the muscles, &c.
   Thus the general effects of compression are null or nearly  so when it occurs
 gradually;  rapid and dangerous, if it be itself rapid.  When the compression
 is slight, the intellect may  remain; when  perfect, it is annihilated : there is
 loss of the senses of susceptibility to impressions, profound coma, stertorous
 respiration, the  functions of the thorax are impeded on account of the inertia
 of the brain.
   In concussion, as we have said, the patient is tranquil, his face is pale, the
 upper eyelid depressed, the  pupils highly dilated, respiration  so gentle as
 almost to be imperceptible ;  pulsations of the heart and arteries  scarcely
 sensible.
   In compression, the patient is agitated, face of a violet red color, pupil con-
 tracted, respiration loud and laborious;  there  is stertor: the thorax, as  it
 were,  loaded with mucus;  all the muscles in action to maintain respiration;
 the pulse is full, hard, and frequent.
  A slight and even a more  severe degree of compression is not always fatal;
 it may be cured  by venesection, purgatives and revulsives.
  In the second degree, the struggle is more violent, the result  more uncer-
 tain ; sometimes the effused blood loses its serum, and is absorbed : if the
 foreign body cannot be absorbed, nature accustoms herself to it.
  If from a sudden cause, the  fracture of the bone for example, blood and pus
 are collected atone  point, the trephine should  be applied and the hone  ele-
 vated, if nature cannot become habituated to the  cause ; but we cannot always
 be certain of the spot where  the effusion exists : fractures, contusions  take
 place from a counter-stroke, and the difficulty here is very great.  When the
 effusion is extensive and there is no hemiplegia, the trephine is useless.
  The trephine, said M. Dupuytren, so often fruitlessly used and then pro-
 scribed by Desault, is therefore frequently  insufficient  to remove the  cause
of the disease, and always dangerous,  less from itself than from inflammation,
following the admission of air.
  It should therefore be applied only to elevate the bone, or give exit to a
sudden and considerable effusion, at a limited and well ascertained  spot in the
cranium.  If a foreign body have passed through two thirds of  the thickness
of the skull, if a ball remains  planted in the bone, or the point of a knife be
broken off in the cranium, a crown of a trephine may assist in  their extraction ;
 it is also  indicated, as  we have  said, in cases of a  small, circumscribed,
pediculated fungous tumor of  the dura mater, which would have pierced the
bone;  but then the danger is always very great.
  Contusion of the brain is  often confounded with concussion.  Contusion is 
CLINICAL SURGERY.
523
a true organic lesion produced by a round body, or one of large surface.  The
parts covering the brain are of different consistence; the external soft parts
and especially the bones may resist the violence of the  blow; but it is not so
with the brain, and its contusion may take place without lesion of the soft or
hard parts;  which, indeed, is generally the case.  These external parts may
change their form without any solution of the integuments, or fracture of the
bones,  and the  brain may  undergo from compression that disorganization
characterising contusion.   Like concussion, contusion possesses also several
degrees.
  In the mildest  form, some  parts are changed, a little blood is effused; a
cure may follow ; but when the tissue is deeply disorganized, and the-quantity
of blood more considerable,  death generally results from this injury, rendered
fatal by inflammation, suppuration,  and the consequent compression.  The
dangerous  symptoms do not appear until the fourth or fifth day, that is when
inflammation takes place, and the danger consists less in the importance of
the injured organ than in its consequences.
  Contusion differs  essentially  from concussion and compression.  Before
pointing its distinguishing  signs, let us examine into its causes and effects.
  Whether there be or not lesion of the external parts, it is generally pro-
duced, as we have said,by bodies more or less round,  or extensive; the causes
are therefore analogous to  those producing  concussion ; hence it is almost
impossible  to distinguish  concussion from confusion, especially in the  com-
mencement.  Concussion almost always complicates  contusion ;  but if there
be  not  concussion, the  patient  does not  experience any immediate injury.
The effects of  concussion  diminish gradually from the date of the injury,
whilst the  contrary obtains in contusion, as the dangerous  symptoms do not
appear until some days after the accident.  The patient feels a constant pain
in the contused spot: paroxysmal fever with delirium comes on; debility,
sometimes coma,  from  compression.  If venesection  has  been judiciously
practised, and purgatives-properly administered, these  symptoms sometimes
disappear and the patient gets well; the inflammation is  thus prevented or
moderated, and the  absorption of pus determined.  But then  the injury is
limited and not  profound ;  if  it be more extensive and severe, the inflamma-
tion of  the brain is generally fatal.
  If the contusion were always direct, we  might perhaps  determine pretty
precisely the point which it occupies, and where the opening should be made;
but as it often is produced by a counter-stroke, this is extrem'ely difficult.
  Inflammation of the brain is  often complicated with arachnitis; there are
then  chills, contraction of the  pupil, acute  sensibility to  light, &c.  After
death the substance of  the brain is  found converted into pulp  mingled with
blood ;  if the patient has lived some time, around this disorganization  some
inflammation exists.  The  substance of the brain is moreover- more dense,
yellow, and studded with red spots,  &c.
" If the contusion be very extensive, and the two lobes of the brain affected,
death follows from concussion or the effect of the contusion.  When only one
lobe is injured, three or four days generally elapse without any bad symptoms.
If the pupils are contracted, there is stertor and absence of the signs of con-
cussion, contusion is to be feared, and recourse  must  be had to general and
local bleedings, and emeto-cathartics.  If inflammation has taken  place, we 
524
LECTURES  ON
must still employ bleedings and revulsives to the limbs and intestinal  canal.
If coma evince a collection of pus, and we can ascertain the precise seat of
the disease, the trephine must be used ; not that this operation gives a great
chance of cure;  for if a little pus flow through  the  opening, the  discharge
does not prevent the new formation of purulent matter, and the trephine often
gives rise to inflammation  of the arachnoid.
   If the contusion be produced by  a fracture, the bony fragments should be
elevated, and a free exit thus afforded to the pus.
   Recapitulation.—Contusion is  one of the most serious  affections  of the
brain;  serious less on account of  its  immediate effects than on account of the
inflammation which follows and causes a considerable production of purulent
matter.  Thus, concussion,  compression,  and contusion become causes of
inflammation ; independently of these causes, it is determined by the presence
of scaly portions of depressed bony projectiles ; and lastly by vicious habits,
stimulating food, abuses in diet, drinks, and the passions, &c.  Inflammation
is consequently one of the most  common diseases of the organs in general,
and particularly of the brain.
   A constant attendant on contusion, inflammation,, generally accompanies
all other lesions  of that organ.
   We have already spoken of erysipelas, a complication so frequent, that
scarcely one  or two escape out of three wounded.  Erysipelatous  or diffuse
phlegmon is more rare, but much more dangerous.
   The  pericranium may  be  also the seat of  an inflammatory  process, the
bones also may become inflamed and suppurate.
   A spent ball, or one striking obliquely, a blow with a stick, a  fall with or
without a wound may produce this  injury, even when the bones have been
slightly contused ; the contused part often becomes necrosed; if the external
table alone be affected, frequently the process  of separating the sequestrum,
exceeding its ordinary limits, gives rise to suppuration in the diploic structure,
and is the cause of death.
   If the contusion be  more severe, and the  entire thickness of the bone be
necrosed at the end of twenty, twenty-five or  thirty  days, another inflamma-
tion supervenes almost always fatal from the collection of suppuration between
the bones and dura mater, determining compression or arachnitis ; the pus, in
this case, is not formed at the expense of the  dead bone, but. at the expense
of the dura mater, which  although of a fibrous nature, does sometimes  take
on inflammation.
   Let us explain ourselves. The bone is either necrosed immediately, or after
the lapse of'some time ; this bone is a foreign  body placed between the exter-
nal and internal parts, and adheres to the other osseous parts which still enjoy
vitality.  Now if we examine the process of  separation of a slough in the
soft parts, we find that it  is by inflammation.   A circle of inflammation is
described around the eschar, extending as  far internally as externally, and
giving rise to a  more  or  less copious suppuration.   The  separation of the
necroled bone and the dura mater must then take place by inflammation; it
the suppuration be not copious, it gives but little inconvenience; on the con-
trary,  if copious, it injures by its quantity (compression), or by  contiguity ot
tissue  and inflammation (arachnitis,  compression, death).
   What name shall be given to this secondary inflammation ?  Ostites!  No; 
CLINICAL SURGERY.
525
tiie inflammation is in the dura  mater.  If the denuded and contused bone
appear blackish, or gray and sonorous, it is almost certain that the necrosis
 ■xtcnds to the internal surface ; and  then  we can and ought to prevent the
effects of inflammation and suppuration by the application of the trephine.
But under the dura mater is another serous tissue, the arachnoid ; beneath the
latter, a cellular  serous, exceedingly delicate tissue;  under this tissue the
brain.  It is useless here to describe the  symptoms of inflammation of the
filfferent tissues and organs, as it would be merely repeating that which  may
be' found in every work on the subject.
   Wounds of the Face are not in general  dangerous of themselves.   I  have
seen  this  part almost  entirely carried away and the patient recover rapidly.
They are, however, frequently fatal on account of the consecutive symptoms.
Another result of these wounds is the abundance and fetor of the suppuration,
which being  constantly mixed with the saliva and carried into the stomach,
 i s productive of  serious gastric and general disturbance.   Let us now examine
 the difference of wounds in the different regions of the face.
   Wounds of the  Nose give to the  face  more  or less hideous  appearance,
 v/hilst those of  the forehead adorn it; hence the necessity of preventing by
 ail possible means deformities of  the nose.   When it is divided, the parts
 should be  brought together and held  by some stitches of  the interrupted
 suture.   If the base of  the organ  be destroyed, art is  nearly powerless, for
 the loss of substance cannot be  remedied.  If the nose  be crushed, this  frac-
 cure  with depression produces great deformity; it maybe prevented by means
 of a  tube or bougie covered with linen and introduced into the nostrils.
    Wounds of the Orbit often produce horrible disorder, and more  frequently
 death.  When  applied close, the pistol acts as in the mouth, by the expansion
 of the air and  the discharge.  The eyelids and the orbit are lacerated,  frac-
 tured ' and the. eye hangs  out upon the cheek, as was seen in the case of a
-youn^ man wounded in July,  the orbit of whose eye had been broken into
 ieverll fragments at its base, the eye was extirpated, the eyelids approximated
 Jo each other,  and the man  cured.  Small  shot  lodged in the  eyelids are
 -enerally productive of no mischief: they may either be left or  extracted ;
 when they penetrate obliquely the  cornea or sclerotica,  there  results  an
 a'buo-o of more or less  extent.   If they strike perpendicularly, they pass
 through, and lodge in the interior, or are lost in the globe of the eye  and we
 can  neither ascertain their existence  nor attempt to  extract them, unless they
 have remained in the anterior chamber ; in the latter case they may be per-
 ceived before or after the consequent inflammation, and be extracted.   Even
  r. the least severe cases, wounds from  small shot cause loss of signt, deform-
 ['v  of the iris or obliteration of the pupil.   But frequently  acute pain
  Jinervenes which cannot be relieved  by any means, then violent inflammation,
 -nnrmnus swelling and agonizing pain.   We are then reduced to the alterna-
  ive rmakTng a&cruciaf incision into the organ itself, or  seeing it burst  or
 discharge its contents.  Inflammation often  extends to the brain and  death
 ^ the consequence.   We have already fully detailed the effects of gun-shot
 wounds  of the mouth, and  pointed out the action of the expansion of the
 air,  the action  of  the powder and projectile  on the pharynx, palate, tongue,

 ]°;Wounds7^e Lower Jaw are very frequent.   If the  bone  be carried 
526
LECTURES ON
away in front, the wound is less serious than if the ball fractured the rest of
the body and the rami.  Danger arises, first, from the compound nature of the
wound, the lesion of numerous nerves, the difficulty of removing the fragments :
secondly, from the inflammation  and fetid suppuration, consecutive  diar-
rhoea, &c.  These wounds should  be treated in the following manner.  The
lower lip must be divided as far as the os hyoides, the edges of the wound
widely separated, as  in amputation of the lower jaw,  the  bony fragments
removed ; the lips and chin should then be brought together, leaving below an
opening for the free  escape of matter.  This plan is equally applicable to
wounds of the shoulder, where the head of the humerus may be divided, and
the fragments of bone removed by making a large flap of  the deltoid and
raising it up; the danger is thus diminished and the limb saved.
   Wounds of the Ear present some peculiar characters which are deserving
of remark.  The membrane of the tympanum is often  ruptured by explosions
of cannon, and blood is discharged from the ear and mouth.   Deafness  is the
result, but generally the  noise merely gives rise to a hardness of hearing :
it  is owing to rupture of this membrane that some persons  have  the power
of passing tobacco smoke through  the ear.
   Wounds of  the organ of hearing are mostly followed by fistula or suppura-
tion  from the  ear or mastoid process, owing to the presence of the  projectile
or some spiculse of bone, and cease only when these  are  removed.  Hearing
may be entirely destroyed by the entrance of a single grain of shot into the
ear,  but this species of projectile seldom goes beyond the external ear.   The
ear may be wholly or partly removed by a sabre wound ;  however slight may
be its union it should be reapplied.  Punctured wounds of  the ear are most
liable to erysipelas.
   We will now consider  wounds of the  Upper Jaw,  of which the following
are remarkable cases.  A young man was struck  in 1830 by a ball at the base
of the left nostril, which  passed obliquely through his face, and came out on
the right side of his neck: he was cured.  He says that his sight is diminished,
and  that he  has lost the sense of smelling.  There is paralysis of the right
half of the face; he can speak and move his tongue.
   In another case the ball traversed the right malar bone, and came out in the
opposite parotideal region; the patient was a boy of fifteen years of age; there
remained nothing but a  slight tumefaction in the malar region, the nose was
uninjured, all the senses  perfect.  Balls may penetrate and lodge in  the an-
trum : when  the patient  moves it follows his movements; the opening should
then be enlarged and the ball extracted.   The cheeks may be either grazed or
pierced by a ball from one side  to the other; the teeth are then  generally broken.
   Wounds of the Neck are very numerous and dangerous.  The neck may be
divided  into  four regions;  in the anterior, the larynx, trachea, and pharynx
may be wounded ; on the sides, the great vessels and nerves; in the  lateral
the  nerves going to  the brachial plexus and the vertebral arteries.   In the
posterior region thick and  strong  muscles;  here, however, they are  not of
much  danger.  In the centre the  vertebral column, the medulla oblongata and
spinalis.  The neck is protected by the clothing, especially in soldiers; there-
fore in July, they were  less  frequently and  dangerously wounded  than the
citizens, who for the most part fought with their necks bare, either from habit
 or on account of the heat. The wounds cannot always be enlarged on account 
CLINICAL SURGERY.
527
of the vicinity of the large vessels and nerves, the general treatment must be
so much the more active.
  Incised wounds of the neck are common in the anterior part of the neck,
especially in suicides.  Many are fatal from their depth and the division of
the carotids; these  arteries, however, sometimes escape, as they recede from
the weapon on account of the elasticity of the cellular tissues, and roll upon
the round surface of the  bodies of the vertebrae.  Unless you be present at
the moment of the injury, nothing can of course be done.
  Fifteen or twenty  years  ago, a medical student  was bathing with some
companions and  drowned;  tracheotomy was performed,  the  carotid artery
was opened.  Lesion of the jugular vein and  nerves seldom  takes  place
without lesion of the carotid ; the danger is then much greater.  The pharynx
above the os hyoides, and the larynx below may be wounded; hence the pass-
age of food and air.
   The wound should be closed, the head kept flexed upon the breast  by a
bandage, the patient seated and supported by pillows; in a word the bandage
must not act.  But this plan has its disadvantages; if the approximation be too
great the lips of the wound fold inwardly, the skin comes in contact with
skin, and no union can take place; or else the lower edge of the wound is
turned backwards,  acts as a valve and causes asphyxia.  For these reasons, I
have always used the suture, taking care to leave a passage for the blood and
pus.  On the sides of  the  neck, the muscles,  but  especially the numerous
nerves  and the roots of the cervical and brachial plexuses may be injured:
these wounds are  dangerous; while superficial wounds of the same  parts
seldom are.
   The  lesion of nerves is  followed by pain, and paralysis limited to certain
 muscles.  I have seen at Saint Cloud patients who were unable to carry the
arm forward  or backward, and who complained of  continual numbness.  In
this region  the wound should be enlarged, not transversely but  according to
 the course of the nerves and arteries. ,The vertebral artery and  branches of
 the carotid may be wounded, and  the  result is either primary haemorrhage,
 which frequently ceases, or secondary, which carries off the patient. Ligature
 of the  primitive carotid does not always arrest the haemorrhage, on account
 of the great number of anastomoses ;  should we therefore dispense with the
 ligature ?  Both ends should if possible be secured, if not one at least; for be-
 cause a measure does not always succeed, it does not follow that it should be
 proscribed.  The inflammatory swelling sometimes tends to arrest the flow of

    The muscles and spinous processes sometimes protect the back of the  neck;
 if great vessels  or the spinal marrow be not implicated these wounds are sel-
 dom dangerous.
    Wounds of the  Shoulder are very numerous; and as it is a part not well
 protected by clothing, they ought  to be more frequent.  Superficial  wounds
 of the shoulder  are seldom important;  deep seated wounds of the same part
 are on the  contrary the most severe among the severe.  Several  regions may
 be here distinguished.  Thus superficial wounds may affect the anterior, pos-
 terior  superbr, inferior and external parts.  If the superior part has  been
 wounded from  before backward, and the wound formed a groove implicating
 merely the skin, the cure is here  much more tedious than m any other part; 
528
LECTURES  ON
the reason of this  consists in the great mobility of the part, easily causing
a rupture of the cicatrix.   Profound wounds which have the same direction,
injure the blood-vessels and nerves, give rise to haemorrhage, partial paralysis,
pain, numbness of the muscles, &c.  Even superficial wounds of the arm-pit
are generally very serious on account of the lesion of nerves and blood-vessels.
If the  brachial  or axillary artery be  divided,  immediate or secondary
haemorrhage generally carries off the patient. Wounds of the back part of the
shoulder are very numerous, and should not be imputed to a want of courage,
as they frequently occur at the moment of taking aim.   Transverse wounds
of this region are not serious if  the skin alone  be injured ;  if the muscles be
implicated, they are more tedious in getting well.   Wounds of the fossa infra
and supra spinata should be enlarged and opened at several spots, but are not
dangerous.  The spine of the scapula may be  injured  without great incon-
venience, except the loss of a few scales of bone.  Sometimes the spine itself
is separated and carried away. I have seen one of these wounds running along
the fossa supra spinata, traversing the spinous apophysis, and coming out at
the fossa infra spinata; if the insertion of the trapezius be divided, the motion
of the  arm is impeded.   The same remark is true as regards the latissimus
dorsi muscle.
   Wounds of the upper part of the Shoulder are more severe.  A woman had
the deltoid muscle and the head of the humerus carried away; she was appa-
rently in a fair  way of recovery, but her existence was terminated by suppu-
ration and inflammation of the thorax.
   Still higher, the acromion is most frequently implicated, and I have seen it
separated, furrowed, broken into fragments, &c.
   In  the  anterior  region wounds are more  dangerous, as this region is
generally  struck perpendicularly, whilst the others are obliquely.  The ball
frequently reaches  the bone and articulation, and whether it remains  or is
extracted  the danger is  great.   If it remain  it occasions  inflammation and
copious suppuration. Wrhen deep seated the danger proceeds from the injury
done to the scapulo-humeral articulation.
   If the coracoid process or the acromion be injured there will be inflamma-
tion, strangulation, suppuration and  fistulae; the  wound  should then  be
enlarged, the patient bled, the abscesses opened, and proper diet observed, &c.
in conjunction  with baths, douches, &c. and other local applications.   We
can readily conceive the danger when the joint is opened ; inflammation and
strangulation oppose the free exit of pus, despite  of large openings; and how
else are the fragments to be sought  for and extracted ? if they remain, they
give rise to pain, fever, &c.   It is  therefore important to know what is the
state of the head of the humerus.   If  it be merely  perforated, the danger is
less; but it is generally broken into many fragments; these cause suppuration
and afterwards exhaustion, sweats, and diarrhoea.   We should  therefore
endeavor to prevent the danger  by our primary treatment.
   If the head of the bone be only moderately fractured the wound should be
enlarged as much  as possible, avoiding the tendons, vessels and nerves, the
fragments extracted, and  counter  openings made  in  a depending position.
Disarticulation  has been advised in cases of comminuted fracture of the head
of the bone, but it is difficult to persuade the  patient, and the surgeon does
not always dare to undertake this operation ; the wounded  man, indeed, can 
CLINICAL SURGERY.
529
seldom  conceive why he should lose his arm on account of  a small opening.
The perfect use of the arm and fingers  renders him  incredulous of such
serious mischief. But is it necessary to remove everything?  I am convinced,
said M. Dupuytren, that a method analogous to that which I have applied to
the lower jaw might be advantageously practised ; that is, to  make a large
incision, expose and remove the fragments.
   Wounds of the Arm are  less dangerous, for the following  reasons: 1st,
they are further from the centre, nearer the extremities.  2d, the anatomy of
the arm explains  the difference.  Being  cylindrical, small, furnished with
only one aponeurotic layer beneath the skin and subcutaneous cellular tissue,
the wound can be more conveniently enlarged.  3rd, all the tendonous parts
are parallel to its  axis, therefore an enlargement  may be made without dan-
ger.  4th, the bone is single, the fragments may  be more readily removed,
and are generally near the surface.
   Thus, the most severe wounds of the arm do not  require  amputation; and
if we are obliged  sometimes to  perform it, it is because there is an accom-
panying injury of the elbow  joint.   But  the arm contains  nerves and large
vessels going  to distant parts, and which in their  course give off numerous
branches.   Now, these vessels and nerves may  be wounded;  the brachial
artery, median, ulnar and radial  nerves may be divided; hence hemorrhage
and paralysis of different parts.   The  nerves are much less exposed  in the
thigh.
   Punctured wounds of the arm  are rare and present no danger but strangu-
lation.   Sometimes they are complicated, according to  their direction, with
injury of the artery or the vein.   I have seen  at least twenty arterioso-venous
 aneurisms in consequence of this kind of wound.  Injuries of the nerves cause
 long and violent suffering.
   Incised wounds are frequently much more serious;  sometimes the bones
 themselves are divided ; this is uncommon, but the wound is then very dan-
 gerous ; more frequently the bone arrests the blow; if both arteries and nerves
 be divided  at once amputation is absolutely necessary.
    Small-shot wounds are only dangerous  when an  artery or  nerve is impli-
 cated.   When the  radial  nerve is injured, there  is loss  of sensation and
 motion in the corresponding part of the hand, which can neither be extended
 nor supinated.  On the inner side the  wound  is more dangerous on account
 of the presence of blood vessels and nerves.
    The following question here naturally presents itself.   Can divided nerves
 reunite ?   I  have twice seen the radial nerve divided, and  sensation  and
 motion  return after a  lapse of two years ; but here the division was simple,
 and without loss of substance.  We know that nerves have a great tendency
 to cross each other, and this influence might be transmitted by the cicatrix.
 In o-un-shot wounds I have never seen any case proving this possibility; how-
 ever I do not pretend  to say it cannot take place.
    Wounds of the posterior part of the Arm are of slight importance.   When
 made by grape or cannon shot they are  more severe, and yet if the soft parts
 only be injured thev seldom require amputation.                   .
    The dan-er is far greater when the bone is  implicated; the fracture is gene-
 rally comminuted  and  more severe in  proportion to  the number of frag-
 ments and the injury of the soft parts, but  do not often demand amputation
          67 
530
LECTURES ON
unless both the blood vessels and  nerves  be wounded, and  there  be  great
destruction of the hard and soft parts.  The conclusion is, therefore, that if
amputation  should  be immediately performed in wounds of other parts, it
should never be hastily undertaken in those of the arm.
  Amputation is indicated, on  the contrary, in cases of wounds by cannon-
shot which have nearly separated  the whole  arm, even when the remaining
flap contains vessels and nerves which are uninjured.
  When the cavity of the elbow joint is opened amputation should be per-
formed without delay.  If the bones of the fore-arm, wrist, or hand be broken
into pieces by a ball, and the  soft parts lacerated, amputation  must be  per-
formed above the injury, and it  must be remembered that these parts possess
an exquisite sensibility, that acute inflammation takes place, often accom-
panied by gangrene, and that  in the majority of cases death is the result  of an
attempt to save the limb, too often useless.  Wounds of the fingers generally
require immediate amputation.   In parts of such sensibility they are always
dangerous.  Tetanus frequently has its origin  from wounds  of that organ.
  Wounds of the Chest with  penetration of the projectile are very common ;
and  the greater number  of men left dead on the field  of battle, perish from
wounds of this nature.   Their  frequency  and danger  depend  evidently on
the volume of this region, its elevated position, and  the  importance of the
wounded  organs.   The lungs, heart and great vessels are rarely injured  with-
out instantaneous suffocation, or fatal haemorrhage.  Persons thus  wounded
ordinarily fall over immediately, apparently dead, pouring out blood from the
wound and the mouth; if respiration continue, it is short, very laborious, in-
terrupted  by sobs; the countenance is pale, distorted, covered with a  cold
sweat; the patient often lies in  a profound stupor, which only ends  in death.
If life be  prolonged, the air passing through the wound  is infiltrated into the
meshes  of the cellular  tissue, and  frequently causes, in  a few hours, em-
physema of the whole of  the body, which sometimes attains an enormous size.
  Even when the ball merely strikes the parietes of the thorax without enter-
ing its cavity, it produces a greater or less concussion and disturbance of the
organs of respiration.  This  contusion frequently gives rise to  a spitting of
blood, which should not be considered as the sign of a penetrating wound. If
the ball meet a rib, it  is generally broken, and  its extremities  may lacerate
the pleura, the lung, and  mask the true  nature of the  wound.   A  ball may
pass  through the chest without wounding the lungs.  These cases and  many
others demand on  the  part of the surgeon  a minute scrutiny, great  skill
and  correctness of judgment.   Again, the nature of  the  symptoms should
guide our diagnosis much more  than the situation of the external wound.
  Fractures of the ribs or other bones comprising the parietes of the  thorax
;;dd greatly to the severity of  the wound.   I have seen patients in whom the
ribs alone have been fractured, without injury of the  lungs,perish despite of
all our efforts ; and others, in whom the  bones were untouched, recover from
some very severe wounds of the respiratory apparatus.  This  difference re-
sults from the  mobility of the osseous parietes ; a mobility which constantly
irritates the neighboring tissue, and develops an inflammation which extends to
the internal organs.
  A ball or grape shot may produce in the chest, as in the belly and limbs, all
the effects of contusion  of the  fourth degree;  these take place when the pro- 
CLINICAL SURGERY.
531
jectile  strikes the cavity obliquely.  The contained viscera are more or less
contused, lacerated, disorganized, the heart and lungs reduced to a jelly, with-
out the least sign of external injury.  When they are crushed, all the parts are
as it were reduced to a heterogeneous mass, whose organization and vitality are
destroyed, and instant death generally follows.  Yet men have survived for
some time, and  even imperfectly  recover; generally, however,  they perish
from secondary symptoms.  These accidents may occur with or without alter-
ation of the skin.  All  things being  equal, the  chances  of cure  are greater
when there is no communication with the interior of the thorax.
   Internal haemorrhage is one of the worst complications of  wounds  of the
thorax.   The danger proceeds not only from the quantity of  blood lost, but
also from the  secondary inflammation thus produced, which  is always  very
rapid, and the consequent effusion.   The  most prominent symptoms of haem-
orrhage are imminent suffocation, an  extreme  anxiety, fainting, paleness, and
change of the countenance, small corded pulse, jerking cough ; and when the
effusion is considerable, the dilatation of the side of the thorax, the separation
and elevation of the ribs, the noise of the fluid against the thoracic parietes on
motion of  the patient, sensible to auscultation  and even to the patient himself.
The first indication in these cases, especially if the vessel be  situated  in the
thickness of the thoracic parietes, is to secure it  by a ligature,  if possible,
before bringing together the edges of the wound.
   Wounds of the Abdomen are also very common on account of the great
size of this region and the softness of its  parietes, which oppose but a slight
resistance to a  ball.   Their danger depends on the injury of internal organs,
and the consequences of this injury; immediate inflammation resulting from
a wound of the liver, spleen and  large intestines ;  secondary inflammation
of the peritoneum and all its reflections following the effusion of bile, faecal
matter, stercoral gases, gastric mucus, in cases of perforation of the  gall
bladder, stomach, small and large intestines;  internal haemorrhage from  the
lesion of vessels, &c.
   Many of the phenomena observed in wounds of the  thorax may be  also
remarked here.  Thus the organs of the abdomen may present all the marks
of contusion in  its  different degrees, and even  of attrition, without  any
apparent external injury.  A French soldier was wounded in 1814, under the
walls of Paris ; a cannon ball struck obliquely his left side without producing
any external wound; he was  immediately carried to the ambulance  at  La
Villette, and on examining the part which had received the blow it was found
to  be of a violet colour, fluctuating  extensively, and deeply disorganized.
The patient was  taken  to the  Hotel-Dieu.   When  I saw him  again  in  the
evenin°", the skin was of a brownish hue,  the left lower extremity was insen-
sible and immoveable ;  there was vomiting, bloody urine,  difficult and painful
respiration, and general stupor.  He died in a.few days.
   After death  we found the subcutaneous cellular tissue, the belly  of  the
sacro-lumbalis muscle, the parietes of the abdomen and left kidney reduced
to  a jelly; the  lumbar nerves lacerated, the transverse processes  of  the
lumbar vertebrae and the last ribs crushed ;  the  abdominal  cavity and wounded
side of  the chest filled with blackish blood ; the skin alone  had resisted  the
action of the ball.
   In a great majority of cases, however,  the skin is  injured  as well as the 
532
LECTURES ON
  internal parts ; we then have according to the size  and velocity of the  ball
 violet, brown, livid, unequal lacerated wounds, covered with black blood, and
 apparently entirely deprived of vitality.  They present in a word, all the
 characters of contused ivounds which have been already described.
   A ball  striking obliquely the anterior  part, of the abdomen, sometimes
 occasions  under  peculiar circumstances a very remarkable phenomenon, I
 mean the rupture of the contained viscera.  It  is difficult  to conceive how
 flexible and  moveable organs, like the alimentary canal, can be  ruptured  by
 external violence without a wound of the abdominal parietes.  Yet numerous
 examples of this species of wound sets aside all doubt.  It must be remarked,
 however,  that in  whatever  manner they  may take  place, ruptures of the
 intestinal  canal are not always followed by effusion of faeces into the perito-
 neal cavity,  and that cures often occur from adhesion established between the
 lacerated and adjoining parts.
   Stupor, a remarkable effect of severe wounds, and which we have already
 described, is especially remarkable in those of the cavity of the abdomen.
   Let us now consider Wounds of the Pelvis.—This bony cavity,  which is
 as it were  an appendix to that of the abdomen, contains  several important
 organs,  and  is therefore liable  to dangerous  wounds.  When a ball passes
 through  this  region, it  fractures the bones,  constituting a serious injury; for
 the bones are deep-seated, covered with a large mass of soft parts, surrounded
 by large blood-vessels  and nerves.  The  organs  which they enclose  are  per-
 forated,  and pour into  the cavity the fluids or  solids which they may contain,
 producing  secondary inflammation almost inevitably resulting in death. Great
 vessels are opened, and the haemorrhage cannot be  arrested; the nerves are
 wounded,  and paralysis  of one  or  several organs ensues, or of the lower
 extremities.  If the ball lodge in the bone or  soft parts, it gives rise to all the
 terminations pointed out in the other regions, such as necrosis, inflammation
 of the periosteum, of the  cellular tissue, large and deep  abscesses,  fistulous
 sinuses,  &c.   The perforation of the bladder is followed by effusion of urine;
 that of the  rectum by extravasation of faeces  ; accidents promptly fatal. Rare
 exceptions sometimes occur.   A private of the  royal  guard, treated  in the
 Hotel-Dieu in  1830, survived nearly 40 days  after a double lesion of the
 bladder and large intestine.  This extraordinary case was accounted  for by
 remembering that the  ball, fired from a window,  had an oblique direction
 downward, and'had not penetrated the cavity of the peritoneum.
  We will now glance over Wounds of the Lower Extremities.—The size
 of the hip  joint, its proximity to the trunk, the numerous organs composing-
 it, render a wound  of  this  part extremely dangerous.   Amputation, which is
 often imperiously  demanded, leaves  a very extensive wound ; lar^e vessels
 and  nerves are divided, and yet there are  many living  proofs of the  effi-
 cacy of this dreadful   remedy.  Fracture of the thighbone is always very
 serious.  This  bone being of a compact structure, if  the ball  possess much
 velocity it  is broken into splinters, and a comminuted fracture  results, the
 more dangerous  inasmuch  as it is complicated with  a wound of the integu-
 ments.   There scarcely exists a fracture which is not comminuted, produced
 by a  ball  striking the shaft of the bone perpendicularly.  Generally, the frac-
ture  is simple, only when the ball  strikes  obliquely.   Now, what happens ?
 At the  moment of the wound  the  individual falls, the ends of the  broken 
CLINICAL SURGERY.
533
bone are forcibly carried  against the surrounding tissues and lacerate them.
Every motion gives rise to a new laceration and most horrible pain.  From
these circumstances the inflammation runs very high ;  the  suppuration is co-
pious and unhealthy; the patient sinks, and death is inevitable.  Amputation
is therefore, in many cases, our only resource.  The disorder of the soft parts,
the injury of arteries and  large nerves, are motives to hasten the operation,
for it should be early performed, in  order to prevent the development of se-
condary symptoms.
  If the bone of the leg be fractured the danger varies according to the situ-
ation and extent of the injury.   At its upper part the tibia is of considerable
size, and  spongy ;  a ball  may therefore  pass  through without fracturing it.
In  similar cases, a  cure  may follow without  a bad symptom.   If the  ball
strike  directly the  broader surface of the bone, towards  its middle, it may
still perforate it without  a complete fracture; but the portions of bone re-
maining on  each  side not being sufficiently strong to bear the weight of the
body, yield, and the fracture becomes complete.
   This bone, however, is mostly broken, like the os femoris, into splinters.  The
fragments  then are numerous, and they should be carefully removed in  order
to abridge the consequences of the injury and prevent its complications.  Rouge,
a printer, had his leg broken by a  ball  on the 28th of July in the Place de
Greve.  Being of a  very irritable constitution, the nervous  symptoms with
which he was attacked were with  difficulty subdued, and we  were  forced to
forego  amputation as the  case demanded.  Symptoms highly exacerbated by
the imao-ination of the patient supervened, and an attack of fever terminated
his existence on the 31st  of August.
   In o-un-shot wounds of the knee joint amputation is indispensable.   If there
be a settled point in military surgery, it is the incurability of these wounds.
   Wounds of the lower  part of the leg, involving the ankle joint, are very
«;aii"-erous and generally  require amputation.  The remarks made as regards
wounds of the  hands and fingers apply equally to those of the feet and toes,
and we will dismiss the subject.
   Let us now recapitulate the principal points relative  to wounds of the limbs.
   1st.  Wounds implicating merely the soft parts and sparing the large ves-
 sels are  seldom dangerous, and heal kindly, provided the openings are suffi-
ciently enlarged.
   2d. There is always more  or  less danger when the bones are involved.
 But fracture of the principal bone of a limb increases  so much the danger of
 the case that we expect only one cure in four cases, and for two reasons: 1st,
 because this fracture is almost always accompanied by a wound; and secondly,
 because it  is almost always comminuted.  Every one. knows that compound
 fractures  produced by what cause  soever, are often  so severe as to require
 amputation;  the contact of the  air, inflammation,  excessive suppuration
 and even gangrene, which result from  them, are often productive  of fatal

 "^d^if a bone be fractured at a joint or in its vicinity, and the joint be  open-
 ed" the wound is exceedingly dangerous, and  the  subsequent symptoms
 p-enerallv demand amputation.                                 .
 S 4th  When -reat vessels ar,e wounded, the patient soon penshes  from
haTmorrhage  unless they  are secured.  This is a frequent cause of death on 
534
LECTURES ON
the field of battle.   The  division of veins seldom gives rise  to haemorrhage
unles large trunks  have been  injured, or the patient been subjected to much
motion.
  It would be superfluous to speak here of the consequences of the destruc-
tion of a muscle, the division of a tendon, the section of a principal nerve, &c.
They are seen every day in civil practice, and every one understands them.
  Treatment of Gun-shot Wounds and their Complications.—The treatment
of these wounds, like that of other surgical  diseases, is divided into general
and local.  The former comprises rest of body and mind, diet in its different
gradations, drinks of diverse nature, pure  atmosphere, loss  of  blood,  &c.
The  latter is directed to the means of arresting haemorrhage, of preventing or
removing strangulation, inflammation, and gangrene : the enlargement of the
wound, extraction of foreign bodies, amputation, ligature, dressing and cica-
trization of wounds, position of the limb, topical applications, &c.  It  may
also be remarked in a general way that, in the same manner as we distinguish
three principal stages of these wounds, one of stupor or nervous debility, the
second of reaction or inflammation, and the third of suppuration or exhaustion,
the treatment  should  consist  successively  of  slight stimulants, then  an-
tiphiogistics, and lastly tonics and roborants.
  Rest, especially when there is a fracture, is of the highest importance.   A
tranquil mind is  no less necessary, for reasons already pointed out in this
chapter.  A pure atmosphere is also  of the greatest  moment.   Therefore the
most  healthy situations should  be selected and the wards kept scrupulously
clean.  It is much better that the wounded should lie in large tents, if possi-
ble,  than be heaped in  hospitals, to fall victims to gangrene and  ataxic and
adynamic fevers.  Ventilation should, however, be cautiously conducted, lest
dangerous consequences ensue.   Currents of air, established by means of air-
holes or windows opposite to each other, are  frequently fatal, by giving rise
to inflammation of  the internal  organs.  We have already said that tetanus
often follows the action of these  currents and the  sudden transition  from
the heat of the day to the freshness  of the night.  For the same reasons the
patients should be prevented from throwing off their bed-clothes lest they be
exposed to the agency of the causes just mentioned.
  The diet demands the strictest attention.   The sudden change from health
to disease, the certain occurrence of  fever, disorder of the internal functions,
and  many  other considerations  render  diet absolutely indispensable.  A
niolern system much abused introduced an extremely severe regimen, which
experience has proved to  be injurious.  Absolute diet in persons who have
not been gradually prepared for it is productive of bad effects.   The strength
of the patient should be supported by soup, fresh vegetables, &c; we must re-
duce, suspend, or increase the nourishment according to  circumstances  and
the stage of the disease, the habits, age, and constitution of the patient.   A
sick Russian will eat with impunity more than a healthy Spaniard.  In 1814,
the wounded Cossacks admitted into the Hotel-Dieu received rations sufficient
for able-bodied  soldiers, and  in addition rations of brandy, which seemed to
have no effect upon the most severe wounds.   The drink should vary accord-
ing to the  stage  of the disease.  At first,  drinks slightly exciting, diluent
when inflammation supervenes, tonic during  the period of suppuration.  The
bowels should be kept naturally open, in order to prevent the  uneasiness of 
CLINICAL SURGERY.
5H5
retention of faeces, and haemorrhage  which might follow violent efforts to
make water or evacuate the intestinal  canal.
  Observation has shown that during the first three days following the wound,
a. fever cf more or less intensity takes place, known by the name of traumatic,
and  which sometimes runs so high that the surgeon should never neglect to
endeavor  to prevent or moderate it.   The nature of this fever is manifestly
inflammatory.  After diet, rest and drinks, venesection is  the most effectual
means of subduing it. It may be established as a general precept that patients
wounded by balls or other projectiles  should be bled and bled even copiously,
having regard to the state  of the patient.   If there be stupor, he would perish
from the  opening of a vein: we  must then wait for reaction.  If a copious
haemorrhage take place, the indication is thereby fulfilled.  But in all other
cases  ve must guard against inflammatory symptoms, and general bleeding
is the best means of accomplishing  our end.
  Wounds of important organs,  as the lungs, brain, liver, &c. require large
and repeated  bleedings.   The old surgeons were not afraid to bleed ten, fif-
teen, twenty times, or even oftener in the early stages of these, wounds, and were
sometimes successful in apparently desperate cases. This practice has been fol -
lowed in some cases of severe wounds of the thorax, with the happiest results.
Experience has proved the absurdity of sucking a wound of the chest in order
to extract the effused blood, and shown that the chances  of cure are much
greater when it is closed immediately  by a suitable dressing, and the introduc-
tion of the air prevented as much as possible.
   Let us now take up the most difficult and complex question  in military sur-
gery,  namely, that relating to Amputation. The first problem to be solved in
wounds of the limbs, is to point out the cases requiring amputation ;  for when
this operation is deemed indispensable, it should be performed without delay,
unless there exist great stupor or disturbance. What circumstances, therefore,
 render it necessary ?  When and how should it be performed ?  What should
be  the after treatment—should we attempt or not  union by the first intention ?
   In  my  opinion  amputation  is absolutely necessary:   1st.  When a ball
 havino- nearly reached the end of its career, and stricken a limb obliquely, has
 fractured  the bone and extensively bruised the soft parts, without, however,
 injuring the  skin.   2d.  All ball or grape shot wounds in which a limb has
 been  dreadfully mutilated,  completely  removed, or holds merely  by such
 fragments, require amputation.  There is then an unequal, lacerated wound,
 parts  struck with  mortification,  projecting bones, in  a word  an enormous
 wound, of which the copious  suppuration is fatal to the patient, who in the
 most  successful  cases recovers  only after a tedious treatment and with an
 unseemly cicatrix.  Notwithstanding all  these  advantages  the rule admits
 some  exceptions.  Thus  if a projectile have carried away the arm at or near
 the shoulder, and at the same time the acromion or coracoid process and spine
 of  the scapula, amputation  is evidently  impracticable; for where is it to be
 performed ? The same is true as regards the hip-joint.  What  must then  be
 done? Remove all foreign bodies  and fragments of bone from the wound;
 arrest the haemorrhage if it be present,  prevent its occurrence if it do not actually
 exist  for it is most probable that it will afterwards take place.   The artery
 should be tied an inch or inch and a  half above the  injury.  But these pre-
 cautions  cannot remove  the danger accompanying these wounds, and arising
  1st  from the concussion  and stupor, which often cause death; 2d. because 
536
LECTURLS  ON
the  patient after escaping  the primary danger may not be able to bear up
against the violence of the inflammation, and abundance of the suppuration;
3rd. if the patient  survive all these perils, he may sink under the process of
cicatrization, which, difficult in an ordinary amputation, is often impossible in
gun-shot wounds ;  4th. and lastly, he is threatened  by the development of
internal inflammations, frequently fatal in their result.
   3rd.  The majority of writers deem amputation indispensable when great
vessels are wounded.   I do not, said M. Dupuytren, concur altogether in  that
opinion.  For instance, if the femoral artery be opened at its middle portion,
I think we should endeavor to save the limb by tying it above.   Although a
single ligature may  suffice, it is much more prudent to secure both ends of the
vessel.  We have thus been frequently successful in comminuted fractures,
not complicated by  a wound.  But if the lesion of the artery be complicated
with a  wound, the  case is much  more serious.  Thus, in recapitulation, 1
should say,  if the artery  alone  be injured, it should  be tied; if the artery
be wounded, and also the bone slightly, still use the ligature; in severe injury
of the bone with a wound, comminuted fracture, amputate; in severe injurv
of the bone, and division of the artery, we should, a fortiori, amputate.
   4th.  Wounds of the principal nerves are not necessarily followed by ampu-
tation.  Which, indeed, are these nerves ?  The radial nerve ?   Even when
this nerve is injured, a certain degree of motion remains in the wrist, and the
preservation of the limb secures the patient from  the dangers of the operation.
The  median? The patient escapes with  permanent contraction or paralysis.
The  brachial plexus ?  It can scarcely be injured without wounding the vessels
at the same time. Here amputation is indispensable; but were the nerves alone
injured, it would be much  better to preserve a slightly useful arm, than subject
the patient to the risk of the operation.  Lastly,  it is not more required in
lesion of the sciatic  nerve.   Paralysis, indeed, results from its complete divi-
sion ; but the danger in amputation of the thigh is so great that it is much-more
prudent not to expose  the patient to it.
   5th. If a large part of the  soft  parts, vessels  and  principal nerves have
been removed, amputation is evidently indicated.
   6th.  If  a long bone is broken into numerous fragments at  its middle part,
should we preserve or sacrifice the limb?  The following is, in  my opinion, a
general rule in these cases.   If the bone be broken only in one or two places,
Hie fragments few, the nerves and vessels unhurt, the disturbance slight in the
soft parts, the wound  should be enlarged and  the preservation of  the limb at-
tempted.  In contrary cases, amputate immediately.   It-is. true patients have
recovered after having refused to submit to any operation; but these cases are
too rare to be admitted as precedents.  In the army  or on fields of battle,
which are  so different from civil hospitals, we should not hesitate for a moment.
The  patient is exposed to  danger from numerous and serious perils;  immedi-
ate or secondary haemorrhage, violent inflammation, strangulation and its con-
sequences, copious  suppuration, colliquative sweats  and diarrhaea, internal
phlegmasiae.  Death generally occurs on the 20th, 30th, or 40th, day.
   7th. Amputation  is again  required when the spongy portion of a bone  near
a large joint, or this joint itself, has been penetrated by a ball, especially if it
have been largely fractured. The same is to be  done in severe injuries of the
phalanges ; which though of apparently unimportant size, from their exquisite
sensibility frequently excite tetanus and other nervous accidents.  In the  large 
CLINICAL SURGERY.
537
joints if one bone alone be injured its resection may be substituted for amputa-
tion.   This operation, however, is impracticable in the inferior extremities; it
would not be prudent to perform it at the wrist, even when the bones of the fore-
arm alone have been injured by a projectile traversing the radio-ulnar diameter
of the limb; it would be perfectly proper if the projectile had carried away the
posterior part of the elbow joint.   It has been also successfully applied to the
lower jaw, but is especially suited to comminuted fractures of the head  and
neck of the humerus.
   8th. In all the cases just enumerated, and in all those in which  amputation
is indicated, it should be performed immediately.   We thus make but  one
wound ;  the patient  has not thought  of preserving his limb, and cares but
little to part with it.  If, on the other hand, he be allowed time to reflect on his
situation and the loss  he is about to undergo, he suffers  doubly from the
sacrifice.
   Injuries resulting immediately from gun-shot wounds are not the only  ones
which may require amputation.  Many circumstances may occur  during the
course of the disease which may render it necessary : thus, 1st. This oper? ion
may be demanded when the inflammation terminating  in gangrene, the latter
occupies the entire circumference of the limb, or being  limited to the soft parts
only, after the separation of the slough, leaves the bone extensively denuded.
In these cases there is no necessity for waiting until  the gangrene is arrested,
provided the operation be performed sufficiently far from the seat of the in-
jury, and in sound tissues.  2d. The operation is indicated, when in the suppu-
rative stage it becomes apparent that the patient can no longer resist its in-
fluence.   It should then be performed quickly, and not wait until debility and
exhaustion have advanced far, or some  internal  complication  be developed.
3d. It also becomes necessary when a wound, dangerous  of itself, is compli-
cated by secondary haemorrhage, unless it can be arrested by securing the ar-
tery at some distance from the wound.
   Here an important question arises.   Should we after amputation endeavor,
or not, to procure union by the first intention ?   Wounds  resulting from
a primary amputation should be immediately united, if the tissues in  which
it has been performed be perfectly healthy.  In this case, indeed, nothing
contra-indicates it; the  patient is not debilitated ; no copious suppuration has
been established which it would be dangerous to suppress suddenly.
   But is it supposed  that union by the first intention can be effected, in the
full acceptation of the word ?  I have interrogated many of the most decided
partisans of this method, and who have all agreed that  there invariably takes
place more or  less suppuration after 15, 20,  or 30 days, even in the most
favorable cases.  This fact I have  also always  observed, but  it takes away
nothin°- from the merits of our operation, which  diminishes the extent of the
wound"and of the suppuration, shortens the  cure and removes  the danger.
However, we will now point out what may be considered as objections to it.
In the first place we  are obliged to secure  even the  smallest vessels;  and
however careful we maybe some one may escape, and immediate or secondary
hemorrhage supervene.   If  hemorrhage take place, the situation is worse;
the effusion and infiltration of blood destroys the adhesion of the parts; it is
exceedingly difficult and sometimes impossible  to find the bleeding vessel.
The "infiltrated fluid  causes  inflammation, and  an  unhealthy  suppuration;
            68 
538
LECTURES  ON
 chills and fever come on, and render the situation of the patient one of great
 danger.
   What we  have said of the circumstances favoring  strangulation and its
 effects leads to the knowledge of the preventive  and curative indications of
 this accident.  It may be prevented by general and local blood-letting, emol-
 lient poultices, purgatives, revulsives, &c.   This same treatment is also proper
 to moderate  its intensity when its development cannot  be prevented.
   But the most efficacious, undoubtedly, of all these means is to enlarge the
 wound (debrider).  The loss of blood resulting from  the incision  serves to
 lessen the engorgement of the parts; thus, far from arresting it, it should be
 promoted as long as the patient can bear it without danger.
   No one denies the utility and even absolute necessity of enlargement when
 strangulation exists and is intense, but some practitioners have thought that
 it should not be used as a preventive  means,  and that by its indiscriminate
 employment the patient  was subjected  to much  unnecessary pain.  Cer-
 tainly it should not be performed without judgment; but there are cases in
 which it is imperiously demanded, as well on account of the  nature of the
 projectile as of the parts wounded.  Thus, in deep  wounds,  with narrow
 openings, involving the aponeurotic and superimposed cellular tissue, produced
 by any cause whatsoever, it is indispensable.  Experience proves, indeed, that
 they generally give rise to symptoms of strangulation, and that serious danger
 may result by deferring the enlargement of the wound as a preventive means.
 In these cases, it is almost always a curative  remedy,  by preventing the  un-
 favorable symptoms which might result from the strangulation.
   Again, it is  not only in wounds  that this operation becomes  necessary;
 there is strangulation in  all the inflammations, as well external as internal,
 which are developed under aponeuroses and in the midst of fibrous tissues.
 It appears in and under the skin,  principally in grooms and others taking
 care of horses ;  such are especially furmicle and the non-contagious anthrax.
   The end of the enlargement of the wound is to remove the compression of the
 inflamed parts, and consequently also  their tension.  Hence it may be per-
 ceived that it  is principally directed against aponeurotic, fibrous and  other
 parts opposing the free development of the inflammatory action.
   This operation requires no other instruments except the bistoury and direc-
 tor ; but in  many cases the finger  advantageously supplies the place of  the
 latter.   It very rarely happens that  the common bistoury is  not sufficient:
 if it is too short a longer one must  be selected, so  as  to operate at greater
 depth in  wounds to be dilated.   Whatever may be its  length it should have
 a button  at its  extremity, especially when it is necessary to enlarge wounds
of some standing, to avoid injuring by its point deep seated parts.  The but-
ton should be placed nearer the back than  the edge of the instrument, that it
 may not  interfere with  its operation ; but when  it is  necessary to enlarge
parts entirely, the  ordinary straight bistoury is indispensable.   The sound
 canula designed to direct it should also have dimensions proportioned to the
depth to  which it is to be carried.  Whenever it is possible to conduct it upon
 the finger, it is better to make use of that than of the  sound, as it is a surer
guide.  If the  entire parts are to be cut through which have  not  undergone
any solution of  continuity, v.e ought to incise them from without towards the
interior by thrusting the sharp edge of the instrument through them.   Accord- 
CLINICAL SURGERY.
539
ing to the case, a single incision may suffice, or several may be required.
One may be sufficient when the contraction is circumscribed to a moderate
extent, but two or more are necessary when the constriction and inflammation
are extensive, as when diffuse phlegmon  is developed under the aponeuroses
of  the  extremities.   There  are  even circumstances under  which we  are
obliged to multiply still  more the number of incisions and increase their ex-
tent,  to prevent  the destruction of all the parts affected by gangrene.  Cru:
cial incisions are necessary in certain cases of inflammation complicated with
circumscribed constriction, as in anthrax and furunculus.
   After incisions, whether simple or multiplied, linear or crucial, pressure
should be made in order to evacuate the serous, purulent, or other fluids,
either infiltrated or collected in cavities, as their presence, besides producing
 inflammation, may create a new constriction.  Many persons may think that
 they  have dearly purchased relief by the vivid pain which pressure creates;
 nevertheless, it is the  only means of obtaining a speedy cure.  If a wound
 pre-exists, the enlargement must be  made from within towards the surface ;
 here  the bistoury is conducted by the director on the finger, or a bistoury with
 the button at its extremity separates the parts in a manner similar to the
 sound.   When  enlargements are made upon  the  surface, their  direction,
 whether lineal or crucial,  is of little consequence, but not so when we operate
 at great  depths, they must then be made parallel to the direction of the ves-
 sels', nerves, muscles, tendons, &c, and as far as practicable at a distance
 from them, in order to avoid  hcmorrhagies, paralysis, and loss of function, of
 which so many examples have been cited.  Thus, I have seen at Saint Cloud
 a patient deprived of the use of the great pectoral muscle by its tendon being
 cut through near its insertion into the humerus, whilst enlarging a wound to
 extract a ball which  was not to be found.
    To be effectual, dilatation must be practised throughout the whole length
 of wounds in which it is necessary, and over  the whole extent  of surface
 which the constriction occupies.  If it is not carried to the depth and length
 of the evil there results but incomplete and  momentary relief.  But while it
 is proper to conform to this rule it is necessary nevertheless to avoid the rash-
 ness of those who for the least wound or smallest occurrence of constriction
 divide a limb throughout its whole length, and by  this practice run the risk
 of useless suffering, dangerous  hemorrhagica, interminable suppuration, and
  finally only accomplish a cure by the formation of large cicatrices, muscular
  and other hernias, and  debility greater or less of different parts, &c.
    If incision is practised only to relieve constriction, the blood must be al-
  lowed to flow as  long as the patient can bear its loss with impunity.  It it
  has  been performed in order to extract foreign bodies, we must immediately
  proceed to search for them by the means hereafter to be noticed.
  P Union by the first intention of parts liberated by incision  is an error we
  h„vt seen committed.  There is in fact inconsistency in operating to remove
  nmi^™™*'**™*** bringing about  reunion, or  ,n other words tp
  r3ducTthe effects the practice was intended to  remove.   Such an  occur-
  rence we have witnessed in a case  of sub-aponeurotic phlegmon deve oped at 
540
LECTURES ON
intention  gave rise to a purulent collection in the interior of the limb.  Parts
thus liberated must be left to themselves, or there should be placed between
the lips of the wound a pledget of linen spread with cerate, and simple dress-
ings solely  applied, which will permit the  exit of pus if formed, and bring
about a more tardy union.
   What has been said with regard to liberating incisions, has a special appli-
cation to wounds of the extremities.  But is this operation practicable in other
regions?  The cranium being covered with a close fibrous tissue, wounds im-
plicating it require  imperiously either incisions  or preventive enlargements,
or division when the constriction is prominent.   We will remark here, lest it
should be omitted,  1st. That in  whatever region  the dilatation  is practised,
which consists in making incisions at the  entrance and  termination of open-
ings, they ought  to be principally performed at the terminating orifice.  The
reason is  plain, for all foreign bodies formed from or introduced by the projec-
tile are found located near this opening; hence larger incisions are necessary to
facilitate  its exit.  2d.  Another general rule to be laid down, is to  enlarge
most extensively the opening which is  most dependent, both to facilitate the
removal of  foreign bodies and to evacuate pus.   In wounds of  the chest by
penetrating weapons, far from enlarging they  should  immediately be closed,
at least if the intercostal  artery is not wounded.  But when the wound is
produced  by fire arms,  a  different  course is to be pursued ; then in  fact the
openings and the tract of the wound are  covered  with a layer  of mortified
substance;  inflammation will arise  and be followed by the  removal of the
sloughs, by  suppuration,  and  sometimes by  the escape of foreign  bodies:
nature is  opposed  to reunion,  and this reunion  is at least useless if not dan-
gerous.
   In the abdomen enlargement is contra-indicated, because by increasing the
opening, additional risk is  encountered of allowing the viscera, to escape from
the  cavity,  and  of  destroying  the  salutary adhesions which the wound has
contracted, and which oppose their  exit.  In  the  pelvis it is impossible; the
bone cannot be operated  upon,  and the only attempts made must be confined
to enlarging the openings in the soft  parts incases where it is thought possible
to remove extraneous bodies.   But you are aware of the difficulty of affording
free issue to pus formed  in this cavity; this is one of  the principal causes of
the great  severity of wounds in this region.  As to the articulations it is rare
for them to  be wounded  without affecting the bones.  Should  they enclose  a
foreign body, the wound must be enlarged and an effort made to extract it.
If they are merely grazed beware how  you open them.  But we have  said that.
almost always, the bones composing them are affected at the same time, and
then enlargement and the extraction  of laminated fragments cannot be dis-
pensed with, provided there is  a  reasonable hope that amputation  may be
avoided.
   To recapitulate: by incisions, dilatation, and  liberation  from  constriction,
three principal indications are proposed. 1st. To prevent the resistance which
the inextensible fibrous tissues oppose  to swelling, or the inflammatory tume-
faction of soft parts; this is preventive liberation: or to remove the resistance
when it exists, and there is constriction; this is curative liberation.   2d. To
afford an easy  exit to the products of suppuration.   3rd. To facilitate the
Search for and extraction  of extraneous  bodies.  With regard   to this last 
CLINICAL SURGERY.
541
indication, enlargement is especially applicable to wounds of which the aper-
ture and track are too small to admit the introduction of the finger or explor-
ing  intrumentSj to those of  which the track is too irregular to arrive directly
upon the substance to be removed, and finally in  those complicated with frac-
ture of bones to facilitate the removal of splinters.
  Bodies found in wounds are of two kinds : one  class consists of the projec-
tiles themselves, and matters introduced along with them, such as pieces  of
clothing, leather, buttons, coins, &c, as also the primitive splinters; the second
is composed of the secondary and tertiary splinters.  We will not reconsider
at this  time the evidences of the  presence of projectiles, nor the difficulty of
being  assured  of their existence.    Let  us proceed  to  the  search for
and extraction of foreign bodies in general.   The patient must be  placed  as
far  as is practicable in the position assumed  at the moment of being wounded.
According to the advice of Ambrose Pare, the best instrument to use is  the
finger, because  the sense of  touch is more accurate than when a  metallic in-
strument is employed.   But if  the finger cannot penetrate to the location  of
the  substance, neither the sound canula, nor that with a  stilet should be em-
ployed, for fear of wounding the parts, but a simple female sound is most pro-
per.  If the finger can reach and feel the body, the dressing forceps will ge-
nerally be  sufficient  to remove it; but if it be deeply imbedded or altered in
shape,  the bullet forceps are preferable, because this instrument seizes it com-
pletely and produces less pain during extraction.  If the depth at which it lies
is very great, or the track be sinuous, or the direction of its course devious,
counter openings must be made.  But it should not be forgotten that if it can-
not be  found, or cannot be seized and extracted without great difficulty, and
without occasioning intense pain, it is much  better to desist entirely, or defer
the  operation to a more convenient period.   When the sloughs are separated,
and suppuration established, the body becomes more apparent and  movable,
consequently more easily seized and extracted.  The projectile being with-
drawn  from the wound, all other foreign substances accompanying it must also
be taken out, but often, however great may be the care  practised, there will
remain fragments of bone, portions of dead tendons, of clothing, wadding, &c.
These  are not expelled until months afterwards by the effort of nature, and
then it is that reunion is accomplished.  Besides, as has been said, balls, shot,
&c, can remain encysted a long time, or during lifetime, within the  tissues of
our  organs, without being  productive of  inconvenience or affecting  health.
We will now examine the indications which are presented by  projectiles im-
bedded in the bones.  If the ball remains in the spongy tissue, it is recognized
by the  want of two orifices; the  only one existing is that leading to the interior
ot"the bone; the resonance and resistance communicated to the sound and stylet
are  conclusive; the impinging of steel upon lead gives out a flat sound, against
compact bone  a clear sound,  and the resonance emitted is very  different.
Ao-ain-t spongy structure there is no resonance, but soft yielding resistance
is experienced distinct from that presented by balls or bone.  Should  a ball
be discovered,  if it is covered  by an envelope from the clothes, it can  be
drawn  to the opening and removed.   Such  an occurrence is rare.  If this
does not happen when the ball is fixed and immovable the piercer is  very use-
ful  as  it easily penetrates it.  The ball is then withdrawn by communicating
a rotatory motion to it, and with management the extraction is accomplished.
But what is to  be done if this will not succeed ?  The integument  must be 
542
LECTURES ON
separated by a crucial incision, the flaps raised and dissected, and the crown
of a trephine applied to the orifice in the bone in order to increase the canal;
then the ball may be removed by the piercer.  The same course is to be pur-
sued when the ball is imbedded in a flat bone as in the cranium between the
two tables.
  If the ball has traversed the bone and escaped, no particular treatment is to
be pursued, the  bony canal is  not to be enlarged, for the osseous tissue has
not the property of tumefying as much as the  soft parts, and  consequently of
producing constriction.   But things are to be managed differently when the
bone is broken into fragments and splinters more or less numerous are sepa-
rated.  This is not the place to set forth the signs of comminuted fractures;
in this case they are  the same as in those from other  causes, and farther aid
is afforded by the touch or an instrument.
  Let us pass to the  indications.  The first consists in the enlargement of the
openings of entrance and escape.  If the latter does not exist, the ball  remains
either in  the bone or soft parts,  where its force is spent.   The ball is then  to
be searched for and  extracted along with the  fragments of bone.  But if the
dilatation having been  made, and the efforts to  find it are very difficult, if
they occasion suffering, if irritable persons are the subjects, we repeat what'
has been said already, it is necessary to abandon all attempts, and not to run
the risk  of spasms, convulsions, and  tetanus.  The wound having been en-
larged, the osseous fragments are to be felt for with the finger and their mo-
bility ascertained. If it is apparent, then the pincers or piercer are to be used.
If it is  partial, that is if secondary scales are found adherent to the flesh,
tendons or aponeuroses, but detached in mass from the bone, they should  be
seized, and if possible the fleshy pedicle cut with scissors or the bistoury. But,
says M.  Dupuytren, if the distance is too  great to allow the action of cutting
instruments, is it right to pull them away ?  I have done this sometimes, but
have found that the inconvenience more than counterbalances the advantages
of so doing;  a profuse flow of blood, great pain, excessive complaint,  spasmo-
dic contractions and other accidents are its ordinary effects, and should  in-
duce us  to avoid it.
   The tertiary scales not being  separated at the time of the accident, their
removal cannot be attempted.   These arise from necrosis, and not becoming
loose  until the end of  forty or fifty days cannot come away  before that time.
But they may then be surrounded by callus, if the portions are too large, and
be expelled by the suppuration.
   In the course of our lectures  the phenomena of sequestrum and provisional
callus have been examined.  But if the provisional callus  has not been able
to form in  consequence of the frequent movements of the wounded limb, or of
deep seated constriction of the soft parts and of the vessels,  the long  continu-
ance of the disease exhausts the patience of both the surgeon and sufferer, and
may be protracted to six months or a year. At length the fragments becoming
movable, they should be seized and removed, and then the two perpendicular
ends of  bone approach  and unite.  The limb remains shortened, but this is
not to be prevented ; all that can be done is  to preserve its straightness unal-
tered.   The callus  which then forms by means of the cellular and  vascular
granulations is permanent, and not provisional; it is not produced around the
bone, but between its extremities.  The treatment and apparatus are the same,
only greater care must be  taken, and the dressing  oftener repeated, for a 
CLINICAL SURGERY.
543
wound exists, and if it was not dressed daily and even twice a day the suppu-
ration would become changed, burrow, and lead to untoward results.
  The dressing  of wounds from fire-arms consists of many details which it
is  important to  appreciate.   Exclusion from the  atmosphere is of the first
consequence ; this is  to be done as soon as circumstances will admit.  Fine
linen pierced with many holes and spread with cerate is best for the purpose;
upon this  is  placed a pledged of lint, thick in proportion to  the amount of
suppuration.  Bandages are injurious,  because  in order to apply them  the
limbs must be  raised, and their position changed.   It is better  to employ
compresses somewhat long, which cross each other and are secured with pins.
Much  importance is  attached to the removal of  the first application,  which
formerly  was done at the end  of  twenty-four hours.   At this epoch,  the
wound was dry, the blood upon its surface adhered closely, the  lint  which
covered it was glued  to it, and much suffering was produced by endeavoring
to remove the adherent dressings.  But  at the present time, surgery has un-
dergone great change; a wound is not undressed until the coverings  are
detached and can be removed  without suffering.  Five, six, or seven days are
necessary for this to take place; the injured surface then commences to suppu-
rate, the  lint is moistened and comes  away without difficulty.  Up  to  this
moment the  exterior  layers should be  removed and  renewed: at the same
time those remaining may be bedewed with some mild aromatic liquor.  The
dressing being  intended  to maintain the fragments, to facilitate  the  expul-
sion of pus, and to bring  together the parietes of  the wound, fillets of linen,
which are preferable to permanent bandages or graduated compresses of lint,
and sponges are to be used, according to circumstances; at each dressing the
wound maybe cleansed by means of injections,  varying in properties accord-
ing  to the stage of the disease.  These consist of solutions of nitric acid, of
mercurial salts,  and the chlorides when putrefaction is present;  camphorated
spirits when there is fetor; and vinomel * when the wound is indolent.  The
chlorides, said M. Dupuytren, are much vaunted as  remedies against hospital
o-an°rene,  and contagious  affections; we have often employed  them unsuc-
cessfully; in 1830 they  were valueless in many cases.  We  attacked the
disease with lotions of nitrate of mercury dissolved in  an excess of nitric
acid, put  on with a camel's hair pencil,  and the experiment was most happy.
   The position of the limb and of the patient merits special attention. The
horizontal posture is  an obstacle to the evacuation of urine, and a cause of its
retention.  This retention is increased gradually; at first a small  quantity is
retained,  then a larger, and finally it is continually voided guttatim.  This is
a sure sign that retention exists, although  there is an  apparent discrepancy
between its occurrence and the continual dribbling of urine ; it is because the
bladder being full  and distended beyond its capacity, discharges the extra
accumulation.   The  catheter  must under these  circumstances  be  frequently
used or left in  the organ; continuance in bed if  fracture exist  is not  less
inconvenient.   The same position preserved sixty or eighty days is  productive
of pain in the hip and  leg, inflammation and excoriation, sloughs of the sacrum,
spinous processes, spine  of the  scapula and of  the trochanter.  To guard
against these the couch is  to be changed, and the transfer managed with care,
&c.  Cold damp  sheets  bring on chills and internal inflammation.  If it is
* A stimulating application composed of wine and honey. 
544
LECTURES  ON
not practicable to change the bed, the eschars are to be prevented by resolu-
tive strengthening lotions, such as solutions of lead, eau de vie &c, by pad9
of fine lint and by plasters of cerate, &c.
  You already know, says M. Dupuytren, what are the methods employed to
apply  ligatures when hemorrhage  occurs from injury to vessels.   It is a
subject of daily remark.  At the present we  shall confine our observations
to arterioso venous aneurism.  What are the modes of treating this species
of aneurism ? Compression ?  It is very difficult to practise, very inconve-
nient in general, and according to the situation produces intolerable  pain and
dangerous tumefaction.  If for  instance  there exists a varicose aneurism
between  the artery and an axillary vein,  compression would be  applied  at
the same time upon these two vessels, and upon the plexus of nerves around
the artery.  Besides compression is useless over an old opening, conical  in
shape,  and organized  like the internal membrane of the artery and vein;
circumstances in which the  ligature itself applied according to the  method
of Hunter fails frequently.
  Two methods are adopted of applying the ligature; one of placing it upon
the artery above the disease as  practised by Hunter, the other of  applying
ligatures above and below  according to  the  ancient method, or with the
modifications I have introduced.  The first, which is  very often successful in
recent varicose aneurisms, fails completely where they have been  of some
standing. In these last cases, it is necessary to have recourse to the ligature
on both ends, either with or without incision of  the tumor.
  Stupor is one of the most serious occurrences attendant upon wounds from
fire-arms; it renders mortal nearly all the cases which it complicates; but the
more alarming it may be, by so much the more must the treatment be energetic
to combat its development and consequences.   Stupor presents two stages,
one of prostration, the other of reaction ; in the first, stimulants are necessary
to sustain the vital forces; and in the second, antispasmodics and antiphiogis-
tics to prevent their  running into excess.  Thus at first the wound is to be
bathed with spirits wine, &c.  Cordial drinks  are administered  internally,
without forgetting at the same time that reaction must supervene, and that its
energy may be increased.  When reaction has  come  on, we  should merely
look on as long as its symptoms are regular, for  it is the method which nature
takes to remove the stupor; but if it is carried to so high a degree as to threaten
life, antispasmodics are to be used, as valerian, camphor, &c.; if these are not
proper, leeches to the wound, emollient fomentations and poultices are to be
employed.  If there is sinking, mild stimulants may be administered.  Should
high fever be present with frequent  full pulse, bleeding is our remedy; if de-
lirium occurs, leeches to the head; if jaundice, cataplasms to the  hypochon-
driac region ; if vomiting, Sedleitz  water or the potion of  Revierus.  In  all
cases, every thing irritating is to be guarded against in the treatment of the
wounded.  They must be removed from  the seat of war, from the noise of
arms, from the cries of victory or defeat.  If the dangers of stupor and reac-
tion have been obviated, it must not be forgotten that they are more  exposed
to ataxic  affections than other cases.
  The treatment of concussion, far from being the same in  all stages of the
affection, must vary according to the  intensity and presence of sinking,  re-
action or irritation; the treatment of such symptoms should consist successively
of stimulants, evacuants, and  even antiphiogistics more or less energetic. 
CLINICAL SURGERY.                       545
Such is the importance of this distinction, that if these different remedies were
indiscriminately employed at all stages of  the affection, in place of assuaging
the symptoms, an untoward event would be in all probability hastened.  Thus
if bleeding is too early practised, life may be jeopardized, or if stimulants are
continued when reaction has come on, inflammatory action may be dangerously
increased.   The plan to be pursued is  this; in the  first instance give mild
stimulating cordial drinks, and wet the skin with spirit or ammoniacal prepa-
rations, &c.  When reaction has come on these must  be  no  longer used; if
stasis  of blood in the vessels  exists, local sanguine  evacuations, either  by
leeches or  cups, are proper; if there  is  fever, general bleeding. But when the
malady continues  a long period, without symptoms of stasis or inflammatory
reaction the best treatment consists in the employmentof revulsive stimulants,
such  as mustard  foot baths, purgative enemata, laxative draughts, &c. But
of all these applications, large  blisters to  the posterior part of the neck and
allowed to remain  there, sometimes are the most effectual.
   I could cite many examples of cases cured by such treatment.  Its efficacy
is  so prompt, that  often in a few hours there  is a notable amelioration, and
this not in cases likely to improve, but in  those where the affection remained
stationary, or threatened to terminate fatally.
   Tetanus is also  among the number of those diseases the treatment of which
is  confined to no fixed and settled method.  A host of remedies have been
brought in array against it, both internal  and  external.  Thus general and
local  bleedings, abundant and  reiterated  warm baths of all  temperatures,
alkaline baths, dashing of cold  water, vapor  baths, mercurial frictions car-
ried to salivation,  electricity, blisters to the wounds to produce suppuration,
or on other parts of the body, moxas to establish revulsion, excisions, enlarge-
ment, cauterization of wounds, removal of the wounded limb when practicable,
&c. &c, have all in their turn been vaunted and employed as external means.
An immense  number of internal medicines have  been  relied  on  as cures
for tetanus, such  as  opium, belladonna,  aconitum, strammonium, camphor,
castor, musk, aether, valerian, digitalis, purpurea, arnica, mercury; sudorifics,
as aqua ammonia, acetate of ammonia, carbonate of potassa, acetate of lead,
tartar emetic, purgatives, spts. of turpentine, poison of the  viper, &c. &c.
The apparent  fertility of these resources  is  a proof of the penury of their
efficacious qualities.  They  all  have been lauded by  their advocates; but their
pretended merits vanish before the light of analysis and experience.  As
tetanus may admit of, and in fact does depend upon a multitude of causes;
and as practitioners for the most part treat it empyrically, it is not astonishing
that the therapeutics of the complaint have advanced so  little.  It  is easily
understood that if vermifuges are prescribed for an individual attacked with
tetanus in consequence of  suppressed perspiration, sudorifics for one labor-
in°- under the same, from a  violent moral  affection,  opium for a vigorous and
 sanguineous man, warm or  vapor baths for one whose head is violently con-
gested failure will be the inevitable consequence.   The treatment then must
be based upon causation, and if in time to come we flatter ourselves  a cure
 will be discovered for this  cruel disease,  it can only  be accomplished by the
 methodical employment of means whose influence is directed against the  ex-
 citing causes.                                     .  ...  .    ,        ,
   Local treatment will consist, according to  the case, in dilating the  wound
               69 
546
LECTURES ON
when constricted, extracting foreign bodies, projectiles, portions of clothing,
wood,  stones and other contained matters in getting rid of the scales, in
reducing and  maintaining in  situ the ends of fractures, and in cutting off
and removing  irritating projections  into  the  soft parts.   If this last is not
performed  in opposition to all internal treatment most skilfully directed the
termination almost invaribly will be unfortunate.  Such an occurrence fell
under my observation in the case of a young  man wounded by a violent cut
from a whip; the knot,  detached from the leash, remained imbedded  in the
cubital nerve.   Nerves  divided partially ought  to  be cut throughout their
diameter.  If suppuration is  suppressed, it  must  be restored ; caustics are
proper either to destroy the remainder of the divided  nerve, or to change the
irritation;  emollients and narcotics to relax the parts and remove pain; and
finally leeches  to relieve tension and inflammation.
   One of the best remedies for tetanus  is the copious abstraction of blood,
generally and  locally, by means of leeches to the neck,  ears and spine, espe-
cially in sanguine subjects, they relax and pave the  way for other remedies.
The patients are to be placed in a dark chamber, remote from noise and
company;  an elevated temperature is to be maintained, the air made moist by
evaporation of  water.   In aid of these, flannel or wool are to  compose  the
coverings,  and baths rendered medicinal by means of poppy heads, carbonate
of potassa, &c. &c. freely employed and  persevered in  for several hours.
These remedies are relaxing to the muscular system, and promote perspiration.
Next are to be used remedies of a calming soothing  nature, and which will
diminish the sensibility of the patient.   Quieting measures are beyond con-
tradiction the very best that can be used for tetanus', but it must be confessed
that hitherto they have been of little avail, even when carried to large doses.
Stupefiers, that is to say narcotics, which tend not solely  to diminish  sensi-
bility but to annihilate it, are indicated.  In  administering them care is to be
taken not to overshoot the mark ;  but atthe same time it must not be forgotten
that the sensibility is exalted, and ordinary doses will not  act, hence they are
to be greatly increased.  I have at times administered  as much  as half  an
ounce of opium during  three or four  days, without changing the progress of
the disease or hindering its fatal termination.
   If it is  concluded  from what has been said that tetanus requires calming
remedies, it is  at the same time obvious that the one which can  be  used with
infallible success has not as yet been discovered.  Shall we attain, some day
or other, this desirable result ? This is what we are unable to decide; we are
however to search for it in all possible ways.   But during this state of sus-
pense those which hold out the greatest prospect of relief are to be employed.
Opium, for example, is at first to be administered in large doses, and then to
be followed up by smaller until relief is obtained, &c.  Rigidity of the jaws,
the  impossibility of swallowing drink and consequently solid articles, fre-
quently preclude  the  use of medicines by the mouth, and render necessary
some other medium; injections into the rectum are therefore brought in aid,
using the least possible quantity of vehicle.
   This substitute, which I among the first  brought forward and  rendered
public, is  of greater  usefulness than by means of the mouth.. This is easily
acknowledged; for the rectum, not having the power of altering and digest-
ing substances thrown  into its cavity, their  action is prompt and energetic; 
CLINICAL SURGERY.
547
hence, doses employed by the rectum should be less by half than those given
by the mouth and taken into the stomach.
  If by chance the mouth or rectum are not available in the administration of
medicines, the endermic method conceived by M. Lember is to be brought in
to our assistance.  In this case, after having removed the skin over a surface
proportionate to the effect we wish to produce, either by means of a blister or
ammoniacal pomatum, upon the mucous body of the cutis are sprinkled one,
two  or more grains of acetate, sulphate, or hydrochlorate of morphia, after
which the part is covered with a plaster of simple cerate.
  It now remains for us to speak of amputation, considered and proposed by
many surgeons, as an  effectual mean of combating tetanus at the moment of
its appearance.  It has been some time since experience has removed from
my mind every illusion with regard to the efficacy of thisoperatioh in cases of
this kind.   But do not the repeated assertions of so many authors, supported
by such celebrated names,  undermine the  firmest convictions, especially
when the severity of the evil and the  extent of danger leave no  choice of
measures ?  It was then through deference  for such respectable opinions,
that  led us to practice this operation some  time since in a case of extreme
severity, after  having  fulfilled all the indications and  exhausted all the re-
sources of  our  art. . But the history of this fact will still more  demonstrate
how  vain are the hopes that are based  upon this measure.   We received in-
to our  wards, towards  the end of June, a young man who had fractured his
leg the evening of his admission.  The  fragments were jagged, especially the
inferior fragment of the tibia; many scales were imbedded in the fleshy parts,
and  there  existed a wound through  wdiich the  extremities of the fractured
bones projected externally.   Whether the patient had caught col I, or devia-
tion  from  his natural  diet, or finally the nature of the  accident operated as
the  exciting cause I  cannot  determine.  Pain and  convulsive  movements
were experienced in the limbs, the jaw became rigid, deglutition was impossi-
ble,  and soon the patient lost the power of articulating sounds.  Such was the
rapidity with  which these symptoms  came  on that  they  presented  tliem-
selves at the  very onset of the disease, and the whole body was agitated by
intermittent convulsive paroxysms.   Amputation was judged necessary  and
carried into effect in  opposition to the resistance of the patient; many ves-
sels  were  tied.  The day passed by happily ;  in the evening he was comfort-
able but the next morning tetanus reappeared ;  a draught given by teaspoon-
fuls  could  not be swallowed.   Three injections, four hours apart, with three
grains acetate of morphia, were substituted, but death occurred the same day.
Autopsy:   We searched in vain throughout the brain, spinal marrow, principal
nerves, and the viscera of the chest and abdomen, but nowhere found organic
lesions'sufficent to explain the occurrence of tetanus.
  Called  in  consultation with  M. Larrey to inspect a  similar case; amputa-
tion  likewise frustrated our hopes.   The wife of one of our general officers,
four months pregnant, fell from her couch and fractured her leg.  Tetanus
came on.  We determined upon amputation,  and it was  as speedily per-
formed as  the circumstances  would allow.  Tetanus however  continued, and
carried off the patient.
  By what rule then are we to be  guided ?  Amputate in the first instance
and  run no risk.   Military surgeons have been accused of being too hasty in 
548
LECTURES  ON
performing amputation;  I have repeated it often, and I again, for the last
time, declare, that from the facts I witnessed  in 1814, 1815, and 1830, my
opinion upon this point is  unchangeable.   In complicated fractures, particu-
larly those from fire-arms, by rejecting amputation more lives are lost than limbs
saved.   Tetanus is one of those diseases which renders null the axiom, " sub-
lata causa, tollitur effectus."  It would be as vain to hope to cure rabies by
amputating the bitten finger, constitutional  cancer or syphilis by removing
the local disease, as to expect to cure tetanus after it had set in by removing
the limb.
  Furthermore, the symptoms  and autopsy conspire to prove that tetanus is
an essential affection of a  nervous nature, without appreciable organic lesion.
  The course to be pursued during convalescence is as important to the phy-
sician  as to the patient.   Many wounded individuals, believing themselves
restored to health, commit  errors, which lead to relapses and death.  Relapses
after wounds cannot bring  back  again the original affection, as in cases of inter-
nal disease,but they engender diarrhoeas, adynamic fevers, &c. which frequent-
ly are  fatal.   Too early  exercise  and motion  where  there has been fracture
occasion often new solution of continuity.  Indulgence of the passions, ex-
posure to the atmosphere, improper diet,  are frequent causes of untoward re-
sults.  It is  easily comprehended how a patient, after having remained two
or three months  in a close atmosphere confined to his bed, will be attacked
with rheumatism, pleurisy, &c, the consequences of exposure and imprudence.
But  the most prolific cause of relapses is error in  diet, or the too sudden
change from a severe and rigid regimen to one nourishing and stimulant.
In the convalescent  department at St. Cloud in 1830, when general interest
was taken in the wounded, and  all sought to regale them, indigestion, vomit-
ing and diarrhoea, &c. were common.  Such occurrences increased to so great
an extent that the patients themselves entered into the plan of an organized
system of discipline.  They chose from among their number sergeants whom
they obeyed  without murmur,  and who confined the  next day all guilty of
any excess the evening before.
  It is then by gradually augmenting the  diet  and increasing almost insensi-
bly its nourishing character, that we are enabled to avoid, by means of hy-
gienic measures, the fatal results of relapses. 
CONTENTS.
Chap.                                                           Page.
 1.  On the  permanent contraction of the fingers, in consequence
       of an affection of the aponeurosis palmaris         -      -       5
 2.  Effects of a pistol shot       -       -       -       -      -      11
 3.  On cataract—its different species, operations,  and treatment  -      13
 4.  On engorgement of the testicles                                   27
 5.  On traumatic emphysema     -----      34
 6.  On caries  of the vertebral  column;  on  fistulous sinuses and
       symptomatic abscesses     -       -       -       -      -      39
 7.  On hydro-sarcocele   ------      44
 8.  On prolapsus of the rectum    -----      47
 9.  On nervous delirium         -----      50
10. On fractures of the interior extremity of the  fibulae, and luxa-
       tions of the  foot    ------      56
11.  On false aneurism of the brachial artery                           76
12.  On fractures of the patella    -----      85
13.  General considerations  on  the  treatment of fractures of the
       extremities                                                   92
14.  On the excision of hemorrhoidal tumors                           96
15.  On luxation of the vertebra, and on  maladies which  seem to
       present that condition     -       -       -       -      -     105
16.  On burns—their causes, different degrees, complications, ana-
       tomical characters, and treatment  -       -       -*■     -     115
17.  On the different causes of permanent contraction of the fingers,
       and their characteristic diagnosis   -                           142
18.  On a particular kind of fibro-cellular encysted tumors -      -     146
19.  On strangulation at the neck of the hernial sac       -      -     153
20.  On the  cysts  which  appear in  the bony tissues, and  of their
       different species   -       -       -       -              -     165
21.  On serous  cysts containing small white bodies  called hydatid
       cysts      -       -       -       -       -       -      -''171
22.  On inverted toe-nail   -       -       -       -       -            176
23.  On luxations of the humerus   -----     181
24.  On the vital and mechanical dilatation of the urethra  -      -     193
25#.  On club-foot......-     199
26.  On the central laceration of the perineum during parturition  -     201
27.  On original luxations of the os femoris       -       -      -     207
28.  On lachrymal tumors and fistulas     -       -'      -            £15
29.  On fissure  of the anus                                           221 
vi
CONTENTS.
30. On ranula    -      -       -       -       -      -            224
31. On abscesses of the right iliac  fossa    -                           232
32. Practical reflections on the use of cauteries and moxas       -     237
33. On hydatid tumors developed  in the muscles and viscera     -     238
34. On fracture of the lower extremity of the os humeri, simulating
       luxation of the elbow backwards    -                           246
35. On exostosis of the upper surface of the last phalanx of the great
       toe        -------     250
36. On fibro cellular tumors of the uterus, commonly known by the
       name of polypus of the uterus      -                           252
37. Observations on tracheotomy  -----     288
38. Of erectile tumors and fungus hsematodes     -                   295
39. On hare-lip   -------     321
40. On anthrax   -       -        -       -       -      -      - ,   325
41. On blenorrhagic opthalmia     -----     327
42. On the formation of callus     -                                  330
45. On fractures of the lower  extremity of the radius, simulating
       luxations of the wrist      -                                  336
44. On amputations      ------     352
45. On hydrocele and its principal varieties       -      -      -     386
46. On the treatment of goitre by the seton       ...     393
47. On the arsenical preparations in cancerous and other corroding
       ulcerations        -.._--     395
48. On symptomatic gangrene consequent  to arterites     -       -     396
49. On luxations of the lower extremity of the ulna      -      -     402
50. On ligature of the principal arteries    -                           404
51. On burns—the means of conducting the healing of burns, with a
       view to their favorable cicatrization       -                   42G
52. On fractures of the neck of the thigh-bone—their causes and
       treatment  -------     440
53. On artificial anus—its anatomical characters, effects, seat, prog-
       nosis, diagnosis, and treatment    -                           453
54. On diffuse phlegmon—its characters and treatment    -       -     474
55. On urinary calculus—principal symptoms, anatomy of the parts,
       preliminary treatment, and operation       -       -       -      485
56. On gun shot wounds  ------     503 
 
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